Working with children is exciting, challenging and enriching. Physiotherapists entering this field of pediatrics will need to be prepared to adapt to the techniques that they have learned in relationship to adults to the ever changing needs of the growing child. The physiotherapist will inevitably work within the context of the child and his family and have opportunity to work with the child in a range of situations extending into home, pre school groups, education and leisure activities. Because of the complex needs of the child and the family, the physiotherapist may work with many other disciplines including medical, nursing, social work, educational and care staff, psychological and psychiatric teams as well as speech and occupational therapists. The physiotherapist working in such teams must be able to communicate his/her observations, assessments and treatment plans to the child, his parents and other members of the team.
To work effectively and efficiently the pediatric physiotherapist must in addition to his physiotherapy skills, have a clear understanding of the development process of the childhood, primitive reflex patterns and pediatric illness and disability.
It is important that patients feel comfortable and reassured by their surroundings during treatment. For children this is of enormous importance. The treatment environment starts as the child enters the waiting area; where children are seen in the same area as adults it is important that provision is made for their specific needs. For the pre-school child the size and furnishing of rooms should be as home like as possible. Children become anxious about large pieces of mysterious equipment which they don't understand. The natural play environment of the young children is on the floor and the treatment environment should have suitable floor coverings of washable carpet, mats or safe rugs. Toys and games for children of varying ages should be available both for reward and distraction as well as to facilitate pediatric physiotherapy treatment.
Pediatric physiotherapy could take place in a number of areas, e.g. hospital ward, department or home, and for children there is an increased possibility of venues. They may include health centre, nursery group, school or recreational group.
When considering childhood disability it is important to remember that one is dealing with a child and family with a disability. Disability is defined as state of body or mind which jeopardizes full functioning throughout a significant development stage or the remainder of that person's life.
Defect: a structural or physiological abnormality.
Disability: a lack or impairment of a particular capability or skill.
Handicap: a condition or set of conditions that hinder or prevent the pursuit or achievement of desired goals.
Congenital Conditions: These are conditions that are present at birth. It would however be misleading to imply that all congenital conditions present themselves at birth. Some are clearly apparent, e.g Down syndrome, talipes, and major cardiac defects. Others do not reveal themselves immediately but only become apparent as the infant or child matures, e.g muscular dystrophy, neurofibromatosis, most cerebral palsy and many hearing and sight defects. This group includes intra uterine infections the outcome of which may or may not be apparent at birth, e.g cytomegalovirus, rubella and toxoplasma. Some conditions are genetically linked, e.g muscular dystrophy, and may occur in several children within the family.
Acquired conditions: These are conditions that are acquired as a result of for example: Illness- encephalitis, meningitis, juvenile chronic arthritis, dermato-myositis, neoplasm, malnutrition, poliomyelitis, etc. trauma- head injury, child abuse, road traffic or playground accidents.
The importance of play activities cannot be overstated. It is a vessel through which child regains skill lost as result of illness or injury. In pediatric physiotherapy arm exercises may be combined with ball works or drawing pictures on a large sheet of paper on the wall. Leg exercises may be combined with touching well placed objects with the toes. Any exercise may be reinforced by using an action song. Standing may be encouraged by placing an attractive activity on suitable height surface. Movement may be encouraged by fetching and carrying games, e.g shopping. Obstacle course provide endless possibilities for the therapist and fun for the child. The child should not be allowed to become bored. The therapist should try to keep activities simple and have a selection to choose from and if the first one fails or fades out quickly.
From about the age of seven children's awareness of their own bodies has matured enough to enable them to co-operate more actively in their pediatric physiotherapy treatment. They have sufficient body and spatial awareness to be able to carry out simply explained exercises and activities. The therapist should plan a number of short activities lasting 5 to 10 minutes. She could allow time for play as a reward between or after therapeutic activities. She should always explain to the child what is expected of him. Parents who are not present during pediatric physiotherapy treatment need to be kept informed about their child's treatment, his progress and any treatment that should be continued at home.
All children use some form of equipment as a part of daily life, e.g. pushchair, feeding chair or baby walker. All children have toys of some description. There is a very thin line between ordinary baby gear and therapeutic equipment.
During the early months many babies will use a fully supporting chair or bouncing cradle seat. Some of these are designed for use as a car seat and indoor chair and are recommended from birth. They give total support at a reclined angle in order to protect the infant's spine from damage. These seats are particularly important for the floppy infant and can in many instances contain the young baby with strong extensor spasms. A baby placed in one of these seats for planned period each day will have an increased opportunity to watch his surroundings and they may assist the development of a mid-line awareness and early reaching and grasping.
A little later a less supporting seat may be introduced at a more upright angle. If plastic baby chairs do not offer enough support consider using a car seat with added foam cushions. It is sometimes easier to provide support from the upholstered surface of a car seat than using vinyl or plastic which tends to be slippery.
High chairs and feeder chairs enable the child that is establishing sitting balance to be safely seated for meal times and play. As the child's sitting ability increases the support given can be reduced by the gradual removal of the cushions. There is an ever increasing range of purpose built chairs for the child with special needs. Therapists working with young children should help the parents not only to identify their child's needs, but also, their own needs in respect of height, weight and function and enable them to go out and choose a pushchair to meet them.
Later, independent mobility may be aided in a number of ways. Some babies enjoy using a bouncing sling suspended from a frame or doorway. These must be placed at the correct height and used for a planned period only. For some children the use of these type of baby bouncer is ill adviced: Very floppy children may be in danger of obstructing their airway. Stiff children may increase the use of their extensor spasm and disrupt the development of the sitting skills.
Specialist equipment is available for children with delayed or disordered motor development. This ranges from simple foam wedges to assist prone development, to prone standing boards, to standing frames, walking aids and a whole range of wheelchairs, manual and power operated.
An appliance may be defined as a piece of body worn equipment. The term includes footwear, splints, calipers and spinal braces. To function effectively an appliance must be a good fit, lightweight and durable.
It would be presumptuous to assume that any one approach to pediatric physiotherapy treatment is the only right, proper and effective measure to use. The therapist working in this field will develop her own range of techniques, so that with an individual child and family she can draw upon them and supplement them as the situation requires. All workers have the one common objective- to be as effective as possible in minimizing the handicapping effect of the condition thereby helping the child to enjoy the optimum quality of life. Within the conventional boundaries of pediatric physiotherapy much is owed to the work of Bobath & Peto. Other systems that offer help and direction to parents include the Portage Teaching Service, and increasing numbers of families are exploring the methods offered by the various 'Institutes of human potential' based on the work of Doman and Delacato.
A neurodevelopmental approach to the treatment of Cerebral Palsy was established in England in 1940s by Karel and Berta Bobath: the approach continues to evolve and is based on the principle of using techniques of handling and positioning in order to inhibit abnormal postures and movements and facilitate desirable normal motor patterns of movement. Parents are taught how to continue treatment into child's daily life activities such as carrying, dressing and feeding. This approach is in use throughout many countries.
The system of conductive education was developed by Dr Andras Peto in Budapest in 1960s. The inscription above the institute in Budapest bears the inscription: 'Not because of, but in order to'.
Work is based on the principle that cerebral palsied children consciously learn movement by constant practice and repetition. This learning is reinforced by the use of voice and rhythmical intention. Professional demarcations are abandoned and a single conductor is trained in all aspects of therapeutic and educational work. Most activities take place within a group setting and are task based and are functionally related.
This early intervention teaching approach was developed in Wisconsin and used for work with socially deprived children. This system has been introduced to Great Britain and offered to families with learning disabled children. Most services work on a home visiting basis, the visitor aiming to teach the family how to break down learning tasks into small attainable steps. The parents are given a chart that describes the teaching activity and records their work with their child. This service is now in use in many areas, often being offered to children with motor disabilities. It works in parallel with other services and therapies and can be a useful reinforcer. To avoid overlap and confusion there must be good, effective liaison between the therapist and the portage worker.
This appoach derives from the work of Temple Fay. In the 1960s Glen Doman and Delacato extended the premise that children must develop through the evolutionary stages of reptilion squirming, amphibian creeping, mammalian crawling to attain the primate upright gait. To this they added elements of vestibular stimulation and techniques of re-breathing. Working through the institutes for human potential, assessments are offered and home programmes devised and monitored. Programmes are arduous for the child and his family, frequently occupying 12-14 hours a day. The child is patterned by up to five workers at a time and exposed to interludes of selected stimulation re-breathing and vestibular stimulatory activities. The aim is to bombard and exploit the areas of the brain that the presumed to be undamaged.