Lifespan, Special Populations and Integrated Cases

The NPTE does not stop at adults with a single diagnosis. It asks you to recognize a 9 month old who cannot sit, to choose the right test for a school age child with cerebral palsy, to spot delirium in an older adult whose "weakness" is really a urinary tract infection, to adapt exercise for pregnancy, and to decide what matters most in a patient with five problems at once. This chapter covers development and pediatric practice, aging, women's and men's health, and closes with integrated cases that train the priority logic the exam rewards.

Section 1Pediatric development and conditions

Principles of development

Motor development proceeds cephalocaudal (head control before trunk, trunk before legs), proximal to distal (shoulder before fingers), and from gross to fine and mass to specific movement. Stability generally precedes controlled mobility. Ages are averages with wide normal ranges; what matters clinically is a pattern of delay, a loss of skills, asymmetry, or persistence of reflexes beyond their usual window. For infants born before 37 weeks, use corrected (adjusted) age, chronological age minus the weeks of prematurity, until about 24 months. A baby born at 32 weeks who is 6 months old chronologically is about 4 months corrected.

Primitive reflexes and postural reactions

Primitive reflexes are stereotyped responses mediated at the spinal cord and brainstem that appear in utero or at birth and become integrated (inhibited by maturing higher centers) during the first months. Persistence beyond the usual age, an obligatory response (the infant cannot move out of it) or asymmetry suggests central nervous system dysfunction, as in cerebral palsy. Absence at birth can mean depression of the nervous system or a peripheral lesion (an absent unilateral Moro with a brachial plexus birth injury). As reflexes integrate, righting reactions (aligning head and body), protective reactions (arm extension to catch a fall: forward about 6 to 7 months, sideways about 7 to 8 months, backward about 9 to 10 months) and equilibrium reactions (trunk curving to keep balance; in sitting about 7 to 8 months, in standing about 12 to 21 months) emerge.

Cerebral palsy

Cerebral palsy (CP) is a group of permanent disorders of movement and posture caused by a nonprogressive disturbance of the developing fetal or infant brain. The lesion does not progress, but the musculoskeletal consequences (contracture, hip displacement, scoliosis, crouch) change with growth. Risk factors include prematurity and low birth weight (the strongest), intrauterine infection, multiple births, hypoxic ischemic injury, stroke and kernicterus. Associated problems include intellectual disability, epilepsy, visual and hearing impairment, feeding difficulty and pain. Diagnosis can now be made or suspected before 6 months using the General Movements Assessment (absent fidgety movements at about 3 to 5 months corrected age), the Hammersmith Infant Neurological Examination and MRI, which allows earlier intervention.

The Gross Motor Function Classification System (GMFCS) classifies a child's usual mobility in five levels, with descriptions for age bands; the level is stable over time and predicts gross motor prognosis. In summary for ages 6 to 12: Level I walks at home, school and in the community without limitation, can run and jump with reduced speed and coordination; Level II walks in most settings but has limitations on uneven terrain, inclines and long distances, uses a railing on stairs, and may use wheeled mobility for long distances; Level III walks with a hand held mobility device indoors and uses wheeled mobility for longer distances; Level IV uses methods of mobility that need physical assistance or powered mobility in most settings; Level V is transported in a manual wheelchair and has limited head and trunk control. Gross motor ability usually plateaus by about age 7 in children at levels I and II, and children at levels III to V may lose function in adolescence as body size outpaces strength.

Management is lifelong and goal directed: task specific and functional training, strengthening (which does not increase spasticity), aerobic fitness, stretching, serial casting and night splints for contracture, orthoses, and equipment. Medical and surgical options include botulinum toxin injections for focal spasticity (followed by stretching, casting and training), oral baclofen, intrathecal baclofen pumps for severe generalized spasticity or dystonia, selective dorsal rhizotomy for selected children with spastic diplegia (good strength, GMFCS II to III), and orthopedic surgery such as tendon lengthening and osteotomies. Hip surveillance with periodic pelvic radiographs is recommended because hip displacement risk rises with GMFCS level, approaching or exceeding half of children at level V. Common gait patterns are equinus (toe walking), crouch (excessive hip and knee flexion with ankle dorsiflexion, often from hamstring tightness, weak plantar flexors or overlengthened heel cords), jump knee and scissoring from adductor spasticity.

Spina bifida (myelomeningocele)

Spina bifida is a neural tube defect from failure of the caudal neural tube to close by about the fourth week of gestation; maternal folic acid supplementation reduces risk. Spina bifida occulta is a bony defect without herniation, often marked by a hair tuft or dimple and usually asymptomatic. A meningocele is herniation of the meninges and cerebrospinal fluid without neural tissue, with few or no deficits. A myelomeningocele contains the spinal cord or roots and causes motor and sensory loss below the level, neurogenic bowel and bladder, and associated brain anomalies. Most children with myelomeningocele have the Chiari II malformation (downward displacement of the cerebellar tonsils, vermis and brainstem through the foramen magnum) and hydrocephalus requiring a ventriculoperitoneal shunt.

PT priorities in spina bifida are classic exam material:

• Shunt malfunction: headache, vomiting, irritability, lethargy, change in school performance or personality, seizures, swelling along the shunt; in infants a bulging fontanelle, rapidly enlarging head and "sunsetting" eyes. This is an emergency; refer immediately.
• Tethered cord: the cord scars to the surrounding tissue and stretches with growth, producing rapidly progressing scoliosis, new weakness or spasticity, changes in gait, back pain and changes in bladder function. Report changes promptly; a loss of muscle function on serial manual muscle tests is a reason to refer.
• Chiari II symptoms: swallowing difficulty, stridor, apnea, upper extremity weakness.
• Latex allergy: very common because of early repeated exposure; use latex free equipment.
• Skin breakdown from insensate skin: teach daily skin checks and pressure relief; watch for fractures in osteoporotic insensate legs (presenting as swelling and warmth with no pain).
• Obesity, contractures, hip dislocation and cognitive or learning issues (often good verbal skills with poor comprehension, sometimes called cocktail party speech).

Down syndrome, torticollis and hip dysplasia

Down syndrome (trisomy 21) causes hypotonia, ligamentous laxity, short stature, intellectual disability and delayed milestones (independent walking often around 2 years). About half of affected children have congenital heart disease (often atrioventricular septal defects), and many have hearing and vision problems, hypothyroidism and later obesity. Atlantoaxial instability from laxity of the transverse ligament is a key safety issue: watch for neck pain, torticollis, change in gait, new clumsiness, loss of bowel or bladder control and hyperreflexia, which suggest cord compression and require immediate referral. Activities with high neck loading (diving, tumbling, butterfly stroke) need medical clearance. Intervention emphasizes strengthening, balance, treadmill training to accelerate walking, joint protection rather than end range stretching of lax joints, and fitness.

Congenital muscular torticollis results from a shortened or fibrotic sternocleidomastoid. Because the SCM laterally flexes the head to the same side and rotates it to the opposite side, a right torticollis presents with the head tilted to the right and rotated to the left. A palpable mass (fibromatosis colli) may be present in the first weeks. It often coexists with plagiocephaly and sometimes with hip dysplasia, so screen the hips. Treatment begins as early as possible: stretching into lateral flexion away from the tight side and rotation toward it (for right torticollis: left lateral flexion and right rotation), active strengthening of the opposite neck muscles, positioning and handling that encourage turning toward the restricted side, plenty of supervised tummy time, and parent education. Referral is indicated for atypical findings (no improvement after several months, ocular or neurologic signs).

Developmental dysplasia of the hip (DDH) ranges from a shallow acetabulum to frank dislocation. Risk factors are female sex, breech position, first born, family history, oligohydramnios and tight swaddling with the hips extended and adducted. In newborns, the Barlow test (adduction with posterior force) dislocates an unstable hip and the Ortolani test (abduction with anterior lift) reduces a dislocated hip with a clunk. After about 3 months these become unreliable; look for limited hip abduction, asymmetric thigh folds, apparent leg length difference and a positive Galeazzi sign (lower knee height on the affected side with hips and knees flexed). Infants under about 6 months are treated with a Pavlik harness that holds the hips in flexion and abduction; caregivers must not remove or adjust it unless taught to, and must avoid hip extension and adduction. Older children may need closed or open reduction and casting.

Section 2Pediatric settings and intervention

Early intervention under IDEA Part C

The Individuals with Disabilities Education Act (IDEA) guarantees services for children with disabilities. Part C covers infants and toddlers from birth to age 3 who have a developmental delay or a diagnosed condition with a high probability of delay. Services are family centered and delivered in natural environments, places where children without disabilities would usually be, such as the home or child care. The plan is the Individualized Family Service Plan (IFSP), which includes the child's present levels, the family's concerns, priorities and resources, measurable outcomes that the family chooses, services and their frequency, a named service coordinator, and a transition plan for leaving Part C at age 3. The IFSP is reviewed every 6 months and rewritten annually. After referral, the evaluation and initial IFSP meeting must occur within 45 days. Coaching caregivers to embed practice into daily routines (bath, meals, play) is the dominant service model.

School based practice under IDEA Part B and Section 504

Part B covers children from age 3 through 21 (until graduation or the end of the school year in which they turn 22 in some states) who need special education. Physical therapy is a related service: it is provided only when it helps the student benefit from special education. School PT therefore focuses on educationally relevant goals: getting on and off the bus, moving through hallways and stairs in time for class, carrying a lunch tray, sitting posture for writing, participating in physical education and recess, and managing equipment. The plan is the Individualized Education Program (IEP), written by a team that includes the parents, at least one general education teacher, a special education teacher, a district representative and, when appropriate, the student and related service providers. It states present levels of performance, measurable annual goals, services, accommodations and the extent of participation with peers. It is reviewed at least annually and the child is reevaluated at least every 3 years. Services are delivered in the least restrictive environment, as much as possible alongside students without disabilities. Transition planning toward adult life must be in the IEP by age 16.

Section 504 of the Rehabilitation Act applies to students with a disability that substantially limits a major life activity who do not need special education. A 504 plan provides accommodations (elevator pass, extra time between classes, adapted physical education, a second set of books). A student with juvenile idiopathic arthritis who performs well academically is the classic 504 student.

Pediatric PT also occurs in neonatal intensive care units, hospitals and outpatient clinics, where the medical model applies and goals may target impairments that are not educationally relevant. In the NICU, care emphasizes developmentally supportive positioning and handling with attention to stress signs.

Developmental tests and outcome measures

Choose a test by age, purpose and population. Norm referenced tests compare a child with a normative sample (useful for eligibility and identifying delay); criterion referenced tests measure mastery of specific skills (useful for planning and measuring change). Discriminative tests identify delay; evaluative tests detect change over time; predictive tests forecast later outcomes.

Adaptive equipment, orthoses and mobility

Equipment should increase participation, protect joints and fit growth. Key choices:

• Positioning and seating: a stable pelvis is the foundation (neutral to slight anterior tilt, level, hips at about 90 degrees with a lap belt at about 45 degrees across the pelvis), followed by trunk supports, head support and a tray. Good seating frees the hands and supports breathing, feeding and attention.
• Standers: prone standers (leaning forward, need some head control), supine standers (for children with poor head control) and upright or mobile standers. Supported standing for about an hour a day, often in divided sessions, is used to promote hip development, bone density and range of motion, and to allow participation at table height.
• Gait trainers and walkers: a posterior walker (reverse walker) promotes a more upright posture and is usually preferred for children with spastic diplegia; gait trainers with trunk and pelvic support suit children at GMFCS III to IV.
• Ankle foot orthoses: a solid AFO controls equinus and gives stability in stance; a hinged (articulated) AFO allows dorsiflexion and controls plantar flexion for children with some control; a ground reaction AFO (anterior shell) creates a knee extension moment for crouch gait; a posterior leaf spring AFO assists dorsiflexion in swing for isolated foot drop; supramalleolar orthoses control mild pronation or supination. Night or resting splints maintain length.
• Wheeled mobility: powered mobility can begin as early as about 18 to 24 months and supports cognitive, social and language development; it does not prevent walking. Manual wheelchairs are chosen for children with adequate arm function and endurance.
• Adapted car seats, bath chairs, communication devices and adapted toys and switches complete the plan.

Section 3Geriatrics

Normal aging versus disease

Aging reduces physiologic reserve, so older adults function well at rest but decompensate under stress (illness, surgery, a new drug). Distinguish expected changes from disease: a slower gait is common, but a sudden decline is never "just age."

Polypharmacy

Polypharmacy, commonly defined as five or more medications, raises the risk of falls, delirium, adverse reactions and interactions. Age related declines in renal and hepatic clearance prolong drug effects. The Beers Criteria list potentially inappropriate medications for older adults. Drug classes that most increase fall risk are sedative hypnotics and benzodiazepines, antidepressants, antipsychotics, opioids, antihypertensives and diuretics (orthostasis), and drugs with anticholinergic effects (confusion, blurred vision, urinary retention, constipation). Beta blockers blunt the heart rate response, so use rating of perceived exertion rather than heart rate targets. Report new dizziness, confusion or falls after a medication change to the prescriber; the PT does not change medications but should flag the pattern.

Cognition: delirium, dementia and depression

Screening tools include the Confusion Assessment Method for delirium (acute onset and fluctuating course plus inattention, plus either disorganized thinking or altered consciousness), the Mini-Cog, the Montreal Cognitive Assessment (below 26 of 30 suggests impairment and it is sensitive to mild cognitive impairment) and the Mini-Mental State Examination (below about 24 of 30 suggests impairment), and the Geriatric Depression Scale. For people with dementia, use simple one step commands, demonstration, consistent routines and the same staff, procedural (implicit) learning through repetition, and a calm environment; redirect rather than argue.

Frailty and falls

Frailty is a state of reduced reserve and vulnerability to stressors. The Fried frailty phenotype counts five criteria: unintentional weight loss (about 10 pounds or 5% in a year), self reported exhaustion, weak grip strength, slow gait speed and low physical activity. Three or more criteria indicate frailty, one or two prefrailty. Frailty predicts falls, hospitalization, disability and death, and it can be improved with multicomponent exercise and nutrition.

About one in four adults aged 65 and older falls each year, and falls are the leading cause of injury death in this group. The STEADI approach screens with three questions: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? A yes leads to a gait, strength and balance assessment, a medication review, orthostatic blood pressure, vision and foot checks, and a home safety assessment.

Fall prevention with the strongest evidence is exercise that challenges balance, ideally with strength training, performed for at least 3 hours per week over time (for example tai chi or the Otago program, a home based strength and balance program for frail older adults). Add home hazard modification (especially after a fall or with visual impairment), medication reduction, treatment of orthostatic hypotension, cataract surgery when indicated, appropriate footwear, vitamin D for those deficient, and assistive devices.

Osteoporosis and home safety

Osteoporosis is defined by bone mineral density as a T-score of -2.5 or lower (osteopenia, or low bone mass, is -1.0 to -2.5), or clinically by a fragility fracture of the hip or spine. Common fractures are vertebral compression fractures (height loss, thoracic kyphosis, sudden back pain after a minor load), distal radius fractures and hip fractures. Exercise for bone uses progressive resistance training and weight bearing impact appropriate to fracture risk, plus balance training and postural extension exercises. Teach spine sparing movement: avoid loaded spinal flexion and twisting (sit ups, toe touches, twisting while lifting), and use a hip hinge. Hip protectors reduce hip fracture in high risk residents who wear them.

A home safety evaluation looks for: loose throw rugs and cords (remove), poor lighting (add bright lights, night lights from bed to bathroom, switches at both ends of stairs), stairs without rails (rails on both sides), slippery tub (grab bars, nonslip mat, tub bench, handheld shower), low toilet (raised seat or safety frame), frequently used items stored high or low (move to waist to shoulder height), clutter in walkways, and pets underfoot.

Section 4Women's and men's health

Pregnancy and exercise

Pregnancy increases blood volume by about 40 to 50%, cardiac output by 30 to 50% and resting heart rate by 10 to 20 beats per minute, while systemic vascular resistance and blood pressure fall in the second trimester. Relaxin and other hormones increase ligamentous laxity. The center of mass moves anteriorly and superiorly, lumbar lordosis and thoracic kyphosis often increase, and the base of support widens. Edema increases carpal tunnel and tarsal tunnel symptoms. Low back pain and pelvic girdle pain (posterior pelvic or symphysis pubis pain worsened by single leg loading and rolling in bed) are common; manage with education, exercise, pelvic belts and positioning.

Healthy pregnant people should get at least 150 minutes per week of moderate aerobic activity and strength training; exercise reduces gestational diabetes, excessive weight gain and preeclampsia risk. Use the talk test or perceived exertion rather than heart rate. Avoid contact sports and activities with a high fall risk, scuba diving, exercise at high altitude without acclimatization in those not living there, overheating (hot yoga), and prolonged motionless standing. After about 20 weeks, limit prolonged supine positioning, because the uterus can compress the inferior vena cava and cause supine hypotension; use left side lying or an inclined position.

Diastasis recti abdominis

Diastasis recti abdominis (DRA) is separation of the rectus abdominis bellies along the linea alba, common in late pregnancy and postpartum. Test the patient in hook lying: she lifts her head and shoulders until the spines of the scapulae clear the table, and the examiner palpates finger widths of separation at, above and below the umbilicus. A separation greater than about 2 finger widths (about 2 cm) is commonly considered significant; also note the depth and tension of the linea alba. Management: teach transversus abdominis activation with exhalation, log rolling or side lying to rise from bed instead of a sit up, splinting (crossed hands pulling the recti toward midline) during head lifts and coughs, avoiding straining and heavy loads early, and progressive core loading as the patient controls doming. Most separations narrow by 8 weeks to 6 months postpartum. After a cesarean birth, protect the incision, splint for coughing and progress lifting gradually.

Pelvic floor and urinary incontinence

The pelvic floor (pelvic diaphragm) is formed mainly by the levator ani (puborectalis, pubococcygeus and iliococcygeus) and the coccygeus, innervated primarily by the pudendal nerve and direct branches of S2 to S4. It supports the pelvic organs, maintains continence by closing the urethra and anorectal angle, and contributes to sexual function and lumbopelvic stability. Pelvic floor dysfunction may be underactive (weakness, incontinence, prolapse) or overactive (high tone, pelvic pain, painful intercourse, constipation); overactive muscles need relaxation and down training before strengthening.

Pelvic floor muscle training is first line care for stress and mixed incontinence in women (strong evidence). Confirm a correct contraction first: the patient should feel a squeeze and lift without breath holding, bearing down, or substituting with gluteals, adductors or abdominals; many people bear down when asked to contract, which worsens prolapse and leakage. Training includes maximal holds (slow twitch endurance, up to about 10 seconds) and quick flicks (fast twitch), commonly about 8 to 12 contractions three times a day for at least 12 weeks, progressing positions from lying to standing and functional activity. Biofeedback, electrical stimulation and vaginal weights are adjuncts. Pelvic organ prolapse (bladder, uterus or rectum descending, with a feeling of heaviness or a bulge that worsens through the day) also improves with pelvic floor training, avoidance of straining, and pessary referral.

Osteoporosis and bone health in women

Estrogen loss at menopause accelerates bone loss for several years, so postmenopausal women make up most people with osteoporosis. Screening with DXA is recommended for women 65 and older and younger postmenopausal women at increased risk. In young female athletes, low energy availability with or without disordered eating causes menstrual dysfunction and low bone density, the female athlete triad, now included in the broader concept of relative energy deficiency in sport. Stress fractures, amenorrhea and weight loss in an athlete warrant referral to a physician and dietitian.

Men's health and prostate cancer care

Prostate cancer is the most common noncutaneous cancer in men. Treatments include active surveillance, radical prostatectomy, radiation, and androgen deprivation therapy (ADT). After prostatectomy, damage to the internal urethral sphincter leaves continence dependent on the external sphincter and pelvic floor, so most men have early stress incontinence; pelvic floor muscle training, ideally started before surgery and resumed after the catheter is removed, speeds the return of continence. Erectile dysfunction is common and pelvic floor training may help. ADT causes loss of bone density, loss of muscle mass with fat gain, fatigue, hot flashes, insulin resistance and higher cardiovascular risk. Combined resistance and aerobic exercise counters fatigue, sarcopenia and functional loss during ADT and is safe for most men. Precautions: screen for bone metastases (prostate cancer spreads to the spine, pelvis and ribs; new night pain or focal bone pain needs evaluation, and loaded or high impact exercise is modified for involved bones), monitor blood counts during chemotherapy, and watch for fatigue and skin effects after radiation.

Section 5Integrated case review

A priority framework

Exam vignettes often contain several problems and ask for what to do first or what is most appropriate. Use a consistent hierarchy:

1. Life threats and medical instability: airway, breathing, circulation, unstable vital signs, chest pain, signs of stroke, sepsis, hypoglycemia, autonomic dysreflexia. Stop, get help, call emergency services or the rapid response team.
2. Red flags that require referral before or instead of treatment: suspected deep vein thrombosis, cauda equina syndrome, fracture, infection, cancer, shunt malfunction, cord compression, delirium.
3. Safety for the session: precautions (weight bearing, hip, sternal, spinal), lines and tubes, vital sign limits, guarding and fall prevention.
4. The patient's goals and function: the activity and participation limits that matter most to the patient and that drive discharge.
5. Impairments that limit those functions.

Then match the action to the setting and the person's role: the PT, not the PTA, decides about plan changes; the setting determines who to call (nurse and provider in the hospital, emergency services in an outpatient clinic, the school nurse and parents in a school).

Worked integrated cases

Choosing across settings

Discharge questions ask for the most appropriate next setting. Consider medical stability, the amount of assistance needed, tolerance for therapy, the home and caregiver support, and payer rules. A patient who needs intensive multidisciplinary therapy, can tolerate about 3 hours a day and is expected to improve fits inpatient rehabilitation; one who needs daily skilled care but cannot tolerate that intensity fits a skilled nursing facility; one who is safe at home with help but leaves home only with considerable and taxing effort fits home health; one who can travel fits outpatient. Always match recommendations to the person's goals, cognitive status and caregiver availability, and include equipment and education in the plan.

Words worth knowing