texas woman's university and scottish rite hospital

TEXAS WOMAN'S UNIVERSITY AND

SCOTTISH RITE HOSPITAL

Therapy Together

Caregiver Manual 01

Contact Information WELCOME

We are excited you are participating in Therapy Together. If you have

questions, concerns, or need to contact the Therapy Together team, please

don't hesitate to call or e-mail.

HEATHER ROBERTS, PHD, OT

[email protected]

(214) 794-8117 cell

ANGELA SHIERK, PHD, OTR

[email protected]

(806) 470-0006 cell 02

mailto:[email protected]




Therapy What is Therapy Together?

Together

Weekly Sessions

References and Resources

CAREGIVER MANUAL OVERVIEW 03

Therapy Together WHAT IS IT?

Therapy Together is a group based intensive upper limb intervention for children ages 3 months to 4 years 11 months that present with cerebral palsy or are at risk for developing cerebral palsy.

The child and their caregiver attend 1 hour weekly sessions and engage in

therapeutic activities at home for 1 hour each day for 8 weeks. The first 7

weeks of the program focus on constraint induced movement therapy

(CIMT) where the preferred hand is restrained with a soft glove to promote

use of the assisting hand. Week 8 focuses on the use of two hands

together.

04

Therapy Together WHAT IS IT? Group session will focus on coaching the caregiver to implement CIMT with their child in the home environment. Each week the therapists and interventionists will teach 1-2 activity domains of upper limb function (i.e. reach, grasp). Each activity domain will include an explanation of the skill using three levels of performance. The activities will be shaped to create a just right challenge for each child that attends the session.

Activity domains addressed in previous sessions will continue to be incorporated into subsequent sessions. As the child and caregiver engage in the activities, the therapists/interventionists will demonstrate, observe and provide feedback to the child and caregiver to support the child’s success with the task.

Overall, the program aims to improve the child’s hand function, improve the caregiver’s ability to coach their child to achieve goals related to hand function while taking into consideration the individual needs of the child and caregiver. The instruction for coaching and upper limb activity practice will occur during weekly group sessions allowing participants in the program the opportunity for peer support. The majority of the upper limb practice will occur in the home environment.

05

5 6 7 12 13 '\4 19 20 21 26 27 28

Schedule and Location SPRING 2020

Schedule Fridays at 10:00 AM

Session 1: February 14th Session 2: February 21st Session 3: March 6th

Session 4: March 20th

Session 5: March 27th

Session 6: April 3rd

Session 7: April 17th

Session 8: April 24th

Location Scottish Rite Hospital

Dallas Campus

2222 Welborn St Dallas, TX 75219

06

Weekly SessionsTH

ERAP

Y TO

GET

HER

INFORMATION AND HANDOUTS FOR EACH WEEK

07

Weekly Session Overview The TEAM Approach

TOPIC Introduce the topic(s) for the session; upper limb domain(s) plus one other component of the therapy together program

ENCOURAGE Sharing, processing and support (ex: What brought you here? How was last week?)

ACTIVITY Focused on upper limb activity domain and caregiver coaching

MOTIVATE How to implement what was learned at home, activity and toy

recommendations, toy library, feedback on progress made

08

THERAPY TOGETHER

Week 1 Topics: 1.Welcome and review of the caregiver manual 2.Getting started and responding to the child’s cues 3.Positioning 4.Constraint 5.Toy selection

Upper limb domain: initiates use and contact with objects 09

HOW TO START

Prepare for the play session (pg 11). Use novel toys and demonstrations to gain the child's attention and encourage them to participate; then maintain their attention with play and a variety of toys.

HOW MUCH HELP

Allow for extra time for the child to initiate. Provide assistance when needed. Change the task if the current task is too hard or if child looses interest or becomes frustrated.

WORKING WITH YOUR CHILD

HOW TO RESPOND

Encourage the child to complete the task, but do not force them. When they are successful, reinforce and respond positively. They are working very hard.

WHEN TO STOP

Discontinue the session if the child becomes tired or uncooperative. It is okay to split up the hour of activities during the day (example: 4, 15 minute play sessions)

Sjöstrand & Eliasson 10

TOYS

Are your toys ready? (pg 16)

PREPARING FOR THE PLAY SESSION

Sjöstrand & Eliasson

ATTENTION

Are distractions minimized (TV, phone, siblings)?

CHILD

Is your child ready to play (fed, clean, alert, healthy)?

POSITIONING

Do you have a table and chair that is suitable? (pg 12)

CONSTRAINT

Do you have a constraint that works well for your child? (pg 14)

11

Positioning Rules SITTING UPRIGHT

The child should be in an as upright and stable position as possible

WHERE THE CAREGIVER SITS

Sit in front of the child or on the child's involved side. The caregiver should

be able to easily make eye contact with the child.

USE A TABLE

If possible, have the child sit at a table. Infant chairs or child sized tables

and chairs can be used and are often a good height. If a regular sized table

is used, make sure the table is not too high.


12

Positioning Options

NEEDS SOME NEEDS TO BE SITS SUPPORT TO SIT RECLINED INDEPENDENTLY

UPRIGHT

High chair, Tripp Trapp Infant bouncer seat Child sized table and Chair, small pillows for chairs

supportSjöstrand & Eliasson

13

Constraint Infants and young children will typically reach to grasp an item with the

hand that is closest to the item. When a child has difficulty feeling or moving one of their hands/arms, they will naturally compensate by using

the hand/arm that is easier to use. Therefore, a constraint needs to be

placed on the non-involved side to allow for opportunities for the involved

hand/arm to practice skills.

The constraint at this age should be soft and comfortable. The constraint needs to prevent the child from grasping with the non-involved hand, but the hand with the constraint can be used during the play session as a

support as needed.


14

Constraint Options

INFANT SEAT SHIRT SOCK CONSTRAINT MITT

https://serfinitymedical.com/products/deroyal-infant-and-Place the child's arm Shirts that can cover the Hand socks or regular child-hand-control-mittens? variant=29424794566731&gclid=CjwKCAiAzuPuBRAIEiwAkkmOunder the strap hand, use a clip or hair tie socks can be used SHjKvAc2swZAhOV4K95Gw4CAeAFwOAyloqiX2zP4_Bwal8cyTn LrVRoCzxUQAvD_BwE

to off the end of the sleeve

Sjöstrand & Eliasson 15

https://serfinitymedical.com/products/deroyal-infant-and

Toy Considerations Is the child interested in the toy? Is the toy the right size? Is the toy the right weight? Does the toy encourage the child to work on the skill?

Consider items at home and checking out toys from the Therapy Together toy library.

16

Initiates Use and Contact with Items

LEVEL 1 LEVEL 2 LEVEL 3

Work on making contact Work on making contact Work on making contact with the item after a with the item on own with item on own

physical prompt or with initiative initiative with grasp assistance

Toy recommendations: cause and effect toys, toys with texture, lightweight and easy to handle rattles, shakers, toys that have an auditory or visual component to draw attention to the toy

17

Week 1 TOY LIBRARY CHECKOUT

Item number Item description Returned

1.

2.

3.

4.

5.

18

Caregiver Log - week 1 CHILD'S NAME: __________________________________________

WEEKLY GOALS

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

NOTES: 19

D1 ■

Co1mments y 1me

Monday

·uesday

·we 1· nesda·y

hu sday

F .d ' y

Sa r ay

Sun .,a·y

·otal ti e:

CHILD'S NAME: __________________________ Consider: - What went well? What was fun? - What was difficult? What was frustrating? - What questions do you have?Caregiver Log - week 1 - Toys that worked / toys that didn’t?

20

CHILD'S NAME: __________________________

Caregiver Log - week 1 Questions on Hand Use

1. This week, how well do you think your 2. Throughout the week, how often do you child used their affected hand during play think your child used two hands during play sessions with the constraint on? and daily activities?

(1) Not as good as last week (1) Less than last week

(2) The same as last week (2) The same as last week

(3) Better than last week (3) More than last week

(4) Much better than last week (4) Much more than last week 21

THERAPY TOGETHER

Week 2 Topics: 1.Hand development part 1: Typical development of hand skills and

development of hand skills for children with unilateral cerebral palsy. 2.Review of goals for your child based on the pre-assessment.

Upper limb domain: upper arm, reaches

22

Approx Age of Onset

(months) Fine Motor Skilll

0 Reflexes such as grasping

1-3 Reaching (ineffective) ..

3 Grasping

4-5 Reach and grasp t

6-7 Control! of reach and grasp \' ...... , ,,_, 9 Pincer grasp

_ ,

10 Cilasps hands

1 2- 1 4 Releases objects crudely

18 Controllled release

www. ooeybr-aif\~.

Helms & Elliot 23

Hierarchy of Assisting Hand Skills in Young Children with Unilateral Cerebral Palsy Most Difficult to Easiest

Notice differences in developmental milestones and development of the assisting hand:

- one hand vs two handed tasks - pre-skills before grasp (hold, contact) - grasp then reach vs reach then grasp - use of the hand as a stabilizer - focus on active movement of the arm and hand - progression of grasp differs and is more dependent on

the position and location of the item

-

Greaves, et al, 2013

24

Upper Arm and Reaches

LEVEL 1 LEVEL 2 LEVEL 3

Work on moving arm away Work on moving arm away from Work on moving arm away from from body toward an item body toward an item body on own with assistance or support with physical prompting, initiative, begin to work on

gradually increase the amount of accuracy of making contact with an movement excepted item or grasp

Toy recommendations: beaded necklaces, scarves, balls, blocks/towers to push over, balloons, toys that were motivating from week 1

25



1.

2.

3.

4.

5.

26


WEEKLY GOALS

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

NOTES: 27

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CHILD'S NAME: __________________________


1. This week, how well do you think your child used their affected hand during play sessions with the constraint on?

(1) Not as good as last week

(2) The same as last week

(3) Better than last week

(4) Much better than last week

2. Throughout the week, how often do you think your child used two hands during play and daily activities?

(1) Less than last week


(3) More than last week

(4) Much more than last week 29

THERAPY TOGETHER

Week 3 Topics: 1.Hand development part 2. Additional examples of hand skill development for

children with unilateral CP.

Upper limb domain: holds/grasps 30

Holds Contact with Objects Stabilizes by Weight

Moves Upper Arm

Moves Fingers

Moves Forearm

31

Stabilizes by Grasp Reaches

Release

Grasp Varies Grasp

Bimanual Manipulation

Grasp

32

Holds and Grasps LEVEL 1 LEVEL 2 LEVEL 3

Work on exploring and pre-grasp skills

Work on holding: maintaining hold of an item after it is placed in the hand

Working on holding object and moving it around

Work on grasping from an easy position, increase frequency

Work on precision of grasping, grasping from a person with different orientations or different sizes of items

Work on grasping from the table, or at a distance with different orientations

Work on advanced grasp patterns (pincer, tripod, index finger poking)

Work on catching moving items

Toy recommendations: ribbons, bead necklaces, small rattles, maracas, sticks, rings More advanced patterns: small finger foods, stickers, beads, pegs

33



1.

2.

3.

4.

5.

34


WEEKLY GOALS

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

NOTES: 35

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CHILD'S NAME: __________________________












THERAPY TOGETHER

Week 4 Topics: 1.Cognition and hand function. Cognitive developmental milestones related to

play and hand skills.

Upper limb domain: holds/grasps 09

ar

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UI

t

1

11 1

EXAMPLES OF COGNITIVE DEVELOPMENTAL MILESTONES 2-24 MONTHS

Consider how hand function and cognitive development are linked

If you have concerns about your child's cognitive development consider working on both cognition and hand function during play sessions.

Developmental milestone checklists can be found on the Center for Disease Control website.

https://www.cdc.gov/ncbddd/actearly/milest ones/milestones-5yr.html

39

https://www.cdc.gov/ncbddd/actearly/milest











40



1.

2.

3.

4.

5.

41


WEEKLY GOALS

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

NOTES: 42

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CHILD'S NAME: __________________________












THERAPY TOGETHER

Week 5 Topics: 1.What is cerebral palsy? Discuss the definition.

Upper limb domain: holds/grasps

45

Cerebral Palsy Cerebral a sy (CP) refers to a g oup of d·sorders in he developme t of motor control and osture,

occurring as a result of a o - regressive impa·irmen o the develo i g cen ral ervous system. The

motor disorders of cerebral alsy can be accompanied by disturbances o sensation~ cognlion,

communication, perception, and/or seizure disorder.

CEREBRAL PALSYThe Si,c 'F-Words' F1 ___ cr;i-(D

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I might do things differen ly but I CAN do them. How I do it is not important. Ple3se let 2 FAMILY They know me best and I trust them to me try! Listen to them. Talk to them. Hear them. RE>spect them.

: or CP

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do what's best for me.

f I j NESS Everyone needs to Having childhood friends ,s important. Please give me stay ftt c1nd he<1ltny, induding me. Help opportunities 10 ma e friends with my peers. me find Wil'JS to keep fit.

Childhood is about fun and play. This is hc,,,v I learn and grov.r. Plei:lse 6 me to develop help me do the activities that I find the i

FUIIJRE I will grow up one day, so please find ways for ndependence and be included in my commumty.

mos1 tun.

World Cerebral Palsy Day ..._!.. worldcpday.org , CanChild Proudly 511f)f)Ofted by The AJ'l>rg.in fo1mdi!rion

B~ M RosetibN!l, P & Gol l~[. I.I'/ (1012). The 'F-wOldi' ii cliildhood d,sah . y I ~~tar lh~ i!

www.canchild.ca ~ow II'@ 1bookl ll1in ! Child. Care, HM!tn and Do!Vflopmi!fll. (38) 4. Vis.it http111www m1rnld.c.1/elll re1eardJ•in-pMaie rf-1wnl1.-,n-cluldhood•disablh1y 1111 more rl!IOOrce1.

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www.gillettechildrens.org











47



1.

2.

3.

4.

5.

48


WEEKLY GOALS

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

NOTES: 49

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CHILD'S NAME: __________________________












THERAPY TOGETHER

Week 6 Topics: Functional classifications: 1.Gross Motor Function Classification System: GMFCS 2.Manual Ability Clssification System: MACS

Upper limb domain: forearm and finger movement 52

GMFCS E ft R between 6'tJh an1d 12'fJh lbi'rthday: Descriptors andl illustrat"ons

GMIFCS Lev1el I Childl'@n walk at h®~ SA:r.ool, ,0:-utd:oors and tn t.i'h c.ommunlty. l'hey can eill.lil'lb $t 1rs 'Without th use ot a, 1ralllng,.. Oi1hi:lnm p r1orm gm~ i1iXlfflli Sikills. $1Jffl

ais ru n1rng,. and j umpl~; but speoo) bailan!l:! ndl c..lll!ord lnaition am llmit.ool.

-· .. ------···· .. -------- .. ., ______ ,. ,. .. _______ ,. .. _______ ,. ,_ .. _______ ,. .. .. .............. .. . .............. ... . ··------- .. .................. .. -------- . ................. .. .. _______ ,. .. ................ .. . ··------- .. -------- ... --- -~

GMFCS Lev1el II ChUdnm walk In most !I tti~s. nlldl climb stZLl.rs holding onto ZL ailing .. ih y m y ,~perl.eni: diflftt:<ulty wa'llki~ lo~ dist n~ and b .'lani:lng,. on un v n t@rli'aln, 1nd1n s. in uowi:led al' Mor oo.nfln d sp~. Chlldr; n Ma!J' W.!!ilk witti phys L11i l MS1$tani: . a, lhalld~ h ldl 1mobllity d vi~ or us d w~L d mobmty over Lo~ dlst!lif'liL@:!l. Childr, n 1h rv only minimal abiUty 't:o perform g;ross i1iXltor Si'kills: such a$ Fll..l.nnl~ and Jum;p1.ng.

"'-I.I I 11 I llll ■■ II.I I I I I l,11 ■■ 11.1,1 I I 11 1111 ■■ 11 .I 1111 I ll ■■■ ol<I I I I I li ■■■ ilol I I I 11. ll ■■ ll ol I 11 11 &l ■■■ ilol I 11 I li ■■■■ ol I it I I I ll ■■ llll ol 11 11 &lll ■■ lllol I 11 11 ll ■■■ lolol I I I I li ll ■■ ll ol 11 11 I ll ■■ ll ol 11111 &l ■■■ illol I I I I li ■■■ llol I I I 11.li ll ■■ ll ol 11 11 ■

GYE"C.5~: 1'111!:11.1.nD aL t11J97- Cli:',-IYledl l.d iSDl.llt214'D C1.i:£tdd: WWW. Cll!ll: hll!I. GIi

GMFCS Lev1el HI Childr; n walk lli!!.l.n~ a, lhai~he'ld i1iXlbUlify dl!'!r!'lce 1n most Indoor s.ett1.ngs. They ma!/ d.1mb s:ta~rs li®ldltlg onto a ralll~ with sup \l"Vl!Slon or as.$li!.tan!l:! . Childnm us · w~l · d i1iXlbility w'ih n trave'l.1.ng long dl!St .n~ nd m y s · l f• prop · I fmr short r dist · ne~.

GMFCS Lev1el IV Chlldr n us m thO:d af mobility 'tlhait require Jp:h'.!f!l.c:al ass1$t.:!lnt:< ,or power,edl 1m®billty Ln m®st s.ett:1ngs. Tooy m 'JI walk ·ror sihort d1$talili: s. !lit. hom · With physical ~!i1$1tallCl ,o us JPOW r,ooi m®biUty mr Z11 DOO/f SL.1,Pil)Qli't

wa'llk r ·w,h · ill position d. At school., outdoor!. and In ith ,i:omrn_11n1t:,. mlldr n arr itirat\sportloo 1n am 1u1al w!-)e@ICJ'hatr ,or us 1pow l'iool 1mobilll'JI.

Chlldr; n !Ir@ tiransportiool l.n a manual wh · e'li:ha~r iill a.ll s tliini$. Ch1ldren r, Um'litoo l.n ti'h Ir ~ IUfy' to m inta'Ln antigravily 1h ad and tru· :le postur, and c.®nt11o'I. ll:!'g · nd arm rno,vem ts.

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lllrpl Dllldi'm'5 Hl:Hp1ll!l ~blune- ~15<1)

More Information can be Found on

the Canchild Website:

https://canchild.ca/system/tenon/a

ssets/attachments/000/002/114/ori ginal/GMFCS_English_Illustrations_

V2.pdf

53

https://canchild.ca/system/tenon/a

1Gr,oss Motor IFu1nct,·'on 1Classification1 ,Siystem - Exp1an1d1e . and R.evis1ed (G F1CS - E &. R:) BEFOIRE 2 ND BIIRTHDAY

LEVEL 1: ~nfia1rnts move ·1rn and out of· sitting and floo:r sit with bo _h hands free to 1mani1pulate 1ob~ects,. Infants. crawl on hands and kne,es, pull to stand ,a1rnd take steps. holding 10n to, fi, mi _ur1e. ~1rnfa1 ts w,alk between 1 ,8 mo 1ths and 2 years of ,age w·~ out the need for

. .:· .._,. l':1 .J • any ass1s1~11ve mou1 i~tY uev1ce. LEVEL 11: Infants ma·ntain floor s1itting but may need o, use theiir hands, for s1upport to m1ainrain balance. Infants areep on their stomadh or crawl on hands, and klrnees. Infants. may pu I to stand ._ nd take steps. ho d·ng on to ·fiurni~u1re. LEVEL 111: ntan' ~ maintain floor siitting w1rnen '~he l1ow ba.dk. ·s s1. ppo1rt.ed. lnfa1 ts, ro and 1oreep fiorward 01rn theiir stomachs,. LEVEL IV: l1mfa1 ts harve head con~rol but trunlk StJ[pport. is requi1red fiorfloo,r siUing. nfa1rm'. 1can 1ro1II to sup'ine rand ma~I' ro~I to prone. LEVEL V: Physi1cal iimpaiirments limit voluntary 1oon~rol of 1mo·v1emernt nfants a1re unable to, maintain antig1ravity. head and trunk postures. iim p1rone and :sijHi1rng. Infants require adu t assistance to ro~ .

1B, TWEIEN 2 ND AND 4™ IB,IIRTHDAY

LEV'EL I: Children i oor sit with both hands, ~ree kl manipulate objec1ts,. · loveme: ts ·n and out om· flloo1r s1itfirng and sta1rndi1ng are perffonmed wi _hout adullt rassiis.tanice. Chii dren walk as the prefemr1ed meU1od of mob.Ii~, w'ithout the ne1ea for airny. ,assi,stive mobility device. LEVEL 11: Chilldren floor s·t but ma:y. have diifficu ty w·~h ba ance w1hen lbo~h hands, a1me firee to1 manipula~e objects. Movem.e1 ts in and O'Lfilt of s1itting are performed withou·_ adult assista1rnoe. Childr1e pul tor stand on a srab e suriace. Chi~dren crawl on ha1rnds and !knees, wi _h a recip1roca,I pattenn cnuise rnoldiing onto ru1nrniture and wa k. usiimg an assis~iv1e mobTty de·vi1ce as prefem11ed methods of m,obirty'. LEVEL 111: Chi dren 1main "aii'n floor sitting often by "W-sittirrngD 1{siit1ing between flexed and ii'nternally' ro ated hips ,and ~rnees.)i 1a1rmd may require adult assist,ance tor assume sitt·ng. Chil, 1ren oree[P on _heir s.tomaorn or 1ora I on rnands and knees (often without ~eaiprocai eg mo,v-ements) 1as, '~hei1r pnimary. methods of seff~mobiliity. Chiilaren may, pu I to sta1rnd on a stable surface and crniuise sho:rt distances. Chilldlr1emil may wa. k short distances indoo1rs using a ha1 d-helld mobilly deviioe (walker) and adu t assistanc-e for stee:ring and turning. LEVEL IV: Chilldren floor sit whern pl1aced but a1re unable to mainta·n a ig · 1ment and bala1rnoe wiit]out use 1of '~hei1r hands, for s1~1pport. Chilldlmemil ffireque: ,ijly. re1quir1e adapt·ve equipment for siitt·ng and smnd·ng. Self-mobillily' for sho:rt distances (wr·_ in a 1moom) is, achieved through 1molliing, creeping on stoma1dh, 1or c1ra~i1rng on hands and knees wi_hout reciprocal lleg mo,v·ement. LEVEL v·: Phy.sica. ·impairments re.stnict volu1 'ta1ry con _rol 1of mo,~m1e1rmt and the ,ability _10 maintain ant1igravity head and trunk postures,. AJII ,a1reas of moto1r 1m·. irnc~io'rn are limite,d. Functional Iii mi _atiions in siitt'ing and standing are 1rn1ot iulty. 1oompensated for through the use of adaptive equ·pmen and assis~iv1e techno:logy,. At Le,tel V 1dhii dren have no 1means. of iimdependent mov1eme1rmt and are ,,~ansported,. Some ch·11dre1 achieve self-mobility using a powered whee chair with extens·ve adapa~i

Retrieved from: https://canchild.ca/system/tenon/assets/attachments/000/000/058/original/GMFCS-ER_English.pdf 54

https://canchild.ca/system/tenon/assets/attachments/000/000/058/original/GMFCS-ER_English.pdf

do you need to know to use ACS?

The child1s abi llify to handle objects in important darlly activffes for ex.amp!1e duming play .and le~:sure, eati rQ .and dressing.

lln which siruaUon is the iehUd independent and to what extent do they need support and adaptaitio ·. 7

■

D11st1nct1ons betwee1n Levels I and I 1Children im Level I may have Ii liifil itations. in handling very sJm:all heavy or fragile

objects which demand detaml,ed me motor control oir effic"ent coordination between hands_ Limri itations may a lso involve perfornance in new and

unfamiliar situations. Children in L1ev1el 11 perform almost the same activiHes as ch ildren in level I but the quality off erformarnce is deoreased or the

perloirrnance is slower_ Funotional d ifferences between · ands ran li mit. reffeotiveness of pert'ormanoe. Children in Level 11 commonty try to siRi plify. handling of objeds, fur example by using a surface for sl!Jpport instead of

hand Ii ng obj~ts with both hands_ Hand es o bJiects ,eas~ly and su cces.sf'ui ly At most.1,

limitatiori11s in · · 1

e 1

ease of penfonmrng manual tasks r1

eq1ui ing1 BipeeiMdL...,,-==::::::::::::,,,,;~~::::::~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ and accuracy. H oweveri, ,any Hm · alio ns in manual! .a.biliUes do n~t restrict independence in daily .activiies ..

I Hand es most o i,ects but 1th some hat r,e · uc,ed qual ty a1nd/or speed of' ach1evem1ent Gertarn aotivimli1es may be avocded or be adhievedl with :some· difficuity; a ~erinathi11e ways of performance mfght be used but manual abilirlies do not u.suarny restrii1ct independence in daily .activities ..

I ■ Hand es ObJ18CIS with d1ff1culty; nee . s hellp to pr,epa-,e andlor modify acti1vit es. The performance~ :slo · and adhiievedl with I imited success regard ing quaJ lty and quantity ..

D,st nct1ons bet een Levels I a.nd .I Children in Level Ill ham::He mriost objects, although slowly or , · lh reduced ~uality of perfoniilnance .. Ch il'.dren in level 1111 commonty meed he~p to prepare 1he activity amifor require adjustments to be made to the environment sinoo 1h eir abi lily to reach oir handle obj,ecis is I imited. They cannot perfonm certa in activities a111d

theiir degree of independence i5 related to the supportiveness of the envi romm1ental oonte.oct

Activ.irlies are· 1penommed independently if they hav.1e been set up or D1st1nct101ffllS between evels Ill and IV adajp1ledl. ....,...-_ ______ Ohildren in level 1111 can perform selected aotiv ities if the situation is prearra111ged

and if the·y get supervision and p l,ent.y of t ime_ Children in Level liV 111eed V. Hand es 8 l1mi1t,ed selection of easily manag,ed c.or11tinuou;5 heJp during the activity and can at best participate meaningfu lly in

ObJ1ects, n adapt,ed .s1tuiat1ons,. P~raorms parts of aotivitiies on l'y parits of an activity.

with elo:ri and wiih llimitedl :success. Requiire.s continuous support and .assEsranoe and/or adapted equi pmenti, for even pa rn.al ac'h ieve menl of the actirvity.

V. !Does not handlle obJects and has. severely hm1t1ed ab1 I 1ty to perform ev,e n s.I mpl e acti1 o ns,. Req,uires total assistan.ce.

D stInct1ons between Levels IV and V Ohi dren in Lev.el IV erform part. of an activity, however they l'ileed he~p

oontinuous.ly_ Children in Level V might at best participate wnh a simpl'e movemrienit in special s.iruations, e _g _ by pushing a button or oocasiornalty hold u111dema nding

objects.

Ages 4-8 years

Retrieved fomr: https://www.macs.nu/files/MACS_English_2010.pdf

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i What o you ne -d to kno to use 'in - ACS? Mlnl~M!ACS users need to nrnd out what ,0:bje ts the chifd usuany handles and how they· handle lhem: \With ease or difloulty, qu okLy ,or slowly w th preoiskJn or r ndomly? For exa m.pie you c . Iii ask about al'l.dl or ,o.biserVie how -, e c · Id uses his or her hands ·hen pis mg and during mea ls, ,orr wham part olpatlng n usual ao1il. ltles of dseUy lru ng.

Ask ques:tlons about ~he ohUd's se~fi-inJ~lated ab[lily nd how muoh arlu[t. he~p and 5iuppo - the dhitd needs, 1to handle everyday ,ob]eot:s, e.g. b:i.ys,_

Below is, a des.er pt on of the five Ml ni-MACS l:e-vels at cMldren's self- nillated ab.llily and the[r need for assfistanoe ,or adleptat on V!fflen handllng objects,.

t Handl s o J cts 1eas ly and success.fuHy. The ch ild may have, a s I igM Ii milatia in performing aciions thal. requ fr@· pre cisio11 a mi coordination between tbe ha11dL~. but thfl'J' can still perfumm fu,em. 'The, child may need somewhat more ad It assistance w en ha111dli111g objects 1compared to other children of th@ same age.

H Handles most obJ1ects, but with .somewhat re ced q al ty· and/or sp ed of ac 1evem n t. Some actions. ca 11 011ly be performed a111d accomplished with some difficulty a111d after pra!Otioe. The, ichild may by a11 alternative, appmachj such as using only 0111@ ha mi. 'lhe child need adu It assistance w handle, objects mar@ freqm~111fly 1compared to ch ildren at the same ag:e.

HI. Handles o · ects ith . aff1cuHy Performance is slow· with limited variation a d quality Easily managed objects are ha died i111depe dently for short periods. Th@• child often needs adu lt help and support to handle objec:ls.

IV. Handles a I mited s lection of eas ly manag · d obj cts In simple actions~ · 1 · e actions air@• performed slowly, with e.xer!Jio111 andlor random p e.cision, 'The child needs. constant adult h,elp and support to handle. objects.

V. Does, not handle objects and has seva ly ~m tad ab l1ty to perform eve .s mp e actions. At bes.t. the ch i Id can push. touch pll"@ss. o hold on to a few· items, i111 constant interaction with an adult.

Distinctions be., een L v Is II and II Ch[ldren [n Level I may have sligllt~ more diffloully hand[lng ilems, lh ·t require good flne motor skills, com.i>ared ~ c lldren wl~hout dlsabi[l~les, of th.e same age . C · [ldren [n Level II handL\e esse ntlal y the same objects, as chlldren n Level I, bu't ~hey may encounter pro1blems pelfoom·Ing tasks a.ndlor take longer 1to perinirm them, so 1they ,often ask 'for help. lF"undt nal dfrfferenoes be I.ween hands may c . use peno nm . nee to be fess effeO't we. 'fh,ey may need more ,guldaooe and praotlce to ream mow ~ handl.e ,objects

._ oompared with ch[ldren Iii Level I.

Dmstinctjons b · an Levels n and HI ChUdren In Level II cain handle most objects, though they may take kJ nger and do so with somewhat lless qua[lty. and (hey may need a tot of· gu d!.ance and pr oUoe ~ lleam how to handle objeo·ts,.

Level Ill children marnage oo 1J1se easily: hand led ,objeots but often need help pla.clng ,obJeots [nan easy position In front ,oft ·em. They perinrm aoUons Vf.iith few suboo m:po ents . Performance is slmv.

ID st nct1ons Chlltcll ren In Level m manage to use easilty ha ndted ob eels lndependen1J;y fo shon periodls. They perimm aotfo s, · 1h few suboom,ponents, and ihtce acUons take a llong Ume to pertorm. Art best, chilrl ren in Lev.el IV can perform simple acUons such a5l grasping a rnd releasl ng eas[ly ha ndted ob ects 1th t. are offered [n an adapted posrtoo n. Ther need ooMt.ant herp.

D ilsti n cti on:s b een Levels IIV and V Oh lldren In Level IV perform individual act o ns Vf.iith a very I m[ed

· sele kJn at ,objects · nd nee . constant help.

At bes;rt dhitdre n In Lev.el V perform s~mpl\e movements [n special Jtu iti'O ns. For example, they can pr,es5l a s·Im pie button or hol . single,

. s mpJe obJrecls.

Ages 1-4 years

Retrieved from: https://www.macs.nu/files/Mini-MACS_English_2016.pdf

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Forearm and Finger Movement LEVEL 1 LEVEL 2 LEVEL 3

Work on exploring items placed near hand (finger extension/flexion)

Work on placing items in the hand palm up and see if the child will maintain the position

Work on opening and closing hand to grasp a variety of objects of different sizes (finger flexion/extension)

Work on moving the arm around once the item is in the hand (turn over to promote supination)

Work on grasp refinement, separating two sides of the hand – isolating index finger, pincer grasp, radial grasp

Work on large range of movement for supination (turning pages in a book, turning over puzzle piece)

Toy recommendations: items for texture, ribbons, light weight rattles, shakers, variety of objects for gross grasp (ball, plastic egg, squishem, stick); books, knob puzzles

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1.

2.

3.

4.

5.

58


WEEKLY GOALS

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

NOTES: 59

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CHILD'S NAME: __________________________












THERAPY TOGETHER

Week 7 Topics: 1.Resources and websites

Upper limb domain: release 62

-r)• Gillette ' ChHdren's

Specialty Healthcare

MANUAL ABILITY CAN CHILD

CENTER FOR DISEASE CONTROL AND PREVENTION: MILESTONES

https://www.cdc.gov/ncbddd/a ctearly/milestones/index.html

CEREBRAL PALSY ROAD MAP

SCOTTISH RITE CLASSIFICATION SYSTEM HOSPITAL www.canchild.ca

www.macs.nu https://scottishritehospital.org/

RESOURCES https://www.gillettechildrens.or g/assets/uploads/care-and-

conditions/CP_Roadmap.pdf

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https://www.gillettechildrens.or

https://scottishritehospital.org

www.macs.nu

www.canchild.ca

Release LEVEL 1 LEVEL 2 LEVEL 3

Work on dropping item or letting go Work on releasing into a large Work on releasing with refinement with intention container (small container, stacking)

Toy recommendations: rings, blocks, buckets of different sizes, toy piggy bank

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2.

3.

4.

5.

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WEEKLY GOALS

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

NOTES: 66

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CHILD'S NAME: __________________________












THERAPY TOGETHER

Week 8 Topics: Overview of “green light” upper limb interventions including bimanual hand skills, embedding goal attainment into daily routines

Upper limb domain: using the involved side as the assisting hand

69

I I

~Improved motor activ' ~e.s

Hyd otherapy

Conductive Educa · n

GoaJrected

train· Bimanual training

Vojta

·proved function & . .s1erf ca re

Goaldirected training

Seating

Treadmill

Home programs

train· Botu · um toxin

Assistive technology

Novak, et al, 2013

70

Strategies for Daily Practice

SET GOALS

Have 1-2 goals that are meaningful and attainable

SET ASIDE 15 MINUTES 4-5 DAYS PER WEEK

Include 15 minute practice sessions in your daily routine (i.e after breakfast, after school, etc)

MAKE IT PART OF YOUR DAILY ACTIVITIES

Practice the goal during daily activities (i.e. work on dressing when getting

ready for bed) 71

Use of the Assisting Hand LEVEL 1 LEVEL 2 LEVEL 3

Work on using the assisting hand to Work on using the assisting hand to Work on using the assisting hand as a stabilize (against body or surface) hold during two-handed tasks – item typical non-dominant hand during two-handed tasks is placed in the hand from the

dominant hand and released to the dominant hand

Toy recommendations: duplos, pop beads, animals out of small containers

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2.

3.

4.

5.

73


WEEKLY GOALS

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

NOTES: 74

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CHILD'S NAME: __________________________












REFERENCES Eliason, A. C., & Sjostrand, L. (n.d.). Baby CIMT Manual. Retrieved from https://ki.se/sites/default/files/migrate/baby-cimt_manual_20151125.pdf

Eliasson, A.C., Krumlinde Sundholm, L., Rösblad, B., Beckung, E., Arner, M., Öhrvall, A.M. , Rosenbaum, P. The Manual Ability Classification System (MACS) for children with cerebral palsy: scale development and evidence of validity and reliability Developmental Medicine and Child Neurology 2006 48:549-554

Eliasson, A.C., Krumlinde Sundholm, L. (n.d.) Mini-Manual Ability Classification System for Children with Cerebral Palsy 1-4 Years of Age. Retrieved from https://www.macs.nu/files/Mini-MACS_English_2016.pdf

F-Words in Childhood Disability. (n.d.). Retrieved from https://canchild.ca/en/research-in-practice/f-words-in-childhood-disability

Greaves, S., Imms, C., Dodd, K., & Krumlinde‐Sundholm, L. (2013). Development of the Mini‐Assisting Hand Assessment: Evidence for content and internal scale validity. Developmental Medicine & Child Neurology, 55(11), 1030-1037.

Helms, C. & Elliot, L. (n.d.). Motor Skills 101. Retrieved from http://gooeybrains.com/2017/04/18/motor-development/

Holmefur, M., & Krumlinde‐Sundholm, L. (2016). Psychometric properties of a revised version of the Assisting Hand Assessment (Kids‐AHA 5.0.) Developmental Medicine & Child Neurology, 58(6), 618-624. Infographic: Understanding of Cerebral Palsy. (n.d.). Retrieved from https://www.gillettechildrens.org/khm/infographic-understanding-cerebral-palsy

Novak, I., Mcintyre, S., Morgan, C., Campbell, L., Dark, L., Morton, N., . . . Goldsmith, S. (2013). A systematic review of interventions for children with cerebral palsy: State of the evidence (Vol. 55).

Palisano, R., Rosenbaum, P., Bartlett, D., & Livingston, M. (2007). Gross Motor Classification System Expanded and Revised. Retrieved from https://canchild.ca/system/tenon/assets/attachments/000/000/058/original/GMFCS-ER_English.pdf

The Definition and Classification of Cerebral Palsy. (2007). Developmental Medicine & Child Neurology, 49, 1-44.

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https://canchild.ca/system/tenon/assets/attachments/000/000/058/original/GMFCS-ER_English.pdf

https://www.gillettechildrens.org/khm/infographic-understanding-cerebral-palsy

http://gooeybrains.com/2017/04/18/motor-development

https://canchild.ca/en/research-in-practice/f-words-in-childhood-disability

https://www.macs.nu/files/Mini

https://ki.se/sites/default/files/migrate/baby-cimt_manual_20151125.pdf

texas woman's university and scottish rite hospital

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