physical therapy

1. High risk infant and Neonatal
Intensive Care Unit
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2. High risk infant
• High-risk infants (HRI) are defined according to a policy
statement from the American Academy of Pediatrics
comprehensively as including
(a) The preterm infant,
(b) The infant with unique human services needs or
dependence on technology,
(c) The infant in danger as a result of family issues (alcohol
and illicit drug use, cigarette smoking, and caffeine intake)
(d) The infant with anticipated early death (foreseen early
passing)

5. Neonatal Intensive Care Unit
• The neonatal intensive care unit (NICU) is a
technologically advanced setting that provides care to
infants who require highly specialized services.
• NICU care is a specialized area within pediatric physical
therapy, involving a different approach than that used in
other types of pediatric settings.

6. pediatric physical therapists (PTs)
need advanced education in areas such as
• early fetal and infant development;
• infant neurobehavior;
• family responses to having a sick newborn;
• the environment of the NICU,
• physiologic assessment, and monitoring;
• newborn pathologies, interventions, and outcomes;
• optimal discharge planning;
• collaboration with the members of the health care team.

7. Common Diagnoses of Infants in the Neonatal
Intensive Care Unit
1. Preterm birth.
2. Very low birth weight.
3. Hypoxic-ischemic encephalopathy.
4. Genetic syndromes and diseases.
5. Compromised respiration.
6. Persistent feeding problems.
7. Seizure disorder.
8. Amniotic band syndrome.
9. Myelomeningocele.
10.Neonatal abstinence syndrome
(NAS).

9. Apgar score
• The Apgar score is a quick way for doctors to evaluate the health of
all newborns at 1 and 5 minutes after birth and in response
to resuscitation.
• It was originally developed in 1952 by an anesthesiologist at Columbia
University, Dr. Virginia Apgar, as way to address the need for a
standardized way to evaluate infants shortly after birth.

10. Score of 0
Score of 1 Score of 2
Component of
backronym
Skin color
• blue or pale all
over
• blue at
extremities,
body pink
• no cyanosis
body and
extremities pink
• Appearance
Pulse rate • absent
• < 100 beats per
minute
• ≥ 100 beats per
minute
• Pulse
Reflex irritability
grimace
• no response to
stimulation
• grimace on
suction or
aggressive
stimulation
• cry on stimulation • Grimace
Muscle Tone • none • some flexion
• flexed arms and
legs that resist
extension
• Activity
Respiratory effort • absent
• weak, irregular,
gasping
• strong, robust cry • Respiration

11. Interpretation of scores
• Scores of seven and above are generally normal; four to six, fairly
low; and three and below are generally regarded as critically low and
cause for immediate resuscitative efforts.

12. levels of newborn care on the basis of functional
capabilities
 Level I: Well Newborn Nursery(35-37 weeks)
 Level II: Special Care Nursery (≤32 weeks)
 Level III: NICU( ≤32 weeks + < 1500 g. + critical
illness)
 Level IV: Regional NICU

13. Synactive Theory of Development

14. • Infant neurobehavioral functioning is understood as the
unfolding of sequential achievements in four
interdependent behavioral dimensions organized as
subsystems.
(1) stabilizes her autonomic or physiologic behavior,
(2) regulates or controls her motor behavior,
(3) organizes her behavioral states and her responsiveness
through interaction with her social and physical environment,
(4) orients to animate and inanimate objects.

15. The Newborn Individualized Developmental
Care and Assessment Program (NIDCAP):
• It is a model for clinical observation of infants in the NICU and
provides the framework for developmentally supportive care based on
the synactive theory.
• Behavioral cues are interpreted and care is provided through
individualized developmentally supportive care to promote self
regulation, behavioral organization, and overall development.
• The implementation of NIDCAP observations and developmentally
supportive care have improved patient outcomes and decreased the cost
of hospitalizations.

16. NICU
TEAMS
physicians
nurses
respiratory
therapists
nutritionists
physical
therapists
occupational
therapists
speech
therapists.

17. Role of Physical Therapy
1. Physical therapists receive
referrals from the neonatologist
or nurse practitioner to initiate
services to high-risk infants in
the NICU.
2. Infants in the NICU may be
referred at a specific time or
gestational age, or based on
their medical or birth history.
3. Physical therapy will be
included in examination,
intervention, reexamination, and
discharge planning.

19. Examination and Evaluation
• The initial examination consists of a chart review; observation of the
infant and caregivers; discussions with the neonatologist, nursing staff,
and the family; and handling or additional diagnostic procedures, if
appropriate.
• Based on the information obtained through the history and observation
of the infant, the physical therapist, along with the NICU team and
family, formulates a strategy for the physical therapy examination.

20. History
• Prenatal, birth, and current medical history and medical status are
reviewed and documented in the initial examination to get insight into
how an infant is functioning.
Observation
• Before the therapist places hands on the infant, information can be
obtained through observation alone.
• The position of the infant and any devices needed to maintain a
position should be noted throughout the examination.

21. • It is good practice to compare an infant’s behavior before (i.e., at rest),
during, and after caregiving/implementation of interventions. (Notice
physiological signs of stress and behavioral signs of stress).
• Through observation, the therapist also learns how the family or
nursing staff responds to the infant’s behavioral cues and supports or
promotes optimal development for the infant during routine caregiving.

22. Assessment of Muscle Tone, Movement, Strength,
and Reflexes:
• Muscle tone is evaluated through the assessment of resistance to
passive movement, observation of movement, and reflex testing.
• Movement and strength can be examined through general observations
with the type and fluidity of movement documented.
• Reflexes The development of reflexes and the symmetry of responses
to reflex testing can provide information about an infant’s neuromotor
system.

23. Neuromotor Assessment
• Screening for neurobehavioral sequelae is paramount for infants with
detectable risks such as preterm birth, atypical intrauterine growth,
encephalopathy, genetic abnormalities, and history of seizures.
• It is important to define the purpose for administering the test, which
may include:
(1) discriminating between infants who are developing
typically versus atypically.
(2) predicting future impairments from current function.
(3) evaluating changes in performance over time.

24. • In some cases, the physical therapist should consider using more than
one assessment tool to enhance the accuracy of results.
• Example of screening tools
1. General Movements Assessment (GMA).
2. Hammersmith Infant Neurological Examination (HINE)
3. The Test of Infant Motor Performance(TIMP)
4. Alberta Infant Motor Scale (AIMS)
5. Neuro Sensory Motor Development Assessment(NSMDA)
6. Bayley Scales of Infant and Toddler Development(BSITD-III)
7. Developmental Assessment of Young Children(DAYC-2)

25. Integrative Neuroprotective Care Approach to
Intervention
• A neuroprotective care approach is an interventional framework that
aligns with developmentally supportive care (interventions used to
support the developing brain or to facilitate the brain after a neuron
injury in a way that decreased neuronal cell death and allows it to heal
through developing new connections and pathways for functionality).

26. There are seven, overlapping neuroprotective core
measures:

27. Reexamination and Discharge Planning
• Physical therapists are continuously reevaluating infants during their
interventions.
• The plan of care for infants in the NICU is dynamic, changing as the infant
grows and changes.
• Physical therapists use reexamination to determine whether there are
changes in the infant’s status, whether goals and outcomes were achieved, and
whether modification in the intervention plan is needed to achieve the goals.
• Recommendations should be made for follow-up at discharge. This may be
a referral to an early intervention program or outpatient/home health physical
therapy.

28. Cardiovascular and Pulmonary
Systems

29. • Cardiovascular and pulmonary (CVP) impairments of body
structures and functions that occur during infancy and
childhood can, in the short term, be life threatening.
• In these cases, medical and physical therapy intervention is
focused primarily on acute-care issues.
• However, the long-term effects of CVP conditions can alter
the physical, social, and cognitive growth of a child, resulting
in multifaceted restrictions on activities and participation.

30. • Physical therapists treating children with CVP conditions must
not only focus on the evaluation and intervention of short-term
CVP systems–related impairments, but also carefully consider
issues related to long-term compliance to therapeutic
interventions, prevention of secondary impairments, and the
effects of impairments and interventions on the maturing
child’s changing social, cognitive, and behavioral development,
and eventual role in society.

31. VENTILATION
CIRCULATION
RESPIRATION
overall level of
functioning of
the CVP systems
at any given
instant.

32. • CVP conditions will have different effects on the components of
daily life and quality of life at different age levels.
• Medical management and interventions for CVP conditions
should consider the broader perspective and impact of care on
activities, participation, and quality of life throughout maturation.

33. Structural Differences in the Cardiovascular-
Pulmonary System of Children Compared with
That of Adults
Airway
• Higher larynx
• Smaller diameter of airways Increased resistance to airflow
Increased work of breathing
• Less cartilage within the airway walls for support
Alveolar
Capillary
Membrane
• Fewer alveoli
• Less developed collateral ventilation channels
• Thicker alveolar walls
• Capillary bed at a greater distance from alveolar wall
Bony Thorax • Increased compliance of the ribcage
• Horizontal alignment of ribcage
Muscles of
Ventilation
• Muscles perform as stabilizers rather than mobilizers
• Decreased length-tension relationship
• Diaphragm fibers have fewer fatigue-resistant fibers

34. Cardiovascular and Pulmonary Conditions
• Pediatric CVP conditions encompass a variety of diseases less often
encountered in adults because
(1) the defects may be surgically corrected by adulthood and no
longer create impairment;
(2) children may physically “outgrow” their symptoms; or
(3) in unfortunate cases, children die from their disease before
reaching adulthood.

35. Conditions That Impair Ventilation
• Ventilation is dependent on airflow through the airways to the respiratory
unit of the lung.
• Factors that affect ventilation include
1. abnormalities of the airway and
lung parenchyma,
2. musculoskeletal abnormalities of
the thoracic pump,
3. neuromuscular abnormalities of
the ventilatory muscles,
4. conditions of central respiratory
control,
5. integumentary conditions that
affect the thorax.

36. Conditions That Impair Circulation
• Circulation is dependent on
1. blood flow,
2. blood volume,
3. vascular resistance,
4. pressure gradients,
5. the force of muscle contraction of the heart.
• Circulatory defects in children are most often related to congenital
cardiovascular structural defects.

37. • Congenital cardiac defects are structural anomalies that either allow
for an alternative route of blood through the CVP systems or obstruct
the usual route of blood flow.

38. A-left-to-right shunts (acyanotic defects)
• Such defects include
1)patent ductus arteriosus (PDA),
2)atrial septal defect (ASD),
3)ventricular septal defect (VSD),
4)atrioventricular canal (AV canal or AVC).

39. B-right-to-left shunts (cyanosis defects.)
• Cyanotic defects include
1. tricuspid atresia (TA),
2. pulmonary atresia (PA),
3. transposition of the great arteries (TGA),
4. tetralogy of Fallot (TOF).
• All cyanotic defects are considered severe, often requiring intervention
as neonate or in early infancy.

40. C-obstructive cardiac defects
• Obstructive cardiac defects result in reduction of blood flow
systemically because of underdeveloped chambers of the heart or
blockages in blood vessels that prevent the proper amount of blood
from traveling to the body to meet its needs. Examples include
1. coarctation of the aorta
2. aortic stenosis.
3. pulmonary stenosis.

41. Conditions That Impair Respiration
• Respiration refers to the diffusion of gases across the alveolar-
capillary membrane.
• The most common pediatric conditions that impair respiration are
1. interstitial lung diseases.
2. congestive heart failure.
3. Sickle cell anemia.
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42. Examination and Evaluation
• many of the measurements used with adults who have CVP
conditions can be used when examining infants and children with
CVP conditions. Specialized equipment is needed to obtain accurate
measurement, such as smaller pediatric stethoscopes, SaO2 sensors,
and blood pressure cuffs.
• The impact of age on the ability to communicate, follow orders, and
remain attention to physical therapy examination and intervention is
inherent in all pediatric treatment
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43. 1-History
• Interviewing a child should yield information not only from the child but also
from parents, guardians, or other caregivers.
• The information obtained from the child and parent interview includes
1) demographics (age, primary language,
race/ethnicity, and gender),
2) Social history (family culture,
resources, social interactions, and
support services),
3) growth and development history
(gestational age at birth, labor,
delivery, and neonatal events),
4) details of the living environment
(e.g., home, school, daycare).
5) A history of present illness, past
medical and surgical history,
present medications, and pertinent
family history.

44. 2-Systems Review
General Observation and Palpation
Initial observation of the general appearance, posture,
breathing patterns, comfort during play and Alterations in
speech patterns activities can provide insight into CVP
status.

45. Tests and measurement
1-Vital Signs
• Measurement of vital signs in children includes
1. HR,
2. RR,
3. blood pressure (BP),
4. oxygen saturation of arterial blood
(SaO2),
5. a body temperature.
6. Body length and weight
7. extremity pulses

46. Comparison of Vital Signs Between Healthy
Children and Adults
Vital Signs Infant Child Adult
Heart rate (bpm) 100-140 80-120 60-100
Blood pressure
(mm Hg)
80/40 100/60 120/80
Respiratory rate
(breath per min.)
40/30 30/25 12/18

47. 2-Auscultation
 Auscultation procedures for child and
adult is the same.
 Infants and younger children may have
difficulty following commands to breathe
in and out for pulmonary auscultation.
 Asking young children to blow at a tissue
or at pretend birthday candles during
auscultation may provide deeper breaths
and more accurate results.
 The presence and intensity of pulmonary
adventitious sounds (e.g., crackles and
wheezes) as well as abnormal cardiac
sounds (e.g., murmurs) must be
documented.
 Transmission of abdominal sounds is
greater in children because of their
smaller size.
 Warming of the stethoscope’s head and
allowing the child to hold or play with
the stethoscope before auscultation can
decrease apprehension.

48. 3-Range of Motion
• ROM of the trunk and upper extremities, focusing on
proximal joints and chest wall excursion, should be
measured.
• Thoracic symmetry can be assessed at the same time.
Observation of any skeletal chest wall abnormalities
should be noted.

49. 4-Laboratory Studies
• Children with CVP conditions routinely have multiple laboratory
tests to assess cardiac and pulmonary status. The physical therapist
must integrate the information from multiple laboratory studies into
intervention planning and execution.
• For example, if laboratory test results indicate relative hypoxemia
based on arterial blood gas values, the therapist may need to reassess
exercise tolerance and consult with the physician for the need for
oxygen during exercise.

50. Comparison of Arterial Blood Gas Values
Between Healthy Children and Adults

51. 5-Radiology
• Chest radiography, computed tomography (CT) scanning, and magnetic
resonance imaging (MRI) can be used to evaluate heart size, amount of
pulmonary blood flow, and pulmonary infiltrates, the alignment of ribs or
atelectasis. The areas of infiltration identified will direct the physical therapist to
the segments of the lung needing intervention.
• An echocardiogram uses sound waves to produce a computer-generated picture
of the heart. (Look at the structure within the heart. Valvular stenosis or
incompetence or congenital defects) Echocardiography is now considered the
standard in diagnoses of congenital cardiac defects.
• Right- and left-side heart catheterization can also determine cardiac
structural defects in children.

52. 6-Electrocardiography
• ECG is used to measure HR and rhythm. ECG differences exist
among premature infants, newborns, and older children.
For neonates Adult
HR
150 and 230 bpm 60-90 bpm
PR interval
70 to 140 ms. (mean of 100) 120-200 ms.
QRS duration
<80 ms (increased with age) <120 ms.

53. Abnormal ECG findings in neonate
Abnormal ECG findings
related to rate
Include sinus arrhythmias, sinus tachycardia (HR> 166
bpm in the first week and 179 bpm in the first month
of life), or sinus bradycardia. (HR<91 bpm during the
first week and 107 bpm in the first month of life).
Abnormal findings related
to rhythm
1. abnormal P waves, which can be related to an
enlarged atria or non-sinus origin of the P wave;
atrioventricular or intraventricular conduction blocks;
2. QRS axis and amplitude deviations, which can be
seen in atrioventricular septal defects, ventricular
septal defects, tricuspid atresia, and Wolff-Parkinson-
White syndrome; and atrial and ventricular arrythmias.

54. 7-Pulmonary Function Tests
• Pulmonary function tests are effort dependent. (Usually initiated
between 6 and 8 years of age)
• Interpretation of the tests must be normalized for body size.
• Modifications of testing procedures, or selection of a subset of
pulmonary function measures, can make testing possible in younger
children.
• he use of specialized equipment, found predominantly in specialized
pediatric pulmonary centers, can make pulmonary function testing
possible even in young children.

58. 8-Ventilation-Perfusion Scans
• Ventilation-perfusion scans are performed to assess the matching of ventilation
to perfusion within the lungs.
• The performance of this test, and interpretation of the results, must
consider the more compliant ribcage, and physical maturation of the
child.
• The test results may be helpful in choosing body positions that optimize
ventilation and perfusion matching for a child’s daily positioning schedule.

59. 9-Exercise Testing
• Exercise testing in children yields information about the CVP systems
(HR, BP, RR, breathing pattern, and oxygen saturation) during
different workloads.
• The results of the exercise test allow a physical therapist to optimally
prescribe aerobic exercise.

60. Exercise and activity tolerance can be assessed at all
ages, although different modes of exercise may be used
For infants and children
under 3 years of age,
“formal” exercise tests are not performed, instead
activity tolerance can be assessed during crying, feeding,
and play activities.
Children older than 3
years of age
can perform submaximal treadmill and stair exercise
tolerance protocols (Bar-Or & Rowland, 2004).
Children older than 6
years of age
can participate in standardized exercise test protocols with
the ergometer workload or treadmill speed adjusted for the
motor skill level.
NB: Exercise test termination criteria are like those used in the adult population and
include reaching the pre-determined end point, excessive dyspnea, dizziness, or
cardiac arrythmias.

61. Physical Therapy Intervention
• Physical therapy intervention for the child with impairments of CVP
structures and functions, and restrictions in activities and participation,
requires a balance between the effects of short-term intervention and
long-term outcomes.
• Children with chronic or progressive CVP conditions may require
physical therapy intervention for a lifetime.
• Teaching family and other caregivers how to provide long-term
maintenance care should be integrated into the initial treatment
framework.

62. • As the child matures, physical therapy intervention should include
methods for more independent pulmonary hygiene programs.
• The inclusion of mechanical aids and independent exercise programs
allows the child with CVP impairments to be more independent in and
responsible for his or her own care.
• Physical therapy intervention includes the child’s social, family, and
medical well-being, in terms of both the immediate needs of a child
during an acute illness and activities to promote long-term function
and health.

63. Airway Clearance Techniques
1. manual secretion removal techniques of postural drainage, percussion,
and shaking
2. active cycle of breathing,
3. autogenic drainage,
4. positive expiratory pressure,
5. chest wall oscillation devices.

64. Increase Ventilation
1. Diaphragmatic Breathing Exercises
2. Segmental Breathing Exercises
3. Range-of-Motion Exercises
4. Positioning Considerations

65. Improve inhalation Improve exhalation
1. Shoulder flexion, abduction, and
external rotation.
2. Trunk extension
3. Neck extension
1. Shoulder extension, horizontal
adduction, and internal rotation
2. trunk flexion
3. neck flexion
The positions of the upper extremity, trunk, and neck
influence thoracic mobility.

66. Exercise and Aerobic Fitness
• Exercise Response in Children
• Current physical activity recommendations for children
• Exercise Prescription for Children

67. Exercise Response in Children differs from
adult:
The differences in cardiac response
1-Higher resting HR and higher
submaximal and maximal HR compared
with an adult.
2-Lower absolute resting stroke volume,
as well as a lower submaximal and
maximal stroke volume.
3- Lower in a child’s resting cardiac
output.
4-Lower relative cardiac outputs at
submaximal and maximal exercise.
5- Lower resting BP values in children.
Pulmonary system differences
1-Lower vital capacity and tidal
volume.
2-Higher resting RRs.
3-Lower resting minute ventilation.
4-Absolute minute ventilation is also
lower at submaximal and maximal
workloads.
5-Higher relative minute ventilation at
submaximal and maximal exercise.
6-Lower absolute VO2max.
7-lower relative Vo2 max.

68. Temperature regulation
1-lower ability to dissipate heat during exercise.
2-Higher heat loss during exercise in cold environmental conditions.

69. Current physical activity recommendations
for children
1-Higher resting HR and higher submaximal and maximal HR
compared with an adult.
2-Lower absolute resting stroke volume, as well as a lower submaximal
and maximal stroke volume.
3- Lower in a child’s resting cardiac output.
4-Lower relative cardiac outputs at submaximal and maximal exercise.
5- Lower resting BP values in children.

70. Exercise Prescription for Children
• Intensity
• Duration
• Frequency
• Mode

71. Equipment
1. Inhalation Devices
2. Vital Sign and Airflow Monitors
3. Mechanical Ventilation and Supplemental Oxygen
4. Implanted and External Medical Devices
5. Adaptive Supports