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Physical Therapy For Children: Behavioural Problems In School

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Physical Therapy For Children: Behavioural Problems In School Questions: Part 1: Based on the evaluation report (below), select two functional goals to be achieved by Jonathon within the next three months. From the evaluation report, list the impairments you feel are most likely contributing to each of the functional limitations (make two separate lists – one for each functional limitation). Part 2: Next, you need to develop intervention/treatment sessions. You may develop one session working on each functional limitation or you may combine the functional limitations (as we are often working on more than one goal in a intervention/ treatment session) and develop two different intervention/ treatment sessions (ie: one for this week and one for next week). Be sure to include the specific play and functional activities, positions in which the child would work, and how you would facilitate each activity with Jonathon. Part 3: Finally, select four of the six following topics and describe how the material covered in this course related to each topic would be applicable to Jonathon. Be specific as to how you would directly use what you learned to address each selected topic and how the information covered would direct your interventions. Educational services to address Jonathon’s needs Lower extremity orthoses and/or serial casts Medical/ surgical management of spasticity Jonathon’s assistive technology / equipment needs Future issues as Jonathan grows and develops Jonathon’s current and future physical fitness needs   Answers: Introduction Paediatric therapy is focused upon the therapy of children having various kinds of difficulties. Therefore, this part of medical biology and the medical practitioners has a greater concern as they are dealing with health issues of children and their health benefits are of greater concern. In this assignment, the key concentration is the 8-year old child Jonathon, who has been diagnosed with spastic diplegia. Jonathon was born prematurely at 32 weeks of gestation when he was weighed only 3 pounds 4 ounces (Campbell, Palisano & Orlin, 2012). Jonathon was kept in NICU for four weeks after his birth. Spastic diplegia is a special kind of cerebral palsy which is a chronic neuromuscular condition of hypertonia and spasticity. The condition is manifested by the tightness and stiffness of muscle, especially in the lower extremities of the body including legs, hip and pelvis. Usually, children diagnosed with this kind of cerebral palsy suffer from the various degree of activity and functional limitation, some of them cannot walk independently (Palisano et al., 2012). The paediatric physical therapy helps those children for improving their movements and daily activities through different kind of specialized exercise and physical therapy. Here, Jonathon needs some treatment sessions for improving his physical impairment and functional limitations. This assignment will be focused on developing functional goals for Jonathon’s health improvements and treatment plans based on this. Part 1 From the evaluation report of Jonathon, it has been revealed that Jonathon has a problem with his lower extremities of body, especially knee, ankle and hip. He has a problem with hip abduction and hip flexion. He has decreased the length of hamstring, femoris and hip internal rotator, thus, he is having the problem with ring-sitting and hip rotation. As well as he is having decreased mobility of the thoracic spine and full shoulder flexion and abduction are a limitations for him. Therefore, his two functional goals for physical therapy should be concerned with the improvement of hip flexibility and movement as well as the improved mobility of thoracic spine for better shoulder flexibility (Batshaw, Roizen & Lotrecchiano, 2013). The strengthening programs can be beneficial for long-term functional gains in the children with cerebral palsy, or specifically spastic diplegia. The strengthening program has been evaluated to enhance self-image, encourages the socialization and influences more active lifestyle of the children with spastic diplegia. Here, children with spastic diplegia, while undergoing strengthening the program, will increase strength, decrease activity limitation and improve his mobility with enhanced perceived societal participation (Palisano et al., 2012). In the case of Jonathon, these improvements are crucial as he is having the similar problem. Therefore, the functional objectives or goals should be set according to the goals of these programs. Two functional goals can be set for the health benefits of Jonathon. One is hip abduction and rotation improvements and the second one is the improvement of thoracic spine flexibility for shoulder movement. There are some limitations, more specifically; there are some activity limitations for Jonathon, listing that limitation will be helpful for understanding the specific health barriers for Jonathon and his appropriate health needs for planning the treatment or intervention sessions (Deluca et al., 2012).   For Hip flexibility, the limitations include: Jonathon ‘s mother is concerned with his left hip ‘turning in.’ Jonathon attempts to ring-sit, but his weight is shifted posteriorly on his sacrum in a posterior pelvic tilt His pelvis is shifted to left with a right side drop Jonathon has a decreased hip internal rotators on the left; his popliteal angle is 45º on right and 30º on left The strength testing results revealed that hip abduction is present only with hip flexion Jonathon is unable to demonstrate hip, ankle or stepping strategies Jonathon prefers to sit in W-sit position, as ring-sitting is difficult for him He can creep on knees and hands, but shows the bunny hop pattern, while doing it He is unable to rise from the floor without support due to the stiffness of hip muscle For spinal cord flexibility, the limitations include: Jonathon’s trunk and thoracic spine are kyphotic and head is forward with capital extension In standing, Jonathon is very asymmetrical For maintaining his trunk upright in a symmetrical position, he demonstrates excessive left lateral trunk flexion Jonathon’s full active shoulder flexion and abduction are limited by 20º bilaterally and forearms supination beyond 30º. He is independent in ambulation by rolling walker but has difficulties in ascending and descending curbs. Part 2 The treatment or intervention session for addressing Jonathon’s health needs is concentrated upon the improvement of spinal cord movement and flexibility and the hip flexibility. For these cases, strengthening program will have several benefits helping Jonathon to improve his daily activities and social participation via motor improvements (Greenberg & Harris, 2012). Intervention session for Hip flexibility and strengthening The trunk-hip strengthening on standing can help Jonathon to improve his hip flexibility. The exercise can help in trunk-hip activation and pelvic tilt motion while standing (Sterling et al., 2013). In spite of recommending the conventional trunk-hip exercise, Jonathon can be recommended to be provided with modified trunk-hip exercise improving the left pelvic tilt during standing. The trunk-hip exercise session will be planned for 3 months. The actual plan will be accompanied for 6 weeks, the exercises for the hip flexibility will be aligned with the physical activity plan for Jonathon’s spinal cord flexibility, and both plans will be assigned to Jonathon in a rotation, i.e. Jonathon will do exercise plan for hip flexion and abduction in one week and will undergo shoulder exercise plan in next week (Kisner & Colby, 2012). It will help him to avoid fatigue or muscle stiffness and will help muscles to become slowly active and lose tightness. Jonathon will be subjected to 30 minutes one-to-one session with his physical therapist per alternative weeks through 3 months. The modified trunk-hip strengthening exercise will have two parts; one is 15 minutes routine physiotherapy and 15 minutes trunk-hip exercise. The second part will consist of modified unilateral bridge exercise and modified prone bridge exercise. In the modified unilateral bridge exercise, at first, Jonathon will be directed to lie on the floor with both hands by sides and then will be guided to extend one leg and bend the other leg aligning the foot on the floor. Then Jonathon will attempt to raise the hip for making a straight line from the shoulder to knee (Howcroft et al. 2012). In this position, he would be guided to hold for 10 seconds and the same activity will be repeated for ten times. Then after taking 2 minutes break, Jonathon will shift to modified prone bridge exercise. Here, he will lie the face down on the floor with the support of forearm. After that, Jonathon will be guided to put his both feet on the wall flatly aligning legs with shoulder-width apart. As it has been revealed that, Jonathon is unable to support symmetrical trunk alignment; his trunk stability should be supported with a towel under his chest and pelvis (Franki et al. 2012). Then, he would be helped to raise slowly his body for creating a straight line from head to knee. In this position, he will have to hold for 10 seconds and repeat the position for ten times.   Intervention session for spinal extensions and flexibility Jonathon has a kyphotic spine and his head is forward with capital extension. Thus during standing, he is very asymmetrical and demonstrates excessive left lateral trunk flexion while maintaining his trunk upright in the position. He has a weak spinal extensors, especially thoracic extensor which i.e., kyphoic and thus he has difficulty in moving his body against gravity and maintain optimal posture and alignment. The overuse of flexor limits his activities of antagonist extensors. For improving his spine extension and flexibility, active prone extension exercise will be recommended (Verschuren et al., 2012). Jonathon will receive this exercise program for three months aligning with the hip exercise in alternative weeks. Jonathon will be advised to lie prone and lift his upper extremities of body and legs off the surface. The position will be like, flying like a superman and he would be suggested to hold his body in this position for 30 seconds. He will receive the exercise for three days per alternative weeks. Initially, the exercise will include only 30 minutes physical activity in the above position while progressing, the extension will include arms extension overhead or leaning over the edge of a table and trying to extend the arm beyond the table’s height. He can be recommended for thoracic extensor for being exercised while seating if he is unable to tolerate pronely. His physical activities can be more attractive and entertaining by making the activities in a fun activities like doing prone activities on a scooter, platform swing for pushing off a wall, knock down objects, wheelbarrow walking. As he attends swimming class, swimming can be advised for doing with support under his belly in swimming pool (Scholtes et al., 2012). Part 3 Educational Services to address Jonathon’s needs Jonathon is getting home schooling, as his psychologist has been suggested this after his cognitive tests. However, it has been revealed that Jonathon misses his classmates and misses their conversation and he uses to avoid difficult tasks by talking. He is not willingly cooperating with the home exercises. All of these scenarios are indicating Jonathon’s needs of being social and spending his childhood like another child with his classmates. Therefore, his parent can send him to a school where children with special needs are provided education and proper care services. His parents can undergo an educational lesson where they will be aware of their child’s health and educational needs. Recreational activities are recommended for his socialization. It will help him to become more active in ADLs (Whalen & Case-Smith, 2012).   Jonathon’s assistive technology/equipment needs AS Jonathon is having difficulties in excessive walking or lifting from the floor as well as other ADLs, Jonathon needs some assistive utensils for improving his daily life activities. In this context, he will need appropriately adapted vehicles, including wheelchair, for mobilization of long distances in roads or towards school. An adaptive tricycle can help him to improve eye-hand coordination and self-esteem and respiration. He needs standing equipment like rolling walker, forearm crutches and AFOs for improving his upright standing and short distance movement. His parents can use adaptive commode and bath chair for promoting his cognitive improvement in completing ADLs. Additionally, communication devices can be used (Darrah et al., 2012). Medical/ surgical management of spasticity There are number surgeries for the children with spastic diplegia. In the case of Jonathon, he has been undergone the bilateral derotation osteotomies and hamstring lengthening as well as heel cord lengthening. In this context, he can also be subjected to tendon lengthening and transfer as well as asthrodesis. However, at his age, physiotherapy is better to be performed, as the multilevel surgery is performed after eight years age (Brossard-Racine et al., 2012). Lower extremity orthoses and serial casts Jonathon has problems in lower extremities and thus he is using solid bilateral AFOs. He can do and off his shoes and AFOs in 10 minutes but quickly distracted. In this condition, serial casting will be beneficial for him. Serial casting of both legs in every 1 to 2 weeks along with the changed angle of casting will help to position the muscles and joints correctly, thereby helping him to improve Jonathon’s health outcomes related to movement and standing (Shikako-Thomas et al. 2013).   Conclusion In conclusion, it is revealed that Jonathon needs special care for the improvement of his lower extremities and movement. After evaluating his health history and medical strength test report, it has been revealed that there are two major functional problems for Jonathon and according to that, functional goals has been set and based on the goals, health interventions were planned. The major two health interventions are physical exercise plan for Jonathon for improving his hip flexibility and shoulder flexibility. In this context, his three months exercise programs have been formulated for improving his health outcomes in standing, shoulder exercise and hip exercises.   Reference List Batshaw, M. L., Roizen, N. J., & Lotrecchiano, G. R. (2013). Children with disabilities. Brookes Publishing: Washington DC. Brossard-Racine, M., Hall, N., Majnemer, A., Shevell, M. I., Law, M., Poulin, C., & Rosenbaum, P. (2012). Behavioural problems in school age children with cerebral palsy. European Journal of Paediatric Neurology, 16(1), 35-41. Campbell, S. K., Palisano, R. J., & Orlin, M. N. (Eds.). (2012). Physical therapy for children (4th ed.). st Louis, MO. Elsevier/ Saunders. Darrah, J., Wiart, L., Magill‐Evans, J., Ray, L., & Andersen, J. (2012). Are family‐centred principles, functional goal setting and transition planning evident in therapy services for children with cerebral palsy?. Child: care, health and development, 38(1), 41-47. DeLuca, S. C., Case-Smith, J., Stevenson, R., & Ramey, S. L. (2012). Constraint-induced movement therapy (CIMT) for young children with cerebral palsy: Effects of therapeutic dosage. Journal of Pediatric Rehabilitation Medicine, 5(2), 133-142. Franki, I., Desloovere, K., De Cat, J., Feys, H., Molenaers, G., Calders, P., … & Van den Broeck, C. (2012). The evidence-base for basic physical therapy techniques targeting lower limb function in children with cerebral palsy: a systematic review using the International Classification of Functioning, Disability and Health as a conceptual framework. Journal of rehabilitation medicine, 44(5), 385-395. Greenberg, M. T., & Harris, A. R. (2012). Nurturing mindfulness in children and youth: Current state of research. Child Development Perspectives, 6(2), 161-166. Howcroft, J., Klejman, S., Fehlings, D., Wright, V., Zabjek, K., Andrysek, J., & Biddiss, E. (2012). Active video game play in children with cerebral palsy: potential for physical activity promotion and rehabilitation therapies. Archives of physical medicine and rehabilitation, 93(8), 1448-1456. Kisner, C., & Colby, L. A. (2012). Therapeutic exercise: foundations and techniques. Fa Davis. Palisano, R. J., Begnoche, D. M., Chiarello, L. A., Bartlett, D. J., McCoy, S. W., & Chang, H. J. (2012). Amount and focus of physical therapy and occupational therapy for young children with cerebral palsy. Physical & occupational therapy in pediatrics, 32(4), 368-382. Palisano, R. J., Chiarello, L. A., King, G. A., Novak, I., Stoner, T., & Fiss, A. (2012). Participation-based therapy for children with physical disabilities.Disability and rehabilitation, 34(12), 1041-1052. Scholtes, V. A., Becher, J. G., Janssen-Potten, Y. J., Dekkers, H., Smallenbroek, L., & Dallmeijer, A. J. (2012). Effectiveness of functional progressive resistance exercise training on walking ability in children with cerebral palsy: a randomized controlled trial. Research in developmental disabilities, 33(1), 181-188. Shikako-Thomas, K., Dahan-Oliel, N., Shevell, M., Law, M., Birnbaum, R., Rosenbaum, P., … & Majnemer, A. (2012). Play and be happy? Leisure participation and quality of life in school-aged children with cerebral palsy.International journal of pediatrics, 2012. Sterling, C., Taub, E., Davis, D., Rickards, T., Gauthier, L. V., Griffin, A., & Uswatte, G. (2013). Structural neuroplastic change after constraint-induced movement therapy in children with cerebral palsy. Pediatrics, 131(5), e1664-e1669. Verschuren, O., Wiart, L., Hermans, D., & Ketelaar, M. (2012). Identification of facilitators and barriers to physical activity in children and adolescents with cerebral palsy. The Journal of pediatrics, 161(3), 488-494. Whalen, C. N., & Case-Smith, J. (2012). Therapeutic effects of horseback riding therapy on gross motor function in children with cerebral palsy: a systematic review. Physical & occupational therapy in pediatrics, 32(3), 229-242.

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