Chapters Putting the Rehabilitation into Complex Rehab Technology THE INTEGRATION OF TARGETED THERAPY IN A DYNAMIC STANDING PROGRAM How normal motor control development and skill acquisition is dependent on practiced opportunities, stacking one skill on another. How Targeted Training Therapy accelerates the acquisition of motor skills for children with neurological impairments, in an upright posture. How the home treatment program utilizes a dynamic standing device to accomplish the treatment goals. Therapy can not end when the child leaves the clinic or school! Yvonne Smith, MPT The home needs to be a major part of the treatment setting The home is the new medical center Intravenous Treatment Advanced Hospice Care Home Monitoring Home Dialysis Telemedicine To name a few Community-based Care Transitions Program Home therapy programs for neurologically impaired children are limited The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings to the Medicare program. Limited, or no, treatment hours paid for by insurance or Medicaid Written ROM and exercise instructions for parents 1
Standing and gait programs, one of the few exceptions Consistent, early home standing programs have proven results Holistic Benefits of Standing Systematic Review and Evidence-Based Clinical Recommendations for Dosing of Pediatric Supported Standing Programs Skeletal Muscular Respiratory Gastrointestinal Urological Integumentary Neurological Ginny S. Paleg, PT, MPT, DScPT; Beth A. Smith, PT, DPT, PhD; Leslie B. Glickman, PT, PhD Pediatr Phys Ther 2013;25:232 247) Standing programs 5 days per week positively affect bone mineral density (60 to90min/d); hip stability (60 min/d in 30 to 60 of total bilateral hip abduction); range of motion of hip, knee, and ankle (45 to 60 min/d); and spasticity (30 to 45 min/d). Standing can also foster gross motor improvement The acquisition of motor skill through normal development Especially needed for children confined to wheel mobility 2
1. Reflexive movement phase 2. Rudimentary movement phase 3. Fundamental movement phase 4. Specialized movement phase Practiced opportunities provide a feed forward system where the acquisition of one skill provides a foundation for acquiring additional skills. One Month Turns head from cheek to cheek when on tummy Lifts head (bobbing) when held in vertical at shoulder Lifts head momentarily when on tummy Four Months Six Months Rolls from back to side Holds head steady and erect in supported position (head control is completed) Sits alone 5-10 seconds while placing hands forward on surface to support self Catches self forward by extending arms forward and opening hands in sitting when losing balance Nine Months Sits steadily and unsupported for more than1 minute Catches self to side by extending arm to side with open hand in sitting when losing balance Stands while holding on to furniture with wide base of support Twelve Months Stands alone 3-5 seconds Walks with 1 hand held 4 steps Walks along furniture (cruising) 3
Fifteen Months Able to change direction while walking without losing balance Stands alone well What is Targeted Therapy? THE STEADY ADVANCEMENT OF MOTOR SKILLS FOR CHILDREN WITH NEUROLOGI CAL CHALLENG ES Definition of Postural control Postural control Closed and open chains SIMPLE STANDER - TARGETED TRAINER Postural control involves controlling the body s position in space for the dual purposes of stability and orientation Anne Shumway-Cook: Motor Control Theory and Practical Application. Philadelphia, Lippincott Williams & Wilkins. 2nd edition, 2001 Postural stability Often referred to as balance Ability to control the center of mass (COM) in relation to the base of support (BOS) Postural orientation The ability to maintain an appropriate relationship between the body segments, (alignment) and between the body and the environment in relation to the task For most functional tasks we maintain a vertical orientation of the body using multiple sensory references (vestibular, proprioceptive, joint receptors and visual senses) 4
Effect of task and environment on postural control All tasks have an orientation and stability component Some tasks weight orientation more than stability blocking a goal in football Others weight stability greater - sumo Important elements in postural control To be able to create symmetry in the body To have the ability to transfer weight in all directions and be able to return to starting point To be able to have the ability to stay upright against gravity To be able to have the ability to move without using too much effort How can we define who has and who does not have postural control? An Open Chain? What is a Chain? A COLLECTION OF RIGID SEGMENTS THAT ARE CONNECTED BY JOINTS Control is required at all joints to maintain or produce a desired geometry or shape A Three-Segment Closed Chain a rigid structure The advantages of using closed chains for a child with CP No movement possible No control required Human structure -bones (rigid segments) -joints muscles (crossing the joints and producing movement) Simplified control requirements Stability without the need for motor control allows focus on gaze Makes fine motor skills possible Makes symmetry easier to achieve Makes muscle work more economic 5
Who here has postural control in sitting? Some Examples WHAT MUSCLE ACTIVITY IS PRESENT? WHAT CONTROL STRATEGIES ARE USED? Complete knowledge about presence or absence of control cannot be made without testing and evidence? Functional Goals Complex structure that requires a high level of neuromuscular control to achieve functional goals in the normal way If neuromuscular control is reduced neuromotor disability can functional goals still be achieved A B C D E..in the way that the physical therapist/orthotist/seating specialist wants? Simplifying postural control open and closed chains Closed chains reduce the need for postural control The options for developing active postural control are limited head and arms only Open chains Open chains require total neuromuscular control Most everyday activities require a combination of open and closed chains 6
Sitting Balance Sitting Balance? A combination of Closed and Open Chains The spine/trunk will be under full active neuromuscular control provided that joints are not at end of range A combination of Closed and Open Chains A further Closed Chain has been introduced Only the cervical spine is unquestionably under active control 37 38 A way of giving postural control and symmetry Does Use Of Closed Chains Matter? Can lead to compensatory tightness e.g. hip flexors, Achilles tendons and, long term, joint strain (in many conditions including cerebral palsy) Apparent functional skills, using Closed Chains, may not be true skills with active control that can be further developed but Closed chains can be a valuable therapy option if used at the therapist s discretion How many children do you know who. sit with one or both hands resting on knee or on a support? cannot maintain an upright trunk posture without supportive seating or a harness / breastplate? can sit hands free but show thoracic and / or lumbar collapse? These postures may be from choice but you need to ensure it is not lack of any alternative due to poor control 7
One way to test postural control Segmental Assessment of Trunk Control (SATCo) The SATCo test (Segmental Assessment of Trunk Control) The SATCo test originated at: } Trunk Segment Tested Head } Upper Thoracic } Mid Thoracic } Lower Thoracic } Upper Lumbar } Lower Lumbar Anatomical landmark between trunk segments Shoulders Axillae Inferior Scapula Lower Ribs Below Ribs Brim of Pelvis Dr. Penny Butler Mr. Richard Major Sufficient segments are supported to enable effective stability of the top-most supported segment. No support is required when testing Full Trunk Control Test requirements 10-15 minutes to conduct the test 2-3 testers / assistants Video recording of the test is recommended Bench with strap system is recommended From: Butler, P. B., Saavedra, S., Sofranac, M., Jarvis, S. E., & Woollacott, M. H. 2010, "Refinement, reliability, and validity of the segmental assessment of trunk control", Pediatr Phys Ther, vol. 22, no. 3, pp. 246-257. Segmental Assessment of Trunk Control (SATCo) Child is seated on a bench, trunk visible Strap system for thigh and pelvic alignment Feet on floor or a stool Manual support is provided for upright posture Hands and arms free Head is upright Segmental Assessment of Trunk Control (SATCo) Each level of static, active and reactive control is tested from head control through lower lumbar control and free sitting ability Testing three aspects of upper thoracic control in an 8 year old with Cerebral Palsy 1. STATIC Align and maintain 5 seconds 2. ACTIVE Hold alignment while turning head or reaching 3. REACTIVE Maintain or quickly return to upright when perturbed 8
Compensatory Strategies Hand support Compensatory Strategies Trunk alignment Sandy Saavedra and Marjorie Woollacott Motor Control Laboratory, Department of Human Physiology, University of Oregon, USA Using the SATCo test, they looked at the Typically Developing Infants and Children with Cerebral Palsy Typically developing infant SATCo Child with cerebral palsy SATCo SEGMENTAL ASSESSMENT OF TRUNK CONTROL (SATCo) 8 years old mixed spastic quadriplegia Hands free floor sitting Head control 1 Static Active Reactive Upper thoracic Mid thoracic Lower thoracic Upper lumbar Lower lumbar Full spinal control 2 3 4 5 6 7 1 2 3 4 Four test sessions over six months 9
What is TARGETED TRAINING? A means of gaining sequential control of the upright posture Features are: Optimal vertical position Support at the required level Challenge to active and reactive control Means of progression Adequate input over time to allow movement learning Looking at normal gross motor development The newborn baby is not having control of body and head at all Carrying the baby around both body and head is supported Kept in a vertical position the baby soon learn to control the head and the parents hands will move down to the neck Normal gross motor development start from the top of the head and moves down, from one segment to the other How is targeted training implemented? The result of the SATCo test tells the level of control Firm equipment- support is then offered directly beneath this point the targeted joint Progression by lowering the topmost point of support Upper Thoracic and Head Control Mid thoracic control 10
Upper lumber control Lower lumber control Targeting equipment Stabilise body below targeted joint Reduce the information overload of too many joints by offering support Hands free of support during TT Promote active and reactive control Means of progression Equipment provides a carefully controlled active therapy supervised by non-professionals FUN! Functional goals At the start of therapy, goals agreed by negotiation with the family, the child (if able) and the physiotherapist Complements pre-existing physiotherapy programme Fully integrated therapy input But Targeted Training does not require practice of the goal TT provides the control building blocks Targeted Training in use The specialised Targeted Training equipment is set up in The Movement Centre by a trained Targeted Training therapist It goes home with the family for use at school or at home on a daily basis (usually 30 min/day 5-6 days /week) The child is reviewed at eight weekly intervals and the equipment adjusted by the Targeted Training trained therapist as required at each assessment A totally supported SAFE child may not learn. 11
The Rocker The Rocker makes it possible to move just a little forward/backwards What posture is ideal for learning trunk control..and so what do we need from the equipment? Sitting and standing Opening up the hip angle in the seating posture will keep up the lumber curve When moving from standing to upright sitting 60 of the movement comes from flexion of the hips and 30 from flattening of the lumbar curve From Mandal 1981 We want to retain the lumbar curve but in a sitting posture Targeted Trainer seated model TT had used a seated posture for trunk control targeting (upper thoracic to upper lumbar) Minimise moments at the spinal joints inherent balanced posture Ideal for motor learning where control is poor and muscles are weak The seat is at a fixed angle of 18 Simple stander / Targeted Trainer In standing: Low or high support With or without the Rocker Transfer: The child walk in the frame The child can be lifted into the frame 12
Targeted Trainer seated In knee - sitting: With low or high trunk support With knee support at the front and if needed at the sides The new proto type in a seating and standing version Transfer: The child can be lifted on to the seat Knees supported on the knee cushion Hip belt mounted Front and sides mounted Where do we go from here? Delivery of Targeted Trainer end of 2015, early 16 Establish PDAC Verification Coding Penny Butler, PhD FCSP founder of the Movement Centre speaking at the APTA Conference, June 8-11 National trained in Targeted Training Therapy 13