Rehabilitation role of OT and PT
Content
CHAPTER 52
REHABILITATION: THE ROLE OF OCCUPATIONAL THERAPY AND PHYSICAL THERAPY
ANNETTE MAJNEMER, BSC (OT), MSC, PHD RENA BIRNBAUM, MSC, OTR EILEEN KENNEDY, BSCPT, MSC, REHAB SC
Medical and technologic advances in the care of children with neurologic conditions have resulted in a greater focus on developmental morbidity and, subsequently, a higher demand for pediatric rehabilitation services. Pediatric neurologists need to appreciate the roles and functions of physical and occupational therapists as part of the management of children with or at risk for developmental disabilities.
Rehabilitation focuses on restoring or optimizing abilities and capacities of individuals through training, compensation, and adaptation of the task or environment. The primary goal is to promote autonomy, productivity, and life satisfaction. Rehabilitation services for children and youth must consider their changing developmental needs and demands and must also appreciate the intense involvement of the family in the rehabilitation process. Children who experience loss of function due to injuries or diseases will undergo rehabilitation interventions to restore or optimize functioning as they continue to grow and develop; however, more frequently, pediatric rehabilitation involves the facilitation of the acquisition of developmental skills and activities in children with a developmental disability. Rehabilitation services may be offered acutely, typically in a hospital setting, or as part of an outpatient service, typically in a community-based setting. In hospitals, rehabilitation specialists play an important role in the diagnostic work-up of children presenting with neurologic conditions. Impairments and delays across developmental domains are identified using objective, age-appropriate
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
evaluation tools. Therapeutic interventions may begin acutely for children with either sudden or newly identified disability (eg, traumatic brain injury, encephalitis, cerebral palsy), with complications resulting from chronic disorders (eg, myelomeningocele, bronchopulmonary dysplasia), or after specialized medical or surgical interventions (eg, selective dorsal rhizotomy, open heart surgery). An important role of rehabilitation specialists in acute care is the identification of ongoing rehabilitation and resource needs of children and families and coordination of such services after discharge. Community-based programs in rehabilitation centers and outpatient clinics and home and school-based services provide ongoing therapeutic interventions to children with health risks or chronic developmental disabilities. This may include monitoring of progress and identification of new resource needs and periodic assessments and interventions at key points in the lifespan to enhance function. Interventions in the community focus primarily on promoting independence, maximizing function at home and at school, and facilitating participation and integration in the community. Working
Rehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
Rehabilitation: The Role of Occupational Therapy and Physical Therapy / 333
on skills and activities in the child’s “natural environment” ensures that all elements of the child’s environment are considered and modified if necessary. Furthermore, everyday activities with respect to personal maintenance, mobility, academic performance, leisure, and recreation are more readily addressed as part of rehabilitation interventions. Rehabilitation interventions include a number of approaches. Remediation emphasizes improvement in the areas of difficulty. For children, this may include restoration of developmental skills and abilities or facilitating the successful acquisition of developmentally appropriate skills. Often, deficits cannot be changed and therefore compensatory techniques (eg, using aids and adaptations, modifying the task, or altering the environment) are used to promote function and minimize the effect of the child’s problems or difficulties. Increasingly, rehabilitation specialists are applying disease prevention and health promotion strategies (eg, developmental stimulation programs and injury prevention strategies) to individuals at risk for developmental disability or secondary complications.
ing, and available resources are also part of the assessment process. If treatment is required, interventions may be carried out directly (ie, therapist works individually with the child) or indirectly (ie, therapist consults with parents, teachers, or other caregivers and recommends strategies to promote function). An individualized treatment plan is formulated to address short-term and long-term goals, and the most appropriate treatment modalities are selected (Table 52-2). Periodic reassessments ensure that goals are being achieved, and treatment strategies may be subsequently adjusted or refined. Discontinuation of services may be accompanied by referral to other programs or periodic follow-up to address new needs or concerns.
Role of Occupational Therapy
Occupational therapy (OT) uses purposeful activity and task analysis to prevent and minimize the impact of disability on functional independence and facilitates the development of those skills and behaviors essential to meeting the demands of everyday life. Philosophically, OT is predicated upon a developmental perspective, with the goal of meeting an individual’s occupational performance needs throughout the lifespan. The term “occupational performance” refers to those tasks in which individuals engage as part of their normal, everyday routine. In childhood, these tasks may include play and recreation, self-care activities, functional mobility, peer and family relationships, schoolwork, and community living skills. Performance in any of these areas is dependent on the individual’s skills within the motor, sensory, cognitive, behavior, and social domains. The focus of occupational therapy is not on the neurologic disease itself, but rather on the impact a disorder has or potentially will have on a child’s ability to function in life roles. The primary goal is to facilitate occupational performance and prevent dysfunction by providing the child with opportunities to develop, restore, and maintain those skills and behaviors necessary for independent living.
Rehabilitation Process
Emphasis is placed on interdisciplinary collaboration. Each discipline brings complementary expertise to the team, to best meet the needs of the child and family. The specific guidelines and procedures for referring a child to rehabilitation specialists are largely determined by the policies and procedures of the facility within which each therapist works. Once a child is referred, rehabilitation specialists may carry out a screening to determine whether services are necessary or may perform a formal assessment. A variety of standardized and nonstandardized assessment tools may be administered (Table 52-1) to identify the child’s strengths and limitations. As part of the evaluation, particular concerns of the child (if appropriate) and the parents are identified and prioritized. Appreciation of the child’s physical and social environment, family function-
TABLE 52-1. Examples of Assessment Tools Used by Occupational and Physical Therapists
Assessment Tool Alberta Infant Motor Scale Batelle Developmental Inventory Canadian Occupational Performance Measure Gross Motor Function Measure Miller Assessment of Preschoolers Motor Free Visual Perception Test Peabody Developmental Motor Scales Pediatric Evaluation of Disability Inventory Vineland Adaptive Behavior Scale Functional Independence Measure for Children (WeeFIM) Area Evaluated Spontaneous gross motor movement repertoire of infants in supine, prone, sitting, and standing positions (weight-bearing, posture, and antigravity movements) Motor, adaptive, communicative, cognitive, and personal–social skills development The client’s self-perception of performance in everyday activities (problem areas and satisfaction with performance) Gross motor functioning (developed for children with cerebral palsy) Mild to moderate developmental delays Visual perceptual processing ability (without motor response) Gross motor and fine motor skill acquisition (mastered or emerging) Child’s functional status (functional skills, caregiver assistance, and modifications) Adaptive behaviors of children (communication, motor, daily living skills, socialization, behavior) Degree of disability in terms of the need for supervision or assistance in functional activities
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
Rehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
334 / The Office Visit: Developmental Delay TABLE 52-2. Selected Examples of Treatment Approaches Used by Occupational and Physical Therapists
Treatment Approach Biomechanical Developmental Motor control or motor learning Neurodevelopmental Occupational performance Rehabilitative Sensory integrative Primary Focus Reestablish or promote the biomechanical aspects of movement Facilitate the mastery of developmental skills Apply practice and feedback techniques to acquire or modify movements using functional tasks Decrease the influence of abnormal muscle tone and postures, prevent contractures and deformities, and promote normal movement patterns Enhance functioning in self-care, productivity, and leisure areas important to the client Maximize independence in spite of residual impairments through the use of compensatory techniques Promote adaptive responses by organizing and integrating sensory processing
Pediatric occupational therapists service children from the newborn period to adolescence. Once a child with a neurologic disorder is referred to OT, a formal assessment assists in the diagnosis of specific disabilities, establishes a baseline level of performance, and determines whether a child requires OT. The major purpose of testing is to provide a comprehensive evaluation of function by determining the child’s strengths and activity limitations. This requires communication with the child’s primary caregivers, as well as an understanding of the medical, psychological, and social factors that can interfere with function. The evaluation of a child’s functioning in occupational performance areas (ie, activities or occupations) includes assessment of self-care, feeding, functional mobility, play, community living skills, and schoolrelated and prevocational tasks. In addition, the assessment of the performance components (skills or abilities) that may influence functioning may include evaluation of reflexes, range of motion, strength and muscle tone, sensory modalities, perceptual motor skills, cognitive abilities, eye–hand coordination and in-hand manipulation skills, concentration, and organizational abilities. Consideration of these elements provides the therapist with a holistic view of the child’s abilities. The actual areas evaluated will vary depending on the age of the child, their developmental level, and the family’s primary concerns. With a neonate, for example, assessment may focus on identifying skills in neurobehavioral organization, movement patterns, and oral-motor control, whereas for a preschooler, more emphasis may be directed toward independence in dressing, preacademic skill acquisition, and cooperative play. A wide variety of standardized assessments are used by occupational therapists, and many require training in the administration and interpretation of these tests. Until recently, most pediatric occupational therapy services were provided predominantly through individual one-on-one therapy. In the past decade, current practice has changed to include a number of service delivery models. Advancements in health care that have improved life expectancy in children with complex health problems, a shift toward shorter hospitalizations, and the integration
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
of disabled children into mainstream schools collectively have created a need to expand OT services from traditional acute-care facilities to community, home-based, or school-based services. Because young children frequently display patterns of behavior that only suggest difficulties in future developmental status, different intervention strategies are required. In addition to traditional remediation, which is aimed at improving areas of difficulty by teaching specific skills in occupational performance (eg, learning to tie shoelaces or to draw a circle), both compensatory and prevention intervention models may also be used. Compensatory mechanisms may be used when a problem within the child cannot be substantially changed, regardless of how early the intervention process begins. Environmental adaptation may be necessary when a child is unable to compensate for a disability and requires specific environmental modifications to perform a task more efficiently. Examples of functional adaptation include restructuring the physical environment in the neonatal intensive care unit, using ramps to assist with functional mobility or positioning in the classroom to optimize learning. Preventive strategies address children who are at risk for developing problems but who have not as yet demonstrated delays in development. For example, the occupational therapist may provide suggestions that enrich the environment so as to decrease the long-term effects of risk factors. Various treatment approaches are used in pediatric OT (see Table 52-2). They provide a systematic way to consider performance problems and identify priorities for intervention. The intervention approach within which activities are presented varies depending on the nature of the dysfunction. For example, play can be used within a biomechanical framework to promote range of motion and muscle strength or within a psychoanalytical framework to facilitate emotional expression. Occupational therapists apply various treatment approaches when providing services and the choice depends upon the age and specific needs of the individual child and the therapist’s expertise and background. Many occupational therapists choose to use a combination of approaches to best meet the specific needs of the child and family.
Rehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
Rehabilitation: The Role of Occupational Therapy and Physical Therapy / 335
Among the unique services offered by occupational therapists working in a pediatric setting are feeding and oral motor interventions; selection of adaptive equipment; fabrication or purchase of splinting, orthotics, and seating devices; and facilitating independence in activities of daily living and developmental progress. Occupational therapists use purposeful activity (or occupation) to promote adaptive skills in children with disabilities. For an activity to generate a response, it should be developmentally appropriate, interesting, and motivating to the child and address specific therapeutic needs. Various activities are used depending on the particular goal for each child. For example, activities that require antigravity movements (eg, game mounted on the wall) or that offer resistance (eg, modeling clay) may be used to increase strength and dexterity, whereas paper and pencil activities may be chosen to improve visual acuity and the ability to discern patterns. The occupational therapist may use meaningful activities combined with physical handling and positioning techniques to facilitate the child’s development of higher-level skills, such as postural control, visually directed reach, grasp, and manipulation of objects. Occasionally occupational therapists may design or fabricate environmental and equipment adaptations, such as positional seating, feeding devices, toys, or orthotics to enhance the acquisition of age-appropriate functions. In summary, occupational therapy aims to improve the child’s abilities while modifying the tasks or environment so as to maximize functioning, allowing the child to meet his or her full potential. Developmental activities such as feeding, moving, communicating, and playing are primary activities of children. Through the use of purposeful, ageappropriate activities and intrinsic motivation, the occupational therapist encourages the child to acquire an increasing repertoire of developmental skills.
Role of Physical Therapy
Physical therapy is a profession with the mandate to assist in the development or restoration of optimal gross motor function. The child with a neurologic or developmental disorder may present with a variety of impairments and subsequent limitations in activity and participation. The pediatric physical therapist uses various assessment tools to determine whether impairments and activity limitations are in fact present and evaluates the extent of the impairment and the degree of the activity limitation in motor function. The physical therapist collaborates with the child and the family to establish realistic intervention goals, with the objective of developing or restoring gross motor function. The physical therapy assessment allows for the determination of the child’s muscle strength, range of motion, reflex activity, postural control, and gross motor function.
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
When evaluating strength, the therapist not only assesses the force of individual muscles but also the functional strength of the child during specific gross motor activities. Postural control is assessed in isolation and in the context of its contribution to motor function. Gross motor development is assessed using a variety of standardized tools, such as the Alberta Infant Motor Scale (AIMS), the Peabody Developmental Motor Scales (PDMS), and the Test of Infant Motor Performance (TIMP). All these measures compare the child with the norm and help to establish the degree of activity limitation. The level of gross motor function of the older child can be determined using the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP). The Gross Motor Function Measure (GMFM) has been developed specifically for use with children who have an established diagnosis such as cerebral palsy. It allows for the evaluation of the amount of change over time in several gross motor domains such as lying, sitting, and walking. The Gross Motor Performance Measure (GMPM), which has recently been developed, allows for the evaluation of qualitative changes in gross motor function. This should prove to be an important measure, as often the child with a disability shows improvement in the quality but not the quantity of movement following an intervention program. Once the evaluation is complete, the therapist works with the child and the family to establish treatment goals and the intervention plan. The plan takes into consideration the needs of the child and the dynamics of the family unit. Intervention strategies are developed by analyzing a gross motor task and determining which components are missing or impaired. In the past, traditional physical therapy intervention was composed of hands-on treatment with the goal of inhibiting abnormal movement patterns and facilitating more normal motor responses from the child. Current principles of motor learning encourage the child to initiate the movement with the therapist acting only as the guide or coach. Movements are repeated in a simple environment, then expanded into more complex situations with regular feedback of performance and results given to the child. This enables the child to better learn and retain the motor task. Strengthening activities were once contraindicated for the child with spasticity, as these exercises were thought to increase the abnormal muscle tone. Recent literature suggests this is not the case, and that, in fact, strengthening of a spastic limb may improve its ability to function. Muscle strengthening in the very young child presents an interesting challenge for the physical therapist. The child may be unable or uninterested in doing specific muscle-strengthening exercises. It is then necessary for the physical therapist to incorporate strengthening into a play activity that suits the age and cognitive level of the child. The intensity and type of physical therapy intervention varies during the course of the child’s growth and develRehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
336 / The Office Visit: Developmental Delay
opment. During infancy and preschool years the child may receive frequent intervention, with the goals of maximizing gross motor performance and preparing for entry into school. This may also involve evaluation of the need for assistive devices such as orthotics, walkers, and wheelchairs to promote best function in the child’s environment. When the child reaches school age, physical therapy may continue as regular treatment but at a less frequent intensity. The therapist may also act as a consultant to ease integration into the classroom and school setting. As the child grows, the physical therapist carries out periodic reevaluations, in collaboration with other members of the medical team, to determine whether any new impairments have arisen such as a scoliosis or joint contractures. The therapist works with the child, the family, and the medical team to develop new intervention strategies to minimize the impairments. Should the child require surgery, the intensity of physical therapy intervention increases in the preoperative period to prepare the child for the surgery and in the postoperative period to return the child to the preoperative level of function. The child with a neurologic impairment may demonstrate a tendency to be less active than other children. This can lead to deconditioning, poor physical fitness, and weight gain that may further impair the child’s mobility. The physical therapist has an important role and responsibility to assist the child with the development and maintenance of both physical and cardiovascular fitness. The therapist can work with the child and the family to determine the child’s exercise and sporting interests and to direct them to the appropriate resources for adaptive fitness and sporting activities. As the child progresses through adolescence to adulthood, the physical therapist can assist the family with the transition from pediatric to adult medical and therapeutic services. This is usually a difficult transition for both the child and the family. The family may find that the services may be dispersed throughout several different institutions with little or no coordination or communication among centers. The physical therapist not only assists the family in determining the appropriate resources but also acts as an advocate for the young adult to ensure that adequate follow-up is obtained. In summary, the physical therapist assists in the development of gross motor skills, which enable the child to be mobile and achieve active participation in his or her environment.
New Directions in Rehabilitation Practice
Rehabilitation specialists increasingly adopt a biopsychosocial view of pediatric rehabilitation, recognizing that developmental disability not only results from the medical
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
(biologic) condition, but is also in part a socially created process (psychosocial). Activity limitations may occur because of deficits or impairments of the nervous system but may be further exacerbated by environmental factors (eg, physical, attitudinal, or social barriers) that inhibit functioning. As such, occupational and physical therapists increasingly appreciate the importance of personal and environmental factors that can influence health and wellbeing. Recently, the World Health Organization endorsed this broader perspective of functioning in their new International Classification of Functioning, Disability, and Health. This holistic view defines health as encompassing body structures and functions (organ system level), activity (individual level) and participation (societal level). This conceptual framework recognizes the importance of contextual factors (personal and environmental) as mediators of functioning and health. With this framework in mind, rehabilitation specialists increasingly use a transactive approach to the therapeutic process, recognizing there is a dynamic interplay between the child’s abilities and deficits, the daily tasks and activities that are expected for their age and culture, and the environmental context (home, school, and community) in which they live. As such, treatment not only focuses on “fixing” or minimizing deficits (eg, spasticity, restricted range of motion, coordination difficulties, and perceptual deficits), but also applies strategies (eg, using aids and adaptations, or simplifying the task) to promote functional independence in spite of the child’s impairments. Family-centered care is a service delivery model that recognizes that the family knows their child best and therefore should work collaboratively with health professionals to prioritize goals and assist in the decision-making process for program planning. Family members are encouraged to participate actively in the rehabilitation process. Therapists provide information and support, thus enabling families to become more competent and confident as caregivers of a child with a disability. Increasing evidence supports the benefits of a family-centered approach to practice in terms of family satisfaction with service and optimizing functional outcomes for the child. Rehabilitation specialists are increasingly embracing the use of a family-centered model of care in practice. In recent years, budgetary constraints coupled with a greater demand for pediatric rehabilitation services have meant health professionals have needed to be even more accountable for the benefits of their interventions. Therapists must now make clinical decisions based on the most current available scientific evidence and new theoretical models in the field. In particular, there has been tremendous development in the area of standardized pediatric outcome measures, enabling therapists to objectively document degree of responsiveness to treatment across a wide
Rehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
Rehabilitation: The Role of Occupational Therapy and Physical Therapy / 337
range of outcomes of interest. Most recently, measures are being developed to quantify change in discrete performance areas (eg, gait analysis or assessment of sensory modalities) and to ascertain benefits in health-related quality of life, level of functioning, and participation. Therefore, clinicians are now expected to build on their core professional knowledge by keeping up to date with new knowledge, to ensure best practice. This concept of evidence-based practice has been accompanied by the advancement of the professional training programs in occupational and physical therapy to a master’s level across North America.
Practitioner and Patient Resources
American Occupational Therapy Association (AOTA) http://www.aota.org AOTA is the nationally recognized professional association of approximately 40,000 occupational therapists, occupational therapy assistants, and students of occupational therapy. AOTA advances the quality, availability, use, and support of occupational therapy through standard-setting, advocacy, education, and research on behalf of its members and the public. American Physical Therapy Association (APTA) http://www.apta.org APTA is a national professional organization representing more than 63,000 members. Its goal is to foster advancements in physical therapy practice, research, and education. Canadian Association of Occupational Therapists (CAOT) http://www.caot.ca CAOT provides services, products, events, and networking opportunities to help occupational therapists achieve excellence in their professional practice. In addition, CAOT provides national leadership to actively develop and promote the clientcentered profession of occupational therapy in Canada and internationally. Canadian Physiotherapy Association (CPA) http://www.physiotherapy.ca CPA is the national professional association representing approximately 9,000 members distributed throughout all provinces and territories. CPA’s mission is to provide leadership and direction to the physiotherapy profession, foster excellence in practice, education, and research, and promote high standards of health in Canada. International Classification of Functioning, Disability and Health (ICF) http://www3.who.int/icf/icftemplate.cfm The World Health Organization’s ICF describes how people live with their health condition. ICF is a classification of health and health-related domains that describe body functions and structures, activities, and participation. The domains are classified from body, individual, and societal perspectives. Because an individual’s functioning and disability occurs in a context, ICF also includes a list of environmental factors.
Summary
Pediatric neurologists need to appreciate the roles and functions of physical and occupational therapists as part of the management of children with or at risk for developmental disabilities. Rehabilitation specialists work collaboratively with the child and family to develop or restore function, increase competency, autonomy, and community integration, and also to prevent disability, social isolation, and family stress. As members of an interdisciplinary team, occupational therapists and physical therapists collectively help neurologically impaired children meet their daily needs and demands in the context of their environment and enable families to become effective caregivers.
Suggested Readings
Campbell SK, editor. Pediatric neurologic physical therapy. 2nd ed. New York: Churchill Livingstone; 1991. Campbell SK, Vander Liinden DW, Palisano RJ, editors. Physical therapy for children. 2nd ed. Philadelphia (PA): W.B. Saunders Company; 2000. Case-Smith J, ed. Occupational therapy for children. 4th ed. St. Louis (MO): Mosby; 2001. Dunn WW. Best practice occupational therapy: in community service with children and families. Thorofare (NJ): Slack Incorporated; 2000. Helders PJ, Engelbert RH, Custers JW, et al. Creating and being created: the changing panorama of paediatric rehabilitation. Pediatr Rehabil 2003;6:5–12.
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
Rehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
REHABILITATION: THE ROLE OF OCCUPATIONAL THERAPY AND PHYSICAL THERAPY
ANNETTE MAJNEMER, BSC (OT), MSC, PHD RENA BIRNBAUM, MSC, OTR EILEEN KENNEDY, BSCPT, MSC, REHAB SC
Medical and technologic advances in the care of children with neurologic conditions have resulted in a greater focus on developmental morbidity and, subsequently, a higher demand for pediatric rehabilitation services. Pediatric neurologists need to appreciate the roles and functions of physical and occupational therapists as part of the management of children with or at risk for developmental disabilities.
Rehabilitation focuses on restoring or optimizing abilities and capacities of individuals through training, compensation, and adaptation of the task or environment. The primary goal is to promote autonomy, productivity, and life satisfaction. Rehabilitation services for children and youth must consider their changing developmental needs and demands and must also appreciate the intense involvement of the family in the rehabilitation process. Children who experience loss of function due to injuries or diseases will undergo rehabilitation interventions to restore or optimize functioning as they continue to grow and develop; however, more frequently, pediatric rehabilitation involves the facilitation of the acquisition of developmental skills and activities in children with a developmental disability. Rehabilitation services may be offered acutely, typically in a hospital setting, or as part of an outpatient service, typically in a community-based setting. In hospitals, rehabilitation specialists play an important role in the diagnostic work-up of children presenting with neurologic conditions. Impairments and delays across developmental domains are identified using objective, age-appropriate
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
evaluation tools. Therapeutic interventions may begin acutely for children with either sudden or newly identified disability (eg, traumatic brain injury, encephalitis, cerebral palsy), with complications resulting from chronic disorders (eg, myelomeningocele, bronchopulmonary dysplasia), or after specialized medical or surgical interventions (eg, selective dorsal rhizotomy, open heart surgery). An important role of rehabilitation specialists in acute care is the identification of ongoing rehabilitation and resource needs of children and families and coordination of such services after discharge. Community-based programs in rehabilitation centers and outpatient clinics and home and school-based services provide ongoing therapeutic interventions to children with health risks or chronic developmental disabilities. This may include monitoring of progress and identification of new resource needs and periodic assessments and interventions at key points in the lifespan to enhance function. Interventions in the community focus primarily on promoting independence, maximizing function at home and at school, and facilitating participation and integration in the community. Working
Rehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
Rehabilitation: The Role of Occupational Therapy and Physical Therapy / 333
on skills and activities in the child’s “natural environment” ensures that all elements of the child’s environment are considered and modified if necessary. Furthermore, everyday activities with respect to personal maintenance, mobility, academic performance, leisure, and recreation are more readily addressed as part of rehabilitation interventions. Rehabilitation interventions include a number of approaches. Remediation emphasizes improvement in the areas of difficulty. For children, this may include restoration of developmental skills and abilities or facilitating the successful acquisition of developmentally appropriate skills. Often, deficits cannot be changed and therefore compensatory techniques (eg, using aids and adaptations, modifying the task, or altering the environment) are used to promote function and minimize the effect of the child’s problems or difficulties. Increasingly, rehabilitation specialists are applying disease prevention and health promotion strategies (eg, developmental stimulation programs and injury prevention strategies) to individuals at risk for developmental disability or secondary complications.
ing, and available resources are also part of the assessment process. If treatment is required, interventions may be carried out directly (ie, therapist works individually with the child) or indirectly (ie, therapist consults with parents, teachers, or other caregivers and recommends strategies to promote function). An individualized treatment plan is formulated to address short-term and long-term goals, and the most appropriate treatment modalities are selected (Table 52-2). Periodic reassessments ensure that goals are being achieved, and treatment strategies may be subsequently adjusted or refined. Discontinuation of services may be accompanied by referral to other programs or periodic follow-up to address new needs or concerns.
Role of Occupational Therapy
Occupational therapy (OT) uses purposeful activity and task analysis to prevent and minimize the impact of disability on functional independence and facilitates the development of those skills and behaviors essential to meeting the demands of everyday life. Philosophically, OT is predicated upon a developmental perspective, with the goal of meeting an individual’s occupational performance needs throughout the lifespan. The term “occupational performance” refers to those tasks in which individuals engage as part of their normal, everyday routine. In childhood, these tasks may include play and recreation, self-care activities, functional mobility, peer and family relationships, schoolwork, and community living skills. Performance in any of these areas is dependent on the individual’s skills within the motor, sensory, cognitive, behavior, and social domains. The focus of occupational therapy is not on the neurologic disease itself, but rather on the impact a disorder has or potentially will have on a child’s ability to function in life roles. The primary goal is to facilitate occupational performance and prevent dysfunction by providing the child with opportunities to develop, restore, and maintain those skills and behaviors necessary for independent living.
Rehabilitation Process
Emphasis is placed on interdisciplinary collaboration. Each discipline brings complementary expertise to the team, to best meet the needs of the child and family. The specific guidelines and procedures for referring a child to rehabilitation specialists are largely determined by the policies and procedures of the facility within which each therapist works. Once a child is referred, rehabilitation specialists may carry out a screening to determine whether services are necessary or may perform a formal assessment. A variety of standardized and nonstandardized assessment tools may be administered (Table 52-1) to identify the child’s strengths and limitations. As part of the evaluation, particular concerns of the child (if appropriate) and the parents are identified and prioritized. Appreciation of the child’s physical and social environment, family function-
TABLE 52-1. Examples of Assessment Tools Used by Occupational and Physical Therapists
Assessment Tool Alberta Infant Motor Scale Batelle Developmental Inventory Canadian Occupational Performance Measure Gross Motor Function Measure Miller Assessment of Preschoolers Motor Free Visual Perception Test Peabody Developmental Motor Scales Pediatric Evaluation of Disability Inventory Vineland Adaptive Behavior Scale Functional Independence Measure for Children (WeeFIM) Area Evaluated Spontaneous gross motor movement repertoire of infants in supine, prone, sitting, and standing positions (weight-bearing, posture, and antigravity movements) Motor, adaptive, communicative, cognitive, and personal–social skills development The client’s self-perception of performance in everyday activities (problem areas and satisfaction with performance) Gross motor functioning (developed for children with cerebral palsy) Mild to moderate developmental delays Visual perceptual processing ability (without motor response) Gross motor and fine motor skill acquisition (mastered or emerging) Child’s functional status (functional skills, caregiver assistance, and modifications) Adaptive behaviors of children (communication, motor, daily living skills, socialization, behavior) Degree of disability in terms of the need for supervision or assistance in functional activities
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
Rehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
334 / The Office Visit: Developmental Delay TABLE 52-2. Selected Examples of Treatment Approaches Used by Occupational and Physical Therapists
Treatment Approach Biomechanical Developmental Motor control or motor learning Neurodevelopmental Occupational performance Rehabilitative Sensory integrative Primary Focus Reestablish or promote the biomechanical aspects of movement Facilitate the mastery of developmental skills Apply practice and feedback techniques to acquire or modify movements using functional tasks Decrease the influence of abnormal muscle tone and postures, prevent contractures and deformities, and promote normal movement patterns Enhance functioning in self-care, productivity, and leisure areas important to the client Maximize independence in spite of residual impairments through the use of compensatory techniques Promote adaptive responses by organizing and integrating sensory processing
Pediatric occupational therapists service children from the newborn period to adolescence. Once a child with a neurologic disorder is referred to OT, a formal assessment assists in the diagnosis of specific disabilities, establishes a baseline level of performance, and determines whether a child requires OT. The major purpose of testing is to provide a comprehensive evaluation of function by determining the child’s strengths and activity limitations. This requires communication with the child’s primary caregivers, as well as an understanding of the medical, psychological, and social factors that can interfere with function. The evaluation of a child’s functioning in occupational performance areas (ie, activities or occupations) includes assessment of self-care, feeding, functional mobility, play, community living skills, and schoolrelated and prevocational tasks. In addition, the assessment of the performance components (skills or abilities) that may influence functioning may include evaluation of reflexes, range of motion, strength and muscle tone, sensory modalities, perceptual motor skills, cognitive abilities, eye–hand coordination and in-hand manipulation skills, concentration, and organizational abilities. Consideration of these elements provides the therapist with a holistic view of the child’s abilities. The actual areas evaluated will vary depending on the age of the child, their developmental level, and the family’s primary concerns. With a neonate, for example, assessment may focus on identifying skills in neurobehavioral organization, movement patterns, and oral-motor control, whereas for a preschooler, more emphasis may be directed toward independence in dressing, preacademic skill acquisition, and cooperative play. A wide variety of standardized assessments are used by occupational therapists, and many require training in the administration and interpretation of these tests. Until recently, most pediatric occupational therapy services were provided predominantly through individual one-on-one therapy. In the past decade, current practice has changed to include a number of service delivery models. Advancements in health care that have improved life expectancy in children with complex health problems, a shift toward shorter hospitalizations, and the integration
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
of disabled children into mainstream schools collectively have created a need to expand OT services from traditional acute-care facilities to community, home-based, or school-based services. Because young children frequently display patterns of behavior that only suggest difficulties in future developmental status, different intervention strategies are required. In addition to traditional remediation, which is aimed at improving areas of difficulty by teaching specific skills in occupational performance (eg, learning to tie shoelaces or to draw a circle), both compensatory and prevention intervention models may also be used. Compensatory mechanisms may be used when a problem within the child cannot be substantially changed, regardless of how early the intervention process begins. Environmental adaptation may be necessary when a child is unable to compensate for a disability and requires specific environmental modifications to perform a task more efficiently. Examples of functional adaptation include restructuring the physical environment in the neonatal intensive care unit, using ramps to assist with functional mobility or positioning in the classroom to optimize learning. Preventive strategies address children who are at risk for developing problems but who have not as yet demonstrated delays in development. For example, the occupational therapist may provide suggestions that enrich the environment so as to decrease the long-term effects of risk factors. Various treatment approaches are used in pediatric OT (see Table 52-2). They provide a systematic way to consider performance problems and identify priorities for intervention. The intervention approach within which activities are presented varies depending on the nature of the dysfunction. For example, play can be used within a biomechanical framework to promote range of motion and muscle strength or within a psychoanalytical framework to facilitate emotional expression. Occupational therapists apply various treatment approaches when providing services and the choice depends upon the age and specific needs of the individual child and the therapist’s expertise and background. Many occupational therapists choose to use a combination of approaches to best meet the specific needs of the child and family.
Rehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
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Among the unique services offered by occupational therapists working in a pediatric setting are feeding and oral motor interventions; selection of adaptive equipment; fabrication or purchase of splinting, orthotics, and seating devices; and facilitating independence in activities of daily living and developmental progress. Occupational therapists use purposeful activity (or occupation) to promote adaptive skills in children with disabilities. For an activity to generate a response, it should be developmentally appropriate, interesting, and motivating to the child and address specific therapeutic needs. Various activities are used depending on the particular goal for each child. For example, activities that require antigravity movements (eg, game mounted on the wall) or that offer resistance (eg, modeling clay) may be used to increase strength and dexterity, whereas paper and pencil activities may be chosen to improve visual acuity and the ability to discern patterns. The occupational therapist may use meaningful activities combined with physical handling and positioning techniques to facilitate the child’s development of higher-level skills, such as postural control, visually directed reach, grasp, and manipulation of objects. Occasionally occupational therapists may design or fabricate environmental and equipment adaptations, such as positional seating, feeding devices, toys, or orthotics to enhance the acquisition of age-appropriate functions. In summary, occupational therapy aims to improve the child’s abilities while modifying the tasks or environment so as to maximize functioning, allowing the child to meet his or her full potential. Developmental activities such as feeding, moving, communicating, and playing are primary activities of children. Through the use of purposeful, ageappropriate activities and intrinsic motivation, the occupational therapist encourages the child to acquire an increasing repertoire of developmental skills.
Role of Physical Therapy
Physical therapy is a profession with the mandate to assist in the development or restoration of optimal gross motor function. The child with a neurologic or developmental disorder may present with a variety of impairments and subsequent limitations in activity and participation. The pediatric physical therapist uses various assessment tools to determine whether impairments and activity limitations are in fact present and evaluates the extent of the impairment and the degree of the activity limitation in motor function. The physical therapist collaborates with the child and the family to establish realistic intervention goals, with the objective of developing or restoring gross motor function. The physical therapy assessment allows for the determination of the child’s muscle strength, range of motion, reflex activity, postural control, and gross motor function.
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
When evaluating strength, the therapist not only assesses the force of individual muscles but also the functional strength of the child during specific gross motor activities. Postural control is assessed in isolation and in the context of its contribution to motor function. Gross motor development is assessed using a variety of standardized tools, such as the Alberta Infant Motor Scale (AIMS), the Peabody Developmental Motor Scales (PDMS), and the Test of Infant Motor Performance (TIMP). All these measures compare the child with the norm and help to establish the degree of activity limitation. The level of gross motor function of the older child can be determined using the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP). The Gross Motor Function Measure (GMFM) has been developed specifically for use with children who have an established diagnosis such as cerebral palsy. It allows for the evaluation of the amount of change over time in several gross motor domains such as lying, sitting, and walking. The Gross Motor Performance Measure (GMPM), which has recently been developed, allows for the evaluation of qualitative changes in gross motor function. This should prove to be an important measure, as often the child with a disability shows improvement in the quality but not the quantity of movement following an intervention program. Once the evaluation is complete, the therapist works with the child and the family to establish treatment goals and the intervention plan. The plan takes into consideration the needs of the child and the dynamics of the family unit. Intervention strategies are developed by analyzing a gross motor task and determining which components are missing or impaired. In the past, traditional physical therapy intervention was composed of hands-on treatment with the goal of inhibiting abnormal movement patterns and facilitating more normal motor responses from the child. Current principles of motor learning encourage the child to initiate the movement with the therapist acting only as the guide or coach. Movements are repeated in a simple environment, then expanded into more complex situations with regular feedback of performance and results given to the child. This enables the child to better learn and retain the motor task. Strengthening activities were once contraindicated for the child with spasticity, as these exercises were thought to increase the abnormal muscle tone. Recent literature suggests this is not the case, and that, in fact, strengthening of a spastic limb may improve its ability to function. Muscle strengthening in the very young child presents an interesting challenge for the physical therapist. The child may be unable or uninterested in doing specific muscle-strengthening exercises. It is then necessary for the physical therapist to incorporate strengthening into a play activity that suits the age and cognitive level of the child. The intensity and type of physical therapy intervention varies during the course of the child’s growth and develRehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
336 / The Office Visit: Developmental Delay
opment. During infancy and preschool years the child may receive frequent intervention, with the goals of maximizing gross motor performance and preparing for entry into school. This may also involve evaluation of the need for assistive devices such as orthotics, walkers, and wheelchairs to promote best function in the child’s environment. When the child reaches school age, physical therapy may continue as regular treatment but at a less frequent intensity. The therapist may also act as a consultant to ease integration into the classroom and school setting. As the child grows, the physical therapist carries out periodic reevaluations, in collaboration with other members of the medical team, to determine whether any new impairments have arisen such as a scoliosis or joint contractures. The therapist works with the child, the family, and the medical team to develop new intervention strategies to minimize the impairments. Should the child require surgery, the intensity of physical therapy intervention increases in the preoperative period to prepare the child for the surgery and in the postoperative period to return the child to the preoperative level of function. The child with a neurologic impairment may demonstrate a tendency to be less active than other children. This can lead to deconditioning, poor physical fitness, and weight gain that may further impair the child’s mobility. The physical therapist has an important role and responsibility to assist the child with the development and maintenance of both physical and cardiovascular fitness. The therapist can work with the child and the family to determine the child’s exercise and sporting interests and to direct them to the appropriate resources for adaptive fitness and sporting activities. As the child progresses through adolescence to adulthood, the physical therapist can assist the family with the transition from pediatric to adult medical and therapeutic services. This is usually a difficult transition for both the child and the family. The family may find that the services may be dispersed throughout several different institutions with little or no coordination or communication among centers. The physical therapist not only assists the family in determining the appropriate resources but also acts as an advocate for the young adult to ensure that adequate follow-up is obtained. In summary, the physical therapist assists in the development of gross motor skills, which enable the child to be mobile and achieve active participation in his or her environment.
New Directions in Rehabilitation Practice
Rehabilitation specialists increasingly adopt a biopsychosocial view of pediatric rehabilitation, recognizing that developmental disability not only results from the medical
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
(biologic) condition, but is also in part a socially created process (psychosocial). Activity limitations may occur because of deficits or impairments of the nervous system but may be further exacerbated by environmental factors (eg, physical, attitudinal, or social barriers) that inhibit functioning. As such, occupational and physical therapists increasingly appreciate the importance of personal and environmental factors that can influence health and wellbeing. Recently, the World Health Organization endorsed this broader perspective of functioning in their new International Classification of Functioning, Disability, and Health. This holistic view defines health as encompassing body structures and functions (organ system level), activity (individual level) and participation (societal level). This conceptual framework recognizes the importance of contextual factors (personal and environmental) as mediators of functioning and health. With this framework in mind, rehabilitation specialists increasingly use a transactive approach to the therapeutic process, recognizing there is a dynamic interplay between the child’s abilities and deficits, the daily tasks and activities that are expected for their age and culture, and the environmental context (home, school, and community) in which they live. As such, treatment not only focuses on “fixing” or minimizing deficits (eg, spasticity, restricted range of motion, coordination difficulties, and perceptual deficits), but also applies strategies (eg, using aids and adaptations, or simplifying the task) to promote functional independence in spite of the child’s impairments. Family-centered care is a service delivery model that recognizes that the family knows their child best and therefore should work collaboratively with health professionals to prioritize goals and assist in the decision-making process for program planning. Family members are encouraged to participate actively in the rehabilitation process. Therapists provide information and support, thus enabling families to become more competent and confident as caregivers of a child with a disability. Increasing evidence supports the benefits of a family-centered approach to practice in terms of family satisfaction with service and optimizing functional outcomes for the child. Rehabilitation specialists are increasingly embracing the use of a family-centered model of care in practice. In recent years, budgetary constraints coupled with a greater demand for pediatric rehabilitation services have meant health professionals have needed to be even more accountable for the benefits of their interventions. Therapists must now make clinical decisions based on the most current available scientific evidence and new theoretical models in the field. In particular, there has been tremendous development in the area of standardized pediatric outcome measures, enabling therapists to objectively document degree of responsiveness to treatment across a wide
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range of outcomes of interest. Most recently, measures are being developed to quantify change in discrete performance areas (eg, gait analysis or assessment of sensory modalities) and to ascertain benefits in health-related quality of life, level of functioning, and participation. Therefore, clinicians are now expected to build on their core professional knowledge by keeping up to date with new knowledge, to ensure best practice. This concept of evidence-based practice has been accompanied by the advancement of the professional training programs in occupational and physical therapy to a master’s level across North America.
Practitioner and Patient Resources
American Occupational Therapy Association (AOTA) http://www.aota.org AOTA is the nationally recognized professional association of approximately 40,000 occupational therapists, occupational therapy assistants, and students of occupational therapy. AOTA advances the quality, availability, use, and support of occupational therapy through standard-setting, advocacy, education, and research on behalf of its members and the public. American Physical Therapy Association (APTA) http://www.apta.org APTA is a national professional organization representing more than 63,000 members. Its goal is to foster advancements in physical therapy practice, research, and education. Canadian Association of Occupational Therapists (CAOT) http://www.caot.ca CAOT provides services, products, events, and networking opportunities to help occupational therapists achieve excellence in their professional practice. In addition, CAOT provides national leadership to actively develop and promote the clientcentered profession of occupational therapy in Canada and internationally. Canadian Physiotherapy Association (CPA) http://www.physiotherapy.ca CPA is the national professional association representing approximately 9,000 members distributed throughout all provinces and territories. CPA’s mission is to provide leadership and direction to the physiotherapy profession, foster excellence in practice, education, and research, and promote high standards of health in Canada. International Classification of Functioning, Disability and Health (ICF) http://www3.who.int/icf/icftemplate.cfm The World Health Organization’s ICF describes how people live with their health condition. ICF is a classification of health and health-related domains that describe body functions and structures, activities, and participation. The domains are classified from body, individual, and societal perspectives. Because an individual’s functioning and disability occurs in a context, ICF also includes a list of environmental factors.
Summary
Pediatric neurologists need to appreciate the roles and functions of physical and occupational therapists as part of the management of children with or at risk for developmental disabilities. Rehabilitation specialists work collaboratively with the child and family to develop or restore function, increase competency, autonomy, and community integration, and also to prevent disability, social isolation, and family stress. As members of an interdisciplinary team, occupational therapists and physical therapists collectively help neurologically impaired children meet their daily needs and demands in the context of their environment and enable families to become effective caregivers.
Suggested Readings
Campbell SK, editor. Pediatric neurologic physical therapy. 2nd ed. New York: Churchill Livingstone; 1991. Campbell SK, Vander Liinden DW, Palisano RJ, editors. Physical therapy for children. 2nd ed. Philadelphia (PA): W.B. Saunders Company; 2000. Case-Smith J, ed. Occupational therapy for children. 4th ed. St. Louis (MO): Mosby; 2001. Dunn WW. Best practice occupational therapy: in community service with children and families. Thorofare (NJ): Slack Incorporated; 2000. Helders PJ, Engelbert RH, Custers JW, et al. Creating and being created: the changing panorama of paediatric rehabilitation. Pediatr Rehabil 2003;6:5–12.
Current Management in Child Neurology, Third Edition © 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc
Rehabilitation: The Role of Occupational Therapy and Physical Therapy Pages 332–337
