Treatment of the Child with Severe Impairments Jacqueline - - PowerPoint PPT Presentation

Treatment of the Child with Severe Impairments

Jacqueline Grimenstein, PT, C/NDT, CKTP jgrimenstein@gmail.com

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Introduction

• What defines a child with severe impairments
• Treating children with severe impairments

presents a unique challenge to set goals that are both realistic and optimistic

• Our role is to assist the child to function

within the family and community and assist the family to nurture and care for their child

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Use of Classification Systems

• Gross Motor Function Classification System
• Manual Abilities Classification System
• Communication Function Classification System
• Eating and Drinking Ability Classification

System Levels IV and V of each system encompasses involvement

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Gross Motor Classification System for Cerebral Palsy

Level IV: self‐mobility with limitations; children are transported or use power mobility for outdoors

i.e. age 2‐4: children floor sit when placed, but cannot balance or use hands for support; frequently require adaptive seating and aids for standing; may roll, creep on belly

Level V: self mobility is severely limited even with assistive technology i.e. age 2‐12: restricted voluntary control to maintain antigravity head and trunk postures; no means of independent mobility, except maybe with a power wheelchair

Palisano, et al. McMaster University, Hamilton, Ontario Dev Med Child Neurology, 39.214‐223, 1997; www.canchild.ca

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GMFCS

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The Manual Classification System

• Level IV: handles a limited selection of easily

managed objects in adapted situations; limited success with assistance of adaptive equipment

• Level V: does not handle objects and has

severely limited ability to perform even simple actions; needs total assistance

Eliasson AC, et al. Dev Med and Child Neurology; 2006; 48: 549‐554. www.macs.nu

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Level V: Does not handle

• bjects and severely

limited ability to perform even simple

• actions. Requires total

assistance.

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Supplementary MACS Level Identification Chart To be used together with the MACS leaflet

Does the child handle most kinds of objects independently? Does the child perform even difficult manual tasks with fair speed and accuracy and does not need to use alternative ways

• f performance?

Level I: Handles objects easily and

• successfully. At

most limitations in the case of performing manual tasks requiring speed and accuracy. Level II: Handles most objects but with somewhat reduced quality and/or speed of

• achievement. May

avoid some tasks or use alternative ways

• f performance.

Does the child performs a number of manual tasks which commonly need to be adapted or prepared, and help only needed occasionally? Level III: Handles objects with difficulty, needs help to prepare and/or modify activities Does the child handle some easy to handle objects if frequently supported? Level IV: Handles a limited selection of easily mange objects in adapted situations, requires continuous support.

Yes Yes Yes Yes No No No No

Field Trial Version, www.macs.nu

The Communication Function Classification System

• Level IV: Inconsistently sends and/or receives

(communication) even with familiar partners

• Level V: Seldom effectively sends or receives

(communication) even with familiar partners

Hidecker et al. Dev Med and Child Neurology. 2011, 53: 704‐710 www.cfcs.us

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The Eating and Drinking Ability Classification System

• Level IV: Eats and drinks with significant

limitations to safety

• Level V: Unable to eat and drink safely – tube

feeding may be considered to provide nutrition

Seller, et al. Dev Med and Child Neurology, 2014; 56: 245‐251 www.sussexcommunity.nhs.uk

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Eating & Drinking Ability Classification System – Algorithm

Is the individual able to swallow food and drink without risk of aspiration?

Yes

Is the individual able to bite and chew on hard lumps of food without a risk of choking?

Yes

Is the individual able to eat a meal in the same time as peers?

Yes

Level I Eats and drinks safely and efficiently

No

Level II Eats and drinks but with some limitations to efficiency

No

Can risks of aspiration be managed to eliminate hard to the individual?

No

Level III Eats and drinks with some limitations to safety; there maybe limitations to efficiency

Yes

Level IV Eats and drinks with significant limitations to safety

No

Level V Unable to eat

• r drink

safely – tube feeding may be considered to provide nutrition www.sussexcommunity.nhs.uk

Purpose of These Classification Systems

• Provide general level of functioning for all who

are involved in the care of a child with neurologic impairments or similar disabilities.

• Do not and cannot address participation
• Are measures of usual performance (not best

performance) on a daily basis

• Information gathered help guide intervention,

planning, goal setting and prognosis for function

• For research purposes – group children for

description and stratification

• May be used to assist administrators and payers

allocate resources

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The Evaluation Process

• ICF Model – Looking at the whole picture
• Evaluating by system
• The role of standardized testing

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The NDT/Bobath (Neuro‐Developmental Treatment/Bobath) Approach

NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. The therapist uses the International Classification of Functioning, Disability, and Health (ICF) model in a problem solving approach to assess activity and participation, thereby to identify and prioritize relevant integrities and impairments as a basis for establishing achievable outcomes with clients and caregivers. An in‐depth knowledge of the human movement system, including the understanding of typical and atypical development, and expertise in analyzing postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activating optimal sensorimotor processing, task performance, and skill acquisition to enable participation in meaningful activities. 14

Individual Functional domain Social Domain Body structure and function Contextual Factors

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International Classification of Function

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ICF Domains

• Pathophysiology
• + contextual factors
• Participation
• Functional Activities
• Family Goals
• ‐ contextual factors
• Participation Restrictions
• Functional Limitations

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Pathophysiology

• Underlying medical condition or injury that

interrupts or interferes with normal physiological and developmental processes in any dimension of the individual.

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Family Functional Goals

• What outcome will benefit the family as a

whole and the child specifically

• Ask family what functional activity will help

them in the care of their child or what task would they like the child to do better

• Ask child, if appropriate, what he/she would

like to change or do that he/she cannot due currently

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Contextual Factors

• Extraneous factors surrounding the child and

family that may influence the outcome of the treatment program either positive or negative

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Participation

• What age appropriate activities within the

family or community can the child take part in

• r is excluded from due to his/her limitations

and how much assistance or support does he/she need to be a functional member of society

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Functional Activities/Limitations

• In this section look at what the child can or

cannot do.

• Examples of positive activities may include:

can walk, can talk, can eat, etc.

• Limitations can include: cannot transition,

cannot feed self, cannot dress self, needs assistance with transitions

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Neuroplasticity:

Research by Jeffrey Kleim:

• Only relevant tasks will induce placticity
• In an intact neuro system it takes around 2000

repetitions to make changes the motor map

• Motor map represents skill efficiency
• Need 500 repetitions to learn a skill and 5000

to unlearn

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Lab – Looking at Early Development

• How does a typical baby develop head and

trunk control

• Video of typical development

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Video Treatment of the Respiratory System

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Lab: Focus on the Core

• Insufficient anti‐gravity trunk control/poor head

control

• Can the child activate and sustain muscle activity
• What affects do you see on the respiratory

system

• Treatment strategies for treating the respiratory

system

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OGANIZATION OF MOTOR BEHAVIOR

Systems Approach

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Interaction of the Individual, the Environment and the Task

• Want the child to perform at his absolute best

within his disability

• Subsystems are plastic and adaptive to both

internal and external changes

• The environment includes everyone the child

comes in contact with on a regular basis

• Initially focus on completion vs quality of

component movements

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How does this fit with the child with severe impairments

• Since children in the level IV and V

classifications do not fit the norm of our evaluation process how do we go about looking at the systems

• Primarily want to look at how the various

systems are equipped to support basic life functions; breathing, state regulation, heart rate, sensory system, awake/asleep cycles and feeding and digestion

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System Integrity/Impairments

• Neuromuscular

– Recruitment of postural muscles

• Can the child initiate muscle activity – What groups, in what

positions; through gravity or against gravity

• Do they over recruit to initiate movement

– Selective control of muscles – can they use any isolated movement patterns for function or what muscle groups are used together – What happens when the child attempts a movement pattern

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• Describe variety of movement synergies in

various postures – can the child only perform a task in a certain position

• Describe issues of postural alignment including

center of mass and base of support and how the two interact – what does their overall alignment look like in various postures

• Describe tone and levels of stiffness

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Posture and Movement

• Define issues with the posture and movement

system that provide barriers to achieving functional, quality movement

• Look at postural strategies to achieve movement
• Levels of stiffness
• Movement is organized around function

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• Sensory System

– Vision: Does the child have functional vision? What tells you how they are using any vision – Hearing: Is hearing intact? Does the child respond to voice or other stimuli? – Which sense does the child use most efficiently and reliably to give and receive information – Does the child respond best when information is presented to one system or paired with 2 systems (sound and light; deep pressure with rhythmic movement

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– Modulation of awareness state level of excitement and how it affects muscle control – How does the child respond to touch

• Change is respiratory rate
• Increase tone, smiling, vocalization

– What’s happening with the vestibular system

• Does the child tolerate movement through space
• What is the response to rocking – does the child prefer
• ne direction over the other

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• Musculoskeletal system

– Range of motion – Planes of movement ‐ can child move in more than one plane – Can the child move against gravity, which body parts and for how long – Oral motor control ‐ how does the child handle saliva, any jaw clenching, controlled tongue movements

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• Respiratory

– Can the child breathe on their own or require mechanical ventilation

• Requires tracheostomy
• Full time; during sleep, during activities
• Require O2

– Rib cage mobility – Breath/swallow coordination – Depth of respirations – Controlled exhalation during talking or vocalizations

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• Skin

– Color and temperature with prolonged positioning – Scarring

• Where are scars located?
• If on trunk do they impede movement of the trunk

during respiration

– Tightness in skin

• Does it interfere with movement or ADL’s

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• Cardio‐vascular

– Heart rate – what happens in new positions or trying new pieces of equipment – Signs of stress with unfamiliar handlers – increased heart rate, respiratory rate or drop in O2 SAT’s – Thermo‐regulation –

• stability in temperature and color in head, trunk and

limbs in different positions or in various pieces of equipment

• color changes in extremities
• Profuse sweating or always cold

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• Regulatory/Arousal

– Other signs of stress: skin flushing, pupil dilation

• r constriction, sweating, vomiting

– Does the child take any medication that can affect alert or sleep states – What is the child’s awake/asleep patterns, does the child shut down with stimulation – Arousal state in newborns according to Brazelton

• Deep sleep

Active sleep

• Quiet alert

Active alert

• Active crying

Drowsiness

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Cognition

• Children with severe impairments can have a

cognitive levels ranging from gifted to profoundly impaired

• Has the child had formalized cognitive testing
• If tested what accommodations were used if

any

• It’s not always about IQ
• How does the child let you know he/she is “in

there”; what stimuli do they respond to

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Hierarchy of Cognitive Skills

Gellert and Pulaski (2014)

• Arousal – focused alertness
• Attention – brief active on relevant and meaningful

stimuli selective alternating/divided attention

• Memory – storing and retrieving (declarative and

procedural)

• Reasoning – comparing/contrasting scenarios in

thoughts

• Problem solving – identifying and solving
• Executive functions – initiation, planning, organization,

time management, self regulation, self monitoring, and error correction

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Digestion

• Digestion/Elimination

– Bowel and bladder patterns – Any reflux or issues with gas and cramping – How is the child fed and how often – How long does it take to feed the child or assist with feeding – Who is able to feed the child – If tube fed any issues with gastric emptying – Height and weight

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• Hormones

– Has the child reached puberty – For females any issues with menstrual cycle – Issues with masturbation – Changes in personality

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Role of Standardized Testing

• Usually required in documentation
• Norm referenced testing: e.g. Bayley, Peabody,

Alberta Infant Motor Scale

– Only measure if the child falls within the range of normal – Diagnostic use only – For this population you will not be able to document change in function

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• Criterion referenced testing: Somewhat better

as can measure levels on the ICF, but still often not sensitive enough to measure change in this population

– TIMP – Test of Infant Motor Performance (34 weeks‐4 months): sensitive to at risk babies and to intervention changes – COPM – Canadian Occupational Performance Measure ‐ shows some sensitivity to children with disabilities

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– The Assessment for Persons Profoundly or Severely Impaired – an assessment tool for people

• f any age who are preverbal and whose mental

age would fall below the 8 month level in typically developing children. It determines client preferences for visual, auditory and tactile stimuli for social interaction and methods of communication

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– The Adapted Sequenced Inventory of Communication Development – assesses the communication skills in adolescents and adults who have little or no speech or are understood by

• nly a few people. Receptive and expressive skills

are measured separately – The Test of Early Communication and Emerging Language – (the 2011 revision of the Nonspeech Test): designed for both assessment and intervention planning

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Other Possible Tests

• GMFM – Gross Motor Function Measure – a

measure of gross motor activity designed to measure change in children with CP ages 5 months to 16 years who function below the skills of a typically developing child of 5 years

• f age. Free software from CanChild

(canchild.org) is available for scoring

– 2 versions – 88 scoring items or shorter version 66

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GMFM

• GMFM 88

– provides more descriptive information about motor function for very young children or children with more complex motor disability such as those functioning in GMFCS level V as it has more items that describe early motor skills.

• GMFM 66

– Takes less time to administer – Items are listed in order of difficulty

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• HRQoL – Health Quality of Life surveys are

usually filled out by families and can assist the clinician in measuring how health status relates to perceived quality of life. This information may help the clinician understand the burden of care and direct goal setting. These HRQol surveys usually measure participation domain of the ICF

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• SATCo – Segmental Assessment of Trunk Control

– allows the clinician to determine the segment

• f the trunk that had and does not have control

in order to be more specific with intervention. The child’s level is assessed statically, actively with anticipatory control and reactively. Research shows that SATCo scores and age predict GMFM scores (Curtis et al, 2015) and correlate well with GMFCS Levels IV and V descriptions (Saavedra and Wollacott, 2015) The SATCo measures the body structures and functions domain of the ICF

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SATCo

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Goal Setting

• Difficult to set standard goals within realistic

time frames

• Primary goal is to determine what is most

important to the child and family in assisting with functional activities and ADL’s

• May want to use Goal Attainment Scaling to

set goals and make them achievable

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Goal Attainment Scale (GAS)

• Goals from GAS can be statistically analyzed

(McDougall and King 2007)

• Scale is set up on a 5 point scale with ‐2 being

current level and 0 being expected outcome

+2

+1 ‐1 ‐2

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Goal Attainment Scale (GAS)

• Goals from GAS can be statistically analyzed

(McDougall and King 2007)

• Scale is set up on a 5 point scale with ‐2 being

current level and 0 being expected outcome

+2 Will be able to bear weight on both legs to assist with a stand pivot transfer +1 Will hold onto caregiver and lean forward to initiate weight shift during transfer 0 Will reach out with both arms to caregiver to assist with transfer ‐1 Will initiate upright posture at beginning of transfer from wc ‐2 Requires maximum assistance to transfer from wheelchair

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Examples of Goals/Outcomes in School

• Child will eat a lunch consisting of pureed food at

school each day within a 30 minute time period in the lunchroom with any one of the school aides feeding him.

• Child will respond to her/his name being called in

the classroom with the teacher standing within 5 feet of the wheelchair by opening eyes

• Child will sit in his/her wheelchair positioned in

its most upright position to attend to a visual computer learning activity for 15 minutes

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Sample Goals Continued

• Child will consistently move his/her arm upon

request in a random pattern to make a mark

• n a paper using an adapted marker during art

time in the classroom

• Child will consistently say two one syllable

word approximations to indicate he wants to turn on his laptop

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Frequency and Duration of Treatment

• Look at areas of ICF to determine which area

will have the most impact from treatment

• Determine treatment model

– Intensive: 3‐11 x per week – Weekly/bimonthly: 1‐2 x per week to every other week – Periodic: Regularly scheduled intervals – Consultative/monitoring: Parent or therapist request

• Identify amount of time needed to achieve set

goals based on frequency

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Treatment Strategies

• Alignment – what boney limitations or

contractures interfere

• Treatment strategies for increasing range of

motion and strength

• Focus on weight bearing, transfers and

transitions

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Lab Increasing Range of Motion

• Myofascial work
• Use of rotation and shaking
• Elongation versus stretching

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Home Programs

• What can the child do on their own?
• What is the role of the family
• What is a realistic home program for this

population

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