Treatment of the Child with Severe Impairments Jacqueline Grimenstein, PT, C/NDT, CKTP jgrimenstein@gmail.com 1
Introduction • What defines a child with severe impairments • Treating children with severe impairments presents a unique challenge to set goals that are both realistic and optimistic • Our role is to assist the child to function within the family and community and assist the family to nurture and care for their child 2
Use of Classification Systems • Gross Motor Function Classification System • Manual Abilities Classification System • Communication Function Classification System • Eating and Drinking Ability Classification System Levels IV and V of each system encompasses involvement 3
Gross Motor Classification System for Cerebral Palsy Level IV: self ‐ mobility with limitations; children are transported or use power mobility for outdoors i.e. age 2 ‐ 4: children floor sit when placed, but cannot balance or use hands for support; frequently require adaptive seating and aids for standing; may roll, creep on belly Level V: self mobility is severely limited even with assistive technology i.e. age 2 ‐ 12: restricted voluntary control to maintain antigravity head and trunk postures; no means of independent mobility, except maybe with a power wheelchair Palisano, et al. McMaster University, Hamilton, Ontario Dev Med Child Neurology , 39.214 ‐ 223, 1997; www.canchild.ca 4
GMFCS 5
The Manual Classification System • Level IV: handles a limited selection of easily managed objects in adapted situations; limited success with assistance of adaptive equipment • Level V: does not handle objects and has severely limited ability to perform even simple actions; needs total assistance Eliasson AC, et al. Dev Med and Child Neurology; 2006; 48: 549 ‐ 554. www.macs.nu 6
Supplementary MACS Level Identification Chart To be used together with the MACS leaflet No Yes Does the child handle most kinds of objects independently? Does the child perform even difficult Does the child performs a number of manual manual tasks with fair speed and accuracy tasks which commonly need to be adapted or and does not need to use alternative ways prepared, and help only needed occasionally? of performance? Yes No Yes No Level III: Does the child Level II: Level I: Handles objects handle some easy Handles most objects Handles objects with difficulty, to handle objects if but with somewhat easily and needs help to frequently reduced quality successfully. At prepare and/or supported? and/or speed of most limitations in modify activities achievement. May the case of No Yes avoid some tasks or performing manual Level V: Level IV: use alternative ways tasks requiring Does not handle Handles a limited of performance. speed and accuracy. objects and severely selection of easily limited ability to mange objects in perform even simple adapted situations, actions. Requires total Field Trial Version, www.macs.nu requires continuous 7 assistance. support.
The Communication Function Classification System • Level IV: Inconsistently sends and/or receives (communication) even with familiar partners • Level V: Seldom effectively sends or receives (communication) even with familiar partners Hidecker et al. Dev Med and Child Neurology. 2011, 53: 704 ‐ 710 www.cfcs.us 8
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The Eating and Drinking Ability Classification System • Level IV: Eats and drinks with significant limitations to safety • Level V: Unable to eat and drink safely – tube feeding may be considered to provide nutrition Seller, et al. Dev Med and Child Neurology, 2014; 56: 245 ‐ 251 www.sussexcommunity.nhs.uk 10
Eating & Drinking Ability Classification System – Algorithm Is the individual able to swallow food and drink without risk of aspiration? Yes No Is the individual able to bite Can risks of aspiration be and chew on hard lumps of managed to eliminate hard food without a risk of to the individual? choking? No No Yes Yes Level III Level V Is the individual able to eat Eats and Unable to eat Level IV a meal in the same time as drinks with or drink Eats and peers? some safely – tube drinks with limitations to feeding may significant Yes No safety; there be limitations to maybe Level II considered to safety Level I limitations to Eats and provide Eats and efficiency drinks but nutrition drinks safely with some and limitations to www.sussexcommunity.nhs.uk 11 efficiently efficiency
Purpose of These Classification Systems • Provide general level of functioning for all who are involved in the care of a child with neurologic impairments or similar disabilities. • Do not and cannot address participation • Are measures of usual performance (not best performance) on a daily basis • Information gathered help guide intervention, planning, goal setting and prognosis for function • For research purposes – group children for description and stratification • May be used to assist administrators and payers allocate resources 12
The Evaluation Process • ICF Model – Looking at the whole picture • Evaluating by system • The role of standardized testing 13
The NDT/Bobath (Neuro ‐ Developmental Treatment/Bobath) Approach NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. The therapist uses the International Classification of Functioning, Disability, and Health (ICF) model in a problem solving approach to assess activity and participation, thereby to identify and prioritize relevant integrities and impairments as a basis for establishing achievable outcomes with clients and caregivers. An in ‐ depth knowledge of the human movement system, including the understanding of typical and atypical development, and expertise in analyzing postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activating optimal sensorimotor processing, task performance, and skill acquisition to enable participation in meaningful activities. 14
Individual Social Functional Domain domain Body structure and function Contextual Factors 15
International Classification of Function 16
ICF Domains • Pathophysiology • Family Goals • + contextual factors • ‐ contextual factors • Participation • Participation Restrictions • Functional Activities • Functional Limitations 17
Pathophysiology • Underlying medical condition or injury that interrupts or interferes with normal physiological and developmental processes in any dimension of the individual. 18
Family Functional Goals • What outcome will benefit the family as a whole and the child specifically • Ask family what functional activity will help them in the care of their child or what task would they like the child to do better • Ask child, if appropriate, what he/she would like to change or do that he/she cannot due currently 19
Contextual Factors • Extraneous factors surrounding the child and family that may influence the outcome of the treatment program either positive or negative 20
Participation • What age appropriate activities within the family or community can the child take part in or is excluded from due to his/her limitations and how much assistance or support does he/she need to be a functional member of society 21
Functional Activities/Limitations • In this section look at what the child can or cannot do. • Examples of positive activities may include: can walk, can talk, can eat, etc. • Limitations can include: cannot transition, cannot feed self, cannot dress self, needs assistance with transitions 22
Neuroplasticity: Research by Jeffrey Kleim: • Only relevant tasks will induce placticity • In an intact neuro system it takes around 2000 repetitions to make changes the motor map • Motor map represents skill efficiency • Need 500 repetitions to learn a skill and 5000 to unlearn 23
Lab – Looking at Early Development • How does a typical baby develop head and trunk control • Video of typical development 24
Video Treatment of the Respiratory System 25
Lab: Focus on the Core • Insufficient anti ‐ gravity trunk control/poor head control • Can the child activate and sustain muscle activity • What affects do you see on the respiratory system • Treatment strategies for treating the respiratory system 26
OGANIZATION OF MOTOR BEHAVIOR Systems Approach 27
Interaction of the Individual, the Environment and the Task • Want the child to perform at his absolute best within his disability • Subsystems are plastic and adaptive to both internal and external changes • The environment includes everyone the child comes in contact with on a regular basis • Initially focus on completion vs quality of component movements 28
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How does this fit with the child with severe impairments • Since children in the level IV and V classifications do not fit the norm of our evaluation process how do we go about looking at the systems • Primarily want to look at how the various systems are equipped to support basic life functions; breathing, state regulation, heart rate, sensory system, awake/asleep cycles and feeding and digestion 30
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