The Clinical Competencies Within Neonatal Physical Therapy 

“Neonatal physical therapy is an advanced practice, subspecialty area within pediatric physical therapy. Pediatric physical therapists need post professional precepted training and experience before providing neonatal care, due to the structural, physiological, and behavioral vulnerabilities of neonates” . Clinical competencies for neonatal physical therapy practice are outlined according to roles, proficiencies, and knowledge areas. The unique role of the neonatal physical therapist is highlighted as a postural control and movement specialist within behavioral, environmental, and family contexts in the NICU. “Due to the direct contact involving examination, interpretation, interventions, as well as multiple adjustments of procedures, and sequences to minimize risk to infants who may be potentially unstable, physical therapist students or physical therapist assistants would not be able to conduct these examinations” .

“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”. “With technological advances in newborn medicine, infants with very low birth weight or acute illness are surviving. Most medically fragile newborns requiring intensive care are transported to tertiary care centers for specialized neonatal services, including physical therapy”. Therefore, there has been an increasing number of requests for neonatal physical therapy in the intensive care unit, due to the expanding number of premature infant cases.

The first 28 days of post-partum is considered the neonatal period. “Full-term infants are born with physiologic flexion as described earlier, a prime example of muscle tone developing in flexor muscles before extensor muscles. This results in generalized moderate flexion in all positions of the neonate, prone, supine, held in sitting, vertical or horizontal suspension, and held in standing”. Additionally, babies who are preterm display a loss of physiologic flexion. Preterm infants have a lack of flexor tone, creating limbs and a trunk that is relatively extended.

This requires a neonatal physical therapist to intervene and perform assessments and prioritize a plan of action, in regard to rehabilitation and accommodation. “The areas most unique to physical therapy include assessment and treatment of movement and postural dysfunction and pulmonary hygiene”. Prematurity is a serious public health concern affecting 1 in 9 infants, amounting to approximately half a million infants per year in the United States alone. Complications of premature birth can include long-term developmental problems, learning disabilities, motor delays, visual perception and impairment, visual-motor problems, executive functioning deficits, and cerebral palsy.

“The purpose of this document is to provide the APTA with a policy statement that defines competencies for therapists practicing in the NICU. Competent clinicians may not have formal training in all of the knowledge areas listed. However, the competent clinician seeks training in her or his areas of weakness, does not attempt to provide service to a client when her and his knowledge is insufficient to recognize the risks, and refers infants needing service to a competent clinician”. The future trends seen in pediatric physical therapy includes a more important role for physical therapist assistants; this includes pediatric education for the PTA, supervision and utilization of the PTA, and delegation of the tasks in pediatrics. “Some considerations to take into consideration for competence regarding pediatric physical therapy is the developing child, background and theory, pediatric evaluation for the PTA, the role of play in therapy for children, orthopedic disorders of childhood, and disorders of the developing hip”.

Providing a family-centered approach models the proper behavior for a rehabilitative intervention. “It is through responding appropriately to infant cues during care that development of behaviorally beneficial neuronal pathways is supported in the infant through modulation of the infant’s neurobehavior” . In this type of setting, there are many factors that contribute challenging obstacles not only for the infant but also the development of the parent-infant relationship. “In the NICU, the infant is exposed to fluctuations in noise levels, temperature, light, and schedules of evaluation and care. The infant may endure noxious stimuli, painful procedures, pharmacologic agents, and too much handling at times” . Naturally, it is common for families to undergo slight separation due to feelings of anxiety, fear, helplessness, loss of control, uncertainty, and worry.

These feelings of family bondage being threatened can impact the parent-infant interaction to a degree. This is where the physical therapist can intervene and provide relationship-based care to the family by fostering the parent-infant relationship. “One model for doing this is the hope-empowerment model by which the physical therapist builds a therapeutic partnership through collaboration with the parent to assist with coping and foster empowerment”. Physical therapists have the unique opportunity to collaborate with parents through instruction and guidance regarding infant handling and positioning, suitable developmental activities, and acknowledgement of infant cues and behavior.

Another important role physical therapists have in the NICU are instructing parents on how to safely handle and position their young infants with skill and confidence. “Learning and practicing these skills with a physical therapist may increase a parent’s ability to participate in infant care, and proponents of family-centered care advocate that appropriate parental involvement will benefit the current and future health of the infant” . “The Infant Care Path for Physical Therapy in the NICU indicates that techniques for facilitating a calm state and motor organization are appropriate throughout the NICU stay, but should be adapted appropriately as the infant develops, the infant-parent relationship grows, and discharge approaches” (Campbell, 2013). “A caring approach and good intentions do not substitute for focused, precepted clinical training in the range of competencies outlines for infant-centered and family-centered care” .

“Family-centered care is the foundation of pediatric physical therapy. Since a child is dependent on a caretaker, we must address both the child and the caretaker when we interact with a child receiving physical therapy” . “Early studies showed that is was difficult to achieve this role based upon white middle-class families, and little attention was paid to social or ethnic differences. Additionally, enhancing parents’ involvement us based on the assumption that the parents can participate in formal processes and, when necessary, draw on the availability of due process of the law. Family-centered care processes are also central to the development of the individualized family service plan (IFSP), the required documentation for early intervention” .

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