Pediatric physical therapy

Definition

Pediatric physical therapy is concerned with the examination, evaluation, diagnosis, prognosis, and intervention of children, aged birth through adolescence, who are experiencing functional limitations or disability due to trauma, a disorder, or disease process.

Purpose

Pediatric physical therapy is indicated when a child has a pathology or suffers a trauma which results in an impairment leading to the loss of function and/or societal disability. Pathologies may include non-progressive neurological disorders such as cerebral palsy , which results from trauma to the brain during or shortly after birth. Children born with genetic syndromes, heart and/or lung defects, hydrocephalus, spina bifida, fetal alcohol syndrome , or drug addiction may also be seen by physical therapists. Pathologies resulting in musculoskeletal impairments include, but are not limited to: juvenile rheumatoid arthritis, hemophilia , scoliosis , peripheral nerve injury, arthrogryposis, osteogenesis imperfecta, and muscular dystrophy . Acquired pathologies that may require physical therapy include traumatic brain injury, spinal cord injury , and cancer .

Pediatric physical therapists are employed in several different settings, including hospitals, outpatient clinics, and school systems. In the hospital, a pediatric physical therapist may work with patients such as those recovering from heart or lung conditions or surgery, burn trauma, orthopedic surgeries, or any number of other conditions. In addition, many neonatal intensive care units (NICUs) also employ physical therapists to evaluate and treat high-risk or premature infants . In an outpatient setting, the same children may be seen further along in their recovery. Children with lifelong conditions may be referred to outpatient clinics upon manifestation of secondary impairments. School physical therapists are employed to insure that children with disabilities or developmental difficulties are functioning adequately in their least restrictive environment.

In any case, the goal of treatment is to diminish impairments and functional limitations to prevent or decrease disability. Treatment may be focused on improving developmental tasks, motor planning, manipulation skills, balance, and/or coordination. The affected child may present with difficulties with ambulation, positioning, communication, attention, cognition, and/or motor function. All of these problems need to be addressed, as they can result in the inability to keep up with peers or perform work at school.

Precautions

Upon patient examination, a physical therapist collects the patient's history and does a systems review. The review includes assessment of the cardiovascular, respiratory, integumentary, musculoskeletal, and neuromuscular systems, including cognition. Physical therapists are educated in differential diagnosis for the purpose of identifying problems that are beyond the scope of physical therapy practice or require the attention of another health care professional.

Description

Examination

Determining a child's need for physical therapy requires both qualitative and quantitative measures to gather information. Observation in natural settings, personal and family history, and subjective information from teachers or caregivers are all valuable pieces of the puzzle. A systems review should be performed, as discussed above. Through observation and measurement, active and passive range of motion and strength should be assessed. In addition, equilibrium and righting reactions and persistent abnormal reflexes should be noted. Posture and gait observation and assessment are essential for providing recommendations regarding exercises, seating, orthotics, and assistive devices.

Assessment of functional motor ability is often performed using a standardized test. In infants, tests often used include, but are not limited to: Movement Assessment of Infants, Peabody Developmental Motor Scales (PDMS), Test of Infant Motor Performance, Alberta Infant Motor Scale, and Bayley Scales of Infant Development II. Tests for children include the PDMS, Bruininks-Oseretsky Test of Motor Proficiency, and Gross Motor Function Measure. These tests look at the ability to perform tasks such as maintaining a prone position or rolling in infants, to walking a balance beam or throwing a ball in children.

Evaluation, diagnosis, and prognosis

Although a child may have been given a medical diagnosis, the therapist should formulate a physical therapy diagnosis upon evaluation of the examination findings. The physical therapy diagnosis focuses not on the pathology (e.g., hydrocephalus), but rather on the dysfunction(s) toward which the therapist will direct intervention (e.g., decreased balance).

The prognosis encompasses a prediction of the level of function realistically attainable and the time period in which it will be accomplished. The prognosis includes the plan of care, which outlines treatment procedures and frequency, in addition to specifying long-term and short-term goals. In a rehabilitation or outpatient clinic setting, goal-setting may be more short-term than in an educational setting, where the tendency is to set yearly goals related to school function.

While goals often encompass the reduction of impairment to prevent functional limitations, reductions of primary impairment can help to prevent secondary impairment as well. For example, a goal focused on reduction of spasticity through proper positioning can help to prevent or diminish the occurrence of muscle shortening and joint contractures.

Intervention

Intervention involves the interaction between therapist and patient. It also includes communication with the family and other professionals as needed, including physicians, nurses, psychologists, occupational therapists, speech and language pathologists, physical therapist assistants, and social workers. In the educational setting, interactions also take place with classroom and physical education teachers, along with paraprofessionals.

Intervention encompasses the coordination and documentation of care, specific treatment procedures, and patient/family education. Physical therapists also must be skilled in recognizing the need to refer a patient back to a physician or recommend the services of other professionals as necessary. The physical therapist usually plays a key role in making recommendations or sometimes participating in the fabrication and fitting of orthoses, walking aids, and wheelchairs. In addition, the physical therapist is instrumental in choosing appropriate adaptive equipment, such as seating devices or standing frames, for the classroom or home.

Specific treatment procedures are numerous, falling into several categories: functional training for activities of daily living; therapeutic exercise ; manual techniques such as mobilization and stretching; and therapeutic modalities. In 2001, evidence-based practice would require the use of recent motor control, motor development and motor learning theories as an umbrella over these treatment procedures. Motor control, development, and learning theories focus on the idea that several factors contribute to emergence of motor behavior. These factors include not only the central nervous system (CNS) as the driving force, but also biomechanical, psychological, social, and environmental components. Teaching and practice of skills under these theories is task-oriented and intermittent versus rote and repetitive. Higher-level learning takes place through problem-solving by the child rather than by the therapist's hands-on facilitation. Emphasis has also been placed on the importance of family-centered care, transdisciplinary service, and treatment in natural environments.

Treatment sessions may take place as frequently as once or twice a day in a rehabilitation setting, to once or twice a month in a school setting. Sessions may last 20 minutes to a full hour. Consultation with other professionals also takes place frequently during a patient's length of stay or a student's education.

Re-examination

A physical therapist is continually assessing a child's abilities and adjusting treatment appropriately. Some or all of the same tests and measures used during initial examination may be again used in order to evaluate progress and determine the need to modify, redirect or discontinue treatment.

Aftercare

Aftercare depends upon the setting in which the child has been treated. After a stay in a hospital, a child may be discharged with the recommendation to continue outpatient or school-based physical therapy. Upon discharge in any case, a physical therapist should provide recommendations for exercises or adaptations, if any, which should be continued at school or at home. In addition, a therapist may make suggestions regarding participation in programs such as adaptive sports leagues, therapeutic horseback riding, camps, etc.

Results

Although pediatric physical therapy addresses problems related to a wide variety of pathologies, the common goal usually is that functional activity increases and that disability decreases. In the case of non-progressive disorders, long-term retention of learned skills and the

KEY TERMS

Motor control —The control of movement and posture.

Motor learning —A set of processes related to practice or experience that results in relatively permanent changes in the ability to produce a skilled action.

Motor planning —The ability to execute skilled nonhabitual tasks.

Neuromuscular re-education —The training of an individual to recover or develop effective sensory and motor strategies for task demands.

ability to transfer skills to different environments and situations are results of effective physical therapy intervention. In the case of progressive disorders such as muscular dystrophy, maintenance of capabilities and/or slowing of functional losses may be the goal.

Health care team roles

The physical therapist and the physical therapist assistant, under the supervision of the physical therapist, are the direct providers of pediatric physical therapy. There are, however, many other key players. Although many states allow direct access to physical therapy, many require a referral from a physician. The physician usually provides the therapist with a prescription for physical therapy that outlines the medical diagnosis, and sometimes, precautions and recommendations. The child's physician and nurses also may provide valuable information regarding past medical history, surgical procedures, and medications.

Occupational therapists, speech and language pathologists, social workers, and psychologists also play important roles in the transdiciplinary provision of services. Physical therapists may work closely with these professionals to combine efforts toward fulfilling a child's maximum potential.

To summarize the various roles of a therapist in pediatric physical therapy, it is necessary to recognize that in addition to the description outlined above, he or she is responsible for consultation, education, critical inquiry, administration, and supervision.

Consultation

There are many facets to the role of consultation. Physical therapists may be called upon to assist other health care professionals in determining whether or not physical therapy services are required for a specific patient, and which types of service are required. In addition, physical therapists may be asked to perform activities such as: assessing an environment or program for accessibility; providing opinions or recommendations on adaptations in the classroom, home or recreational arena; and making recommendations for compliance with the Individuals with Disabilities Education Act or the Americans with Disabilities Act .

Education

Physical therapists are responsible for educating patients and families, as discussed earlier. This education may include: general information about a disease and course of physical therapy treatment; teaching of home exercises and adaptations; instruction on prevention of secondary impairments; and suggestions for long-term wellness. In addition, pediatric physical therapists may be asked to provide information about disabilities to teachers or students in a school, or provide in-services to physical education teachers about adaptive sports. Pediatric physical therapists also are responsible for furthering their own education, mentoring future physical therapists and PT assistants, and increasing public awareness of areas in which physical therapists have expertise. The American Physical Therapy Association (APTA) offers a program for specialized certification, which is governed by the American Board of Physical Therapy Specialties (ABPTS) to facilitate the continuing education of physical therapists.

Critical inquiry

Pediatric physical therapists have a responsibility to the profession to critically examine research findings and apply them when appropriate to their daily practice. In addition, physical therapists should look for ways to conduct and/or participate in research to evaluate the effectiveness of interventions and philosophies used in the profession.

Administration and supervision

The pediatric physical therapist must be concerned with administrative activities related to human resources, equipment, finances, and facilities. Supervision of physical therapist assistants, student physical therapists and assistants, and physical therapy aides is often a responsibility. This responsibility may include monitoring quality of care and productivity as well. The physical therapist is directly responsible for the actions of these individuals and therefore should adhere to American Physical Therapy Association guidelines stipulating the levels of supervision required.

Resources

BOOKS

American Physical Therapy Association. Guide to Physical Therapist Practice, 2nd ed. Alexandria, VA: American Physical Therapy Association, 2001.

Campbell, Suzann K., Darl W. Vander Linden, and Robert J. Palisano. Physical Therapy for Children, 2nd ed. Philadelphia: W. B. Saunders Company, 2000.

PERIODICALS

Hayes, Margo Starks, et. al. "Next Step: A Survey of Pediatric Physical Therapists' Educational Needs and Perceptions of Motor Control, Motor Development, and Motor Learning as They Relate to Services for Children with Developmental Disabilities." Pediatric Physical Therapy 11, no. 4 (Winter 1999): 64-182.

King, G. A., et. al. "An Evaluation of Functional, School-Based Therapy Service sfor Children with Special Needs." Physical and Occupational Therapy in Pediatrics 19, no. 2 (1999): 31-52.

ORGANIZATIONS

American Physical Therapy Association, Section on Pediatrics. 1111 North Fairfax Street, Alexandria, VA 22314-1488. (703) 684-2782. <http://www.apta.org>.

Peggy Campbell Torpey, MPT