Transcript Upright Posture: Success for Young Children with Physical

Up; New Success for Young Children with Physical
Disabilities and/or Multiple Challenges
Gayle Wiens, PT, Assistive Technology Specialist
Copyright 2014
Questions or
Comments?
ADAPT ShopA Program of Southwest Human
Development
Who can access ADAPT Shop?
• Arizona Children with DDD or DDD and
Long Term Care
• Maricopa County-initial home visit
• Families from other counties in Arizona
are seen at ADAPT Shop
• Families contact their DDD SC to request
ADAPT Shop Services
• Contact Tina Martin, Senior Program
Manager for Assistive Technology 602633-8686 with new referrals or for
appointments.
Assistive Technology
For early SUCCESS!
ADAPT Shop helps with
Assistive Technology:
• Sitting supports and custom adaptations
• Help with beginning play and beginning to use hands.
Also, switches when needed
• Beginning communication strategies for complex children
• Trials with various powered mobility; Go Baby Go, Our
Multiple Switch Scooter, Power or Power Assist W\C
• Help identifying appropriate iPad apps
• Help identifying helpful medical equipment, including
standing and moving for very weak children, and
recommendations for orthotics that might be helpful
ADAPT Shop Model
Search for unrealized
potential
Look for the child’s
strengths
Discover the child’s
interests to build
meaningful activities
Find out what is
meaningful to each
child and their family
and use it to plan
your intervention.
Ideas for Finding Meaningful Tasks
Use things any child would like:
• Increased participation in play with someone they love/like e.g.
using Step by Step to direct the play and make comments. At school,
kids want to play with other kids. At home, play with family members.
• Going outside This is a big one! Position them near an open door.
• Being in charge of the activity e.g. using an iPad app that is
interactive and that they do themselves. Telling other people what
to do.
• Making choices among things they usually don’t have access to
e.g. things from the kitchen for pretend cooking, choice of their
brother’s Hot Wheels cars, choices of family members, clothing and
accessories to try on and look in the mirror. This is GREAT for
vocabulary development and FUN.
• Anything mega fun! These kids are putting out a huge amount of effort
so activities need to be extra fun to be worth it! e.g. squirting your
brother with a switch operated water squirter, yelling out (on device)
DANCE PARTY and kids start dancing, turning the music on and off for
the Dance Party.
ADAPT intervention often starts
with custom seating
Flailing, constant movement Child
only tolerated sitting anywhere for
5 min max; wheelchair, Child Life,
therapy chairs so 95% day laying
on floor.
5 minutes later in his new chair,
Notice the visual focus on iPad
What’s a Happy Chair?
I like it!
A Happy Chair is a custom
designed and constructed chair
made of foam and plastic.
Some look similar
Some look quite different
Blocks illustration for sitting AND
Standing
Simulating
pelvic tilt in
sitting
or unstable,
pronated
foot in
standing
The Solutions:
• The custom contour seat stabilizes the
bottom block (pelvis) for sitting and the
back of the chair helps them to align their
spine. Then, they can balance their head
on top. You know you have achieved
alignment when you see intermittent chin
tucks.
• Similarly, Cascade Orthotics stabilize foot
(bottom block) for standing.
What happens in the commercial
chairs we use ?
• Unless the chair includes support directly at the sacrum, a ramp
that lifts the femur at the end of the knee that holds the legs in
line with the hips, and lateral leg support to keep them aligned
with the hips, the child’s bottom slides forward. You see this all
the time, when someone “pulls up” the child in his chair it is
because the bottom slid forward.
• The only thing I know that really works for this problem is the
custom contoured seat.
• Commercial contour seating often fails to provide support at the
sacrum, and sometimes fails to keep the legs aligned with the
hips. The ramp that is needed near the knee gets broken down
with use and sometimes slopes down instead of up.
350 Happy Chairs later…..
I’ve learned that normal alignment
leads to normal development.
Sitting but poor functioning,
pelvis unstable so many
compensations.
Seating for Prevention!
• Begin supported sitting at 5 months. Gets them off
their head! Less torticollis and plagiocephaly.
• Can provide positioning before 5 months if needed.
NICU grads and infants are welcome if there is a
need. (must have DDD)
• Good supportive seating can prevent the
development of scoliosis. If a child is hanging to
the same side, tilting the head to the same side,
let’s intervene before the problem occurs!
• Bumbos are not the answer for kids with significant
muscle tone differences.
Infant with Down Syndrome age
4 months. See kyphosis already
3 months later- child sitting alone,
pelvis stable with sacrum at 90,
kyphosis completely resolved.
Why not just use commercial
equipment?
• Young children with significant neuromotor
delays aren’t very successful with commercial
equipment, which is designed to fit an age or
size RANGE and strap the child in so they don’t
fall out.
• We want more than just safety, we want
normal alignment (for comfort and health) and
for the child to be able to function.
• The more severe the physical challenge, the
more perfect the chair has to fit for the child to
be able to function.
Seating to make functioning possible
ADAPT Shop is about
……increasing quality of life for children
and their families.
Unstable pelvis, couldn’t
stay in umbrella stroller,
takes 2 hands to hold in
sit. Constant movement.
3 months later; sitting to play, vision
better
Who
needs a
Happy
Chair?
Kids with high tone
Kids with low tone
Kids with poor pelvic
stability or
fluctuating tone
Children laying on the floor or
tilted back in wheelchairs. They
need seating too!
But they have nice tilt in space
wheelchairs….
• The Lazy Boy effect;
How well do you pay
attention when fully
supported and leaned
back?
• Tilt in space is good for the bus or a nap!
I’ve learned that almost all children want
to be upright after about 6-8 months old.
Upright doesn’t just mean sitting!
• As the children started to get stronger from sitting
in their Happy Chairs, I noticed that the contour
seat held them in the correct position to stand if
their trunk was moved forward (nose over toes).
• I talked to the children first and asked them if
they wanted to stand up. Boy, did they!
• The look on their face is priceless! They are so
proud and happy! I’m so sorry I don’t have photos
of this facial expression because my hands are
busy helping them stand. Remember when your
young child did something for the first time? That
look of joy is unmistakable.
Standing for kids in
wheelchairs
All by myself!
Standing, even if
your
hands don’t know
what to do yet.
Helping with Standing-Orthotics
For low toned
feet
1st
AFO’s
for
standing
2nd
articulated
AFO for
stepping
For children
with
increased tone
or moderate to
severe
physical
challenge
Kids like standing
Standing is exciting
Standing?? Our therapist says
they aren’t ready for standing yet.
• Yep! Children that roll in the door, tilted back in
their wheelchairs, head falling off the headrest,
yes, those children.
• But, they don’t even have good head control!
Standing with good support makes it easier to hold
your head, not more difficult.
• More than 80% of the children that I use the stand
up bar with, pull to stand the first time we try it.
• Almost all the children enjoy standing in the
KidWalk and the majority take some steps.
• My first goal for them is standing for transfers but if
a child keeps progressing, we help them keep
moving!
What is standing good for?
Benefits from using the stand up bar include:
• Significantly improved core strength in neck and trunk
• Grip begins to happen and they are more successful with
toys
• Longitudinal arch of the hand starts to develop
• Shoulders relax and muscles elongate, improving
functional reaching
• Attention span increases because if they space off, they
start to fall.
• New visual perspective on their environment leads to
better use of visual skills
Kids like
moving
too!
• This is the
KidWalk, it works nicely
for children that need a
lot of support. It is unique
among gait trainers
because it allows the hips
and seat to move to the
side to unweight a foot for
stepping and allows a little
movement up and down to
prevent locking of knees and
to reduce spasticity. It holds
them in good alignment and I
see less sitting. I use it as
a dynamic stander (child can stand
and play in it) and as well as
a gait trainer. Children
find it very comfortable and
like being able to move and
experimenting while feeling safe.
Child’s posture before
Child’s posture after
Standing but not Standers
• The standing we do is DYNAMIC. It involves moving and
using their own power to stand or move.
• The skill I want to teach with standing is weight shift to one
side so they can pick up a foot to take a step. This means
moving and asymmetry.
• Standers lock kids into standing symmetry and the straps
do all the work below the chest. They couldn’t move a leg
if they wanted to. This teaches kids that they can lock their
body or collapse but not how to shift weight and step.
• Standers are appropriate for children with paralysis, for
most other children, there are better options.
Mommy and Me
The Purpose
of Happy
Chairs:
Getting
Stronger
Increasing
Function
Better Quality
of Life
Red Rocket Scooter-up to 4
directional switches
Purpose of use of Red Rocket
• 1) Give movement experiences to children that
have not had success with moving in an upright
posture
• Allow the children to learn by making mistakes,
as all children learn as they begin to move. E.g.
crawling children bang their head repeatedly on
a coffee table before they finally learn to duck.
• Move at a slow enough speed that they can
work on visually processing WHILE they are
moving.
Purpose of Red Rocket cont.
• Help the child visually and cognitively begin to anticipate
obstacles and use problem solving skills to figure out how
to avoid them.
• Allow the child to begin to explore their environment and
all the sensory motor experiences that come with it.
• Increasingly, speech therapists and assistive technology
specialists tell us movement comes before
communication. As the child moves themselves,
communication is stimulated. They have something to talk
about!
• As the child is able to move themselves, steer themselves
and solve problems, others begin to see the child’s true
abilities and potential.
• Humans are more likely to talk to someone who is moving.
Social Scripts for Young Children
by
Dr. Caroline Musselwhite
• Our first workshop by Dr. Caroline Musselwhite
was a huge success! We are encouraging families
to use a Step by Step with Levels to help their child
interact with their siblings, friends and families. I
often share Caroline’s handout about how to make
a social script with a child that can be recorded
onto the Step by Step and used by the child for
interaction. Remember-the child MUST choose the
messages or else it will not be their voice and their
self expression. Sometimes I help them create a
first script about something meaningful to the child
such as a script to interact with a sibling when they
arrive home from school.
Switch toys, Other Resources
• We have a limited number of switches and
battery interrupters available for ADAPT
Shop clients.
• Various other beginning level aug comm.
options are also available for ADAPT Shop
clients.
• We can help families find appropriate iPad
apps to use with their child
• Sometimes we arrange for trial equipment
when it is particularly needed. We believe in,
“try before you buy” as much as possible.
Referrals? 602-633-8686 Tina
Martin, Senior Manager for AT
Under 3 years old:
• Team needs to determine that the child has a need
that the team feels they cannot meet without
outside resources.
• Child needs a relevant goal on the IFSP. For
example, child will sit and play with support or
explore possible switches for active play with toys
or explore some beginning aug comm activities.
• Service Coordinator gives us permission to
proceed
• Simple, one page referral form
• We try to schedule to visit with one or more team
members
Referrals- 3+
• Service Coordinator adds 12 hours of
PT for the ADAPT consultations. This is
IN ADDITION to any ongoing therapy
and will not interfere with ongoing
therapy.
• Same simple, one page referral form
• We try to schedule to include the child’s
ongoing therapist whenever possible.
Questions?