PEDIATRIC REHABILITATION

Prof.Dr. Şafak Sahir Karamehmetoğlu Prof.Dr. Şafak Sahir Karamehmetoğlu İstanbul University Cerrahpaşa Medical Facultyİstanbul University Cerrahpaşa Medical Faculty

Physical Medicine and Rehabilitation DepartmentPhysical Medicine and Rehabilitation Department

HISTORY (1)Prenatal: 1. Age of the mother

2. Previous diseases

3. Coincident diseases

4. Habits

5. Unusual weight gain or loss

HISTORY (2)

Prenatal:

6. Drugs

7. Radiation

8. Trauma

9. Rh factor discrepancy

10.Genetic disease

HISTORY (3)Perinatal:

1. Delivery duration

2. Prematurity

3. Anesthesia

4. Drugs (induction)

5. Trauma

ÖYKÜ (4)Perinatal:

6. Low birth weight

7. Low Apgar scores

8. Incubator

9. Intensive care

10.Sucking reflex

HISTORY (4)

ÖYKÜ (5)Postnatal:

1. Trauma

2. Infection

3. Metabolic diseases

4. Vascular anomaly

5. Oxygen deficiency

HISTORY (5)

School age:1. Previous diseases2. Coincident diseases3. Allergy4. Drugs5. Epileptic seizure

HISTORY (6)

HISTORY (7)School age:6. Surgical intervention7. Trauma 8. Blood pressure9. Pulse rate10.Nutrition

DEVELOPMENT - 1

1. Heihgt

2. Weight

3. Head circumference

4. Growing

5. Follow-up

Motor function Cognitive function

0-1

month

Flexor tonus predominates, when prone turns head to side, automatic reflex walking, rounded spine when held sitting, hands fisted, grasp reflex

Cry, head turning to voice, basic trust, mistrust, does not differantiate between self and mother

4

months

Head midline, when prone lifts head to 90° and chest slightly, turns to supine, hands mostly open, midline hand play

Recognizes bottle, laughs, responsive vocalization, lap baby, sense of basic trust

7

months

Maintains sitting, may lean on arms, rolls to prone, bears all weight, bounces when held erect, cervical lordosis, intermediate grasp, bangs objects

Differentiates between familiar person and stranger, holds bottle, looks for dropped object, talks to mirror image, uses single words

10

months

Creeps on all fours, pivots in sitting, stands momentarily, slight bow leg, increased lumbar lordosis, pincer grasp, mature thumb to index grasp, finger feeds, bangs two cubes

Shouts for attention, imitates speech, waves bye-bye, uses “mama” and “dada” with meaning, inhibits behavior to “no”, can retrieve an object hidden from view

DEVELOPMENT - 2

Motor function Cognitive function

14

months

Walks alone, arms in high or mid- guard, wide base, excessive knee and hip flexion, foot contact on entire sole, slight valgus of knees and feet, pelvic tilt and rotation, piles two cubes, holds crayon full lenght in palm,

Uses spoon with overpronation, removes a garment, understands simple commands, shame and doubt, pleasure in controlling muscles and sphincters

18 months

Arms at low guard, mature supporting base and heel strike, seats self in chair, walks backward, emerging hand dominance, holds crayon end in palm

Imitates housework, carries, hugs doll, drinks from cup neatly, points to named body parts, identifies one picture, says “no”, jargons

2 years Begins running, walk up and down stairs alone, jump on both feet in place, builds 8-cube tower,

Two word phrases, uses verbs, “me” “mine”, follow simple commands, comprehends symbols

3 years Walks upstairs alternating feet, uses overhand throw, catches with extended arms hugging against body, imitates three cube bridge

Most children toilet trained day and night, pours from pitcher, washes and dries hands and face, deals with issue of genital sexuality

DEVELOPMENT - 3

Motor function Cognitive function

4 years

Walks down stairs alternating feet, hops on one footplantar arches developing, sits up rom supine position without rotating, handles a pencil by finger and wrist action like adults

Cooperative play, dresses and undresses with supervision , gives connected account of recent experience, questions why, when, how, repeats four digits

5 years

Skips, tiptoes, balances 10 seconds on each foot, hand dominance expected, draws man with head body, and extremities, throws with diagonal arm and body rotation, catches with hands

Creative play, competitive team play, uses fork stabbing food, brushes teeth, self-sufficient in toileting, has number concepts to 10, adjust himself to the inorganic laws

6 years

Rides bicycles, roller skates, prints alphabet; letter reversals still acceptable, mature catch and throw of ball

Uses fork appropriately, knife for spreading, plays table games, shows mastery of grammar, uses proper articulation

7 years

Continuing refinement of skills Comb hair, grooming, capable of logical thinking

DEVELOPMENT - 4

GENEL DURUM

GENERAL HEALTH

•Fever

•Blood pressure

•Pulse rate

•Posture

•Discoloration

•Edema

PHYSICAL EXAMINATION-1

Inspection (most informative)

1. Reaction to separation from the parents

2. Apparent visual and auditory awareness

3. Temperament (calm/hyperactive, compliant/difficult)

4. Spontaneous exploration and interest in toys, games, or books in the room

PHYSICAL EXAMINATION-2Inspection (most informative)

5.Style, concentration, attention span, or distractibility during play

6.Level and manner of motor activities

7.Attempts to engages the parents and examiner in conversation, vocabulary, complexity of language, and quality of speech

8. Interaction with parents and examiner (appropriate, shy, demanding)

• Blue sclerae (osteogenesis imperfecta)

• Asymmetric face (facial palsy)

• Café-au-lait spots (neurofibromatozis)

• Scoliosis (idiopathic)

• Foot deformities (spina bifida)

PHYSICAL EXAMINATION-3

PHYSICAL EXAMINATION-4

Palpation:

• Fontanelles

• Skin (fever, sweating, coldness)

• Noduls (rheumatic diseases)

• Muscles (tonus, fibrosis, hypertrophy)

• Joints (swelling, redness, tenderness)

PHYSICAL EXAMINATION-5

Neurologic examinationReflexes (Moro, palmar, plantar)Tonus (normotoni, hypertoni, hypotoni)Active motionMuscle strenght (0-5)Coordination (proprioception)Sensation

PHYSICAL EXAMINATION-6ROM

1.Prone

2.Supine

3.Side-lying

4.Standing

5.Walking

PHYSICAL EXAMINATION-7

ROM

1. Elbow extension (- 25°)

2. Hip extension (- 30°)

PHYSICAL EXAMINATION-8

Walking disorders

1. Asymmetric step width

2. Toe walking

3. Crossing

4. Trendelenburg

5. Stepping

6. Ataxia

SENSATION

1. Abdominal T6 – T 12

2. Kremaster L1 – L2

3. Anal S4 – S5

OTHER ORGANS

1. Heart (anomaly, myopathy, collagen disease, sci, Guillain Barré, polio, drug)

2. Lung (myopathy, trauma, scoliosis, polio, cp)

3. Urinary bladder (spina bifida, sci)

4. Bowels (spina bifida, sci)

FUNCTIONAL EVALUATION

1. Sight

2. Hearing

3. Speech

4. Gross motor

5. Fine motor

6. Social behavior

Torakal instabilite kriterleri-2

MAJOR DISEASES1. CP

2. SB

3. TBI

4. SCI

5. NMD

6. Amputations

7. Rheumatic diseases

8. Trauma

CP• Brain injury• Non-progressive• Persistent• Modifiable • Motion, tonus,

coordination and posture are affected

• Rehabilitation

• Education

• Team work

• Participation of the family

• Head• Body• Extremities• Epilepsy • Sight• Hearing• Speech• Perception • Behavioral changes• Mental retardation

TYPES

1. Spastic

2. Flaccid

3. Atetoid

4. Ataxic

5. Mixt

SPASTIC

1.      Hemiplegic

2.      Diplegic

3. Quadriplegic

PHYSICAL EXAMINATION

1. Muscle tonus 2. DTR

3. Primitive reflexes (+)

4. Postural changes (+)

5. Motor development 6. Abnormal motion (+)

Muscle Testing

5/5 Normal 100

4/5 Good 75

3/5 Fair 50

2/5 Poor 25

1/5 Trace 10

0/5 Zero 0

Grading %

Ashworth  

0: Normal tonus 1: Minimal 2: Moderate 3: Severe 4: Very severe

REHABILITATION TEAM

1. Physiatrist 2. Pediatrist3. Physiotherapist4. Nurse5. Social worker6. Psychologist7. Occupational therapist8. Speech therapist9. Special education teacher10.Child development specialist11.Child educator12.Family

General aims in CP rehabilitation

1. Reach an understandable speech

2. Near normal use of the upper extremities

3. Functional use of lower extremities in walking

4. Near normal appearence

Management of Spasticity1. ROM exercise2. Positioning 3. Stretching exercises4. Strenghtening exercises5. Local cold applications6. Electrical stimulation7. EMG biofeedback8. Stretching splints9. Baclofen, diazepam 10. Local injections (botulinum toxin A)11. Tendon transfers, myotomy, tenotomy12. Orthoses and assistif devices

Rehabilitation is a process, including medical, economical, vocational and social aspects.