Jen Salas is back for Volume 2 of the NGPT Pediatric Physical Therapy series! Today's volume covers prepping for that first peds job, continuing education and more.
NGPT: Some of our readers have zero pediatrics experience. They are just getting started in per diem jobs to get their feet wet. What are some baseline essentials to consider when beginning practice in a pediatric environment?
Jen: A good place to start is learning the expected gross motor milestones. In time you’ll learn that a delay in rolling, if not addressed, will almost certainly lead to weak core muscle strength, which can almost certainly wind up resulting in delayed sitting skills, possibly delayed standing, walking, and so on down the developmental skill line. A fair understanding of fine motor & speech/language/cognitive milestones will also serve you well. In time you will make connections about how all these domains impact each other and determine ways to tailor your treatments for the most impact across these domains.
Also, know when reflexes should be integrating and emerging, what visual and auditory skills are developing at each stage, and how these factors impact what you can expect from the child as well as how it should drive your treatment choices.
NGPT: We have heard that pediatrics patients, obviously, have a much greater family member involvement level than most other settings. Can you say how that will impact treatment for a new pediatric PT?
Jen: A lot of physical therapy is education, so in this case, it's just a focus on educating family members, rather than the patients. Know how to explain the above developmental milestones and any delays/abnormalities in non-medical language that is parent-friendly. Welcome questions and ask questions. Both are vital. Parents will often leave out crucial information or fail to ask a therapist certain questions, simply because they are unaware that the information is pertinent.
Discuss progresses as well as difficulties as you see them AND as the parent sees and experiences them at home and within the community. Such conversations can enhance the treatment approaches you take. Mindfulness about the underlying goals of your treatment “games” should be ever-present. Mindfulness of your own posture, actions, breath patterns, and word choices with your patient and the family/caretakers present is also important.
I digress from that point with a question: What if we all learned early on in life HOW our bodies are meant to move? Can an infant develop with muscular strength and symmetry within the first year and have a solid, balanced, developing toddler-hood once they achieve verticality? Can a toddler develop into a child into a pre-teen, teen, adult without muscular imbalances or physical limitations to function? You have the beautiful opportunity to facilitate this essential movement learning in your patients and their parents.
NGPT: Some of our readers have asked how to best relate to children, after treating adults for their entire careers.
Jen: That is a great question! It's not so different from working with some adult patient populations. The best tip I can give is to speak through the movements as you do them. For example, kiddos who have major difficulty in executing a sit-up would benefit from singing the following,"first your chin to your chest, now lift your head...neck...shoulders...belly.” For babies learning to roll from back to belly, as I facilitate hip flexion and trunk rotation, I say in a sing-songy voice, “up and overrrrrrr,” ending the words only when the movement is completed.
Age appropriate language with your patients will go far. With infants, this includes attention to your voice intonation, and sometimes including silly sounds or consonant repetition.
NGPT: If you could pick one diagnosis that aspiring pediatric PTs should learn about, what would it be, and why?
Jen: Definitely take a class on the assessment and treatment of torticollis & plagiocephaly, no matter how much you think you understand it. This is one diagnosis that, if treated poorly, could really have negative affects that last a lifetime. It goes a lot deeper than simple side bending and lateral rotation of the neck. What do you know about sutures, plagiocephaly (brachycephaly, scaphocephaly), craniosynostosis, cyclic vomiting disorder, helmets and occular muscles? How about opthalmologists, orthotists, and other specialists/ professionals with whom you will communicate to provide the most effective care for this patient population?
NGPT: You know we're dealing with a super prepared and eager to please readership on here :) Do you have any particular scales or tools that you recommend an aspiring pediatric PT learn before starting a new job?
Jen: Oh yes! I recommend learning the PDMS-II (Peabody Developmental Motor Assessment) tool before you start your new job. If they don't use that, make sure you learn what they do use as an assessment tool, and learn it - inside and out. You'll want to be able to explain the results to parents with confidence. That means understanding what the deficiencies mean and, more importantly, how you can help them address the roots of the issues.
There is a wonderful poster-sized chart you can order that has all the expected milestones in the various domains for each age & stage. Get it, and put it up in your clinic. Reference it often. Don’t just try to memorize it right away; I can assure you that learning will come with time and practice. It’s also a good idea to speak with the pediatricians who sign off on your evaluations and plans of care, to make sure you are on the same page regarding proper assessment tools and what they mean to your mutual patient.
NGPT: Let's talk continuing education. Many of our readers mention that making the leap to pediatrics requires taking a certain amount of continuing education before taking the plunge, at least if they're lacking in the hands-on experience department. Can you recommend particular courses for the aspiring peds PT?
Jen: I definitely recommend taking continuing education out the wazoo (yes, I used the word “wazoo”...sometimes in pediatrics we make up and use silly words)! Obviously, I mentioned the importance of taking a course in torticollis and plagiocephaly, but there is plenty more to learn :)
Take classes related to the infant, child, typical & atypical development, high muscle tone, low muscle tone, gait abnormalities, cognitive/social/emotional/sensory developmental issues & their interplay on the gross motor domain of development.
NGPT: Some of our readers have already been certified in manual therapy disciplines, pilates, yoga and other forms of "adult" practice that they'd love to incorporate into pediatric practice. Is this actually done in the peds world?
Jen: Absolutely! You should definitely consider adult courses and courses oriented towards other related fields; just know that you may have to extrapolate the clinical pearls to apply to the developing body.
A great example is the benefits of taking a Maitland Manual Stabilization course, which is certainly geared toward treating adults. They offer great cues/techniques that could be utilized with an infant or child needing external stabilization to help with proprioception and muscle recruitment. Foundation Training is a fantastic newer movement program, created by an out-of-the-box thinking chiropractor. I’ve seen first-hand how it enhances core strength, postural control, and proper biomechanical movements by targeting posterior chain muscle activation in any body that is vertical. There is clear applicability for toddlers, kids, preteens, teens, and adults.
NGPT: Clearly, you're open to interdisciplinary education. What other courses can you recommend from beyond the PT continuing education realm?
Jen: Oh my gosh, where do I begin? Well, consider the value of a physical therapist attending a course on feeding that is geared toward speech therapists and occupational therapists. You might be surprised to learn that a PT’s assistance can be extremely helpful in the process of improving oral motor skills. Think core strength: if we can sit up with strong postural control, our anatomy of swallowing and digestion have a more strong and stable base of support for that system.
Visual motor control courses geared to OTs can also be helpful; consider that perhaps what you are seeing isn’t truly positional torticollis. What if it is an adaptation to weak ocular muscles?
What about a course on infant massage? Typically, these courses are taken by occupational therapists. As a PT, you can learn extremely useful information on stomach massage that can have a direct impact on digestive motility, comfort, willingness to move, and ability to move. That translates to strength and motor control gains in the stomach muscles that affect skills like rolling and sitting. Infant massage also teaches arm massage techniques that can be useful for your young patients with brachial plexus injuries, and that’s just the beginning.
NGPT: Thank you, Jen! I'm sure everyone's feeling a little overwhelmed about continuing education, but you've really provided some great information and a fantastic starting point for our readers. Any parting words until our next chat?
Jen: I agree: if your brain is reeling from the thought of CEUs, that’s a great place to leave you for now :) Don’t forget to read my previous post, if you haven't already. Finding the area you are passionate about will most certainly drive your direction with regard to many of the courses you take. A pediatric therapist needs lots of “tools in their bag”, “tricks up their sleeves”, silly songs, and fun games. Try to always remain open: don’t lose that child-like skill of being a “sponge” for new information. Within your learning experiences, you just may find that new paths and passions that you never could have imagined present themselves. This is an exciting field and world, new grad! How will you choose to share your goodness?