OCCUPATIONAL THERAPY

In pediatric occupational therapy (OT) there is considerable overlap with physical therapy.Many children with disabilities related to cerebral palsy or spina bifida are easily recognized to need OT.There are, in addition, many children with more subtle defects that interfere with fine motor, sensory, or cognitive development that might benefit from OT.The emphasis of the therapist is to help in the overall functional performance that is age appropriate.The two theoretical approaches to OT are sensory intergration (SI) and neurodevelopmental therapy (NDT).SI dysfunction relates to abnormal sensory function related to touch, proprioception, and kinesthetics as well as to vision, hearing, and taste.The concept relates to developmental dyspraxia, which results in poor skill in dressing and eye-hand functions.NDT relates to functional movement that results from reflex and postural responses.Neonates are evaluated using the Brazelton Neonatal Behavioral Assessment Scale.Infants are evaluated using the Bayley Scales of Infant Development and the Peabody Motor Scales.

                Positioning strategies are used in the neonatal intensive care unit to help posture and muscle tone.The therapist can help the family to become comfortable in infant feeding and handling.In the first few years of life, the problems relate to fine motor coordination skills especially of the hands.The therapist will assist by devising specific exercises that involve games and play to learn the skill to achieve the developmental milsetones.

                Preschool children benefit from interventions that ready them for school activies.Using paper and pencil and dressing and eating are skills that should be able to be learned during this time.The school-age children and adolescents who need OT will often be identified by the school.Interventions in the area of coping in activities of daily living and developing independence may be indicated.

ENVIRONMENTAL CONTROL UNIT

An environmental control unit (ECU) is a device that helps to operate electrical or mechanical devices for patients with motot impairment.The equivalents are the remote-control devices used to control garage doors and electronic equipment.The purpose of an ECU is to improve the capabilities of the disabled individual.There are direct devices as well as radio-controlled (wireless) devices that can be activated by touch, voice, computer, or even eye movement.They need to be age-appropriate and feedback is sometimes necessary to show that activation has accured.

WHEELED MOBILITY

For some patients the primary purpose will be to achieve independent mobility.For other it is a means of transportation in which someone else provides direction and control.The wheelchair may be manually propelled or electric.The standart manual wheelchair has two larger wheels with two forward swiveling wheels for direction.Newer lightweight models are designed for recreational use and athletic competition.Powered wheelchairs tend to be restricted to order children who have no potential for walking.

POSTURAL SUPPORT SYSTEMS

Adaptive seating systems are designed to provide postural support to achieve stable sitting particularly if there is poor muscle control or musculoskeletal misalignment.There is flexion of the hips, knees, and ankles to 90  although if there are contractures or deformity, particularly of the spine, the right angle may not be appropriate.There are different levels of support.First is the planar system, which is a flat seat and back, and the next level is the contoured system.The latter provides improved lateral support.The third level is the custom-molded system, which conforms to the body of the patient.The purpose is to provide support and to relieve pressure.The seat is improved with some lateral contouring and the back si slightly curved for lateral stability.If pelvic stabilization is necessary, a seat belt, either over the thighs or in front of the hips, will help.Additional support may be needed laterally for the legs and the head.

Assistive Technology

Equipment and devices are used extensively in physical therapy to aid in improving function.There are a wide range of assistive devices which vary from simple splints to computer-controlled functional limbs.There are four major types of devices: postural support, wheeled mobility, environmental control units, and alternative communication devices.

                The team evaluating the individual patient will make recommendation for specific devices.Justification for the expense needs to be made to the provider.Providers of rehabilitation equipment are a section of the National Association For Medical Equipment Suppliers.There is a national registry of suppliers who meet standarts of practice.

                Performance and skills are assessed and the equipment that has the potentialto help the problem is identified.Realistic goals should be established to demonstrate improvement.Funding is applied dependent upon the various options which include federal, state, and local agencies as well as private insurance.

Physical Therapy

It used to be that the physician would evaluate and refer the child for physical therapy that would be indicated for the specific condition.Nowadays the physical therapist often participates in the multidisciplinary team that performs the evaluation.The therapist makes diagnostic decision related to impairment and functional limitation.After deciding that treatment is indicated the next desicion is to define the therapy and the duration.The justification for treatment is easier if there is an endpoint that can be reached.Unfortunately, many chronic conditions do not respond very well and so secondary effects, for example, the prevention of contractures, may be important.

TABLE 8-1. LIMITATION OF SPORTING ACTIVITIES FOR MEDICAL CONDITIONS

Contact or Collision                 Limited Contact                                      Non-contact

Basketball                               Baseball                                                  Archery

Boxing*                                   Bicycling                                                  Badminton

Diving                                      Cheerleading                                           Body building         

Field hockey                            Canoeing/kayaking(white water)           Bowling

Football                                   Fencing                                                   Canoeing/kayaking

Ice hockey                               Field                                                          (flat water)

Lacrosse                                    High jump                                             Crew/rowing

Martial arts                               Pole vault                                              Curling

Rodeo                                      Floor hockey                                            Dancing

Rugby                                      Gymnastics                                             Field

Ski jumping                             Handball                                                    Discus

Soccer                                     Horseback riding                                        Javelin

Team handball                        Racquetball                                                Shot put

Water polo                              Skating                                                    Golf

Wrestling                                   Ice                                                         Orienteering

                                                  Incline                                                   Powerlifting

                                                  Roller                                                    Race walking

                                                Skiing                                                      Riflery

                                                  Cross-country                                        Rope jumping

                                                  Downhill                                                Running

                                                  Water                                                    Sailing

                                                Softball                                                   Scuba diving

                                                Squash                                                    Strength training

                                                Ultimate Frisbee                                    Swimming

                                                Volleyball                                               Table tennis

                                                Winsurfing/surfing                                 Tennis

                                                                                                                Track

                                                                                                                Weightlifting

*Boxing not recommended for children

      Notes: (1) Contact or collision should be avoided with absence or persintent abnormality of eye, kidney, or testis. (2) Caution necessary for spinal cord injury, bleeding disorders, carditis, enlarged liver or spleen, poorly controlled convulsive disorder. (3) Other medical conditions should be evaluated in an individual basis.

                        Pediatric physical therapy is designed to achieve optimal motor function for mobility and to aid in the activities of daily living.Early identification of infants and children who will benefit from therapy is important.The objective is to reduce the effect of chronic illness upon developmental milestones.Screening of motor development milestones may not pick up mild abnormalities and careful history and physical examination is necessary for full evaluation.Parents notice movement of their children and may be able to find abnormalities if they are told what to watch for.

                Although physical therapists do not require a specific referral in most states it is usual for the physician to write orders for therapy.It is important for the therapist to be aware of other medical problems in designing a therapy.This includes seizures, cardiac or respiratory problems, and other conditions that may impact the therapy.

                Physical therapy has in the past used clinical experience to justify its usage.In the era of managed care, there needs to be scientific justification for recommendation of a particular therapy for a specific condition.The initial consultation results in the development of a treament plan which is individualized to manage the specific problems areas.For example, the plan might include what exercises are indicated and which appliances or devices may assist.Outcome measures should be defined and assessments made to evaluate success and cost effectiveness.

                Conditions that can be evaluated include loss of motion, weakness, and deformities.Treatment strategies can be devised based on the disability.Musculoskeletal impairment, which results in contractures, may respond to exercise and splinting.Weakness can be managed by strengthening exercises including weights or by exercising in apool using water as resistance.Treatment is focused on interventions that reduce impairments and optimize functional potential.Learning and re-learning motor tasks is a major part of rehabilitation of neurologic and orthopedic impairment.The acquisition of skills of motor perfomance is a complex process.

Physical Fitness

Physical Fitness combined health-related fitness and motor fitness.Although there is evidence that physical fitness benefits adults by preventing heart disease, it is not clear whether childhood activity results in adult benefits.Healthy Children 2000 was put forward in 1990 and includes specific objectives to increase the physical activity and fitness levels of youth.The proposals defined goals to increase the amount of exercise and the proportion of children participating, as well as to reduce the problem of obesity.

                Exercises include those for range of motion which are used to increase joint mobility and to reduce contracture.These can be diagrammed so that the caregivers can provide ongoing therapy.Exercises can be passive range of motion, in which the patient allows the  caregiver to perform the movement.Active range of motion means that the patient performs the motions without assistance.Resitive range of motion implies that weight or physical resistance are added.

                Conditioning is the process whereby exercise repeated overtime results in changes in the body and in the ability to perform exercise.Training is exercise that is designed to improve performance in a specific activity by repeated exercise.Improvement in fitness results in improved muscle strength and endurance.Muscular strength can be affected by training especially at or after puberty.Most training programs require several weeks before benefits are seen.Health –related benefits of exercise are important for all children whether or not they have a disability.There are limitations for participation in sports activities that are indicated for chronic conditions in children. 

Assessment

Classification of functional perfomance in the presence of disabling conditions may be from the World Health Organization’s International Classification of Impairment, Disabilities, and Handicaps and intergrated by the National Center for Medical Rehabilitation Research.The result is a five-dimensional classification of pathophysiology, impairment, functional limitation, societal limitation, and disability.

                The motor milestones discussed in the previous chapter provide the means to document development.The Alberta Infant Motor Scale is an observational scale that is used between 1 and 5 years of age to assess gross motor milestones.The Denver II score remains the most widely used screening tool used by pediatricians.The Peabody Developmental Motor Scales assess gross and fine motor function up to 42 months of age.

                There are a number of tests that have been derived for children with disabilities althougth no specific tests have been identified to be particularly outstanding.They include the Gross Motor Function Measure (GMFM) and the Prediatric Evaluation of Disability Invertory (PEDI).The  Functional Independence Measure for Children (WeeFIM) assesses self-care, sphincter control, movement, and communication.One of the most important questions parents of children with motor disorders ask is, “Will my child walk?” There are many factors that result in the ability to walk  gait, the mechanisms of the pathological gait have become clearer.

                The physical therapist will assess the range of motion and the universal goniometer is the most wdely used measuring instrument.This is more useful in older children and adults than infants and young children.Manual muscle testing is used to assess strength.

Motor Development

Movement promotes cognitive and perceptual development and the three work together to form the basic for functional development.This means that motor development does not progress in isolation.The early stages of motor development are designed to achieve the upright posture (standing), mobility (walking), and manipulation (hand movements).As these stages progress, children  develop the skills needed for independence in the activities of daily living.For infants and young children, these activities inclide feeding, self-care, and play.The milestones that are achieved start with functional head control and then upright trunk control.In the second half of the first year mobility increases with crawling and creeping, and pulling to standing, leading to independent walking, which usually occurs between 9 and 15 months of age.

                Fine motor activity development involves control of the hand to reach and grasp, and object manipulation and release.The achievement of the stages to improve coordination will be in part dependent upon the tools (toys) and objects that are available.The progression is from holding to rotating objects.When a child shakes a toy such as a rattle, the feedback in the form of noise makes the toy more interesting.The next progression is holding objects in both hands and then transferring objects from hand to hand.At about 7-8 months of age, the infant learns to bend, to squezee, and to tear or pull objects apart.

                The preschool-age child progresses through skipping, running, and hopping, which demonstrate gross motor development.Sports and playground games are an important part of motor development of school-age children.Fine motor activity improvement is shown by learning to feed and to dress oneslf.

                Infants tend to have motor development disorders that may lead to contractures.The management of the disorder is destined to improve strength and to increase range of motion.The preschool child has more complex motor development with coordination.Language is progressing and communication brain injury resulting in psychomotor delay in addition to motor disorders.adolescents are at risk for spinal cord injury.

Pedriatric Rehabilition

The definition of rehabilitation services is to help ill, physically impaired, or handicapped individuals to reach their potential recovery after illness or injury.It is implied that the therapies include physical, occupational, and speech therapies.Therapy may be initiated in the hospital but many of the services are provided in the clinic or at home.

                The initial treatment is frequently an evaluation followed by the development of a treatment plan.The physician who specializes in rehabilitation medicine is called a phusiatrist, and the two main areas of therapy are physical and occupational.There are nurses who specialize in rehabilitation and child life specialists who help with the psychosocial aspects of care.Physical therapists work mostly with motility issues including motor development and strength of the back, legs, and feet.Occupational therapists work with the upper extremities, especially arms and hands, and help with activities of daily living.Speech and language therapists manage understanding language and development of speech.The orthotist makes braces and the prosthetist makes artificial limbs.

                The conditions that benefit most from rehabilitation in pedriatrics include cerebral palsy, rheumatoid arthritis, spina bifida, traumatic and asphyxial brain (and spinal cord) injury, burns, and muscular dystrophy.