PT616 Comprehensive Capstone

Homework 10B/Case Study 10 Pediatrics

TEAM GREEN

Please complete the activity below as a group (rotation 4) and submit the assignment
through the Canvas portal by 11.59PM on Thursday, November 17. Please use a font
color other than black for your responses.

Question 1:
Samantha, a 40 month old white female, was diagnosed with Down Syndrome. Be sure
to cite your resources in answering these questions. You do not need to upload any of
the resources. You may use the table provided or organize another way.
a. Describe 5 signs and symptoms of Down Syndrome.
1. Hypotonia – low muscle tone resulting in weakness and decreased muscle
strength making functional movement difficult
2. Slow learning – Learning compared to a normally developing child in their age
group is delayed including decreased attention span and impaired judgement
3. Delayed speech – child starts talking at a later time than a normally developing
child in their age group
4. Ligament laxity – looseness of the ligaments and instability that can cause
increased flexibility in the joints creating increased risk for subluxation and joint
damage
5. Impaired vision – visual defects include Hyperopia (farsightedness), Myopia
(nearsightedness), congenital cataracts, astigmatism, nystagmus, lazy eye, tear
ducts blocked, and Blepharitis (eyelash follicle infection)

b. Discuss the concerns you would have as Samantha’s PT related to these signs
and symptoms. How would these affect:
1. treatment.
2. motor development.
3. future mobility and function.
Sign/Symptoms Effect on Tmt Effect on motor dev Effect on future
1. Hypotonia Encourage With hypotonia, Main goal for PT is
movement with there is a delay in to help the child
weight bearing to postural strategies develop good
promote bone and postural control posture, proper foot
growth and which decreases alignment, and
stability. Develop a stability causing efficient walking
treatment plan for compensatory pattern. Hypotonia
proximal control to strategies. They can affect the
improve postural have a delay in child’s future by
stability and functional causing them to
facilitate co- movement which create substitutions
contractions for creates a delay in leading to abnormal
stability, and sensory movement which
perform postural exploration. Poor could create

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 assessment. processing of contractures
Involve play for sensory input, resulting in inability
functional specifically with to move
movement. Assess proprioception and functionally.
body alignment in vestibular Compensations can
weight bearing to mechanisms, lead to long term
ensure that no causes limitations complications like
contractures in motor learning pain, improper foot
develop and that and planning. They alignment, and an
proper orthotics are develop a feed inefficient walking
prescribed if forward postural pattern. This can
necessary. Look at control technique be prevented
foot alignment causing them to through PT
when the child rely more on vision interventions.
comes to stand and for postural control
consider Sure Step and balance. Their
Orthotic for reaction times are
medial/lateral slower and they
stability and have decreased
increased coordination which
proprioception. will cause
Perform Relaxed increased safety
Calcaneal Stance, issues. They will
put foot in STN and develop abnormal
check calcaneal movement patterns
inversion and (W-sit, 180 degree
eversion. PDMS-2 leg split from prone
can be performed to sit, wide BOS,
to assess gross out toeing, and
and fine motor knee
delays. Watch for hyperextension)
knee resulting in
hyperextension, W- substitutions which
sitting, 180 degree could create
leg split, out toeing, contractures.
and any other
substitutions. The
goal of PT is to
facilitate the
development of
optimal movement
patterns.
2. Slow learning The PT needs to They have a PT is critical
figure out the decreased number because it will
child’s learning of sulci in the brain improve a child’s
style and determine with a simpler long-term functional

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 what motivates the pattern, particularly outcome by
child to learn. in the frontal lobe. preventing the
Education needs to Decreased sulci = development of
be performed with decreased abnormal
both the parent and intelligence. movement patterns
teacher to relay the Structural that are likely to
best techniques to abnormalities in the become more
enhance the child’s dendrites and serious problems in
learning. The PT pyramidal tracts in adolescence and
needs to the motor cortex into adulthood.
understand that causing Slow learning could
child may not retain incoordination. affect the child in
treatment There is a delay in the school system
techniques to myelination greatly because the
facilitate movement between 2 months child may not be
until repetitive and 6 years able to advance in
measures are creating an overall grades as quickly
taken. Children with motor delay. The as the other
DS need structure, child not going to children. A child
consistency, and a be able to perform with down
familiar motor tasks in non- syndrome might
environment to get familiar areas right need a specific
their best away; transferring learning plan that
performance. When environments will caters to their
learning something be an issue. learning style and
new make sure that Inability to move needs.
the child is not and perform
fatigued and well transitional
fed. The child movements could
learns in small create contractures
pieces so make and abnormal
sure to break down movement patterns.
the activities into Parents need to be
small components. educated on how to
Know when to end facilitate proper
the session if the movement and
child is too mentally motor development
fatigued. Plan in different
sessions around environments.
child’s optimal time
to learn.
3. Delayed speech Child would need Speech uses the Children are able to
referral to a same muscles for comprehend the
speech/language feeding and relationship of
pathologist and respiration words and
treatment should therefore weakness concepts at 10-12

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 include breathing, in this musculature months however
speech, and could lead to delays they don’t have the
swallowing in those areas as motor development
techniques. Parent well. Motor for speech. Most
education is development for children with Down
essential for proper muscles used in Syndrome are able
communication to speech, respiration to use speech as
enhance speech and feeding is an their primary
motor development essential communication with
in children with DS. component of the help of a SLP.
speech/language Sign language can
treatment. The be used for those
decreased that don’t develop
development of this the motor skill
musculature could needed for speech.
also create This can affect the
decreased sensory child’s future
exploration through because they might
the mouth which not be able to
inhibits the sensory communicate their
experience and needs effectively
learning in this way. with their parents or
teacher. This also
decreases
interaction with
peers of the same
age that are
communicating
through speech.
4. Ligament laxity It decreases It can cause the An X-ray is
postural child to have recommended for
control/support. decreased ability to Atlanto-axial
Want to provide perform transitional instability from the
family with movements. It can ages 3-5 years old.
education on also affects the Ensure that they
proper body child’s ability to maintain proper
mechanics to stabilize proximally alignment to ensure
decrease leading to that subluxation
subluxation risks decreased distal injuries do not
and joint damage. movement thus occur. PT needs to
Orthotics and decreasing perform frequent
splinting might be functional play. The checks for genu
necessary. In case child may not valgum, scoliosis,
of Atlanto-axial create motor pes planus,
instability, the PT or development metatarsus primus,
parent needs to pathways needed patellofemoral

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 ensure that the because of instability, hip
child does not decreased instability
hyperflex their movements or development to
neck. Be sure to abnormal ensure the child
check the hips for movement patterns does not acquire
instability and look used due to any of these
for genu valgus, increased ligament deformities. The
foot deformities, laxity. parent needs to be
and patellofemoral educated on how to
instability. watch for certain
Adduction and IR of things that are
the hip can lead to common with
dislocation so ligamentous laxity
prescribe a happy in children with
strap or hip helper down syndrome.
if necessary to
prevent this.
Perform frequent
spine checks for
scoliosis.
5. Impaired vision Watch out for It can hamper Make sure that the
safety issues due postural and child has frequent
to the child’s balance reactions eye examinations
inability to see. because children by an
Make proper vision with down Ophthalmologist.
referrals that are syndrome rely more Make the parent
necessary. on their vision with aware of signs and
Motivation uses these reactions. symptoms that
such as toys may With decreased could occur with
be ineffective due vision they are gradual visual
to the child’s unable to perform impairment.
inability to see. balance reactions Impaired vision can
creating decreased also affect the
motor patterns for child’s safety with
the vestibular ambulation and
system. Impaired other functional
vision also movements. Make
decreases their the parent and
ability to perform teacher aware of
transitional proper safety
movements with precautions to take
motivation such a with children with
toy. This decreases visual impairments.
the motor
development
pathways

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 necessary to
achieve functional
movement and
play.

c. Citations:
1. Russek, LN. Hypermobility syndrome. Physical Therapy. June 1999; 79(6):591-
599. http://ptjournal.apta.org/content/79/6/591.
2. Vision and Down Syndrome. National Down Syndrome Society.
http://www.ndss.org/resources/health-care/associated-conditions/vision--
down-syndrome/. Published 2012. Accessed November 17, 2016.
3. What are common treatments for Down Syndrome? National Institutes of Health.
https://www.nichd.nih.gov/health/topics/down/conditioninfo/Pages/treatme
nts.aspx#f6. Accessed November 17, 2016.
4. Winders, P. Physical Therapy & Down Syndrome. National Down Syndrome
Society. http://www.ndss.org/Resources/Therapies-Development/Physical-
Therapy-Down-Syndrome/. Published 2012. Accessed November 17,
2016.
5. Winders, P. The goal and opportunity of physical therapy for children with down
syndrome. Down Syndrome Quarterly. June 2001; 6(2):1-5.
http://www.ndss.org/PageFiles/3007/down_syndrome_quarterly.pdf.
6. Class note from Pediatric class PT 638

Question 2:
The PT has completed the basic components of the initial examination (provided in
Homework 10A). Based on this information, the class discussion and what you know
about Samantha, answer the following questions, providing appropriate references and
justifications.
a. Develop THREE appropriately written goals to be achieved at the conclusion of
the school year (36 weeks). Remember that the goals must be related to
educational goals because the child is in the preschool setting.

b. For each of the year-long goals, develop 2 appropriately written short term goals,
with one to be achieved at the conclusion of the first 18 weeks of the school year
and the second to be achieved at the conclusion of the first 27 weeks of the
school year. Use the table below. Remember to relate the goals to the
educational setting.

c. Based on your short term goals, the information you know about Down
Syndrome, and what you know about the patient, suggest PT interventions to
address each short term goal (each goal will have 1 intervention that relates to
that goal). Interventions should be progressions, based on the assumption that
the student will achieve the 18 week short term goal. Use the table below. Be
specific and justify your selection of the intervention.

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Goal 1 to be met by 36 weeks, patient will demonstrate trunk rotation in standing
independently for 3 out of 3 trials to ambulate with a functional gait pattern
from classroom to playground.

Short Term Goals Intervention Justification

1. By 18 weeks, 1. Place Samantha prone on a Incorporates the
patient will therapy ball and perform trunk abdominals and obliques
demonstrate rotation of shoulder girdle while which facilitates trunk
rolling with pelvis maintaining pelvic girdle stability rotation. Learning this
and shoulder using toy as motivation. technique allows Samantha
girdle counter to learn transitional
rotation with Min A movements to facilitate play
and VC for 2 out of with peers during preschool.
3 trials for 3
sessions in order
to perform
transitional
movements during
functional play with
peers.
2. By 27 weeks, 2. In sitting, utilize NDT with Functional for child during
patient will proximal points of control on play and utilizing muscle
demonstrate trunk pelvis and low back to facilitate actions the child has for
rotation in sitting elongation on the WB side and functional movement.
with Min A for 2 shortening on the NWB side. Allows Samantha to
out of 3 trials for 3 Facilitate movement of pelvic functionally play with her
sessions in order girdle forward while maintaining peers for proper social
to functionally stability of the shoulder girdle to interaction during preschool
scoot and achieve counter rotation. activities.
participate in
functional play in
sitting with peers.

Goal 2 to be met by 36 weeks, patient will perform transitional movements from

supine<->sit with independence for 3 of 3 trials for functional play with
peers and ability to sit at play centers to facilitate learning at preschool.

Short Term Goals Intervention Justification

1. By 18 weeks, 1. Utilize NDT to facilitate Functional for the child
patient will perform transitional movement when during play, this activity
transitional rolling to come to sit from supine. facilitates the utilization
movements from We will facilitate pelvic girdle muscles, such as the
supine<->sit with dissociation from the shoulder abdominals and obliques,
Min A and VC for 2 girdle by allowing the lower used for counter rotation.
of 3 trials to extremities to initiate the roll and Targeting these muscles

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increase ease of allowing the shoulder girdle to and strengthening them
transitional come after to finish roll. We will helps achieve the goal of
movements to then use approximation at the WB counter rotation for eventual
facilitate normal arm for stability as we facilitate supine <-> sit
play with peers. the LE off the mat and the pelvis independence. This goal
to come to sit. helps the child with
transitional movements that
will be incorporated when
the child is engaging in
functional play with their
peers in the preschool
setting.
2. By 27 weeks, 2. Use a toy for motivation and Initiate re-learning of
patient will perform use blocked repetition for transitional movement and
transitional supine<->sit. Since a child with work into random repetition
movements from down syndrome has better to cement motor pattern.
supine<->sit with success in learning when tasks Repetition helps develop
CGA for 2 of 3 are broken down into small motor pathways for
trials to increase components, we could break this transitional movement. This
ease of transitional task down and use blocked goal facilitates normal play
movements to repetition with each part then with peers and ability to sit
facilitate normal move to random repetition to at play centers in order to
play with peers facilitate learning. follow classroom learning
and ability to sit at techniques at preschool.
play centers to
facilitate learning.

Goal 3 to be met by 36 weeks, patient will perform independent ambulation

without parent/teacher at side without emotional disturbance for 300’ with
SMO for 3 of 3 trials for independent household ambulation and ability to
ambulate from classroom to playground at preschool.

Short Term Goals Intervention Justification

1. By 18 weeks, 1. Practice walking without Using functional task for
patient will perform someone directly at side for short learning using blocked
independent intervals by using toy as repetition. Blocked
ambulation without motivation. We will start with a repetition with small
parent/teacher at short distance and increase it by components helps the child
side with 2 or less 15 to 30’ with each trial until the initially understand the
emotional child has successfully achieved movement pattern. We will
disturbances for 100’. move into random repetition
100’ with SMO for to facilitate learning of the
2 of 3 trials to transitional movement. This
decrease goal helps the child achieve
dependence for ambulation necessary to
functional move around the classroom

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ambulation around during play or preschool
classroom for play learning activities.
with peers and
movement from
each learning
center at
preschool.
2. By 27 weeks, 2. Use backward chaining to walk Backward chaining is a
patient will perform from classroom to playground at reliable and valid way to
independent school. Therefore, we will start facilitate learning in a
ambulation without from the end result such as the functional pattern especially
parent/teacher at playground area and back up a in children. This goal helps
side with 1 or less few feet with each session until the child ambulate with
emotional the child can successfully walk peers to access the
disturbances for form the classroom to the playground in a functional
200’ with SMO for playground. way.
2 of 3 trials to
decrease
dependence for
functional
ambulation to
access classroom
for play with peers
and ability to move
from classroom to
playground.

Question 3:
We recommended the SureStep SMOs for Samantha. Based on her examination and
What you know about these orthotics, answer the following questions. Cite resources to
support your selection of the orthotics.
a. Provide 3 justifications to the physician for the recommendation of the SureStep
SMOs as opposed to another type of orthosis.
1. Improves proprioception which children with Down Syndrome crave during
ambulation
2. Improves medial and lateral support at the foot and ankle for the child to
prevent calcaneal collapse
3. Maintains alignment throughout the LE to prevent genu recurvatum and
excess valgum to improve functional motor performance. This can decrease
deformities or contractures due to misalignment.

b. Compare the funding considerations of Medicaid and private insurance.

Medicaid with pay for the SMO but patient needs prescription from orthopedist or
neurologist. Private insurances will pay for SMO but need prescription from

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 pediatrician. Make sure that your documentation provides evidence that justifies
need for orthotic device.

c. Briefly describe how you will explain the need for the orthotics to Samantha’s
parents.
Samantha’s feet are collapsing/rolling inward causing her legs to lose their
alignment for proper positioning when standing which makes her unstable when
standing and walking. This could increase her risk for falls and further injuries
down the road. Because her ligaments that hold the joint in place are more
flexible than in other children her age, we need to fix her alignment so that we
prevent any stress on her joints when she stands and walks. Proper alignment is
so important for preventing injuries. Since we caught this early, it could be a very
easy fix with an orthotic device, which is like a brace but allows her to move
properly while maintaining an aligned position. Essentially, it helps her remain
stable so she can focus on standing and walking. This orthotic is called a Sure
Step. With the use of the Sure Step, we can decrease all of these risks, put her in
a more stable position and help her walk more correctly. Sure Steps are very
convenient, lightweight, and do not draw attention to your child’s impairments.

Citation for SMO research:

1. Class notes from pediatric course PT 638

2. Martin, K. Effects of supramalleolar orthoses on postural stability in children

with down syndrome. Developmental Medicine and Child Neurology.
2004; 46:406-411.

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