To pediatric therapists, each workday is often filled with both challenges and rewards. The difficulties children with developmental disabilities face on a daily basis can certainly test a therapist's professional skills. But the elation those same kids feel when they reach a goal is enough to warm anybody's heart.
Mobility is one area of pediatric therapy that encapsulates both aspects. Megan Acquaro, PT, DPT, and Kathleen Kane, MS, OTR/L, know this firsthand. They comprise the two-person, OT/PT team at JAG Pediatric Therapy, which opened in November in West Orange, NJ, and now serves around 15 children. The clinic is a subdivision of JAG Physical Therapy, founded by John Gallucci Jr., MS, ATC, PT, DPT, and including six New Jersey locations.
Patients present with conditions such as cerebral palsy, developmental coordination disorders, fine-motor delay, gross-motor delay and Marfan syndrome. They range in age from four months to 12 years.
Independence in mobility can lead to progress in many other areas for young patients, including socializing with peers and succeeding in school. Kathleen Kane, MS, OTR/L, helps patients and their families at JAG Pediatric Therapy in West Orange, NJ, integrate the most appropriate mobility devices into their lifestyles.
Acquaro, clinical director at JAG Pediatric Therapy, has been a physical therapist for three years and previously worked at Children's Specialized Hospital in New Jersey. Additional diagnoses she treated there included spinal cord injuries, spina bifida, brain injury, infant prematurity and torticollis. So which pediatric conditions are most likely to create a need for mobility devices?
"Definitely spina bifida and cerebral palsy," Acquaro related. "Spina bifida seems to be the most prominent in terms of mobility itself being the primary goal for parents. Often because there isn't an additional cognitive component-it's just the physical mobility that needs to be addressed."
Mobility options vary depending on the age and status of the patient.
"A lot of times the goal is ambulation in any way. So, often they're starting off in a gait trainer with progression to a walker. Sometimes when they're very little, if they're not ready for gait training necessarily or the focus is more on treatment than mobility, I've used a mobile stander to help children get around the classroom and be able to interact a bit better with their peers."
When it comes to choosing the appropriate mobility device for a child, therapists can have great influence.
"I think many times the therapist plays a big role because she's seeing the client or patient every week, depending on the frequency of therapy," said Acquaro. "So the PT or OT is the one who's trialing the device in weekly sessions to determine what would be most appropriate. Often physicians will write a prescription based on what the family wants or what they think is most fitting. Then it's up to the therapist to really implement those trials and determine with the family what will work best."
Like Acquaro, Kane helped launch JAG Pediatric Therapy. An OT for about two years, she previously practiced inpatient subacute rehab with adults. Kane also has participated in many clinical rotations at pediatric facilities, ranging from hospitals to outpatient clinics and school systems.
"Pediatrics is my passion," she told ADVANCE. "I have a specialization in pediatrics from school and my dream was always to work in an outpatient pediatric facility, so I was really excited to join JAG."
Kane added that the clinic adheres to a one-on-one patient philosophy.
"We try to schedule it so there's only one child in the clinic at a time," she explained. "We do have separate treatment rooms, so if I'm working with an OT patient, I have my own treatment area with a door that can be closed away from the gym. But it only happens occasionally that a child would be receiving OT from me while another child receives PT from Megan."
Likewise, for children who require both PT and OT, the treatments typically take place on different days and are never combined in one session.
"I'd say about one-fourth to one-half of the kids on my caseload come in two times a week," Kane added. "Usually with those children, the individual treatments range from a half-hour to 45 minutes. Whether because of attention difficulty, fatigue or endurance issues, an hour may be too long. For the kids who come in only once a week, sessions can definitely last an hour. It really depends on my recommendations and what parents feel is most appropriate."
Among the population at JAG, only a few children who have cerebral palsy currently require mobility devices.
"Right now we rent equipment for those families through a local vendor, based on the child's gait training needs," Acquaro said. "We expect to start purchasing more equipment once we have a better idea about what our client base will be going forward."
How do children typically react to the idea of using mobility devices?
"A lot of times the kids are really interested and excited because it's a form of independence they haven't had before," related Acquaro. "So it's great to provide them with some way to get around on their own, be upright and at the same level as their peers. That allows them to explore their environment better and, especially in the classroom, really feel like part of the group."
If children would benefit from a device, Acquaro said it makes sense to start them as young as possible. "Mobility can play such a huge part in the development of all other areas, particularly for their social, emotional and cognitive development. So especially for that independent mobility, the earlier, the better, based on the child. You can start at that 11-, 12- or 13-month age range as long as it's appropriate."
Similar to any assistive device, there are contraindications to keep in mind as well.
"You definitely have to take into account their cognitive and visual ability," Acquaro noted. "You can still implement mobility with those kids, but you have to be a little more careful about what you choose. For example, powered mobility may not be the best option if they don't have the capacity to understand how to use the device or if visual difficulties are a factor."
There can be great monetary differences between various types of mobility devices.
"Especially for those kids who need powered mobility, it can be a huge cost to the family," said Acquaro. "So you really need to take that into account... Powered mobility may be great and what they need, but it might not be appropriate if they're at an age where they're growing really quickly. Because you can't replace a powered wheelchair as easily as you could something else. There's also the outside cost of adapting your car to transport it."
For related reasons, Acquaro likes gait trainers that are easily customized.
"I tend to favor trainers with many different active components that can be modified or removed as the child progresses. I find those work really well, especially if a child may be fast progressing. There are also some kids who just need a walker and not the gait trainer itself."
Insurance coverage inevitably comes into play as well.
"Absolutely, and insurance is changing every day," Acquaro added. "Part of our job is trying to figure out what's happening with insurance and what will be covered by different providers. The therapist plays a huge role in writing letters of medical necessity and also filing appeals if claims are denied."
So if a child uses a mobility device like a wheelchair, for example, what might a therapy session for him involve at JAG?
"It's really important in occupational therapy to work on cognitive and visual abilities," explained Kane. "Such as how he's going to maneuver in his environment and how he's able to get in and out of the chair to play on the floor with other children. It's also working on positioning to set up for fine-motor activities in his school environment. Along with addressing any other underlying difficulties he might be having in his everyday life. Those sessions can also involve a lot of education with parents."
Both Acquaro and Kane noted that although parents almost universally want what's best for their children, some are concerned about negative perception when it comes to mobility devices.
"There can be a stigma attached to certain equipment we want to use," Acquaro related. "For example, when a child is at the point of transitioning from a stroller to a wheelchair. So many times, our job includes explaining to families how important it is for a child to have that independence."
"Just helping them understand that whatever makes the child happiest and allows him to function best in his environment is what really matters," added Kane.
So what drew these two therapists to pediatrics as a specialty?
"Actually the way I discovered pediatric OT was through personal experience," Kane related. "In high school, I babysat my cousin who was diagnosed with autism spectrum disorder. So I was able to see her grow and how independent she became in activities of daily living and school-based activities through all her different therapies. It made me really appreciate OT and how we use that occupation-centered approach to help families and children. I just love seeing kids succeed in their environment."
Acquaro expressed similar inspiration.
"To me, it's really about being able to see kids achieve a level of independence, whether it's through mobility or something else," she concluded. "Helping them reach potential that even their own parents might not have realized was attainable for them."
Brian W. Ferrie is an ADVANCE contributing editor.