Pediatric PT can often feel like a world apart from other areas of PT practice, and within that specialty sits school-based intervention. Narrow that field even further to preschool early intervention - now there's a unique practice area. I've been working with NEIU #19's Early Intervention (EI) Program for more than 20 years.
It's easy to see what makes EI so different. Our team is made up of professionals who may or may not have a medical background - teachers, teacher assistants, personal aides, speech pathologists, occupational therapists, physical therapists, social workers, nurses, service coordinators and of course, the child's family. Our service is provided in non-clinical settings like typical preschools, Head Start classrooms, specialized early childhood classrooms, day care facilities and homes.
And then there are the children. They are young, just 3 to 5 years, and they become eligible for EI by showing a 25 percent delay in one or more areas of development. PT is added to the EI program when the team identifies gross-motor problems that impact the child's participation in the preschool program, such as limited balance or difficulty walking. It's my job to improve a child's gross-motor skills so he can participate in all aspects of his preschool-age program.
The challenges are huge. The children might be medically frail, have short attention spans or be unable to follow verbal directions. Add that to the typical childhood desire to avoid difficult tasks, and you're beginning to see the picture.
Best practice in pediatrics is to translate our PT tasks into play activities. "Step-ups" needed for hip and knee extensor strength, for example, might be done as the child builds a block tower or colors on a vertical surface. But what's a PT to do when play won't entice a reluctant preschool child to engage in gross-motor activities?
A possible solution to these challenges is for the PT to engage the whole preschool class in a fun gross-motor activity. Group play creates peer models, showing the reluctant child that movement can be fun.
To explain how I've made this work, I'll use Joseph as an example, a 4-year-old boy who attended a specialized early intervention class. All the children in Joseph's class had developmental delays, but he was the only child who received PT. He had a diagnosis of cerebral palsy and used a wheeled reverse walker to navigate his preschool. His gross-motor annual goal was to stand unsupported for 20 seconds and take three independent steps during free play.
Joseph liked table-top activities, songs and being with his classmates. He moved slowly and cautiously, was frightened by rapid movement and was afraid of falling. This limited his ability to tolerate balance challenges and reach his gross-motor goals. Since classic individual PT would separate him from his peers and challenge his balance, both non-preferred activities, I was concerned that Joseph might react negatively to PT intervention. I wanted to avoid that.
I described my dilemma to the classroom teacher, and we agreed on a possible solution: a classroom-wide group gross-motor activity. I explained that she and her staff had to manage the other children's participation in the activity; I was there only for Joseph and my obligation was to him. She understood. We were on our way.
As I started setting up a large floor mat and surrounding it with unfolded sheets of newspaper, the children wandered over. "What are you doing?" and "Are we gonna get to play too, or is this just for Joseph?" and, best of all, "Hey Joseph, Miss Jeanne has something really cool today!"
The teacher and I asked the class to gather around the mat. Joseph came with his friends, then stood beside me and leaned against his walker. I said, "Who wants to have a snowball fight?"
"Me!" came the response a dozen times over.
"Me, too!" I said, then squatted down and grabbed a sheet of newspaper, crumpled it, and threw it across the mat at the teacher. Laughing and squealing, the children repeated my action, squatting and crumpling and throwing over and over. Joseph was trying to join in the fun, so I manually guided him through a dozen repetitions of squat to stand so he could grab some newspaper and crumple it. I supported at his pelvis during a dozen reps of lifting his arm overhead to throw. A few times, I was able to release my support, just for a second or two. He had stood unsupported! The pleasure on his face made it clear - he enjoyed playing with his friends and
didn't notice that these balance challenges were the same tasks he had found frightening in isolation.
Soon, a heap of wrinkled newspaper lay on the mat. We heel-sat around the pile of snow and buried our hands, then long-sat and buried our feet, and then asked for volunteers who wanted their whole bodies buried in the snow. Joseph watched his friends lay in the snow, then while tall-kneeling, bent and tossed handfuls of paper on top of them.
The children took turns making snow-angels, then being a "snow plow" (crawling), and walking through the snow. The teacher brought over a 10-inch-high bench, and the children jumped into the snow. As long as his friends went first, Joseph eagerly tried each of these tasks, even walking through those uneven heaps of paper with one hand held, stepping on and off that raised surface, before collapsing into the snow with a giggle.
When cleanup time inevitably came, the teacher asked the children to place all the crumpled newspaper into three white garbage bags. This presented more opportunities for Joseph to practice squat to stand, and more balance challenges while reaching out of his base of support. The teacher then stacked the three bulging bags on top of each other and, voila, a snowman was born. Later that day, the occupational therapist was only too happy to have the children create eyes, mouth and buttons for our snowman, and even dressed him up with a scarf and hat.
During the 30-minute activity, Joseph moved between squat and stand dozens of times, did some unsupported dynamic balance in heel-sit, tall-kneel and long-sit, stood with one-hand support and briefly without support a couple times, stepped on and off a raised surface, and walked across an uneven surface with one-hand support. I was pleased with his participation - he had allowed many different balance challenges and sensory experiences without showing his usual fear of falling.
We continued group gross-motor activities in this manner with Joseph's class for several weeks. Then one day, his teacher called me with news - during free play time, Joseph had taken his hand off a support surface and took a single unsupported step to a nearby toy. He was on his way to meeting his PT goal.
Jeanne Moran is a physical therapist for the NEIU #19 Early Intervention Program based in Tunkhannock, PA.