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229 Cards in this Set
- Front
- Back
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Who is a pediatric audiologist?
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The Audiologist performs an audiological test battery to include physiologic measures and developmentally appropriate behavioral techniques
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What's the number one birth defect in OK?
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hearing loss
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Goal standard tool for infant hearing screening:
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Automated Auditory Brainstem Response Audiometry (AABR)
One initial screen, one rescreen, and if don't pass at that time, refer to pediatric audiologist. |
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Most hearing loss is diagnosed within:
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Below 1 month of age
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JCIH 2007
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Joint Committee on Infant Hearing 2007
Expanded the definition of hearing loss to include conductive, sensory, and auditory nerve dysfunction |
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Types of hearing loss:
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Conductive (outer and middle ear)
Sensorineural (In cocclea, inner ear, nerve to the brain) |
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The outer ear includes:
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The pinna and ear canal
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The middle ear includes:
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the eardrum and ossicles. This is where children develop infections.
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The inner ear:
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Where the cochlea is located- the snail shaped structure.
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How is sound relayed through the ear?
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Funneled into ear canal where sound waves cause eardrum to vibrate.
This causes the ossicles to vibrate which causes the hair cells in the cochlea to move. Movement of hair cells sends a current that stimulates the acoustic N which relays info to the brain. |
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Hearing milestones: newborn-
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Crying and startling to loud sounds.
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By 2-3 months:
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Children differentiate their cries to communicate states of comfort by cooing.
Can laugh and distinguish changes in tone of voice. Auditory behavior- eye widening, eye shift, quieting. |
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Developmental milestones: 4-6 months
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Turning their head towards a sound to find the source.
Make noises and babble, even if they are deaf. Those w/ hearing loss lack the essential feedback necessary and babble regresses and eventually stops if infants don't have access to sound. |
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Developmental milestones: 6-12 months
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Children babble
Repeat syllables Use pointing and facial gestures to communicate. |
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Developmental milestones 9-12 months
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Child should be able to directly localize sound to side, directly below, ear level, and indirectly above ear level.
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Developmental milestones: 12 months
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Understands 50 or so words.
Few spoken words, use jargon. Melody of child's native language. Respond to name. Follow simple directions |
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Developmental milestones: 18-36 months
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Rapid speech development
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Developmental milestones: 3 years
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Know thousands of words, make short sentences, sing songs.
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High risk factors for hearing loss
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Caregiver concern regarding hearing, speech, language, or developmental delay.
Family history of permanent childhood hearing loss. Neonatal intensive care of more than 48 hours |
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Other factors for hearing loss associated w/ having spent time in neonatal ICU
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Extracorporeal membrane oxygenation,
assited ventilation, exposure to ototoxic meds, hyperbilirubinemia requiring exchange transfusion, in utero infections, craniofacial anomalies Physical findings like a white forelock. Neurofibromatosis, osteopetrosis, and usher syndrome Neurodegenerative disorders Culture-positive postnatal infections including meningitis Head trauma Chemotherapy |
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Behavioral observation audiometry
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No conditioning or reinforcement necessary.
No specialized equipment Disadvantages: only sensitive to those w/ severe hearing losses. |
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Visual reinforcement audiometry
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Ages 6-30 months or developmentally delayed children.
Look for conditioned head turn towards sound w/ reward of animated, lighted toy. Sensitive to even mild hearing losses. |
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Conditioned play audiometry
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Play activity used to conditioned child.
Children 2-4. Traditional equipment |
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Auditory brainstem response audiometry (ABR or BAER)
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Gold standard for initial screening of newborn.
Test of choice in difficult to test patients. Electrodes placed on scalp, patient relaxed/sleeping, place on earphones. Audiologist obtains info about the condition of the inner ear and/or auditory nerve. |
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Evoked potentials (wave forms) in ABR
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Interpreted by audiologist in determining hearing sensitivity levels.
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the ABR measures
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Sound as it travels throught he outer, middle, inner ear and up the auditory N to the brainstem.
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Otoacoustic emissions
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The outer hair cells of the cochlea emit an echo in the presence of acoustic stimulation that can be measured.
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Tympanometry
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A measure of middle ear pressure, eustachian tube function, and compliance of the middle ear system.
Not a hearing test, but indicates any middle ear problems. Patient doesn't have to be asleep. Any age Used w/ other screening tools for hearing. |
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Three types of hearing losses:
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Conductive- loss in the outer and/or middle ear.
Sensorineural loss- loss in the cochlea or auditory N/brainstem Mixed loss- combination of the above two types |
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Audiogram-
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An audiologist worksheet.
Graph of hearing. Plot responses based on frequency and intensity tested. |
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Grief and coping cycle
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Dreams
Diagnosis made Grieving begins Denial, fear, and depression Coping New dreams |
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Ability to to cope can be altered:
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Just trying to comprehend the disparity between their desires for their child and the disability that exists compounds their emotional and intellectual efforts to adjust to the situation.
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What parents may feel:
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Grief
Depression Shame Why me? Why my child? Am I being punished for my bad acts/sins Tell them it's a natural thing and point out all the good things. |
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Stages of adjustment
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Stage 1- shock
Stage 2- denial Stage 3- anger Stage 4- resignation Stage 5- adjustment Stage 6- enjoyment |
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Shock
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Parent may be shocked and cry or become dejected.
May express feelings through physical outbursts or occasionally inappropriate laughter. |
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Denial
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Extension of shock.
Denies child's disability. Tries to avoid reality of the situation. Propose various actions in attempt to change reality. Shop for a cure or try to bargain for a different reality |
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Anger
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May be in the form of rage.
Withdrawal Passive from intense feeling of guilt. Verbally attacks anyone who might be blamed for the situation. |
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Resignation
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Resigned to the fact the child has a disability.
May slip into depression. Feelings of shame, guilt, hopelessness, and anxiety stemming from being overwhelmed become intense. |
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Acceptance
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Parents achieve unconditional positive regard for the child.
Coping skills are strengthened. Understanding and appreciation of the whole child, not just their condition- begin to recognize strengths. |
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Symptoms of depression
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Persistent or empty sad mood.
Feeling hopeless, helpless, worthless, pessimistic, and/or guilty. Substance abuse Fatigue or loss of interest in ordinary activities Disturbances in eating and sleeping patterns. Irritability, increased crying, anxiety or panic attacks. Difficulty concentrating, remembering, or making decisions. Thoughts of suicide, plans, or attempts. Persistent physical symptoms or pains that don't respond to treatment |
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Stressors found to increase risk of depression symptoms in maternal depression:
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Having an unintended pregnancy
Arguing w/ a partner more than usual during pregnancy. Having bills they couldn't pay |
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Danger signs of suicide
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Talking about suicide
Statements about hopelessness, helplessness, or worthlessness Preoccupation w/ death Suddenly happier, calmer Loss of interest in things one cares about. Visiting or calling people one cares about. Making arrangements; setting one's affairs Giving things away |
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Key concepts of Dunn's model of sensory processing:
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Interaction between neurological thresholds and behavioral responses.
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Neurological threshold continuum
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NS operates based on excitation and inhibition
It's the balance of these operations that determine how responses are generated. some refer to this as modulation of input. |
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Excitation
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Occurs when neurons are more likely to respond or are activated.
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Inhibition
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Occurs when the likelihood of responding is decreased or responses are blocked.
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Habituation
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NS's recognition that something familiar has occurred, non-harmful.
Neurons stop firing Habituate to the sounds |
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Sensitization
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NS mechanism that enhances potentially important and harmful stimuli.
Recruit more neurons Smell of smoke |
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Neurological threshold
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Amount of stimuli required for a neuron or neuron system to respond.
Some thresholds are very high and require a lot of stimuli to fire. Some are very low and takes very little stimuli to meet threshold and fire. Our job is to support the neurological threshold. |
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Establishment of threshold
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Based on genetic endowment
Personal life experiences Demands/supports of environment |
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On the threshold continuum... habituation= ___, super sensitive= ___
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Habituation= high threshold
Super sensitive= low threshold |
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Behavior responses/self regulation
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Strategies people use to manage their own needs and preferences.
Passive vs. active strategies. |
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Passive strategies
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Let things happen to them (either miss cues, become overwhelmed and distracted, irritated)
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Active strategies
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Work to control the amount and type of sensory input
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Threshold continuum behavioral response (x axis of chart)
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Passive (left) or active (right)
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Upper L on threshold continuum
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Low registration
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Upper R on threshold continuum
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Sensation seeking
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Lower L on threshold continuum
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Sensitivity to stimuli
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Lower R on threshold continuum
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Sensation avoiding
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Low/poor registration
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Eeyore
High threshold, passive Misses sensory stimuli Uninterested Slowed responses Withdrawn Doesn't notice what others do. Overly tired High ability to focus Unaffected by varying environments often ignored |
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Sensory seeking
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Tigger
High threshold, active Enjoys sensory stimuli Continuously engaging Fidgety Creates sensation in the environment Derives pleasure Generates ideas to create sensory experiences Notices and enjoys activity in the environment Adds to the experience |
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Sensation avoiding
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Piglet
Low threshold, active Limits exposure to sensory stimuli Rule bound Reliant on rigid rituals Enjoys structure and routine Needs predictability Fear is common Look like eeyore, but when add sensation they'll remove themselves unlike eeyore who may react |
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Sensitivity to stimuli
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Mad Hatter
Low threshold, passive Aware of sensory stimuli Distractible Discomfort w/ sensation Complainer Notices what is occurring in environment Particular about task completion parameters |
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Children w/ autism tend to be in what part of this continuum?
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Sensory avoiding, which is why they need routine
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Sensory profile
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gives you info about where the child prefers their sensory experience in each of the four categories. If unsure, begin with low threshold.
Gives info about each sensory system. We're not there to fix, but support. If don't like auditory, don't want to use it. If prefer tactile, use this as a medium to frame our intervention. |
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Infant Toddler sensory profile
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Birth-3 years
0-6 mo: 36 items 7-36 mo: 48 items |
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Emotional regulation
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Core process underlying attention and social engagement.
Essential for optimal social-emotional and communication development and for development of relationships. |
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Mutual regulatory capacities
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Ability to solicit and secure assistance from others in regulating one's own arousal.
Occurs w/in the context of an interaction. |
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Self-regulatory capacities
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Self-initiated and self-directed strategies, the ability to independently attain an optimal level of arousal.
Reflect on previous experience. |
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Regulatory compacities are a critical factor in
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supporting social and emotional development b/c it maximizes the amount of time the child is in an optimal arousal state, well-regulated emotionally, and actively engaged.
Children w/ sensory differences often rely on the caregiver and don't develop strategies. |
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Lens for viewing emotional regulation:
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How can I support their emotions to cope rather than them acting out in rash behavior.
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All behavior serves a function:
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Regulate attention
Communicate Engage in purposeful/goal oriented activity. |
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Developmental progression:
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Behavioral (SP)
Language (LP) Metacognitive (CP) Under stressful situations, language is compromised. |
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Behavioral strategies
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Simple sensory motor actions.
Become evident, in part, according to the internal drive for homeostasis. Shaped through interactive feedback from adults and peers. Dependent upon motoric abilities. Closely tied to neurophysiological factors. |
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Support for the threshold:
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Registration- provide more intensity.
Seeking- provide more opportunities. Sensitivity- provide more structure. Sensory avoiding- provide more structure, decrease input. |
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Thinking
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Prevention strategies- environmental manager to support threshold needs.
Necessary skills to teach |
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Participation costs and benefits:
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Childhood participation
Family life |
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Starting points: behavioral strategies
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Mouthing/chewing objects
Rocking, jumping, crashing Hand flapping Humming |
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Sensory diet:
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Diet of nutrition, but instead of nutrition think sensation. Sensory seekers need sensory snacks all the time, avoider-sensory breaks all the time.
Total daily sensorimotor experiences a person requires to interact adaptively with the environment. Assist child to maintain optimum levels of arousal and organization throughout the day. Naturally occurring opportunities for children to get the sensory stim they need. Functional activities are excellent means of building daily sensory diet. |
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Excitatory vs inhibitory activities: excitatory
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Rapid, irregular movement
Light, swift, unpredictable touch Varied texture/flavor of diet Loud, varied sounds Fill the threshold, things that are unpredictable |
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Inhibitory activities
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Rhythmic, regular movements
Firm, slow, predictable touch Bland, consistent diet Repetitive, soft sound Deplete the threshold |
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Language partner
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Scripting language
Expressing emotions w/ symbols, pictures, signs Use language to request break or assistance. Use language to request regulating activity. use self talk to support attention (I'm okay) |
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Meta-cognitive strategies
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Understands how to grade emotions.
Describes plausible factors for emotion of self and others. Uses self monitoring and self talk to guide behavior Collaborates and negotiates w/ peers in problem solving. Uses emotional memory |
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Peace board
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Try to figure out how to come up w/ solutions
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Autism spectrum disorders (ASD)
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Group of related brain-based disorders that affect a child's behavior, social, and communication skills.
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Hallmark of autism
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Impairment in social interaction skills.
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When can autism be accurately be diagnosed?
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18 mo-2 years
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Impairments related to autism may look like:
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Social- difficulty making/keeping friends, prefer to play alone, difficulty initiating interactions, difficulty understanding social cues.
Communication- may/may not be verbal, may communicate w/ pictures/gestures/devices, may repeat words, may memorize movie scripts. Interest/play/activities- may only play w/ one activity, difficulty w/ pretend play, difficulty occupying time "productively" Self-stim behaviors- things such as hand flapping, spinning, self-injurious behavior, etc. |
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5 types of pervasive developmental disorders
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Autistic disorder
Asperger's disorder Rett disorder Childhood disintegrative disorder Pervasive developmental disorder- NOS |
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Autistic disorder
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Social impairment
Language and communication disorder Repetitive interests and activities Onset prior to 36 months |
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Asperger's disorder
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Social impairments
Repetitive interests and activities Average intelligence |
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Rett disorder
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Social impairment
Language and communication disorder Onset prior to 36 months Period of normal development followed by a loss of skills. Only diagnosed in girls |
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Childhood disintegrative disorder
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Social impairment
Language and communication disorder Repetitive interests and activities Period of normal development followed by significant loss of skills in several areas Normal development prior to 36 months |
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PDD-NOS
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Social impairment
Language and communication disorder and/or repetitive interests and activities |
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New DSM-V criteria: autism spectrum disorder must meet criteria 1-3
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1. Clinically significant, persistent deficits in social communication and interactions as manifested by all of the following: Deficits in nonverbal and verbal communication, lack of social reciprocity, Failure to develop and maintain peer relationships.
2. Restricted, repetitive patterns of behavior, interests, and activities as manifested by at least 2 of the following: stereotyped motor or verbal behaviors or unusual sensory behaviors, excessive adherence to routines and ritualized patterns of behavior, restricted/fixated interests. 3. Symptoms must be present in early childhood. |
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Diagnosing autism
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Usually done by licensed psychologist or physician w/ expertise in ASDs.
Tools: Autism Diagnostic Observation Schedule (ADOS) and Autism Diagnostic interview |
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Who can diagnose autism?
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Medical diagnosis (DSM-IV) licensed psychologist or medical doctor.
School diagnosis (IDEA)- school psychologist |
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Screening for autism should be done:
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twice, at 18 and then 24 months.
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Symptoms of autism: social differences
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Doesn't snuggle when picked up
Doesn't keep eye contact or makes little eye contact Doesn't respond to parent's smile Doesn't look at objects parents are pointing at Doesn't bring objects to show parents Doesn't have appropriate facial expressions Unable to perceive what others may be thinking/feeling Doesn't show concern for others Difficulty making friends |
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Symptoms of autism: communication differences
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Doesn't say single words by 15 months or 2 word phrases by 24 months
Repeats exactly what others say w/o understanding meaning Doesn't respond to name Refers to self as you and others as I Often doesn't seem to want to communicate Doesn't start or can't continue conversation Doesn't use adults or toys in pretend play May have good rote memory Loses language milestones between 15-24 months |
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Symptoms of autism: behavior differences
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Rocks, spins, sways, twirls fingers, or flaps hands
Likes routines, order, and rituals Obsessed w/ a few activities Plays w/ parts of toys instead of the whole toy May have splinter skills Doesn't cry if in pain or seem to have fear May be sensitive to smells, sounds, lights, textures, or touch Unusual use of vision Unusual or intense, but narrow interests |
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Autism and motor clumsiness
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Many individuals w/ ASD have difficulty w/ both gross and fine motor skills.
Difficulty not just w/ the task, but the motor planning involved in completing the task. Typical challenges: handwriting, riding bike, and ball skills. |
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Causes of autism
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Likely more than one cause.
Likely a combination of genetic components that may cause autism in combination w/ exposure to environmental factors. Linked to biological or neurological differences in the brain which affect the way parts of the brain function. |
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Environmental factors and autism
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Pesticides
Metals Organic pollutants Infections Medical procedures and drugs Nutritional factors |
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Appropriate interventions can influence long term outcomes:
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Improved IQ scores
Improved functional communication skills Improved adaptive skills Improved social skills |
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Ziggurat model
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Comprehensive framework for assessment and intervention planning for individuals w/ high functioning Autism and Asperger syndrome
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Strengths of Ziggurat model
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Provides a structure for helping you "see the autism"
Includes an assessment tool to help you ID the individual's strengths. Provides a comprehensive intervention planning framework. |
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Functional behavior assessment:
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understanding the factors that contribute to challenging behavior:
Antecedents (triggers) Behavior (how person acts described in an objective manner) Consequence (what follows the behavior to reinforce or redirect) |
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3 key elements of a behavior support plan
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Prevention strategies- How can we prevent behavior from occurring?
Replacement skills- What do we want the child to do instead of the challenging behavior? Response strategies- How will we respond? How will reinforce good behavior and redirect not so good behavior? |
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Ziggurat model IDs characteristics related to:
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Social
Restricted patterns of behavior and interests Communication Sensory Cognitive Motor Emotional vulnerability Medical and biological factors |
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Individual Strengths and Skills Inventiory (ISSI) of Ziggurat
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Assists in IDing the individual's strengths that can be used when planning intervention
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Ziggurat model
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Sensory differences and biological needs
Reinforcement Structure and visual/tactile supports Task demands Skills to teach |
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Sensory differences and biological needs:
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Sensory preferences- can interfere w/ ability to function.
Biological needs- sleep, dietary issues, other medical issues (seizures, GI, etc) |
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Sensory preferences:
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Use sensory profile assessment to ID.
Provide supports and/or sensory diet based on individual's preferences |
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Lighting and other visual input
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Consider types of lighting: fluorescent can be aversive, natural light or lower lights when possible.
Move individual's seat or workspace to be in more comfortable lighting Allow them to wear sunglasses or a ballcap. |
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Sounds
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Move individual away from aversive sounds, try earplugs/headphones, reduce noise, talk softly.
Recognize their coping strategies: humming or other noisemaking, self-stim behavior |
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Smells
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May be sensitive to certain smells or may use smell as a way to learn about objects.
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Seating
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Cushions
Bean bag chair or pillow area Rocking chair Exercise ball |
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Positive reinforcement
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Any pleasant object or activity that is given to a person following a behavior that increases that behavior.
Behavior is likely to happen more often, for a longer period of time, and improve in quality. |
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Ways to ID reinforcers
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Talk to individual about what they find motivating or interesting.
Watch them carefully to see what captures attention. Watch how younger children spend their time. |
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Why use visual supports?
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Tell individuals exactly what's expected of them, including clarifying rules, the social expectations, and demands of the task.
Help structure the environment. Help individuals avoid frustration by giving them a means for making choices, telling wants and needs, and expressing feelings. |
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Strengths of individuals w/ ASD
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Visual processing
Rote memory Special interests Analytical thinking, formal/logical rules, understanding absolutes. Straightforward, honest, objective. Serial info processing |
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5 point scale
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Scale of 1-5 to ID with how a student is feeling in a particular situation
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Describe the 8th nerve.
how is it created, where start, where go.... length? |
AUDITORY NERVE/8th nerve is only 5 mm long, it is made up of the COMBINED VESTIBULAR (goes to the vestibule) and COCHLEAR (goes to the cochlea) nerves. Nerve fibers from the cochlea enter the IAM from the modiolus. The IAM is about 5 mm across. The IAM then turns toward the brain stem. 2 branches of the vestibular nerve enter the IAM at the corner where it turns (basal turn). Hence the vestibular and cochlear combine into the auditory nerve/8th nerve at the basal turn of the Internal Auditory Meatus (IAM). The IAM ends at the Brain stem where the 8th nerve ENTERS the BRAIN STEM. It ENTERS the MEDULLA OBLONGATA (medulla oblongata is the lower half of the brainstem) laterally at the level of the lower PONS (where cochlear bundle goes into the cochlear nucleus and then divides into the VENTRAL/DORSAL nuclei). Then the nerve acends from the lower pons on up to the CNS/auditory cortex. The last fibers (4th and 5th Order) end below the FIssure of Sylvius.
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Interventions for task demands
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Break task into smaller steps
Allow more time Provide written or visual instructions Allow individual to choose order of tasks. Allow breaks Provide organizational supports |
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Skils to teach: underlying characteristics checklist area
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Social
Communication Restricted pattern (coping and strategies for expanding skills) Sensory Cognitive Motor Emotional regulation |
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Role of PT in autism treatment
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Address any motor deficits that are interfering w/ participation in daily life activities.
Assist in developing leisure skills that include physical activity for overall health. |
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Social skills intervention
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Critical component of effective intervention for individuals w/ ASD.
Social expectations change w/ age, so this skill must be constantly addressed. |
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Social skills intervention w/ younger children-
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Start w/ development of foundation skills including joint attention, language, and symbol use.
Provide opportunities to practice play and social skills. Use checklists to help ID what skills child has and what should be targeted. |
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Social thinking:
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Developed for individuals w/ just below average to well above average IQ.
Teaches social understandings before teaching social skills. Taught to consider: Points of view, emotions, thoughts, beliefs, and intentions of others. |
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Video-modeling
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Shown to be effective for children 3-18 y/o to teach:
Communication skills Interpersonal skills Play skills Emotional regulation Higher cognitive functioning |
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Peer training
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Carefully select peers who are:
Socially skilled Generally compliant w/ instruction Regular school attendance Willing to participate in training Able to imitate a model |
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Peers in teaching motor skills
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Best to start w/ 1-2 peers.
Perform during the time of day the motor skill usually occurs ie PE |
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The rehab of children w/ SCI presents unique challenges to the rehab team:
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Growth and development
Child/family centered care Duration of the rehab process Continued participation |
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Most common cause of SCI in children:
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Trauma- MVA, sports, violence, and falls
Boys twice as likely as girls. Ages 0-5 and 10-15 are most commonly injured. |
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Non-traumatic SCI causes:
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tumor, transverse myelitis, epidural abscess, AV malformation, MS
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Pediatric SCI developmental anomolies:
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Instability of atlanto axial joint: down syndrome, juvenile RA, os odontoideum
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Anatomical/biomechanical features of pediatric spine (<8-10)
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Increased mobility: ligamentous laxity, shallow facets, large head, incomplete vertebral ossification.
Increased risk of upper cervical injury- developmental anomalies and large head relative to spine Prevention and screening is important. |
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SCIWORA
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SCI w/o radiographic abnormality. if kids have an injury there may not be bony damage, but there is SC damage.
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Traumatic SCI in ped population results in:
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55% results in tetraplegia (quadriplegia)
45% results in paraplegia |
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Tetraplegia
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Damage between C1-T1 root levels.
About half of these are incomplete. |
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Paraplegia
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Damage below T1
40% are incomplete. |
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Complete SCI
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No motor function or sensation in lowest sacral segment (S4/5)
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Incomplete SCI
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Some function below level of injury remains AND motor function or sensation is preserved in lowest sacral segment.
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Defining the level of SCI
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Look for a 3 MMT grade w/ a 5 for the muscle above it's innervation.
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Defining the rpecise level and type of SCI is important for predicting:
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The likelihood of further neurologic recover.
The expected level of functional independence related to mobility, self-care, etc. |
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At what ages can you use ASIA standards to classify sensation and motor function in a child w/ SCI?
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Between 4-6 and older
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What do you use to classify level of SCI injury in children younger than 4?
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Possibly observational motor assessment.
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Medical complications following SCI
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Hip disorders/scoliosis
Skin care Respiratory dysfunction Pain Autonomic dysreflexia Orthostatic hypotension DVT Spasticity Hypercalcemia Heterotrophic ossification Bowel/bladder dysfunction. |
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Hip disorders/scoliosis
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Unique to kids w/ SCI
99% of kids w/ SCI before puberty develop scoliosis. Hip- s/l, d/l, contractures, fx, etc risk increased. |
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Skin care and SCI
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Pressure relief techniques and skin monitoring
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Respiratory dysfunction and SCI
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increased likelihood of sickness b/c can't clear airways
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Autonomic dysreflexia
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Disruption of sympathetic outflow.
Noxious stimulus like bladder distended below level of injury causes reflex sympathetic discharge which spikes BP. Sit them up, remove tight clothing, try to find source of problem. |
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Orthostatic hypotension
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Related to disruption in sympathetic outflow.
Resting BP is lower after SCI naturally. |
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Spasticity and SCI
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Occurs w/ injury above the L1-2 level b/c this is where UMN portion of SC ends.
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Hypercalcemia and SCI
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Increased Ca in blood; occurs in young boys w/ SCI b/c about 40% of blood Ca lost after SCI. As bone remodels, more calcium spills out.
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Heterotrophic ossification
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True bone forming in ectopic sites.
Bone may form in joint spaces such as hips. |
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Outcome measures for younger children w/ SCI
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WeeFIM
PEDI |
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Outcome measures for adolescents w/ SCI
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FIM
SCIM |
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QOL outcome measures for kids w/ SCI
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PedsQL 4.0
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Outcome measurements for participation w/ SCI
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CAPE
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Goals in SCI rehab
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Improve independence
Improve function skills related to mobility and self care Improve knowledge of condition Provide necessary equipment/ongoing maintenance Guidance in planning for the future and return to school. Continued participation and activities. Work w/ whole family to establish realistic outcomes related to level of injury, completeness of injury, age of child, and family expectations |
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Wheelchair prescription and management
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Power vs manual
Pressure relief techniques Advanced wheelchair skills |
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Children w/ LE function may require:
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orthotic prescription and gait training if ambulation is an appropriate goal.
Work on standing balance as people w/ incomplete SCI and low level paraplegia have muscle imbalances and sensation abnormalities. |
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Selective shortening lengthening of muscle groups may aid in function. Ex:
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Person w/ C6 quadriplegia lacks hand function, but selective shortening of long finger flexors allows tenodesis grip when wrist is extended. Don't do things w/ extended fingers.
People w/ quadriplegia and upper thoracic injuries lack trunk control, but shortening of back extensors creates some artificial stability in sitting. People w/ short hamstrings overstretch back extensors. |
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Prevention of secondary impairments w/ SCI
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Pressure relief for skin health.
Contracture prevention Spasticity management Monitor hips and maintain ROM (esp add/flex to prevent s/l) Seating systems and bracing to prevent scoliosis Prophylactic exercise/education to prevent UE overuse injuries. |
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Requirements for successful walking
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Progression
Stability Adaptation |
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Progression
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Rhythmic stepping pattern to move forward
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Stability
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Postural control
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Adaptation
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Adapt to changing environment and task demand
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Factors that, if not present, will limit development of independent walking:
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Sufficient extensor strength to support body during single limb stance.
Dynamic balance Postural control |
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Pre-ambulations skills
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Newborn stepping
Pull-to-stand (7-11 mo) Cruising (8-13 mo) Climbing Squatting |
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Development of gait: beginning walker (11-16 mo)
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Lack of reciprocal arm swing- initial high guard.
Persistent hip abduction through stance/swing phases. Short step length Short period of single limb support. High cadence, low velocity |
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Development of gait: 18-24 mo
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Improved vertical alignment of trunk, more erect posture.
Gradually decreasing BOS Increased time spent in single limb support. Increased velocity Heel strike at 24 mo |
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Development of gait: 3 years
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Onset of mature gait pattern
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Determinants of mature gait
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Duration of single limb support
Velocity Cadence Step length BOS |
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Causes of common gait deviations in CP
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Bone deformity
Decreased ROM/spasticity Weakness |
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Bone deformity
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Secondary impairments caused by failure of physiologic bone remodeling, spasticity, muscle imbalance and disuse, compensations to improve function, etc.
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Femoral anteversion/antetorsion
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Caused by a combination of: Persistent fetal andeversion/torsion due to delayed WB.
Abnormal muscular forces due to spasticity |
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External tibial torsion
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Develops as a result of:
Repeated dragging of foot in ER for improved clearance. |
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Pes valgus
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Commonly seen in kids w/ spastic diplegia or quadriplegia.
Caused by: muscle imbalance, tightness, weakness |
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Follows femoral anteversion/torsion and ER of tibia:
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Lever arm syndrome
Pes varus/equinovarus |
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Lever arm syndrome
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Series of bony deformities caused by persistent femoral anteversion/antetorsion.
Excessive anteversion > tibial ER > pes valgus Pattern of bony malalignment: Leads to patellar instability Places mm that are already weak and spastic in a disadvantaged position. |
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Pes varus/equinovarus
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Commonly seen in kids w/ spastic hemiplegia.
Caused by overactivity in mm that PF and supinate the STJ. Over time, contracture and bony deformity can result. |
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Abnormalities in walking associated w/ spasticity and contracture frequently impact what muscles?
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2-joint muscles
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Contracture
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Static loss in ROM
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Spasticity
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Creates a dynamic loss of ROM b/c resistance to stretch.
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Spasticity in hip adductors combined w/ weakness of abductors and extensors can lead to:
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Hip s/l and d/l in minimally ambulatory or nonambulatory child
Scissoring of gait pattern in ambulatory child where swing leg moves across midline and crosses over opposite leg |
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Spasticity or contracture of hip flexors:
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impacts gait and posture by decreased step length, increased pelvic anterior tilt/lumbar lordosis.
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Jump gait
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Most common gait pattern in kids w/ spastic diplegia.
Increased hip flexion, knee flexion, and PF in stance. |
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Crouch gait
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Increased hip flexion, knee flexion, and DF in stance.
Often caused by isolated heel cord lengthening w/o addressing hip and knee contractures or can be part of natural history of ambulatory person w/ diplegia. |
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Recurvatum/abnormal PF-knee extension/hyperextension
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PF spasticity or contracture cause knee hyperextension during stance by preventing tibial advancement.
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Stiff knee/limited swing phase knee motion.
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Decreased knee ROM during swing.
PF force production is reduced, people compensate using a spastic rectus femoris which flexes the hip and extends the knee. Causes the knee to extend, so to clear toe, they must circumduct, ER extremity, or vault. |
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True equinus/toe walking
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Often seen in gait of younger children w/ diplegia as they begin to walk.
Ankle PF throughout stance w/ knee/hip extension. |
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Prediction
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To declare in advance.
To ID which specific individuals have or will develop a target condition or outcome. |
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Prognosis
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The determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level.
Relationships among IDed impairments and perspectives of the client contributes to the prognosis. |
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Prognosis for gross motor function in cerebral palsy: Creation of motor development curves.
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Evidence based prognostication about gross motor progress in kids w/ CP.
Differences in the rates and limits of gross motor development among kids w/ CP by severity. Kids w/ the most severe disabilities attain gross motor abilitites faster and at a lower level than a child w/ less severe disabilities. Rate- how fast they did it; limit- how well they did it. Limit is small, rate is fast in children w/ more severe disabilities. |
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Spasticity
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Velocity dependent response; hyperreflexive; clonus
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Measurements of spasticity
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Modified Ashworth scale
Tardieu measure |
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Modified Ashworth scale
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0-4 to grade spasticity and hypotonia.
Look at levels of resistance to muscle tone. |
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Tardieu measure
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5 point scale.
Velocity dependent scale to see how much resistance there is. Used to quantify spasticity. |
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Assessing functional abilities w/ spasticity
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gait, reaching, sitting, laying down, posture, completing other ADLs. PEDI, GMFM, Peabody, BOT2, SFA
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Positioning to reduce spasticity
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Position to prevent contractures (usually in extension, but depends on region), AFOs, supportive sitting device, arm support for eating, inhibit movement you don't want- ex: put pillow or something between legs, orthotics/splinting, put in positions of stretching out the spastic muscle. Need long term stretching.
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Ice & spasticity
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Decreases neural muscle spindle firing and inhibition of muscle tone. Good when used with passive stertching.
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Heat and spasticity
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superficial heat offers short term effects and can increase extensibility, but doesn't have long term effects. US increases extensibility of muscles as well. Need to stretch following. Consider therapeutic swimming.
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Neuromuscular E-stim (NMES)
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e-stim of muscle to cause it to contract. Use as compensation or reeducation of muscle. Used for antagonists muscles that grow weak b/c the agonist is tight- reciprocal inhibition. Strengthening, reed, ROM, etc.
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Therapeutic E-stim (TES)
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Controversial. Increase BF, metabolic activity, muscle activity, etc.
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Serial casting/orthotics
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Put a padded cast on the joint to immobilize a joint lacking full ROM to reduce muscle tightness. Cast changed on a weekly basis to increase range until reaching target goal.
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Diazepam
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It has a potent action on the GABAA receptor and, at least in part, acts at the level of the spinal cord. It is effective in treating all types of muscle spasms. The major limitation is sedation seen at muscle relaxant doses. Hyperpolarizes muscle cell.
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Dantrolene sodium
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acts peripherally blocking calcium release blocking excitation contraction coupling in sk m
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Baclofen
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GABA agonist, surgically implant pump into abdomen and catheter goes directly into SC and is programmed based on the person. Fewer side effects than taken orally. Refill like it's a shot about every three months, may need to be replaced every three years. Used for more severe cases.
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BOTOX
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Injection into specific m every 2-3 months that impairs release of Ach. Release muscle that is injected.
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Selective dorsal rhizotomy
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surgically cut some of dorsal N rootlets coming off of SC enough to preserve strength, but reduce spasticity.
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Brachial plexus injury (BPI)
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Injury to the brachial plexus, usually occurring during a difficult vaginal delivery.
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BPI can occur w/:
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Traction to the shoulder to deliver the head during breech delivery.
Traction to the head during vertex delivery (head first). Presence of a cervical rib or shortened scalene muscles. |
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Other risk factors for BPI:
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Weight greater than 7.7 lbs.
Difficult delivery of shoulders. Prolonged labor. Maternal diabetes. Sedated hypotonic infant during delivery. Breech presentation. |
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BP damage can occur:
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Where the N rootlet attaches to the SC.
Anterior or posterior rootlets. Distally where the rootlets coalesce and exit the vertebral column. |
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Types of damage to BP
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Partial to full rupture
Recovery after full rupture is limited. Recovery after partial injury can take as little as 4-6 months, as long as 2-4 years depending on location and severity. Axon regrowth about 1 mm per day |
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Erb's palsy
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Most common BPI
Upper roots (C5-6) Shoulder extension, IR, adduction Elbow extended Forearm pronated Wrist and fingers flexed "waiter's tip" position |
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Erb's palsy muscle involvement:
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Rhomboids, levator scapulae, serratus anterior, subscap, deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, supinator, long extensors of wrist.
Grasp usually intact. |
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Klumpke's palsy
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Involvement of lower N roots (C7-T1).
When purely C7-T1 is present, shoulder and elbow movements aren't impaired. Forearm typically supinated. Paralysis of wrist flexors and intrinsic mm of wrist and hand. Rare. |
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Erb-Klumpke palsy
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Combination of upper and lower roots (C5-T1).
Results in total arm paralysis and loss of sensation |
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BPI and torticollis
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Positional torticollis can develop away from involved arm.
Could also be present to the same side due to trauma causing opposite BPI. B/c clavicular injury, scar tissue, or SCM tightening. |
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Anatomical compensations for BPI
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Grasping an object occurs w/ IR of shoulder, forearm pronation, and wrist flexion.
Possible neglect of involved UE due to sensory loss. Contractures and abnormal bone growth are associated. |
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Activity limitations w/ BPI
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Vary depending on extent of pathology.
Primary limitations: relate to impaired reach, grasp, and decreased use of UEs together. Unilateral preference in developmental activities. Limb neglect Sensational deficits can lead to injuries. |
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Mallet scale
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Used to describe the extent of injury and movement.
1-5, 5=normal |
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Surgical treatments for BPI
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Neurosurgery- 5-10% of kids. N grafting, neuroma dissection.
Orthopedic surgery- to provide necessary ROM for hand to reach head and mouth. |
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Indications for surgical repair in BPI
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No improvements for 2 months, no muscular strength in antigravity position at 6 months.
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Ortho treatment options in BPI
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Functional strengthening
Stretching, bracing, splints if indicated Kinesiotaping and theratogs to facilitate underactive mm. |
