Developmental Coordination Disorder in the Preterm Infant. .

1. Developmental Coordination Disorder in the Preterm Infant.. Incorporation of movement strategies to promote typical developmental progression Liz Bishop, PT, DPT, PCS LBishop.DPT@gmail.com

2. Focus points for today • Movement strategies when working with the preterm infant population • Hands on components to incorporate directly into practice • Encouraging Family/Caregiver buy-in and comfort • Therapeutic aides

3. Take home/What to incorporate into your practice • Identify poor movement strategies used by pre-term infants. • Understand the family friendly approach to encourage home participation in interventions. • Demonstrate tactile and verbal cues to encourage typical developmental progression.

4. What is DCD? • DSM IV: • Skill attainment below expected for age • Interferes with academics or ADLs • Onset of symptoms was early in development • Has to be in excess of expected abilities when intellectual disability or vision impairment is present • Not explained by neurologic disease

5. When to seek a diagnosis of DCD • “Clumsy child” • Difficulty in social circumstances • Problems with ADLs • Poor sport participation • Behavioral issues • Tendency to become obese (male>female)

6. What is the base issue in DCD? Research findings: • Motor coordination due to underlying sensory integration issue • Visual Memory Deficits • Kinesthetic/Perceptual Deficits • Motor Planning Deficits • Heavy Reliance on Visual Feedback

7. Testing for DCD • BruininksOseretsky Test of Motor Proficiency (BOT) • Movement Assessment Battery for Children (M-ABC) • Developmental Coordination Disorder Questionnaire (DCDQ)

8. BOT-2 • Fine Motor • Fine Manual Control (precision/Integration) • Manual Coordination (Dexterity/Coordination) • Gross Motor • Body Coordination • Strength/Agility

9. M-ABC • Takes an observational approach • Checklist for classroom teacher • Evaluates 3 areas • Manual dexterity • Ball skills • Balance (static/dynamic) • https://youtu.be/9ZjQILd5esk

10. DCDQ • Parent report that ranks child’s skills 1-5 with 5 being typically functioning/minimal difficulty

11. Prevalence of DCD • Males are more likely to be diagnosed, nearly 2:1, however, recent research suggests more even presentation across gender • High prevalence in preterm population • Approximately 5-6% of school aged children suspected DCD • Up to10% are deemed to be “clumsy”

12. Why preterm population? • Developmental Coordination Disorder in School-Aged Children Born Very Pre-Term and/or at Very Low Birth Weight: A Systematic Review • Found significantly more likely to receive dx of DCD • Calls for early identification • Calls for research into why this occurs in pre-term infants

13. Full Term Infant • 37-40 weeks • Birth weight 6-9lbs • Fetal position (physiological flexion) • Vaginal Birth • Full in-utero development has occurred • Lungs • Feeding • Able to tolerate handling & enjoys close contact with parents

14. Preterm Infant • Viable pregnancy is 24wks • Birth weight as little as 1lb or less • Full body extension • Frequently emergency C-Section • Prior to significant development in-utero • Unable to tolerate handling/contact with parents

15. Comparison at 28weeks

16. Pre term infant in NICU- effects on parents • Life preserving equipment • Unable to hold their child regularly • Constant medical staff • Witness their child struggling/uncomfortable and unable to assist • Huge financial strain • Work/home vs. being with their child

17. Identifying possible DCD • Risk factors • Preterm? • Other possible diagnoses at play? • CP? • DMD? • Progression of development • Delayed beyond adjusted age? • Movement patterns • Do they appear typical or odd/compensatory?

18. Identification of poor movement strategies • Extension patterning/full body movement vs. muscle isolation • Asymmetries between sides • Muscle tone • Is child able to piece movements together fluidly? • What appears to be the main issue? Sensory vs. motor planning

19. Treatment Approaches • Task specific: Find area of participation and work specifically to achieve improved participation • Impairment based: Find impaired system and specifically target- Sensory systems, proprioception, heavy reliance on vision, etc.

20. Top Down- Task specific • Multiple repetitions with tactile and verbal cues, gradually weaning as child demonstrates skill progression • Begin simple and increase difficulty as child masters/becomes confident • Generalize skills in multiple settings

21. Tactile/Verbal Cues • Many research articles point to poor proprioception/motor planning • Repetition. Repetition. Repetition. • Therapist hands on then wean to independence • Keep verbal cues consistent and brief • “Hand” vs. “Put your hand here.”

22. Bottom up- Sensory integration • Body awareness • Positional awareness • Pressure input • Reflex integration • https://youtu.be/rCssTMZ7yzY • Aquatic therapy • https://youtu.be/iQJYHpWvvrc?t=44

23. Treatment Approaches • Encourage physical activity for a lifetime • Multiple trials, avoiding failure • Educate parents to seek out appropriate activities • Encourage patience in parents from early on- “Try for 5” • https://www.youtube.com/watch?v=91MtVYVKokE

24. Therapeutic Strategies for Home • Use items already present within the home whenever possible • Incorporate strategies into play • Ask parents their biggest concerns/desires • Show parents how to specifically work on hands on strategies • Give specific goals and timeframes for each day- then reassess next visit

25. Therapeutic Aides • SPIO • Sure Step SMO • Hip Helpers • Weighted push toys

26. SPIO

27. Sure Step SMO

28. Hip Helpers

29. Weighted/Braked push toys

30. Case Study • Baby B, male • Born at 23 weeks weighing 1lb, 2oz. • Remained in NICU for 110 days • Came home on oxygen via nasal cannula • FTT • Currently 18 months; 14 mo adjusted

31. HEP for Baby B • Hands on rolling practice- gradually giving child more responsibility • Sitting balance in laundry basket with movement • Sit to stand at surface with hands on assistance to break up extension pattern • Intermittent pressure • Slowing down movement progression

32. Case Study • Baby K, female • Born at 23 weeks weighing 1lb 5oz • Remained in NICU for 5 months; 2 months intubated • Dx: Bilateral Grade II IVH; Stage 3 ROP repaired; bronchopulmonary dysplasia at discharge • Currently 17 months; 13 months adjusted

33. HEP for Baby K • Rocking strategies; deep squeezes/joint compression • Hands on transitional progression movements, gradually giving more responsibility. • Utilized sensory strategies within each movement to make best gains

34. Upcoming Research • Effects of Dual Tasking on Dynamic Postural Control • MaryJo Davenport- davenportm@slu.edu • SLU PT Program • Using GAITRite to compare probable DCD/DCD vs. typical child • Walking; stepping over object; singing ABCs; while wearing vibration waist band

35. Hoped for Research/Standardized Assessment • Assess preterm infant population and determine possible/probable DCD • Educate parents on strategies to lessen impact of probable DCD • Strategies that work best to assist early development in probable DCD

36. Summary • DCD is present in as many as 5-6% of school aged children • Premature infants are surviving at very early ages predisposed to DCD • Diagnosis occurs in school aged children • Various therapeutic strategies to assist in early movement patterns • Arm parents with knowledge, skills, and confidence to work through their child’s challenges.

37. Questions?

38. Personal Plug • www.Facebook.com/GTOT2015/ • http://gatewaytykesontrykes.org/

39. Pediatric Therapists in STL • STL Pediatric Therapy Special Interest Group- Courtney Dunn • Courtney.dunn@bjc.org • https://www.facebook.com/groups/328730207519974/ • Upcoming May 2nd, 7pm • Orthopedic Management of Patients with Cerebral Palsy- Dr. PooyaHosseinzadeh • Children’s Hospital, Edison Cafeteria

40. MO First Steps • Early Intervention program for Missouri • Great pay rates ($17/unit; mileage reimbursement) for independent contractors (easy to become this) • Currently in need of providers- especially PTs in St. Louis and surrounding areas • To become a provider on your own: • MOFirstSteps.com • “Providers” tab • “Enroll with First Steps”

41. MO First Steps • Who to contact for enrollment • MOFirstSteps.com • “Home” tab at upper left hand corner • “SPOE Locations” • Find your region on the first page and then the contact person (Director of that SPOE) on the second page.