PT for Preemies Involving Families and other Team Members

1. PT for PreemiesInvolving Families and other Team Members Presented by Ann Barton, PT, MS, PCS & Suzanne English, MA

2. OBJECTIVES • Will identify 3 key points of immature systems related to the last 12 weeks of fetal development. • Will identify one fact related to preterm birth. • Will identify 1 advantage and 1 disadvantage of 2 commonly used assessment tools. • Will state 3 benefits of tummy time. • Participants will identify early intervention strategies based on their role in EI.

3. What is preterm birth? • Babies born before 37 completed weeks of pregnancy are called premature. • About 12.5 percent of babies (more than half a million a year) in the United States are born prematurely. March of Dimes

4. Who is at high risk for health problems? • Infants born before 32 weeks gestational age are at the highest risk • >1150 infants born in SC in 2005 fell in this category • Based on percentage estimates from March of Dimes

5. “Just the facts ma’am” • 1 of 8 babies is born premature • Most preemies are born between 34-36 weeks GA (>70%) • 13% between 32-33 weeks • 10% between 28-31 • ~ 6% before 28 weeks GA March of Dimes

6. Vital Statistics for SC • Preliminary 2005 Data • * 55,333 live births • ~ 7193 premature births (1/8) • 5035 born between 34-36 weeks • 935 born between 32-33 weeks • 719 born between 28-31 weeks • 431 born before 28 weeks GA *National Center for Health Statistics 2006

7. What systems are immature at ~ 28 weeks EGA? • Cardiopulmonary and Circulatory System • Musculoskeletal System • Integumentary System • Neuromotor system

8. Cardiopulmonary and Circulatory System • Increased airway resistance due to very small bronchi and bronchioles • Ribs and sternum have less stability for the diaphragm • Soon after birth myocyte (muscle cell) division decreases regardless of EGA – leading to less capillary density and limited contractile strength • Low iron stores – anemia of infancy • Key point; altered lung and cardiac muscle function

9. Musculoskeletal Immaturity • Muscle fiber increase is incomplete and the size of the existing muscle fibers is small • Muscle fiber differentiation is immature • Skeleton lacks ossification of term infant • Keypoint; small, weak muscles with unstable skeleton

10. Integumentary Immaturity • Skin is thin or absent prior to 30 weeks • Allows increased evaporative cooling • Less ability to protect against some pathogens • Less elasticity – prone to edema • Key point; increased risk for illness and injury due to less protection

11. Neuromotor Immaturity • Limited myelination present • Immature respiratory centers lead to apnea of prematurity • Cerebral white matter is vulnerable to hemorrhage due to decreased regulation of cerebral blood flow • Vascular bed of the retina matures between 32-40 weeks/prone to develop ROP (retinopathy of prematurity) • Key point; immature central nervous system

12. Assessment Tools • Various Tools include • Global - Curriculum-based • Hawaii Early Learning Profile (HELP) • Assessment, Evaluation and Programming System (AEPS) • Motor • Peabody Developmental Motor Scales (second edition) • (PDMS-II) • Test of Infant Motor Development (TIMP)

13. Hawaii Early Learning Profile • Purpose • HELP “is a widely-used, family-centered, curriculum-based assessment for use by professionals working with infants, toddlers, young children, and their families”. VORT Corporation

14. Hawaii Early Learning ProfileHELP • Advantages • Comprehensive curriculum- based tool that identifies family and infant strengths and needs across many domains • Assists in determining "next steps" for intervention and support • Provides individualized family-centered information and support, and can be used to monitor progress.

15. Hawaii Early Learning Profile HELP • Disadvantages • HELP is not standardized or normed. • It is not intended to be used to calculate a child's single-age equivalent (score or % delay). • Not a single instrument intended to be used for diagnosis

16. Assessment, Evaluation and Programming SystemAEPS • Definition • Comprehensive curriculum-based assessment system covering six developmental areas • For use with birth to six years old • Ties together assessment, goal development, and ongoing intervention

17. AEPS • Advantages • Criterion-referenced tool • Comprehensive assessment; addresses the developmental areas of gross motor, fine motor, adaptive, cognitive, social-communication, and social • Includes caregivers in assessment, intervention, and evaluation activities • Addresses assessment, goal development, and helps select intervention content, • Produces information that can be used directly to formulate goals and objectives

18. AEPS • Disadvantages • *Not yet validated for use in states that require an eligibility decision based on a standard-deviation or percent-delay determination. (research reportedly underway) • Can be time consuming to administer • Has very few items for young infant * Paul H. Brooks Publishing Company 2007

19. How can early intervention help? • The curriculum based assessment will help to identify child strengths, needs, services and other resources • The PT evaluation will help to determine the specific systems that are rate limiters for motor development

20. Peabody Developmental Motor Scales – Second Edition (PDMS-II) • Purpose • Provides a comprehensive sequence of gross and fine motor skills from which the developmental skill level can be obtained

21. Peabody Developmental Motor Scales – IIPDMS-II • Advantages • Norm-referenced • Valid and highly reliable measure • Discriminates motor problems from normal developmental variability i.e. those known to be “average” and those expected to be low or below average

22. PDMS-II • Disadvantages • Assesses only motor areas • Not responsive to change in children with severe physical disabilities • Not necessarily valid for planning intervention

23. Test of Infant Motor PerformanceTIMP • Purpose • A test of functional motor behavior in infants between the ages of 34 weeks postconceptional age and 4 months post-term. • Constructed to assess postural control needed in age-appropriate functional activities involving movement • Intended to signal developmental deviance at an early stage so that effective intervention can prevent serious impairment.

24. TIMP • Advantages • Discriminates among infants with varying degrees of risk for poor motor outcome • Predicts 12-month motor performance with sensitivity 92% • Can be used in the special care nursery and in community-based programs • Looks at quality of movement in a functional context versus just skills • Useful for planning interventions for high risk infants or infants with neurological conditions

25. TIMP • Disadvantages • Targets a very finite population • Designed to be administered by therapists with close contact and personal emotional involvement with the babies.

26. Early Infant Assessment • Muscle tone • Development of reflexes • Quality of movement responses • State organization • Postural control

27. Tips to Remember • Defining the eligible population is an ongoing challenge • Results of assessment tools can be informative but do not replace clinical judgment • Scales measuring motor development are one component of a comprehensive evaluation • Some tools may underestimate the degree of delay present

28. Globally displays hypotonia Decreased flexion patterns and midline orientation due to < physiological flexion Presents w/extension and abduction patterns Those infants who have been on mechanical ventilation may show hyperextension of the neck and trunk arching Strong physiological flexion Mild flexion contractures that gradually reduce Presents with flexion and adduction patterns Spontaneous movements may be limited by strong physiological flexion What we know about thepremature vs. term Infant

29. Development During the First Quarter • Emphasis on functional head control • At birth, righting is intact with support in upright • Head turning typically in place in supine • Lots of stretching, kicking and thrusting movements of the extremities • Lots of turning and twisting of the head and trunk

30. Supine • The term infant typically lies in supine with head turned to one side • Physiological flexion dominates the upper and lower extremities. • Preemies may need positioning to bring the arms and legs from lying flat against the floor.

31. Low Tone vs Term

32. Sleep position impacts head shape

33. Prone – Baby’s First Work • Prone Positioning Promotes • Strengthening of back and neck extensors • Weight bearing through the hands • Focusing at close range • Movement exploration • Lateralization and cross lateral movements

34. Early head lifting

35. Tummy Time

36. Arching vs prone on elbows

37. Limited Prone Positioning • Poor head control, Flat spots on head • Low energy • Hands fail to open routinely • Delayed visual exploration • Mobility with substitute patterns • Immature development of righting reactions • Delayed ability to cross midline

38. Goals of therapeutic handling • Decrease hyperextension of the neck and trunk (in supine the hip and knees are gently flexed) caution is taken to avoid hyperflexion of the neck • Sidelying is also used to reduce neck and trunk hyperextension and promote normal muscle tone and promote proximal stability; • Reduce elevation of the shoulders (bring hands to buttocks) • Promote an alert calm behavioral state

39. First Quarter Activities • In supine encourage eye contact, reaching, sound imitation; use blankets as needed for extremity support • Carry in ways to promote head control • Supported sit with trunk control • Tummy time (family on floor) • Strengthening through pull-to-sit

40. Carrying to promote head control

41. Prone Play Suggestions • Provide prone or sidelying playtime daily (*15 minutes/day) • Parent can lie supine with infant prone on parent’s chest to interact • Parent can place infant on table and sit within vision range while supervising for safety • Use blanket roll under chest for young infant/Use mirrors • Most interesting object is parent’s face

42. Development During Second Quarter • Roll from supine to prone likely accidental early in the second quarter • Body schema improves with lots of exploration of hands and feet in supine • Movement by bridging or crawling • Development of sitting with support

43. Second Quarter Activities • Reaching acts in sidelying • Encouraging lifting legs in supine & rolling • Encouraging pivoting in prone and playing on extending arms in prone (head up to 90 degrees) • Provide time for play in supported sit with fading assist • Look for increased activity in supine

44. Rolling w/extension pattern

45. Low tone features

46. Development During Third Quarter • Constant movement • Supine preference decreases • Pivoting in circles on the tummy • Unsupported sitting • Exploration paramount; leads to pulling up into kneel and possibly stand by end of third quarter • Some infants use rolling but most will creep on hands knees

47. Third Quarter Activities • Need to see lots of movement during this time with transitions from sit • Reaching out for toys while holding four point • Prone mobility is important to encourage; this movement can be assisted • Can encourage modified tall kneel

48. Rocking in four point

49. Development During Fourth Quarter • Prone and supine are mostly transitional • Hands and knees is the basis for creeping • Assumes and maintains tall kneeling • Cruising to early walking • Plantigrade creeping on extended arms and legs becomes part of the repertoire • Walking at last

50. Fourth Quarter Activities • Encourage upright mobility with fading support as needed • Identify furniture for pulling up and cruising • Promote play in stand without supports • Identify environmental safety hazards for caregivers • Identify opportunities to practice upright with caregivers