The Role of Physical Therapists in the NICU

With new advances in technology and research, and an increased focus on individualized care, survival for neonates has become more of a norm rather than an anomaly. There were 10,877 premature infant participants in a neonatal mortality study from 2013 to 2018, ranging from those born at 22 weeks to 28 weeks gestational age. It was found that 78.3% survived to discharge.¹
 
While there are numerous factors and various members of the health care team that contribute to the continually improving statistics, there is one that is often not well understood—the role of the physical therapist in the neonatal intensive care unit (NICU) setting. This article aims to shed insight into the roles and responsibilities of a neonatal physical therapist, as well as briefly highlight wound care and the use of manual lymphatic drainage in the NICU setting.
 
Any infant born pre-term, which is defined as less than 37 weeks of gestation, is at risk for a multitude of developmental difficulties that may be cognitive, neuromotor, or social/emotional in nature.² Neonatal physical therapists are knowledgeable in the developmental outcomes of neonates who are at risk.³ There are increased developmental risks for those born at low or very low birth weight, or born at earlier gestational ages. With these come increased risks of medical conditions such as respiratory distress syndrome, intraventricular hemorrhage, retinopathy of prematurity, periventricular leukomalacia, hypoxic ischemic encephalopathy, hyperbilirubinemia, necrotizing enterocolitis, and a number of other conditions. There is a high association with grade 3 and 4 intraventricular hemorrhages and cerebral palsy.⁴ Neonatal physical therapists provide care while in the NICU and are able to then guide families towards future clinicians and resources if appropriate as diagnoses like cerebral palsy are lifelong.

What Does a Physical Therapist Do in the NICU?

The roles and responsibilities of the physical therapist in neonatal physical therapy are vast but can include: examining neonates and interpreting the findings, developing and implementing a plan of care to prevent neurobehavioral disorganization and other complications that are a result of prematurity, designing interventions and discharge plans, collaborating with all members of the health care team and family.³ Evidence-based practice is utilized in plans and interventions, with a focus placed on minimizing and managing potential risks while providing the best care. Neonatal physical therapists are responsible for nurturing brain growth and development.²
 
There are many interventions that neonatal physical therapists can provide when appropriate. These are dependent on the infant’s medical stability, age, and readiness. Some examples of therapeutic interventions are: positioning, self-calming strategies, passive range of motion, joint compression, encouraging parent-infant bonding (kangaroo care), activities to encourage lower extremity flexion and then flexion of the upper extremities, and education.² Positioning and other interventions are key for facilitating midline and compensating for decreased flexor tone in those who are lacking the physiologic flexion seen in full-term infants. Neonatal physical therapists are also assessing for plagiocephaly and torticollis, making referrals and educating on these matters. There is a constant flow of communication between physical therapists and the other members of the NICU multidisciplinary care team.
 
In the NICU, physical therapy is scheduled around the feeding schedule in order to aid infants in achieving a calm and awake state prior to feeding. This involves self-regulation interventions—hands to mouth being a great example—that allow the infant to calm and achieve that. Difficulties self-regulating like increased work of breathing and trouble interacting with caregivers are associated with less optimal neurodevelopment.²
 
With feeding, it is important to note the emergence of the suck, swallow, breathe reflex which becomes a coordinated reflex between 32–36 weeks gestational age. It may first be seen between 28–29 weeks. There is a high risk of aspiration without this, impacting social participation, familial bonding, and oral feeding.²
 
As previously mentioned, kangaroo care is an intervention with both immediate and long-term results. It is a method of holding an infant that involves skin-to-skin contact. Skin is the largest organ and positive touch goes a long way. Immediate effects include improvements in autonomic stability—respiratory rate, oxygenation, and temperature. Long-term effects are decreased mortality, decreased risk of sepsis, decreased hospital readmissions, and lower pain scores.⁵
 
Neonates’ ability to experience pain is fully present. A prospective study in 2003 concluded that pain is prolonged and more intense in newborns, especially for those born prematurely.⁶ Afferent pathways, which carry pain impulses from peripheral nerve endings, are fully developed by 24–26 weeks, while efferent pathways that help control pain are not fully developed until 36–40 weeks. Minimizing pain can be achieved by providing containment with hands during painful experiences, swaddling, allowing hands to mouth, and sucking. Repeated exposure to painful stimuli can negatively affect behavioral and neurodevelopmental outcomes.⁶
 
The NICU is an incredibly different environment from the womb. Infants are going from a place with limited visual input, muted sounds, boundaries, no gravity, and with natural thermoregulation to a place that is bright, loud, has no boundaries, has gravity, and, for those less than 28 or 29 weeks, thermoregulation is done mechanically as they are unable to thermoregulate themselves. Methods to make this transition less stressful include dimming the lights, lowering voices, providing the physical boundaries that they need via positioning pillows and supporting their posture and movement.
 
The performance and development of neonates are affected by multiple systems and environmental factors, calling for the use of the dynamic systems model by the neonatal physical therapist. This model takes into account the multiple elements of an infant’s biological makeup, family and physical environments, and the task or goal at hand.⁷ None of these components is independent of the other. Any component has the potential to facilitate or restrict an infant’s ability to develop postural control, achieve movement, self-regulate, or interact. Physical therapists utilize this model when working with an infant to help facilitate motor tasks such as hand to mouth.
 
Two dynamic systems models highlighted by the Academy of Pediatric Physical Therapy as principles to guide physical therapy practice in the NICU are the synactive theory of development and the theory of neuronal group selection.³ The synactive theory of development involves an observation of the responses of the neonate to the challenges of life outside the womb with a focus on achieving physiologic stability. Infant communication is not always obvious. Neonatal physical therapists are able to observe an infant’s communication or stress through the autonomic system (sneezes, hiccups, oxygen saturation), the musculoskeletal and neurologic systems (posture, tone), attention and orientation, and through their self-regulation of the previously stated systems.⁷ This is how the PT can assess their responses and tolerance to items such as positional changes, self-regulation techniques, stimuli, and so much more. Infants who may be at high risk can demonstrate behaviors such as sleeping during feeding, not locating sound, or losing stability when not swaddled.
 
The theory of neuronal group selection takes into account the storage of information, creation of new behavioral patterns, and neural plasticity. The state of the infant’s body and the environment are affecting the brain during intrauterine and extrauterine development. Neonatal PTs assist in nurturing brain growth by introducing different environmental experiences.⁷
 
Every brain and infant is unique therefore physical therapists utilize the International Classification of Functioning, Disability and Health (ICF) when assessing an infant in order to look at them as a whole, rather than their health condition. The ICF takes into account body functions and structures, activities, participation, environmental factors, personal factors, and contextual factors.

How Wound Care Works in the NICU

Infants in the NICU are not immune to skin injury. They are actually at an increased risk of it due to the intensive, life-saving treatments they are receiving and their developmental immaturity.⁸ With impaired thermoregulation, neonates are at a higher risk for epidermal stripping and infection, and these issues can be further compromised by edema. Adhesive dressings or tapes have the potential to cause skin stripping, which can result in full-thickness tissue loss. It is not until 36 weeks that the neonate’s skin is similar to that of an adult, with thicker epidermal and dermal layers.⁹ Epidermal stripping can be minimized by using liquid skin barriers and clear films, pad splints and straps rather than tape, and soft silicone dressings.¹⁰ Diaper dermatitis and thermal injuries are also common neonate wound types that may be encountered and can be managed by knowledgeable clinicians.
 
One important area that should not be overlooked is the delicate tissues of the nares and nasal septum. Non-invasive ventilation can result in nasal injury due to the already compromised skin integrity. This can look like blanchable erythema, non-blanching hyperemia, skin erosion to excoriation, columellar necrosis, or full-thickness skin loss.¹¹ Lower gestational age, lower birth weight, and incorrect sizing of the non-invasive ventilation systems place neonates at further risk of skin breakdown. Proper wound care in the NICU is critical.

Manual Lymphatic Drainage in the NICU

Is there a use for manual lymphatic drainage in the NICU? The answer is yes. Edema is common in premature infants, particularly when the urinary and circulatory systems have not yet fully developed. Infants also have a high water content and fluids are routinely administered in the NICU.¹² Integrating manual lymphatic drainage or manual edema mobilization is important for optimal neuromotor development and outcomes in infants with edema. Primary congenital lymphedema can also be present at birth or diagnosed at a very early age.¹³

In Conclusion

Neonatal physical therapy is a growing field, contributing to the continuously improving outcomes of the tiniest patients and their brain development while they’re in the NICU and beyond. As experts in movement, neonatal physical therapists have the ability to directly impact musculoskeletal development and neuromotor control through a variety of individualized interventions, and provide education and support to families.
 
Hannah Aviles, SPT, is enrolled in the University of Central Arkansas Doctor of Physical Therapy Program.

References
 
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