Yasmin is a sixteen-year-old girl with athetoid cerebral palsy, GMFCS level IV. She is passionate about her studies and has already gone to check out a few colleges. She is thinking about living in a dorm. As her PT, are there measures that will help you learn about her current level of participation? You know about her activity capacity, but not as much about her current level of performance – and that is what will matter as she transitions to more independent living. After some thought, you decide to update the TRANSITION-Q for health management skills and the ACTIVLIM-CP for daily activities. Additionally, you are going to update Yasmin’s COPM to prioritize her individual goals.
I’ve recently discovered the world of performance and participation measures. They can begin to bridge the gap between physical therapy appointments and higher participation in daily life. Some measures are free and translated into many languages. Other measures assess global performance change after PT intensives, Botox, or surgery. Many of these are new to me, aside from the CHAQ, PEM-CY, COPM, and GAS. It is exciting to think of the potential and I look forward to trying them out in the months to come! Continue reading “Tests & Measures for Participation”
Luca is a 7-year-old boy with Duchenne Muscular Dystrophy. As his physical therapist, you are wondering about tests and measures that fit into the activity section of the ICF. Thinking of how to quantify his activity, you decide to use the North Star Ambulatory Assessment (NSAA) to measure transitions and mobility, the Timed Floor to Stand-Natural (TFTS-N) to time his rise from the floor, and the Six Minute Walk Test (6MWT) to measure distance walking.
Continue reading “Tests, Measures, & Classification Systems for Activity”
“When Phoebe’s little legs are tucked under her body, I see how she was able to fit into the tiny space of the womb. At first I was concerned because I didn’t know why her legs were positioned like that.”
Babies born at gestational term have a tightness to their bodies called physiological flexion. Space was limited in the final trimester and the baby assumed the most compact position with arms and legs held close to her core. Physiological flexion provides some passive stability for the newborn baby to use for function. Practice will provide an opportunity to decrease muscle tightness through active movement. In turn, active movement provides sensory input and postural control. Development happens gradually, month by month with one skill building upon another. The posts in the milestones category describe the maturation of babies in the first year of life as they begin tightly flexed and learn to roll, sit, cruise and stand.
Continue reading “Why Do the Legs of Newborn Babies Look Bowed?”
Elise is constantly falling during her school day. She often has skinned knees and bruises. Although she is 10, she walks down stairs one step at a time. As Elise’s physical therapist, what will you use to measure her functional balance skills? How will you document her progress?
Balance is defined as the ability to keep the center of mass over the base of support.
Postural control is the act of maintaining, achieving or restoring a state of balance during an activity.
Link to Pediatric Balance Scale Score Sheet with minimal detectable change (MDC) & minimally clinically important difference (MCID) values.
Pediatric physical therapists informally evaluate balance and postural control in every movement. Multiple body systems contribute to balance, and this makes measurement of functional balance somewhat challenging.
Continue reading “How to Use the Pediatric Balance Scale”
“My 6-month old daughter rocks on her belly and moves her arms all around. It looks like she is swimming on land! What is going on while she is playing like that?”
This swimming motion, common during the development of 5-6 month olds, is also known as pivot prone. The first time you might see something like this would be during a Landau reaction. The Landau reaction emerges at approximately 3 months as a reflex/postural reaction, allowing the baby to extend against gravity while held at the stomach. However, by 5-6 months of age, the baby has developed the strength and flexibility to play with it in a variety of ways while on the floor. These new sensations and movement keep interest in the activity. You might see a few seconds of swimming motion followed by a push into the floor or rocking back and forth. In these actions, the baby is strengthening their postural control system to balance flexion and extension. The difference in this stage is that the gluteals are becoming active and the hips are fully elongated. With practice the thighs begin to come off the ground through the action of the gluteals. During pivot prone, there is eccentric action of the abdominals as the baby extends so there is also controlled motion through the range.
During pivot prone play, the baby is strengthening and discovering:
Continue reading “6 Months: Pivot Prone”
Q: What happens when a baby brings hands to knees and then weight shifts or looks to the side?
A: Her whole body rolls to the side and she learns to control it and use it for function.
Around 5-6 months, this little one has learned to initiate some big movements like pushing up onto hands while on her stomach and grabbing knees and feet while on her back. She is busy reaching and looking around. Combining foundation skills such as hands to knees and weight shifts, larger movements begin to evolve, like rolling from back to side (otherwise known as supine to sidelying). At this stage babies may enjoy playing while balancing in sidelying. They may also enjoy the sensation of rolling.
What is happening as this baby rolls from supine to sidelying?
Continue reading “5 Months: Rolling to Side”
Life is so exciting for the six month old; once she learns to roll to the side, it is fun to play in this position. Beyond fun for the little one, what special things are happening with development at this stage? After all, play is child’s work.
- Mastering the balance of flexion and extension in the trunk: she is able to play in sidelying without falling forward or backward.
- Increasing shoulder girdle control and stability- allowing propping on one arm to play.
- Emergence/increasing lower extremity dissociation: one foot can prop to meet the ground and stabilize in this position. To do this, one leg must be flexed, the other extended while weight is increasingly shifted to the hip that contacts the floor.
- Foot weight-bearing: bringing the foot to meet the ground and getting some weight on to different parts of the foot in order to prepare for standing.
- Lateral flexibility and of the trunk/rib cage.
- Lateral head righting against gravity.
From this position your little one can grab toys to mouth, providing a whole new level of independence for exploration! All of these movements build the foundation for transitions that come in later months like progressing to side sitting, getting up on all fours and pulling to stand.
Your 5-month-old just learned to lift his feet from the ground and grab them with his hands. What’s next? Putting the toes into the mouth, of course!
This is such a sweet phase of development. Here is a quick review of the amazing things that are happening as your baby pulls her toes to her mouth.
- Activated abdominal muscles! You can see activity in the lower abdominals from the wrinkles on this baby’s tummy. Additionally, the baby’s pelvis is up off the ground.
- Developing and strengthening downward visual gaze/capitol flexion.
- Developing and strengthening balance of postural flexors and extensors, now in advancing to a diagonal motion.
- Grasping and pulling feet with either one or both hands.
- Activating quadriceps muscles as the leg straightens.
- Stretching out hamstrings from the physiological flexion present at birth.
- Stretching the toes into extension.
- Foot desensitization (with the heel pounding that happens when the feet hit the floor again).
- Tactile input from mouthing, grabbing, stretching; preparing the feet for walking.
- Developing general body awareness.
When a baby discovers this position, they are becoming experts at rolling to their side.
There are hundreds of medical reports in Kiyoshi’s file. In addition to oligoarticular juvenile idiopathic arthritis (JIA) he has uveitis and a seizure disorder. Kiyoshi has severe pain, joint contractures and difficulty moving around. Medications are not controlling the inflammation, there have been more seizures lately and his foot orthotics are too small. How do you begin physical therapy decision-making with a child this complex?
The International Classification of Functioning (ICF) conceptual framework allows you to apply your knowledge and skills to challenging situations. It will take a while to sort information into proper categories and edit. However, once this is complete, connections become clear and sound clinical decision-making will follow. The question I get asked most often about the ICF is , “where do you start?”. This post will guide you as you fill in the ICF/NDTA Enablement Model categories for the first time. Continue reading “10 Strategies For Filling In the ICF-CY/ NDTA Enablement Model”
Freya is a 6-year-old girl with ataxic cerebral palsy. She moved to California from Iowa last month and has been prescribed six months of physical therapy. Freya’s parents are concerned; she has been having difficulty going down the front stairs of their new home. As her physical therapist, do you have a standardized test that will measure her initial gross motor function? In six months, how will you determine whether Freya has made progress?
GMFM-66 Quick Facts:
- 5mo-16 years
- Cerebral palsy or Down Syndrome
- Test re-test reliability GMAE-scoring method: 0.9932
- Most sensitive to change in children 5 years and younger
- Motor growth curves link
My Gross Motor Function Measure User’s Manual is tattered. I could not work without the GMFM! Like all things that are well designed, the creators have taken a complex concept and made it logical and simple. The GMFM is an evaluative measure that assesses change in motor function over time. I can test Freya in January, provide PT 1x/week and then retest in July to determine if she has made significant progress. In addition, I won’t overlook Freya’s inability to reach across midline while I am heavily focused on her stair skills; the test covers all domains from lying and rolling up to running and jumping, with each skill being incrementally harder than the last (in the GMFM-66). Continue reading “How to Use the Gross Motor Function Measure (GMFM-66)”