case presentation- sebastian · case presentation- sebastian . sebastian is a 10 year old in 4th...

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CASE PRESENTATION- SEBASTIAN Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP Spastic diplegia-GMFCS IV He can propel and maneuver manual wheelchair around school Transfers in and out of his wheelchair mostly independently Needs means to transition to classroom, lunch room, gym Wants to participate in physical education class with typically developing peers Can walk using walker short distances, but is in plantarflexion and knees and hips are flexed with extreme hamstring tightness (even with AFOs he does not get feet plantigrade and is up on toes with knee flex) IEP GOALS 1. Sebastian will improve his independence by getting into his wheelchair 1 time a day for at least 3 consecutive days in a 9-week collection period 2. With supervision only, Sebastian will improve his independence by using an assistive device to walk 60-100’ within the school setting for 3 out of 5 days in a 9-week period 3. Sebastian will roll in mobile stander independently from classroom to physical education so he is able to participate in activities 3/5 days List equipment options on the right to support goals.

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Page 1: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

CASE PRESENTATION- SEBASTIAN

Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP

• Spastic diplegia-GMFCS IV

• He can propel and maneuver manual wheelchair around school

• Transfers in and out of his wheelchair mostly

independently

• Needs means to transition to classroom, lunch room, gym

• Wants to participate in physical education class with typically developing peers

• Can walk using walker short distances, but is in plantarflexion and knees and hips are flexed with extreme hamstring tightness (even with AFOs he does not get feet plantigrade and is up on toes with knee flex)

IEP GOALS 1. Sebastian will improve his independence

by getting into his wheelchair 1 time a day for at least 3 consecutive days in a 9-week collection period

2. With supervision only, Sebastian will improve his independence by using an assistive device to walk 60-100’ within the school setting for 3 out of 5 days in a 9-week period

3. Sebastian will roll in mobile stander independently from classroom to physical education so he is able to participate in activities 3/5 days

List equipment options on the right to support goals.

Page 2: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Sebastian DOB Insurance ID#

NEWTON COUNTY SCHOOL SYSTEMPhysical Therapy Department

Palmer Stone School 1110 North Emory St.

Oxford, GA 30054 (770) 788-5383

Fax 678-625-6304

LETTER OF MEDICAL NECESSITY

Student Name: Sebastian DOB: Age: 8 yrs. Insurance #: Physician: Last Office Visit Diagnosis: spastic diplegic cerebral palsy, unspecified type Height: 47” Weight: 48#

Equipment Requested: Size 2 R82 Rabbit mobile stander, with attachments Reason for request:

1. Sebastian has cerebral palsy and is unable to stand and walk by himself. He needsthis stander to help him to elongate legs to prevent orthopedic contractures, as wellas the other benefits listed later in this letter, and to be able to have a form ofindependent mobility around his home in addition to the wheelchair as being indifferent positions has different benefits.

2. He is using a loaner Rabbit stander that he has outgrown, and it is missing parts sothat it no longer fits him adequately.

Current equipment: Ti-Lite manual non-tilting wheelchair (13”) with Power Assist; wears AFOs; we tried KAFOs as well, but he didn’t wear; loaner Rabbit stander as mentioned above Time period stander will be needed: permanently may need a stander; this stander should be able to be used for 3-5 years depending on growth

Team Members providing input: • Mother• Teachers• Physical Therpist: Lynda Reagan• Assistive Technology Professional: David Hayes ATP, Numotion• Manufacturer representative: Malachi Slice, ATP, Etac - US

Date of this letter: 12/7/2018 Brief Medical, Developmental, and Social History: born prematurely and has spastic diplegia but otherwise is fairly healthy. Sebastian underwent rhizotomy surgery 3/25/2017 and did go through inpatient and outpatient rehab 2017-2018 at Children’s Healthcare of Atlanta, then locally.

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Page 3: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Sebastian DOB Insurance ID#

General Information: School: goes to South Salem Elementary School, Newton County Therapy Services: 1x /week, 30 min., through school Primary language spoken in the home: English Vision/Hearing: within functional limits Pain: no complaints of pain Communication/Cognition: verbal; in regular education with special education services as resource Tone: moderate hypertonia in legs; underlying low tone in trunk but appears increased because of “fixing” and stabilizing; some carryover of tone in upper extremities Head control: good Trunk control: fair; can sit independently UE PROM: within normal limits for all LE PROM: moderate tightness in heel cords and hamstrings so that he does have decrease in PROM of legs Manual Wheelchair propulsion: independent with both arms, but slow and often pushes with one arm more than the other Posture: Pelvis: posterior tilt; very kyphotic; pelvis scoots forward in his wheelchair Respiratory: within functional limits Skin Integrity: intact Sensation: generally intact Accessibility: house is accessible Gross Motor/Functional Abilities:

• Sebastian is a student at South Salem Elementary who has been receiving physical therapy services through the school system for 30 minutes once a week to work on transfers, walking with walker short distances, elongation of muscles to improve gait and standing posture, and positioning in stander.

• Sebastian underwent a Dorsal Rhizotomy surgery at Children Health Care of Atlanta (CHOA) 3/25/2017. He had intensive outpatient and inpatient rehab services following surgery. He has done fairly well since surgery but still has a lot of spasticity in his legs, has tight hamstrings, and keeps hips and knees in flexion and wants to stand on toes.

• Sebastian uses a manual wheelchair as his main means of locomotion. He can propel himself and has progressed with speed and independence and endurance. He still is sometimes slow, depending on where he is going and if he wants to go there and how cooperative he is being.

• Sebastian wears bilateral AFO's (ankle foot orthosis) throughout his school day. Sebastian can get out of his wheelchair with verbal cues. He will crawl on his hands and knees but not reciprocally to get to where he wants to go.

• He can pull up onto his walker if it is steadied for him to pull up onto and then turn around with contact guard. He then is able to walk in the hallways with supervision to occasional contact guard to help with steering or getting his position back for 25’. He is usually up on his toes and his legs will cross at times, however, less than they did prior to the surgery. He can get back down to the floor if walker is held steady with minimal assist, however he tends to want to just bend his knees and drop to the floor going forward instead of turning around and then lowering down.

• He will pull to stand up onto his wheelchair independently, but he needs minimal to moderate assist to lift his foot up onto the foot plate to then be able to place his knee

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Page 4: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Sebastian DOB Insurance ID#

onto the seat and rotate to sitting in his chair. He requires minimal assist beyond lifting his foot and then knee up to then follow through with the transition.

• Sebastian uses a borrowed stander (from the school) at home to allow for stretching of his legs. He is less stiff and activities even though they continue to be slow and labored, they appear to be less labored. Sebastian is easily distracted, and his cooperation is not always good which contributes to him being slower than he can be on most occasions. He has gotten to where he does not need constant coaxing and bribing to encourage him to follow through with an activity asked of him, and instead he will try to cooperate more.

• He is very motivated to be with his peers (for example to play in PE). He does better if his peers are around and him trying to participate as they are. He often will try to do things he thinks he needs to do versus following adult’s instruction.

Equipment Trials: He used a Rabbit stander when in inpatient Rehab at CHOA in 2017, then has been borrowing a Rabbit stander for the last 1 ½ years and it worked for him, but he has outgrown the loaner stander. Additionally, it is missing essential accessories for positioning. He also has used a Rabbit mobile stander at school successfully. We tried a Rifton prone stander. This was not successful as it was not mobile, he did not like being in it, and he was not positioned adequately. We trialed an EasyStand sit-to-stand stander. Even though it did have the capability of being mobile and it did help to elongate his legs, it took up much more room and student and school staff did not like using it as much as the Rabbit stander. Clinical Summary: Sebastian presents with delays in his gross motor skills. He cannot stand or walk alone (needs assistive device of a walker to walk; only has 75’ duration so is not a functional ambulator). He needs a Rabbit stander as he is borrowing one and he has outgrown it, and it has missing parts. Sebastian can self-propel his wheelchair for short distances. He needs a Rabbit stander for these benefits: to allow his legs to lengthen and to prevent further contractures of LEs so that he can continue to get in his wheelchair and sit comfortably, as well as ambulate

• to be in a different position so that he does not develop pressure sores; skin integrity; pressure relief

• improve hip integrity and “hip health” • increase bone mineral density • tone reduction • improve cardiopulmonary function • improve psychological well being • aid bowel/bladder function as he tends to be constipated • improve functional capabilities and physical activity

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Page 5: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Sebastian DOB Insurance ID#

Recommended equipment: Rabbit Stander, Size 2 with these components:

• Back support: to position back an pelvis in neutral alignment • Chest support: to position trunk upright • Hip support: to position hips in neutral alignment and maintain hips and pelvis in

correct position • Flip up footplate: to position feet optimally; also to enable footplates to be moved

out of the way and allow him to place feet on ground to transfer into wheelchair • Knee Support: to position knees in alignment due to tightness • Foot support straps: to position his feet as he tends to have spasms and pull feet out

of proper position • Play box: for surface/compartment to hold educational materials; also to provide

surface for his arms to push against for erect posture (to decrease kyphoscoliosis posture).

Goals:

1. Improve postural alignment-the recommended standing system will provide the support needed to stand in good postural alignment and stability during the day.

2. Maximize pressure relief – the recommended stander will provide good shock absorption, pressure relief and skin protection.

3. Accommodate range of motion limitations (tight hamstrings) –the recommended standing system is designed to accommodate

4. Increase comfort and standing tolerance – the recommended standing system will improve comfort therefore tolerance for standing.

5. Meet caregivers’ goals – the recommended system will achieve family’s goal of having a standing system to use for functional activities at home.

6. Promote/improve independent mobility- the recommended stander, with its lightweight and physical properties, will allow proper wheel placement and independence in self propulsion of the stander to get around the house.

Plan: The recommended stander and attachments will be delivered to the patient’s house and checked by this therapist and medical equipment provider, to ensure proper fit and to ensure that the equipment is delivered as prescribed. Please see to this child’s needs and approve funding for this stander and the attachments above. If he does not receive this stander, he could regress in physical/gross motor function, and develop further contractures that necessitate extensive orthopedic surgery. Sebastian may lose the ability to stand, bear weight through his lower extremities and independently propel himself for functional mobility in home and school. I am writing this letter as his school therapist. Sebastian does not have a private therapist because his insurance does not pay and there is not a private therapist in this area. This letter of medical necessity is written about his need for a stander at home, not at school, and does not in any way reflect that the school needs to purchase one for home. His use of a stander at home is a “medical model” issue, not a school issue, so insurance should be contacted and would be the source of payment for this item at home. The school will have a stander available for him to use at school.

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Page 6: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Sebastian DOB Insurance ID#

I CERTIFY THAT THIS CUSOM EQUIPMENT IS MEDICALLY NECESSARY. Physical Therapist Name: Therapist Signature: Lynda Reagan, PT Date: License Number: Expiration Date: Physician Name: Signature: Date: License Number: Rehab Technology Supplier Name Signature: Date: Number: Expiration Date:

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Page 7: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

NAME: Sebastian TEACHER _______________________________ DATE _______________________________

M T W TH F M T W TH F M T W TH F M T W TH F

Mobile Stander

Walker

Activity Chair

Sitting

Page 8: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Sebastian 2020 Gross/Fine Motor Plan

Time Activity Participation Environmental Support7:30 Morning Work Individual until bell Ti-Lite manual w/c7:45 School Start/

AnnouncementsHomeroom with peers w/c

7:50-8:20 Enrichment/Intervention

Work Centers On floor (prop sitting or R82 Scallop), sitting on bench

8:20-9:50 Reading lessons(small group lessons, mini lessons on carpet)Writing lesons(handwriting or Ipad)

Work Centersrotating through work centers and interacting with teachers, parapros and peers in different groups

w/cWombat Living (high-low to table or floor)Independent prop sitting or R82 Scallop

9:50-10:00 Transition to bathroom with parapro supervision Potty Seat and rails on toilet until progress without

10:00-10:30 Math lessons Work Centers w/c to adapted desk orR82 Wombat Living on high/low base

10:30-10:45 Transition (Walking with walker to the stander)

with parapro supervision Kaye WalkerR82 Rabbit

10:45-11:30 Specials Music, PE Computer, Art

Interaction with peers and teacher

R82 Rabbit

11:30-11:40 Transition (stander to wheelchair)

Bathroom R82 Rabbit w/c

11:40-12:10 Lunch Lunchroom w/c12:10-12:25 Transition to bathroom with parapro supervision Potty Seat and Rails on toilet until progress

without12:25-1:45 Social studies/Science lessons Work Centers w/c

R82 Wombat Living1:45-2:00 Wheel to gym/

Prepare for dismissalDismissal/After School Participation with Peers

w/c

Page 9: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

CASE PRESENTATION- TRENTON

Trenton is 5 years old

• Born premature: Spastic quadriplegia CP (GMFCS V) • Trenton cannot roll, sit, stand or walk by himself • Dependent for all ADLs, transfers and mobility • Spasticity throughout extremities; hypotonic trunk;

strong adductor spasticity and scissoring when standing

• Tightness developing in hip flexors, hamstrings and heel cords

• Sits with posterior pelvic tilt and kyphosis • Likes to interact with kids and adults • Loves to stand with assistance and in stander he tries

to use arms to bat at toys but cannot activate toys or switches very often

• Does try to play games such as vocalizing back if you make vocal noises to him

• Very curious and would love to try to propel gait trainer • Has rigid frame tilt-in-space wheelchair that is difficult

to get into family vehicle

IEP GOALS 1. Trenton will initiate and take 10-20

steps in a gait trainer when walking in his classroom from one center/activity to another to participate with classmates

2. Trenton will be positioned in 3-4 positions throughout the day 5 days/week as he participates in classroom activities (stander, adapted chair, wheelchair, mat on floor, bean bag, sitting with support)

3. Trenton will stand in stander for 60 min/day for 3-5 days a week to participate in learning activities and active board lessons.

List equipment options on the right to support goals.

Page 10: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Trenton DOB: Medicaid#:

Step In Time Therapy, LLC Lynda Reagan, P.T.

190 Bostwick Rd. Oxford, Ga. 30054

Phone: 770-823-7301; Fax: 770-784-1893

LETTER OF MEDICAL NECESSITY/EVALUATION

Patient Name: Trenton DOB: Age: 2 yrs. 6 mos. Physician: Medicaid#: Last Office Visit: Diagnosis: spastic quadriplegia cerebral palsy (G80.0) Date: 05/26/2017

History: do not have medical history or records

Description of Equipment requested: R82 Gazelle Stander, Size 1, with attachments Reason for request: Trenton is using a borrowed stander with missing accessories and it does not fit properly. He falls off the side of it when he flexes laterally. The supports are too soft and flexible and do not position him adequately. He needs stander because he cannot stand and bear weight. Team Members providing input:

• Mother,• Physical Therapist: Lynda Reagan, PT• Assistive Technology Professional: David Hayes, ATP, Numotion• Manufacturer Representative: Curtis Philyaw, APT, CPST, Etac- US

General Information: Height: 38” Weight: 25 # Pain: no complaints of pain Equipment: Zippie Tilt-in-Space wheelchair is on order; using borrowed KidCart now; asking for a grant for Convaid Cruiser Accessibility: house is accessible Prognosis: permanently dependent for mobility. The stander requested is deemed medically necessary for the following time: permanently or until he outgrows Therapy Services: Speech/Feeding (Nancy Geiss), OT (Becky Lee) and PT (Lynda Reagan) weekly privately Language spoken at home: English Communication/Cognition: nonverbal; communicates by fussing and crying; difficult to tell what level child will be but is delayed with cognition Vision/Hearing: family is assuming it is intact Equipment: I let the family borrow a prone stander as I feel it is important for him to keep legs stretched out and for his body to keep a sustained standing position with weight bearing on feet and legs. The stander is too small for him now and he really needs a supine stander as he does not have good head control. I also let them borrow a bath chair and Tumbleform feeder seat as he needed some positioning devices to stimulate him and provide him multiple position changes throughout the day. Family also have a Bumbo and Seat 2 Go for sitting with someone needed to support his head since he cannot hold his head up.

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Page 11: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Trenton DOB: Medicaid#: Patient’s current level of function: Tone: hypertonic in upper and lower extremities; hypotonic in trunk Head control: poor Trunk control: poor; maximum assistance for sitting ADLs: totally dependent UE PROM and LE PROM: within normal limits for all except tight hip adductors, heel cords and hamstrings bilaterally; potential for increased tightness here and in arms as he keeps legs in scissoring position, yet sits in equipment a lot at home, and arms have flexor tone. UE Strength and LE Strength: very decreased strength and motor control for age; he appears to be strong, but it is just the extensor tone in upper and lower extremities. Respiratory: within functional limits (WFL) generally but decreased lung capacity Skin Integrity: intact Sensation: seems to have decreased sensation/be hyporesponsive Gross Motor:

• Trenton can focus on and track objects and faces; he smiles and laughs but cannot verbalize and I have not heard him vocalize.

• In supine (lying on back), he tends to keep legs in extension pattern with slight hip adduction and internal rotation with ankles plantarflexed. The ATNR reflex is still present so that dominates a lot what he is doing with his arms and head. He tends to keep arms in flexor patterns with hands fisted. He can roll head to each side to look at something; cannot flex forward

• In prone (lying on abdomen), he can lift head momentarily and rotate to either side but cannot weight bear well on forearms to hold head up for longer. If he is having a fairly good day, he can sometimes hold head up for 6-10 sec. He needs moderate to max. assist in prone to position forearms.

• Mom says sometime Trenton moves around and wiggles but does not roll any direction by self.

• When placed in sitting, he needs maximum assist to sit up on the floor or a bench or chair as he does not have trunk control. Head control is poor too as he tends to keep head extended (capital extension). Sometimes he flexes head forward but then lies head forward towards chest rather than being able to keep head in neutral. He can hold head in neutral just a few seconds.

• In supported standing, he needs maximum assist to hold the position and he keeps legs extended and ankles plantar flexed. He does have AFOs that fit well and do keep his ankles in a neutral position instead of plantarflexed and pronated. He has no step initiation.

• Trenton is observant and likes to play. He can do gross hitting/batting at movements with arms so that he can activate switch toys or noisy toys. He cannot grasp or use hands more purposefully. He does like to hold toys in middle with both hands if positioned just right.

• DP-3 standardized testing results 4/2017: Raw Score Standard Score Confidence Band descriptive % rank age equiv 1 less than 50 +/- 6 delayed .1% 2 mos.

Raw and standard score in the “delayed” category; age equivalent at 2 mos. old even though he is 2 years. 6 mos. old.

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Page 12: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Trenton DOB: Medicaid#: Equipment Trial: We have tried Rifton, Leckey, Jenx Monkey, and R82 Gazelle and R82 Caribou standers. The R82 Gazelle Stander was selected as the stander that met most of his needs. It enables him to be placed into stander and positioned by just one person. Trenton’s increased tone makes it difficult to place him into other standers. We determined that he does not have good enough head control to be in a prone stander at this time as his head flexes forward most of time due to poor head control. His positioning was good and his head was well supported in the Gazelle in the supine position or in the prone position with the head support. Clinical Summary: Trenton cannot stand alone and is non-ambulatory. He needs a stander to allow legs to elongate and to prevent further contractures of LEs which will enable him to continue to get into wheelchair or adaptive stoller, positioned correctly and comfortably, and allow weight bearing into hips. Proper positioning will deepen the acetabulum position in hip joint and prevent hip dislocations. This stander allows for hip abduction, which has been shown in studies in Sweden and Australia to significantly decrease hip dislocations in kids who cannot stand and walk alone (see references), which Trenton is at risk for getting. It will also keep him from developing pressure sores as he has decreased sensation. Recommended equipment: R82 Gazelle Supine Stander, Size 1, with these components:

• Mounting hardware, 36-9475– to be able to mount headrest • Turtle Bar System, short, 98619-25 – for mounting headrest to main frame • Anatomic head support, small, 5099001 – to hold the head posteriorly; poor head control • Head support with facial aperture, 88117-1-to support head as he does not have head

control (head flexes forward, shoulder protract • Trunk Support extension, size 1, 88106-1 – to allow for trunk length and to attach supports • Side/Trunk support pads,88075-1- to position trunk upright due to child flexing laterally • Strap for Side supports, 88250-1-to keep trunk aligned • Trunk Strap, 88200-1 – to hold trunk back and keep from laterally flexing • Knee support pads/straps, 88161-1– to position knees in place and decrease flexing • Foot support/88145-1- to secure positioning of feet in stander • Tray, 88108-0: for educational materials and to help allow child to be upright as child can

push up on tray to stand more erect and counter kyphotic posture that often develops. Goals:

1. Improve postural alignment. The recommended standing system will provide the support needed to stand in good postural alignment and stability throughout the day.

2. Maximize pressure relief. The recommended stander will provide pressure relief and skin protection.

3. Accommodate range of motion limitations (tight hamstrings) 4. Increase comfort and therefore standing tolerance. 5. Meet caregivers’ goals. The recommended system will achieve family’s goal of having a

comfortable standing system to use for functional activities at home. Plan: The recommended stander and attachments will be delivered to the patient’s house and checked by this therapist and medical equipment provider, to ensure proper fit and to ensure that the equipment is delivered as prescribed. Without the recommended stander which would provide opportunities for Trenton to bear weight through lower extremities, he is at risk for developing additional range of motion limitations and contractures as well as hip subluxation and/or dislocation. Additionally, without the opportunity to

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Page 13: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Trenton DOB: Medicaid#: be in supported standing program using the recommended equipment on a consistent basis, Trenton will not have the ability to participate in various functional activities and is at risk for not developing the skills needed to take steps for assisted walking/mobility. I CERTIFY THAT THIS CUSTOM EQUIPMENT IS MEDICALLY NECESSARY.

Physical Therapist Name: Therapist Signature: Lynda Reagan, PT Date: License Number: Expiration Date: Physician Name: Signature: Date: License Number: Rehab Technology Supplier Name Signature: Date: Number: Expiration Date:

Scientific References Supporting Standing/Hip Abduction for Hip Health

1. Hagglund G, Wagner P, Risto O, PerLarnert.(2014) Hip displacement in Relation to Age & Gross Motor Function in Children with Cerebral Palsy. J Child Orthop Mar;8(2):129-134

2. Martinsson C & Himmelmann K (2011) Effect of weight-bearing in abduction and extension on hip stability in children with cerebral palsy. Pediatric Physical Therapy; 23:150-157.

3. Macias-Merlo L, Bagur-Calafat C, Girabent-Farrés M & Stuberg W (2016) Effects of the

standing program with hip abduction on hip acetabular development in children with spastic diplegia cerebral palsy. Disability & Rehabilitation Journal 38(11) p1075-1081.

4. McLean, L, Magnuson, S, & Gasior, S. (2014) Positioning for Hip Health: A Clinical Resource,

Sunny Hill Health Centre for Children BC, Canada. Poster Presentation, The 30th International Seating Symposium. March 4 - 7, 2014, Vancouver Canada.

5. Miller et al. (2017) Prevention of hip displacement in children with cerebral palsy:a

systematic review. Developmental Medicine & Child Neurology 59: 1130–1139.

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Page 14: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Trenton DOB ____________ Medicaid#: _________________

Step In Time Therapy, LLC Lynda Reagan, P.T.

190 Bostwick Rd. Oxford, Ga. 30054

Phone: 770-823-7301; Fax: 770-784-1893

LETTER OF MEDICAL NECESSITY/EVALUATION

Patient Name: Trenton DOB: Age: 4 ½ years Medicaid#: Physician: Dr. __________, M.D. - Pediatrician Last Office Visit: 3/2019 Diagnosis: spastic quadriplegia cerebral palsy (G80.9); abnormal development; developmental delay (R62.50) Description of Equipment requested: R82 Mustang Gait Trainer with accessories Reason for request:

• We tried using the above gait trainer and he had the strength and initiation to independentlytake steps without needing the therapist to propel.

• He has a Gazelle stander that fits him well and he can stand in it but it does not allow him tomove and he really likes to move.

• He does not have access to borrow/loan a gait trainer on an ongoing basis and needs to beable to be standing and learning how to take steps; gait trainers we have access to are toosmall and did not suit his needs

• He needs gait trainer as child is unable to walk without an assistive device and assistance.• He needs more support than a walker can give.

Prognosis: dependent for mobility for years. The gait trainer requested is deemed medically necessary for the following time: permanently as long as he continues to fit into it (he may never have capability to use walker)

Team Members providing input: Mother Physical Therapist: Skye Camp, PT & Lynda Reagan Assistive Technology Professional: David Hayes, ATP, Numotion Manufacturer Representative: Gary Quellet, ATP, Etac -US

Date of evaluation: 3/27/2019

Medical History: do not have full medical history or records but he was born premature. He saw his orthopedist, Dr. Schaeffer, about 12 mos. ago. He felt that his hips were subluxing and that he may benefit from varus de-rotational osteotomy, but then the doctor said they would concentrate on hernia repair and testicular descension surgery and wait 6 months to decide on doing the major orthopedic surgery. Trenton goes back to the orthopedist this month. We really want him to have the gait trainer because weight bearing has shown to improve the seating of the hip in the socket, the density of bones, and helps to elongate muscles.

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Page 15: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Trenton DOB ____________ Medicaid#: _________________ General Information: Height: 42” Weight: 30# Pain: no complaints of pain Equipment the client has already: manual tilt-in-space wheelchair; adaptive stroller (Convaid Cruiser-received a grant- they use for convenience for short trips); R82 Gazelle stander; solid ankle AFOs; SWASH hip orthosis Accessibility (are ramps needed, etc.): house is accessible Type of family vehicle family: conversion van and a SUV Therapy Services provided: Lynda Reagan, PT – Step In Time Therapy; Skye Camp – PT with

Jasper County School System; Nancy Geiss- Speech Pathologist (sees at home); OT -Active Kids facility

Language spoken at home: English Communication/Cognition: he is nonverbal, but he communicates by fussing or crying; or being happy and smiling; does make vocal sounds but they are not intelligible Vision/Hearing: intact Patient’s current level of physical function: Muscle Tone: hypertonic in all extremities, but hypotonic in trunk Head control: poor as he extends his head back a lot Trunk control: none; child cannot sit up by self ADLs (Activities of daily living): dependent for bathing, dressing, hygiene, transfers/mobility UE PROM and LE PROM (passive range of motion): within normal limits for all except tight hamstrings bilaterally with potential for hip adductor and heel cord tightness because of spasticity UE Strength and LE Strength: very little active control; decreased motor control and very limited ability but can sometimes hit a switch or a toy with music Posture: kyphotic spine so sits with c-curve Respiratory: within functional limits (WFL), but does get sick easily Cardiac: within functional limits (WFL) Skin Integrity: intact; does have potential for pressure sores because of decreased activity level when sitting in wheelchair, so using a gait trainer will give pressure relief Sensation: within functional limits but did not do full sensory test Gross Motor:

• Trenton can focus on and track objects and faces; he smiles and laughs but cannot verbalize. He does try to vocalize, especially when I have a toy that repeats the noises he makes.

• In supine (lying on back), he tends to keep legs in extension pattern with slight hip adduction and internal rotation with ankles plantarflexed. The ATNR reflex is still present so that dominates a lot of what he is doing with his arms and head. He tends to keep arms in flexor patterns with hands fisted. He can roll head to each side to look at something; now does flex head forward a little to look at something.

• In prone (lying on abdomen) with support to hold his forearms in a good position for weight bearing or with him lying on wedge, he can lift head for 12-22 seconds and rotate to either side before fatiguing.

• Trenton wiggles but does not roll any direction by self. • When placed in sitting, he needs maximum assist to sit up on the floor or a bench or chair as

head and trunk control are poor and he tends to keep head extended (capital extension) or flexed forward and does not have mid-range control In sitting, he can hold up in semi-neutral for 8-12 seconds.

• He does have AFOs and they fit well and, in all positions, they do keep his ankles in a neutral position instead of plantarflexed and pronated.

Sample

Page 16: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Trenton DOB ____________ Medicaid#: _________________

• In supported standing, he needs maximum assist to hold the position and he keeps legs extended and hips slightly adducted. Without the AFOs on he would be plantarflexed at ankles, but with the AFOs, he stands with feet plantigrade. He has difficulty with dissociating his legs but now he has made improvement that he will initiate steps if I hold him at his trunk. He does get legs stuck on each other as he often is in too much adduction, but this is a huge improvement, and he does better when I count with him as he steps. I have tried several different types of gait trainers and he really likes being in them but cannot make it move on his own.

• Trenton is observant and likes to play. He can do gross hitting/batting at movements with arms so that he can activate switch toys or noisy toys. He cannot grasp or use hands very purposefully but does try. On a good day when a little more relaxed, he can sometimes open his hand (right moreso) and grab something, but then cannot release it voluntarily. He does like to hold toys in middle with both hands if positioned just right and toys right there.

• Trenton now has his own R82 Gazelle stander as I feel it is important for him to keep legs stretched out and for his body to keep a sustained standing position with weight bearing on feet and legs. He looks good in the stander, and now does not have to have someone right there next to him entertaining him as he is happy in it. Family has been instructed to use the stander for 45-60 min once a day. The Gazelle stander has a hip abduction component and studies in Sweden have shown that standing in the stander with hips in abduction decreases the potential for hips to dislocate.

• DP-3 standardized testing results 3/2/2019: Raw Score Standard Score Confidence Band descriptive % rank age equiv 1 less than 50 +/- 12 delayed .1% 2 mos. Standard score in the “delayed” category; age equivalent at 2 mos. old even though he is 4 years 6 mos. old.

Equipment Trial: We have tried these gait trainers: R82 Mustang gait trainer worked because he was able to initiate steps even his initial time, and he had the gait trainer moving after only being in it 5-10 minutes. The Rifton gait trainer did not work because it does not have the capability of having head support, it did not provide the trunk support in the way that helped give the stability he needed, he could not take independent steps, he could not propel the device by himself and instead needed moderate assistance. We also tried an old loaner Pony gait trainer but it was not the right size and he could not make it move or take steps, and it did not have the head or trunk support needed. I had a KidWalk to trial, but mom felt she wanted something more compact. I tried a Kaye posture control walker and know from trial and experience that the client does not have the ability to be able to use a regular walker and needs more positioning support. He is not able to hold onto handgrips and has no trunk, pelvic or hip control. Clinical Summary: Child cannot stand alone and is essentially non-ambulatory as child needs assistive device and assistance. Child needs a gait trainer to allow legs to elongate and to prevent further contractures of LEs so that child can continue to get in wheelchair and sit comfortably. Child will benefit from taking steps with assistance or independently therefore increasing his mobility and independence.

Sample

Page 17: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Trenton DOB ____________ Medicaid#: _________________ Recommended equipment: R82 Mustang Gait Trainer, Size 2, with these components:

• Head support – he has poor head control and extends his head most of time; he did well during the equipment trail with the Mustang with the head support on

• Turtle Bar System – a bar system to attach head support • Chest Support – circumferential support to keep trunk upright as child laterally flexes or

extends trunk; has no trunk control and needs full support to stabilize • Arm Support – he cannot hold onto any handgrips so he needs an arm support where his

forearms rest and can be strapped in, then he can push up on the arm support to stand up more straight

• Hip support on curved bar – helps keep hips and pelvis in position so that he can stand up and take independent steps

• Pelvic support- he needs circumferential pelvic support to keep his pelvis from shifting side to side as he does not have control of pelvis, trunk or hips.

• Seat – to support for his pelvis and buttocks, separate the hips, and provide resting surface • Leg Separator – Trenton has hip adductor spasticity which leads to extreme difficulty

dissociating/separating legs, so when he takes steps he scissors. The leg separator keeps him from scissoring and allows him to take independent steps

• Ankle Prompts – to provide guidance for correct walking pattern • Attendant guide bar – for safety; to be used to make sure that he does not crash into

anything by attendant being able to help steer it. He could propel the demo by himself but was not able to steer or guide it.

The Mustang was tried with each of these attachments on and off, and these were determined to be medically necessary in order for him to be able to use it.

Goals:

1. Improve postural alignment - the recommended gait trainer will provide the support and stability needed to stand in good postural alignment during walking.

2. Maximize pressure relief – the recommended gait trainer will provide pressure relief and skin protection as the child will have opportunity to be positioned outside of his wheelchair

3. Accommodate range of motion limitations –the recommended gait trainer will allow the child to stand and move even though the child has decreased range

4. Increase comfort and standing tolerance – the recommended system will help the child obtain an optimal position for gait, decrease energy expenditure and pain to maximize time in standing position for walking.

5. Meet caregivers’ goals – the recommended gait trainer will achieve family’s goal of having a piece of equipment that their child can use in the home for learning how to take steps thereby increasing his mobility, independence and participation in activities of daily living.

Plan: The recommended gait trainer and attachments will be delivered to the patient’s house or school and checked by this therapist and medical equipment provider, to ensure proper fit and to ensure that the equipment is delivered as prescribed. The family will be at the fitting so that they can be instructed in how to use the equipment and the frequency and duration on using the gait trainer at home.

Sample

Page 18: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Trenton DOB ____________ Medicaid#: _________________ I CERTIFY THAT THIS CUSTOM EQUIPMENT IS MEDICALLY NECESSARY.

Physical Therapist Name: Therapist Signature: Lynda Reagan, PT Date: License Number: Expiration Date: Physician Name: Signature: Date: License Number: Rehab Technology Supplier Name Signature: Date: Number: Expiration Date:

Sample

Page 19: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

NAME: Trenton TEACHER _______________________________ DATE _______________________________

M T W TH F M T W TH F M T W TH F M T W TH F

Stander

Gait Trainer

Activity Chair

Feeder Seat/Bean Bag

Sitting

Prone/Floor Time

Page 20: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Gross/Fine Motor Plan

Time Activity Participation Environmental Support7:30 Free Time Centers with peers Zippie Tilt-in-Space or Convaid Cruiser w/c

7:40-8:10 Prep/Breakfast Class/Lunchroom w/c or R82 Wombat or x:panda

8:10-8:25 Toileting Bathroom R82 Flamingo

8:25-9:00 Calendar time, weather, names, songs, hand motions

Floor sitting in circle with peers R82 Scallop or Bench sitting

9:00-9:30 Recess Outside or Sensory Room to transition/play

R82 Mustang gait trainer

9:30-9:40 Transition to Stand (Gait trainer to Stander)

Work Centers R82 Gazelle Stander (prone)

9:40-10:30 Literacy LessonsLetters, Phonics, Story, Activity

Classroom in standing R82 Gazelle Stander (prone)

10:30-10:40 Transition from Stand to W/C; wash hands/prep

Classroom w/c

10:40-11:10 Lunch/Feeding Classroom/Lunchroom w/c

11:10-11:20 Toileting or Walking Bathroom R82 Flamingo or gait trainer

11:20-11:45 Math Lessons Instruction with teacher/manipulatives R82 Wombat or x:panda

11:45-12:15 Specials-Art, Music, Computer, PE

Classroom or gym Gait Trainer or Adaptive Bike

12:15-12:30 Snack Sitting at table/with tray R82 x:panda

12:30-1:30 Nap on mats in classroom mat

1:30-1:35 Transition to Wheelchair classroom Zippie Tilt-in-Space or Convaid Cruiser W/C

1:35-1:50 Review of Day/Music Interaction with class Zippie Tilt-in-Space or Convaid Cruiser W/C

1:50-2:00 Prepare for Dismissal Transition to Bus Zippie Tilt-in-Space or Convaid Cruiser W/C

Page 21: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

CASE PRESENTATION- JAYLEN

Jaylen is an 8 year old boy with anopthalmia (born with no eyes) and cerebral palsy • GMCF IV • Fair trunk control and good head control • Sits on the floor by himself but does not try to do transitions like scooting,

pulling self onto chair, etc. • He just started performing sit to stand by himself, which is an improvement, yet

he is not safe as he cannot see and he has poor balance • Wears a helmet when not secured in equipment due to poor balance • He can use both arms for some activities. • In standing, he puts weight on lower extremities, but not fully, and flexes

forward at the trunk • Slight hip flexor tightness and -30 degrees knee extension. Difficult to weight

bear because of the pelvic and hip asymmetry and leg length difference • Likes to move and has potential to walk with gait trainer. Does not hold onto

handgrips well and lacks the stability needed yet to do • When you facilitate him to walk with hands held or with gait trainer, he flexes

hips high as if marching • Non-verbal but enjoys interactions with peers, adults and family • Dependent for all activities of daily living (ADLs), partly because of no vision • Has a tilt-in-space wheelchair. He has not been able to even try to push the

wheelchair because the tilt-in-space configuration with small wheels does not allow this as an option. It is obvious that he does not need a wheelchair with that much support and he would do well with a manual wheelchair.

• Has a Convaid Cruiser which mom uses for community outings due to ability to fold and place in car

IEP GOALS 1. Jaylen will continue to help those

assisting him transition himself with minimal assistance only from one piece of equipment to another 3x/day

2. He will assist with transfer to/from wheelchair or chair to assistive device to walk to restroom 1x/day

3. He will walk from his classroom to other classroom (such as PE, music, art, computer) with assistive device and moderate assistance 100’ 1x/day, 3-5x/week

4. He will be in a stander 60 min/day 3-5 days/week in order to participate in circle time

5. He will get in and out of his wheelchair with moderate assistance 2/3 trials

List equipment options on the right to support goals.

Page 22: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Jaylen DOB Medicaid#:

NEWTON COUNTY SCHOOL SYSTEM PALMER STONE SCHOOL

PHYSICAL THERAPY DEPARTMENT 1110 North Emory St.

Oxford, GA 30054 770-788-5383; Fax 678-625-6304

LETTER OF MEDICAL NECESSITY/EVALUATION

Patient Name: Jaylen DOB: Physician: Dr. Cares, Pediatrician Last office visit: 9/2019 Medicaid#: Diagnosis: R62.50; Q99.9 chromosome abnormality (missing SOX2 gene from 3rd chromosome); developmental delay; anophthalmia (no eyes)

Description of Equipment requested: R82 Meerkat Size 3 Stander Team members involved with patient: Mother Therapists: Lynda Reagan – PT Teacher: Ms. Bratcher Assistive Technology Professional: David Hayes –ATP Equipment Manufacturer: Gary Quellet, ATP, Etac- US Teacher – Ms. Joy Bratcher Pediatrician: Dr. Cares

Height: 52” Weight: 58 # Pain: no complaints of pain Prognosis: wheelchair dependent for mobility. The Meerkat dynamic stander is requested to be used for the following time: permanently (or until he outgrows; it should last him 3-5 years and he may even be able to be walking some by then)

Date of evaluation: 10/21/2019

General Information: School: goes to SID class at South Salem Elem. School, Newton County Therapy Services: weekly through school Primary language spoken in the home: English Vision/Hearing: blind/visual impairment; hearing within normal limits (WNL) Communication/Cognition: nonverbal; not fully cooperative as he tends to flex arms and legs and sometimes drop rather than try to do what is asked; severe intellectual delay Present Equipment: manual wheelchair (serial #Z1SE-014001); Rifton gait trainer that he has outgrown; has never owned a stander

Sample

Page 23: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Jaylen DOB Medicaid#: Current Function: Gross Motor: Jaylen sits independently on the floor and on a bench. He will assist to coming to stand from the chair and will weight bear on his feet for a short time before dropping to the floor. He will creep on his hands and knees a very short distance before returning to sit on the floor. He will go into tall kneel and will jump with excitement on his knees. He does not have the strength, function, motor control, coordination, coactivation, stability or balance to stand or walk currently by himself. He can walk with moderate assistance in a gait trainer. He could do better if he were more cooperative, but he gets really excited and lifts and moves his arms and legs so much, but in a flexion pattern and not in a more erect posture. Because he cannot see, he can’t really move the gait trainer by himself, so walking is not functional at this point. Posture and Alignment: Jaylen sits erect in his wheelchair or while on a bench or the floor. He will often keep his neck extended slightly. He moves about on the floor but does not usually creep throughout to explore his environment even though he can creep on his hands and knees. He will stand with moderate support but tends to want to go back to the floor to sit.

Neuromotor Control and Coordination: (postural tone, automatic reflexes, coactivation, reciprocal inhibition) Jaylen present with decreased co-activation proximally with increased tone in his lower extremities distally greater than proximally. His movement patterns are primarily in the sagittal plane but does have lateral and some rotational movement when having a wide base of support. He has dissociation between the limbs but is decreased within the lower extremities distally decreased greater than proximally.

Sensory (sensation, sensory integration function, gravitational and postural insecurities). Jaylen is visually impaired therefore he uses his hands to grasp and reach for people and things. Postural security appears to be decreased as he tends to want to be on the floor versus upright in standing even with support but can reciprocally walk when placed in a gait trainer. Jaylen will often move and shake his head to give himself vestibular feedback and when on the floor in sitting on his knees will transfer back and forth between sit and quadruped and turn in circles for vestibular input.

Communication: Jaylen will say Mama clearly otherwise he was not noted to say incomprehensible words. He will let his likes and dislikes known through smiling and frowning. He appears to understand some verbal commands as he will try to follow through if stated to stand up once assist is provided.

Sample

Page 24: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Jaylen DOB Medicaid#: Tone: moderate hypertonia throughout, more involved in legs and L arm Head control: fair Trunk control: fair; can sit up, but laterally flexes to one side in sitting ADLs: dependent for all transfers, ADLS and mobility UE PROM: within normal limits for all LE PROM: tightness in hamstrings and heel cords Manual Wheelchair propulsion: cannot propel Respiratory: within functional limits (WFL) Skin Integrity: intact Sensation: seems to have decreased sensation Accessibility: house is accessible Clinical Summary: Jaylen cannot stand alone and is non-ambulatory at this time except with moderate assistance in a gait trainer. He would benefit from having an R82 Meerkat dynamic stander as standing would keep legs elongated and give him proprioception to help show him what it is like to be fully weight bearing through legs in extension, instead of as in flexion as he tends to do at all lower extremity joints. In case reader is unfamiliar with this stander here is the description: The upright Meerkat stander not only addresses all of the benefits of standing (see attached systematic review of the benefits of standing in pediatrics.Paleg 2013); it also has a dynamic component (rocker option included at no additional cost) to improve postural control, thereby improving function, as well as functional mobility. The Meerkat stander is a dynamic stander, which was presented March 2018 at the International Seating Symposium in Vancouver British Columbia. The Meerkat stander has been available in the United Kingdom for several years and used as a tool for postural control with tremendous results. The Meerkat can be used as a “regular” upright stander, as well as a “Dynamic stander” to incorporate the concepts of segmental postural control. The concept of segmental postural control is to support the child right beneath the area where movement control is challenged, and lowering the support as the child progresses. Numerous studies utilizing the concept of targeted training and the use of a rocker base resulted in improvement in independent sitting balance, trunk, as well as motor control (Butler, 1998; Curtis et al, 2018). Research has shown that trunk control is fundamental to function and movement in the upright posture, such as sitting (Curtis et al 2015) and it has also been shown to be a fundamental contributor to walking ability (Heyrman et al 2014). Research has also confirmed that typical developing infants gain postural control through an upright posture (Saavedra, et al 2012). And physiotherapist and researcher, Frances George, has demonstrated through a prospective case series the effective use of a dynamic standing as part of a prescribed therapy program for progression in movement and function (George 2018).

Sample

Page 25: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Jaylen DOB Medicaid#: Equipment trial: We have used a Rifton supine stander, Rifton prone stander, EasyStand stander, R82 stander, and all provide too much support and he cannot learn postural control through them. Jaylen has fair head and trunk control so when he stands in the Meerkat, especially with dynamic base with rocker on it, he can work on segmental trunk control and strengthening, as the trunk support can be moved down a he gains control. Jaylen is blind as he has no eyes and he loved the Meerkat because he could do the rocking motion that he loves and as he rocked back and forth, he was using his trunk muscles. Recommended equipment: R82 Size 3 Meerkat stander with these components:

• trunk support: to help hold trunk erect and in line with the vertical support; as he improves, the trunk support can be lowered to help him gain segmental control

• pelvic support: to hold hips and pelvis in alignment and vertical with the support

and prevent lateral shifting • knee supports: to have a surface to push against knees to help them stay in

extension as we need full extension of legs for full weight bearing and for training and leg strengthening

• large foot sandals: to keep feet from sliding; to keep feet in alignment with legs

• rocking base: standard feature (not an upcharge); to help him experience movement and work on segmental trunk strengthening and control

Plan: The recommended Meerkat stander and attachments will be delivered to the patient’s house and checked by this therapist and medical equipment provider, to ensure proper fit and to ensure that the equipment is delivered as prescribed. I CERTIFY THAT THIS CUSTOM EQUIPMENT IS MEDICALLY NECESSARY. Physical Therapist Name: Therapist Signature: Lynda Reagan, PT Date: License Number: Expiration Date: Physician Name: Signature: Date: License Number: Rehab Technology Supplier Name Signature: Date: Number: Expiration Date:

Sample

Page 26: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Jaylen DOB Medicaid#: REFERENCES

1. Butler PB and Major RE (1992). “The learning of motor control. Biomechanical considerations”, Physiotherapy 78(1) 1-6.

2. Butler, PB. (1998). “ A preliminary report on the effectiveness of trunk targeting in achieving independent sitting balance in children with cerebra palsy”. Clin Rehabil 12(4), 281-228.

3. Butler PB, Major RE, Saavedra S, Jarvis SE. (2004). “Biomechanical considerations of postural strategies: a neglected facet of postural control (or “Kids do what’s good for them!)”. Abstract, Proc of meeting of the Collaborative Project on Developmental Neurology, Groningen, The Netherlands.

4. Curtis DJ, Butler P, Saavedra S, Bencke J, Kallemose T, Sonne-Holm S and Woollacott M (2015). “The central role of trunk control in the gross motor function of children with cerebral palsy: a retrospective cross-sectional study”. Dev Med Child Neurol 57(4), 351-357.

5. Curtis, DJ, Woollacott, A./ Bencke, J., Lauridsen, HB, Saavedra, S., Bandholm, T., Sonne-Holm, S. (2018). “ The functional effect of segmental trunk and head control training in moderate to severe cerebral palsy: A randomized controlled trial”. Dev Neurorehabil 21(2), 91-100.

6. George, F.K. (2018). The importance of static and dynamic posture: how making static equipment dynamic may improve movement and function of children with neurological impairment - A retrospective service evaluation. Association of Paediatric Chartered Physiotherapists Journal. 9(2), pp.56-63.

7. Hanna SE, Bartlett DJ, Rivard LM, Russell DJ (2008).Tabulated reference percentiles for the GMFM-66 Gross Motor Function Measure for use with children having cerebral palsy, April 2008, available at www.canchild.ca

8. Heyrman L, Feys H, Molenaers G, Jaspers E, Monari D, Nieuwenhuys A and Desloovere K (2014). “Altered trunk movements during gait in children with spastic diplegia: Compensatory or underlying trunk control deficit?”. Research in Developmental Disabilities 35, 2044–2052.

9. Major RE and Butler PB (1995). “Discussion of segmental stability with implications for motor learning”, Clinical Rehabilitation, 9, 167-172.

10. Pin TW, Butler P, Shum SLF (2018). “Targeted Training in Managing Children with Poor Trunk Control: 4 Case Reports”.

11. Paleg GS, Smith BA, Glickman LB (2013). “Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs.” Pediatr Phys Ther. 25(3):232-47.

12. Saavedra SL, van Donkelaar P and Woollacott MH (2012). “Learning about gravity: segmental assessment of upright control as infants develop independent sitting”. J Neurophysiol 108, 2215- 2229.

13. Saavedra SL and Woollacott MH. (2015) “Segmental contributions to trunk control in children with moderate-to-severe cerebral palsy”. Archives of Physical Medicine and Rehabilitation, doi: 10.1016/j.apmr.2015.01.016.

Sample

Page 27: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

NAME: Jaylen TEACHER _______________________________ DATE _______________________________

M T W TH F M T W TH F M T W TH F M T W TH F

Dynamic Stander

Gait Trainer

Walker

Activity Chair

Sitting

Rest/Floor Time

Page 28: Case presentation- Sebastian · CASE PRESENTATION- SEBASTIAN . Sebastian is a 10 year old in 4th grade in regular education with Resource through Special Education/IEP • Spastic

Gross/Fine Motor Plan

Time Activity Participation Environmental Support7:30 Free Time Centers with peers R82 Flyer Wheelchair

7:40-8:10 Prep/Breakfast Class/Lunchroom w/c or R82 Wombat

8:10-8:25 Toileting Bathroom R82 Flamingo

8:25-9:00 Calendar Time, weather, names, songs, hand motions

Circle time with peers R82 Scallop or Bench sitting or R82 Wombat Living

9:00-9:30 Recess Outside or Sensory Room Walker/R82 Crocodile Gait trainer to transition and play

9:30-9:40 Transition to sitting Classroom W/C or adaptive seating

9:40-10:10 Literacy LessonsLetters, Phonics, Story, Activity

Classroom W/C or adaptive seating

10:10-10:30 Math Lessons Manipulatives in classroom W/C or adaptive seating

10:30-10:40 Transition from Stand to W/C; wash hands/prep Classroom W/C or adaptive seating

10:40-11:10 Lunch/Mobility Lunch Time W/C (can walk if time)

11:10--11:40 SpecialsWalking/bike riding or Music

Physical Education or Recess or Sensory Room

R82 Crocodile Gait Trainer orAdaptive Bike

11:40-12:30 Classroom Instruction/AAC/laptop/Ipad With peers or individual W/C or R82 Wombat

12:30-12:45 Toileting Bathroom R82 Flamingo

12:45-1:15 Music Interaction with instruments R82 Meerkat

1:15-1:45 Life Skills Lessons Standing at play kitchen or other centers

R82 Meerkat

1:45-2:00 Transition to W/C Prepare for Dismissal Convaid Flyer