Managing Pediatric Rehabilitation

Before beginning pediatric rehabilitation, confirm:

Required clinical questions:

• What is the child's age (chronological and corrected gestational age if premature)?
• What is the diagnosis (cerebral palsy, Down syndrome, developmental delay, pediatric TBI, congenital anomaly)?
• What developmental milestones has the child achieved and which are delayed?
• What is the family's primary concern and functional goal for the child?
• What educational setting does the child attend (early intervention, preschool, school-age) and are school-based services in place?
• Are there medical complexities (seizures, feeding difficulties, respiratory support, orthopedic hardware)?

Required documents:

• Physician referral with diagnosis and ICD-10 codes
• Birth history (gestational age, birth weight, NICU stay, complications)
• Developmental pediatrician or neurologist evaluation if available
• Current IFSP (Individualized Family Service Plan, ages 0-3) or IEP (Individualized Education Program, ages 3-21)
• Prior therapy evaluation reports
• Imaging (brain MRI for CP/TBI), genetic testing results if applicable

Step 1 — Classify Developmental Status and Functional Level

For cerebral palsy (most common pediatric rehab diagnosis):

Gross Motor Function Classification System (GMFCS) — 5 levels:

• Level I: Walks without limitations; limitations in more advanced gross motor skills
• Level II: Walks with limitations; difficulty with running, jumping, uneven surfaces
• Level III: Walks using handheld mobility device indoors; wheeled mobility outdoors/community
• Level IV: Self-mobility with limitations; transported or uses power mobility in community
• Level V: Transported in manual wheelchair in all settings

Manual Ability Classification System (MACS) — 5 levels (ages 4-18):

• Level I: Handles objects easily and successfully
• Level II: Handles most objects but with somewhat reduced quality/speed
• Level III: Handles objects with difficulty; needs help to prepare or modify activities
• Level IV: Handles a limited selection of easily managed objects in adapted situations
• Level V: Does not handle objects; severely limited ability for even simple actions

Communication Function Classification System (CFCS) — 5 levels:

• Level I: Effective sender and receiver with unfamiliar and familiar partners
• Level II: Effective but slower pace with unfamiliar partners
• Level III: Effective with familiar partners
• Level IV: Inconsistent even with familiar partners
• Level V: Seldom effective even with familiar partners

Age-adjusted developmental milestones (screen):

• Gross motor: head control (3-4 mo), sitting (6-8 mo), crawling (8-10 mo), pulling to stand (9-12 mo), walking (12-15 mo)
• Fine motor: palmar grasp (3-4 mo), transfer (5-7 mo), pincer grasp (9-12 mo), stacking (12-15 mo)
• For premature infants: use corrected age until 24 months

Step 2 — Select and Administer Age-Appropriate Standardized Assessments

GMFM (Gross Motor Function Measure):

• 88 items across 5 dimensions: lying/rolling, sitting, crawling/kneeling, standing, walking/running/jumping
• Each item scored 0-3 (0=does not initiate, 1=initiates, 2=partially completes, 3=completes)
• GMFM-66 (Rasch-analyzed 66-item version) provides interval-level scores for tracking change
• Administer in standardized environment (mat, supportive surface, no shoes unless stated)

PEDI-CAT:

• Computer adaptive test measuring daily activities, mobility, social/cognitive, responsibility
• Age range: birth to 20 years
• T-score normative comparison (mean 50, SD 10)
• Tracks change over time with scaled scores

Step 3 — Develop Family-Centered Goals and Intervention Plan

Goal-setting with the family:

• Use the Canadian Occupational Performance Measure (COPM) to identify family-prioritized goals
• Goals must be functional and participation-based: "Child will independently eat with adapted spoon during school lunch" not "improve UE ROM"
• For IFSP (0-3 years): goals are family outcomes embedded in daily routines
• For IEP (3-21 years): therapy goals support educational participation

Evidence-based interventions by GMFCS level:

Intensive therapy models (evidence-based):

• CIMT (modified pediatric): 3-6 hours/day, 2-3 weeks for UE hemiparesis
• HABIT (Hand-Arm Bimanual Intensive Therapy): 6 hours/day for 2 weeks for bimanual function
• Goal-directed training: task-specific, repetitive practice of functional goals (60-90 min sessions)
• Hippotherapy: when available, for trunk control and postural stability (requires trained therapist and certified equine center)

Step 4 — Coordinate Across Service Settings

Pediatric rehab often spans medical and educational systems:

Early intervention (0-3 years):

• Services under IDEA Part C; documented in IFSP
• Natural environment (home, daycare) is preferred service setting
• Therapy supports family routines, not clinic-based protocol
• Transition planning to Part B (school) services begins at age 2.5

School-based services (3-21 years):

• Services under IDEA Part B; documented in IEP
• Therapy must support educational participation (not medical model goals)
• Frequency determined by educational need, not medical diagnosis alone
• PT/OT/SLP are "related services" — available only if needed for FAPE (Free Appropriate Public Education)

Medical outpatient therapy (all ages):

• Physician-ordered, medically necessary skilled therapy
• Goals address medical functional limitations beyond educational need
• Can be concurrent with school services if addressing different goals
• Insurance authorization required; document distinct medical necessity

Step 5 — Monitor Growth, Development, and Equipment Needs

• Reassess with standardized measures every 6 months minimum (developmental change is the baseline expectation in children)
• Track GMFCS level — this may change in early years (typically stable by age 6)
• Growth monitoring: skeletal growth affects orthotic/wheelchair fit; schedule equipment reviews with growth spurts
• Orthotic reassessment: every 6-12 months or with growth; document brace type, fit, and functional benefit
• Wheelchair seating: annual reassessment minimum; document posture, skin integrity, and functional access
• Musculoskeletal surveillance: monitor for hip subluxation (in CP GMFCS III-V, hip X-rays per screening protocol), scoliosis, and contracture development

Checkpoint B — Pre-Finalization Review

Before finalizing pediatric rehabilitation documentation:

• Chronological and corrected age documented
• Diagnosis with GMFCS/MACS/CFCS classification if CP
• Developmental status compared to age-appropriate milestones
• Standardized assessment administered with scores and percentiles
• Family goals incorporated using COPM or family interview
• Intervention plan is evidence-based and matched to GMFCS level
• Equipment needs assessed and recommendations documented
• Service coordination across medical and educational settings documented
• Caregiver training plan included
• Next reassessment date established

Quality Audit

• Age-appropriate standardized assessment used (not adult instruments)
• GMFM scored correctly with dimension totals and overall percentage
• GMFCS level documented with age band (classification varies by age)
• Goals are family-centered and participation-based, not impairment-only
• Corrected gestational age used for premature infants under 24 months
• Educational vs. medical service distinction maintained in documentation
• Equipment recommendations include specific product, size, and justification
• All [VERIFY] flags resolved or escalated to developmental pediatrician
• IDEA/IFSP/IEP coordination documented when applicable
• Documentation appropriate for the service setting (medical vs. educational)

Guidelines

• Never apply adult rehabilitation benchmarks or instruments to pediatric patients — use age-normed tools
• Family-centered care is the standard: parents/caregivers are partners in goal-setting and intervention
• CP motor prognosis is linked to GMFCS level: children at Level I-III typically achieve independent ambulation; Level IV-V typically use wheeled mobility as primary mode
• Early intervention intensity matters: evidence supports intensive, goal-directed, task-specific therapy over passive stretching or NDT alone
• Constraint-induced movement therapy has strong evidence for hemiplegic CP in children ages 2-8 with minimum hand grasp ability
• Do not delay power mobility assessment for children who cannot walk independently — independent mobility supports cognitive and social development from age 12-18 months
• Growth-related changes in CP (lever arm dysfunction, muscle-tendon unit shortening) may cause functional decline in adolescence despite therapy — document and plan proactively
• Botulinum toxin injections for spasticity in CP require coordinated therapy intensification post-injection
• Transition planning (pediatric to adult services) should begin at age 14-16 and be documented in the rehabilitation plan
• All pediatric therapy documentation is HIPAA-protected and FERPA-protected in educational settings — handle accordingly