Sweeney, Jane K. PT, PhD, PCS, FAPTA; Heriza, Carolyn B. PT, EdD, FAPTA; Blanchard, Yvette PT, ScD
Neonatal physical therapy is an advanced practice area in pediatric physical therapy that has evolved from the early 1970s when regional neonatal intensive care units (NICUs) were established and neonatal mechanical ventilation became available to increase survival in infants born preterm in tertiary units. In today’s NICUs and intermediate care units, neonatal physical therapists (PTs) require advanced training and competencies to safely and effectively meet the neurodevelopmental and musculoskeletal needs of infants who have been physiologically unstable as well as the educational and emotional needs of their parents, who are highly stressed. The neonatal PT must acquire the comprehensive knowledge and clinical competencies in neonatal care to participate as equal partners with the team of neonatal nurses and neonatologists who have completed subspecialty neonatal training and certification in their respective disciplines.
Clinical practice guidelines for pediatric PTs in the NICU are presented in two sections: part 1: specialized training models, clinical competencies, and decision-making algorithm and part II: NICU practice frameworks and evidence-based practice considerations. This article focuses on part I with part II to follow in the next issue of Pediatric Physical Therapy.
Neonatal practice is a highly specialized area within pediatric physical therapy in which vulnerable infants with complex medical, physiological, and behavioral conditions may inadvertently be harmed through examination andintervention procedures. The NICU is not an appropriate setting for PT assistants, PT generalists, and PT students. Pediatric PTs need expanded training in many areas including family systems, NICU environment, collaborative team work in a critical care unit, infant development, brain development, physiological evaluation and monitoring, and infant neurobehavioral functioning. Even routine caregiving procedures may pose risks to fragile neonates with physiological and metabolic instability and incompletely developed musculoskeletal, neuromuscular, cardiovascular/pulmonary, and integumentary systems. Continuous examination and evaluation are required during each contact to determine whether the infant is beginning to move outside the limits of physiological, motor, or behavioral state stability during handling or feeding. Because of the complexity involved in communication and teaching for stressed, grieving families, advanced training and mentoring are indicated in grief management, crisis intervention, family systems, and adult learning approaches.
Several clinical training models may be considered by pediatric PTs preparing for neonatal practice: precepted practicum, neonatology fellowship, or neonatal training as a part of a pediatric residency. The length of clinical training in neonatal care may vary from 2 to 6 months depending on the following variables:
* Practitioner’s previous experience in pediatrics, especially early intervention practice, hospital-based infant and pediatric care, and exposure to training in behavioral observations of fragile neonates. Practitioners with previous experience and training with fragile infants will likely require a shorter practicum duration to become independent in competency-based training requirements;
* Individualized, precepted practicum based on the level of acuity and regional and local variables such as cultural diversity and healthcare reimbursement to match the demographics of the future NICU practice setting of the trainee; and
* Completed American Physical Therapy Association (APTA)-accredited neonatology fellowship or pediatric residency program that includes a neonatology rotation.
Resources on neonatal topics to support clinical training are available on the Neonatology Special Interest Group link on the Section on Pediatrics, APTA Web site: www.pediatricapta.org. Parent education brochures, NICU-related videos/CDs, and continuing education courses are outlined.
Sequenced, gradual entry to neonatal care is advised with clinical experience starting with infants born full-term and older, medically fragile, hospitalized children requiring respiratory equipment and cardiorespiratory monitor instrumentation. These children, while medically fragile, are usually more stable than infants born preterm and on ventilator equipment in the NICU. As such, they are less vulnerable to inadvertent overstimulation from professionals in a subspecialty training process. Gradual entry to the NICU after experience in a pediatric ICU, pediatric ward, newborn nursery, and intermediate care nursery is strongly advised before attempting to examine or intervene with infants and parents in the NICU. Observations of nursing care and respiratory therapy for fragile infants with complex medical conditions are additional valuable components in mentored training.
Exposure to the developmental trajectory and neuromotor patterns in outpatient follow-up for NICU graduates is a critical learning experience for all neonatal therapists and should be included in a precepted practicum. This valuable experience helps develop a perspective on various neonatal neuromotor findings (ie, asymmetry, tone abnormalities, jittery movement), which may turn out to be transient. The clinical follow-up also provides valuable opportunities to see the parents outside the NICU environment, learn about their ongoing challenges and successes in caregiving, and adapt the neonatal therapy program to their current priorities. Observation and participation with pediatric PTs working with NICU graduates in home-based and community-based early intervention programs are advised to enhance NICU discharge planning skills and liaison with community resources.
Precepted practicum opportunities may be accessed through selected medical centers. An alternative method is university-based, specialized training modules for experienced pediatric therapists through directed clinical studies as a part of advanced doctoral study.
Residency or Fellowship Training
Now that the opportunity for residency training in pediatrics is offered in the United States, PTs may access precepted NICU training through a pediatric residency program. Pediatric residencies accredited by the APTA have a minimum length of 10 months, a part of which may be conducted in an NICU setting depending on the practice scope of the residency program. Shortly, APTA-accredited neonatology fellowship programs will be available and will offer comprehensive preparation for appropriate, accountable, evidence-based, and ethical practice in neonatal physical therapy. Regardless of the model of training selected for neonatal practice preparation, clinical competencies specific to newborn infants and families should guide the training and provide an evaluation structure for trainees.
The clinical roles and proficiencies for neonatal PTs, developed by task forces from the Section on Pediatrics, APTA, were first documented in 19891 and expanded in 1999.2 The competencies for neonatal physical therapy practice in these current updated practice guidelines are delineated by roles, clinical proficiencies, and knowledge areas. The roles of the neonatal PT such as screening, examination/evaluation, intervention,consultation, scientific inquiry, clinical education/professional development, and administration are organized in Tables 1 to 7. The neonatal physical therapy competencies were updated through a consensus process by a 3-member NICU Task Force of pediatric PTs with extensive neonatal expertise and geographical diversity, appointed by the Section on Pediatrics of the APTA. External review of the clinical competencies and algorithm was conducted by an additional expert panel of 5 pediatric PTs with neonatal expertise representing varying geographical regions of the United States. Further validation of the neonatal physical therapy competencies through a nation-wide practice analysis could provide an expanded framework for neonatology fellowship programs and for delineation of the practice.
CLINICAL DECISION-MAKING ALGORITHM
An algorithm for clinical decision making in neonatal physical therapy, revised from the 1999 algorithm,2 reflects the needs of contemporary practice and is outlined in Figures 1 to 3. Pathways for neonatal physical therapy management decisions are described for examination, evaluation, intervention, and re-examination with terminology compatible to the Guide to Physical Therapist Practice.17 The algorithm was modeled from the Hypothesis-Oriented Algorithm for Clinicians I18 and II.19 The framework of the IFC20 adopted by the House of Delegates, APTA, 200821 and the Synactive Theory of Development proposed by Als22 are embedded in this algorithm. The algorithm also provides a means for using evidence in decision making.
During the history taking process (Fig. 1), the primary care team and family identify strengths and challenges (PFSL) and decide on an examination strategy. On the basis of the observation of the infant’s activities, an infant strengths and challenges list is generated. The neonatal PT examines strengths and challenges (ISCL) at the body function and structure, activity, and participation levels of the ICF, which leads to the therapist’s strengths and challenges list (TSCL). All 3 strengths and challenges lists are merged and appropriate infant-centered/family-centered goals are then developed.
Before intervention (Fig. 2), the neonatal PT develops an intervention plan based on infant-centered/family-centered goals and implements this plan with respect to the cardiovascular/pulmonary and integumentary systems17 (autonomic system),22 the musculoskeletal and neuromuscular systems17(motor behavior),22 behavioral state,22 and responsivity10 (attentional-interactive behaviors).22 The 4 categories are arranged according to (1) coordination, communication, and documentation such as supporting, developing, and promoting family/professional relationships; (2) education and consultation for family and primary care team such as training to support and promote the infant’s care, development/learning, health, nutrition, and safety; and (3) interventions provided by the PT, family, and members of the primary care team such as (a) use of adjunct accessories/or aids that support the infant in self-regulation of physiological state, promotion of smooth coordinated movement, and organization of movement including hand to mouth behavior for self-regulation of behavioral state and (b) physical and social environment modifications such as dimming lights and decreasing noise to support physiological, motor, or behavioral stability and to promote infant/caregiver interaction during feeding in the NICU. Interventions are also directly provided by the neonatal PT. Direct physical therapy handling is a primary service provided by the neonatal PT to address impairments, activity limitations, and participation restrictions. No direct physical therapy handling indicates that neonatal PTs should not engage in providing primary services to the infant.
The neonatal PT conducts re-examination (Fig. 3) to determine (1) changes in the infant’s status, (2) whether initial infant-centered/family-centered goals and outcomes were achieved, and (3) if not, to modify or redirect components of the intervention plan to achieve goals and outcomes. The clinical decision-making sequence as outlined in the algorithm not only affords the neonatal PT pathways for making evidence-based clinical decisions for the care of infants in the NICU but also provides the therapist with a framework to support clinical reasoning in neonatal physical therapy.
To guide the specialized practice of neonatal physical therapy, clinical training models have been presented and roles and proficiencies were outlined. A decision-making algorithm offers a flow chart for clinical reasoning. Before working in a neonatal unit, pediatric PTs must have precepted clinical training to develop refined skills in examining and intervening with fragile, vulnerable infants with structural, physiological, and behavioral vulnerabilities predisposing them to become unstable during routine procedures. Because each contact by the PT involves ongoing examination, interpretation, and modification or resequencing of procedures, the NICU is not an appropriate setting for PT assistants and aides and PT generalists and students. The potential to do harm with this vulnerable infant population must be recognized. A caring approach and good intentions do not substitute for focused, precepted clinical training in the range of competencies outlined for infant-centered and family-centered care. Instead, interested practitioners will benefit from structured, mentored competency-based training in neonatal physical therapy.
These guidelines may be used as a framework for developing competency training mechanisms for PTs entering neonatal practice, practitioners seeking more advanced levels of neonatal care competencies, and directors of pediatric residency and neonatology fellowship programs. In part II of the practice guidelines, theoretical frameworks and evidence-based practice recommendations will be delineated.
The authors express appreciation to the medical illustrator, Thomas Pierce, BA, for graphic expertise and to the following physical therapists serving as content reviewers: Marie Reilly, PT, PhD; Jan McElroy, PT, DPT, MS, PCS; Beth McManus, PT, ScD, MPH; Elizabeth Ennis, PT, EdD, PCS, ATP; and Sheree Chapman York, PT, MS, PCS.