Exam and Eval of Atypical Development Flashcards by Jocelyn Flores

Describe the posture in a 4-month-old infant with severe L Torticollis.

Which muscles are shortened?

L SB / R rotation

SCM / Scalenes / Upper Trap / Levator Scapulae / shortened

SCM is main contributor!

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T or F: Atypical development may start out just as typical development does.

Many typical components are missing

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What do babies do as a result of the missing components associated with atypical development?

They compensate

These compensations soon become pathological and cause abnormal / atypical movement postures and patterns

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What should you think if a child only recently began walking on their toes?

RED FLAG

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What questions can you ask when obtaining a Developmental History?

Achievement of Specific Milstones - When did the child start sitting / walking?

How long have they been walking on their toes?

Chronological / Adjusted Age

Observed Level of Function (fine and gross motor, ADLs)

Does info make sense with established dx or referral concerns? - Clinical Picture

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The quality of ___ may provide an indicator of the chronic neurological condition of the fetus.

fetal movement (“Did you feel baby move?”)

Overall quality of pregnancy - high BP (preeclampsia) / placenta avulsion

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What aspects of a child’s chart should you consider beforehand?

Age (select appropriate toys / testing items ahead of time)

Diagnosis

Primary Concern (what do you expect to see - Clinical Picture)

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Essential Elements of History (Overall)

General Demographics - age (chrono and corrected) / gender / diagnosis

Social History and Living Environment - pt lives with who and where? / does what?

Employment - job / school / play

Developmental History

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Important Aspects of PMH

Reason for referral

Primary dx / comorbidities

Functional Status and Activity Level

Medications

Prior clinical tests / surgeries

Maternal pregnancy / birth history

Family hx

General health status

Health habits

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Systems Review (Examination)

Cardiopulm / Integumentary / MSK / Neuromuscular / Vision, Hearing, Cognition

Communication Skills / Affect / Cognition / Language Abilities / Learning Style

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Systems Review Findings

May affect patient management process / narrow focus of tests and measures

May identify need to refer patient to other providers

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Tests and Measures:

Skeletal Exam

Muscle Function

Skeletal Exam: Anthropometric Characteristics / Joint Integrity and Mobility / Posture / ROM

Muscle Function: Muscle Performance (Strength / Power / Endurance)

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Tests and Measures:

Reflexes

Movement: Frequency / Pattern / Control

Reflexes: Presence or absence of Primitive Reflexes

Movement: Gait / Locomotion / Balance / Motor Function (Motor Control / Learning)

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Tests and Measures:

GM / FM Functional Skills

Skin and Sensation

GM / FM: Motor Function / Neuro-Motor Development / Self- Care and ADLs / Work (job / school / play)

Skin: Integrity / sensory / pain

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Tests and Measures:

Equipment

General Observations

Equipment: ADs / Orthotic, Protective Devices (how old is the equipment?)

General Observation: Aerobic Capacity, Endurance / Arousal, Attention, Cognition / Circulation / Environmental Barriers / Ventilation, Respiration

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Methods of Examination

ALL are important

Interview: Taking history from client / parents / caregiver

Observation: Naturalistic observation

Direct Handling

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Essential Components of an Examination

Functional Skills

PROM (key for ITW) / AROM

Muscle Tone

Skeletal Alignment (Posture)

Balance / Postural Control

Muscle Strength

Quality of Movement

Primitive Reflexes

Pain

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Functional Skills (Examples)

Developmental Milestones

Methods of Play

ADLs

AROM: Assess through play

Gait

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Perseveration (Definition)

The inability to stop activity when appropriate

e.g., Red Light, Green Light

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Eye Dominance

3-4 years

Typically established by age 6

Ask child to look through kaleidoscope / camera window / toilet paper roll - will often hold up to dominant eye

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Hand Dominance

3-4 years

Usually established by age 4-6

May change hands during early years as child is learning how to perform differing tasks / activities

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Leg Dominance

~3 years

Typically established by age 6

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Modified Ashworth Scale (MAS) Grading

0 - Normal tone (no increase)

1 - Slight increase in tone / catch and release or minimal resistance at end range flexion, extension

1+ - Slight increase in tone / catch followed by minimal resistance at end range

2 - Increase in muscle tone throughout most of the range / affected parts easily moved

3 - Considerable increase in tone / passive movements difficult

4 - Affected part rigid in flexion or extension

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Ankle Clonus Grading

0 - Absent

1 - Un-sustained (a few beats at a time)

2 - Sustained (continuous beating)

3 - Spontaneous / light touch provoked and sustained

DTR Grading

0 - No reflex jerk 1 - Lower than normal reflex 2 - Normal reflex 3 - Higher than normal reflex 4 - Exaggerated reflex + clonus

At what age can you start MMT?

Not attempted before the age of 5 Typical 8-year-old should be able to follow basic MMT'ing direction

FLACC Observation Scale

Used w/ infants, preschoolers, and non-verbal children (to assess pain) Face / Legs / Activity / Cry / Consolability - each category scored 0 to 2 Higher overall score = increased severity of pain

Wong-Baker Faces Pain Rating Scale

Ages 3+

Verbal Analog Scale

Ages 10+ Asked to describe pain on a scale of 0 to 10 0 - None / 2 - Annoying / 4 - Uncomfortable / 6 - Dreadful / 8 - Horrible / 10 - Agonizing

What are the two general types of diagnoses?

MSK Diagnoses Neuromuscular Diagnoses

Prior to initiating PT for CMT, what MUST be done?

We would need to rule out Non-Muscular Torticollis (can be related to serious conditions - Cervical Rib / Cataracts)

Which SCM is tight in the case of *Right* Torticollis? How would the infant's posture look in this case?

R SCM is tight R Lateral Flexion (SB) / L Rotation

Comprehensive treatment of CMT includes a screening for ___ due to the association between CMT and ___.

hip instability, DDH

What value of asymmetry related to hip abduction ROM may be indicative of hip dysplasia?

5-10 degrees

Tumors (thickening or lump) in the SCM area due to CMT usually resolve by when?

12 months of age

In the case of CMT treatment, the prognosis is better if the infant is treated at what age?

BEFORE 1 year

What is key in the process of providing conservative treatment for CMT?

A comprehensive home program - exercises / ROM that are comfy for children and caregivers

In the case of conservative CMT treatment, when are WS activities on a ball / lap effective?

After / around 3-4 months

Plagiocephaly (Definition)

Misshapen head

Brachycephaly (Definition)

Flat head Type of Plagiocephaly

Scaphocephaly (Definition)

Elongated head

When does the Posterior Fontanelle usually close?

1-2 months

When does the Anterior Fontanelle usually close?

7-18 months

Why is it better to provide an infant with a cranial orthosis earlier in life?

Once fontanelles close, the orthosis can no longer help mold the skull

Is Developmental Dysplasia of the Hip (DDH) always visible at birth?

No! Hip may have been / appear to have been typical at birth before dysplasia was found later

What mechanical factors are thought to predispose infants to DDH?

Small intrauterine space Breech position Fetal hip against mother's sacrum

What physiologic factors are thought to predispose infants to DDH?

Maternal hormonal influence of estrogen and relaxin

What environmental / cultural factors are thought to predispose infants to DDH?

Strapping of children's LEs in extension - Cradle Board (Eskimo / Native American cultures)

What is the *gold standard* for confirming hip dislocation?

Ultrasound

What is the most consistent clinical sign of Hip Dysplasia in neonates?

Hip abduction limitation / asymmetry 5-10 degrees difference in ROM of hip abduction can be a sign

In addition to CMT, what other bony abnormality is associated with DDH?

Metatarsus Adductus / Calcaneovalgus

Types of DDH (Newborn)

Typical and Stable Subluxable Dislocatable Dislocated and Reducible Dislocated and Not Reducible (most severe)

Pavlik Harness

DDH treatment in infants less than 3 months old Puts hip into position of flexion / abduction and restricts hip extension / adduction

Closed Reduction and Spica Cast

DDH treatment in infants aged 3-6 months Considered if ~3 week trial of Pavlik Harness not successful in reducing a dislocated hip

Pavlik Harness (Complications)

Avascular Necrosis Femoral Nerve Palsy Inferior dislocation

Surgical treatment is usually required for dislocated hips between ___ and ___ months of age.

6, 18

Diagnosis of hip dislocation in children aged 2 or older is generally considered to mandate what type of surgery?

Open Reduction

Older children with continuing Acetabular Dysplasia may benefit from what procedure?

Pelvic Osteotomy Remodeling potential of Acetabulum decreases with age