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.

NormalDevelopmentalSequence

The basis for many physiotherapy approaches

Wegaincontrolofourbodygraduallyfromthetopdowninasequentialmanner:

• Head• Trunk(upper,middle,lower)• Pelvis• Lowerlimbs.

Whathappensifitgoeswronge.g.braininjury…

…andthechildisunabletomakethesegains?

Physiotherapy

ThechildisreferredtoseeapaediatricphysiotherapistwithintheNHSwhowillworktoassistthemtoovercomethe

obstaclesofpoormovementcontrolsothatfunctionalgainscanbemade.

Mostofourreferralsaregeneratedbecause,despitethisassistance,thechildcontinuestohavesignificantmovementcontroldifficulties.

“Stabilizingtheorientationoftheheadisaprioritytaskforthenervous

system,forthemovementperformancetobeaccurate.”

MassionJ,AurentyR,MouchninoL,DeatA(1991)

Gaining head control

Headcontrol

Assessingwhetherachildhascontrolintheirtrunkcanbealot

morecomplicated…

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

IntroductiontoTargeted

Trainingtherapy

• 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….

Reactivecontrolcanbechallengedbyaddingawobbleboardorrockingbase.

TargetedTrainingreplicatesnormaldevelopmentoftheuprightposture.

Benefits

• Providesadailyinputoftherapy• Doesnotrequireprofessionaltodeliver

• Easytolearn• Empowersfamilies• Complementsstandardphysiotherapy

• Investmentforthefuture.

Collaborations

OngoingcollaborationwithMMUandLJMUandKeele Universityregarding:

• Servicedevelopment• Usingtechnologytoenhancepatientexperienceandservicedelivery

• Teachingonpostgraduatecourse

WhyisTargetedTrainingnotwidelyavailable?

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.

Raisingfunds!

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

EvidenceandResearch

ThankYou!

TheMovementCentreRobertJonesandAgnesHuntHospital

OswestryShropshireSY107AG

Tel:01691404248

www.the-movement-centre.co.uk