Pediatric+PT+Interventions

Please use this wiki page to post links that demonstrate/describe interventions strategies for the case presented on the final exam. Be sure to post a description/explanation with the item. This item may be created by you or someone else, but please remember it should be of good quality, applicable to the case, within the scope of pediatric PT practice, and unique (it may not be posted by more than one student).

__Dance Therapy for Children with Cerebral Palsy__ -Dance therapy is helpful in the development of coordination in children with cerebral palsy. Because dancing is such a complex action, involving different parts of the child’s body and the coordination of moving those parts with the rhythm of the music, a child with cerebral palsy is able to practice use of their limbs in a fun, artistic way. Children love to dance to music, and children with cerebral palsy will strongly benefit from the opportunity to gain coordination between their limbs, develop their sense of rhythm, and just have a little fun. Here's a clip on youtube from NBC News that did a clip on dance therapy for children with CP. []

[] This link provides a description for Balloon Volleyball. This game would be used to increase his trunk strength while sitting, which will translate to increased strength while standing or walking. Variations include: not keeping score, changing the distance of the barrier between each person, changing the support provided to the pt, changing the distance outside of the pt's seated base of support to vary self-perterbations.

http://www.basketball-hoop.com/wp-content/uploads/2011/03/mini-basketball-hoop-3.jpg This is a picture of a Mini-basketball hoop. This game can be played while sitting or standing with an arm holding on to the walker. It will help with increasing dynamic balance, core strength, and reaching out of base of support. You can hang the goal on the back of a door and increase or decrease the distance from the goal to make it harder/easier. Increasing the distance to reach for the ball will increase the difficulty. You can keep score, play HORSE with siblings/parents, etc.

Obstacle Course Here is a video that gives several ideas of how to set up an obstacle course for children (a few of the activites in the video, like jumping rope, are too advanced for this case). To start, you may want to do only 2-3 tasks, and as he improves you can add activities or make them more difficult. Since he can only walk short distances, you can mix in activities that are easier for him along with walking (e.g. log-rolling or creeping). This would help improve his endurance and walking ability.

__Using a physioball__
media type="youtube" key="4LOXdIGcJdg" height="315" width="420" A physioball could be used for a variety of activities for children with cerebral palsy. For the case on the final, it could be used to improve his sitting posture by having him sit on the ball. The activity could progress by having a parent move the ball gently in various directions, or by increasing the sitting time duration. The child could lay prone on the ball to target the trunk extensors specifically. Different sizes/shapes could be used, or the ball could be inflated to different levels to change the ball responsiveness.

Standing balance and endurance exercise: [] Here is a video that shows aquatic therapy done with children and children with disabilities. This would be a great tool to use with Austin to increase standing balance and endurance which will help with walking and functional mobility. To progress the pool exercises you could increase the number of exercises and decrease rest breaks, decrease the depth of the water to decrease support, use changes in current or add pertubations to challenge balance, can add core/LE exercises to increase strength, change the BOS in the pool to narrow stance, staggered stance, single leg stance. I also found it interesting that the narrator in the video mentions that the water typically relaxes a child and decreases tone which would also help with standing balance.

__**CP and taking off your SOCKS!**__
[] Here is a link to a little boy with CP who is concentrating on taking off his own socks while keeping his sitting balance. Specifically for Austin, this would be a great tool to increase sitting balance. He could practice putting on and off socks every morning or afternoon as part of his routine, but yet still get the practice in for sitting balance. I would have a designated sport for him to practice this with, i.e. while sitting in front of a bean bag chair, due to his low backward protective reactions.

=Yoga for Children= Yoga is an intervention option for some children with CP. It is a gentle and safe way to help increase body awareness, strength and flexibility. This could be an effective treatment for Austin because it can address all of his limitations by working on core strengthening, posture, head and trunk control, strength, flexibility, and balance. Yoga will also work on breathing an relaxation techniques which can also be beneficial for Austin.

This videos of a children with CP doing yoga: [] [] [] [] []

__Body Weight Supported Treadmill Training in conjuction with NMES for children with CP__ [] This is a link discussing the use of BWSTT in conjunction with NMES to improve strength and endurance in children with CP. There has not been a lot of research performed on this topic but for the few cases that have been performed, researchers have seen improvements in the children's abilities to ambulate independently. This could be a beneficial treatment intervention for Austin to improve his endurance with ambulation so that he can improve his speed of getting to lunch and the playground through school as his mother and teacher would like.

=**Tic Tac Toe**= [] [] Here are a couple links for images of tic tac toe on the playground (these were the best images I could find to show tic tac toe being played on the wall). Sitting/standing balance, core control and strength, LE strength, endurance, and confidence can all be targeted with this intervention. Austin is currently having trouble reaching outside his BOS and overhead without losing his balance and is unable to stand independently. First, I would have him start playing tic tac toe in various seated positions including crisscross applesause to prevent w-sitting, v-sitting to help with hamstring stretching, and sitting in his classroom chair with manual support at the pelvis. We could progress from sitting to tall kneeling and ultimately to standing. The goal would be to use external manual support or his AD for support at first and gradually remove support. There are several variations that can be done with the tic tac toe board as well. Starting off, the board should be smaller, closer to Austin, and lower on the wall so that the highest row is at shoulder height. This can be progressed by moving the board further away, making the boxes larger and more spread out, and raising the height of the board so Austin is required to reach overhead. The X’s and O’s can also be manipulated. You can start off by handing them to Austin, put them on the floor close to him and further out so he has to reach to pick them up, hold them above shoulder height so he has to reach them before putting them on the board, etc. This is a great activity to increase play/participation with peers and brothers, can have beneficial carryover at home when reaching for clothes, food, books, etc. and would make therapy much more fun!

=Red Light/Green Light= Red Light/Green Light is a fun and interactive game that can be used to increase Austin's endurance and speed with walking with his reverse rolling walker. The strategy would be to start with letting him walk at his self-paced speed and with frequent "red lights" to allow for multiple rest breaks. Progressions can include: verbally instructing him prior to starting the game that you want him to walk as fast as he can and providing verbal encouragement to keep going fast during the "green lights"; decreasing the frequency of the "red lights", thus decreasing his opportunities for rest breaks; increasing the distance over which the game is played as his endurance improves. To introduce a competitive edge to it, you could challenge him to walk a farther distance each subsequent session or to walk the same distance as the previous session in a faster time. The following link is of a little girl with CP playing Red Light/Green Light in the hallway at her mom's work. Although she does not use an assistive device while she plays the game (you can see her Loftstrands leaning against the wall in the background), you can still get the general idea of what Austin's lower extremity gait pattern may resemble. media type="youtube" key="entKx0306MA" height="315" width="420"

=Seated Lower Extremity Strengthening=

=
When seated a child can do many activities to strengthen the lower extremities. To maintain the child's interest in strengthening, activities such as kicking a ball can be utilized. In the following video, you will see a boy stopping a ball that is rolled toward him by using his feet. In the video, the child has velco attached to his feet, so he can lift his feet to reach the ball. By lifting his feet off the floor, the seated position becomes dynamic and will also challenge postural strength and balance. This type of activity can be fun for a child who has siblings who could participate by rolling the ball to the seated child.===== []

= = =Standing shave cream craft for standing balance= Spray shave cream on a table or countertop. Have the child stand in front of the table or counter and draw letters, numbers, animals, etc. Child can use one hand to balance and one to draw or can use both hands to draw if able. Can make the task more difficult by having the child stand on foam or dyna discs. Make sure he/she isn't compensating by leaning on the table or counter. The link I have attached is with a child in sitting, but you can still get the idea and the girl seems to be having a good time! media type="youtube" key="QP7qJCEVZxc" height="315" width="420" Sitting activities on the floor to work on balance outside of Austin's base of support would be good for him to work on. Austin would be seated on the floor unsupported initially with some trunk support provided by the therapist during the activity. I would utilize the board and incorporate activities of interest to him such as placing the letters of the alphabet in order or his numbers as this age level spends a lot of time working on the alphabet and numbers. The letters and numbers would be all scattered up on both sides of Austin to facilitate him having to turn to reach on both sides of his body. The blocks in the above picture could also be utilized as well. This activity could be progressed by placing the objects further out of Austin's base of support (above shoulder height for example), decreasing the level of trunk support by the therapist, and moving from sitting on the floor, to sitting in a chair, to standing.

=__** Walking on Uneven Surfaces: To Improve Walking Endurance and Walking Speed **__= Since Austin has trouble walking from his classroom to the lunchroom and playroom, he requires exercises that will improve his endurance and speed. I recommend that Austin spend time walking outside with his reverse rolling walker on the grass, pavement, etc. with his family. He should attempt to ambulate at least 10 feet without rest breaks, and increase his distance up to 60 feet with minimal breaks. By walking on uneven surfaces, Austin will have an easier and more efficient time walking through the flat hallways in school. Since Austin's teacher wanted him to increase his speed with transitions, his family can time him walking a certain distance, and with each trial Austin will try to decrease his time. This will also be a fun, recreational activity for Austin to participate in with his parents and brothers. media type="youtube" key="VdJShBkq-10" height="315" width="420"

=__Doing the WAVE__= Performing regular sit to stands is an important way to strengthen LE and improve balance and control. Sit to stands are extremely functional and a necessary component for transfers, but how in the world can we have kids perform repeated sit to stands? Well, how about you do the wave! Not only will this strengthen LE and it will challenge the kid in dynamic balance as the arms go overhead challenging balance. Also, you are able to be by the side of the kid just in case they need assistance or lose balance. For progressions you can vary the speed (go quicker up and down) which will also work on endurance and timing. Here is the link on how to perform the wave. Pediatric PT Interventions

=__Sitting and Reaching__= Austin will sit in a circle sit or v-sit position, place toys far enough away to either side or in front of him so that he has to weight shift and reach for the toy. This will help with Austin’s core strength and his balance. Mom can also hold toys above his head so that he has to reach up for the toys while maintaining his balance. The young girl in this video needs more assistance than what Austin will require, But Austin can be given assistance as needed to keep from losing balance. [|reaching video]

__**Wii-hab: LE strengthening, posture control and balance exercises:**__ The Nintendo Wii system has a variety of games that can help to strengthen the lower extremities, and improve balance and posture. The video attached includes a harness used to help the child maintain upright while the therapist helps him play the games, but other videos show that you can provide assistance to help the child maintain upright while they play the games. The games that are commonly used in the rehabilitation setting are Ski jumping which involves squatting then coming up to standing, Wii fit jogging with assistance to work on endurance and balance, and balloon or bubble breaking to work on balance. The Wii can also be used to look at where the child's center of balance is during different activities which can be used to determine how much assistance is needed and allow the child to try to correct on their own. This is a good way to keep the child engaged in therapy by making it fun and functional for children, it can also allow the child to participate in play with siblings or peers at home. I know this is not available in all clinics or schools (although they are becoming much more prevalent) and not all parents have one at home, but just by watching these YouTube videos you can get an idea of how to turn the exercises into games and have the child do them without the Wii system. The first video below shows a child doing Wii hab therapy at a clinic using the harness for support and the second video shows a child doing Wii games at home.

media type="custom" key="11567460" media type="youtube" key="NenYzx1vJWI" height="315" width="420"

Here is also a link to another Wiki page that I found that has information about Wii-hab in general and how it can be used for children with CP. It also provides research outcomes that were improved by using some different Wii games, I thought it was a good and easy to understand resource! []

Ring Toss: [] Austin will improve his standing balance and endurance, UE strength, trunk and core strength and balance and have fun playing the game! Start off with the targets close to Austin at hip height and take many breaks. Progressions include standing without as many rest breaks (increase standing endurance), increase the distance to the targets up so he has to throw farther (increase UE strength and his walking endurance because he will have to walk farther to retrieve the rings), increase the weight of the rings (improve UE strength), and move to the floor (more difficult to pick rings up off the floor so it will work on his trunk control and strength to bend down and then stand back up without losing his balance, will also work on leg strength with bending down and then standing upright).

Aquatic Therapy for kids:[] This link is for treating pediatric patients in the pool for aquatic therapy. This child in the video does not specifically have CP but presents like many CP children and the benefits talked about by the therapist will all be great for Austin. Increased LE strength, increased trunk strength, increased endurance, walking can carry over to walking on ground, decreased tone while in the pool.


 * Lego Therapy**

One activity that a lot of little boys like is building with legos. This activity could be used to target several of Austin's deficits. First of all you could start by playing iwth legos on the floor while sitting. This would allow Austin to reach for objects outside his base of support, but would be engaging and rewarding because he was learning to build something. To progress this you could work on standing with the legos at the edge of the table. This would work on standing and balance. This would also work on trunk control and lower extremity strengthening. You could also place some of the lego pieces throughout the room so that he would have to walk to go find them so that he could continue building his masterpiece.



Aquatic Therapy


Aquatic therapy can be a fun and interactive way to work on multiple therapy goals.This is the //"BIG BLUE WHALE".// The individual squats under water, then jumps up with their head extended as well as arms. This works on lower extremity strength by moving through the resistance of the water.It encourages full extension of the lower extremity as well. It also works on head and upper thoracic posture as your are encouraging the child to extend their head, neck and arms. The buoyancy of the water assists kids who are unable to generate powerful thrust. This could be progressed by having the child try and make as big of a splash as possible as they exit the water, even measuring how far the farthest drops went. Also adding weights or moving to deeper water will increase the difficulty of the activity.