Prescribing Therapy Services for Children with Motor Disabilities
Linda J. Michaud and Committee on Children With Disabilities
2004;113;1836-1838
Pediatrics
This information is current as of April 3, 2006
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
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AMERICAN ACADEMY OF PEDIATRICS
CLINICAL REPORT
Guidance for the Clinician in Rendering Pediatric Care
Linda J. Michaud, MD, and the Committee on Children With Disabilities
Prescribing Therapy Services for Children With Motor Disabilities
ABSTRACT.
Pediatricians often are called on to pre-
child has motor problems severe enough to interfere
scribe physical, occupational, and speech-language ther-
with mobility, self-care, or communication, thera-
apy services for children with motor disabilities. This
pists may provide a program to help the child ame-
report defines the context in which rehabilitation thera-
liorate, compensate for, or adapt to the impairment
pies should be prescribed, emphasizing the evaluation
or disability. Physical, occupational, and speech-lan-
and enhancement of the child’s function and abilities
guage therapists, working with the family, child,
and participation in age-appropriate life roles. The report
encourages pediatricians to work with teams including
physician, and teacher, promote a positive functional
the parents, child, teachers, therapists, and other physi-
adaptation to impairment or disability in the context
cians to ensure that their patients receive appropriate
of the child’s developmental progress.
therapy services. Pediatrics 2004;113:1836 –1838; children
Physical therapists focus on gross motor skills and
with motor disabilities, physical therapy, occupational
functional mobility, including positioning; sitting;
therapy, speech-language therapy.
transitional movement such as sitting to standing;
walking with or without assistive devices (eg, walk-
BACKGROUND
ers, crutches) and orthoses (braces) or prostheses
Pediatricians commonly are asked to evaluate (artificiallimbs);wheelchairpropulsion;transfersbe-
children with motor disabilities and to write
tween the wheelchair and other surfaces such as a
prescriptions for physical, occupational, and
desk chair, toilet, or bath; negotiation of stairs,
speech-language therapy services. Although many
ramps, curbs, and elevators; and problem-solving
states require a physician’s prescription for such ser-
skills for accessibility of public buildings. Physical
vices, many physicians have limited formal educa-
therapists often have responsibilities for procuring
tion about these therapeutic interventions.1
adaptive equipment related to ambulation, position-
The spectrum of motor impairments affecting
ing, and mobility.4–6
function in children and adolescents is wide and
Occupational therapists focus on fine motor, visu-
comprises many congenital and acquired conditions,
al-motor, and sensory processing skills needed for
primarily involving the neurologic and musculoskel-
basic activities of daily living such as eating, dress-
etal systems, including but not limited to cerebral
ing, grooming, toileting, bathing, and written com-
palsy, traumatic brain injury, myelomeningocele,
munication (handwriting, keyboard skills).7 Occupa-
spinal cord injury, neuromuscular disease, juvenile
tional therapy services may include training in
rheumatoid arthritis, arthrogryposis, and limb defi-
school-related skills and strategies to help children
ciencies. These conditions are associated with motor
compensate for specific deficits.7
impairments including muscle weakness, abnormal
Speech-language pathologists address speech, lan-
muscle tone, decreased joint range of motion, and
guage, cognitive-communication, and swallowing
decreased balance and coordination. There are vari-
skills in children with disabilities.8 Speech therapy is
ations in severity within each of these conditions.
the therapy most commonly prescribed by pediatri-
Many children with impairments attributable to
cians.
these conditions will have some degree of disability
The services that can be provided by physical and
that may limit their participation in age-appropriate
occupational therapists and speech-language pathol-
activities at home, in school, and in the community
ogists overlap. For example, a physical or occupa-
and should benefit from physical, occupational,
tional therapist can address motor delay or dysfunc-
and/or speech-language therapy services.
tion in the very young child. Depending on the
The pediatrician needs to understand the role of
community, occupational therapists or speech-lan-
physical, occupational, and speech-language thera-
guage pathologists may address deficits in oral mo-
pists in the overall treatment of children with motor
tor skills associated with feeding dysfunction related
disabilities and the therapeutic interventions that
to motor disability. Occupational therapists and/or
may improve function and participation.2,3 If the
speech-language pathologists provide expert consul-
tation related to adaptive equipment, environmental
The guidance in this report does not indicate an exclusive course of treat-
modifications, and assistive technology devices such
ment or serve as a standard of medical care. Variations, taking into account
as environmental control units, augmentative com-
individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad-
munication systems, adapted computers, and adap-
emy of Pediatrics.
tive toys.6
1836
PEDIATRICS Vol. 113 No. 6 June 2004
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EVALUATING THE EVIDENCE
tor disabilities clearly cannot be based entirely on
The therapeutic methods, frequency and duration
sound scientific evidence. As the knowledge base is
of service, setting in which the service is delivered,
expanded related to the effectiveness of therapy in-
and service delivery system vary.9 Evaluating the
terventions, evidence-based practice described as us-
efficacy and effectiveness of therapy for motor dis-
ing the best available evidence, along with clinical
ability is difficult, because treatment is not a stan-
judgment, and taking into consideration the priori-
dardized, readily quantifiable process that can be
ties and values of the individual patient and family
prescribed in discrete, consistent units. Individual-
in a shared decision-making process, as outlined by
ized therapy programs vary in many parameters and
the Institute of Medicine, is advised.19
incorporate subjective as well as objective elements.
SERVICE DELIVERY
Clear documentation of efficacy related to the vari-
able parameters of therapy continues to be elusive.
Therapies for a child with motor impairment are
This problem may in part reflect difficult method-
required to be provided by the school if the disability
ologic issues including the measurement of treat-
interferes with the educational process.20 Recently,
ment-related change on a background of develop-
managed health care has made it more difficult for
mental maturation, the establishment of appropriate
children with special needs to receive therapy ser-
outcome criteria, heterogeneity of the populations
vices outside of school, with insurance companies
involved, and the complex nature of the interven-
denying services for children who attend school,
tions.10,11
maintaining that therapy is mandated at school and
A recent review of the evidence to support the
is partially funded with education and third-party
effectiveness of neurodevelopmental treatment for
monies.9 Therapy services at school for students who
are eligible for Medicaid and whose disabilities are
children with cerebral palsy indicates that this pop-
medically based can be reimbursed by Medicaid if
ular method of intervention does not confer an ad-
the disability has an adverse effect on the child’s
vantage over the alternatives with which it has been
ability to benefit from the educational program.9 Ser-
compared in altering abnormal motor responses,
vices also may be provided in environments other
slowing or preventing contractures, or facilitating
than the hospital or school, as appropriate for the
more normal motor development or functional mo-
child’s individual circumstances; such other environ-
tor activities, nor does more intensive neurodevelop-
ments include child care, home, or job settings.
mental treatment result in greater benefit.12 Physical
therapy alone was found in 1 well-designed study to
THE PEDIATRICIAN S ROLE
be less effective in improving motor development
The pediatrician’s responsibility in writing a pre-
after 1 year than the therapy incorporating develop-
scription for therapy includes providing an accurate
mentally appropriate play and learning skills for
diagnosis when possible. When the exact cause of the
children younger than 3 years with motor impair-
disability is not apparent, the physician must pro-
ment.13
vide an accurate description of the medical condition
Improvement in motor function is more likely to
and note whether the child has a transient, static, or
occur when the goals of therapy are specific and
progressive impairment. In addition to the primary
measurable14 and established in partnership with the
motor disorder, all potential associated problems
child’s parents and other caregivers. Intensive
such as learning disabilities, mental retardation, sen-
amounts of physical therapy may confer no advan-
sory impairment, speech disorders, emotional diffi-
tage over routine amounts of therapy,15 and long-
culties, and seizure disorders must be identified, and
term therapy may confer no advantage over short-
a care plan must be recommended. There are some
term therapy. Provision of a home exercise program,
children with special needs whose medical condi-
with instruction of family members and caregivers in
tions may be affected adversely by movement or
therapeutic exercises and age-appropriate activities
other specific therapeutic activities; therapists and
to meet the child’s goals, is generally indicated. This
caregivers should be advised to take appropriate
program can include recommendation of participa-
precautions with these children.
tion in sports to increase endurance, strength, and
The physician’s prescription for therapy should
self-esteem in a natural setting with peers.16 Aquatic
contain, in addition to the child’s diagnosis: age;
therapy, hippotherapy (horseback-riding therapy),
precautions; type, frequency, and duration of ther-
and participation in karate, gymnastics, and dance
apy; and designated goals. Goals for physical, occu-
classes in integrated or special classes also can be
pational, and speech-language therapy do not de-
considered to meet the child’s therapeutic goals. Par-
pend solely on the diagnosis or age of the child, and
ent and caregiver education by all therapists is crit-
they are most appropriate when they address the
ical in effective partnerships with families for imple-
functional capabilities of the individual child and are
mentation of therapy programs.
relevant to the child’s age-appropriate life roles
Some programs such as patterning have little ef-
(school, play, work).9 The pediatrician should work
fect on functional skills and are inappropriate for
with the family, child, therapists, school personnel,
children with motor disabilities.17 Scientific legiti-
developmental diagnostic or rehabilitation team, and
macy has also not been established for sensory inte-
other physicians to establish realistic functional
gration intervention for children with motor disabil-
goals.20 The pediatrician can assist families in iden-
ities.18
tifying the short- and long-term goals of treatment,
Prescribing therapy services for children with mo-
establishing realistic expectations of therapy out-
AMERICAN ACADEMY OF PEDIATRICS
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comes, and understanding that therapy will usually
REFERENCES
help the child adapt to the condition but not change
1. Sneed RC, May WL, Stencel CS. Training of pediatricians in care of
the underlying neuromuscular problem. Pediatri-
physical disabilities in children with special health needs: results of a
cians should be encouraged to seek and use expert
two-state survey of practicing pediatricians and national resident train-
ing programs. Pediatrics. 2000;105:554 –561
consultation as in any other area of medicine. Help-
2. Consensus statements. Pediatr Phys Ther. 1990;2:175–176
ful resources may include local and regional diag-
3. Piper MC. Efficacy of physical therapy: rate of motor development in
nostic and intervention teams, early intervention and
children with cerebral palsy. Pediatr Phys Ther. 1990;2:126 –130
developmental evaluation programs, developmental
4. Kurtz LA. Rehabilitation: physical therapy and occupational therapy.
In: Batshaw ML, ed. Children With Disabilities. 5th ed. Baltimore, MD:
pediatricians, pediatric physiatrists, pediatric neurol-
Paul H. Brookes Publishing; 2002:647– 657
ogists, pediatric orthopedists, and orthotists.
5. Carlson SJ, Ramsey C. Assistive technology. In: Campbell SK, Vander
Regular communication among parents and other
Linden DW, Palisano RJ, eds. Physical Therapy for Children. 2nd ed.
caregivers, therapists, educators, and prescribing
Philadelphia, PA: WB Saunders; 2000:671–708
6. Jump J, Bouwkamp M, Morress C. Assistive technology. In: Rudolph
physicians should be ongoing, with periodic reeval-
CD, Rudolph AM, Hostetter MK, Lister G, Siegel NJ, eds. Rudolph’s
uations to assess the achievement of identified goals,
Pediatrics. 21st ed. New York, NY: McGraw-Hill; 2003:545–547
to direct therapy toward new objectives, and to de-
7. Kurtz LA. Physical therapy and occupational therapy. In: Rudolph CD,
Rudolph AM, Hostetter MK, Lister G, Siegel NJ, eds. Rudolph’s Pediat-
termine when therapy is no longer warranted.21
rics. 21st ed. New York, NY: McGraw-Hill; 2003:544 –545
Changes in the child’s status (eg, surgical interven-
8. Kummer AW. Speech pathology for the child with disability. In: Ru-
tion, school-to-work transition warranting assistive
dolph CD, Rudolph AM, Hostetter MK, Lister G, Siegel NJ, eds.
technology intervention) may indicate resumption of
Rudolph’s Pediatrics. 21st ed. New York, NY: McGraw-Hill; 2003:545
9. O’Brien MA, Huffman NP. Impact of managed care in the schools. Lang
specific short-term, goal-directed services.
Speech Hear Serv Sch. 1998;29:263–269
10. Tirosh E, Rabino S. Physiotherapy for children with cerebral palsy.
Evidence for its efficacy. Am J Dis Child. 1989;143:552–555
SUMMARY
11. Ottenbacher KJ. Efficacy of physical therapy: rate of motor development
Successful therapy programs are individually tai-
in children with cerebral palsy. Pediatr Phys Ther. 1990;2:131–134
12. Butler C, Darrah J. Effects of neurodevelopmental treatment (NDT) for
lored to meet the child’s functional needs and should
cerebral palsy: an AACPDM evidence report. Dev Med Child Neurol.
be comprehensive, coordinated, and integrated with
2001;43:778 –790
educational and medical treatment plans, with con-
13. Palmer FB, Shapiro BK, Wachtel RC, et al. The effects of physical
therapy on cerebral palsy: a controlled trial of infants with spastic
sideration of the needs of parents and siblings. This
diplegia. N Engl J Med. 1988;318:803– 808
can be facilitated by primary care pediatricians and
14. Bower E, McLellan DL, Arney J, Campbell MJ. A randomised controlled
tertiary care centers working cooperatively to pro-
trial of different intensities of physiotherapy and different goal-setting
vide care coordination in the context of a medical
procedures in 44 children with cerebral palsy. Dev Med Child Neurol.
1996;38:226 –237
home.22,23
15. Bower E, Michell D, Burnett M, Campbell MJ, McLellan DL. Random-
ized controlled trial of physiotherapy in 56 children with cerebral palsy
Committee on Children With Disabilities,
followed for 18 months. Dev Med Child Neurol. 2001;43:4 –15
2003–2004
16. Johnstone KS, Perrin JCS. Sports for the handicapped child. Phys Med
Adrian D. Sandler, MD, Chairperson
Rehabil. 1991;5:331–350
J. Daniel Cartwright, MD
17. American Academy of Pediatrics, Committee on Children With Disabil-
John C. Duby, MD
ities. The treatment of neurologically impaired children using pattern-
Chris Plauch Johnson, MD, MEd
ing. Pediatrics. 1999;104:1149 –1151
18. Mulligan S. Advances in sensory integration research. In: Bundy AC,
Lawrence C. Kaplan, MD
Lane SJ, Murray EA, eds. Sensory Integration: Theory and Practice. 2nd ed.
Eric B. Levey, MD
Philadelphia, PA: FA Davis; 2002:397– 411
Nancy A. Murphy, MD
19. Committee on Quality of Health Care in America, Institute of Medicine.
Ann Henderson Tilton, MD
Improving the 21st-century health care system. In: Crossing the Quality
Chasm: A New Health System for the 21st Century. Washington, DC:
Past Committee Members
National Academy Press; 2001:39-60
W. Carl Cooley, MD
20. American Academy of Pediatrics, Committee on Children With Disabil-
Theodore A. Kastner, MD
ities. The pediatrician’s role in development and implementation of an
Individual Education Plan (IEP) and/or an Individual Family Service
Marian E. Kummer, MD
Plan (IFSP). Pediatrics. 1999;104:124 –127
21. Levine MS, Kliebhan L. Communication between physician and phys-
Liaisons
ical and occupational therapists: a neurodevelopmentally based pre-
Bev Crider
scription. Pediatrics. 1981;68:208 –214
Family Voices
22. American Academy of Pediatrics, Committee on Children With Disabil-
Merle McPherson, MD
ities. Care coordination: integrating health and related systems of care
Maternal and Child Health Bureau
for children with special health care needs. Pediatrics. 1999;104:978 –981
Linda J. Michaud, MD
23. American Academy of Pediatrics, Medical Home Initiatives for Chil-
dren With Special Needs Project Advisory Committee. The medical
American Academy of Physical Medicine and
home. Pediatrics. 2002;110:184 –186
Rehabilitation
Marshalyn Yeargin-Allsopp, MD
Centers for Disease Control and Prevention
All clinical reports from the American Academy of Pediatrics
Staff
automatically expire 5 years after publication unless
Stephanie Mucha, MPH
reaffirmed, revised, or retired at or before that time.
1838
THERAPY SERVICES FOR CHILDREN WITH MOTOR DISABILITIES
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Prescribing Therapy Services for Children with Motor Disabilities
Linda J. Michaud and Committee on Children With Disabilities
2004;113;1836-1838
Pediatrics
This information is current as of April 3, 2006
Updated Information
including high-resolution figures, can be found at:
& Services
http://www.pediatrics.org/cgi/content/full/113/6/1836
References
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