Pediatric+PT+Interventions

Choose one of the intervention strategies you listed in the PCRT for Austin and/or included in your home exercise program. Post an item (link, handout, photo, video, etc) on this page that describes, illustrates, or demonstrates that intervention. Be sure to post your own written description/explanation with the item. Then also post a link to your item or post on our class [|Facebook Group]. 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).

CRooney**:** While brainstorming treatment ideas for Austin, I kept thinking back to an experience I had early on in PT school and how beneficial it seemed to be for children not only with cerebral palsy, but also with other neurological, motor, or intellectual disabilities. It sounds crazy, but I observed and volunteered in an adaptive martial arts facility. This specific facility taught American karate, but after doing some research I found several schools nationwide that taught a variety of martial arts disciplines. I thought I could implement a few of the core stability strategies with Austin. The school I volunteered at was initiated by an R.N., and I was amazed at the improvements I saw some of the kids make just over the one- month span I observed through. There were several children with CP that were students there. Two that I remember walked with loft-strand crutches as primary mobility, and one that was highly dependent but able to maneuver a power wheelchair fairly well. They did all kinds of activities these kids, but one that stuck out to me as interesting, fun, and that seemed to be successful involved a sort of “wrestling” (I don’t know what it would be called in karate language). The instructors used either small noodles or rods, as well as their body weight for this exercise. The more dependent child was placed supine for the activity, but the other two children were able to do the activity in sitting and half kneeling. Below is a video of what it sort of looked like for the child who was wheelchair bound. Based on feedback from his mother, her son’s UE strength and ability to hold his posture upright in his chair had improved quite a bit since beginning this intervention. On the first day I was observing, this child’s PT was actually at his class educating the karate instructors on how to transfer him to the mat, and learning some of the karate techniques so she could apply them on occasion. I thought it was really cool how the PT was willing to collaborate with her patient’s family and karate instructors. I think that some martial arts like activity would be beneficial for Austin to promote core stability, strength and endurance training, as well as weight-bearing in quadruped and other positions, which could help manage his spasticity. Since Austin is motivated to participate in adaptive sports, adaptive martial arts could be a great option for him to be involved in the community if he had access to such a facility. The children at this facility were always smiling, and the exercises helped improve their strength and function, taught them means for protecting themselves, improved their self-esteem, and taught them discipline. Here is a documentary on the facility I observed at, if you are interested. Dr. Gupta mentioned C.H.A.M.P.S. during his lecture as well.
 * Adaptive Martial Arts Activities**

media type="youtube" key="y8Uyr610-hw" height="273" width="448"media type="youtube" key="xwSQuGzGMtc" height="273" width="448" align="right" CTeague(Abbott): I wanted to focus on strengthening Austin's gluteal/hip muscles to improve his postural stability with the ultimate goal to increase walking efficiency and safety. For this exercise I would have Austin lying on his back on a firm/solid surface. I would instruct him to lift his hips as high as he can towards the ceiling so that he would be performing a bridge. Initially he will most likely need manual assistance to perform this exercise, but the goal would be to gradually take away this support. Since Austin is in kindergarden, a way to make this exercise more like a game I would instruct the teacher to play the song "London Bridges Falling Down". The entire class could perform this exercise with key words that would cue them to go up in a bridge position and key words that would cue them to go down. The total length of this song is about 2 minutes, so they could progress the amount of time spent in the bridge position.
 * London Bridges Falling Down**

Wii
AMiller: An intervention I want to incorporate in Austin’s therapy to target his balance deficits is the Wii. There are several Wii games that can work both dynamic sitting and standing balance. In standing Austin can be challenged in frontal plane weight shifting with the snowboarding game. For working weight shifting in the sagittal plane he could play downhill skiing or hitting the soccer ball. To work maintaining center of gravity he could do yoga poses. And to work both dynamic sitting and standing the marble game (shown in the video below) is a good option. All of these games can be made harder/ have different levels so that as Austin improves, the games continue to challenge him. Not only is this activity a good option to work several different aspects of balance, but it is also disguised in a game so he is more likely to be enthusiastic to participate both in clinic and at home. Marble game video demo: []

Playground Equipment
JGentry: For Austin's home exercise program I wanted to incorporate using a community playground to improve his balance and strength endurance. This is a fun activity where Austin will be able to interact in his community can his entire family can participate. Using playground equipment Austin can improve his upper extremity strength, important for using his loft strand crutches, by hanging from the monkey bars. Here is a video of a child with CP being challenged by her mother to hang for as long as possible. [] Perhaps Austin can challenge his one of his parents to a hanging contest, or challenge his brothers (with the help of his parents). Austin can improve his upper and lower extremity strength and coordination by hands and feet crawling to get onto the playground equipment. [] His reward will be to go down the slide. This activity similar to what his peers will be doing and the other children will be a form on encouragement for Austin to complete this tasks. The swing, teeter totter, and balance beam are just a few activities that Austin can do with assistance that will challenge his balance and improve his endurance. The possibilities for interventions are limitless on a playground. Ehaynes: For Austin’s therapy I would like to incorporate using the Swiss ball to address his balance and postural control deficits. We would first start off with just sitting on the ball and I would be providing manual assistance as needed. After this was accomplished we would progress to sitting on the ball and maintaining an appropriate upright sitting posture while the ball moves forward and backward or from left to right. Another thought is to have Austin perform reaching tasks outside of his comfort zone while sitting on the ball. I thought about making a game out of him reaching for his fishing pole, and practicing casting since he his in a local scouting troop. This would address his dynamic sitting balance/postural control. Like any other exercise intervention the Swiss ball activities can be adjusted to make the activity harder or easier and make it appropriate for each individual patient.
 * Swiss Ball Intervention**

This video shows a therapist and a child working on sitting on a Swiss ball. []

dbowman: I also opted to work on seated balance during Austin's therapy session. However, I wanted to begin with him seated in his regular desk chair from school. Austin has difficulty reaching outside his base of support even from a stable surface, so I may consider progressing him to a ball later but would start from a firm chair. I would ask Austin to reach for objects that he may have in his desk such as pencils and markers and progress to larger items such as books. The video I have included is more advanced than the level that Austin would begin at. However, it does illistrate important principles such as reaching in diffierent planes and using core strength to control movement rather than using hands to stabilize. Austin is not yet ready to pick up objects from the ground but should progress to that as it is functional and kids are always dropping things. Austin will likely become bored with this activity after a few days so teachers and therapists will have to be creative and perhaps incorporate pictures or math concepts into the reaching tasks to keep Austin interested.

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AAshenden: I also chose to work on balance with Austin. Like Debra, I would first have Austin work on seated balance (He could also do this activity in sitting). I would progress this to standing balance. One way to make this fun for Austin would be to have him paint with shaving cream while standing. Similarly to what the kids are doing in this picture, you can even make the shaving cream different colors. Austin can draw animals and write to keep him interested. This activity would work on balance as well as core strength since Austin can reach just outside of his limits of stability and the limits can be increased as his balance improves. You could also have him start with assistance from a therapist or holding onto a table, and this assistance can be gradually removed.
 * Standing Balance**

SHurst-Sneh: One of my interventions I chose to work on with Austin was his balance. Like Abby stated I would initially want to start working on Austin's sitting balance first. My final goal with this intervention would be to get Austin to be able to sit independently without any loses of balance while reaching outside of his base of support. I would have Austin sit on various surfaces and challenge his balance by having him reach for objects outside his base of support. This could be done during classroom activities and or play when things are handed to him. Once Austin meets this goal I would want to progress to standing activities. This in when the balance board intervention could come into play. Initially, I would want Austin to be steady on solid ground. The balance board could then be implemented to challenge Austins's balance even further. The board will help with weight shifting as well as maintaining balance on an even even surface. In the video the therapist is working with a young girl on the balance board. This small video clip shows just one way to this piece of equipment could be used. http://www.youtube.com/watch?v=-X-Hg56Ndc0


 * Obstacle Course**

CStingley: I think some type of obstacle course would be a great intervention for Austin. This could address several of the impairments seen including core and lower extremity strength, along with balance. Austin could crawl under items, maneuver over items, or even walk a portion of it with his crutches. I included a video of an obstacle course using typical items at home (chairs, blankets, tables, pillows). Portions of this obstacle course may be too challenging for Austin at first, but these types of things are all about trial and error. The teachers could make up an obstacle course he can do with his peers at school or he can play alongside his brothers at home. Since they are 2, maybe he can be the example and show them how to go through the course the first time. Normally, children love obstacle courses and will go through them again and again. This may also help to address his endurance impairments since he is needing several rest breaks. He will be improving his endurance and won't even realize it since he's having so much fun!

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Play Therapy
CEbert: Similar to what Jessica wrote about using playground equipment, I would like to incorporate what is called "Play Therapy" into Austin's program. All children love to play, but for children with CP, like Austin, playing can be difficult. Play Therapy has a therapeutic and psychological component to it that helps kids with CP feel like they can fit in just like normal developing children do. Play Therapy can help to improve a child's self-confidence, ability to learn, and help them adapt to different environments. By targeting physical, cognitive, and emotional needs of a child, you really get the opportunity to look at the child as a whole. The good thing about Play Therapy is that it can be formal or informal in nature. It is usually administered by a therapist, so it is a skilled intervention. Their job is to make sure that the therapy performed is safe and done in a safe environment. The play therapist helps to coach parents and other educators how they can modify play space to better suit a child that has CP. For more information on Play Therapy, please visit the following website: http://cerebralpalsy.org/about-cerebral-palsy/therapies/play-therapy/

**Intervention to improve gait using ball**
JCox: Since Austin's mother's main goal is for him to be able to walk throughout his school with an assistive device rather than being pushed in a wheelchair I wanted this intervention to focus on working toward that goal. He currently uses a reverse rolling walker and has just begun taking a few steps with loftstrand crutches. Using an exercise ball to improve gait, as demonstrated in this video, can be used to give Austin some upper extremity support while walking, but allows him to really focus on lower extremity coordination and placement in the forward and backward directions. I would start by giving him lower extremity or trunk support as needed while he walks forward, and then progress this intervention by giving less support and work on walking backward. I could also instruct him in sidestepping with the ball. It is still very important to work on gait with the exact assistive device that he will be using, but this can be used as a great alternative to allow him to focus directly on balance and lower extremity coordination instead of fumbling with using an unfamiliar device, such as loftstrand crutches. Similar interventions and exercises could be initiated while Austin stands at the ball, such as heel/toe raises, hip strengthening exercises, and single leg stance/balance activities. media type="youtube" key="Y92qrc-rG-o" height="315" width="560"

Improving Austin's Strength
ACrowl: Along with Jenna, I wanted to incorporate something that would help to improve Austin's ambulation skills as that is his mother's main goal. I wanted to incorporate some type of hip strengthening program as the hip abductors and extensors are especially important for stability while ambulating. My inspiration came from this website: []. This website is a part of "Rehab Management" - this specific page describes the benefits of strength training, how important strength training is for kiddo's with CP, and also describes the multiple muscles that are important to strengthen (spinal extensors, abdominals, hip muscles, scapular stabilizers, and ankle df's/pf's). I chose to specifically work on Austin's hip muscles for his HEP. I think a fun, accesible activity would include kicking a ball. I would start with static standing with Austin in his walker kicking forward, sideways, and backwards to work hip flexor's, hip abductor's, and extensors. I would like to progress from standing with the walker to standing with his forearm crutches to standing with only one upper extremity for support. From there, I would like to work on kicking while ambulating and/or adding weights to his legs. Here are a couple of pictures to demonstrate:



AVaysfligel: I came across quite a bit of resources that point to the benefits of dancing games and activities in improving not only the social aspects but also coordination and endurance components of development in children with CP. I also found a video, posted below, that talks about dance in children with CP who are in wheelchairs (the kids seem to be at around the same GMFCS level that Austin probably is). It is a specific program, overseen by physical therapists, so this particular activity may not be appropriate for Austin, however, the video discusses some general benefits of dancing such as increased strength, increased confidence, social participation, improved coordination, etc. One of my goals for Austin was to improve his standing balance so I would recommend that he participates in these dancing games in his lofstrand crutches as much as possible. The activity I included in the HEP was "Freeze Dance"--the kids continue dancing around until the music stops and remain "frozen" until the music resumes. The same activity may be performed using his reverse rolling walker if the crutches are too difficult. At first, I would give Austin frequent rest breaks, but my hope would be that his endurance continues to improve with these activities, and thus would translate into his everyday ambulation endurance to increase his long distance walking. http://www.youtube.com/watch?v=YUGD1J9Ywdw
 * Dancing Activities:**

LHildebrand: Since Austin uses a wheelchair for long distances and community mobility but still relies on someone to push him, I thought some basic wheelchair training would be a good intervention to improve his mobility and independence as he enters school-age. Since Austin can only use his walker indoors, his wheelchair is the device he will probably be using on the playground so these skills will help him be able to participate in recess better with his peers. Also since Austin is active in his community and participates in adaptive sports these wheelchair skills could be helpful.
 * Wheelchair Skills Training**

The first website I found has several videos showing basic wheelchair skills for both manual and power wheelchair users and is designed especially for kids. The videos are short but gives good step-by-step instructions for each skill. http://www.kidz-unlimited.org.uk/course/view.php?id=12&page=66

This website was much more in-depth and had information that would be good for wheelchair skill training at all ages and levels. There is a training manual that is very detailed with skill checklists for users and caregivers and specific instructions on skills and tips for both power and manual wheelchairs. The website also has videos of many of the skills. There are wheelchair skills tests that could be a great way to document changes pre- and post training with objective outcome measures. One aspect that I really liked was there was a list of several games that could be incorporated into the training program to work on skills in a fun environment which would be great with kids. Some of the games included tag, dodge ball, obstacle courses, jousting, etc. http://www.wheelchairskillsprogram.ca/eng/

JLeonard: I really wanted to work on his seated balance as well as his endurance in general with different activities and thought that playing basketball may be motivating for him since he is involved in adaptive sports. I would focus on getting him to reach outside of his base of support while seated and also working on tall kneeling balance while playing basketball, working on getting him to catch himself from falling backward. I found a video of a sports camp that is offered for children with CP and thought it was an amazing organization, and it is not too far away. There are a lot of different sports going on in the video, but mainly I wanted to focus on throwing a ball or tapping a balloon for Austin to work on his seated balance, also working on having him tall and throwing a basketball at a goal (which isn't shown in the video). Camp Independence Sports Camp for Kids with CP I also think that bowling would be another fun game for him to also work on getting him to reach outside of his base of support and this game can easily be made at home with recycled water bottles and can be filled with sand or colored water, whichever the parent would like (filled enough to add weight, but not too much that he can't knock them over).
 * Sports Activities/ Basketball:**

SWilliamson: With Austin, because he requires frequent rest breaks during ambulation and can only walk short distances, I wanted to work on endurance. I listed a few ways that I would work on this task in the intervention section of the PCRT. One way I wanted to do so, was to support Austin while he performed a fun activity like bouncing ,jumping, dancing, or wiggling in place for extended periods. The idea is that I would ask Austin to do one of those tasks until the timer went off. Throughout his therapy sessions, I would increase the amount of time on the timer, and hopefully over the course of time, Austin would increase his activity endurance and be able to complete the task for longer and longer periods. When looking for resources to support this kind of activity, I came across a tool nicknamed "The Spider Cage". The cage has multiple uses, including strengthening, and balance. For Austin I would put the belt on him, and hook it to the bungee cords. From there, I would begin timing his preferred activity. This equipment would be a great assistance in helping Austin to increase his cardiovascular endurance, and the bounciness of the bungee cords would also make the activity feel more like play for Austin. In addition to increasing his cardiovascular endurance, the prolonged activity would also help to increase Austin's lower extremity strength. Because this cage has multiple uses, I think it would be a great tool to use with Austin. It is a great way to support him and help him to get stronger, while feeling like play at the same time. media type="youtube" key="uJc4hO63LcA" width="425" height="350"

M.Bagwell: One of my interventions to work on with Austin was sitting unsupported while moving his arms in and outside of his base of support. I chose to use a homemade "rain stick" out of everyday materials. This rain stick would allow Austin to challenge himself while also having fun. I would start with Austin sitting in a good supportive chair having him tip the stick upside down. I would then have him add shaking the stick back and forth as well as side to side. After he got the hang of this without falling over I would decrease the amount of support the object he was sitting on gave him. Eventually I would want to progress this exercise to sitting on the floor cross-legged shaking the rain stick back and forth, side to side, and overhead. The weight of the stick will add a strength component to his trunk and upper extremities. The "loose" nature of the contents will create momentum changes challenging his trunk musculature to stabilize him and the moevment of the whole object away from his body in all directions will also challenge his trunk musculature to support him. This will ultimately allow him to be able to participate in his daily routines at his desk reaching for crayons and during playtime with his peers playing and reaching for shared toys.
 * Trunk strength with "Rain Stick"**

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NUtech: When creating a home exercise program for Austin I realized how hard it may be to get a child interested in doing these activities when at home. I found this video online that suggests making a mini exercise video. It would be interactive as you would be able to time how long they did an activity by using different songs. Most young children enjoy "sing-along" type videos and this may be a good way to get the child doing their HEP and making it easy for the family to understand. This video is a quick snippet of what the whole video would be like. If you wanted to take it further you could video yourself or a peer model the same age as the child so they really have someone to follow. I wanted Austin to practice different types of walking to not only gain endurance by being on his feet, but to also strengthen his weak glutes and hamstrings to help provide more stability in his gait. This video shows how you can add the theraband around your ankles as a progression to walking forward which could also be done in different directions. When added to music the exercises feel more like play and it may keep the child more upbeat and interested in the activity. Since this video uses written explanations it would be important to have a parent with the child reading the instructions and helping them participate. This would also provide good family bonding time. media type="youtube" key="7yrjnLIwHe0" width="425" height="350"


 * Balloon Activities**

PGorman: One of the activities I wanted to focus on with Austin was to address his sitting balance. A fun and challenging way to do this would be to do balloon batting. Having Austin sitting on the floor with one of his parents to support him, the other parent could gently hit a balloon to Austin and challenge him to either catch it or hit it back. The parent could hit the balloon to different positions to challenge him to reach beyond his base of support and help him improve both is sitting balance and core strength. This activity could be progressed to standing, again having a lot of hand held support from his parents to make sure he maintains his safety. By improving Austin's sitting balance and core strength, he will be able to become more independent in his transfers (toileting, sit to stand, etc) and also help improve his functional mobility while walking by having better core strength. The video shows a girl running around to hit the balloon, which Austin wouldn't be able to do, but gives a general idea of how the game would be played.

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Walking Activities ABullerman: I wanted to challenge Austin with his reverse walker so he could hopefully become more efficient in walking longer distances on different terrains. I was reading a blog by StarFish Therapies that was full of really good ideas (can be found at https://starfishtherapies.wordpress.com/). One of the blog posts was about different ways to challenge walking in a child. You can try walking backwards, adding different terrains (rubberized playground floor, grass, sand, couch cushions, yoga mats, plush carpet), adding obstacles (similar to the Crossing the River game), or going uphill/downhill. Although I would like Austin to become more efficient with his Lofstrand crutches to get around the classroom I believe that his reverse walker will be his primary mode of locomotion and by challenging him with that he can start figuring out how to respond to changes and thus will help to improve his balance and efficiency.