This is a question many in the pediatric therapy world have been pondering and practicing for a number years. Elaine Owen, MSc SRP, MCSP has completed quite a lot of research through her work as superintendent and clinical specialist physiotherapist at the Child Development Centre in Bangor, Wales, in the UK. Through her careful study of the gait cycle, she has inspired us to think differently about the way the segments of the foot and leg are aligned at various times in the cycle, and she encourages us to replicate normal gait more closely through the use of not just an AFO, but AFO/footwear combinations.
In her paper The importance of being earnest about shank and thigh kinematics especially when using ankle-foot orthosis, Elaine points out that contrary to the common belief that the lower leg is vertical at midstance (the way many solid-ankle AFOs are designed), the lower leg is actually inclined 10-12 degrees at this time in the gait cycle, and this inclined position places the knee joint over the center of the foot, which provides stability in single limb stance. This information begs the question, are we actually causing more work for our clients, as they struggle to move their center of mass forward over an unnatural vertical lower leg position? Could we increase efficiency and more closely approximate normal gait by adjusting the pitch of the AFO at midstance through the use of specific footwear or external additions to the brace?
Beverly Cusick, PT, MS, COF/BOC has done much to bring this, among other current concepts, to the attention of practicing pediatric therapists and orthotists. In her paper, Help Patients Manage Equinus Deformity, Use Orthoses to teach children to optimize body weight carriage on the feet, Ms. Cusick describes a paradigm shift in brace design for children whose ankles are plantarflexed (toes pointed downward) while walking. In addition to the concepts brought to light by Ms. Owen, Ms. Cusick considers the sensory benefit of gaining full heel loading in the brace as an essential component of the effort to improve postural control in standing and – when feasible – walking all day long. Modified AFOs combined with modified footwear can provide the wearer with a strong biomechanical training tool.
To get acquainted with these concepts, click on the references above and the Progressive Gaitways, LLC website: www.gaitways.com.
To learn a lot more about how to bring them into your practice, attend a joint education course from Easter Seals DuPage & Fox Valley and Shriner’s Hospital presented by Beverly Cusick, PT, MS, NDT, COF/BOC in May:
The ongoing budget impasse has had profound consequences on nonprofits throughout the state of Illinois. Court orders, laws and federal money have funded many state services and programs. However, 10.6% of the budget currently remains unfunded as the state is not authorized to spend money on these programs without a budget in place. These unfunded programs primarily involve higher education and human services which include child care and many other grant funded programs. Up to this point, there’s been a lack of urgency between the two sides in resolving the budget impasse sparking fears that a budget won’t be reached into the spring or much later.
Unfortunately, the prospect of ending the budget impasse early in 2016 looks bleak. This concern is confirmed by Illinois State Representative Patricia R. Bellock who notes:
“My most important priority in 2016 is to help pass a responsible budget that meets our essential priorities in securing a safety net for the most vulnerable children and families in our community.
Budget negotiations are still ongoing, but I feel it is unlikely that anything will happen until March. The reality that we work with is we cannot tax our way out or cut our way out of this budget shortfall. A balanced budget can only be achieved with a responsible combination of new revenue and long overdue reforms and agreement by the leaders of the General Assembly and the Governor.”
The budget stalemate has created an atmosphere of uncertainty in Springfield that has trickled down to individuals in need, human service agencies and communities causing permanent harm in the process.
This involves emphasizing the importance of keeping Early Intervention funding at current levels. Previously there were discussions in Springfield of potentially raising the definition of a developmental delay from 30% to 50%. Increasing the definition of developmental delay would deny thousands of children early intervention services in Illinois.
Early Intervention is a crucial program serving more than 20,000 infants and toddlers from birth to three-years old. In addition to the developmental benefits of Early Intervention for children, it’s critical that policy makers understand the fiscal benefits the Early Intervention program provides. Potentially restricting eligibility for Early Intervention will escalate the number of children who need more intensive and costly services in the future. It’s estimated that every $1 spent in Early Intervention saves up to $17 in future costs. By conveying to our elected officials the importance of Early Intervention services we can help ensure its proper standing in the next budget agreement.
Here’s what you can do:
Email Governor Rauner through his constituent page and let him know you oppose potential Early Intervention cuts:
Email / fax / call your Illinois General Assembly Legislators to let them know the importance of protecting the Early Intervention program! Don’t know who your rep is? You can look it up online through the state’s board of elections site:
Include signature with printed name, address, phone number and legislative district if you know it. Include a picture of your family too; we think your statement will be even more impactful.
Send a letter to your Legislator.
Continue to raise awareness on social media using the hashtag #EImatters.
Easter Seals DuPage & Fox Valley remains committed to continuing services. While we are committed to service continuity, we question our ability to do this if the budget stalemate continues. It’s also important to understand how the budget impasse might be impacting families and human services throughout the state.
A question I am often asked is about working at a private, non-profit pediatric therapy center. What makes us different?! Well some unique qualities that compliment other services! Below are the top five reasons to enroll a child in private therapy (primarily from a speech-language perspective!).
Enhancing School Services
Many children have significant issues that require more frequent, intense services in order to progress. Unfortunately, the public school districts are limited by the hours in the school day. Participating in outside therapy services allows for a child to work on similar goals or additional goals.
For some children, the repetition of school goals helps them progress faster and allows them more time to understand concepts. For other children, the school therapist may be working on one area of need where the private therapist is targeting another area of need. We are happy to collaborate with school therapists. I find that this is the best recipe for success!
Your child did not qualify for Early Intervention Services (EI)
Currently, the Early Intervention Program for the state of Illinois requires a child (0-3 years of age) to have a 30% or more delay in 1 area of development in order to qualify for services, have a qualifying underling medical diagnosis (e.g. Down Syndrome), or have 3 or more risk factors for delayed development. In many cases, children do not meet the criteria as listed above for services through the Early Intervention system, but still present with developmental delays.
For example, a child may be evaluated for speech and language delay
through the early intervention system and only found to have a 20% delay in expressive language. In most cases, a child with a 20% delay would not receive services through EI, but may benefit from private therapy in order to improve their expressive language skills to a more age appropriate level. Just because your child has not qualified for EI does not mean they will catch up to their peers without assistance. A private speech and language evaluation may be warranted to determine if your child would benefit from speech therapy services.
Your child has feeding or oral motor issues
Often, feeding and oral motor skills are not addressed in the school system as these skills may not be considered as educationally relevant as other skills. It can also be difficult to find a Speech Pathologist who has experience in working with children with oral motor and feeding deficits. Private speech therapy services can address your child’s feeding and oral motor deficits as these skills are extremely important. Here at Easter Seals DuPage & Fox Valley our speech pathologists have an extensive knowledge of oral motor and feeding deficits in pediatrics.
Your child can participate in co-treat Sessions
When appropriate, co-treat sessions may be of benefit for your child. A co-treat session is when 2 therapies are rendered simultaneously. Often children may be receiving speech therapy along with occupational therapy or occasionally physical therapy. This allows both therapists to work together in order to improve different skills.
For example, the occupational therapist can assist with improving sensory regulation so the child is better able to attend and understand speech and language concepts. The physical therapist can assist the speech pathologist with body positioning/posture to achieve the best speech/voice possible for a child with motor deficits. This is a strength at Easter Seals DuPage & Fox Valley. We often have multiple disciplines work together to get a holistic picture of a child’s needs.
Your child has minor speech/language deficits that are not addressed by the school
Some children may present mild articulation issues that may impact their ability to communicate, but are not severe enough for a child to qualify for school therapy. Private speech therapy can address these issues if found developmentally inappropriate through a private speech and language evaluation.
If you feel your child would benefit from private speech and language intervention, please visit our website here. Let me know in the comments if you have additional questions!
Poop. Pooping. Pooped. A word that is usually reserved for little babies, and usually not for anyone older. Though we all do it, discussion after infancy wanes and it is just assumed we do. Terms like ‘bowel movement’, ‘stool’, and ‘number 2’ replace the cute and friendlier term of ‘poop’. However, one of the most common challenges seen in all people, and especially our children, is the ability to produce a stool that is soft, formed, easy to pass, and on a regular basis. Otherwise known as constipation, this quirk in the gastrointestinal system is connected to a myriad of more problems that need to be addressed. Often the underlying root problem of constipation is overlooked, as parents, doctors, therapists all aim to solve the other problems. As a wise doctor once said, “You have to be able to make the package and deliver it”. So let’s look at what contributes to constipation, how this creates further problems, and some ways to make a package and deliver it.
The Gastrointestinal System
In simpler terms, the GI system is a long tube that starts at our mouth and ends at our anus. The process starts when we eat and drink, whatever that might be. Digestion begins in our mouth using our jaw, teeth, lips, cheeks and tongue, and then saliva is released into our mouths to help break the food down. We swallow this food down our throat, through our esophagus and into our stomach. In the stomach churning begins, pushing the food around and breaking it down further, as more secretions from the stomach are released to help water it all down as it makes its way to the end of the stomach, and in a timely fashion, is released into the beginning of the small intestines. At this point more chemicals are released out into the body, sending a message to the brain that nourishment is coming in, and beginning to decrease our hunger, while also telling the GI system to move things along.
In the intestines, more secretions, from the gall bladder and pancreas, are received by the newly arrived stomach contents, which further breaks the particles of food down in this very fluid environment. Muscular contractions, known as peristaltic waves, move the contents along the small intestines, and these minute particles of food and fluid are pulled into our system in the small intestines to provide the nutrition needed for our bodies to function. About two hours after eating, chemicals are released into the body again, telling the brain that it might be getting hungry. Back in the intestines, the peristaltic waves continue to push the mix out of the small intestines and into the large intestines. There a spectrum of bacteria are found to further help the digestive process by feasting on any fiber in the diet creating a small amount of gas, and water begins to be pulled back into the body, thus creating what will become flatulence (gas) and poop. As the formed mass sits in the rectum near the anus, nervous tissue senses the presence and helps further push the contents out of the body.
What causes constipation?
Unfortunately so many things can mess this finely tuned process up, and contribute to constipation. With children, abnormal anatomy function is one, and includes low and high muscle tone, neurologic disorders, Hirschprungs disease, anal atresia or stenosis, lack of activity and immobility. Medications can also mess up the process, and a few known include analgesics, anticholinergics, anticonvulsants, antidepressants or antipsychotics, chemotherapeutics, and long term use of laxatives. Factors such as fatigue, anxiety, changes in routine or lifestyle, lack of routine, negative associations with eating/stooling, improper positioning, behavioral withholding, encopresis and inability of a child to let a parent or caregiver know they need to use a toilet. Diet is most often deemed the culprit, and lack of fiber or fluid is the go to blame. Although these two areas do contribute to constipation, other associated areas of diet include, poorly chewed foods (oral motor delays, low strength and endurance with eating), difficulty swallowing liquids (thickened liquid diet, dysphagia, nipple size, breathing coordination), excessive fluid losses (drooling, vomiting, fevers, renal conditions), and dairy or soy protein sensitivity (IgG, IgE testing, improvement when removed from diet).
What might give one cause to consider if a child has constipation? Frequency of stooling is a clear identifier. But when a parent describes challenges with stools using terms such as rabbit pellets, Snickers bar, little smears, dry rocks, marbles, can pick it off of his diaper, goes into the corner and cries, paces the room first, we know when he’s pooping, and grunts loud and long an intervention should be considered. Other signs that a child is constipated can be very poor eating, small little portions of food or drink, behavioral challenges, vomiting, GE reflux, spit up, aversion to eating, and enlarged abdomen.
Causes of constipation are so many, and the resolution to this is not as simple as giving a child more fluid or fiber. In fact, more fiber with not enough fluid can compound the problem by increasing constipation. So when trying to help find the right solution, a multidisciplinary approach may be the best. Speaking to the child’s pediatrician is the first place to start, and sometimes the solution. Asking to consult with a
gastroenterologist may be the next step, or seeking the help of a registered pediatric dietitian/nutritionist to review the diet and make adjustments where needed. If the child is seen by any therapist, physical, occupational or speech, inquiring about tone, breathing, oral motor skills with eating and drinking can be helpful.
Physicians are often needed initially to help with the immediate concerns of constipation and alleviating the situation. Use of lubricants, bulk producers, stimulants and stool softeners can be very helpful. These include laxatives such as enemas, Senokot, Ex-Lax, Metamucil, Mineral oil, Colace, Miralax, and Lactulose.
Diet changes, assisted by a registered dietitian/nutritionist can include increasing sources of fiber in the diet through grains, fruit and vegetables. Increasing fluid intake through drinkable fluids, or higher watery foods such as fruits and vetetables, or pureed versions of these foods. Trialing off of dairy products, but incorporating other foods to help replace these nutrients. A physical therapist can help if the contributing factor is poor tone, and use of an abdominal binder, SPIO suit, abdominal massage, positioning, breathing coordination have been shown to help in some children. Occupational therapists can help children become more aware of their body, and learn to know when they need to stool if their awareness is poor, or help with managing behaviors that persist once the constipation has been resolved. Speech language pathologists trained in feeding can also ensure the child is managing their eating and drinking well, check respiration as well, and give solid points on positioning with feeding. Bowel management programs do exist, and these programs can help with management of stooling in a broader manner that includes much of what has been listed above, as well as management of timing through the day.
The bottom line (no pun here) is that everyone should be able to stool comfortably and easily on a regular basis. Food and fluid need to go in continually to help with growth and development of all children, and what goes in will ultimately have leftovers that need to come out. With little babies, management is much more controlled, as a parent has access to seeing what has come out in the diaper. But as children age, parents have less access to their child’s bodily functions, children are less vocal about what may or may not be happening, and challenges with pooping can go unnoticed and unresolved. The screaming, crying, pulling, difficulties with eating in infancy are clear signs of constipation that are not going to be seen as children age. But do know that older children who have constipation are going to demonstrate their discomfort somehow. Ensuring an older child is pooping comfortably on a regular basis is a must, and involves a bit more, uncomfortable at times, conversation. But in the end (again, no pun) it can solve a load (really?) of problems.