PHTH-560 Integrated Ortho management Lab 1 Infant evaluation Torticollis/Plagiocephaly

Isabelle Gagnon PT, PhD

Assistant Professor School of P/OT, McGill University Physiotherapist - researcher Trauma Programs and Child Development Program Montreal Children s Hospital of MUHC Isabelle.gagnon8@mcgill.ca

Stephanie Arpin PT MCH Jennifer Sailofsky PT JRH Krithika Sambasivan MSc (cand)
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Where are we?

Plan: Lect. Ortho Growth and development Torticollis/Plagiocephaly Infant case
History taking/communication Evaluation of the newborn/infant Torticollis/Plagiocephaly

Neuro

CRW Lab.

4 groups = 2 coachhouse downstairs, 1 coachhouse upstairs, 1 Hosmer House Webcam system

CRW

Back pain

Lab

Evaluation of the child

Lab

Back conditions

Lect

Neurological conditions

Lab outline: what will we do today?

Specific skills to be addressed: History taking for infants General Examination/evaluation of newborns and infants Particular techniques for torticollis and plagiocephaly assessment Techniques for the treatment of torticollis/plagiocephaly Readings (material for exam) Chapter 9 Campbell Supplemental readings (to complement your understanding of the material): Amiel Tisson Article (web link) Reference values neck range of motion (weblink)

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The Evaluation of infants

Our case for today 3 month old baby girl, coming for a physiotherapy assessment regarding a possible motor delay

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Preparation: Students in pairs

What do you know? Age What should you expect in terms of global development? Reason for referral: delayed motor development How would that show? What do you need to do? Structure your assessment How different from adult assessment?

PREPARATION 15 minutes in pairs Lab manual

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Communication skills with children

Communication skills
Dealing with parents/not patient directly In ortho/neuro/cardioresp; not rare that diagnosis has not been made yet, work with uncertainty Communicate with infant/child to elicit collaboration Introduce yourself as a physiotherapist working with the pediatric population (what do you do?)

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The Evaluation of infants

Documents needed:

Evaluation form for infants (WebCT)

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Evaluation of infants: framework

ICF Model (WHO, 2001)

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Subjective Evaluation: The interview

SUBJECTIVE EVALUATION : REASON FOR CONSULTATION: PARENT EXPECTATIONS: HISTORY: Prenatal: mother and child High blood pressure, diabetes, other complications Perinatal: mother and child Gestational age, labor (spontaneous/induced, duration), delivery (position of the baby), birth weight, APGAR, postnatal evolution Development to date: Head control, smiles, time spent in prone, other positions depending on age, feeding history and patterns Other information: General health status, pertinent developmental or medical history of siblings, history of any illnesses
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Subjective Evaluation: The interview

SUBJECTIVE EVALUATION : REASON FOR CONSULTATION: PARENT EXPECTATIONS: HISTORY: Prenatal: mother and child High blood pressure, diabetes, other complications Sample questions Perinatal: mother and child Gestational age, labor (spontaneous/induced, duration), delivery (position of the What brings evolution baby), birth weight, APGAR, postnatal you to this visit?

What do you hope to gain Development to date:from this visit? Head control, smiles, time spent in prone, other positions depending on age, feeding What would help? history and patterns
Other information: General health status, pertinent developmental or medical history of siblings, history of any illnesses
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Common orthopedic reasons for consultation with an infant (details will be discussed later)
Torticollis Will be seen in detail later Clubfoot Talipes equivarus, 3 dimensional deformation of foot forefoot adducted, calcaneus is small, hindfoot in varus, equinus of ankle

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Common orthopedic reasons for consultation with an infant

Metatarsus Adductus Forefoot curved medially, hindfoot normal slight valgus position, full ROM in DF

Calcaneovalgus Forefoot curved laterally, hindfoot in valgus, full or excessive DF

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Common orthopedic reasons for consultation with an infant

Developmental Dysplasia of the Hip dislocation of the hip joint that is present at birth

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Subjective Evaluation: The interview

SUBJECTIVE EVALUATION : REASON FOR CONSULTATION: PARENT EXPECTATIONS: HISTORY: Prenatal: mother and child High blood pressure, diabetes, other complications Perinatal: mother and child Gestational age, labor (spontaneous/induced, duration), delivery (position of the baby), birth weight, APGAR, postnatal evolution Development to date: Head control, smiles, time spent in prone, other positions depending on age, feeding history and patterns Other information: General health status, pertinent developmental or medical history of siblings, history of any illnesses
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APGAR
Sign A 0 1 2

Activity (Muscle Tone)

Absent Absent No Response

Arms and Legs Flexed Below 100 bpm Grimace

Active Movement Above 100 bpm

P Pulse

Grimace (Reflex Irritability) Appearance (Skin A Color)

G R Respiration

Sneeze, cough, pulls away Blue-gray, pale Normal, except for Normal over all over extremities entire body Absent Slow, irregular Good, crying

Scores 7 are considered within normal limits

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Subjective Evaluation: The interview

SUBJECTIVE EVALUATION : REASON FOR CONSULTATION: PARENT EXPECTATIONS: HISTORY: Prenatal: mother and child High blood pressure, diabetes, other complications Perinatal: mother and child Gestational age, labor (spontaneous/induced, duration), delivery (position of the baby), birth weight, APGAR, postnatal evolution Development to date: Head control, smiles, time spent in prone, other positions depending on age, feeding history and patterns Other information: General health status, pertinent developmental or medical history of siblings, history of any illnesses
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Subjective Evaluation: The interview

Investigations (completed, still to come): Neurodiagnostic tests, consultations with other professionals (including alternative medicine) PERSONAL FACTORS General behavior/motivation: Infant temperament, sleep routines ENVIRONMENTAL FACTORS Child-caregiver interactions: Social situation: Living arrangements, siblings, daycare, activities Services to date: Current medical follow-up (pediatrician); consultation to other healthcare practitioners (including alternative medicine) for this problem or others

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Subjective Evaluation: The interview

SUBJECTIVE EVALUATION (continued): Investigations (completed, still to come): Neurodiagnostic tests, consultations with other professionals (including alternative medicine) PERSONAL FACTORS General behavior/motivation: Infant temperament, sleep routines ENVIRONMENTAL FACTORS Child-caregiver interactions: Social situation: Living arrangements, siblings, daycare, activities Services to date: Current medical follow-up (pediatrician); consultation to other healthcare practitioners (including alternative medicine) for this problem or others
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Evaluation of infants
ICF Model

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Evaluation of infants
ON EXAMINATION: GENERAL OBSERVATIONS: Behavior, state regulation Spontaneous play/activity Interaction with environment, parents POSTURE: Age appropriate Size and shape of head, face, skull; asymmetries

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Engaging infants
Baby s vigilance state quiet sleep active sleep drowsiness quiet alert active alert crying Sensory issues pain medication Developmental level

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Evaluation of infants
ON EXAMINATION: GENERAL OBSERVATIONS: Behavior, state regulation Spontaneous play/activity Interaction with environment, parents POSTURE: Age appropriate Size and shape of head, face, skull; asymmetries

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Evaluation of infants
EVALUATION OF BODY FUNCTIONS AND STRUCTURES VISUAL RESPONSES: Visual focus Visual tracking to and past midline, symmetry of eye movements Spontaneous abnormal eye movements (nystagmus) AUDITORY RESPONSES Awakens or startles to loud noises Localization (eyes to sound, head to sound) SENSATION: As appropriate

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Evaluation of infants
EVALUATION OF BODY FUNCTIONS AND STRUCTURES VISUAL RESPONSES: Visual focus Visual tracking to and past midline, symmetry of eye movements Spontaneous abnormal eye movements (nystagmus) AUDITORY RESPONSES Awakens or startles to loud noises Localization (eyes to sound, head to sound) SENSATION: As appropriate

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Evaluation of infants
TONE: Rest/Activity Axial: UE: LE: Very related to age, use of Neuro evaluation Amiel Tison or INFANIB for example may help in decisions; MAI items would be another way) Associated reactions RANGE OF MOTION/FLEXIBILITY: Head/neck: UE: LE: Trunk:
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Amiel Tisson Evaluation

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Movement assessment of infants: tone items

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Movement assessment of infants: tone items

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Movement assessment of infants: tone items

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Movement assessment of infants: tone items

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Movement assessment of infants: tone items

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Movement assessment of infants: tone items

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Evaluation of infants
TONE: Rest/Activity Axial: UE: LE: Associated reactions RANGE OF MOTION/FLEXIBILITY: (see reference values article for neck ROM) Head/neck: UE: LE: Trunk:

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Evaluation of infants
REFLEXES: Primitive: DTR: STRENGTH: Head/neck: UE: LE: Trunk: POSTURAL REACTIONS Righting Equilibrium Protection
In all appropriate positions (suspension, sitting, kneeling, standing )
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Review and demonstrate if necessary

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Evaluation of infants
REFLEXES: Primitive: DTR: STRENGTH: Stroking over muscle belly, manual muscle testing (difficult), functional performance Head/neck: UE: LE: Trunk: POSTURAL REACTIONS Righting Equilibrium Protection
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Muscle testing for infants: Functional

Functional measurements usually Many systems proposed, none empirically validated Based on observation of movement and transitions
Description Functional (F) Weak functional (WF) Grade Normal for age of only slight impairment or delay Moderate impairment or delay that affects activity pattern, base of support, or control against gravity, or decreases functional exploration Severe impairment or delay, activity pattern has only elements of correct muscular activity Cannot do activity

Nonfunctional (NF)

No function (0)

Turman & Van Vranken, 2002; In Daniels and Worthingham s Muscle Testing
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Muscle testing for infants

Functional measurements usually Many systems proposed, none empirically validated Based on observation of movement and transitions
Description Functional (F) Weak functional (WF) Grade Normal for age of only slight impairment or delay Moderate impairment or delay that affects activity pattern, base of support, or control against gravity, or decreases functional exploration Severe impairment or delay, activity pattern has only elements of correct muscular activity Cannot do activity

Nonfunctional (NF)

No function (0)

Turman & Van Vranken, 2002; In Daniels and Worthingham s Muscle Testing
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Evaluation of infants
REFLEXES: Primitive: DTR: STRENGTH: Head/neck: UE: LE: Trunk: POSTURAL REACTIONS (age appropriate as per reflexes sheet) Righting Equilibrium Protection COORDINATION:
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Movement assessment of infants: postural reaction items

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Evaluation of infants
REFLEXES: Primitive: DTR: STRENGTH (muscle power/endurance): Head/neck: UE: LE: Trunk: POSTURAL REACTIONS Righting Equilibrium Protection COORDINATION:
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Evaluation of infants
ICF Model

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Evaluation of infants
EVALUATION OF ACTIVITIES AND PARTICIPATION COMMUNICATION: BALANCE: Sitting : Standing:

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Evaluation of infants
GROSS MOTOR FUNCTION: Description in all positions and transitions for appropriate age group Position, function in position, transition in and out of position

STANDARDIZED TESTS for infants (examples) Alberta Infant Motor Scale (AIMS) EVIDENCE BASED SUMMARY

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Alberta Infant Motor Scale

(Piper, Darragh)

Purpose: Identify babies presenting with a motor delay and evaluate motor development over time ICF component targeted: Activities Characteristics: 58 items based on performance in 4 basic positions (supine, prone, sitting, standing) scored on a 0-1 scale, using specific descriptions for each item developed based on neuro-maturational theory but also on systems theory Age range: 0-18 months (or acquisition of independent walking) Norm-referenced Reliability Inter-rater: 0.86-0.98 Test-retest: 0.86-0.99 Validity content: 1 dimension concurrent: other tests-good predictive: 10th percentile at 4 months 5th percentile at 8Isabelle Gagnon PhD months

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Analysis: Identify problems

Impairments
List and prioritize the impairments you identified

Activity limitations/Participation restrictions

List and prioritize the AL/PR you identified

Environmental factors
List and prioritize the EF you identified

Personal Factors
List, if any, PF identified http://apps.who.int/classifications/icfbrowser/

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Analysis: Diagnosis
Summary
Summarize your findings and interpretation. State your physiotherapy diagnosis.

Goals
Determine your intervention goals for this patient and his family. This should be done with the family. Determining intervention objectives is part of the evaluation process. Goals must be functional, realistic and meet needs of the child and of his family. Your goal will be used as an outcome measure to determine the effectiveness of your intervention. It is expressed with the help of an Action verb. It must me Measurable (ex. Jimmy will crawl in 4pt over a 10cm obstacle; or Mary will maintain sitting for 20 minutes in her high chair).

Adequate goals: 1) need to be set with patient and family 2) should be relevant to the person (s) concerned 3) should be challenging but realistic and achievable 4) should be measurable (in order to measure or determine success) SMART goals Specific; Measurable; Achievable; Relevant; Timed

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Treatment Plan
Plan
What is your plan with this child

Therapy plan Home program

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Home programs for families

Points to review Essential component of the intervention Little hands-on interventions in Qubec Detailed, illustrations Teaching children vs adults Explain Demonstrate Practice Write it down! Take context into consideration

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Congenital Torticollis

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Specifics of assessment
History and Subjective Assessment: Pregnancy, delivery, neonatal course Associated conditions Family history Other: Feeding position preference, gaze preference, time spent in various positions, sleeping position, carrying positions, treatments to date, what have they looked up, when did they notice the problem, orthosis Observation: Head/Neck resting posture Trunk posture Extremities position, spontaneous movements Cranio-facial morphology
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Specifics of assessment
History and Subjective Assessment: Pregnancy, delivery, neonatal course Associated conditions Family history Other: Feeding position preference, gaze preference, time spent in various positions, sleeping position, carrying positions, treatments to date, what have they looked up, when did they notice the problem, orthosis Observation: Head/Neck resting posture Trunk posture Extremities position, spontaneous movements Cranio-facial morphology
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normal

plagiocephaly

brachycephaly

scaphocephaly

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Specifics of assessment

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Anthropometric measurements

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Plagiocephalometry

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Specifics of assessment
Body function/structures: Neck ROM (active/passive) Neck Strength UE/LE ROM and Strength Tone Reflexes Activities/Participation: Gross Motor Development

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From Ohman and Beckung, 2008

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Specifics of assessment
Body function/structures: Neck ROM (active/passive) Neck Strength UE/LE ROM and Strength Tone Reflexes Activities/Participation: Gross Motor Development

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(Ohman, 2008)
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Specifics of Treatment
Stretching-Strengthening-Positioning
Controversy over modalities So need to revert to theoretical models of intervention to determine best approach

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Specifics of Treatment
Stretching-Strengthening-Positioning
Controversy over modalities So need to revert to theoretical models of intervention to determine best approach

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Specifics of Treatment
The MCH exercise booklet or sheet

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