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TIPS OF THE TRADE THINGS TO DO BEFORE YOU START YOUR "OFFICIAL" EXAMINATION 4 Main Things:

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Open Environment (big room) Essential to establish rapport with patient and family/caregiver (biggest) Early communication with the patient/family/caregiver Efficient and flexible plan O R C F

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COMMONLY SEEN REFERRAL DIAGNOSES

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Commonly seen: -abuse -TBI Can see orthopedics

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DEVELOPMENTAL DELAY Typically used to describe a child? Could mean?

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Typically used to describe a child that is not developing appropriately in *one or more areas* (fine motor, gross motor, etc.) without a known cause Could mean ANYTHING

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REFERRALSAYS... Walks with a limp Drags left foot Doesn't use right arm Won't sit up Walks on toes Tight muscles 1.) Are any of these diagnoses? 2.) It may be necessary to help family pursue a diagnosis?

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1.) No - but turned out to be an in urtero stroke. 2.) we cannot diagnose, but we can mention it.

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OBSERVATION should be? Part of establishing __________ Can occur during? Allows for the most natural assessment What to observe?

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Play based Part of establishing rapport Can occur during caregiver interview Allows for the most natural assessment What to observe -

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CAREGIVERINTERVIEW 1.) Birth history -explain three questions? 2.) Medical history - 5 questions:

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1.) ask questions about birth history -was the child 38 month at birth or 40 months = need to know to find adjusted age = what to expect -any problems during delivery (c-section or vaginal) -birth weight 2.) Medical history Illnesses, including seizure activity, surgery, hospital stays, medications Equipment, if applicable Imaging or other *diagnostic testing* Any *prior history of therapy* or getting therapy anywhere else

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CAREGIVERINTERVIEW 1.) Development history 2 main things? 2.) Social History -5 main things

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1.) Development history When were milestones achieved Growth and feeding 2.) Social History Daily routine, including sleep Home environment Primary caregiver Where does the child spend the majority of the day Educational history, if applicable

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SYSTEMSREVIEW 1.) Cardiovascular-pulmonary Observation of _________________, monitor as needed Note history of/current use of ______________ 2 other things? 2.) Neurological* State regulation, and 2 other things? 3.) Musculoskeletal* -what to look out for? 4.) Integumentary Scars, skin lesions/rashes, hair patches or excessive hairiness

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1.) Cardiovascular-pulmonary Observation of respiratory rate, monitor as needed Note history of/current use of oxygen Heart rate and BP 2.) Neurological* State regulation, eye contact and tracking, shunt 3.) Height, weight, *head circumference/shape*, pain

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SYSTEMSREVIEW Endocrine system Onset of puberty, if applicable; emotional lability, stature GI - look for?? Reflux, vomiting, constipation, weight gain/loss, tracheostomy, G tube Lymphatic/Immune - ask about? Any swelling, joint pain, general malaise, h/o immunosuppression Genitourinary Bowel/bladder function

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GI = look for GI tube. Immune: ask about juvenile RA

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STANDARDIZED ASSESSMENTS May be ______________, _______________ or used as _________________. Must choose wisely Are frequently becoming a requirement for? Will discuss specific assessments and strategies

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May be predictive, diagnostic or used as outcome measures Must choose wisely Are frequently becoming a requirement for insurance purposes Will discuss specific assessments and strategies

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PAIN 1.) 2 main ways to attain? Over ____ pain assessment tools for infants Common tools are? (3) Ask parent about reports of pain Inquire about pain in age appropriate terms

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1.) ask parents or use wong-baker FACES Over 40 pain assessment tools for infants Common tools are 0-10 rating scale, FACES and the universal pain assessment tool Ask parent about reports of pain Inquire about pain in age appropriate terms

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NEUROLOGIC SYSTEM 1.) 3 main things 2.) 2 other important ones:

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Deep Tendon Reflexes -Other reflexes, righting and protective reactions Report of numbness or tingling, report or observation of legs "giving away" Seizure activity Clonus -Unsustained clonus common in newborn and up to a year old Muscle Tone

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TONE What is tone? How do we describe it? How do we measure it? How do we assess it? -what position? -Observation of? (3) When assessing fir soacticity?

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What is tone? -muscle tonicity or flacidity How do we describe it? -hypertonia or hypotonia How do we measure it? (don't memorize -Tardieu Scale -Modified Ashworth Scale (unreliable in kids) -Mild, moderate, severe How do we assess it? -With child lying supine, passive movement of upper and lower extremities -Observation of sitting and standing posture and voluntary movements. assessing for spasticity : move faster (velocity dependent)

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DYSTONIA Define: Can be _______________ or?

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involuntary jerky twisting movements. Can be a diagnosis on its own or a symptom of a neurological disorder

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RIGIDITY Difference from spasticity? Due to? Incredibly difficult to break/move through range, often stays where placed

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RIGIDITY Not velocity dependent Simultaneous contraction of agonist and antagonist muscles Incredibly difficult to break/move through range, often stays where placed

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seizures 1.) 3 ways of management:

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oMedications oSurgery oVagal nerve stimulator -having a seizer = magnet can reset it.

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HYPOTONIA Define: Often described as: Common in? Thought to be due to? Will see? Children with low tone may "hang" on ligaments, move less, have poor mid range control, difficulties with postural control and balance

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Excessively low resistance to passive stretch Often described as "floppy", "mushy" Common in certain diagnoses (e.g. Down Syndrome) Thought to be due to decreased descending outputs Will see excessive ROM Children with low tone may "hang" on ligaments, move less, have poor mid range control, difficulties with postural control and balance

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why do we need to include muscle tone in exam?? - *objective measures are less effective for kids*

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1.) can affect all motions

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WHY ASSESSING MUSCLE TONE IS IMPORTANT Need to understand for effective? - Not just "is it there" but? Abnormal tone influences (2) what condition has tight adductors?

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Need to understand for effective plan of care development - Not just "is it there" but "what is it affecting, if anything?" Abnormal tone influences - active movement such as sitting, standing, running, jumping, etc. - passive range (muscle length) CP

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MUSCULOSKELETALSYSTEM:RANGEOFMOTION General passive screen of UE/LE range Visual estimation Goniometry if indicated

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General passive screen of UE/LE range Visual estimation Goniometry if indicated *Not common*

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GENERALSCREEN/ESTIMATION Decision making regarding how to assess ROM must be made on a case by case basis Will need to spend more time with more involved cases, such as cerebral palsy, where ROM limitations are generally a significant concern why can it be a problem to do ROM? Starting with a quick screen of passive ROM will help guide you to decide whether to measure As you gain experience, visual estimation will become a useful toolFunctional assessment of ROM during play and standardized testing

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Decision making regarding how to assess ROM must be made on a case by case basis Will need to spend more time with more involved cases, such as cerebral palsy, where ROM limitations are generally a significant concern you can get caught up and think it is the restriction motion when it isn't Starting with a quick screen of passive ROM will help guide you to decide whether to measure As you gain experience, visual estimation will become a useful toolFunctional assessment of ROM during play and standardized testing

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MEASURING Goniometry reliable in? Much less reliable in? _________________ can be appropriate

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Goniometry reliable with healthy children Much less reliable in children with pathologies (e.g. cerebral palsy) Special tests can be appropriate

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Strength 1.) Manual muscle testing Less effective in? 2.) Dynamometry Has been shown to be reliable in some populations, but availability may be limited 3.) what strength is not available for kids??

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1.) Manual muscle testing Less effective in young children vs. 12+ 2.) Dynamometry Has been shown to be reliable in some populations, but availability may be limited 3.) Isokinetic machines May not be widely available Systems not designed for children

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STRENGTH 1.) Assessment of functional skills -4 ways 2.) Portions of standardized assessments In infants, strength is very closely tied to? 3 main things

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STRENGTH 1.) Assessment of functional skills To/from squat/stand To/from sit/stand To/from floor/stand To/from walker/wc 2.) Portions of standardized assessments In infants, strength is very closely tied to developmental skills Sit ups, push ups, broad jump

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BALANCE 1.) May assess during other portions of exam Portions of standardized testing Observe during play, walking and running 2.) Part of caregiver questioning 3.) What is the most common Pediatric Balance Scale (modified from Berg Balance scale)

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1.) May assess during other portions of exam Portions of standardized testing Observe during play, walking and running 2.) Part of caregiver questioning 3.) Pediatric balance assessments available Pediatric Balance Scale (modified from Berg Balance scale)

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OTHER TESTS 1.) TUDS -stands for? 2.) Could be an indicator of? Any pattern acceptable as is? ______ stairs

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1.) Timed up and down stairs (TUDS) 2.) Could be an indicator of ability to be active in community and at home Any pattern acceptable as is use of rail or not 14 stairs

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FITNESS 1.) When/Why assess fitness? - (3) 2.) Under 6 years Assess informally Look for signs of fatigue

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1.) When/Why assess fitness?Referrals for obesity Outcome measure for certain patient types If poor endurance is noted as a functional issue 2.) Under 6 years Assess informally Look for signs of fatigue

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FITNESS 1.) _______________ and over may participate in standardized protocols such as ______________________ 2.) Muscle Power Sprint Test 6 timed 15-m runs then calculate velocity, force, power 3.) 6 minute walk test

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1.) 6 years and over may participate in standardized protocols such as Modified Bruce Protocol 2.) Muscle Power Sprint Test 6 timed 15-m runs then calculate velocity, force, power 3.) 6 minute walk test

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WHEN THE EXAM IS OVER... If you do not feel you have enough information what do we do? Caregivers will want information from you right away what to do to assimilate information?

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If you do not feel you have enough information, can complete at another time Caregivers will want information from you right away It is okay to take time to step away to score tests or give yourself time to assimilate information

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WHENTHEEXAMISOVER... Make recommendations at that time, if able -Regarding? Be cautious with ______________________ - Be judicious about ___________________ or __________________ on the first visit - Referral recommendations

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Make recommendations at that time, if able -Regarding frequency of visits, episode of care Be cautious with recommendations - Be judicious about home exercise plan or equipment recommendations on the first visit - Referral recommendations

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DOCUMENTATION EXAM + ASSESSMENT + PLAN = EVALUATION 1.) Have a template to follow then add/change as needed Make notes on standardized test form Often difficult to document as you go Don't just report scores of tests 2.) Assessment what to put here?

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DOCUMENTATION EXAM + ASSESSMENT + PLAN = EVALUATION 1.) Have a template to follow then add/change as needed Make notes on standardized test form Often difficult to document as you go Don't just report scores of tests 2.) Assessment Problem list

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DOCUMENTATIONEXAM+ASSESSMENT+PLAN=EVALUATION 1.) Write goals last Objective, functional, measurable model still applies Caregiver/patient directed Correlate with impairments found, based on priority given Start with where they are, not where you expect them to be for their age Add modifiers as needed...doing a skill once is not the same as being able to replicate it

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Start where they are not where they should be... - write attainable goals based on how they present: quadruped > roll > crawl.

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COMMON ERRORS IN REPORTS 4 common errors

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Being vague Reporting only scores of standardized assessments Failing to assess strength Relating findings to goals

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