pediatric rehabilitation prof.dr. Şafak sahir karamehmetoğlu İstanbul university cerrahpaşa...
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PEDIATRIC REHABILITATION
Prof.Dr. Şafak Sahir Karamehmetoğlu Prof.Dr. Şafak Sahir Karamehmetoğlu İstanbul University Cerrahpaşa Medical Facultyİstanbul University Cerrahpaşa Medical Faculty
Physical Medicine and Rehabilitation DepartmentPhysical Medicine and Rehabilitation Department
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HISTORY (1)Prenatal: 1. Age of the mother
2. Previous diseases
3. Coincident diseases
4. Habits
5. Unusual weight gain or loss
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HISTORY (2)
Prenatal:
6. Drugs
7. Radiation
8. Trauma
9. Rh factor discrepancy
10.Genetic disease
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HISTORY (3)Perinatal:
1. Delivery duration
2. Prematurity
3. Anesthesia
4. Drugs (induction)
5. Trauma
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ÖYKÜ (4)Perinatal:
6. Low birth weight
7. Low Apgar scores
8. Incubator
9. Intensive care
10.Sucking reflex
HISTORY (4)
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ÖYKÜ (5)Postnatal:
1. Trauma
2. Infection
3. Metabolic diseases
4. Vascular anomaly
5. Oxygen deficiency
HISTORY (5)
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School age:1. Previous diseases2. Coincident diseases3. Allergy4. Drugs5. Epileptic seizure
HISTORY (6)
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HISTORY (7)School age:6. Surgical intervention7. Trauma 8. Blood pressure9. Pulse rate10.Nutrition
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DEVELOPMENT - 1
1. Heihgt
2. Weight
3. Head circumference
4. Growing
5. Follow-up
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Motor function Cognitive function
0-1
month
Flexor tonus predominates, when prone turns head to side, automatic reflex walking, rounded spine when held sitting, hands fisted, grasp reflex
Cry, head turning to voice, basic trust, mistrust, does not differantiate between self and mother
4
months
Head midline, when prone lifts head to 90° and chest slightly, turns to supine, hands mostly open, midline hand play
Recognizes bottle, laughs, responsive vocalization, lap baby, sense of basic trust
7
months
Maintains sitting, may lean on arms, rolls to prone, bears all weight, bounces when held erect, cervical lordosis, intermediate grasp, bangs objects
Differentiates between familiar person and stranger, holds bottle, looks for dropped object, talks to mirror image, uses single words
10
months
Creeps on all fours, pivots in sitting, stands momentarily, slight bow leg, increased lumbar lordosis, pincer grasp, mature thumb to index grasp, finger feeds, bangs two cubes
Shouts for attention, imitates speech, waves bye-bye, uses “mama” and “dada” with meaning, inhibits behavior to “no”, can retrieve an object hidden from view
DEVELOPMENT - 2
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Motor function Cognitive function
14
months
Walks alone, arms in high or mid- guard, wide base, excessive knee and hip flexion, foot contact on entire sole, slight valgus of knees and feet, pelvic tilt and rotation, piles two cubes, holds crayon full lenght in palm,
Uses spoon with overpronation, removes a garment, understands simple commands, shame and doubt, pleasure in controlling muscles and sphincters
18 months
Arms at low guard, mature supporting base and heel strike, seats self in chair, walks backward, emerging hand dominance, holds crayon end in palm
Imitates housework, carries, hugs doll, drinks from cup neatly, points to named body parts, identifies one picture, says “no”, jargons
2 years Begins running, walk up and down stairs alone, jump on both feet in place, builds 8-cube tower,
Two word phrases, uses verbs, “me” “mine”, follow simple commands, comprehends symbols
3 years Walks upstairs alternating feet, uses overhand throw, catches with extended arms hugging against body, imitates three cube bridge
Most children toilet trained day and night, pours from pitcher, washes and dries hands and face, deals with issue of genital sexuality
DEVELOPMENT - 3
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Motor function Cognitive function
4 years
Walks down stairs alternating feet, hops on one footplantar arches developing, sits up rom supine position without rotating, handles a pencil by finger and wrist action like adults
Cooperative play, dresses and undresses with supervision , gives connected account of recent experience, questions why, when, how, repeats four digits
5 years
Skips, tiptoes, balances 10 seconds on each foot, hand dominance expected, draws man with head body, and extremities, throws with diagonal arm and body rotation, catches with hands
Creative play, competitive team play, uses fork stabbing food, brushes teeth, self-sufficient in toileting, has number concepts to 10, adjust himself to the inorganic laws
6 years
Rides bicycles, roller skates, prints alphabet; letter reversals still acceptable, mature catch and throw of ball
Uses fork appropriately, knife for spreading, plays table games, shows mastery of grammar, uses proper articulation
7 years
Continuing refinement of skills Comb hair, grooming, capable of logical thinking
DEVELOPMENT - 4
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GENEL DURUM
GENERAL HEALTH
•Fever
•Blood pressure
•Pulse rate
•Posture
•Discoloration
•Edema
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PHYSICAL EXAMINATION-1
Inspection (most informative)
1. Reaction to separation from the parents
2. Apparent visual and auditory awareness
3. Temperament (calm/hyperactive, compliant/difficult)
4. Spontaneous exploration and interest in toys, games, or books in the room
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PHYSICAL EXAMINATION-2Inspection (most informative)
5.Style, concentration, attention span, or distractibility during play
6.Level and manner of motor activities
7.Attempts to engages the parents and examiner in conversation, vocabulary, complexity of language, and quality of speech
8. Interaction with parents and examiner (appropriate, shy, demanding)
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• Blue sclerae (osteogenesis imperfecta)
• Asymmetric face (facial palsy)
• Café-au-lait spots (neurofibromatozis)
• Scoliosis (idiopathic)
• Foot deformities (spina bifida)
PHYSICAL EXAMINATION-3
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PHYSICAL EXAMINATION-4
Palpation:
• Fontanelles
• Skin (fever, sweating, coldness)
• Noduls (rheumatic diseases)
• Muscles (tonus, fibrosis, hypertrophy)
• Joints (swelling, redness, tenderness)
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PHYSICAL EXAMINATION-5
Neurologic examinationReflexes (Moro, palmar, plantar)Tonus (normotoni, hypertoni, hypotoni)Active motionMuscle strenght (0-5)Coordination (proprioception)Sensation
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PHYSICAL EXAMINATION-6ROM
1.Prone
2.Supine
3.Side-lying
4.Standing
5.Walking
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PHYSICAL EXAMINATION-7
ROM
1. Elbow extension (- 25°)
2. Hip extension (- 30°)
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PHYSICAL EXAMINATION-8
Walking disorders
1. Asymmetric step width
2. Toe walking
3. Crossing
4. Trendelenburg
5. Stepping
6. Ataxia
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SENSATION
1. Abdominal T6 – T 12
2. Kremaster L1 – L2
3. Anal S4 – S5
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OTHER ORGANS
1. Heart (anomaly, myopathy, collagen disease, sci, Guillain Barré, polio, drug)
2. Lung (myopathy, trauma, scoliosis, polio, cp)
3. Urinary bladder (spina bifida, sci)
4. Bowels (spina bifida, sci)
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FUNCTIONAL EVALUATION
1. Sight
2. Hearing
3. Speech
4. Gross motor
5. Fine motor
6. Social behavior
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Torakal instabilite kriterleri-2
MAJOR DISEASES1. CP
2. SB
3. TBI
4. SCI
5. NMD
6. Amputations
7. Rheumatic diseases
8. Trauma
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CP• Brain injury• Non-progressive• Persistent• Modifiable • Motion, tonus,
coordination and posture are affected
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• Rehabilitation
• Education
• Team work
• Participation of the family
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• Head• Body• Extremities• Epilepsy • Sight• Hearing• Speech• Perception • Behavioral changes• Mental retardation
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TYPES
1. Spastic
2. Flaccid
3. Atetoid
4. Ataxic
5. Mixt
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SPASTIC
1. Hemiplegic
2. Diplegic
3. Quadriplegic
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PHYSICAL EXAMINATION
1. Muscle tonus 2. DTR
3. Primitive reflexes (+)
4. Postural changes (+)
5. Motor development 6. Abnormal motion (+)
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Muscle Testing
5/5 Normal 100
4/5 Good 75
3/5 Fair 50
2/5 Poor 25
1/5 Trace 10
0/5 Zero 0
Grading %
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Ashworth
0: Normal tonus 1: Minimal 2: Moderate 3: Severe 4: Very severe
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REHABILITATION TEAM
1. Physiatrist 2. Pediatrist3. Physiotherapist4. Nurse5. Social worker6. Psychologist7. Occupational therapist8. Speech therapist9. Special education teacher10.Child development specialist11.Child educator12.Family
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General aims in CP rehabilitation
1. Reach an understandable speech
2. Near normal use of the upper extremities
3. Functional use of lower extremities in walking
4. Near normal appearence
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Management of Spasticity1. ROM exercise2. Positioning 3. Stretching exercises4. Strenghtening exercises5. Local cold applications6. Electrical stimulation7. EMG biofeedback8. Stretching splints9. Baclofen, diazepam 10. Local injections (botulinum toxin A)11. Tendon transfers, myotomy, tenotomy12. Orthoses and assistif devices
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Rehabilitation is a process, including medical, economical, vocational and social aspects.