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Putting the Rehabilitation into Complex Rehab Technology THE INTEGRATION OF TARGETED THERAPY IN A DYNAMIC STANDING PROGRAM

Chapters

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

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.

Home therapy programs for neurologically impaired children are limited

Limited, or no, treatment hours paid for by insurance or Medicaid

Written ROM and exercise instructions for parents

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Standing and gait programs, one of the few exceptions

Consistent, early home standing programs have proven results

Holistic Benefits of Standing

Skeletal

Muscular

Respiratory

Gastrointestinal

Urological

Integumentary

Neurological

Systematic Review and Evidence-Based Clinical Recommendations for Dosing of Pediatric Supported Standing Programs

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).

Especially needed for children confined to wheel mobility

Standing can also foster gross motor improvement

The acquisition of motor skill through normal development

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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

Rolls from back to side

Holds head steady and erect in supported position (head control is completed)

Six Months

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)

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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 CHALLENGES

Postural control Closed and open chains SIMPLE STANDER - TARGETED TRAINER

Definition of Postural control

”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)

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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?

What is a Chain? A COLLECTION OF RIGID SEGMENTS THAT ARE CONNECTED BY JOINTS

An Open Chain?

Control is required at all joints to maintain or produce a desired geometry or shape

A Three-Segment Closed Chain – a rigid structure

No movement possible

No control required

Human structure – -bones (rigid segments)

-joints muscles (crossing the joints and producing movement)

The advantages of using closed chains for a child with CP

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

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Some Examples WHAT MUSCLE ACTIVITY IS PRESENT?

WHAT CONTROL STRATEGIES ARE USED?

Who here has postural control in sitting?

A B C D E

?

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

…..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

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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

37

A combination of Closed and Open Chains

A further Closed Chain has been introduced

Only the cervical spine is unquestionably under active control

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Sitting Balance?

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

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One way to test postural control

The SATCo test

(Segmental Assessment of Trunk Control)

Dr. Penny Butler Mr. Richard Major

The SATCo test originated at:

Sufficient segments are supported to enable effective stability of the top-most supported segment. No support is required when testing Full Trunk Control

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Anatomical landmark between

trunk segments

Shoulders

Axillae

Inferior Scapula

Lower Ribs

Below Ribs

Brim of Pelvis

Trunk Segment Tested

Head

Upper Thoracic

Mid Thoracic

Lower Thoracic

Upper Lumbar

Lower Lumbar

Segmental Assessment of Trunk Control (SATCo)

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

Each level of static, active and reactive control is tested from head control through lower lumbar control and free sitting ability

Segmental Assessment of Trunk Control (SATCo) 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

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Compensatory Strategies

Hand support

Compensatory Strategies

Trunk alignment

Sandy Saavedra and Marjorie Woollacott

Using the SATCo test, they looked at the Typically Developing Infants and Children with Cerebral Palsy

Motor Control Laboratory, Department of Human Physiology, University of Oregon, USA

Typically developing infant SATCo

Hands free floor sitting

SEGMENTAL ASSESSMENT OF TRUNK CONTROL (SATCo)

Child with cerebral palsy SATCo

2

3

6

5

1

4

7Full spinal control

Head control

Upper thoracic

Mid thoracic

Lower thoracic

Upper lumbar

Lower lumbar

2

3

6

5

1

4

7

22

33

66

55

11

44

7Full spinal control

Head control

Upper thoracic

Mid thoracic

Lower thoracic

Upper lumbar

Lower lumbar

1 2 3 4

Static Active Reactive

Four test sessions over six months

8 years old mixed spastic quadriplegia

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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

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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….

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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

From Mandal

1981 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

We want to retain the lumbar curve but in a sitting posture

Opening up the hip angle in the seating posture will keep up the lumber curve

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

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Targeted Trainer seated In knee - sitting:

With low or high trunk support

With knee support at the front

and if needed at the sides

Transfer:

The child can be lifted on to the seat

Knees supported on the knee cushion

Hip belt mounted

Front and sides mounted

The new proto type in a seating and standing version

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