targeted training: an innovative concept for promoting
TRANSCRIPT
TargetedTraining:AnInnovativeConceptForPromotingUprightControlPaulineHolbrook(BA,MCSP),DirectorandClinicalLead
Aboutus
• Weareanindependentcharity
• BasedatorthopaedichospitalinOswestry,Shropshire
• TreatingchildrenfromallovertheUK.
Whowetreat
Wetreatchildrenwhohavedifficultieswithmovementcontrol:• MajorityhaveCerebralPalsybutwealsoseechildrenwhohave;
• GlobalDevelopmentalDelay• DownSyndrome• Geneticconditions• Somewhohavenodiagnosis.
Referrals
• Physiotherapists• OccupationalTherapists• Consultants• GPs• Families(selfreferral)• Casemanagers• Socialworkers.
Wegaincontrolofourbodygraduallyfromthetopdowninasequentialmanner:
• Head• Trunk(upper,middle,lower)• Pelvis• Lowerlimbs.
Physiotherapy
ThechildisreferredtoseeapaediatricphysiotherapistwithintheNHSwhowillworktoassistthemtoovercomethe
obstaclesofpoormovementcontrolsothatfunctionalgainscanbemade.
Mostofourreferralsaregeneratedbecause,despitethisassistance,thechildcontinuestohavesignificantmovementcontroldifficulties.
“Stabilizingtheorientationoftheheadisaprioritytaskforthenervous
system,forthemovementperformancetobeaccurate.”
MassionJ,AurentyR,MouchninoL,DeatA(1991)
Gaining head control
Trunkcontrol
(images from PDMS II)
• Trunkcontrol(childrenandadults)istypicallyassessedbytheabilitytogetinandoutofsitandabilitytoholdsittingpositionwithorwithoutproppingonarms
• GlobalmeasuresoftrunkcontrolDONOTprovidespecificinformationtoguidetreatment.
Whenitisdifficult
Ifyoudon’thavesufficientneuromuscularcontroltoachieveandmaintainuseful
posturesupagainstgravity,yousoonlearntocheat.
Wemakeiteasierforourselvesbyclosingchains.
Collapse of the spine into full flexion or full extension
Weusethemallthetime.Itiseasytomovebetweenthemwhenyourbodyhasfullneuromuscularcontrol.
Openandclosedchains
Thelesscontrolyourbodyhas,themoreyouDEPEND onclosedchains.
Thedemandforneuromuscularcontrolisreduced.
Neuromuscularcontrolmaybeseverelycompromisedandsubtleuseofclosedchainswillthenstillenableaposturetobeheldandfunctionachieved.
SittingBalance
• AcombinationofClosed andOpenChains
• Thespine/trunkwillbeunderfullactiveneuromuscularcontrolprovidedthatjointsarenotatendofrange.
• AcombinationofClosedandOpenChains
• AfurtherClosedChainhasbeenintroduced
• Onlythecervicalspineisunquestionablyunderactivecontrol
Control can only be identified or improved if Open Chains are used
SittingBalance?
Closedchainsgoodorbad?
Closedchainscanbeavaluabletherapyoption–ifusedatthetherapist’sdiscretioni.e.
rehabilitation.
Iftheyarebeingusedasacompensatorymechanismforhiddencontrolproblemstheymustbeidentifiedandeliminatedbefore
progresscanbemade.Howdowerevealthem?
IntroductiontoSegmental
AssessmentofTrunkControl(SATCo)
Areliable,validatedandinternationallyrecognised
assessmenttoolandoutcomemeasure.
LevelofManualSupport
ControlLevel
Providesregionaldifferentiationoftrunkcontrol.
SATCo:Requiresopenchains
23
65
1
4
7
Static(steadystate)Alignandmaintain5seconds
ActiveHoldalignmentwhileturningheadorreaching
ReactiveMaintainorquicklyreturntouprightwhenperturbed
Threeaspectsofcontrol
• Findthelevelwherecontrolispoor(SATCo)• Provideequipmenttoholdallpointsdistaltothisinanupright,neutralalignment
• Designaprogrammeofspecificexercises• Teachthefamily/carer• Setgoals,includingchild,familyandphysio• Reviewevery8-10weeks,reassessandprogressasable
• Courseoftherapyis9-12months.
ImplementingTargetedTraining
• Carryout1:1exerciseprogrammeeverydayusingtheequipmentprovided
• For30mins(ortwoshortersessions)
• Followadviceandrecommendations
• ReturntoTheMovementCentreevery8-10weeksforreviewandreassessment.
TargetedTrainingathome
• Communicationwiththechild’smainphysiotherapistbeginsatpointofreferral.
• Engineerswhobuildandmodifytheframes
• CommunicationwithOrthotistwhenspecificrecommendationforAFOsortuning
• O.T.,Consultant,classroomassistants,carersincludedasdiscussedwithfamilies
WorkingwithotherProfessionals
AchildwillstartTargetedTrainingwithsupportattheappropriateleveland
progressdownwardasfaraspossibleascontrolisgained.
Atotallysupported‘safe’childmaynotlearn….
Benefits
• Providesadailyinputoftherapy• Doesnotrequireprofessionaltodeliver
• Easytolearn• Empowersfamilies• Complementsstandardphysiotherapy
• Investmentforthefuture.
Collaborations
OngoingcollaborationwithMMUandLJMUandKeele Universityregarding:
• Servicedevelopment• Usingtechnologytoenhancepatientexperienceandservicedelivery
• Teachingonpostgraduatecourse
TheChallenges
• Assessmentstake2-3hours• Fundingisnotsimple• Equipmentisbespoke• Someresistancefromclinicians
• TrainingrequiredtodeliverTargetedTraining
• OnlinepresenceandSocialmediause
TheTeam
Clinical:Physiotherapistsandphysiotherapyassistants.NonClinical:Marketing,fundraisingandfinancialmanagement.
Butwebothhavetospeakeachother’slanguage,andfacilitateeveryaspectofourwork.
Fundingourwork
TheMovementCentreisaregisteredcharityand,assuch,wedonotautomaticallyreceiveanyNHSfundingbutrelyonvoluntaryincometocontinueourwork.Inordertodothis:• WeapplytoindividualTrustsandFoundations• Weworkwithcorporatepartners• Werun,andassistotherstorunfundraisingevents• Throughraisingawarenesswereceiveindividualdonations.
Fundingthetherapy
WeaimthateverychildwhocouldbenefitfromTargetedTrainingisabletoaccessthetherapy,therefore:• Weapplyto CCGsthroughthe IFRrouteforindividualchildren,butthemajorityarerefused
• Ourfundraisersworkwiththefamiliestoestablishafundingpathway
• WeidentifyTrustsandFoundationsthatfamiliescanapplytoandassistwiththeapplications
• Wehelpthefamilieswithfundraisingevents• Familiescanapplytousforsupportfromourownfundraising.
OnlineandSocialMedia
Thisplaysakeyroleinallaspectsofourwork.Itisvitalforour
marketing,ourfundraising efforts,communications,andcreatesa
communityforoursupportersandfamilies.
TwitterandFacebook
Thisgivesusaplatformtoengagedirectlyandindirectlywithmanyvariedaudiences.Thiscreatesaculture,whichsupportsourserviceusersfromstarttofinish.Findusat:• Twitter:@TMCOswestry
• Facebook:/TMCOswestry
TimeInvestment
Tomakethisworkitisvitalto:• Beproactive,constantlymonitoringandupdating,andproducingcontent
• Engagewithothers• Bereactive;respondingtoenquiriesfromnewandcurrentfamilies,fundraisers,andotherorganisations.
Thiscanbeafulltimejob!
TheFuture
• Ongoingresearch• Trainmorephysios• Equipmentavailability• In-houseorthotist• OtherlocationsintheUK• Reachmorechildren