Course:KIN366/ConceptLibrary/ChildhoodPhysicalTherapy

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Movement Experiences for Children
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KIN 366
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Instructor: Dr. Shannon S.D. Bredin
Email: shannon.bredin@ubc.ca
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Physical therapy (also known as physiotherapy, often abbreviated as PT) is a health care profession that remediates impairments and promotes mobility, function, and quality of life through medical examination, diagnosis, and physical intervention (therapy using mechanical force or movement)[1]. People who practice physical therapy are known as physical therapists. Paediatric physical therapy is a specialization of the physical therapy profession that caters specifically to children (from birth to age 12[2]) and focuses on promoting normal motor development and growth, as well as rehabilitating health conditions that affect a child’s movement capability or acquisition of motor skills.

History

The practice of physical therapy can be traced back as early as 460 BC to Ancient Greek physicians, such as Hippocrates and Galenus, who advocated for the use of massage and manual therapy to treat people. The epidemic of poliomyelitis (or polio) affecting children in the United States of America in the late 1800s led to a rapid development of the modern physical therapy practice[3]. The earliest providers of physical interventions in the during the polio epidemic were physical education teachers, coaches of gymnastics, and practitioners of corrective exercise, who worked alongside physicians to provide children affected by polio with interventions such as massage, muscle training, and corrective exercise[1]. Ever since its conception as a modern medical practice, physical therapy has been heavily invested in the rehabilitation of children. World War I was another historical factor that promoted the early development of physiotherapy, as many of the soldiers returning from war needed rehabilitation to address the functional limitations and physical impairments resulting from injuries they sustained during the war [1].

The governing body of physiotherapy in America, the American Physiotherapy Association (APA) was formed in 1922. In the 1930’s, the APA allowed the American Medical Association to accredit physical therapy schools, thereby allowing physical therapy to be fully recognized as a medical profession. Legislation was created around the profession of physical therapy, and by 1959, 45 American states had a Physical Therapy Practice Act that protect and define the profession of physical therapy, their scope of practice, and their billing practices[4].

The practice of physical therapy evolved greatly during the 1940’s and 1950’s, as manipulative procedures on the spine and extremity joints[5] became part of mainstream practice. Physical therapy first became a commonplace fixture in hospitals across North America and Europe and then began to move away from in-hospital practices to private outpatient clinics, colleges and universities, as well as geriatric care centres[6].

The specialization of physical therapy occurred in 1979, when the American Board of Physical Therapy Specialties was established in 1979, with the first established specialization of cardiopulmonary physical therapy completing the specialization process in 1985[7]. Since then, seven other specializations have been established, including paediatric physical therapy. Canada’s governing body in physical therapy, the Canadian Physiotherapist’s Association also has a specialization in paediatrics[8].

Evidence-based Practice

Evidence-based practice refers to using the most current research and up-to-date knowledge to guide decision-making within the context of treating individual patients [2]. This practice allows for the most effective scientifically-supported treatment to be administered (i.e. knowledge-to-action translation). This is particularly an important practice in PPT because new research on its application on pathological paediatric populations, such a Cerebral Palsy, is constantly being published[9].

Critically Appraised Topics

Critically Appraised Topics (CAT) are collaborative online databases (similar to wiki’s) compiled by medical practitioners for the purpose of answering clinical questions (i.e. questions to relate to the medical advice that a practitioner provides to their patient) that arise during a medical practitioner’s practice[10]. CAT have been shown to facilitate practical and quick application of evidence-based medicine to actual physical therapist interactions with their patient, which benefits patients because they receive the most informed clinical advice from their physical therapist[11][12].

When a clinical question arises during a paediatric physical therapist’s interaction with their patient, they would go onto a CAT database to see if another practitioner has already created a CAT that is relevant to the clinical question at hand. A CAT would contain a clinical question (for example, “in a patient with infantile scoliosis, will manual therapy or analgesia be more effective for reducing pain?”), all the relevant and updated research-based evidence on the topic, and the best interventional practice that can be inferred from that evidence.

If a paediatric physical therapist cannot find a CAT relevant to their clinical question, they would take on the responsibility of creating a CAT on their particular clinical question and do the research required to answer the CAT with research-based evidence so that other paediatric physical therapists that have a similar clinical question can consult their CAT in the future for the most current research-based evidence on their specific clinical question.

Model of Patient/Client Management

The following model of patient/client management taken from Campbell (2012)[2], is an example of a systematic model used by evidence-based paediatric physical therapists in order to maximize treatment outcomes and facilitate comprehensive decision-making in practice. It includes 5 elements: examination, evaluation, diagnosis, prognosis, and intervention.

Examination

During an examination, paediatric physical therapist first obtains information on a child’s history, including past and present health issues. Then, a therapist will conduct a systems review, which involves a brief screening of a child’s motor abilities/impairments that will help focus the rest of the examination on the issues that need to be addressed. Then, after analyzing the information from the history and systems review, a therapist will conduct select tests, which are focused on the issues uncovered by the systems review, and provide information required to make an informed diagnosis and prescribe an effective evidence-based intervention.

Evaluation

A therapist will then evaluate the information gathered during the examination to make judgements about the current status of the child. This includes judgements about the impairments in growth and development the child is displaying, and the subsequent activity limitations and participation restrictions that these impairments impose on the child.

Diagnosis

During diagnosis, the therapist identifies a pattern of dysfunction or impairment in order to identify the preferred evidence-based prognosis and interventions available to paediatric populations presenting with similar patterns of dysfunction or impairment.

Prognosis

The therapist than looks to the current treatment options available to children presenting with the pattern of impairment or dysfunction identified during diagnosis to identify the most appropriate intervention procedure for the child. Issues that the therapist needs to address at this stage include the resources available to the child and their parents/guardians and the activity limitations that arise from a child’s physical conditions. The therapist then predicts the likely outcomes of the intervention (for example, the level of improvement that may be attained through an intervention, and the amount of time required to reach that level of improvement).

Intervention

Once an evidence-based intervention has been chosen, and consent has been obtained from the child’s legal guardians, the therapist will interact with the child to provide the intervention. Paediatric physical therapy interventions may include exercise prescription and instruction, instruction for self-care and home-management, manual therapy (such as massage or spinal manipulation), and the prescription and fabrication of rehabilitative devices and equipment (such as orthotics or crutches).

Physical Therapy in Cerebral Palsy

Physical therapy has been shown to improve gross motor skills, gait performance, and participation in motor activities in paediatric (age 4-12) populations with CP[13]. It has also been shown to improve upper-limb functioning and activities of daily living in CP populations[14].

Cerebral Palsy

Cerebral Palsy (CP) is a group of permanent disorders of motor development that lead to limitations in motor activity and postural impairments, and are thought to be caused by interruptions to development of the fetal or infant brain[15]. Common symptoms arising from CP include spasticity, dyskinesia (i.e. inability to move properly), scoliosis, epilepsy, desensitization, attentional deficits, cognitive deficits, and inability to walk[16].

Evidence-based Prognosis of Cerebral Palsy

Novak et al. (2014)[17] conducted a systematic review of CP literature, which resulted in the following evidence-based findings about the prognosis of CP:

  • CP is a lifelong disorder.
  • People with CP have a normal life span expectancy.
  • Most children (upwards of 70%) with CP will walk, either independently or with aid.
  • Severity predictions are most accurate at 2 years of age, thus a systematic evaluation of CP patients, including brain imaging and an intensive examination of the patient’s motor and cognitive abilities, should be performed at the 2-year landmark.
  • Pain and sleep symptoms may be under-recognized and under-treated in CP populations.
  • Without rehabilitation, deterioration of a CP patient’s musculoskeletal system can be very severe, and can drop them one full Gross Motor Function Classification System level (a system used to classify walking ability). Thus, it is very important for CP patients to receive rehabilitation.

Physical Therapy Interventions in Cerebral Palsy

Neurodevelopmental Therapy

Neurodevelopmental Therapy (NDT) was developed by Berta and Karl Bobath in the 1940’s, and has become one of the most widely used interventions in the physical rehabilitation of CP populations. NDT originally focused on the inhibition of motor reflex perseveration, reducing abnormal muscle tone, and promoting normal developmental sequences through postural training and handling techniques (i.e. guiding a child passively through a movement so that they get the experience of the movement)[18]. It has since evolved to focus primarily on functional goal attainment, such as proper weight-bearing and weight-shifting, and normalizing muscle tone.

There is weak to mixed evidence on the effectiveness of NDT in CP populations[19]. NDT has been shown in the literature to have a modest effect on improving upper-limb functioning [20] and gait performance in CP populations[21]. However, other literature reviews have shown that NDT is ineffective in inhibiting reflexes and promoting normal muscle tone[22].

Strength Training

Strength Training (ST) in CP populations was proposed in the 1950’s by Dr. W.M. Phelps, to great opposition from much of the paediatric physical therapy community[22]. Many prominent paediatric physical therapists, including the Bobaths, ascertained that CP populations do not suffer from muscle weakness and that activities requiring effort would promote hypertonia (i.e. abnormal increased muscle tone). However, research has emerged suggesting that muscle weakness is, in fact, a symptom of CP, especially of the lower-limbs[23], and that ST is an effective intervention for promoting improved muscle strength, gross motor skills, and gait velocity[24][25].

There are also options outside of traditional resistance training available to CP populations, such as aquatic training[26], which has been shown to be clinically effective and may be more fun for children. There is no evidence of hypertonia resulting from ST in CP populations[22].

Constraint-induced Therapy

Constraint-induced therapy (CIT) is used in rehabilitating CP patients who have asymmetrical impairments. It involves restricting use of a patient’s less-impaired arm with a constraining device, such as a mitten or a sling, and engaging them in functional tasks, such as training in activities of daily living, that promote the use of their more-impaired arm, which they might not usually use because of their impairment[27]. CIT has been shown to have a moderate effect on increasing the quality of functional hand use, and the speed and dexterity of task completion[28].

Practical Application

  • Paediatric physical therapists should educate themselves on the most up-to-date research in their field, and engage in CAT databases to increase the practicality of applying evidence-based practice to actual patient encounters.
  • Paediatric physical therapists who already are using CAT should update their research as often as possible (at least once every 3 months) as one of the main limitations of CATs cited by Foster et al. (2001)[10] is the “short shelf-life” of CAT, as new research is consistently being published.
  • Oxford University has developed a resource called Bandolier (available here) to help therapists create and manage CAT database websites.


  • In the physical rehabilitation of CP patients, evidence-based practice is particularly important, as new research and interventions for CP populations are constantly being published in the literature, and unfortunately, outdated care is currently being provided[29].
  • The literature suggests that at 2-years of age, a systematic evaluation of CP patients should be conducted, as severity predictions are most accurate at this age[30].
  • Pain and sleep symptoms should be researched more thoroughly, and paediatric physical therapists should be more sensitive to these symptoms, especially pain, during their examinations and evaluations of CP patients[31].
  • The evidence behind NDT in CP rehabilitation is weak to mixed, and the literature suggests that there may be more effective evidence-based interventions for promoting functional muscle tone and motor functioning available in to CP patients[22].
  • ST seems to be fully supported by the literature as a way of decreasing muscle weakness in CP populations, and increase gait performance and gross motor ability [24][25], and no significant adverse effects have been reported from ST use in CP populations[22]
  • Optimal frequency, intensity, time, and type (FITT) parameters of ST in CP populations have been proposed by Damiano and colleagues as follows: using loads of at least 65% of the child’s maximum voluntary contraction, 4 sets of 5 repetitions, and a training frequency of 3 times per week[24].
  • CIT is a viable treatment option for CP patients with asymmetrical symptomatology to increase the speed and quality of functional hand use[32][28].

References

  1. 1.0 1.1 1.2 Pinkston, D. (1989). Evolution of the practice of physical therapy in the United States. Physical Therapy. Philadelphia. Pa: JB Lippincott Co, 2-30. Chicago
  2. 2.0 2.1 2.2 Campbell, S. K., Palisano, R. J., & Orlin, M. N. (2012). Physical therapy for children. St. Louis, Mo: Elsevier/Saunders.
  3. Neumann, D. A. (2004). Historical perspective - polio: Its impact on the people of the united states and the emerging profession of physical therapy. Journal of Orthopaedic and Sports Physical Therapy, doi:10.2519/jospt.2004.0301
  4. Murphy, W. B., & American Physical Therapy Association. (1995). Healing the generations: A history of physical therapy and the american physical therapy association. Alexandria VA: American Physical Therapy Association.
  5. McKenzie, R., & May, S. (1990). The Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy 2 Volume Set.
  6. Klinteberg, M. (1992). The history and present scope of physical therapy. International Journal of Technology Assessment in Health Care, 8(1), 4.
  7. American Board of Physical Therapy Specialties - ABPTS. (n.d.). Retrieved February 28, 2015, from http://www.abpts.org/
  8. Canadian Physiotherapy Association. (n.d.). Retrieved February 28, 2015, from http://www.physiotherapy.ca/
  9. Novak, I. (2014). Evidence-based diagnosis, health care, and rehabilitation for children with cerebral palsy. Journal of Child Neurology, 29(8), 1141-1156.
  10. 10.0 10.1 Foster, N., Barlas, P., Chesterton, L., & Wong, J. (2001). Critically Appraised Topics (CATs). Physiotherapy, 179-190.
  11. Straus, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2005). Evidence-based medicine: how to practice and teach EBM.
  12. Sackett, D. L., & Straus, S. E. (1998). Finding and applying evidence during clinical rounds: the evidence cart. Jama, 280(15), 1336-1338.
  13. Christy, J., Chapman, C., & Murphy, P. (2012). The effect of intense physical therapy for children with cerebral palsy. Journal of Pediatric Rehabilitation Medicine, 5(3), 159-170.
  14. Anttila, H., Autti-Ramo, I., Suoranta, J., Makela, M., & Malmivaara, A. (2008). Effectiveness Of Physical Therapy Interventions For Children With Cerebral Palsy: A Systematic Review. BMC Pediatrics, 14-14.
  15. Rosenbaum, P., Paneth, N., Leviton, A., Goldstein, M., & Bax, M. (2006). A Report: The Definition And Classification Of Cerebral Palsy April 2006. Developmental Medicine & Child Neurology, 8-14.
  16. Colver, A., Fairhurst, C., & Pharoah, P. (2014). Cerebral palsy. The Lancet.
  17. Novak, I. (2014). Evidence-based diagnosis, health care, and rehabilitation for children with cerebral palsy. Journal of Child Neurology, 29(8), 1141-1156.
  18. Miller, F. (2007). Physical therapy of cerebral palsy. DE: Springer Verlag.
  19. Anttila, H., Autti-Ramo, I., Suoranta, J., Makela, M., & Malmivaara, A. (2008). Effectiveness Of Physical Therapy Interventions For Children With Cerebral Palsy: A Systematic Review. BMC Pediatrics, 14-14.
  20. Law, M., Cadman, D., Rosenbaum, P., Walter, S., Russell, D., & DeMatteo, C. (1991). Neurodevelopmental therapy and upper-extremity inhibitive casting for children with cerebral palsy. Developmental Medicine and Child Neurology, 33(5), 379-387.
  21. Adams, M. A., Chandler, L. S., & Schuhmann, K. (2000). Gait changes in children with cerebral palsy following a neurodevelopmental treatment course. Pediatric Physical Therapy, 12(3), 114-120.
  22. 22.0 22.1 22.2 22.3 22.4 Barry, M. J. (2001). Evidence-based practice in pediatric physical therapy. PT [H.W.Wilson - GS], 9(11), 38.
  23. Wiley, M. E., & Damiano, D. L. (1998). Lower-extremity strength profiles in spastic cerebral palsy. Developmental Medicine and Child Neurology, 40(2), 100-107. doi:10.1111/j.1469-8749.1998.tb15369.x
  24. 24.0 24.1 24.2 Damiano, D. L., & Abel, M. F. (1998). Functional outcomes of strength training in spastic cerebral palsy. Archives of Physical Medicine and Rehabilitation, 79(2), 119-125. doi:10.1016/S0003-9993(98)90287-8
  25. 25.0 25.1 Unger, M., Faure, M., & Frieg, A. (2006). Strength training in adolescent learners with cerebral palsy: A randomized controlled trial. Clinical Rehabilitation, 20(6), 469-477.
  26. Kelly, M. E. (2005). Effects of aquatic exercise on the energy expenditure, levels of fatigue, and motor function of children with cerebral palsy
  27. Charles, J. R., Wolf, S. L., Schneider, J. A., & Gordon, A. M. (2006). Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: A randomized control trial. Developmental Medicine and Child Neurology, 48(8), 635-642.
  28. 28.0 28.1 Taub, E., Ramey, S. L., DeLuca, S., & Echols, K. (2004). Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics, 113(2), 305-312. doi:10.1542/peds.113.2.305
  29. Novak, I. (2014). Evidence-based diagnosis, health care, and rehabilitation for children with cerebral palsy. Journal of Child Neurology, 29(8), 1141-1156.
  30. Novak, I. (2014). Evidence-based diagnosis, health care, and rehabilitation for children with cerebral palsy. Journal of Child Neurology, 29(8), 1141-1156.
  31. Novak, I. (2014). Evidence-based diagnosis, health care, and rehabilitation for children with cerebral palsy. Journal of Child Neurology, 29(8), 1141-1156.
  32. Charles, J. R., Wolf, S. L., Schneider, J. A., & Gordon, A. M. (2006). Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: A randomized control trial. Developmental Medicine and Child Neurology, 48(8), 635-642.