19 Chapter 09 – Lecture Unit 9: Physical Therapy across the Lifespan

PHYSICAL THERAPY
ACROSS THE LIFESPAN

You have probably heard the expression, that “the more things change, the more they stay the same”. That principle is can be found in many areas of our life as well as in our chosen profession of physical therapy.  One example is that can be found through an overview of the worlds of pediatric and geriatric conditions and physical therapy.  While many of the conditions are very specific to each of those times of life, our treatments goals and interventions may be very similar.

For example, while a child with Spina Bifida presents with a very different set of specific impairments than an elderly patient with osteoporosis, our goals for improving safe functional mobility in a way that engages the interest and abilities of the patient will be remarkably the same.  Once you are a practicing clinician, you may develop an appreciation for this phenomenon in many of your therapy experiences. This leads us to our general learning objective for this chapter:

• The student will be able to identify the principles of physical therapy interventions for pediatric and geriatric patients

Our first section will be an overview of pediatric conditions and interventions; section two, geriatric conditions and interventions.

PEDIATRIC PHYSICAL THERAPY

• The student will be able to discuss a few general patient diagnoses commonly seen in pediatric patients.

Systems:

• Neuromuscular
• Musculoskeletal
• Integumentary
• Cardiorespiratory

General Diagnoses:

• Down Syndrome
• Cerebral Palsy
• Autism Spectrum Disorder
• Spina Bifida
• Torticollis
• Fetal Alcohol Syndrome
• Burns

1. Down Syndrome: Key Features

1. Etiology: Trisomy 21: Term used to describe the location of the chromosomal dysfunction responsible for the condition.
2. Low muscle tone and Ligamentous laxity are primary physical impairments and are responsible for:
   1. Impaired muscle strength
   2. Impaired mastery (and safety) with motor skills
   3. Predisposition to joint injury
3. Cognitive delays
4. Speech difficulties
5. Delayed in acquiring developmental milestones

2.  Other issues may include:

1. 1. heart abnormalities
   2. Frequent respiratory infections
   3. Leukemia

Down Syndrome Practice:

Your patient is a 7yo with a diagnosis of Down Syndrome.  Your CI asks for your input regarding there therapeutic exercises. Which of the following would you select?

1. Exercises to help strengthening the LEs and Trunk
2. Activities to stretch the muscles of her LEs
3. Activities to stretch the muscles of her LEs and UES.
4. Interventions to improve the flexibility of her trunk

You may have been able to arrive at the correct answer already.  However, if not, take a look again at the possible answers.  Do you see that answers 2,3 and 4 are pretty much the same?  They are all seeking to improve ROM.

Remember, we said when 2 answers (in this case 3) are virtually identical, then either neither can be correct OR look for the ‘all of the above / none of the above’ option.

That is true here.   When a patient has low muscle tone and lax (loose) ligaments, their joints are hypermobile.  There will be no need to stretch them – they are (over) flexible already.  What is needed is answer #1. Strengthening.

1. Exercises to help strengthening the LEs and Trunk
2. Activities to stretch the muscles of her LEs
3. Activities to stretch the muscles of her LEs and UES.
4. Interventions to improve the flexibility of her trunk

Cerebral Palsy:

• Etiology: Usually due to a lack of oxygen to brain during birth
• Please remember: This is a non-progressive brain damage
• Motor delays and abnormal muscle tone are the result of the brain damage
• There are often other problems too: delayed speech and cognition, vision and hearing loss
• For some, there will be surgeries and medical interventions to help minimize the abnormal muscle tone. For example, to lengthen the tendons of the muscles (surgically) to treat contractures or medications to reduce spasticity.

Spina Bifida:

• Etiology: A Failure of the neural tube to close
• Abnormal neurological and muscular development in lower extremities: Paresis.
• Hydrocephalus
• Deformities of the feet which may require surgical interventions and / or orthotics.
• There is an INCREASED RISK FOR PRESSURE ULCERS
• The weakness of the LEs will require the use of assistive devices, wheelchairs, and LE braces.

Torticollis

• Etiology: Shortness of the sternocleidomastoid muscle causing the head to be turned and tilted to one side. This may occur due to the baby’s positioning in the mother during pregnancy.
• A possible consequence of torticollis is that the baby will not be able to freely move their head. This will result in the baby lying with their head in one position for an extended period of time. Doing so, can lead to Plagiocephaly which is a flattening of one side of the skull. A flat spot on the back or one side of the head can develop, for example, if the baby remains in one position for too long.

The student will be able to explain the rationale for providing physical therapy for pediatric cases.

• • IMPROVE FUNCTION: Improving function in the areas noted below will help avoid skin breakdown, contractures, impairments related to immobility (such as respiratory infections, digestive disorders or cardiac issues). Further, as these skills develop, the caregivers will be required to provide less assistance: Something desirable for all as it minimize the risk of injuries for the caregiver and the child.
    • Bed mobility: May require special mattresses or assistive technologies to adjust the bed position (like a hospital bed)
    • Gait and transfers: Make require assistive devices like wheelchairs, transfer boards, walkers, crutches, etc.
    • Bathing / dressing: Again, may require any number of assistive devices including bedside commodes, grab bars, reachers, etc.

• GAIN INDEPENDENCE:
  • In the home: This will greatly reduce the general stress level in the home and greatly increase the child’s sense of self.
  • At school: The more independence is gained, the more the child to interact with the other students.
  • With “play”: Self-evident, but something that needs to be addressed. “Play” is essential for mental, emotional and social development…as well as a great means to improve physical mobility.
• MOVEMENT IMPROVEMENT: These are the areas you will address as a PTA. You will create games and activities to improve the patient’s:
  • Balance
  • ROM
  • Strength
  • Safety
  • Coordination
  • Endurance
• IMPROVED PARTICIPATION WITH FAMILY AND PEERS: This is the overarching goal. It matters little if we can improve a patient’s ambulatory ability (from 30’ with a walker to 35’ with a walker) if it doesn’t lead to a greater purpose (goal).
  • Home
  • School
  • Community: Church, clubs, recreation, sports, music and so on

Finally: Please remember that the most effective means to achieve the goal above is through the use of a team approach.  That means working closely with the patient, the patient’s family and caregivers, the patient’s school teachers as well as any other discipline involved in the care of the patient: OT, OTA, SLP, etc.

This “team approach” is referred to as INTERPROFESSIONAL COLLABORATIVE CARE. This approach is not limited to pediatrics but can be found in all areas of patient care including geriatrics.

GERIATRICS

Look to visit the chapter on Geriatrics (Musculoskeletal Disorders)

 Terms and Conditions:

• PRESBYCUSIS: Age-related hearing loss
• SARCOPENIA: Loss of muscle mass associated with aging
• OSTEOPOROSIS: A condition that leads to decreased mineralization of the bones.
• RHEUMATOID ARTHRITIS (RA): A disease of the immune system that causes chronic inflammation of the joints
• OSTEOARTHRITIS (OA) or Degenerative joint disease (DJD): A common disorder that causes destruction of the articular cartilage and underlying bones. It is associated with joint use or overuse, primarily in the case of joint malalignment, previous injury, or muscular weakness. Other factors that have been identified as risk factors for OA include advancing age, being overweight, and having a positive family history for OA. The hip, knees, spine, and hands are the joints most common affected by OA. The disorder does not appear in symmetrical patterns and may affect only one or 2 joints in the body.

Please go to the link above to learn the differences between RA and OA.  There is a drag and drop activity embedded in the text for you to assess your knowledge.  This will be a very helpful tool for your studies and to assure your comprehension of these conditions.

• FALLS:

Perhaps one of the most surprising facts about aging is the frequency with which people over the age of 65 fall each year.  Although the statistics vary, for individuals over the age of 65, one out of every three will fall at least once a year. For those 85  or older, that frequency increases to four out of every five persons.

Falls are the number one cause of hip fractures and accidental death for the elderly and the second leading cause of head trauma and spinal cord injury.

From the CDC.gov

• Every 11 seconds, an older adult is treated in the emergency room for a fall.
• Every 19 minutes, an older adult dies from a fall.
• Falls result in more than 2.8 million injuries treated in emergency departments annually:
  • Over 800,000 hospitalizations
  • More than 27,000 deaths.
• In 2015, the total cost of fall injuries was $50 billion; estimated to be ~$68 billion for 2020.

When investigating falls, three categories of fall risks factors emerge:

Extrinsic: This refers to environmental factors that lead to a fall. “Trip hazards” like cords or clutter on the floor, poor lighting, an unlocked wheelchair, an unsecured throw rug, etc.  The list here is endless and is specific to the patient’s environment.   The solution is to address the environment. The challenge is to have the patient appreciate the role the environment may have in reducing their risk for a fall.

Intrinsic:  This refers to the ‘internal’ factors that lead someone to fall.  Such items would include: The side effects of medications, the patient’s pain or weakness, orthostatic hypotension, weight bearing restrictions, impairments resulting from their diagnosis, visual loss, etc.   If these are not addressed through education, exercise or other interventions, than these intrinsic factors will lead to a fall.

Behavioral:  While you may not read as much about the behavioral risk factors for a fall, it just may be that this is the most significant area of concern.  If a patient is aware of their extrinsic and intrinsic risks, they can take control of their situation.  They can make FAVORABLE or UNFAVORABLE choices.

• They can choose to clean (or have someone clean) their environment – making it more patient friendly. Favorable.
• They can choose not to ambulate when they are tired, in pain or do not have help. Favorable.
• They can choose to rake the leaves despite 8/10 knee pain and general fatigue. Unfavorable.
• They can choose to take their medications or discuss their medications with their doctor or caregivers. Favorable.

In short: They can choose to make Favorable (safe) decisions or Unfavorable ones. However, if their behaviors are “risky” due to faulty thinking (from any number of reasons), then they are more likely disregard their extrinsic and intrinsic fall risks and end up on the floor.

Geriatric Physical Therapy and the PTA

As we mentioned at the beginning of this chapter, there are many similarities in the treatment approaches and goals for the pediatric and geriatric patient.
Let’s take a look at the list from earlier and see some of this overlap.

• To IMPROVE FUNCTION: As with pediatric cases, the PTA will seek to improve the function of the geriatric patient for many of the same reasons:
  • To avoid skin breakdown, contractures, impairments related to immobility (such as respiratory infections, digestive disorders or cardiac issues).
  • To decrease the level of assistance from caregivers
  • For bed mobility: Special mattresses or assistive technologies may be needed.
  • For gait and transfers: Assistive devices like wheelchairs, transfer boards, walkers, and other devices may be needed.
  • Bathing / dressing: Again, may require any number of assistive devices including bedside commodes, grab bars, reachers, etc.
• To help the patient GAIN INDEPENDENCE:
  • In the home: To decrease their fall risk and reliance on others.
  • With “play”: Although “play” may look different for the older adult, “Play” is essential for mental, emotional and social health….as well as a great means to improve physical mobility.
• Areas the PTA will address to improve MOVEMENT:
  These are the areas you will address as a PTA. While you may not use ‘games’   to help your geriatric patient improve these areas, you just might too.
  • Balance
  • ROM
  • Strength
  • Safety
  • Coordination
  • Endurance
• To allow your patient to improve their PARTICIPATION WITH FAMILY AND PEERS:
  • Again, of what value is it if we can improve a patient’s ambulatory ability (from 30’ with a walker to 35’ with a walker) if it doesn’t lead to a greater purpose (goal).
  • Home
  • Community: Church, clubs, recreation, sports, music and so on

Practice: