Occupational/PhysicalTherapyApproachand Management. - - PowerPoint PPT Presentation

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Occupational/PhysicalTherapyApproachand Management. - - PowerPoint PPT Presentation

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Occupational/PhysicalTherapyApproachand Management. AndreaR.Mettler,OTR Updated December2010 1 MeasurementTools Updated December2010 2 TherapyEvaluations/ OBPIeval form

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SLIDE 1

Updated December2010 1

Occupational/PhysicalTherapyApproachand Management.

AndreaR.Mettler,OTR

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SLIDE 2

Updated December2010 2

MeasurementTools

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SLIDE 3

Updated December2010 3

TherapyEvaluations/OBPIeval form

GeneralManagementProtocolinOBPI InitialAssessment Inpatientvs OutpatientEvaluation InpatientEvaluation:Familyeducation;positioning;PROM

exercises;precautions;splintingneeds;recommendations

OutpatientEvaluation:OBPIEvaluationform,familyeducation,

expectations,precautions,developmentalassessment

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SLIDE 4

Updated December2010 4

TherapyEvaluations

Subjective

Canbeveryinsightfulonfamilydynamics Emotionalstate,copingabilities Familyperception/goals/expectationsforthechild. Availabilityofthefamilytoassistwithrehabprocess

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SLIDE 5

Updated December2010 5

TherapyEvaluations;History/Subjective

Pertinentmedicalhistory Toincludegestationalage,birthweight,presentation,

deliveryhistory,maneuversifused,shoulderdystocia present?

Complicationsafterbirth Developmentalhistory,feedingabilities Adaptiveequipment,previoustherapies Specialdiagnostictests Pictorialdocumentation

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Updated December2010 6

4montholdinfantwithLOBPI

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Updated December2010 7

TherapyEvaluations

ObjectiveFindings Precautions IDwhichlimbisaffected IDrestingpostureinallappropriatedevelopmental

positionsincluding:supine,prone,sidelying. (agedependent)

Reflextestingininfants Musttestbotharmstogetbaseline

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Updated December2010 8

6WeekoldinfantwithROBPI

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Updated December2010 9

TherapyEvaluations

Objective: PassiveROM:Ininfants3monthsorless,besureto

takeintoaccountphysiologicalflexionanditseffects

  • nPROM

Precautions:Beawareofpotentialshoulder

subluxation/orradialheaddislocationtoprevent injuryduringPROMexercises

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Updated December2010 10

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Updated December2010 11

TherapyEvaluations

ActiveROM Details,Details,Details EffectsofgravityonAROM Substitutional compensatorypatternsofmovement MalletScaleofactivemovement

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Updated December2010 12

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Updated December2010 13

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Updated December2010 14

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Updated December2010 15

TherapyEvaluations

Strength Howtoassessininfant? 1.Observation 2.Palpation– testindifferentrangesandindifferent

relationshipstogravity

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Updated December2010 16

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Updated December2010 17

TherapyEvaluations/strength

AMS(activemovementscale)Score GravityEliminated

0Nocontraction 1Contraction.Nomotion 2<50%,motion 3>50%motion

AgainstGravity

5<50%motion 6>50%motion 7Fullmotion

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Updated December2010 18

SATScale

O– Nocontractionfeltinthemuscle 1– Contractionfeltbutnovisiblemovementobserved 2– Motiontoodifficulttoperformagainstgravity;must

bedoneinhorizontalplane

3– Motionupto50%offullROMheldlessthan1minute;

AROMrepeated5timeswithnoticeabledecreaseinROM asreps25areperformed

4– Motion50100%offullmotionheldforonesecond;

AROMrepeated5timeswithnoticeabledecreasein motionasreps25areperformed

5– MaximumAROMheld2secondsandrepeated5times

withnoticeabledecreaseinROMasreps25are performed

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Updated December2010 19

SATScale

6 MaximumAROMheld2secondsandrepeated5times

withnodecreaseininROMasrepetitionscontinue

7– MaximumAROMheld2secondsandrepeated10times

using1lbsweightwithnodecreaseofROMasreps continue

8 MaximumAROMheld2secondsandrepeated10times

using2lbsweightwithnodecreaseofROMasreps continue

9 MaximumAROMheld2secondsandrepeated10times

using3lbsweightwithnodecreaseofROMasreps continue

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Updated December2010 20

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Updated December2010 21

TherapyEvaluation

Sensation:

Lighttouch Painfulstimuli Temperature Howdoweobjectivelymeasureininfants? Observation,parentreport

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Updated December2010 22

TherapyEvaluations

PrimitiveReflexes

Palmar graspreflex Plantargraspreflex MoroReflex Traction ATNR

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Updated December2010 23

TherapyEvaluation

MuscleTone

Assessentirebody Newbornphysiologicalflexion Whendoesthisdiminish? Positionatrest

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Updated December2010 24

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Updated December2010 25

TherapyEvaluations

Atrophy

CircumferentialMeasurements

  • Size

IDlimbdiscrepancyinlengthorcircumference Landmarks:humeralheadtolatepicondyle Ulnar orradialheadtostyloid process. Limblengthdiscrepancycouldberelatedtosheardeformity. Ininfants,measureinmetricsystem

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Updated December2010 26

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Updated December2010 27

TherapyEvaluation

Developmentalprogression Dependentonage Lookforsymmetry

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Updated December2010 28

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Updated December2010 29

InfantDevelopmentReview

Onemonthold:Physiologicalflexion,Graspreflex Twomonthold:holdsheaduprightwhentrunksupported Threemonthold:+headcontrol,voluntaryswiping&reaching Fourmonthold:propsonforearms,rolling,bilateralreaching Fivemonthold:sitswithminsupport,handtomouthpattern Sixmonthold:increasedposturalcontrol,weightshifting

Reference:NormalDevelopmentofFunctionalMotorSkills Rona,Alexander;Regi Boehme,BarbaraCupps. MotorSkillsacquisitioninthefirstyear:LoisBly(therapyskillbuilders)

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Updated December2010 30

InfantDevelopmentReview

Sevenmonthold:equilibriumreactionsemerging Eightmonthold:rocksforwardandbackwardsinquadruped. Ninemonthold:Crawling,increaseintransitionalmovements Tenmonthold:Pullstostanding,cruising,pinchemerging Elevenmonthold:standswithlesssupport,pincergrasp Twelvemonthold:independentwalking

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Updated December2010 31

TherapyEvaluations

JointIntegrity Checkforsubluxations ordislocations Checkforjointcapsuletightness Checkforglenohumeral changes

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Updated December2010 32

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Updated December2010 33

TherapyEvaluations

Scapulohumeral relationship

Changeswithpassiveandactiveabduction

Inordertoaccess180degofshd abduction,youneedamobilescapula.

Scapulamoves– 30oofactiveabductionand700 ofpassive abduction

Toassessforsheardeformity:Palpationoftheclaviclewith

thethumbandthespineofthescapulawiththeindexfinger. (scapularelevationgradingscale)

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Updated December2010 34

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Updated December2010 35

TherapyEvaluations

Questionstoasktoassistinsettinggoals:

Areproblemsrelatedto nervedysfunction? biomechanicalissues? muscleimbalance? sensoryloss?

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Updated December2010 36

TherapyEvaluations

Associatedproblems

Visualneglectofinvolvedside Torticollis Hemidiaphragm paralysis

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Updated December2010 37

TherapyEvaluations

Specialconsiderationsforolderchildren

ToneofuninvolvedUE Subluxation ofoppositeshoulder Trunkstability

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Updated December2010 38

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Updated December2010 39

TherapyEvaluations

LongTermConsiderations

Arthriticchanges Bonedensity/bonehealth Limblengthdiscrepancy/deformity Musclecontractures Sensorydeficits Apraxia:limbneglectandsensorimotor skills

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Updated December2010 40

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Updated December2010 41

TherapyEvaluations

LongTermConsiderations

Posture Selfinjury Developmentalskills ADL’s

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Updated December2010 42

TherapeuticManagement

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Updated December2010 43

OBPITreatmentInfant

NeedtodeterminefrequencyofOT/PTsession Whyitisimportanttotreatinfantsmoreoften? Whenshouldtreatmentbegin?

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Updated December2010 44

BPITreatment

EssentialBeginnings TeachparentROMexercises Iftheyarenotcomfortabledoingthem,showthem hand

  • verhandtoshowtheexactrangeavailable
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Updated December2010 45

Treatment/Infants

PROM

Shouldbeperformedthroughfullcomfortablerange butshouldbegentleandpainfree Ifclavicular fracturepresentavoidROMfortento fourteendaysasperMD’sorders

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Updated December2010 46

TreatmentPositioning

Infants: Nolongerpinningarmtochestunless fracturepresent Olderinfants(4month+) SupineandProne Shoulderabductedto90degrees withexternalrotation

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Updated December2010 47

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Updated December2010 48

TreatmentGoals

1st priority FAMILYEDUCATION

includingtraditionaltreatment:ROM,scapular; glenohumeralstabilization Precautions/plans CarryingandfeedingtheinfantwithOBPI Carseatposition Diagnosticworkup,specialists

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Updated December2010 49

TreatmentGoals

MaintainPROM/preventcontractures ObtainAROM Preservejointintegrity Promoteageappropriatedevelopmentalskills

acquisition

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Updated December2010 50

TreatmentGoals

PromotesensoryawarenessofinvolvedUEinhopes

  • freducingapraxia

PromotevisualawarenessofinvolvedUE(midline) Prevent/minimizecompensatorypatternsof

movement

Monitorpotentialassociatedproblems

medialrotationposture/deformityrelatedtomuscle imbalances

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Updated December2010 51

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Updated December2010 52

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Updated December2010 53

Treatment/Infants

PROMpointstoremember

radialheaddislocation supportnormalscapulohumeral rhythm

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Updated December2010 54

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Updated December2010 55

TreatmentAROM

EarlyfacilitationofAROMiscriticalforthe

preventionoflearnednonuse GeneralGuidelines

Startingravityeliminatedorgravityreducedposition

whenelicitingconcentriccontraction

Reflexescanbehelpfultoelicitmusclecontraction Weaknesscandevelopinmusclesnotdirectly

affectedbythelesion

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Updated December2010 56

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Updated December2010 57

TreatmentAROM

Facilitationofshoulderstabilityisthefoundationfor

controlledarmandhandfunction

Weightbearingandweightshiftinprone Assistedreachwhileinprone

Vibration/tappingtorhomboids

Promotescapularweightbearing facilitatesco

contractionbothwithscapularmoversandstabilizers

Activationofabdominals

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Updated December2010 58

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Updated December2010 59

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Updated December2010 60

FacilitationofReach

Gentlehumeralcompressionduringreach Humeralguidancewhilefacilitatinghumeralflexion

andER(inhibitexcessivehumeralabduction)

Stabilizingandmobilizingscapula Facilitatereachwithoutgrasp,butreachtotouch

easier

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Updated December2010 61

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Updated December2010 62

FacilitationofSupination

Earlysupination beginswithelbowflexion Getshoulderinneutrallyrotatedpositionfirst Cylindricallyshapedtoyspresentedinverticalfashion Facilitatessupination Presenttoystoradialsideofhand

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Updated December2010 63

FacilitationofSupination

TreatmentStrategies

Encouragehandtomouthandtoytomouthplay Fingerfeeding Bimanualholdingoftoys Bangingblocks Holdingbottleatfeeds Stickersonpalmersurfaceorwrist Weightshiftingwhileinprone

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Updated December2010 64

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Updated December2010 65

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Updated December2010 66

FacilitationofER

Gentlestretchtopectoralsisessential MFR,strain/counterstrain Gentlejointmobilization Massage Trunkrotationwhileweightbearingonfixed(involved) UE Reachingouttosidewithhumerus fixedagainsttrunk

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Updated December2010 67

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Updated December2010 68

FacilitationofGrasp

TreatmentStrategies

Toytomouth Tractionandpropioceptive inputthroughpalm Weightbearingthroughpalm/correctionof weightbearingthroughdorsalsurface Holdlargeobjectrequiringtwohands Usevelcro straponhandtomaintainhold

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Updated December2010 69

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Updated December2010 70

BPITreatmentinfant

TeachParents Properpositioning Sensorystimulation Visualorientation Propercarryingandpickinguptechniques

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Updated December2010 71

TreatmentPositioning

Sidelying onuninvolvedsidetopromote midlineorientationofinvolvedlimbaswellas spontaneousplay Sidelying oninvolvedsidetrunkshouldbe reclinedbackslightlytowardssupinetoavoidundue pressure(ifhemidiaphragmatic,thisshouldbelimited butstillperformed)

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Updated December2010 72

BPITreatment

Tummytime Essentialforpreparationforfutureuse

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Updated December2010 73

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Updated December2010 74

BPITreatment

SensoryStimulation

Facilitateinvolvedarm Exploringotherbodyparts Provideinfantmassageoverinvolvedlimb Providevibratoryinput Providejointcompression Providevarietyoftextures Altertemperatureoftoys

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Updated December2010 75

TreatmentVisualInput

Involvedarmshouldalwaysbeinvisualfieldtoreduce chancesofdevelopmentalapraxia ofnonuse Placebellonsmallwristbandtoencouragechildto look atarmwhenspontaneousmovementoccurs

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Updated December2010 76

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Updated December2010 77

BPITreatment

Useofvibrationcanachievealotatyoungage Canactivatemuscle Promotesensoryawareness Assistwithnerveregeneration

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Updated December2010 78

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Updated December2010 79

BPITreatment

DevelopmentalSequence

Generalpointsofconsideration Utilizeageappropriateactivities Keepitfunthroughvarietyofstimulation Insuresuccessfulexperience Watchentirebodyforcompensations

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Updated December2010 80

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Updated December2010 81

BPItreatmentTransitionalMovement

Rollingsupinetosidelying toprone(andviceversa) Alwaystobothsides Weightshiftinsitting Creepingonhandsandknees

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Updated December2010 82

BPITreatment/NMES

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Updated December2010 83

BPITreatment/Constrainedinduced

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Updated December2010 84

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Updated December2010 85

BPITreatmentSplinting

Goals Preventcontractures Promoteincreasedfunction Protectjoint Deficitsdeterminesplintingneeds notallinfantsneedsplinting.

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Updated December2010 86

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Updated December2010 87

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Updated December2010 88

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Updated December2010 89

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Updated December2010 90

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Updated December2010 91

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Updated December2010 92

TherapyInterventionFollowingModQuadProcedure

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Updated December2010 93

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Updated December2010 94

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Updated December2010 95

PostSurgicalRehab/ModQuad

StatueofLiberty(SOL)splintisremovedbyOTon

postopday#1 toassesscurrentshoulderAROM

AROMtestedantigravity&gravityeliminatedplanes BasedonAROMfindingsdecisiononsplintwearing

timeismade

AROMmightberestrictedbypainanddressings TypicallyinfantssleepwithSOLfor3weeks

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Updated December2010 96

PostSurgicalRehab/ModQuad

Typicallyinfantsunder1218monthsdonotneed

splintingduringdaytime Splintingatnighttimeonlyfor3weeks

Children2+moreawareofpainanddiscomfort Mightneedsplinting18/7for13weeks Splintistopromotehealingandforpaincontrol Importanttoremovesplint12hoursatleast2xday

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Updated December2010 97

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Updated December2010 98

PostSurgicalRehab/ModQuad

AROM/AROMbeginimmediately Infant’s and younger children restrict AROM on non

affectedextremity(elbowsplint)

Children12+:pillowsplintwithshoulderat80/90

degreeangletopreventnumbness/tingling

ProtocolforolderchildrenvariesandAAROM/AROM

beginatpostopday#1andperformedeveryhour

Compensatory patterns big problem for older children

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Updated December2010 99

PostSurgicalRehab/ModQuad

Formaltherapytypicallyresumesatpostopweeks23 Encourageactivemovementandfunctionthrough

playandparticipationinselfcareskills

Nonresistiveactivities:balloons,bubbles,magnets Donotencourageinternalrotationoradduction

attheshoulder

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Updated December2010 100

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Updated December2010 101

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Updated December2010 102

PostSurgicalRehab/ModQuad

Postopweeks:03:PROM/AAROM/AROM

Toshoulderflexion/abduction/external rotation

  • Postopweeks:36:Therapymightresume

ContinueAROM/AAROM Aquaticsmightbegin Discouragecompensatorypatternsof movement

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Updated December2010 103

PostSurgicalRehab/ModQuad

Postopweeks6andafter

Discontinuenighttimesplint

Scarmassage Assessmentofthescapularstabilizersonbothsidesmust bedonepriortobeginprogressivestrengthening Considerkinesiotaping,theratogs,specialbracestobuild andmaintainscapularstability TES/othermodalitiescouldbestarted

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Updated December2010 104

PostSurgicalRehab/ModQuad

SpecialConsiderations

Childrenwithsheardeformitywillcontinuetoexhibit

shoulderAROMdeficits

CTscanisorderedatpostopweek3to6toassessshear

deformityandplanforTriangleTiltsurgery

TTsurgeryistypicallyplaned36monthsfollowingMQ

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Updated December2010 105

TherapyInterventionFollowing TriangleTiltProcedure

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Updated December2010 106

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Updated December2010 107

PostSurgicalRehab/TriangleTilt

OTperformsplintcheckandfamilyeducationonTT

protocolandpostopday#1

Saro brace:worn24/7withoutremovalfor3to6

weeks

Thiswillbependingonseverityofsheardeformity

  • Saro positiongoal:elbowcreasefacingupwards
  • Clearplasticofsplintfromaxillary area
  • Splintshouldbesittingabovehipjoint
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Updated December2010 108

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Updated December2010 109

PostSurgicalRehab/TriangleTilt

Postopdressingsareremovedbypediatricianatpost

  • pweek#1

ElbowPROMbeginsatpostopweek#1toprevent

elbowstiffness

Saro braceisremovedatpostopweek3to6athome

  • rtherapyclinic

Heatmodalitiesrecommended:hotpackorbath Expect loss of ROM at shoulder and elbow NoSaro braceatnightuntilfunctionalAROMat

shoulderandelbowregained

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Updated December2010 110

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Updated December2010 111

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Updated December2010 112

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Updated December2010 113

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Updated December2010 114

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Updated December2010 115

PostSurgicalRehab/TriangleTilt

SendfollowupvideotoDr.Nath Weeks36to8:FullPROMandAROMastolerated

Therapyresumesatpostopweeks36(whensaro brace

isnotlongerused)

Earlytherapygoals:IncreaseAROMtoshoulder

flexion/abductionandelbowflexion

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Updated December2010 116

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Updated December2010 117

PostSurgicalRehab/TriangleTilt

Weeks8to12:

ContinuewithprogressiveAROMactivities RestricteduseofthenonaffectedUEencouraged

Allcompensatorymovementstobediscouragedsuch

ashikingthehip,rotatingorbendingbodybackward

Serialcastingattheelbowmightbestartedifelbow

flexioncontracturepresent(refertocastingprotocol)

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Updated December2010 118

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Updated December2010 119

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Updated December2010 120

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Updated December2010 121

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Updated December2010 122

PostSurgicalRehab/TriangleTilt

Weeks12+:Beginstrengtheningprogram

Weight bearing as tolerated

Assess:alignmentofthescapulaontheribcage Alignmentandmobilityoftheglenohumeraljoint AROM/PROMandstrength Treatmentfocusinitiallyonstrengtheningofthe

scapularstabilizerstopromotescapulohumeral rhythm

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Updated December2010 123

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Updated December2010 124

PostSurgicalRehab/TriangleTilt

TherapyafterTTprotocolbeginswithafrequencyof

2xperweek Therapyisrecommendedforatleast6months followingTTsurgery Thefollowingmodalitiesarealsorecommended TES/Biofeedback,kinesiotaping,bracingetc.

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Updated December2010 125

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Updated December2010 126

Discussion,Comments,Questions