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					PT for Preemies
Involving Families and
other Team Members
      Presented by
 Ann Barton, PT, MS, PCS
            &
  Suzanne English, MA
             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.
      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
     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
       “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
       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
   What systems are immature at ~ 28
             weeks EGA?


• Cardiopulmonary and Circulatory System

• Musculoskeletal System

• Integumentary System

• Neuromotor system
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
    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
 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
    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
                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)
       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
      Hawaii Early Learning Profile
                 HELP
• 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.
       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
               Assessment, Evaluation and
                  Programming System
                        AEPS
• 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
                        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
                      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
    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
            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
            Peabody Developmental Motor Scales
                           – II
                        PDMS-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
                 PDMS-II
• Disadvantages

  – Assesses only motor areas

  – Not responsive to change in children with
    severe physical disabilities

  – Not necessarily valid for planning
    intervention
      Test of Infant Motor Performance
                       TIMP

• 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.
                            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
                  TIMP
• Disadvantages

• Targets a very finite population

• Designed to be administered by
  therapists with close contact and
  personal emotional involvement with the
  babies.
       Early Infant Assessment
•   Muscle tone
•   Development of reflexes
•   Quality of movement responses
•   State organization
•   Postural control
          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
        What we know about the
       premature vs. term Infant
• Globally displays        • Strong physiological
  hypotonia                  flexion
• Decreased flexion        • Mild flexion
  patterns and midline       contractures that
  orientation due to <       gradually reduce
  physiological flexion    • Presents with flexion
• Presents w/extension       and adduction patterns
  and abduction patterns   • Spontaneous movements
• Those infants who have     may be limited by strong
  been on mechanical         physiological flexion
  ventilation may show
  hyperextension of the
  neck and trunk arching
   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
            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.
Low Tone vs Term
Sleep position impacts head
           shape
        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
Early head lifting
Tummy Time
Arching vs prone on elbows
     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
   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
      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
Carrying to promote head control
       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
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
       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
Rolling w/extension pattern
Low tone features
     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
     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
Rocking in four point
    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
       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
Early Walking Picture
             After walking
• Getting to stand without supports
• Arms move down from high guard to low
  guard
• Child practices getting up and down from
  furniture
• Creeping up and down stairs
• Narrowing base of support in walking
        Continuum of caregiver
             involvement
•   Noninvolvement
•   Passive involvement
•   Information seeking
•   Partnership/reciprocal interaction
•   Service coordination
•   Advocacy
 What does the evidence tell us
          about PT
• Research in early intervention is limited
• Problem of withholding intervention
  diminishes
• PT interventions do serve to enhance
  parent responsiveness to children
• Communication, coordination and
  education/instruction are relevant
  components in early intervention
           What does the evidence tell
            us about effectiveness of
              family-centered care?

• Evidence is scarce
• Difficult to identify literature that has
  examined family-centered care
• Studies vary in how family centered
  care is defined
 What impacts child skill development and
              adjustment?
• The family’s ability to build support
  networks
• Family participation
• Quality of the home environment
• Maternal mental health
• Quality of parent-child relationships
• Family stressors
    Strategies to encourage family
             involvement
• Assess the family’s needs
• Educate
• Communicate openly and listen
• Involve other family members/caregivers
  as relevant
• Collaborate (what’s working/what’s not)
• Reassess and refocus
        Role of Families
Nearly all empirically supported
treatments include a parent component.

It is well established that parents can
learn and successfully apply skills to
change the behavior of their children.
       Who should serve the child?

• No one discipline can provide services
  that incorporate all child and family
  needs
• Effective interventions require multiple
  levels of collaboration
• Professionals are needed who are
  adequately prepared to serve in the
  expanded scope of practice in early
  intervention
            Children need time for practice!



It takes 10,00 hours of
dedicated practice to become
an expert….
Preemie Case Study
                            Bibliography
•   Hummel, P., Fortado,D, Advanced Neonatal Care. 2005;5(6) Impacting Infant Head Shapes
•   Jansen, Lucres MC., Ketelaar, M., Developmental Medicine and Child Neurology 2003 45:58-
    69, Parental experience of participation in physical therapy for children with physical
    disabilities.
•   Scales,L., McEwen, I. Murray, C. Fall 2007 pp 196-202, Parent’s Perceived Benefits of
    Physical Therapists’ Direct Intervention Compared with Parental Instruction in Early
    Intervention.
•   Tecklin, J., Pediatric Physical Therapy, Third Edition.
•   Vort Corporation Website http://www.vort.com/products/help_overview.html
•   March of Dimes Website Factsheet
    http://www.marchofdimes.com/professionals/14332_1157.asp
•   Garber, J., APTA 8th Annual Advanced Clinical Practice, High risk Infants: Developmental
    Evaluation and Intervention in the NICU
•   Assessment, Evaluation and Programming System,