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Evaluation and Management of Neuromuscular Disease Physical therapy management Jennifer majors, PT Children’s mercy hospital Kansas city, MO

Introduction: Physical Therapy will be an important addition to your life.  Your physical therapist will provide you with activities and recommendations regarding stretching, exercise, ambulation, positioning, equipment and mobility needs.  The degree to which your therapist will be involved will be individualized and based upon need.  You will encounter Physical Therapists in various settings including: Medical and School based.

Stretching Goals: Prevent the development of contractures and to prolong ambulation.

Main focus of Stretching Calf muscles Hip flexors Iliotibial Band (ITB) Knee flexors Shoulder flexors Elbow extensors/supinators Wrist extensors Chest wall excursion/expansion

Calf muscles: Gastrocnemius/Soleus Ankle will be positioned into plantarflexion. Ankle dorsiflexion will be limited.

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Hip Flexors: Iliopsoas Hip will be positioned into flexion Hip extension will be limited. Pelvis is tilted forward, increasing lumbar lordosis.

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ITB Legs will be positioned into a wide base of support. Legs will be limited into adduction.

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Knee Flexors: Hamstrings Knee will be positioned into flexion. Maintain range=ease with transfers and with positioning.

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Upper Extremties Shoulder flexion decreased Elbow extension and forearm supination decreased Wrist extension decreased.

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Chest Wall Excursion/Expansion Chest wall will tighten secondary to weakness of intercostals. Air stacking should be performed 3-4 times daily.

Frequency

Exercise Goals: Maintain muscle balance of strength at joints, increase confidence and self-esteem, and maintain endurance.

Target Muscles Proximal Muscles Lower Extremity:               Knee extensors               Ankle dorsiflexors               hip extensors

Target Muscles Proximal Muscles Upper Extremity:               Shoulder girdle and stabilizers               Elbow flexors forearem supinators               Wrist extensors

Target Muscles Trunk:         Low back and stomach muscles         Intercostals

Games and Functional Activities Swimming Karate Bicycling Therapy Ball Theraputty

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Ambulation Goal: Maintain endurance, increase cardiovascular condition, delay progression of scoliosis, prevent progression of contractures, increase self-esteem. Surgery protocol Encourage, however, monitor for changes and negative effects.

Exercise Pacing Take frequent breaks Sub-maximal work load Do not over fatigue muscles

Positioning and Equipment Goals: To optimize function and increase independence with activities of daily living.

Proper Positioning Facilitate active movements Increase cardiovascular condition Delay progression of scoliosis Assist with prevention of contractures

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Equipment Braces and splints

AFO: Ankle Foot Orthosis

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KAFO:  Knee Ankle Foot Orthosis

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HKAFO: Hip Knee Ankle Foot Orthosis

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RGO: Reciprocating Gait Orthosis

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TLSO: Thoraco-Lumbar-Sacral Orthosis

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Equipment Hand splints:          Wrist cock-ups           Forearms splints          Supination splints          Resting hand splints

Equipment Walkers

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Equipment Standers:           Tri-stander           Vertical, prone and supine            Mobile stander

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Equipment Carseats

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Equipment Nighttime positioning                Recumbent Positioning Orthosis

Equipment Transfer Equipment           Transfer boards           Hoyer Lifts            Van Lifts

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Equipment

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Wheelchair Goal: Maintain independent mobility, provide supportive seating system to optimize function and cardiovascular condition, provide appropriate seating system to delay progression of scoliosis.

Supportive Seating Components Seating               Support the pelvis               Provide pressure relief               Incorporate lab belt

Supportive Seating Components Back            Support trunk/Align spine over pelvis            Lateral support            Chest strap

Supportive Seating Components Head rest Adjustable arm rest with upper extremity support Leg rests

Supportive Seating Components Allow for pressure relief:            Tilt            Recline

Power Mobility Electric Wheelchair Scooter

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Wheelchair Accommodate assistive technology and equipment needs. Flexible seating systems, able to modify as needed.

Other Therapeutic Approaches

Respiratory Care Objective Measurements Monitor respiratory function

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Respiratory Care Air stacking

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Respiratory Care Instruct in assistive cough techniques and breathing exercises to increase thoracic expansion.

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Respiratory Care Instruct in postural drainage and chest physiotherapy. Instruct in rib mobilization/positioning.

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Aquatic Therapy

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TES: Therapeutic Electrical Stimulation

Manual Therapy

Hippo Therapy

Evaluation/Reeval and Documentaion Medical Model               Initial stage               Transition Stage               Non-Ambulatory Stage

Evaluation/Reeval and Documentaion School Model         IFSP: Individualized Family Service Plan         IEP: Individualized Education Plan         501 Plan: Barriers, busing, elevators

Documentation Objective documentation Letters of medical necessity

Conclusion

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