Children with special health care needs (SHCNs) represent a growing population of patients with unique needs and are important from a health care services and policy perspective. Physiatry as a specialty is uniquely suited to take a primary role in the management of SHCN children and can play a major part in limiting the degree of impairment and disability that these children are at risk of attaining. Of importance to the physiatrist is an understanding of the role and impact that physical and cognitive development has on common physiatric problems and how these problems may differ in the pediatric population versus the adult population. This chapter seeks to define many of the common issues addressed by the pediatric physiatrist and points out important aspects of these issues that are unique to the pediatric population.
EPIDEMIOLOGY OF SPECIAL HEALTH CARE NEEDS
As defined by the federal Maternal and Child Health Bureau, SHCN children are those who are at increased risk for a chronic physical, developmental, behavioral, and emotional condition and who also require health care–related services of type or amount beyond that required by children in general.1 A number of studies over the past 10 to 15 years have attempted to define the prevalence of childhood disabilities. An estimated 12.8% of children in the United States met criteria for SHCNs in 2001, with a substantial percentage of them (17%) having unmet health care needs.2 Boyle et al demonstrated an increase in the prevalence of developmental disabilities from 12.8% to 15% from 1997 to 2008.3 Of further concern is the effect that childhood disability has on the individual's health as he or she ages and the implications this holds as the child transitions to adult-based care. A recent study assessing adult-based outcomes in individuals with cerebral palsy (CP) and spina bifida (SB) showed an increased incidence of chronic pain (59%) and progressive deterioration of functional ambulatory skills (44%) in participants with CP and poor aerobic fitness (80%) in individuals with both CP and SB.4 Additional studies are clearly needed to further define the physical and functional changes seen by SHCN children as they age.
The physical complications encountered by children with physical disabilities are similar to those seen in adults with physical disabilities, and general management strategies for those complications tend to be similar. However, key differences between children and adults exist and may necessitate modifying those strategies, or applying additional considerations, in order to effectively treat the patient. These differences are mostly secondary to childhood developmental considerations, including body growth, cognitive development, neuromotor development, and cardiovascular adaptation.
There are many disorders of tone and movement that lead to complications in pediatric rehabilitation; a few common types will be discussed in this section. Spasticity is an involuntary, velocity-dependent increase in muscle tone and is ...