Questions:
1. How reliable are goniometric measurements in children? How reliable are goniometric measurements in children with cerebral palsy? What does this mean for us as physical therapists?
2. How should strength be assessed in children? How does this vary with age? How would your assessment of a child’s strength vary per diagnosis?
3. a. Compare and contrast norm-referenced instruments (or tests) and criterion-referenced instruments (or tests) and explain how each type of test is used in paediatrics?
b. Describe the difference between a standardized test and a “normed” or normalized test?
4. Bayley II ( a comprehensive developmental assessment) compared to the TIMP?
5. a.What age level are Kyle’s gross motor skills?
b. What are important things you would want to ask for the subjective portion of your evaluation?
c. What are important things you would want to observe for the objective portion of your evaluation? How would you plan to get this information?
d. What standardized assessment tool might you choose for evaluating Kyle? Why would you select this particular tool?
6. Use the information provided in the written evaluation to document his functional and limitations. Select one functional limitation, and, using the information provided in the written evaluation as well as your knowledge about children with cerebral palsy, identify the contributing impairments?
7. Compare and contrast the types of musculoskeletal impairments frequently observed in children with myelomeningeocele and in children with spinal cord injury. How are they similar, how are they different and why?
Answers:
1. How reliable are goniometric measurements in children? How reliable are goniometric measurements in children with cerebral palsy? What does this mean for us as physical therapists?
Goniometer is an instrument applied in the measurement of the joint motion of the human body and goniometric measurements are considered as one of the primary component with respect to a comprehensive and integrate assessment in the medical field. This particular measurement technique is highly reliable for evaluating the active and passive joint range of motion (ROM ) in children but it should be kept in mind that certain factors are important to be considered in this case as there is age associated differences with respect to ROM values (Campbell & Palisano). In case of a full term new born the flexion contractures of the hips and knees will be secondary to intrauterine positioning. The children also need to be made relaxed in order to avoid eliciting stretch reflex in children (Tecklin, 2008).
Analysing the reliability of goniometric measurement in children with cerebral palsy it was observed that the inter-examiner reliability with respect to goniometric evaluations of hip abduction in children with cerebral palsy was low compared to an inclinometer which further depicts the limitations of a Goniometer (Herrero et al., 2011).
Goniometer is an important evaluation tool used frequently by the physical therapists. This instrument helps the physical therapist to perform objective measurements that is subsequently important for understanding the progress of patient in terms of physical motion (Whittaker, 2009).
2. How should strength be assessed in children? How does this vary with age? How would your assessment of a child’s strength vary per diagnosis?
In order to assess the muscle strength of children it is performed with the evaluation of both upper and lower extremity muscle strength with investigation of the motor function. Muscle strength can be assessed by testing the child’s elbow flexion and extension. Wrist dorsiflexion test is also performed and testing the child’s grip also helps in understanding the strength of the concerned child (Chiocca & Chiocca, 2015). Additional it is also essential to palpate the limbs for muscle mass, tone, strength and joint range of motion and crepitus (Atitesting.com, 2016).
For the purpose of evaluation of muscle strength in infant, the baby is lifted under the axillae and if it is observed that the infant maintains a wedged position the infant has normal muscle strength. If the baby slips between the hands indicate shoulder muscle weakness. For toddlers and pre-school children the ability to climb a certain height, throwing a ball and moving around a bed is evaluated to assess the muscle strength. The grip strength is assessed for evaluate the muscle strength for the adolescents (Atitesting.com, 2016).
If it is observed that a particular child indicates muscle weakness in the lower extremity it is due to myelomeningocele.
3. a. Compare and contrast norm-referenced instruments (or tests) and criterion-referenced instruments (or tests) and explain how each type of test is used in paediatrics. b. Describe the difference between a standardized test and a “normed” or normalized test.
A norm-referenced test is implemented to investigate the overall performance level of an individual in association to a representative group which is further used to form the age groups and for other diagnostic reasons. On the other hand the criterion-referenced tests are utilized to assess the performance level of a subject in connection to a criterion or an external standard. This particular test is not useful in determining the age groups and finds its application in program planning and evaluation. Variability of scores is obtained in the norm-referenced tests while as the criterion-referenced test is dependent on absolute standard variability of scores is absent (Montgomery & Connolly, 1987).
In paediatrics norm-referenced tests are Bayley Scales of Infant Developments and the Gesell developmental scales. The former scale is applied to analysing the motor and mental status of the child while the latter is applied to detect the motor deviations in the areas of adaptive, gross and fine motor, language and personal development of the child. For analysing the general development of a child the Criterion-referenced test is used in paediatrics. Movement Assessment of Infants or MAI is an example of Criterion-referenced test (Montgomery & Connolly, 1987).
A standardized test is generally considered as a norm-referenced test whereby a test is conducted under a uniform set of conditions with respect to a child on whom the test should be performed. Whereas a normalised describes an adjustments of values measured on distinct scales with respect to a notionally common scale or gradient (Mulvenon).
4. Bayley II ( a comprehensive developmental assessment) compared to the TIMP
The Bayley Scales of Infant Development is a standard test applied for measuring the motor and cognitive performance level of the infants. It comprise of distinct scales in order to evaluate the gross and fine motor standard in order to analyse the cognitive development, language and motor functioning of the infant. On the other hand the Test of Infant Motor Performance or TIMP can be used to analyze the motor functioning of the infants who are the risk of developmental delay (Campbell & Palisano). Age of the infant (34 weeks post menstrual age or PMA) is considered as the age standard for performing this particular test. With reference to a research based comparative study it can be stated that the efficacy of TIMP is greater than that of Bayley II as this test is more accurate with respect to intervention at early age of the infants who are identified to belong to the risk zone (Campbell et al., 2013).
5. a. What age level are Kyle’s gross motor skills?
b. What are important things you would want to ask for the subjective portion of your evaluation?
c. What are important things you would want to observe for the objective portion of your evaluation? How would you plan to get this information?
d. What standardized assessment tool might you choose for evaluating Kyle? Why would you select this particular tool?
In order to assess the patient’s medical condition it is important the whether there was any complication during pregnancy and the type of delivery. It is also important to know the gestational age at birth, the child weight, APGAR scores at birth. Other important data in this regard include medical history of the patient including any history of surgery. Whether the child has received any therapy surgery if yes what was the duration of the therapy service. Information regarding the overall health of the patient inclusive of the patient’s vision and audibility functions. Also it is important obtain information regarding the eating patterns, sleeping pattern, temperament of the child, child’s most preferred activity, play position and latex allergies (Pediatric Evaluation, 2016).
Observations that should be made for the objective portion of evaluation include:
Whether the infant interact with toys, the child attends to visual and auditory stimuli, and communication level of the infant. Additionally it is also important to evaluate the proportionality among the limbs, presence of any asymmetries, child posture, and the respond of the child towards touch, range of motion and whether any resistance is present in the range of motion. Further as a part of objective evaluation it is also important to examine the skin colour of the child, heart rate, respiration rate, child’s vital signs change with activity, autonomic responses to positional changes, head righting reactions and assessment of the gross motor activity (Pediatric Evaluation, 2016).
In order to obtain the above mentioned information it is essential to perform a peripheral vascular assessment, assessment gait, inspection of the posture, movement and general body symmetry. Further it is also required to inspect the limbs for skin changes and body symmetry and it is required to palpate the limbs for investigation of the muscle mass, tome, strength, joint, range of motion (Atitesting.com, 2016).
Popliteal angles can be considered in order to evaluate the hamstring strength.
6. Use the information provided in the written evaluation to document his functional and limitations. Select one functional limitation, and, using the information provided in the written evaluation as well as your knowledge about children with cerebral palsy, identify the contributing impairments.
With reference to the case study it was observed that Jacob expressed muscular weakness in his lower extremities although the functionality of his upper extremity was normal. It was also observed that Jacob’s lower extremities were limited to 100-130 degrees abduction, 70-80 degree ankle dorsiflexion and 90 degree heel to ear angle. The subject’s toe grasp was observed to be bilateral. According to the assessment made it was confirmed that this 15 month old infant patient has an elevated lower extremity tome and delayed gross motor skills (Physical Therapy Initial Evaluation, 2016).
As it was indentified that the subject’s mobility in the lower extremity was limited due to delay in gross motor skills the other contributing impairments in this regard are neuro-impairments, limited physical activity and learning disability. It is also essential to mention that impaired motor functionality along with learning disability is the major indicators towards restricted physical activity (Beckung & Hagberg, 2007). Researches further support that loss of selective motor control is considered to be responsible for interfering with gross motor function compared to the effect of other impairments. Daily activity is restricted in this case that further adds as the contributing impairments (Ostensjø, 2004).
7. Compare and contrast the types of musculoskeletal impairments frequently observed in children with myelomeningeocele and in children with spinal cord injury. How are they similar, how are they different and why?
A child born with myelomeningeocele expresses impaired musculoskeletal impairments. This is particular type of birth defect occurs in1 out of 4000 births where the backbone and the spinal cord do not close before birth. Myelomeningocele is also recognised as a type of spina bifida. In addition to muscular weakness a child affected with myelomeningocele express partial or complete paralysis in the lower extremity of the body particularly in the legs. Formation of ‘clubfoot’ and weakness in the hips, legs and feet of the infant can be enlisted as the musculoskeletal impairments in children born with myelomeningocele. A condition known as hydrocephalus is also visible in infants born with myelomeningocele (Updated by: Kimberly G Lee, 2016). On the other hand spinal cord injury in children is not a birth defect as it is due to a traumatic injury that may subsequently result to a bruise, a partial tear or a situation was transection in the spinal cord. Severe spinal cord injury in children may result in lifelong musculoskeletal impairments. Among the major musculoskeletal impairments resultant due to spinal cord injury include muscular weakness, loss of voluntary muscle mobility particularly in the chest and limbs followed with loss of sensation in the chest and limbs (Brainandspinalcord.org, 2016).
Comparing between the impairments resulted from Spina bifida or Myelomeningocele and Spinal Cord Injury it can be stated that both of them lead to severe muscular weakness and also causes particular or complete paralysis of the lower extremities of the body of the body of the affected infant. On the other hand it is further observed that Myelomeningocele is an inborn defect in the neural tube of the infant while spinal cord injury result in partial or complete tear in the spinal cord (Stanfordchildrens.org, 2016). Hydrocephalous condition is distinct in Myelomeningocele which is absent in spinal cord injury.
References
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Updated by: Kimberly G Lee, a. (2016). Myelomeningocele: MedlinePlus Medical Encyclopedia. Nlm.nih.gov. Retrieved 6 February 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/001558.htm
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