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Frequently Asked Questions: AnswersQuestion 1:Don't children have to learn to crawl before they can learn to walk?It would be wonderful if all children were able to learn to sit, stand, and walk by going through the sequence of developmental skills typical of most infants; but obviously, it doesn't always work. Surveys conducted at the Blair Learning Center, birthplace of MOVE, showed that students with severe disabilities either did very well learning to move independently or they became vegetative. There were very few students who improved their motor skills once they were past the age of seven and all but one of the students regressed if they could not perform the skills independently. Snell 1987, suggests that some teachers, especially those who are new to the field of special education, fail to select meaningful instructional goals for students with severe disabilities because the teachers are following the tenets of most developmental assessment devices. These assessments suggest that the first skills to be taught are the ones the student has failed on the list of skills normally performed by infants and toddlers. The theory behind the developmental model is that children need all of the skills displayed by infants in order to master skills displayed by older children. Although these teachers are able to teach their students, the skills the students learn are not relevant to the needs of daily life and often emphasize the student's disability because the skills are meant for children much younger. It often takes years to teach a student with severe motor delays to "marine crawl" (stomach on floor), an equal number of years to teach the student to assume a high creeping position, and even more years to teach the student to creep on hands and knees. For our students with the most severe disabilities, even the most diligent parent/therapist/teacher would, at best, end up with a 22-year-old student whose sole means of ambulation is crawling. One has to ask oneself, "How often do adults use crawling?" Most people give up long before then and therefore, the student graduates with no means of ambulation. Methods for determining what should be taught has been the weakest link in special education for students with severe disabilities. According to Snell, 1987, the selection of skills to be taught is possibly the single most important factor in determining the quality of education the student will receive. Although special education teachers have proven repeatedly that virtually all students learn, albeit some more rapidly than others, not all students are learning skills that are pertinent to daily living and to expanded environments in adulthood. The most successful teachers are those who have taken the time and energy needed to sort out priorities for individual students by talking frequently with the care providers and by taking an "ecological inventory" of the student's current and future environments. This is the model followed by the MOVE Program to insure that students graduate from the public school system with skills necessary to their adult lives. The students are taught to sit, stand, and walk first. If there is still educational time left after these skills are taught, other areas (such as creeping, rolling, climbing onto furniture, walking sideways, etc.) can be addressed if deemed important. Back to Frequently Asked Questions Question 2:
Whose job is it to teach children to sit, stand, and walk?TEACH is the key word in this question. Most children learn to sit, stand, and walk, without any formal instruction. Traditionally, physical therapy has followed the medical disease-oriented approach of treating the underlying problem so that learning can proceed in an automatic manner. The best treatment method is the one that makes a positive, functional difference in the life of the student, the parents, and the community today as well as when the student graduates from the public school system. When it became apparent that students with chronic, severe disabilities were not generalizing their skills from the therapy environment to the school and home environment, teaching the skills became a necessity and involved parents, teachers, and therapists. Bleck, 1984, observed that therapists have traditionally taken a disease-oriented approach to treating children with motor dysfunction. In other words, an attempt has been made to "cure the disease" in order for normal development to progress. Unfortunately, according to Bleck, the child with cerebral palsy will become an adult with cerebral palsy because there is no known cure for brain damage. Disease-oriented treatment approaches can be considered a failure if the child grows into adulthood with virtually the same disabilities and the same or greater limitations for participating in activities. On the other hand, the function-oriented approach can help the student resolve dependence on others by assigning priorities to learning experiences. These include, according to Bleck, communication, activities of daily living, mobility, and walking (in order of decreasing importance). There is a general consensus of opinion among leading therapists and medical personnel that therapy services have very little value unless the procedures for management and movement are incorporated into every facet of the student's life. In 1984, Campbell defined management programs as including passive activities which would insure bone and joint health. These activities might include supported sitting with proper alignment, standing in standing frames or similar equipment, and being moved or held in positions that reduce the likelihood of abnormal muscle tone and resulting deformities. Instructional or active programs, on the other hand, involve teaching the student specific movement responses that can be used functionally in daily living. Management programs are necessary until the student has acquired enough independent movement skills to become self-managing. The MOVE Program is based upon the teaming of special education instruction with therapeutic methods and includes the ecological inventory, prioritization of goals, chronologically age-appropriate skills, task analysis, prompts for partial participation, prompt reduction, and the four different stages of learning: acquisition, fluency, maintenance, and generalization. Education and therapy share in the responsibility for teaching these four stages of learning. Leadership is determined by the availability of therapy services to individual students. If therapy is available, the therapist can do the initial assessment. The educational team meets with the parents to determine long and short-term goals using the top-down model. The therapist and the educational staff then meet to coordinate the program. Parental involvement in teaching can be included in any of the four stages of learning. By the time the student enters the maintenance stage, even the busiest of parents are usually willing to participate because it is so much easier than the previous methods of physical management they were using. Even though the therapists, teachers, and caretakers share information and decision-making regarding the student and the learning activities, parents or caretakers are not required to do the actual teaching unless they choose to do so. Bleck's study (1984) noted several factors that impact the family. First, home-therapy schedules can consume enormous amounts of time and energy and may even destroy the traditional relationship of parent and child. If the therapy recommended by the therapist is mere busywork the tragedy is even greater. In the same study, Bleck also criticizes home therapy programs for further complicating the already complex situation in homes that include handicapped children. He suggests further that medical and therapy providers need to remember those complexities and avoid assigning needless home treatments and programs. Karl and Bertha Bobath (in Scrutton, 1984) strongly suggest that management techniques be explained to the caretakers of the student so that deformities and abnormal movements are not encouraged. This is particularly important to very young children who spend the majority of the time with their parents and do not have access to other teachers. At this time, is it natural for the parents to provide the major educational opportunities. When the student begins attending school for the majority of the day, however, the emphasis for learning shifts to the classroom teacher. Even though Snell, 1987, agrees that parents should have opportunities for decision making, each parent should decide the degree to which he or she will be involved in the decision-making and in the actual teaching of the child. 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How much do range of motion exercises and positioning help the child with cerebral palsy?Of course, normal range of motion and normal body alignment are desirable goals; but, historically, we have not always been successful in achieving these goals with our students who require help to move. Range of motion exercises that are practiced twice a week for 15 minutes cannot have much effect on a student who practices non-range of motion for the other 5,010 minutes of the week. The question we need to ask is, "Range of motion to do what?" Campbell, 1987, states that management programs for students should be coordinated with any active intervention program that the student is receiving. In other words, an active intervention program designed to develop pelvic mobility could be carried over to other situations where management is necessary. We have found that range of motion exercises have little or no effect unless they are used in daily functional activities and they have the best effect when they are self-directed by the student. Positioning or proper body alignment requires the same questioning: "Positioning to do what?" The most common questions about positioning are related to sitting. Why do we need to sit? The most obvious answer is that standing all of the time is too tiring and we cannot function well when lying down. That leaves sitting. As we mentioned before, there are two basic sitting positions; leisure sitting which involves leaning against the backrest and functional sitting which involves leaning forward from the hips to perform a function. For some reason, we use leisure sitting almost exclusively for receiving information (watching television or listening to a speaker). When we give information by speaking or when we perform a function such as eating or writing, we almost always lean forward and assume a functional sitting position. In the past, we have placed our students who do not have the ability to sit independently almost exclusively in leisure sitting positions. Often, we even recline the back of the seat to make sure that they are leaning back. There are several reasons for this:
2. A reclined sitting position takes pressure off of the spine and hips of people who are at risk for scoliosis. 3. We can see their faces and therefore establish eye contact while we talk to them. 4. And, of course, that's the way most wheelchairs and seating systems are made. The other reason is speech production. It is easier to speak when we lean forward because it is easier to contract the diaphragm and push air through the vocal cords. If you start coughing while leaning back, you quickly become aware of how the diaphragm works. The body reflexively pulls forward to allow the contraction of the diaphragm so that coughing can occur, which is a common need in our children with chronic congestion. If our goals are to help our students clear their lungs or to develop language skills then we need to help them assume a functional sitting position. If our goal is to have them listen to a lecture or watch a program, then we need to help them assume a leisure sitting position. The ideal situation would be one where the student could go quickly and easily from one position to the other without changing seats. In summary, both functional and leisure sitting positions are important; but, in the past, we have put most of our energies into developing maintenance systems for leisure sitting alone. We have practically ignored the need for functional sitting positions. For various reasons, we have placed many of our students in reclined positions which do not allow them to practice the skills they need for independent sitting and do not allow them to use their hands or bodies effectively. C.M. Mulcahy, et al, 1988, noted that even a small five degrees of recline can have a negative effect on a child's posture and physical ability which can delay or prohibit the acquisition of independent sitting. According to Mulcahy, a reclined sitting posture can promote extensor thrust and cause the arms to be held in a high guard position which reduces functional arm and hand use. Additionally, the student often tries to counteract an insecure feeling of falling by straining forward. This reaction is often perceived as a further indication of lack of head control requiring even greater restraint. The study also notes that a reclined sitting position alters the line of vision for the student and often results in the student staring at the ceiling rather than observing life. The normal sequence for learning sitting balance is to recover a sitting position from a forward prop, then from a side sitting position, and lastly, from a reclined position because it requires greater strength and coordination. Complex tasks requiring orientation and cognitive ability are performed better in an upright sitting position, according to an investigation into sitting postures referenced in the study. Before positioning can be addressed, you must determine the function the child will be performing and then analyze normal body alignment. A very common example of abnormal body alignment concerns toileting needs. Most children who lack independent sitting balance are placed on a toilet in a leisure sitting position or even in a reclining position. This is not the normal position for urination or defecation and it is not conducive to learning how to use public restrooms where back rests are not available. Simple prompts can be constructed from PVC pipe to help the student practice functional sitting skills while performing specific activities such as toileting. The same is true of all positioning whether it involves sitting, standing, or walking. The position must not only be as normalized as possible, but must also meet the functional needs of the activity. Activities without functional purposes such as side lying, rolling over balls, propping on wedges, etc. have not proven effective in helping children with severe disabilities gain independent motor skills. There are other reasons for the lack of success. A few obvious ones are:
2. Often, the positioning of the student is considered the entire program. Students with severe disabilities usually do not acquire skills without direct intervention and even when they are taught skills, they do not generalize them from one situation to another without more direct intervention. For example, a student who practices reduced muscle tone while side lying is unlikely to recall that muscle tone while sitting in a chair for lunch. 3. Tired or busy people only do what they have to do. Students with severe disabilities have to get on and off the bus, eat/drink, and be toileted (or have diapers changed). Skills associated with these tasks will be performed every day regardless of the busy schedule. Other programs or activities can be shelved when necessary. 4. It is almost impossible to set goals for or to measure the progress of side lying, wedge propping, or similar passive exercises. Without goals, there can be no success.
Back to Frequently Asked Questions Question 4:
What is the best treatment method?Bleck, 1984, noted that a rare study conducted to determine the efficacy of Neuro-developmental Treatment (N.D.T.) physical therapy for students with cerebral palsy showed no significant differences between the treated and untreated children after a one year follow-up. The 47 children used in the study were all under the age of six and were randomly divided into three treatment groups. One group received N.D.T. therapy for 12 months, the second group received no therapy for 12 months and the third group received no therapy for six months followed by six months of therapy. At the time this study was conducted, the N.D.T. model of physical therapy was being used basically in "pull out" programs whereby the therapist would work with the student using discrete trials in artificial environments such as medical treatment units. It was assumed that these motor patterns would then be remembered in other environments and would automatically be used for functional activities. Karl and Bertha Bobath, (in Scrutton, 1984), changed the emphasis of the N.D.T. model after realizing that the improved motor skills were not being carried over into activities of daily living. They now suggest that therapists should task analyze the functions that need to be performed and provide therapy while the child is performing the activity in a natural environment such as the home or the school. Campbell, 1987, agrees with the concept of including motor skill training throughout the entire day. She explains that it is common for students to receive "motor programs" for part of the day and other programs for the rest of the day. She has noted that basic motor skills are required for every learning situation including communication, self-help, vocational, leisure, and recreational, as well as academics. So, the bottom line is: The best treatment method is the one that makes a positive, functional difference in the life of the student, the parents, and the community today as well as when the student graduates from the public school system. Back to Frequently Asked Questions Question 5:Don't we have to break up primitive and abnormal reflexes before children can learn to move?The traditional approach to primitive and abnormal reflexes has come into question in several studies. Karl and Bertha Bobath (in Scrutton, 1984) no longer include tonic neck and tonic labyrinthine reflexes in their assessment of children. They found that they had grossly overrated those reflexes in explaining the abnormal patterns of the hypertonic child. According to Bax, 1986, abnormal reflexes, primitive responses, and muscle tone are the result of the current cerebral pathology of the student. Any changes over time are probably due to a natural developmental process rather than to any mediation by a therapist or medication given to the student. Bax also suggested that therapists who compare the failure to inhibit a persistent asymmetric tonic neck reflex with the prevention of a dislocated hip in the wind-swept child syndrome, will understand the importance of changing the orientation of therapy from clinical treatments to providing skills leading to a productive life. In other words, if a reflex can be "broken up," then it was a habitual movement pattern rather than a true reflex. If it cannot be "broken up," then the student needs to learn how to work and move without being a slave to the motor dysfunction. Regardless of the etiology of the movement patterns, the therapist can help a student perform functional activities such as eating, while learning appropriate movement patterns. Back to Frequently Asked Questions Question 6:
What do you do about dislocated hips, scoliosis, and other joint deformities?According to Bleck, 1984, the most common and serious structural change in children who have severe physical disabilities is dislocation or partial dislocation of the hip. This deformity is seldom present at birth but develops as the child grows older and experiences abnormal muscle pull from spastic muscles, femoral torsion, and the lack of bearing weight on the legs. As one set of muscles pulls the leg in one direction, the corresponding set of muscles fails to balance the pull; then, the femur (thigh bone) moves to a position away from the acetabulum (hip socket) until the femur has no shelf on which to sit. Bleck noted that some children with cerebral palsy do experience osteoporosis (brittle bones) but it is almost always limited to children who have total body involvement, are dependent on wheelchairs, and spend much of their time lying down. The osteoporosis is overwhelmingly due to lack of weight bearing and proper stress on the bones. Bleck's study also observed that dislocation of the hip is found almost exclusively in people who have total body involvement and are non-ambulatory. If a child learns to walk by the age of four or five, Bleck concludes, the probability of hip dislocation will be greatly reduced. Children who become household walkers and use assistive devices for partial weight bearing may retain the subluxation (partial dislocation) but they will not have totally dislocated hips. The ability to walk is a major influence on hip dislocation. Generally speaking, a person who has the combination of a flexion contracture of the hip due to iliopsoas spasticity and femoral torsion will have hips that dislocate if the person is non-ambulatory and spends the majority of time sitting or lying down. On the other hand, a person who is partially weight bearing is likely to have subluxation of the hips and a person who is fully weight bearing will have normally located hips. Scrutton, 1984, adds that scoliosis is usually secondary to pelvic asymmetry. If one hip dislocates, the child does not have an even foundation for sitting and it is impossible to align the trunk over the hips. If the child attempts to align the trunk over the hips, the spine must compensate for the uneven foundation and curvature results. Pelvic symmetry seems to be important in preventing scoliosis. The factors important to preventing hip dislocation and thus pelvic asymmetry, are abduction (separating the legs), external rotation of the legs (keeping the knees from turning inward), and early weight bearing. In summary, the best way to prevent hip dislocation, pelvic asymmetry, scoliosis, and brittle bones is to provide the child with many opportunities to bear weight on the legs in an aligned position. One orthopaedic surgeon recommended aligned weight bearing for all non-ambulatory students regardless of hip formation UNLESS pain is present. If the student is experiencing any pain or discomfort, surgery may be the only alternative. Back to Frequently Asked Questions Question 7:
Aren't some children too retarded to learn to walk?Before we can address this question, we need to explore our definition of the term "learn". It is true that human babies, unlike most animals, cannot walk immediately after birth. Most people "learn" to walk automatically around the age of one without any active intervention or teaching process. The most important and possibly the only necessity for automatic walking is that the motor areas of the brain have not been tremendously damaged. Experience, or the chance to practice the movements necessary for walking, keeps muscles from atrophying while the brain matures; but lack of experience does not seem to play a vital role in learning to walk. Studies with American Indians and Eskimos who kept their children in papooses as well as children who have been ill or restrained during the first months of life indicate that they quickly "catch up" when given the chance. Damage to the cognitive areas of the brain seems to have little or possibly no effect on learning to walk. Bleck, 1984, reported that mental retardation had little if any effect on the ability to walk. In 1979, Shapiro, et al, (in Bleck , 1984) studied 152 children with profound mental retardation. These children had neither an acquired nor a progressive degenerative disease. The majority of the children who had no major neurological disability walked by the age of six years; however, only 10 percent of the children who had both mental retardation and cerebral palsy learned to walk. These authors concluded that the major determinant for learning to walk was the lack of brain damage to the motor areas of the brain. Cognition was a far less important determinant. The conclusions that most experts draw from the existing information is that damage to the cognitive areas of the brain alone may slow down the process of automatically learning to walk but will not preclude walking. Back to Frequently Asked Questions Question 8:
At what age should we stop trying to teach a child to walk?Bleck and Nagel, 1982, share the opinion with many others that walking patterns are basically set by the age of seven and that nothing will change appreciably beyond this age. They conclude that a number of children will never walk and certainly by the age of seven, those who are going to walk with or without assistive devices will have done so. This information can be found repeatedly in medical literature. Almost everyone agrees that by the age of seven, those children who are going to learn to walk automatically will have done so; but that does not answer our question: Can we TEACH children to walk after the magic age of seven? Our studies have shown that almost all children can improve their motor skills if those skills are taught systematically. The exceptions have been those children who have degenerative motor diseases, those who are totally paralyzed, or those whose medical needs supersede the need to improve their ability to sit, stand and walk. Some of our students have become independent walkers while others need help to maintain balance. But all of them continue to improve long after seven years of age. Our original goals (weight bearing only) were far below the goals we set today. We were expecting the children to reach their peak around Level II. Almost all of them have gone far beyond those goals and we have now come to the conclusion that people will probably continue to learn as long as we continue to teach them. Back to Frequently Asked Questions Question 9:
The MOVE (Mobility Opportunities Via Education)® Program is designed to help individuals who are non-ambulatory improve their abilities to sit, stand and walk while participating in functional activities. Prompts, ranging from hip belts to foot straps, are used as necessary and faded as soon as possible. Students/clients are placed in a functional sitting position. Leaning forward about 10 degrees with their feet flat on the floor makes it easier to:
The addition of weight bearing and moving in an upright position has further benefits.
Bone health improves because pressure or weight on the bones keeps them healthy and helps prevent osteoporosis and deformities. Habitually incorrect positioning of the spine may cause scoliosis, or curvature of the spine, by too high, too low or uneven muscle tone. This can be prevented, or at least delayed, by proper support and positioning of the body and by giving the individual the opportunity to learn to control his muscles. The hip joint is a ball and socket joint. In babies, the socket (acetabulum) is small and doesn’t curve very far around the ball (of the femur). The development of the socket is a result of pressure or weight bearing on the joint. When a baby fails to walk or crawl at the regular time, the joint doesn’t develop normally; when muscle tone is abnormal, it is easier for the femur to be pulled out of the hip socket. As part of the MOVE Program, students are placed in a weight bearing position, thus helping to prevent dislocation of the hips or to stop them from getting any worse. Bowel functioning often improves, due both to the exercise they get and to their correct body alignment when sitting on the toilet. Also, because it is easier to place a student on the toilet once they have the sitting skills, they are taken to the toilet more often rather than changed on a changing table and so are more likely to become toilet conditioned. As a person gains motor skills, he becomes easier to look after at home and at school. An individual who can stand for 30 seconds can be helped out of his wheelchair and be pivoted onto a regular chair or his bed. A person who can stand for one minute or more, can have his diaper removed while standing up before sitting on the toilet. This means the caretaker will never have to lift or carry him. This is important as the student grows taller and heavier. As mobility skills improve, a person has better access to the community. A young person who can walk 50 feet with one hand held can walk from the house to a car, sit in the car and then walk into a restaurant or theater. The family is more likely to include this child in family outings if they do not have to use a van with a lift, load and unload equipment, or carry him; the wheelchair can be left at home. People who can sit on a regular toilet can use public restroom facilities, another important consideration on longer trips out. Also, there are great benefits for the teacher. She sees progress in her students as they becoming more functional in everyday settings. The MOVE Program gives her a framework by which to measure student success and gives her the feeling that she is teaching her students something of value and importance. Back to Frequently Asked Questions Question 10:
We know that some of our tiny tots are going to grow up with severe physical and learning difficulties. We also know that if these children do not have the opportunity to practice sitting, standing and walking when they are 7-15 months old, the time when children are normally experimenting with weight bearing and learning balance, the possibility of these tiny tots learning mobility skills is lowered. The MOVE Program encourages early movement and learning and can be used alongside developmental approaches like Bobath (NDT) to help facilitate the acquisition of movement skills. MOVEMENT IS THE FOUNDATION FOR LEARNING. Movement is learned by action-reaction. Children learn when they see something that fascinates them; they want to roll toward it, to feel its texture or to explore its properties. Movement teaches children about themselves and their environment, about concepts like up and down and in and out. It is also through proprioception (pressure on the muscles and joints) that they find out what their body is like; head goes on top, feet are underneath. If children do not have movement skills it becomes difficult for them to learn about themselves and about their environment, creating gaps in their early learning concepts. The MOVE program helps fill these gaps. It encourages parents, therapists and teachers to observe and find out what the child would really like to be able to do and task analyze ways to help the child and family achieve success. MOVE works by setting up simple, clear goals to help the child play, communicate, explore and learn with increasing independence. It sets up a framework for finding ways in which children can move. It is up to us as parents, educators, therapists and friends to provide them this opportunity. Back to Frequently Asked Questions Question 11:
Most children are sitting and weight bearing in standing by 9 months of age (corrected). Children with special needs can usually benefit if given opportunities to work on those skills at or soon after the age-appropriate times, along with other developmental skills. It takes them longer to fully develop the skills, but it is important to give them some of the learning opportunities available by being more upright. Standing in a dynamic stander or gait trainer allows a child to bear weight and work on head and upper extremity control. For children in day care, it allows them to be at peer height. Baby departments and toy stores now have equipment that sometimes works well, particularly for less involved children, to help them stand or walk. For low-tone children, some of the bouncers and stationary exersaucers are helpful. The child should be monitored very closely in any equipment or position. The child should not be allowed to go into extremely abnormal patterns (such as total body extension or looking only in one direction) that would stop further development. Many times, however, as a child is assisted in standing, walking or sitting, head and extremity control become more symmetrical and functional within the first few minutes of working on it. When the pattern improves and then deteriorates again, it is often caused by fatigue and is a signal that it is time to rest or go on to something else. Giving a young child opportunities to move and make choices enhances their learning. Extra support should be given for safety and security while enabling movement. Giving priority to movement helps the child build strength and control. More prompts (supports) are used initially, and then removed gradually as the child gains control and balance. Removing prompts too quickly can cause a child to be fearful. Health is a major consideration. Upright positioning and movement help move and clear secretions. However, ear infections, surgery, major seizure episodes etc. can cause a loss in skills. Patience, time and improved health usually help the child regain the skills. It is important not to get discouraged and give up on MOVE activities. When the children are ill or recovering, watch closely for their physical cues to tell you how much activity they can handle. If they are weak or feeling bad, do activities they can tolerate and stop when they fatigue, even if it is much less than usual. Sometimes it takes weeks or months to get back to baseline. MOVE activities are also a good time to work on communication skills. The child’s body language, vocalizations, eye gaze, and affect are all ways the child is communicating. For example, MOVE activities often give the child opportunities to look at or go toward a favorite toy or person, express pleasure about a certain activity, indicate "more", or make a choice as to which toy or activity to do first. Sitting, standing, and walking are good activities to incorporate into group or peer situations. This really helps (when it is available) with motivation, communication, and choice making. Combining MOVE with early intervention helps a parent or caregiver know what to work on and how to recognize and measure progress, enables choice making and communication, and includes activities throughout the day that give children opportunities to practice sitting, standing and walking. Back to Frequently Asked Questions |