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Assistive Technology: Creating Independence for Students with Cerebral Palsy - January 2010

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Assistive Technology: Creating Independence for Students with Cerebral Palsy

By: Liz Bell, DPT, ATP


As a PT working in the school setting, I sometimes feel like I spend as much or more time getting equipment ordered, delivered, adjusted, adapted, and repaired for my students as I do performing actual hands on therapy ….and there is nothing wrong with that.

IDEA, Individuals with Disabilities Education Act, defines an assistive technology device as any item, piece of equipment, or product system, whether acquired commercially, off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of a child with a disability.

IDEA defines assistive technology services as any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device.

When I began as a pediatric PT 16 years ago, I asked myself … how do I decide on an appropriate piece of equipment? When or why would I use this over that? Am I making my students independent by giving them equipment or making them dependent on the equipment?

I recall meetings with outside clinicians informing me that giving a student with Cerebral Palsy a walker too soon would prevent them from ever walking independently, a wheelchair too soon would cause my student with Muscular Dystrophy to deteriorate faster, and using a gait trainer with a student with CP might destroy the student’s ability to EVER use a standard walker because ALL gait trainers create dysfunctional patterns and postures…I was told NEVER to use them!

The message 16 years ago was clear; adaptive equipment issued by a Physical Therapist was to be used as a last resort for a child with cerebral palsy and could actually impede the functional progress of some children. Use of Adaptive equipment, especially certain mobility aides, could hold a child with CP back from achieving their full potential. Fortunately, times have changed and the medical community has embraced the use of adaptive equipment and assistive technologies of all kinds to enhance the function and independence of those living with physical impairments. I hope to share some thoughts and ideas for using Assistive technology with students with CP.

To begin, let me give you my very general definition of Cerebral Palsy. Cerebral Palsy is a condition in which damage to the brain causes a miscommunication between the person’s brain and their muscles. How that miscommunication presents itself and impacts each individual will obviously vary.

So what do we do for a child with CP? Do we jump right into treatment and focus all our time and efforts on the neuroplasticity of the human brain? Do we stretch and bend and facilitate muscles hoping that with repetitive stimulation the brain cells surrounding the damaged area of the brain will change in their function and shape. The function and shape of these undamaged cells could begin to take on the functions of the damaged brain cells? At least, that’s what we’ve been taught. Or do we find adaptive equipment and devices to enhance and replace function lost by damage to the brain. Or do we do both? The answer, as with many such complex questions, is…it depends…

While no two individuals with CP are exactly the same, there do tend to be some similarities. There are similarities in the way a miscommunication between the brain and muscles will impact the human body. The fact that there is a miscommunication means there will be “abnormal muscle tone.” This miscommunication may either produce an increase in tone which may pull the body into postures that increase energy expenditure, decrease motor control, and may even contribute to joint deformity or it may produce a lack of tone which may limit active movement. Regardless, a PT must always address tone in the child with CP.

As experienced therapists will tell you, abnormal muscle tone can be influenced for short periods of time via various types of therapeutic touch and techniques. It’s during those short periods of time we are hoping to strengthen muscles and promote alternative more functional patterns of movement; in essence, banking on the neuroplasticity of the human brain. However, once the therapist’s hands are off, all too often, the student with moderate to severe CP will experience the return of their abnormal muscle and find very little change in functionality.

So what can we, as PTs, do about abnormal tone long term? The answer is….a lot. Even though we can’t wave our therapist wands and make abnormal tone go away, we can play a big part in addressing the functional effects of abnormal muscle tone. One way to address the effects of tone is by promoting the appropriate use of orthotics.
The right orthotic intervention combined with the right mobility device can produce amazing results in enhancing functional mobility. One mobility device that I’ve grown particularly fond of is called a Smart Walker http://aodmobility.com/docs/SW_brochure.pdf Early on in my career I was often frustrated by results I got using mobility devices for students with moderate to severe CP . Many of the children couldn’t fix their pelvis sufficiently in a sling seat or even on a hard seat enough to control their trunk and produce an effective stepping pattern. I felt as if I needed 4 hands to facilitate the patterns I wanted.

The Smart Walker device, which is customized to each user, in essence attaches an orthoses to the mobility device and supports the student like nothing else I’ve used. I had a student who could only walk independently with this device. All other gait trainers and walkers I tried left him dependent on caregivers who had to assist with continuous support and facilitation.

Another favorite mobility device of mine in recent years has become the power assist wheelchair. Some of my students with milder impairments have benefited and gained greater independence from a power assist wheelchair rather than traditional powered chairs and scooters. These chairs can be self propelled similar to a manual wheelchair by the user pushing on the wheels. The advantage of these power assist chairs is the functionality they provide. A lift van isn’t required to transport these lightweight chairs. The wheels easily pop on and off and a teenager can pick up their friend with a physical impairment, throw their chair in the trunk, and take a trip to the mall or out to a movie. This has been wonderful for some of my high school students. The user isn’t limited to where they can go and who they can go with because their powered wheelchair requires a lift van.

I asked two very experienced Physical Therapists who work with children and young adults diagnosed with cerebral palsy about some of their favorite pieces of Assistive Technology and how they’re using them in combination with their hands on PT interventions…

Susan M. Simcock, M.S., P.T. reported that during her PT sessions, in addition to addressing vital functions, improving head, neck and trunk control, and working to reduce reflex dominance, she uses equipment to prevent deformity and assist with gait training. “I use supine and prone standers, abductor wedges, and splints to prevent contractures and gait trainers are excellent motivators to begin basic ambulation skills.” Ms. Simcock said. Using AT equipment combined with hands on techniques, such as, manual contacts to facilitate muscle contractions and approximation to facilitate co-contraction, seems to work well for Ms. Simcock.

Karen Pierz, PT, MS, Early Childhood Special Education has developed “whole class activities” in her school district. Her early childhood students with and without physical impairments assume prone on elbows, tall-kneel, and half-kneel positions, for a story and 2-3 songs during the day. Ms. Pierz reports, “They all need the practice, and then my student who has a physical impairment doesn't feel singled out. I see improvement in these positions for the whole class when I incorporate them into my motor groups.”

Ms. Pierz has 2 students on her caseload, at the moment, both s\p bleeds in the cerebellum. Says Ms. Pierz, “I have been using standing frames with as little support as possible, but enough to let them know where their center of gravity is and have the experience of standing in one place. They have both become more focused, less irritable, and have increased their participation in the group activity. The 2 speech paths in these rooms also position the children this way for speech and have seen improvement.”

“The Rifton high back mobile chair is also a favorite of mine and staff, says Ms. Pierz, they adjust easily, move easily around the school, and have a low profile for such a supportive piece of equipment. The ease of transitions from task to task allows the children to be more available for the next task.”

“As far as home programs, for my EC children, I always encourage the parents to buy a 16" ball from Target and use it as their child's TV watching seat. As they progress to ambulation and are working on curbs, I send home a 3-4" thick piece of foam (14x16) that I have drawn different shapes on. The parent calls out a shape and the child stands with the foam in front of them and lifts their foot to touch that particular shape. With my children with hemiplegia I send home swim fins to walk around in to encourage dorsiflexion, reports Ms. Pierz. These examples remind us that even an off the shelf toy can work extremely well as a low tech piece of assistive technology.

The important thing for therapists to keep in mind is that assistive technology, whether it’s a swim fin or a 6 thousand dollar stander, can positively impact the function of a child with CP. While we are doing our hands on treatments, it’s important to keep in mind that taking our hands off and letting a piece of assistive technology do some of the work can be a very good thing.



RESOURCES

Huang, I-Chun; Sugden, David; Beveridge, Sally. "Children's perceptions of their use of assistive devices in home and school settings" Disability and Rehabilitation: Assistive Technology 4.2 (2009). 10 Dec. 2009
http://www.informaworld.com/smpp/content...0802613701

Krause J, Carter RE, Brotherton S. Association of mode of locomotion and
independence in locomotion with long-term outcomes after spinal cord injury. J Spinal Cord Med. 2009;32(3):237-48. PubMed PMID: 19810625; PubMed Central PMCID: PMC2718818.

Salminen AL, Brandt A, Samuelsson K, Töytäri O, Malmivaara A. Mobility devicesto promote activity and participation: a systematic review. J Rehabil Med. 2009 Sep;41(9):697-706. Review. PubMed PMID: 19774301.



This Month's Featured Author: Liz Bell, DPT, ATP.

Dr. Elizabeth Bell is a Doctor of Physical Therapy and a RESNA certified Assistive Technology Professional who has 17 years experience providing assessment, training and instruction in the areas of Physical Therapy and Assistive Technology. Dr. Bell has presented numerous workshops related to both Physical Therapy and Assistive Technology Practice and has been approved as a Physical Therapy CE sponsor by the Illinois Department of Professional Regulation and meets all requirements for PT CE providers in the state of Illinois. IDPR Physical Therapy Sponsor License No: 216-000172.




Tags: January 2010 Newsletter PT Cerebral Palsy Assistive Technology Article