Telehealth: Navigating New Norms

 During the last year, many of us have grown accustomed to alternative ways of receiving medical care. For our therapists and other healthcare workers, they have had to find a way to prevail through the unfamiliarity and continue providing necessary therapies and treatments. Thanks to the possibility of Telehealth, No Limits Therapies and our therapists have been able to do just that.  As you could expect, many of our therapists expressed some uneasiness when they were informed that some of their treatments would be conducted through a computer. Although our therapists felt immediately grateful for the opportunity to carry out necessary treatments to clients during this time, the transition was all new to them. Our therapists, whether it be an occupational therapist, physical therapist, or speech therapist rely heavily on physical cues and interactment from their clients. Our therapists soon realized they would have to become more innovative in order to determine new ways of treatment that didn’t rely on being physically present with their clients.  The biggest struggles in this journey, expressed by our therapists, has been adjusting to the use of technology and things like Zoom, Google powerpoints, and other resources. With limited activities and more obstacles with technology use and limited patient interaction, they have had to set aside time to create new games and activities for their telehealth clients. Our team expressed that what normally motivated their clients in the clinic, might not have the same outcome in virtual treatment. Our therapists told us that they had to figure out what resources their kids had at home. With some kids, it was possible for them to create their own obstacle courses at home using household things like couch cushions and rolled up blankets. One of our physical therapists, Karina Moore, told us that one of her clients uses bags of dog food to walk across or jump over for an altered activity. Our therapists have learned to utilize whatever the kid has at hand. Our occupational therapist, Emily Barber, told us that her clients often use items like cans of beans, grocery bags, laundry baskets, and other common items in their telehealth sessions. Emily also told us about the positive effect of being able to track their clients eyes on the screen during Telehealth sessions for visual motor skills and processing. She explained that this is something she might not otherwise notice in a clinic session.  Therapists expressed that they have not been alone in this journey as client’s parents and families have been very involved and eager to help in Telehealth sessions. With a patient that is younger, parents have been able to help their kid and the therapist by creating an obstacle course, finding access to items that could be used as alternative equipment, or encouraging their kid through treatment. Our therapists feel that they would not be able to make it through this time without such positive influence from parents and families. In turn, parents and families have been able to gain a positive impact from the experience as well. By being more involved, they have been able to encourage their kids more frequently and effectively. By having the opportunity to witness their child’s session from home, they have been able to pick up on activities that they could do with their kid outside of treatment sessions. Our therapists have been able to work with the parents and families directly and discuss their kids development first hand. This benefit has been impeccable to the overall support of a patient as well as their progression and well being.

Reflexes?!?! What is the big deal?

If you have been around No Limits Pediatric Therapies long, you have probably heard one of the occupational therapists mention “primitive reflexes.”  You may be wondering what is a primitive reflex?  And what is the big deal? According to Webster Dictionary, a reflex can be defined as “an automatic and often inborn response to a stimulus that typical involves a nerve impulse passing inward from a receptor to the spinal cord and then passing outward from the spinal cord to an effector (such as a muscle or gland) without reaching the level of consciousness and often without passing to the brain.”  For this blog post, we will be focusing on primitive motor reflexes and how they can impact your child’s function. According to the Medical Dictionary, a primitive reflex is defined as “any of various simple, stereotypic, automatic neuromuscular responses characteristics of the mature fetus and newborn but typical inhibited (or integrated) during the first year of life: primitive reflexes are directed by the brainstem centers and include Moro, rooting, and tonic neck reflexes.” It is thought that these reflexes help infants learn to organize motor behavior.  Integration can be defined as “the inhibition by higher centers of neurological control which modify the reflex in such a way that the pattern of response is no longer stereotypical.  The reflex does not disappear; it may reactivate under stress or during activities requiring great strength.”  If these so called “primitive reflexes” continually remain to be displayed beyond the expected of typical developmental time period, their presence by indicate an underlying developmental of neurological issue.  When a child’s primitive reflexes do not integrate, they may interfere with a child’s development of more advanced motor skills, which could lead to difficulty participating in one home, educational or community environments to their highest potential.   Now, let’s take a look at the three primary tonic reflexes: Asymmetrical Tonic Neck Reflex (ATNR): Onset: 0-2 months     Integration: 4-6months Stimulus: Rotation of the head Response: Arm and leg on the “jaw” side extends. Arm and leg on the “skull” side flex. Importance for Baby: Assists with early eye-hand regard, provides vestibular stimulation, changes the distribution of muscle tone. Significance on Early Development if Persists: May impair ability to roll, use hands smoothly together at midline, poor visual regard for object(s) being held, poor balance. May impair creeping or crawling. Baby loses balance and/or falls when rotates his head from midline; very frustrating and causes excessive fatigue. Symmetrical Tonic Neck Reflex (STNR): Onset: 4-6 months       Integration: 8-12 months Stimulus: Flexion and extension of the head (neck) Response: With neck flexion the upper extremities will flex and the lower extremities will extend. With neck extension the upper extremities will extend and the lower extremities will flex. Importance for Baby: The STNR assists in the development of bilateral patterns of body movement. Allows the child to move up against gravity and assume quadruped (on all fours like a dog). Integrates as the child begins to crawl and can lift the buttocks from the heels without flexing the neck. Integrated when rocking back and forth on hands and knees. Significance on Early Development if Persists: Interferes with advanced reciprocal creeping. Impairs dissociation between the two lower extremities and transitioning between quadruped to sitting to kneeling to standing and vice versa. If strongly influenced by the STNR a baby will not be able to creep; will bunny hop versus true creeping/crawling on the floor. Tonic Labyrinthine-Prone & Supine (TLR): Onset: Birth               Integration: 6 months Stimulus: Change of orientation of the head in space; position of head in relation to gravity while prone (on belly) and supine (on back). Response: In prone flexor tone will predominate with arms flexed by the child’s chest. In supine extensor tone will predominate. Importance for Baby: Allows the baby’s posture to adapt to that of the head. Significance on Early Development if Persists: Will interfere with movement that requires smooth grading of flexor and extensor muscles. In supine child will have a compromised ability to raise their head up against gravity; this will affect anti-gravity control for movements such as bringing feet and hands together and rolling. In prone (on belly) child will have compromised ability to raise head, extend spine, and bear weight on elbows.  This, in turn, will limit time spent on his/her tummy for crawling and developing the movement in their pelvis and shoulders that sets the stage for moving in and out of various body positions (sitting to stand). Without such ability, the baby will be without options for exploring. This will affect social and cognitive gains.  (Above graphics from “Primitive Motor Reflexes & Their Impact on a Child’s Function”) Now that we have reviewed tonic reflexes, how can  the presence of these primitive reflexes effect your older child? Influences of Retained Asymmetrical Tonic Neck Reflex (ATNR):  Poor isolation of individual body movements Pore sitting posture Attention & Focus Impaired pre-writing and writing Impaired scissor use Fasteners/Typing/Musical Instruments Impairments in reading Keyboard Use Impairment in gait (walking) Running Influences of Retained Symmetrical Tonic Neck Reflex (STNR): Decreased strength and balance Sitting Floor Sitting Walking Writing Ball handling skills Influences of Retained Tonic Labyrinthine Reflex (TLR): Walking Sitting Writing  Balance Now, we have discussed primitive reflexes and how they may present in your older child; as well as the difficulties they may lead to.  Let’s look at some activities to help integrate these reflexes. Prone for fine motor activities & games- The elbows provide a point of stability for freeing the hands for manipulating. Hold a large dowel with both hands, use this to push a ball back and forth Use arms to push a ball back and forth Color, paint, draw, read, or complete puzzle in prone Use whistles or play games that require blowing through a straw Pivot in both directions Prone on therapy ball, platform swing, or over bolster Prone on scooter board-push off with arms from wall to glide backward Prone on scooter board-being pulled by a rope while grasping onto it with both hands  Superman/SuperWoman – prone extension with arms

Benefits of Heavy Work Activities

Benefits of Heavy Work Activities Emily Barber, MS, OTR/L With the craziness and busyness of summer and schedule changes, our bodies can often become disorganized, we can become more anxious and stressed due to ever-changing schedules, and lose focus and attention easier. A child experiencing this may accidentally breaks things often, appear clumsy and uncoordinated, and may have a lot of energy with the excessive need to crash and bump into objects, walls and/or people. Children seeking these movements may be seeking input to calm and organize their bodies. Heavy work activities, which are simply any type of action that pushes or pulls against the body, can help provide the deep pressure input they are craving and allow them to move their bodies in a safe way. Heavy work activities provide proprioceptive input to the joints and muscles. Proprioception is about knowing where your body is in space. Problems within our proprioceptive system occur when the messages that tell a child where he is, how to move, and how much effort to exert aren’t as strong. Proprioceptive input, or deep pressure input, can be very calming, organizing, and regulating to the body and can decrease stress and anxiety through heavy work activities. Heavy work can also increase body awareness, focus and attention. Heavy work activities might include: • Animal walks • Jumping on the trampoline • Swimming • Playing with play dough (kneading, pulling, squeezing) • Climbing on the jungle gym • Doing the monkey bars • Blowing bubbles • Jumping jacks • Push-Ups • Riding a Bike • Creating an obstacle course • Doing Yoga • Pulling a heavy wagon • A pillow fight • Running through the sprinkler • Tug of War • Carrying beanbags or weights around the house • Rock climbing • Hop-Scotch When your child appears to be craving proprioceptive input and “bouncing off the walls,” provide them with some heavy work activities!  Ask your occupational therapists at No Limits Pediatric Therapies for additional suggestions or about heavy work benefits for your child!