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The Power of Play

Fun meets function when treating children with mobility challenges

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When Lisa Mackell, MPT, saw a strong need for a pediatric business that could service children from neonatal hospital discharge through school age, she decided to do something about it. In 1991, the pediatric physical therapist founded Theraplay Inc. in suburban Philadelphia, which incorporates pediatric therapy services in a play environment.

Physical, occupational and speech therapists are employed at Theraplay in various settings, including homes, outpatient centers, and schools. Special education teachers are also employed for early intervention services.

"Regardless of where the child is receiving therapy or why the child needs therapy, a therapist works diligently to ensure that the therapy is provided in a fun and motivating environment," explained Mackell.

All types of pediatric therapeutic needs are treated at Theraplay, from very subtle developmental delays to severely physically involved children. Therapists are experienced in treating newborn infants with brachial plexus injuries, premature infants with delays, children with autism, children with language issues, and children with mild-to-severe sports injuries.

To deliver the best and most comprehensive care, therapists understand the importance of working closely with many professionals, said Erin Fitzsimmons, PT, DPT, physical therapy coordinator at Theraplay's office in Horsham, Pa.

"At Theraplay, we treat our patients with a team approach and this carries over to include the disciplines of occupational therapy and speech therapy," Fitzsimmons remarked. "Many people feel that it's as simple as 'the PTs treat the lower extremities and the OTs treat the upper extremities,' but it goes so much further than this."

The PT/OT Partnership

Fitzsimmons' background in physical therapy began when she was a young patient receiving treatment for sports injuries. She started with Theraplay as a PT student in June 2011, embarking on her final six-month clinical affiliation.

"After graduating from Arcadia University in January 2012, I began working as a full-time therapist in the Horsham office and have been there since," she said.

At Theraplay, Fitzsimmons said physical therapists carry out hourly treatment sessions that are therapeutic yet fun for the patient. Beyond this, their role involves educating the patient and caregivers, participating in educational opportunities and training, and marketing to educate nearby physicians, nurses, teachers and parents about various diagnoses and the benefit of physical therapy. PTs also communicate daily with other professionals regarding the care of patients, including orthotists, physicians, and school personnel.

The majority of patients at Theraplay present with global limitations, so collaboration is key. PTs and OTs work together to provide comprehensive care and bring different backgrounds to work on various goals. Fitzsimmons said this partnership benefits both the children who are treated as well as the therapists.

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Erin Fitzsimmons, PT, DPT, [left] works with young patient Tori Eccleston at Theraplay Inc. in Horsham, Pa. Therapy is weaved into fun activities the child can relate to, and co-treatments with therapists such as Marianne Cramer, MS, OTR/L, [at right] bring different perspectives and backgrounds to the plan of care. "We make sure to take into consideration all aspects of the child's life," Fitzsimmons said.

"There's a lot of overlap between the two disciplines, and coming from different backgrounds it is beneficial to work together to learn from each other to provide the best care," she shared.

In addition, it's recommended that many children receive all three disciplines twice a week.  However, when it's appropriate for the patient, co-treatments are recommended. These co-treatments maximize therapeutic interventions within a session and allow for the two therapists to work together to problem solve or provide hands-on therapy.

"During a co-treat, the PT might address the child's posture and sitting balance that are essential to complete fine-motor tasks that OTs are focusing on. Another example includes an OT addressing visual-perceptual limitations while the PT focuses on strengthening muscles to work together to help the child walk up and down stairs safely," Fitzsimmons said.

At Theraplay, therapists are responsible for writing letters of medical necessity to obtain equipment being recommended.  

"We will spend time discussing each discipline's goals and desired effects of the intended equipment and use this to draft our letter. In addition, we make sure to take into consideration all aspects of the child's life, including home set-up, caregiver training and support, financial means, and daily routine," Fitzsimmons said.

Pediatric Mobility Limitations

At Theraplay, therapists treat mobility limitations in children from birth to 21 years old. However, the term "mobility issue" is broad and can range from a child who has difficulty keeping up with peers in school, to one who is learning to negotiate his environment with a wheelchair.  

"Mobility is not limited to simply walking, and as PTs, our goal is to help children achieve mobility in the most energy-efficient way," said Fitzsimmons.

There are many causes of mobility limitations in children - congenital disorders such as cerebral palsy and spina bifida, hypotonia, generalized muscle weakness, decreased range of motion, chronic illnesses, infections, concussions, visual limitations, skeletal injury, pain due to conditions such as juvenile rheumatoid arthritis, as well as conditions involving the cardiac, pulmonary, gastrointestinal or nervous systems.

In Theraplay's infant population, mobility issues are most often due to prematurity, brachial plexus injury, hypotonia, torticollis or GI conditions such as reflux. These mobility limitations include difficulty with transitional skills, rolling, crawling, or even moving symmetrically.  

"For instance, a child with reflux may spend little time on his belly and become delayed in skills such as transitioning to quadruped and crawling," said Fitzsimmons. "Another example is a baby with torticollis who develops a preference for one side of his body due to asymmetry in strength, which carries over into atypical movement patterns. Later in life, we treat children with mobility issues due to cerebral palsy, toe-walking and muscle weakness."

These limitations affect how children complete daily skills, as well as how they walk, run, jump and keep up with peers. Fitzsimmons gave an example of a 2-year-old girl with a rare birth disorder that has led to low muscle tone and muscle weakness, and has limited her ability to ambulate independently. Another example, she noted, is an 8-year-old boy who is struggling to navigate his environment in his new power wheelchair.

Toe-walking, a commonly treated diagnosis, may develop for various reasons, and affects a child's visual, sensory and vestibular systems, which leads to difficulty keeping up with peers.  

Most of the older children seen (aged 13-21) are referred following an injury or surgery that has affected their mobility. They receive therapy to get back to ambulating without assistive devices and returning to sports.

Prescribing Exercises

The list of exercises recommended for children with mobility limitations is endless, Fitzsimmons said. However, prescribed exercises depend on the issue being addressed, and most involve stretching and strengthening. PTs also work on neuromuscular re-education and apply NDT principles to help facilitate movement.

"For babies born prematurely, I may give exercises to make sure they achieve the alignment and strength needed to move the same way a full-term, typically developing infant would," Fitzsimmons added. "Some examples include a lot of prone play to allow for hip flexors to lengthen and appropriate lordosis to form, hands-to-feet to lengthen hamstrings and strengthen abdominals, encouraging transitions through side-sit to strengthen hip abductors, and a lot of cruising and squatting to develop eccentric strength of various muscles. All of these are essential to develop an energy-efficient, quality gait pattern."

Children who demonstrate toe-walking are prescribed exercises including stretches for the gastroc and soleus muscles, active dorsiflexion with resistance to increase anterior tibialis strength, and posterior weight line training to re-train where their center of mass should lie.  

Many children at Theraplay demonstrate generalized muscle weakness and/or low muscle tone, leading to delays in skills and difficulty with various movements.  

"Exercises for these kids are provided to strengthen and improve endurance. Examples include weight shifts on a ball for core strengthening, animal walks and creating obstacle courses," said Fitzsimmons.

Children who are more involved, and are using or are in need of a mobility device, are given exercises such as practicing transfers with PTs or caregivers, strengthening lower extremities through bridging or sit-to-stands, and stretching to prevent contractures.

Fitzsimmons knew early on that she wanted her career to focus on children. Since starting at Theraplay in 2012, she has attended a variety of continuing education courses to further her knowledge, specifically in pediatrics.

"Physical therapy is an exciting field to be part of, especially in pediatrics, as I'm able to influence the lives of children and watch them grow and develop," she said. 

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Beth Puliti is a frequent contributor to ADVANCE.




     

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