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RAISING THE BAR IN PEDIATRIC THERAPY

Photos
Adaptations and Therapy Ideas

e mail Barbara

bkhballpt@gmail.com

The Upsee Harness

This harness invented by a mother of a child diagnosed with Cerebral Palsy can be used to help a child experience assisted stepping with the help of an adult.

Further down this page the suggestion to use dog leashes to assist with progressing a child's foot during stepping activities. In therapy the leash may be sufficient to allow for work with stepping. The Upsee looks like an excellent suggestion to promote home carryover for stepping exercise.

These creative solutions to difficult challenges are always a great find for interventionists and families who work to help physically challenged children progress in their motor skill development.

For more information visit:

www.fireflyfriends

 

The Mimo Baby Monitor

The Mimo baby monitor lets you see the things that you actually care about and are already checking.
Our new respiration sensors are the softest and most comfortable sensors around. They let you check that your baby is breathing, no matter what they're doing.
With our temperature sensor, you can know that you've got your baby dressed properly, and that the A/C is working.
The body suit records the motion of your baby so that you can tell how active they are.
With our medically backed sleep algorithms, know when your baby falls asleep, and how well they're sleeping.
Our organic cotton baby Kimono is tested by babies and approved by mothers.

It would be wonderful if babies could safely experience deep, organizing sleep.

For more informaiton visit:

www.mimobaby

 

Tortle by Dr. Jane

Repositions baby to prevent flat head syndrome. Tortle is a simple, comfortable beanie that helps prevent and treat early stages flat head syndrome: plagiocephaly & torticollis. It makes the job of repositioning newborns safe and easy.

For more informaiton visit:

www.tortle

LegWeights

The LegWeight is ideal for profiding proprioceptive input (weight/compression), for individuals who experience diminished sensory feedback. It can help increase kinesthtic awareness during gross motor activities. Designed to allow for maximum flexibility and mobility of the lower leg, it can also be used for various gross motor and strengthening activities.

For more informaiton visit:

www.especialneeds

Brielle and Kyrie Jackson

Kyrie and Brielle Jackson were born on October 17, 1995, a full 12 weeks ahead of their due date. The standard practice, that time, at The Medical Center of Central Massachusetts in Worcester, where the twins came into the world, was to place them in separate incubators in order to reduce the risk of infection. Both babies were placed in separate incubators, a standard practice to reduce the risk of cross-infection. Kyrie, who weighed 2lbs 3 oz, was making good progress and gaining weight, but her tiny sister had breathing and heart-rate problems, there was little weight gain and her oxygen level was low.

On November 12, tiny Brielle went into critical condition. Her stick-thin arms and legs turned bluish-gray as she gasped for air. Her heart rate soared. The Jackson parents watched, terrified that their little daughter might die.

It is said that desperate moments call for desperate measures. Nurse Gayle Kasparian, after exhausting all the conventional remedies, decided to try a procedure that was common in parts of Europe but virtually unknown in the United States. With parental permission, she placed the twins in the same bed. No sooner had she closed the incubator door, Brielle snuggled up to Kyrie and began to calm down. Within minutes, her blood-oxygen readings improved. As she dozed, Kyrie wrapped her left arm around her smaller sister. Brielle's heart rate stabilized and her temperature rose to normal.

In due time, the twins went home. Their parents placed them, once again, in the same bed where they continued to thrive. Even after five years, according to mom and dad, the twins still slept together and, not surprisingly, still snuggled.

The photograph of Kyrie hugging her little sister, dubbed the "Rescuing Hug," appeared in both Life magazine and Reader's Digest. It brought fame to the pair and spurred a growing interest in co-bedding premature twins, triplets, and quads. The University of Massachusetts Memorial, for example, has co-bedded at least 100 sets of multiple birth preemies. Observing this practice over a period of five years, the hospital staff there has not found a single case of twin-to-twin infection. In addition, clinical studies have shown that premature twins enjoy substantial benefits when they are placed in the same bed together. One researcher, Mary Whalen, reports the following benefits:

    Decreased number of apnea problems
Improved blood-oxygen levels
  Increased weight gain
Better feeding
Greater temperature regulation
Decreased agitation
Decreased length of hospital stays and likelihood of re-admission

Little Kyrie's hug encircles every one of us, reminding us in the most gentle of manners that we are called to participate through love in the lives of all our neighbors.

This is an amazing story.... The thing that takes it to another level for me is that the nurse placed the newborns in prone. YEA!! The nurse honored the need for the girls to experience body on body self calming in order to set the foundation for self regulation and calming to occur.


SureStep Orthotics

This is the first orthotic I learned about that was specifially designed for the hypotonic foot. In my experience the low tone child expresses a greater awareness of his/her base while wearing the SureStep orthotics and at times he/she will complain that when they are removed it feels as though the feet are missing.

"The SureStep SMO's have had a huge influence on the way I approach the foot and ankle in our pediatric patients with stance phase issues. Though we have had great successes in our own methodology of controlling foot and ankle alignments without pressure, the SureSteps havecreated a functional response at terminal stance that we never thought we could get in a lower profile orthosis."
- Testimonial from the website.

Dynamic - Response - Ankle-Foot Orthosis

This innovative new AFO reportedly not only assists with heel strike but also creates a lengthening to the heel cords with each step. Finally a dynamic brace that keeps the heel well seated and allows the calf muscles to continue working during walking.

This design is for the high tone or spastic ankle/foot.



The Power of Advertising?

If advertisements influence our perceptions of normal, then what do these ads conclude?

1. In an advertisement as big as day displayed in the window at a major bank in the middle of Manhatten we see that neck asymmetries in babies are so prevalent in our society that twins both have strong tilts.

2. In an ad from Skymall Magazine we can see that toe walking is so ordinary now that children can be provided playroom equipment that allows them to practice standing on toes.

3. Seen in a magazine this image of a child pushing a button on a bubbler in order to provide water to the dog screams poor alignment and apparent weakness. Secondary to back to sleep positioning many children present with thoraco-lumbar hyper-mobility and shoulder girdle weakness. It is now so common that many typical development assessments have changed the expectations and values for "normal". Shockingly it is now "normal" control for a child to have the type of joint instability and proximal weakness depicted.

4. Yet another example of the prevalence of scapular winging and shoulder girdle instability is evident in a diaper ad where children are presented walking through a downtown in diapers. How is this type of proximal instability going to affect overall posture, strength, physical skills and alignment as these children age?

5. THANK YOU to another diaper commercial that actually shows a father holding his baby in prone while the child naps. If only more people would attend to this image and realize children can successfully sleep in prone and stay safe.

6. Finally, an ad from Pediatric PT shows us that when a child is fit with orthotics to prevent him from locking his knees or standing on his toes, it is fine if the orthotics create a crouch standing posture instead. The fact that hamstrings and hip flexors will get tight needs to be considered. This position also leads to greater collapse in the low back, weakness due to disuse and poor alignment in the abdominals and through the shouders.

S.E.R.F. Strap (Stability thru External Rotation of the Femur)

Although I have never tried this equipment, it appears to be a nice solution to use for children that struggle to stay out of strong hip internal rotation during standing and stepping.

www.djortho.com

Therapy and Cardboard Boxes

My great nephew Jackson and his friend show how a sturdy box can be used as a tool to help a child sit. Low tone children may benefit from having the exo-skeleton of end ranges surrounding them so that they can safely stay in sitting and even free their arms to interact with toys.

I will also have children stand in a cardboard box when I want to limit their abilities to stagger step as a strategy for staying upright. Keep in mind that while they develop control other than staggering children may need close supervision to safely stand in a box.

Dynamic Movement Orthotics Limited

DM Orthotics is a soft surgical goods manufacturer based in the United Kingdom.

The company combines tradition and experience with state of the art computer assisted design and technology in the manufacture of bespoke goods.

Our range includes the world renowned Dynamic Movement Orhosis (DMO) used extensively in the treatment of neuromuscular conditions to improve sensory feedback and biomechanical alignment.

Dynamic Movement Orthotics Ltd understand the need for, and is committed to providing, relevant research on the DMO.

Check them out at http://dmorthotics.co.uk/

Mia's Apps - Technology for Tots

The website includes a short video showing the use of it. After watching the video I e-mailed the company to ask for clarification on how the little girl's eye movements were being detected (with the father sitting behind her). Martin, the dad, quickly responded ans was delightful.

Check them out at http://www.miasapps.com/icomm.html

SAFO

At a course in West Virginia a participant asked my opinion regarding SAFO's. I had to admit I had never heard of the product. They are Silicone AFO's that support the foot reportedly without restricting joint mobility. Although I have never used these products I wanted to present the information because Dorset Orthopaedic is a company that is creating ground breaking technology for individuals with mobility deficits.

Check them out at www.dorset-ortho.com

Silicone Ankle Foot Orthotics

Images of the SAFO Go; SAFO One; and SAFO Walk.

Check them out at www.dorset-ortho.com

Table as a Ramp

At the West Virginia course a parent allowed her child to participate as a child who received treatment by the instructor. His mother was kind enough to send images she recorded on her cell phone. This image is presented as a reminder that therapists must be creative. In a room with almost no toys or equipment this child was challenged to use his motor system by working on an incline. He worked in standing both up hill and down. He was also tipped into the wall to create vertical prone and at the end he sat on the high end of the table with his legs hanging over while he completed a task of putting toys away. Simply by setting up the environmnet to manipulate his base of support this child was challenged to recruit greater motor organization.
Plunger Poles

Cheryl Gaudette attended a course and shared one of her ideas as a birth-3 clinician. She has children use 1 or 2 plungers when they could benefit from poles for balance in standing and when learning how to step or walk.

Taylorbar
The "Tummy Time" Prone Positioner


Grandparents invented the Taylorbar to assist their granddaughter. The Taylorbar is a prone positioning device that gently and comfortably keeps a child in the prone position to facilitate valuable "tummy time", while allowing her the freedom to move about on her tummy unimpeded.

www.taylorbar.com


Moon Sandals: Features of the moon sandals include:

-they widen the base of support to improve stability
-they allow increased anterior/posterior and lateral control in standing
-they promote more knee flexion during stepping inhibiting a locked  knee pattern of swing through
-they promote foot flat standing and walking allowing the ankle to develop greater co-activation
-they inhibit toe standing and toe walking
-they help strengthen anterior tibialis musculature by requiring foot flat stance and greater knee flexion for ankle dorsi-flexion during swing
-they can be manufactured to fit a variety of size shoes
-the tread helps it to be a non skid sandal that can be worn on most surfaces
-they are easy to apply under a regular shoe allowing the wearer to continue using existing orthotics

Shoe Board: The Standing board features include:


-it stabilizes the feet for standing to allow balance reactions to develop in the trunk, hips, and knees
-it stabilizes the feet yet allows work in squat and from squat to stand in the hips, knees, and ankles

-it stabilizes the feet yet allows work in rotation where the trunk and shoulders rotate off the stable feet

-it stabilizes the feet yet allows the head to move into different planes        during play such as reaching and looking between the legs, reaching and looking over the head, reaching and looking behind and to the sides

-it stabilizes the feet in a range that is shoulder width to inhibit a wide or narrow base of support

-it frees the therapists hands away from the patient's legs or feet to be able to present objects or assist in other areas.

Graphite Inserts
Wedge Shoes

Working with an orthotist, graphite inserts and wedge shoes can be used to inhibit toe walking. The rigid insert prevents the shoe from breaking at the ball of the foot preventing the child from moving onto toes.

All shoes afford some roll off at the front to allow normal walking. Children who toe walk and/or children who walk with a crouch pattern through his/her knees and hips cannot roll forward onto the toes of the shoes to allow a crouch walking pattern when an orthotist uses shoe sole material to fill in the roll off space.

TheraTogs from Progressive Gaitways

TheraTogs™ are a revolutionary orthotic undergarment and strapping system that gives clients with sensorimotor impairment an exciting new modality for improving postural alignment and stability, movement skill and precision, and joint stability.

TheraTogs™ are designed and developed by Beverly Cusick, PT, MS.
Progressive GaitWays, LLC
www.theratogs.com

Neoprene Compression Garments

These can provide increased body awareness and sensory feedback. Neoprene wraps can be purchased in the weight lifting section of stores such as Wal-mart, K-mart, Target.

A neoprene wrap was cut and sewn to create the dorsiflexion assist shown.

The neoprene can be wrapped around the trunk to increase stability and promote greater dynamic alignment proximally.

The wrap can be cut and fabricated into a wrap to help a child hold a bike or trike handle, a bat or paddle or a walking assist device.

NuStim Wraps

Fabrifoam material with stretch and compression. This moderate elasticity-knitted blend material has a multi-directional stretch. These wraps function well as an alternative to neoprene wraps and are made of a breathable material.

www.rehabmart.com

This product is also available from other providers if you are motivated to shop around for the best deals.

Benik

Pre-fabricated and custom garments can be obtained through BENIK 1-800-442-8910

www.benik.com

SPIO

Stabilizing Pressure Input Orthosis. These flexible garments provide compression to assist with stability and proprioceptive deficits.

www.spioworks.com

Hip Helpers

These were invented by a therapist to help low tone children keep their hips in more ideal alignment in order to activate the proximal control they need to get trunk and hips to work together.

They are available through:
Hip Helpers Inc.
1332 Holly Point Rd.
Virginia Beach, VA 23454
1-757-481-2407

www.hiphelpers.com

Add-A-Bands

Produced by an OT with safety and functional control as the goals. Add-A-Bands are an assistive device designed to facilitate the development of normal movement patterns in children with low muscle tone and/or lax hip ligaments. The latter may contribute to excessive flexibility making it difficult to develop an adequate base of support from which to attain a good position to move. Consequently, a child may have difficulty moving with ease and efficiency, and undesirable habits may develop such as moving from sitting to lying through the middle of wide split legs. When properly adjusted, Add-A-Bands facilitate the optimal base of support at the knees and/or feet of a child when the spacing of his or her legs is excessively wide. Combinations of movements at the hip joints are then permitted without restriction other than limiting excessive widening.

Add-A-Bands can also be used as a positioning assist to limit excessive widening of the legs with children experiencing muscle weakness or paralysis from nerve damage.

www.wiltse@add-a-bands.com

 

i2i Head Support

The i2i head support desiged by Leslie Fitzsimmons is designed to 1) Improve eye contact which promotes socialization 2) Improve ease of feeding 3) Improve saliva management and decrease drooling 4) Decrease caregiver time spent re-positioning 5) Improve ability to communicate and interpret responses.
As a head support system, this product truly brings vertical alignment into a new potential.

It is available through:
Stealth Products

www.stealthproducts.com

Nada Chair

NADA Chair
244 Larpenteur Ave. W.
St. Paul, MN  55113
1-800-722-2587
1-612-644-4466
www.nadachair.com

This child is not able to keep her pelvis vertical when floor sitting. Using the NADA chair she can successfully and safely sit. As she stays in floor sitting she eventually is able to recruit her spinal extension allowing her to use her arms to interact with the toys. Note that a neoprene wrap is added at the knees to keep the straps of the NADA chair from slipping.

 

Cube Chairs

Using the cube chair along with knee extension splints and the nada chair a child can be positioned to stretch hamstrings and heel cords. This home carryover can prevent ROM deficits with growth and even gain functional range of motion.

www.sensoryedge.com

Trampoline system

Children can learn to use the proprioceptive and vestibular input of jumping to help them modulate and organize. This can also be used for strengthening and building cardio-vascular endurance.

www.sensoryedge.com

Knee Immobilizers

The immobilizers shown in this photo are from dj Orthopedics, LLC
t. 1-800-321-9549
www.djortho.com

This child felt safe enough to stand independently knowing that his legs could not collapse. He was also able to reach and move his head using his vision dynamically when he was confident that his legs would stay stable.

Elbow Immobilizers

The same type of immobilizers can be used at the elbows and this strategy is strongly recommended. Note how the child shown is using his elbow flexion and humeral extension to stay upright. When elbow immobilizers were added, his trunk co-activation immediately improved along with his overall hip and trunk alignment. Since he couldn't use his arms to counterbalance his forward lean, he improved his alignment.
The second child increased his active hip and knee extension when wearing the elbow splints rather than pulling his body up in a chin up type pulling pattern. His head continues to stay forward because he is has not integrated this more upright posture.

Dog Leashes

Simple dog leashes are used to help propel objects without having to bend over and to promote stepping getting the foot to move in front of the shoulders. This has been an excellent tool to preserve the alignment and stress to the therapist or parent.

In the first picture a child that is unable to walk independently is able to walk with the assist of the leashes attached to his shoe strings. He keeps his body in better vertical alignment when he is given mobile assist that he can't pull against.
When the straps are kept tighter the person assisting can also help the feet align out of his preferred internal rotation. This is a great tool for helping the child transition into improved walking independence.

The same type of leash is used to pull a trike or walker to help a child practice moving their legs in rhythmical repetitive active assisted experiences.

Having someone walk in front of the child to control the leashes, step length and speed of stepping can be facilitated.

In the last picture the child has no assist behind so the therapist is careful not to promote a step length than would cause him to tumble backwards. He has significant gravitational insecurity and avoids vertical alignment from fear of falling back which is why he is flexed forward in his hips, trunk and head. Increasing the step length allows him to assume greater vertical alignment and use better motor patterns. Using the leashes allows him to move at his own pace to process the new alignment without triggering fear.

Vertical Prone

I call this position vertical prone. We can work children and adults of all ages in prone without having them on their stomach on the floor or on a ball. Those are great activities for people that can do it, but many individuals can't function in prone and become even less active.

In vertical prone the child is caused to lean into a surface. The therapist can then shift from side to side and load the arms and legs.

This position creates the need for co-activation in the entire body. In both of these pictures the child is also standing on a ball so the input and challenge through the ankles recruits greater strengthening and activation of the foot into the surface.

Suspended Trapeze

When a child holds a trapeze the shoulder girdle and head stay lifted and the natural progress creates knee and hip extension. The child that is unstable working in standing is often willing to work in standing as long as they get to hold something. Giving them a suspended trapeze allows them to feel safe but does not promote their typical pulling through their arms and hanging in their trunk.

In the second picture we see a child with athetoid motor control who has difficulty holding the trapeze so her mother provides assist. The child is practicing moving her leg in a specific task. She is unable to do this specific leg movement without activating an extension thrust. Using the suspended trapeze allows her to pull some but feel that the thrust is actually knocking her over. As mother allows the bar to move in greater ranges the child is required to control her vertical alignment to avoid falling.

Vibration

Vibration can be used to increase awareness and dampen aversive responses to input and as a sensory input to help define the child's body. The vibrators can be held to increase input to a deprived area, or to de-sensitize an over-sensitive area. Amazingly the vibrators can work in many ways.
The child can stand on a vibrator (bare foot or with shoes and orthotics) to increase the awareness of their base of support.

Brookstone Vibrators:  Order online at www.brookstone.com or 1-877-463-3580
Sku# 280321 Pinpoint Massager $15.00.


Massager Vibration

Z-Vibe

Abilitations Products Magazine at www.abilitations.com
or 1-800-845-1535

Climbing / Swinging

Motivation is everything so create ways to allow children to do activities that lead to range of motion, joint mobility, trunk stability, sustained grasp, balance...

Help them achieve the difficult work of stretching, strengthening and balancing during their play.

Chewy Tubes and P & Q's

Abilitations Products Magazine at www.abilitations.com
or 1-800-845-1535

Upholstery Foam

A flexible foam that can be purchased at fabric stores can be cut using an electric carving knife. It can also be glued using a spray glue that is available at the craft or fabric store.

The foam can be used to make a customized seat as shown in the first picture. This child was using a strong knee flexion pattern when she would sit on the floor so this seat was constructed to hold the legs in better alignment.

The second picture shows how the foam can be cut to fit inside an existing chair to contour the chair for the child. This simple additional contour allowed the child to stop sliding laterally and falling over the side of the chair. It also stopped the forward sliding of the pelvis.

The foam can be cut to contour support in strollers, swings, high chairs, car seats and many other positioning devices for children.

Bumbo Chair

The Bumbo Seat places the baby's bottom at a lower level than the leg openings. This seating position provides excellent support for the lumbar area of the vertebral column. It also prevents your baby from getting out of the Bumbo.

The Bumbo is lightweight (3 pounds) so it can easily go to grandma's house or anywhere you travel.

The Bumbo is soft and comfortable for your baby.

www.bumboshop.com

"Summer" Infant Super Seat

It is designed like the Bumbo seat but has an inside seat liner which can be removed to allow larger children to use while still providing time to develop better head and upper trunk control. It has a seat belt, as well as a belt to attach to a chair for a booster seat at the table if needed. It comes with a tray with a few toys, which can rotate to spaces on the tray for food and drink.

FYI: I see EI clients and they have approved the Bumbo seat in the past; so I decided to add this on the IFSP for an infant with Downs syndrome and a Brain trauma child. I submitted a letter of medical need, the predetermined IFSP goal, a photo of the seat found on a "medical website", and one was recently approved. I'm real excited as most of my clients have limited funds and now they can have a seat. Thought you might like to see it and maybe add it to your website? It is available at Walmart and BabiesRUs sites too.

Submitted by: Debra Walters P.T.

Electrical Stimulation

Strengthening is the most important thing that can be done in therapy to help a spastic muscle become more functional. The spastic muscle is a weak muscle that needs to be strong throughout it's full range.

In this picture the child that is a toe walker is working to strengthen her plantar flexion muscles while working them in dorsiflexion ranges.

3 Wheeled to 2 Wheeled Bike

Winner of the 9th International Bicycle Design Competition in Taiwan spring 2005.

Go slowly , and the back wheels splay out like a tricycle for balance. Ride faster, and they pull in to form a single wheel. Designers Scott Shim, Ryan Lightbody and Matt Grossman.

This product is currently not available to my knowledge but shows ideas for the future.

The LIttle Tikes 3-in-1 Tricycle

This tricycle has been a nice recommendation for a few families as it comes with a high back support, chest harness and seat belt (or if not you can contact Little tyke and they'll send one), and push handle for parents. I have been able to get EI to approve pedal attachments for the feet and these trikes have worked for even some of the more involved toddlers.

The only problems with the newer trikes is the fact that toddlers can just leave their feet on the pedals and be pushed without pedaling. I have a father who figured out how to remove the front wheel cover and someplace he drills a hole to add a screw so the pedals always pedal when the kids are pushed and they work like I want to teach them how to pedal.

Submitted by: Debra Walters P.T.

Hatchbacks Elites- Footwear

At last. Function & style in an AFO compatible shoe!
The patented "easy fit hinge" system allows ease of entry, and have been custom molded to fit around a brace. This means that most children will be able to wear their normal shoe size.

www.HatchbacksFootwear.com
1-800-726-5432

Standing on a Wedge or Ramp

Dorsiflexors should be strongest when they are activated with the foot in plantarflexion and plantarflexors should be strongest when they are activated with the ankle in dorsiflexion. If you want to strengthen plantarflexors to work in their lengthened range have a child stand on a ramp or wedge leaning up the hill. Have them stand facing down the hill to strengthen the dorsiflexors. This is an easy way to help a child who has available range recruit the pattern of using ankle control with hip and knee extension. It also helps the child that collapses into a crouch give up the forward shoulders because they feel like they are falling if they collapse in the head and shoulders. For children who can't follow directions, standing them on the ramp facing up or down hill causes them to recruit a new pattern of alignment to stay upright.

Crutches and Crutch Tips

This company understands how to design these devices for users of all ages. They are accessible and user friendly as well as fit for the pediatric arm in diameter and length.

The crutch tips are anti-slip and oversized for greater stability.

www.fetterman-crutches.com
1-888-582-5544

KidsterDani®

This all in one device allows a child to use one base to have a
seating as well as a standing mobility device.

DavisMade and Gunnell have combined their products to make this multi-functional product. The Gunnell Seating system can be customized for the child. The prone standing support has proven success in supporting standing and mobility.

The systems can be manual or electric.

www.standingdani.com

DOC Band

Research supported orthotic device to treat positional plagiocephaly

www.cranialtech.com

 

BARBARA HYPES P.T.

RESOURCES AND INTERVENTION STRATEGIES