Introduction to Paediatric Physiotherapy

Original Editor - Robin Tacchetti Top Contributors - Robin Tacchetti, Jess Bell, Kim Jackson and Naomi O'Reilly

Introduction

Physiotherapists / physical therapists work to maintain and improve their patients' or clients' function and movement. Paediatric physiotherapists work with children who experience some disruption in their development and their families. Typically paediatric physiotherapists will address motor issues, but their patients may also present with other impairments that affect cognition, language and psychosocial issues.

"Often you hear, well, what do we [paediatric physiotherapists] do? And you'll have a parent say, oh, it just looks like you get to play all day with kids. That sounds like so much fun, but really there's a lot more to it ... we work with children and their families to assist them to reach their maximum potential. And we really want these children to function as independently as they possibly can. For some that might not mean complete independence, but we want to get as close as we can." -- Krista Eskay

Developmentally, children typically follow a predictable pattern of motor skills attainment, although timelines can vary. Genetic makeup, cultural expectations, caregiver practices, and interactions within the environment all have an impact on how children learn functional skills.

You can learn more about motor development principles here and infant motor and cognitive development in this Plus course. For more information on motor milestones in infants, please see: Gross Motor Milestones in Infants 0-14 Months.

Aims of Paediatric Physiotherapy

When working with children with physical impairments or disabilities, the overall goal of the paediatric physiotherapist is to promote independence. Physiotherapists aim to help their clients / patients achieve developmentally appropriate functional skills, decrease the impact of an impairment, impart adaptive strategies, and educate the family and caregiver to ensure carryover.

Goals during paediatric physiotherapy sessions include:

1. Promote independence
2. Increase participation
3. Facilitate motor development and function
4. Improve strength and endurance
5. Enhance learning opportunities
6. Ease challenges associated with daily caregiving

Common Paediatric Impairments

Neurodevelopmental conditions among children are on the rise. These disabilities can be related to congenital or acquired health conditions which result in temporary, permanent or progressive impairments. Depending on the disability, all or different aspects of a child's life can be affected. Some examples of childhood disabilities include:

• Cerebral Palsy
• Spina Bifida
• Traumatic Brain Injury
• Autism Spectrum Disorder
• Intellectual Disability
• Juvenile Idiopathic Arthritis

Where Do Paediatric Physiotherapists Work?

Paediatric physiotherapists can work in a diverse group of settings, including:

• Schools
• Outpatient Centres
• Hospitals
• Rehabilitation Centres
• The child's home
• Neonatal Intensive Care Units

Early Intervention and Family-Centred Care

There is also a focus on early intervention in paediatric physiotherapy. Early intervention services are a set of interventions that support and provide resources for families of special needs infants and toddlers aged between 0 and 3 years.

Traditionally, early intervention was based on an expert model where a therapist created goals and provided follow-up care based on a child's impairment. Any interventions provided by the family were adjuncts to those provided by the healthcare professional. The overall care and decision-making for the child was in the hands of the therapist. This model is referred to as a rehabilitation model.

Family-Centred Care

However, there has recently been a shift from this therapist-driven model to a family education/empowerment model. to focus on the child's participation and activities with their family. The family-centred care (FCC) model enables collaboration between the therapist and family where the goals and aspirations of the family are central to the intervention. Moreover, interventions have shifted from what the child cannot do to what the child can do.

It is important to note that changes in a child's development can impact the entire family. Caregivers and family members may develop feelings of vulnerability and guilt or feel unable to care for their child. However, this family-centred model of care shifts the decision-making from the clinician to the caregivers as they are considered the experts in their child's needs and abilities. Acknowledging the family's interest and values is, therefore, critical. This process provides opportunities for the families to feel empowered and increase their self-confidence as they face daily challenges.

Team

In most paediatric settings, the physiotherapist will work collaboratively with other members of their team. Each team is different, depending on the needs and wants of the family and the child. In general, the team will include the child, parent/caregiver and other specialised medical personnel such as speech-language pathologists / therapists, occupational therapists, psychologists, social workers, teachers and physicians. The child is considered the most important member of the team.

Paediatric physiotherapists may work in the following types of teams:

1. Multidisciplinary:
   • professionals work independently, providing separate evaluations, goals and interventions specific to their discipline
   • there is generally less communication between team members
2. Interdisciplinary:
   • team members interact with each other in relation to the evaluation and development of an intervention plan
   • interventions are typically provided by the individual provider but occasionally co-treatments occur
   • there is more communication among team members than in a multidisciplinary team
3. Transdisciplinary:
   • team members provide joint evaluations, collaborate on goal development and interventions
   • one provider is the primary provider who works with family on a regular basis (they implement the intervention plan for all disciplines while consulting with other providers)
   • the primary provider is chosen based on the discipline needed the most by the child and family

** Despite which team approach is used, coordination, communication and documentation are all essential .

Patient / Client Management Model

The patient / client management model refers to the typical components of physiotherapy practice, including the examination, evaluation, diagnosis, prognosis, interventions and outcome measurement. For each of these components, there are additional factors paediatric physiotherapists must consider.

• Examination:
  • Ask about birth history (prenatal, perinatal and postnatal)
  • Ask about developmental milestones
  • Ask about parent, caregiver or patient concerns
  • For a systems review, it is important to know norms for the child's age (e.g. blood pressure, heart rate, respiratory rate etc)
  • You must use appropriate tests and measures for a child's age and developmental level (i.e. paediatric-specific and special tests and measures, diagnosis-specific tests and measures)
• Evaluation:
  • Consider the child, the family and their community (e.g. who is the caregiver, where does the child spend their day, what resources are available, what is important to the child and their caregivers?)
• Diagnosis:
  • Understand how a diagnosis might impact function (need to understand paediatric-specific diagnoses)
  • Understanding the diagnosis will help you to understand the trajectory of a child's rehabilitation
• Prognosis:
  • Your understanding of the diagnosis will help you determine an appropriate physiotherapy prognosis for each child - e.g. are they likely to achieve a certain goal? What level of function might they reach?
• Interventions:
  • Need to consider how to teach a client about what they need to do and who will help them complete any interventions (like home exercise programmes)
  • Who is present during a treatment session who can help ensure carryover at home?
  • How can you get a young child to perform an exercise or movement pattern?
  • Will the child be able to listen and understand during a treatment session?
• Outcome Measures:
  • Consider if an outcome measure is appropriate for the child's age and developmental level
  • Does an outcome measure have good metrics?
  • Do you have the appropriate resources to complete an outcome measure?
  • It is important to answer these questions to make sure you can appropriately monitor and track progress

But "at the end of the day, just like any other PT [physiotherapist] in any other environment, we're really going to make sure that we're committed to evidence-based practice. We're really going to make sure that we're committed to having that patient in family-centred care. We're going to work on care across all disciplines and potentially have some really nice team-based approaches and we want to make sure that we're emphasising participation in the goals of the patient and the family. So that's it for just a little intro to paediatric PT. We'll be getting into a lot more details with all of this soon." -- Krista Eskay

Resources

• Family Centred Intervention and Early Diagnosis
• Best Practice in Developmental Skills Training in Early Intervention