M.O.V.E., mobility opportunities via education

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MOBILITY OPPORTUNITIES VIA EDUCATION

® A curriculum written to serve children and adults with severe disabilities

MOVE International. a nonprofit 501(c)(3) organization serving children and adults

with disabilities, is the exclusive licensee of the M.O. V.E. (MobUity Opportunities Via

Education)® Curriculwn For more infonnation concerning the MOVE Curriculum

. and Program, training, and other products and services, contact:

®

INTERNATIONAL 1-800-397-MOVE (6683)

1300 17th Street

Bakersfield, CA 93301

Email: [email protected]

URL: www.move-international.org

Fax:: (661) 636-4045

1st Prlnting - 1991 2nd Printing - 1992 3rd Printing - 1994 4th Printing - 1995 5th Prlnting - 1995 6th Printing - 1999 7th Printing - 2003

Prlnted in the United States of America

Copyright e 1990. 1999 Kern County Superintendent of Schools. a California public education agency. ALL RIGHTS RESERVED No part of this publication may be reproduced or transmitted in any form or by any electronic, mechanical or other means [including the use of information storage and retrieval systems) without written permiSSion from the copyright holder. . ISBN 1-929093-00-4

The following are trademarks/service marks of the Kern County Superintendent of Schools: "MOVE", "M.O.V.E. (Mobility Opportunities Via Education)", 'Top-Down Motor Milestone Test",

NI4iVE. NIiNE· INTERNATIONAL

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Linda Bidabe Founder and Author of the MOVE Program

and M.O.V.E. (Mobility Opportunities Via Education)® Curriculum

Sheron Renfro

MOVE Kern County Superintendent of Schools Office, Bakersfield, CA

Larry Reider

Chairman, MOVE International Board of Directors and Kern County Superintendent of Schools Bakersfield, CA Assistant Superintendent, Educational Services Kern County Superintendent of Schools Office, Bakersfield, CA

John Lindsay

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[ ABOUT

MOVE ]

Mobility Opportunities Via Education (MOVE) reflects our belief that people with severe disabilities can achieve mobility one move at a time. MOVE underscores our commitment that we are here for all people-no matter what their disability. It is much more than a curriculum. MOVE is the result of years of testing. trials. research. patience and faith that people with disabili­ ties can gain or regain mobility. It represents care and concern by teachers, trainers, physical therapists. physiotherapists. parents and caregivers who are committed to moving people with disabilities from a restrictive environment to a more inclusive lifestyle. What we today call MOVE began in 1986 as a summer pilot project in a special education class­ room operated by the Kern County Superintendent of Schools in Bakersfield. California. Less than 20 children with severe disabilities (their life consisted mostly of lying on bean bags) participated in that pilot. The success in just a few weeks showed us the potential to help many more. Kern County Superintendent of Schools, Kelly F. Blanton was equally impressed and provided seed money to help the program grow. This proved to be money well spent. The positive results contin­ ued and before long people from other states, who learned about MOVE by word-of-mouth. moved to Bakersfield to enroll their children. The concept was expanded to three school districts-two in Los Angeles and one in Tulare County. California. In 1991. the MOVE CUrriculum was published. and the program really took off through­ out the United States and internationally. In 1994, the deCision was made to create a not-for-profit foundation to help train more profession­ als and fund research. During this time, MOVE began to include adults with severe disabilities. Model sites were established in 1999 to give parents and professionals the opportunity to witness MOVE clients and see first-hand how it works. The fact that MOVE has rapidly expanded from the original small pilot to international presence attests to its progress and success in teaching children and adults with severe disabilities to sit. stand and walk. To date the curriculum has been translated into nine languages. MOVE is here today because of hundreds of professionals, paraprofessionals, parents and caregivers. They have become our advocates. These are people who refused to accept the status quo and believe that all people, no matter what their disability. deserve an improved quality of life. Their dedication helped thousands and we are in their debt. We know you too will find the MOVE curriculum a rewarding advancement that will benefit many once thought beyond help. Our sin­ cere thanks for your interest and commitment. D. Linda Bidabe MOVE founder and Author

Larry E. Reider Chairman

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[TABLE OF CONTENTS ]

Introduction ......................................................................................................... 1

Chapter 1: Rationale. History and Data .............................................................. 5

Chapter 2: Using the MOVE Curriculum

• A Case Study: John Masters ...................................................... 22

• MOVE Assessment Profile ........................................................... 59

• Step 1 - Testing ...................................................................... 59

• Top-Down Motor Milestone Test ........................................ 60

• Summary of Test Results .................................................. 77

• Step 2 - Setting Goals ............................................................ 78

• Step 3 - Task Analysis ........................................................... 80

• Step 4 - Measuring Prompts .................................................. 82

• Step 5 - Reducing Prompts .................................................... 88

• Step 6 - Teaching the Skills ................................................... 90

Chapter 3: Testing Information ......................................................................... 95

Chapter 4: Teaching the Skills ........................................................................ 145

Chapter 5: Physical Prompts-Sitting

• Sitting Prompts ........................................................................ 212

• Prompt Reduction Plan-Sitting ................................................. 217

• Arm Control Prompts-Sitting .................................................... 218

• Prompt Reduction Plan-Arm Control. ........................................ 219

• Physical Prompts-Sitting: Information ..................................... 220

Chapter 6: Physical Prompts-Standing & Walking

• Standing & Walking Prompts .................................................... 228

• Prompt Reduction Plan-Standing & Walking ............................. 235

• Arm Control-Standing & Walking ............................................. 236

• Prompt Reduction Plan-Arm Contro1. ........................................ 237

• Physical Prompts-Standing & Walking: Information ................ 238

Chapter 7: Combination Special Skills ............................................................ 245

Chapter 8: Selecting & Using Equipment ........................................................ 257

Chapter 9: Some Commonly Asked Questions ................................................ 267

Chapter 10: Glossary ........................................................................................ 281

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PROGRAM OVERVIEW

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obility Opportunities Via Educa­ tion, or MOVE, is a top-down, activity-based curriculum de­ signed to teach students basic, func­ tional motor skills needed for adult life in home and community environments. It combines natural body mechanics with an instructional process designed to help the students acquire increased amounts of independence necessary to sit, stand, and walk.

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TARGET POPULATION: The program was originally designed to meet the needs of students over the age of seven who had not developed the physical skills necessary to sit indepen­ dently, bear weight on their feet, or take reciprocal steps. In the early stages of program development, only students with profound, multiple disabilities were addressed. Because of our success, the target population was expanded to include the infant development pro­ grams as well as students with ortho­ paedic disabilities.

PROGRAM OVERVIEW:

Target Population Purposes of the Program Eligibility for the Program Using the M. o. V.E. Curriculum 2

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PURPOSES OF THE PROGRAM: The MOVE Program is designed to: 1. Use education as a means to system­

aticallyacquire motor skills. 2. Use therapy services for cyclic cor­ roboration, i.e., therapists provide medical consultation when needed and help establish functional pro­ grams, train staff and parents to use the program, and periodically (on a cycle) work with the individual and staff to update the program.

3. Provide a program whereby partici­ pants naturally practice their motor skills while engaged in other educa­ tional or leisure activities. 4. Reduce the time and energy require­ ments for custodial care.

5. Provide a way to measure small incre­ ments of functional motor skills and therefore, provide a way to show improvement.

7. Provide the individual with the basic motor skills which are needed for development of other skills such as expressive language, self-care, and work opportunities. Because of our success, the target population was expanded to include the irifant development programs as well as students with orthopaedic disabilities.

The MOVE Program is based on team­ ing the expertise of education and therapy to address the functional needs of students when they become adults. This teaming resulted in the develop­ ment of eqUipment specifically designed to meet the following needs: 1. The equipment places students in

6. Provide a sequence of motor skills which

a. are age appropriate and based on a top-down model of needs rather than the traditional developmental programs based on the sequential skill acquisition of infants.

b. are valuable and usable to the participant right now as well as in adulthood. c. increase the availability of envi­ ronments in the community as well as in the home.

d. range from the level of zero self-

positions for performing functional activities such as moving from one place to another, self-feeding, self­ controlled toileting, table work, and leisure activities. 2. The eqUipment allows the staff to physi­ cally manage the student while teaching appropriate movement patterns. 3. The equipment is designed so that assistance can be reduced as the student gains motor skills. 4. The equipment allows the students to practice their motor skills indepen­ dently.

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5. The equipment is designed to help improve the bone and joint health of the students and to increase the muscle strength of the extensor mus­ culature of the body.

ELIGIBILITY FOR THE PROGRAM: Access to medical consultation and/ or physical therapy is needed for any students with the following conditions: a. Head too large to be supported by the neck. b. Circulatory disease that prevents the participant from being placed in a vertical position.

c. Respiratory distress.

USING THE MOVE

CURRICULUM:

The MOVE Curriculum provides a com­

prehensive system (STEPS ONE through SIX) for testing, setting goals and keep­

ing records. The MOVE Assessment Profile (see pages 59 and 79-93 for an example) is a workbook to be used with the MOVE

Curriculum. (MOVE Assessment Pro­ files are available from MOVE Interna­ tional.) Included in the workbook are

directions and worksheets to guide you through the six steps of the MOVE

Program. The MOVE Assessment Profile

helps you set up a plan of action for a student and document progress over time.....

d. Brittle bones.

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e. Muscle contractures.

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f. Curvature or rotation of the spine.

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g. Hip dislocation.

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h. Foot or ankle abnormalities.

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i. Pain or discomfort in any part of the body. j. A ny other condition that may require medical consultation.

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Exclusion from the program is limited to those individuals whose medical needs contraindicate (make it inadvis­ able) the need to sit, stand, and walk. People with paralysis or degenerative neuro-muscular diseases can partici­ pate to improve bone and joint health for as long as it is medically feaSible.

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CHAPTER ONE

RATIONALE, HISTORY & DATA

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[ CHAPTER ONE]

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RATIONALE, HISTORY AND DATA RATIONALE, HISTORY & DATA: Learning Models "Rate of Learning" 1984 - A Cold Hard Look

NEEDS & DESIRES: Foundationfor Change TASK ANALYSIS: Building Change Levels of Success Stages of Learning Data to Support Success

"BOTTOM UP" VS.

"TOP DOWN" MODELS: e know that most people are capable of learning. Some, however, learn skills more rapidly than others. Many factors play a role in the speed of acquiring new skills such as necessity of the skill, interest, availability of practice, past experiences, expectations, and neuro­ logical integrity.

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Developmental or "bottom up" models teach motor skills in a sequence taken from normal infant development. This method seems to work well for infants who are only slightly delayed in their motor skills. It has not worked well for the majority of students who are past infancy. The intent of the developmental model is to help children learn skills they have missed. Children who learn slowly do not have the time to perfect all of these infant skills. RATE OF LEARNING refers to the number of trials

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or practice sessions it takes for a per­ son to learn new material. Even though students who have a "slow" RATE OF LEARNING obviously do learn, they require more practice sessions than students who learn faster.

goal needed by the student as an adult in priority life activities. Given the same number of practice sessions using the top-down model for selection, the five skills that the student masters might be: 1. Stands for three minutes with help

We can use the concept of RATE OF LEARNING to help us make broad pre­ dictions about the future abilities of our students to acquire new skills. If, for example, it takes an individual student 2,000 trials to learn a new motor skill and we are only going to be able to offer that child 10,000 practice sessions during the school years, the child will be able to master five new skills. If those five skills are taken from a list of "missed" skills on an infant develop­ ment scale, the student could graduate from school with the following skills: 1. Holds rattle.

2. Props on elbows while prone. 3. Waves bye-bye. 4. Turns to sound. 5. Inspects fingers. If it takes a student 2,000 trials to learn

to maintain head control while being pulled to a sitting position (one session per day for six years), then we might predict an equal number of trials to learn to maintain sitting balance on the floor. If we use a developmental model for skill selection, the student could be pushing up to a sitting position on the floor by the age of 18. The "top-down" model (ecological ap­ proach), on the other hand, begins by selecting a specific target or ultimate

2. 3. 4.

5.

to maintain balance. Walks 10 feet with help to maintain balance. Sits on a conventional chair for 30 minutes without ties. Nods head yes or no to answer

posed question.

Sits on conventional toilet without support.

Obviously, from comparing these two lists of goals, RATE OF LEARNING pre­ dictions should also help us in our selection of WHAT to teach.

1984 - A COLD HARD LOOK Before the MOVE Program, we, too, selected the skills to be taught from a sequence of normal infant development. Even though we would skip some skills that we thought were impossible or non-essential, the selection process still followed the basic contention that stu­ dents had to learn to crawl btifore they could walk. In 1984. we took a cold, hard look at the results of these en­ deavors. COMMUNICATION SKILLS

Other than smiling or crying, the major­ ity of the students had no expressive language. Speech therapy which in­ cluded augmentative and alternative 7

language training produced little or no change. The majority of the students appeared to have far better receptive than expressive language, i.e., many responded by looking at the speaker to their names being called and words like mama, bus, eat, and drink. A physical assessment was made of the students to determine the most logical form of alternative communication.

were unable to make meaningful choices. At that time, we did not know whether they were cognitively unable to differentiate or whether they did not understand that they had options. EATING SKILLS

The majority of students with motor delays required one-on-one assistance at meal time. Most of the students had The students were then introduced to a severe feeding problems complicated by program developed at the Blair Learning chronic upper respiratory distress. At Center in Bakersfield, California to minimum, a class of 10 students with teach students symbolic representation. motor delays required five hours of As an example of the program, the adult assistance to consume lunch (30 students were taught to touch or look at minutes per student). The most obvious a paper cup filled with their favorite problems were a lack of head control, liquid to indicate the desire for a drink. tongue thrusting, and an uncoordinated When the student reached a proficiency swallow pattern. level. an empty paper cup was substi­ tuted for the full cup. In stages, the TOILETING SKILLS empty cup was cut down until only the circular bottom remained. It contained Students under the age of seven were a picture of a cup and the student routinely placed on toilets. Toilet train­ therefore was using symbolism to indi­ ing efforts were reduced or completely cate the desire for a drink. dismissed as students grew older, be­ came heavier, or developed deformities The same method was used for the that made sitting difficult. Whenever category of food. It began with a real possible, students had diapers changed spoon with a favorite food and ended on changing tables. As they grew too with a small picture of a spoon. Using large to be lifted safely, they were the same technique, varieties of food changed on mats on the floor or on and drink were offered. The shocking bean bags. Large students with skeletal result of the program was that the deformities took an average of 20 min­ students who had any sort of mobility utes of adult assistance for a single skills (crawling, rolling, squirming) were diaper change (2 adults x 10 minutes). able to succeed in the program and A class of 10 large students with motor make meaningful choices. Those stu­ delays required three hours and 20 dents who lacked any sort of mobility minutes of adult attendance to provide custodial care a minimum of twice a day. 8

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MOTOR SKILLS

Therapy services were provided by California Children Services (C.C.S.) for those students who had medically eli­ gible diagnoses and were deemed ca­ pable of making measurable progress in developmental activities by the clinic physician. The vast majority of the therapy services were delivered in the "consultant" mode. That is, the thera­ pist would discuss the student's needs with the classroom teacher and instruct the teacher in positioning and activities that would benefit the student. The classroom teacher would then try to fit those activities into the student's class­ room day. A number of articles published by E.E. Bleck, R.K. Beals, and others reported that children older than seven who had not gained independent motor skills by the age of seven were unlikely to ever do so using traditional develop­ mental programs based on the sequen­ tial skill acquisition of infants. Students at the Blair Learning Center supported these findings. From a review of the charts of the non­ ambulatory students at the Blair Learn­ ing Center who were eligible for the C.C.S. therapy program, 99 percent had regressed on the developmental scale after they reached the age of seven or eight. As students grew older, gravity became the enemy to already weak muscles. Positioning became more difficult and deformities developed. In a comparison study involving 50

students with physical disabilities, no statistical differences were found be­ tween the skills of students who were 3.5 to 8 years of age and those 8 to 12.5 years of age. In each group of 25 stu­ dents, 76 percent were functioning below the developmental age of six months in gross motor development. All were receiving services from C.C.S. Only one child had learned to walk after the age of six. HOME LIFE

Students who could be lifted and car­ ried easily were taken out into the com­ munity with the rest of the family. As the students grew larger and more difficult to lift and transport they stayed home more often. The majority of the teenage students who were non-ambulatory went into the community only to attend school (via bus with a wheelchair lift) and for medi­ cal appointments. When the family went out, one member stayed at home with this person. Occasionally a sitter was hired. Sometimes, the person was left unattended for short periods of time. Bathing was considered the most diffi­ cult task to be performed in the home. Many children were bathed once a week in a bathtub or shower and had sponge baths in bed the rest of the time. Usually the child ate at different times than the rest of the family and often in a reclining or semi-reclining position in the living room or bedroom. Diapers were often changed in the same envi­

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ronments because moVing the child was so difficult.

the size of the students.

Mter visiting a number of other schools The mother in the home often slept With With students Similar to ours, we con­

her child with the disability because of cluded that we were not alone in our

the periodic need for repositioning or inabilities to provide our students with other attention during the night. Variety a meaningful education. In every in­ in home and community enVironments stance the time requirements for custo­ decreased in direct proportion to the dial duties were so overwhelming that severity of physical disabilities and the little time was left for education. size of the children. Parents and teachers were physically exhausted. The only sensible solution SCHOOL LIFE seemed to combine education with the custodial duties that demanded so The classes for students With severe much time. This was the beginning of disabilities averaged 10 students per the selection process of the tasks to be classroom with a teacher and an in­ taught. structional aide. Between the teacher NEEDS & DESIRES: and aide, 10 hours of instruction were available. If diVided equally, each stu­ FOUNDATION FOR CHANGE dent received 60 minutes. SELECTION OF ACTIVITIES Students who were non-ambulatory and functioning below one year on the de­ The foundation for the MOVE Program velopmental scale required one-on-one was laid by interviewing parents to assistance to participate in any activity. determine the needs of their children Lunch required a minimum of 30 min­ and analyzing the basic minimal actiVi­ utes per student. Changing diapers or ties necessary for a functioning adult in toileting required an average of 10 min­ the home and community. Some of utes per change. Custodial care {two these basic actiVities included: diaper changes and lunch} required 50 of the 60 minutes available per day. IN THE HOME

Students too large to be lifted by one person required even more instructional time. Many students with severe physi­ cal disabilities required specialized procedures such as putting on and removing braces, postural drainage, periodic suctioning, etc. Instructional time decreased in direct proportion to the severity of physical disabilities and

- Eating with the family or peers

Bathing or showering

- Getting in and out of bed - Dressing and grooming - Toileting - Communicating Participating in leisure activities

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IN THE COMMUNITY

- Shopping - Going to appointments (medical, dental, hair dresser or barber, etc.) - Eating in restaurants - Attending social activities both indoors and outdoors (church, picnics, movies, etc.) Using public rest rooms - Riding on public transportation or in regular cars The selection of functional activities to be addressed is probably the single most important aspect of achieving independence. Even though everything we do requires physical skills, the selec­ tion of specific activities limits record keeping and makes the program man­ ageable. Selecting the activities to be performed comes first and then the physical skills needed to perform the component tasks will be analyzed. Logically, the best selection process is to choose the activities most desired by the students and their parents or care­ givers because these activities will be practiced voluntarily. We have found that students who can speak for them­ selves almost always select age-appro­ priate activities and work hard to per­ fect those things which they have cho­ sen.

and moving from one place to another are some of the functional activities that must be addressed by all students no matter what skill level or what degree of disability the participant might have. Amazingly enough, we have found that all 16 motor skill areas are eventually

After visiting a number of other schools with students similar to ours, we concluded that we were not alone in our inabilities to provide our students with a meaningful educa­ tion.

addressed no matter what the student or caregiver selects because entire ac­ tivities rather than isolated tasks are being practiced. Most of the students who have been involved in the MOVE Program have been unable to select activities for themselves but we were surprised at some of the answers we received from the students who could speak. When asked, What do you wish you could do?, we received the following answers: Turn over on those bars (parallel bars) like they do on television.

Go to that other bathroom where the

Also, activities which must be per­ formed every day in spite of busy sched­ ules are logical selections because they are already established within the daily routine of the student. Eating, toileting,

rest of the kids go. Get on and off the bus all by myself. Stand in linefor lunch with everybody else.

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Play Atari at lwme with my brother. Get drinks out oj the reJrigeratorJor my dad.

When we asked parents and caretakers, What activities at home are most d!fficult Jor you?, they responded: Bathing my child.

have never known it to produce the deSired effects in a child past infancy. For one thing, anyone past infancy finds this task very difficult because the gravitational pull increases as legs grow longer. The task completely changes once the student is moved from a su­ pine pOSition (on back) to a prone posi­ tion (on tummy) so the student doesn't generalize the movement.

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Helping my child in and out qf bed. Changing diapers / toileting / dressing. Not being able to communicate with my child. Transporting my child. Eating/ self:feeding. Getting my child in and out oj the wheelchair.

We used these responses as a basis for activity selection. We then added activi­ ties that are needed at school. Infant development models use the opposite process. These models select tasks first, then hope that the tasks will evolve into the desired activities. We have found that the likelihood of this happening decreases proportionately with the severity of the disabiliity and advance­ ment of the age of the student. For example, a common task found on developmental models is "kicks legs reciprocally." This requires the student to lie on the back, lift legs in the air, and extend one leg while flexing the other. Logically this task is supposed to lead to reCiprocal leg movements while prone (crawling and creeping) and even­ tually walking. Although this activity does no harm, we

We, in special education, are very crea­ tive and determined. We devised every­ thing imaginable from upside-down bicycles to crawling machines. Unfortu­ nately, none produced the desired ef­ fects of learning to crawl, much less learning to walk. By addressing the task (kicks legs re­ ciprocally) we lo&t sight of the goal (walking for mobility) and our creative energies tunneled backward toward infancy rather than moving forward toward adulthood.

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TASK ANALYSIS: BUILDING CHANGE

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COMPONENTS OF MOBILITY

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Each of the activities mentioned by the parents were then task analyzed to determine the physical skills required in order to accomplish these skills. The skills fell into 16 categories: A. B. C. D. E.

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Maintains a Sitting Position Moves While Sitting Stands Transitions from Sitting to Standing Transitions from Standing to Sitting

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F. Pivots While Standing G. Walks Forward H. Transitions from Standing to Walking I. Transitions from Walking to Standing J. Walks Backward K. Turns While Walking L. Walks Up Steps M. Walks Down Steps N. Walks on Uneven Ground O. Walks Up Slopes P. Walks Down Slopes Within the 16 categories, 74 individual skills are listed and these are referred to as "MOTOR MILESTONES" because these skills have proven to be crucial to the functions of daily life. VARYING LEVELS OF SUCCESS Even though these skills are on a con­ tinuum, they have been divided into four levels of success. Not all students are able to master the skills required for graduation from the program. But even if the student only improves enough to master the next higher level, the life of the student and of the student's caregivers changes dramatically. Our experience suggests that 99 percent of the people with physical disabilities can improve their functional skills and physical health regardless of age or disability. The four levels are determined by defin­ ing the needs and expectations of stu­ dents, parents, caretakers, therapists, and educators. The greatest hope is that every student will be able to have independent mobility within the home and community but time constraints, multiplicity of disabilities, and the

neurological integrity of individual stu­ dents means that total independence might not always be possible. A hierar­ chy of needs has been established re­ sulting in the following levels of suc­ cess: GRAD LEVEL - Completion of these skills will assure the student of inde­ pendent mobility in the home and mini­ mal assistance in the community. Par­ ticipants who complete this level will graduate from the program and can expand their motor skills through tradi­ tional programs. A wheelchair will never be needed. LEVEL I - Completion of skills at this level will assure that no lifting of the participant by the caretaker will be reqUired. The participant will be able to walk with both hands held or with a walker for a minimum of 300 feet. A wheelchair will be needed only for long distances. LEVEL II - Completion of skills at this level will assure that the participant will be able to walk at least 10 feet with help from another person in maintaining balance and shifting weight. Lifting will be minimal due to help from the partici­ pant. A wheelchair will be required for distances of more than 10 feet. LEVEL III - Completion of skills at this level will improve bone health and func­ tioning of internal organs and decrease the likelihood of joint deformities and pain. The skills were grouped into the four

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levels by looking at the records of stu­ dents who had been involved in the MOVE Program for three or more years. Students who were near independence in walking had other skills in common such as the ability to sit on a chair for extended periods of time and the ability to stand with minimal help in maintain­ ing balance. The same was true of stu­ dents who could walk with both hands held, etc. These common skills were

We, in special education, are very creative and determined. We devised everything imaginable from upside­ down bicycles to crawling machines. Unfortunately, none produced the desired effects of learning to crawl much less learning to walk.

defined and grouped together to form the four levels of success. Virtually anyone can sit, stand, and walk if the person is given enough physical assistance. Additionally, we found that most people can improve their motor skills if these skills are taught and practiced systematically. Our questions, therefore, did not ask whether students will be able to sit, stand, and walk. Instead we asked how much help they will need in order to begin the learning process. Is it impor­ tant to them to spend the time, effort, and resources needed to improve their skills? All educational programs require in­

structional time, staff, and equipment to varying degrees. The speed of skill acquisition depends upon the student's rate of learning, the instructor's ability to provide appropriate experiences, and the amount of time spent on the activ­ ity. Because time has always been limited in special education classes, positioning students in supportive devices for lying down, sitting, and standing has often been considered the totality of the mo­ tor program. Using substitutes for motor skills is not the same as TEACHING motor skills. We should be very careful to maintain a clear distinc­

tion between the two. Appropriate

MOVEMENT, not static positioning, is the key to improved health and inde­

pendence.

We need to shift our instructional attentions away from the concept of contain­

ing a child toward the concept of help­

ing the child move. You will note that only two of the 16 sections in the MOVE

Program address static skills: A. MAIN­

TAINING A SITTING POSITION and C.

STANDING. The other 14 sections ad­

dress movement in varying degrees of complexity. The MOVE Program is designed to offer the students only as much help as they need to accomplish movement and then to reduce that help until they are functioning as indepen­ dently as possible.

Our students with severe physical disabilities have repeatedly proven to us that they cannot acquire mo­ toric skills without systematic in­ 14

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struction. Previously. we were trying to treat the underlying cause of the dis­ ability with the assumption that auto­ matic learning would then occur. For example. a common practice is putting children through range of motion exer­ cises to improve joint mobility, to stretch muscles, and to allow for mo­ toric skill acquisition. This makes obvi­ ous sense especially when we look at other athletic accomplishments but it has not made significant changes in our students. We know that time limitations for exercise periods are one of the rea­ sons for failure. In other words, range of motion exercises that are practiced twice a week for 15 minutes cannot make a significant difference when non­ range of motion is practiced the other 5,010 minutes of the week.

dents who automatically learned to stand or walk by simply spending time in an upright position. What HAS made a difference is systematic teaching of selected skills that are practiced every day while performing functional activi­ ties. The MOVE Program is based upon the teaming of instruction with therapeutic methods. This includes the ecological inventory, prioritization of goals, chronological age-appropriate skills, task analysis, prompts for partial par­ ticipation, prompt reduction, and the four different stages of learning: acqui­ sition, fluency, maintenance, and gen­ eralization. (Snell and Brown, 2000)

STAGES OF LEARNING: This is only a part of the problem. A few of our dedicated parents have relig­ iously practiced range of motion exer­ cises with their children, sometimes for hours every day without fail. And even though the student's joints remained flexible, these children did not gain skills. Other than postponing the onset of fixed deformities, nothing was gained. The same is true of the static position­ ing techniques and devices we have employed. Even though seating systems can and do decelerate the deterioration of the skeletal system, the devices alone have not proven effective in the acquisi­ tion of independent sitting skills.

ACQUISITION STAGE

The first step in acquiring new motor skills is often the most difficult. For this reason, STEP SIX: TEACHING THE SKILL will deal mostly with the acquisi­ tional stage. During this stage, the student is learning new skills at the "just manageable difficulty" level. Be­ cause the new skills require total con­ centration and effort. they are not used in combination with functional activities until they become manageable by the student and the staff. When these new skills improve, they are used function­ ally in the classroom and incorporated in activities at home.

Standing frames have played the same role in maintaining joint and bone in­ tegrity but we have not had any stu­ 15

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TIME AND STAFF

There are any number of ways to set up a mobility program depending upon the educational setting, the staff, and the amount of time made available for ad­ dressing these new skills. At the Blair Learning Center, students spent about an hour each day in what we referred to as aerobics class during which the students addressed acquisitional skills. The MOVE Program has been designed to be successful in any setting, includ­ ing integrated schools, rehabilitation centers, and home teaching situations. For us, combining staff members and students for aerobics class was fun as well as successfuL We consider this a "pull in" program rather than a "pull out" program because we were increas-

When a student improves a skill. everyone cheers and feels partially responsible for the improvement. Teachers. like students, need rein· forcers.

ing environments rather than isolating students. From the very beginning of training, the students worked with a variety of adults; this process assured that the students could function with more than one or two people. The aerobics time encourages busy teachers, aides, and therapists to share information and to work with more than

just their own students. It also is a learning process and a morale booster for students and staff alike. When a student improves a skill, everyone cheers and feels partially responsible for the improvement. Teachers, like students, need reinforcers. PHYSICAL SETTING

Blair at Sequoia (Blair has gone through the process of reverse integration) has a "mobility park" specifically designed to meet the needs of the MOVE Program. When the weather permits, the students have aerobics in this area. When the weather is not conducive. aerobics is included in the classroom. The mobility park has smooth concrete at both ends to allow easy movement of mobile standers and walkers. Curbing is around the concrete area so that the students can explore without fear of turning a walker over or running a mobile stander off the edge. The center of the park has a sloping hill with grass. One side of the hill is cut away and steps with the same dimen­ sions as buses have been inserted. By including these in the mobility park, we are able to begin the acquisitional phase of ascending and descending steps using a realistic model as well as being able to practice walking on slop­ ing ground and uneven surfaces.

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iii:­ The center of the park has a concrete wall around a sand area. One section of the wall is the same height and width as a conventional bathtub. This allows

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the staff to help students practice get­ ting in and out of a bathtub without being confined and isolated in a small area like a bathroom. The sand is used for practicing walking on uneven ground.

rushed and sometimes have a tendency to explain the termination of an activity by saying John is tired. He needs to rest. The truth is that WE are tired, bored, impatient, or whatever. John is fine. If we are not strong enough to help our

PROGRAM RESPONSIBILITY If the student has therapy orders, the

therapist can work directly with the student while in aerobics class to teach new skills by using the prompt reduc­ tion format of the MOVE Curriculum. Since therapy time always is limited, the therapist can train others to help in this acquisitional phase. If the student does not have access to therapy, the teacher can establish the format for the acquisitional phase using the MOVE Curriculum. Aerobic routines then are practiced entirely by the educational staff. LENGTH OF TRAINING SESSIONS

students practice skills, we need to use equipment that will help us. Since we cannot address all students simultane­ ously, we need to have safe sitting, standing. or walking options where the students can at least practice mainte­ nance of the skills already learned while waiting for our attention. If we are bored, we need to look for improvement in smaller increments so that we can recognize our successes. If we have too much to do, we need to either get some more help or drop some activities. The thing we do NOT need to do is put the student down for a nap. In some situ­ ations, students are spending the ma­ jority of their school time "resting" in bean bags or on the floor .

When we first started, we assumed, like everyone else, that our students tired quickly so we had the students practice skills in short sessions. During the acquisitional phase, our students do seem to tire rather quickly just as we tire when we are learning a new skill. In subsequent phases, however, we are the ones who tire qUickly, not the stu­ dents. This is probably because we are helping many students and therefore are getting much more exercise than individual students and we are accus­ tomed to moving easily without hinder­ ance. We get impatient, bored, or

17

®

FLUENCY STAGE

When the student becomes proficient with the skills addressed in the acquisi­ tional phase, the skills are introduced into the educational programs and used functionally in as many activities as possible. If the student is eligible for therapy services. the therapist helps provide the functional program by com­ bining the therapy goals with the edu­ cational goals. If the student does not have therapy services. the teacher pro­ vides the functional program.

moves his diaper. John will pivot and sit on the toilet with balance provided by the adult. When finished. the adult will help John maintain his balance while he pushes himself to a standing position, pivots, and grasps the hand rails. He will maintain his standing balance while the adult replaces his diaper and adjusts his clothing. The adult will then help him walk to his next activity.

­

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if we are bored. we need to look for improvement in smaller increments that we can recognize our suc­ cesses.

EXAMPLE:

so

A. THERAPEUTIC GOALS: 1. Improve standing balance 2. Improve use of upper extremities 3. Gain the ability to shift weight on feet 4. Increase speed of assisted, directed walking

B.EDUCATIONAL GOAL: "John" will maintain a dry, unsoiled diaper 50 percent of the time when placed on a toilet every two hours during schooL

The resulting functional, activity-based program would then be: John will walk from the bus or class­ room to the bathroom at a rate of at least one step per second. The adult in attendance will support him from one side only and reqUire him to shift his own weight while walking. When he arrives at the toilet, he will grasp the rails beside the toilet and maintain a standing position while the adult re-

-

IiMAINTENANCE STAGE

By the time the student has reached the maintenance phase, the activities have become a way of life and do not reqUire specific programming. Training of the specific skill is limited to introducing new people to the methods of physical management for each student. (By this time. it is easier to have John stand to have his diaper removed than it is to have him lie down on a change table or a mat and thus, the skill is guaranteed to remain in use.) While these skills are being maintained, new skills are being introduced at the acquisitional stage. GENERALIZATION STAGE

In the generalization stage, the objective is to expand the use of the acquired skills in many settings including the 18

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school, home and the community with a variety of adults in attendance.

gance and Gessell). The highest func­ tioning student (CA-6 yrs.) was still functioning below the IS-month level of In the MOVE Program, the skills needed development. for sitting, standing, and walking are taught SIMULTANEOUSLY. The student All of the students were diagnosed as does not have to perfect sitting skills having multiple disabilities and 12 were first, then perfect standing, and then diagnosed as having cerebral palsy. Ten walking. The student will be addressing of the students had deformities in joints all of these skills at various times dur­ and/or the spine. The other five had ing the day regardless of the student's very low muscle tone. These 15 were developmental level. originally selected for the study because they had all regressed on the develop­ mental scale as they gained size. All Before the MOVE Program, we, like most other people, were following the were at risk for severe deformities. (See developmental model. We would try to next page for review of program data teach head control by propping on el­ referred to above.) .. bows. sitting with neck collars, etc. When we started teaching sitting. stand­ ing. and walking simultaneously. we found that head control often improved immediately when a student was placed in a front leaning walker. This, of course, was often due to motivation because many of the students wanted to be moving. The same is true of trunk, hip, leg. and arm control. The Gestalt theory of "the whole is equal to more than the sum of the parts" certainly proved to be true with our students.

DATA TO SUPPORT PROGRAM SUCCESS: The following is a review of 15 students who completed three years in the MOVE Program. Chronological ages upon en­ tering the program ranged from six years to 16 years with the majority of the students functioning below six months on developmental scales (Bri­ 19

[~=P~R~O_G~RAM~=D=A=T=A;;;;;;;;;;;;;;;] Sept., 1986

Aug., 1989

9

14

2. Sits on a stool for five minutes. (If a person can sit this long without support, the caregiver has ample time to get the person off the bed, the edge of the bathtub, etc.)

9

12

3. Bears full weight on feet for one minute. (In one minute, a person's diaper can be removed or clothing adjusted and the person can be placed on the toilet. The person can also stand to have a diaper reapplied.)

6

13

4. Pulls to a standing position with an aide. (A person who can assist in getting to a standing position does not have to be lifted.)

3

12

5. Maintains standing balance for one minute when stabilized at the knees.

(A person who can maintain hip, trunk, and head balance

while leaning against a table or counter, has free arm move­ ment for brushing teeth, washing hands, etc.)

0

10

6. Walks five feet using reciprocal steps when balance is provided by a front leaning walker or by another person.

(The ability to walk a minimum of five feet gives access to

almost any toilet or small space inaccessible to a wheelchair.)

5

14

7. Gets up from a chair, walks 20 feet, seats self in a

0

2

6

13

1. Sits on a classroom chair for 30 minutes.

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(This is the average length of time for any classroom activity

and for most meals.)

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chair without assistance. (A person who has achieved these skills will have indepen­ dence within the home environment.)

8. Some functional use of upper extremities. (Functional use is defined as self-feeding, wheelchair move­ ment, or purposeful grasp and hold.)

20

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CHAPTER TWO

USING THE MOVE CURRICULUM

( CHAPIER Two: USING

11ffi MOVE CURRICULUM ]

A CASE STUDY: JOHN MASTERS STEP 1 - TESTING

T

EST the student using the TOP­ DOWN MOTOR MILESTONE TEST found in Chapter 2.

This is a placement test rather than a diagnostic test. Parents, teachers or therapists familiar with the student need to directly test only those skills which they have not had an opportunity to observe. Usually, the test can be completed in about 15 minutes.

STEP ONE - Testing The 16-page TOP-DOWN MOTOR STEP TWO - Setting Goals

MILESTONE TEST can be found in Chapter 2, beginning on page 60. To

administer the test, start reading at the highest skill level (GRAD LEVEL) and STEP THREE - Task Analysis proceed down each page until you reach a skill that the student has mastered. STEP FOUR - Measuring Prompts This is the entry level of the student and should be marked with an "E" along with the date.

STEP FIVE - Reducing Prompts

STEP SIX - Teaching Skills

For the most part, the student should be able to accomplish all of the skills below their entry level, so these bubbles

22

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can be filled in. This method eliminates testing and addressing skills that the student is already performing. Two methods of record keeping have been provided. The test provides a brief description of each milestone skill being tested and provides a place to record the date of skill achievements. This record should give you some indication of the student's rate of learning and is convenient as a reference for instruc­ tional planning. The results of this test can be trans­ ferred to the SUMMARY OF TEST RE­ SULTS to provide you with an overview of the student's current skills in all 16 areas (A through P) on a single page. This form can be found in Chapter 2 on page 77 following the TOP-DOWN MO­ TOR MILESTONE TEST. An explana­ tion of the skills used in the summary is found beginning on page 97. This record will provide you with a "menu" of skills to choose from and will immedi­ ately show the strengths and weak­ nesses of the student.

Generally, these students lacked the opportunity to practice the skills, needed systematic prompting, or needed medical attention. Highly developed skills often indicate that the student enjoys the activity and these skills can be linked to less prac­ ticed skills to achieve as much inde­ pendence as possible. For important and detailed information on the TOP-DOWN MOTOR MILE­ STONE TEST, please refer to Chapter 3 on page 96.

Tests and records of student progress should serve functional purposes. Precious time should not be wasted on the "paper chase",

The majority of students will have skills grouped closely together within the skill levels. In other words, the student will basically be functioning on the GRAD LEVEL, LEVEL 1, LEVEL II. or LEVEL III (page 13).

o

Some students, however, may show On page 25 you will see an example of a wide fluctuations between skills. We completed SUMMARY OF TEST RE­ have had a few students who passed all SULTS for a student named John Mas­ of the sitting and movement skills at the ters. We will now follow John through GRAD LEVEL but who could not bear all six steps of the MOVE Curriculum. weight on their feet even momentarily. 23

CASESTUDY----------------------------~ JOHN MASTERS: A COMPOSITE CASE STUDY

STEP 1 - TESTING

John is an 11 year old boy who has been in the program for two years. Be was diagnosed at birth as having cerebral palsy. When he was five, he sustained head injuries in a traffic accident. Even though he has been diagnosed as spastic quadriplegic, he had more functional use of the left side of his body than the right side. Be entered the program functioning mostly on LEVEL m with some static sitting skllls on LEVEL II. Be had some tightness in his right hip and knee and was unable to bear any weight on his feet even momentar­ ily. John had been receiving therapy services approximately two times per week since he was two. Be was eligible for the therapy services providedby the state ofCalifornia. When John entered MOVE at age nine, he displayed discomfort when anyone attempted to fully extend his right hip and knee. The therapist was consulted before any programming began. John had no verbal skllls other than occasional babbling. no means of moving from one place to another, and was "at risk" for developing severe deformities in the hips and spine due to uneven muscle tone and lack of exercise. Toilet training had been abandoned. Be ate pureed food fed to him by an adult. Be could momentarily grasp small items placed in his left hand but his right wrist was contracted and he did not attempt to use his right hand or arm for any activities. All items placed in his left hand were brought to his mouth. As you can see from his SUMMARY OF TEST RESULTS on page 25,

John has now completed many of the MOTOR MILESTONES required for completion of LEVEL II. In STEP 2, we will talk to John's parents and decide what functional tasks John needs to address now. In STEP 3, we will use John's SUMMARY OF TEST RESULTS to help us select the milestone goals that will meet the needs of each of these functional tasks.

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SUMMARY OF TEST RESULTS

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3-11-90 DATE___________________________________

1. Fill in squares representing the current skill levels. 2. Fill in all squares to the right of the current skill levels. 3. Circle skills to be addressed next. GRAD LEVEL

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A. MAINTAINS A SITTING POSITION

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John Masters

LEVELH

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D. TRANSITIONS FROM SITTING TO STANDING

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E. TRANSITIONS FROM STANDING TO SITTING

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K. TURNS WHILE WALKING

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PREREQUlSITE SKILLS FROM OTHER SECTIONS ARE INDICATED BY ITAUCIZED LETTERS AND NUMBERS

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STEP 2 - SETTING GOALS

the skills tested in STEP ONE.

Select specific functional activities that the student needs to perform.

The term "FUNCTIONAL ACTIVITIES" refers to activities that are necessary to daily living such as eating, toileting, and communicating and also includes educational endeavors such as reading, writing, and math. Every activity we perform requires motor skills. No mat­ ter what activity is chosen, motor skills will be addressed.

In STEP ONE, the student was tested using the TOP-DOWN MOTOR MILE­ STONE TEST. Now, in STEP TWO, specific activities are going to be selected which will use

-­ -

CASE STUDY----------------------------­ ..

­

JOHN MASTERS: STEP 2 - SETTING GOALS When John moved to our area, his parents felt defeated. They looked

like tired soldiers trudging through another muddy swamp when they

attended his rust Individualized Education Program (I.E.P.) meeting.

Our principal chaired this meeting and after the standard explanation of

John's rights, he asked the simple question, "By the time John graduates

from the public education system, what do you want most for him to be

able to do?"

John's mother hesitated. Then she proceeded with words that tumbled over each other. "You'll say I'm unrealistic. But I wish John could walk. We worry about what will happen to him when we get older. Who will take care of him? We don't think it's fair to assume that his sister will have that responsibility. If he could just walk and not have to be lifted or carried, we could take care of him a lot longer. It's something we don't talk about much because we don't see many options, but it's something we worry about all of the time."











John's father then broke in and said, "Excuse me if I seem a little defensive but we've been told so many times that we must accept John as he is. We DO accept John and we love him. He's our son but we also think things could improve. I'm gone on business trips a lot and my wife has to do everything for John. He's getting to be a big boy.







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2 26

CASESTUDY----------------------------~

STEP 2 - SETTING GOALS (Continued) It's really hard for her to take care of him when I'm not there. In fact, she's already hurt her back several times. Our daughter has to help get John out of bed and put him in his wheelchair when I'm not there. "I don't know what's going to happen when he gets bigger. It's something we worry about quite a bit. John's legs seem to hurt him a lot. I guess it's too much to expect him to walk. But if he could just help get himself out of his chair or bed, we would be happy--no, we would be ecstatic!" By the second Individualized Education Program meeting, things had changed dramatically for John and his family. John no longer experienced pain and helped move himself from chair to chair by momentarily bearing his own weight on his feet. He could maintain his . own sitting balance for a few seconds while someone fastened the straps on his chair. He could move his legs reciprocally for short distances when supported by a walker or another person. His parents entered the second Individualized Education Program meeting with a much different attitude. Rather than being defensive and apologetic for their "inability to accept John as he was", they were armed with their dreams. At the end of the second year, it was time to plan the third Individualized Education Program. Since John cannot yet speak for himself, his parents were asked to speak for him and for themselves. The question was asked, "What activities would you like for John to improve this year? tt His father said, "John's very favorite activity is going to our local yogurt parlor with the family. He loves the color and busy atmosphere as much as he loves his chocolate yogurt. The family doesn't go very often because it's a hassle to load up John's wheelchair, get John in his car seat, and unload the wheelchair. "Once we get there, we repeat the whole procedure all over again to com:e home. If John didn't need the wheelchair and could sit on the chairs provided in the parlor, we would go more often. We all talked about what John wants and agreed that if he could speak, he'd yell for the yogurt parlor. tt ,..r--'-­

21 27

-r-­ CASE STUDY

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STEP 2- SETTING GOALS (Continued) His mother reported that, "Changing John's diaper is so much easier since John has learned to bear weight on his feet because I can change him whDe he's standing. I don't have to lift him anymore, but I would like to start toDeting him at home. He is consistently having bowel move­ ments after his supper. I believe we could avoid soDed diapers altogether if he could sit on our toDet." John's teacher suggested one goal might be for John to fe~d himself lunch at a table with the rest of his class rather than being isolated in a wheelchair with a tray. "Eventually,.. said the teacher, "we would like for John to be able to sit anywhere to eat and, of course, we would like for him to be able to feed himself in a socially acceptable manner." John's parents agreed. The teacher had met earlier with John's physical therapist. The therapist suggested that "walking backward" be added to John's goals. The therapist observed John's mother helping John get into his wheel­ chair and that the mother picked him up to move him backward. She was in an awkward position when she did this and placed a great deal ofstrain on her lower back. "If John was able to step backward," said the therapist, "his mother would not have to pick him up to help him sit on any seat, including the front seat of the car." Before the meeting ended, the speech/language pathologist, psy­ chologist, and the school nurse encouraged the family by discussing the improvement in John's potential for expanded communication, speed in acquiring information, and general health. The words "acceptance" and "unrealistic" never entered the conversation.....

~-

2 STEP 3 - TASK ANALYSIS Target the motor milestone goals that need to be improved for each of these functional activities.

In STEP ONE, the student was tested using the TOP-DOWN MOTOR MILE­ STONE TEST. In STEP TWO, specific functional activi­ ties were selected as a result of the

28

needs and desires of the students. their parents / care providers and of the people who are helping the students. Now. in STEP THREE. individual com­ ponents of these functional activities are targeted for instruction. Once the desired outcomes (goals) have been established. the team begins to focus on specific mobility skills to be taught (Step 3). Skills are selected be­ cause they are needed to accomplish the goals from Step 2. Although it is tempting to try and address all of the skill deficits for an individual. focusing programming on the specific skills related to the goals allows the team to provide intensive and consistent prac­ tice on the highest priority skills for that individual.

CASESTUDY----------------------------~

Let's follow the activities chosen by John Masters and the people who help him..

JOHN MASTERS: STEP 3 - TASK ANALYSIS The four major activities selected by and for John were: 1. Going into the community without using a wheelchair.

2. Using a conventional toilet (as opposed to a large potty chair). 3. Feeding himself lunch while sitting at a table with his peer group. 4. Walking backward to help seat himself without being lifted. ~-

3 29

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CASESTUDY----------------------------~

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STEP 3 - TASK ANALYSIS (Continued)

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The casual record keeper would simply ask, "Why are these activities difficult now?" The answers would be:

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1. I t's difficult to take John to the yogurt parlor without his wheelchair because he requires a lot ofsupport whne walking and can't sit safely for long periods of time without specialized seating.

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2. I t's difficult to tonet John at home because he can't sit safely on a conventional tonet. There isn't enough room (or the desire) to add a large potty chair to the bathroom at home.

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S. I t's difficult to help John feed himselfbecause as he brings the spoon to his mouth, he leans to the right and loses his sitting balance.

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4. John has to be lifted to be placed on a seat because he can't step backward.

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The natural conclusion would be that John needs to improve his sitting skUls (SECTIONS A and 0), his skills in walking forward (SECTION G), and his skills in walking backward (Section J). The casual record keeper would simply look at the SUMMARY OF TEST RESULTS com­ pleted earlier for John Masters, see where he is functioning now. and strive to accomplish the next higher skill from the TOP-DOWN MOTOR MILESTONE TEST. (See page 25 which shows the skills A.3., 0.7.• G.4.• and J.3. circled.)

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NOTE: In the MOVE Program. skills needed for sitting. standing, and walking are addressed simultaneously. Students don't need to learn to sit first. then stand. then walk. They can experience the joy of indepen­ dent movement (moving legs reciprocally) before being able to sit independently. The curriculum format has prerequisite skllls bunt into each of the 16 categories so that success is possible regardless of the functional level of the student.

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For the more structured program with detalled record keeping, you would task analyze the activity by physically or mentally going through the task step-by-step. The following examples are taken from the activities John has selected.

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CASESTUDY.----------------------------~

STEP 3 - TASK ANALYSIS (Continued) SELECTED ACTMTY: Going to the yogurt parlor TASK ANALYSIS: 1. WALK TO THE CAR.

(SECTION G: Walks Forward)

2. S TOP WALKING AND REMAIN STANDING. (SECTION I: Transitions from Walking to Standing) 3. T URN TO SIT ON THE SEAT IN THE CAR.

(SECTION F: Pivots While Standing)

4. S TEP BACKWARD TO POSITION SELF.

(SECTION J: Walks Backward)

5. LOWER SELF TO SITTING. (SECTION E: Transitions from Standing to Sitting) 6. PIVOT LEGS AFTER SITTING.

(SECTION B: Moves While Sitting)

7. REMAIN SITTING WITHOUT CAR SEAT. (SECTION A: Maintains a Sitting Position) 8. PIVOT LEGS TO GET OUT OF CAR.

(SECTION B: Moves While Sitting)

9. STAND UP FROM SITTING POSITION. (SECTION D: Transitions from Sitting to Standing) 10. STAND IN PLACE WHILE ADULT CHANGES POSITIONS. (SECTION C: Stands) 11. START WALKING. (SECTION H: Transitions from Standing to Walking) 12. TURN TO ENTER PARLOR.

(SECTION K: Turns While Walking)

13. STOP WALKING AND REMAIN STANDING. (SECTION I: Transitions from Walking to Standing) 14. TURN TO SIT.

(SECTION F: Pivots While Standing)

15. STEP BACKWARD TO POSITION SELF.

(SECTION J: Walks Backward)

16. LOWER SELF TO SITTING. (SECTION E: Transition from Standing to Sitting) 17. REMAIN SITTING ON CONVENTIONAL CHAIR. (SECTION A: Maintaining a Sitting Position) (REVERSE PROCEDURE TO GO HOME.)

3 31

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CASESTUDY----------------------------­

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STEP 3 - TASK ANALYSIS (Continued)

~

SELECTED ACTMTY: Toileting

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TASK ANALYSIS: 1. WALK TO THE TOILET IN THE BATHROOM.

(SECTION G: Walks Forward)

2. STOP WALKING AND REMAIN STANDING TO ADJUST CLOTHING FOR TOILETING. (SECTION I: Transitions from Walking to Standing) (SECTION C: Stands) 3. T URN TO SIT.

(SECTION F: Pivots While Standing)

4. S TEP BACKWARD TO POSITION SELF TO SIT ON TOILET. (SECTION J: Walks Backward) 5. L OWER SELF TO TOILET. (SECTION E: Transitions from Standing to Sitting) 6. S IT COMFORTABLY ON THE TOILET. (SECTION A: Maintains a Sitting Position) 7. W HEN FINISHED, STAND UP FROM SITTING POSITION. (SECTION D: Transitions from Sitting to Standing) 8. STAND IN PLACE TO ADJUST CLOTHING.

(SECTION C: Stands)

MAY NEED TO TURN. (SECTION F: Pivots While Standing) 9. S TART WALKING. (SECTION H: Transitions from Standing to Walking) 10. WALK TO SINK TO WASH HANDS.

(SECTION G: Walks Forward)

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STEP 3 - TASK ANALYSIS (Continued) SELECTED ACTIVITY: Eating a meal with peers TASK ANALYSIS: 1. WALK TO THE TABLE.

(SECTION G: Walks Forward)

2. S TOP WALKING AND PREPARE TO SIT. (SECTION I: Transitions from Walking to Standing) (SECTION C: Stands) 3. T URN TO SIT.

(SECTION F: Pivots While Standing)

4. S TEP BACKWARD TO POSITION SELF.

(SECTION J: Walks Backward)

5. L OWER SELF TO CHAIR. (SECTION E: Transitions from Standing to Sitting) 6. P IVOT LEGS WHILE SITTING TO FACE TABLE.

(SECTION B: Moves While Sitting)

7. S IT COMFORTABLY IN A FUNCTIONAL SITTING POSITION. (SECTION A: Maintains a Sitting Position) 8. WHEN FINISHED, PIVOT LEGS TO STAND UP FROM TABLE. (SECTION B: Moves While Sitting) 9. STAND UP FROM SITTING POSITION. (SECTION D: Transitions from Sitting to Standing) 10. STAND IN PLACE.

(SECTION C: Stands)

11. S TART WALKING. (SECTION H: Transition from Standing to Walking) 12. WALK TO NEXT ACTIVITY.

(SECTION G: Walking Forward)

33 I

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CASESTUDY-----------------------------­

~

STEP 3 - TASK ANALYSIS (Continued)

~

SELECTED ACTIVITY: Helping seat self without being lifted TASK ANALYSIS:

~

1. WALK TO THE CHAIR.

(SECTION G: Walks Forward)

2. TURN TO SIT.

(SECTION F: Pivots While Standing)

3. STEP BACKWARD TO POSITION SELF.

(SECTION J: Walks Backward)

4. LOWER SELF TO CHAIR. (SECTION E: Transitions from Standing to Sitting)

-

..-.-­ -

-.-­

­

-

Mter finishing the task analysis, the instructor looks at the SUMMARY OF TEST RESULTS for the individual student and estab­ lishes priorities for skills to be addressed. On page 25 you will see John's SUMMARY OF TEST RESULTS with the skills A.3., B.7., G.4., and J.3. circled. These skills were selected for the following reasons:

-

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A.3. and B.7.

Although John can "freeze in space" to remain sitting for a few minutes, he loses his balance if he leans to the right (his more involved side) especially if he is trying to use his left hand for anotheractivity such as feeding himself. Improvement in John's abllity to bring himself back to an erect sitting position when he

-

-

--

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3 As you can see from the detailed task analyses many areas are practiced with each activity. If you are using a detailed record keeping system, these task analyses will be used during STEP SIX: TEACHING THE SKILLS to establish the priorities and amount of time spent on each specific skill. No matter what your record keeping system or the order in which skill areas are addressed. eventu­

ally all 16 areas of the MOVE Program will be addressed out of necessity. The purpose of selecting specific motor milestone goals is to ensure that the key elements needed for specific activi­ ties are addressed first. Usually motor skills are improved because of the de­ sire to participate in a specific activity as opposed to some future event.

34

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CASESTUDY____________________________

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STEP 3 - TASK ANALYSIS (Continued) leans to the right would increase the amount of time John would be able to sit independently. This would help him accomplish his activity goals.

G.4. Walking forward is required for all of John's selected activi­ ties and is a prerequisite for all of the areas L through M. Without being able to bear his own weight while walking a minimum of 10 feet. it is impractical and too difficult to have John walking up and down steps. on uneven ground. or on slopes. The distance from the handicapped parking space to the tables in the yogurt parlor is more than 100 feet so John definitely needs to work on his walking skills. J .3. Stepping backward is a skill often ignored because the instructor can manipulate the student to avoid the need to step backward. In other words. the instructor can usually help the student walk close to the seat and pivot so that the student is directly in front of the chair. This has been the case with John. If a parent or the instructional staff did not get the timing just right. they would simply pick John up to move him backward even though he is too large to do this safely. If John learns to step backward. this will alleviate the back strain of those helping him. It also will serve as a foundation for his eventual goal of independent movement.....

STEP 4 - MEASURING PROMPTS In STEP TWO, specific functional activi­ Try the activities to determine how much help (prompts) the student needs in order to perform each activ­ ity now. In STEP ONE, the student was tested using the TOP-DOWN MOTOR MILE­ STONE TEST.

ties were chosen as a result of the needs and desires of the student and of the people who are helping the student. In STEP THREE, individual tasks or components of the activities (motor milestone goals) were targeted for in­ struction.

35

~

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~

®

Now, in STEP FOUR, we are going to establish a communication system for talking about how much help the stu­ dent receives right now. We also are going to measure that help through the use of numbers. The term "PROMPTS" refers to the amount and type of assistance given a student to help perform an activity. In this curriculum, prompts refer to physi­ cal assistance. Physical prompts can be classified as either INSTRUCTIONAL or SUBSTITUTIONAL and can be provided by another person and/ or by a me­ chanical device. In this curriculum, we use the term "PROMPTS" as a reference to physical instructional prompts rather than substitutional prompts.

r=

ment. A conventional wheelchair is designed to be used as a substitute for walking. It is not designed to improve walking skills. Seating systems are usually designed to maintain a specific sitting position but are not designed to help the student improve independent sitting or movement while sitting. The vast majority of students with dis­ abilities can benefit from the reduction of instructional prompts. The difficulty in the past has been that physical prompts were poorly defined and, there­ fore, difficult to reduce. The purpose of the prompt system is to provide a sys­ tematic way to reduce assistance to students and provide a common lan­ guage for everyone who is working with the student.

INSTRUCTIONAL PROMPTS are designed

to help a student perform a task while The MOVE Curriculum has three types

learning new skills. These prompts can of prompts. be systematically reduced until the student is as independent as possible. The first maintains a static sitting pos­

For example, a student who cannot ture: walk independently might have an adult (PHYSICAL PROMPTS-SIlTING, see help maintain balance. As the student Chapter 5, page 212). improves, the adult systematically gives less and less help. The student might The second teaches standing and use a walker while learning new skills walking: but the mechanical support is reduced (PHYSICAL PROMPTS-STANDING as the student gains strength. AND WALKING, see Chapter 6, page 228). SUBSTITUTIONAL PROMPTS are de­ signed to take the place of skills without The third one is for hand and arm use: the expectation of improvement. Adults (ARM CONTROL-SIlTING, page often act as substitutional prompts for 218; and ARM CONTROL-STAND­ students. For example, picking a stu­ ING AND WALKING, page 236). dent up like an infant does not require active participation from the student and is therefore a substitute for move­ 36

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In this curriculum, students are given only as much help as they need to accomplish a task. The assistance is reduced as they become stronger and more independent. Using our prompt systems, maximal assistance in any category receives a score of 5 and can be reduced to no assistance, which is a score of O. For the casual record keeper, the prompt systems can be used as a general gUide to help teachers and parents know the amount of help they give the students. For the more detailed record keeper. the prompt systems can be used to write LE.P.s or other specific instructional plans. If the goal requires static sitting skills

ARM CONTROL FOR SITTING, STANDING, OR WALKING, has been separated from the other prompt sys­ tems because arm and hand use is not necessarily needed to master independ­ ent sitting, standing, or walking. The use of the arms and hands. however, is a highly desirable skill and should be included whenever possible.

The prompts reqUire a "center out" control of the arms. In other words. the student is required to control the shoul­ ders. elbows. and hands. (Wrist rota­ tion, finger dexterity. and other fine motor hand movements generally have little functional value without the ability to control the shoulders and elbows.)

(Section A and the skills B.6. through B.11.). use the chart labeled "PROMPT REDUCTION PLAN-SITTING". The vast majority of students with disabilities can benefit from the reduction of instructional prompts. The dUJlculty in the past has been that physical prompts were poorly defined and, therefore. dUficult to reduce.

If the goal reqUires standing and walk­

ing skills (Sections C through Pl. use the chart labeled "PROMPT REDUC­ TION PLAN-STANDING OR WALKING". These charts can be found in Chapters 5 and 6 under the sub-heading "PROMPT REDUCTION PLANS". NOTE: In Secti()n B (Movement While Sitting - B.7. through B.II.), the hips are required to move in order to pivot on the seat. By the time these skills are addressed, the static sitting prompts have been reduced to 0 and do not ap­ ply. Guidance is the only prompt needed in these lastJour Movement While Sitting goals. The amount oj guidance should be reduced as the student improves the skills.

The arm control prompts provided in this curriculum relate to sitting. stand­ ing. and walking rather than activities such as self-feeding. dressing. writing. etc. It is assumed that once arm place­ ment and purposeful grasp have been achieved. the instructor will continue to help the student refine and use the arm and hand movements to achieve the deSired activities. 37

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A, ......-­-CASESTUDY----------------------------_

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JOHN MASTERS: STEP 4 - MEASURING PROMPTS

--

As a reminder, the four major activities chosen by and for John

were:

--

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1. Going into the community without using a wheelchair.

,....­

2. Using a conventional toilet (as opposed to a large potty chair).

-

,.......

3. Feeding himself lunch while sitting at a table with his peer group. 4. Walking backward to help seat himself in a chair.

-

Whether you are a casual or detailed record keeper, the ENTRY LEVEL prompt chart should be completed. By using this, you can immediately see the functional level ofthe student. In STEP 5 this chart will help you decide what prompts to reduce first.

--

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Let's look at SECTION G: WALKS FORWARD first. John can walk short distances when another person stands behind him and helps him shift weight, but he tires quickly and allows his knees to buckle. This requires another person to support him. The distance from the handi­ capped parking space to the tables in the yogurt parlor is approximately 100 feet. For John to walk that far now, he would have to use a front leaning walker with forearm prompts because it would be too difficult for another person to support him.

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If you look at the PROMPT REDUCTION PLAN - STANDING OR WALKING on the next page. you will see a sketch of how John could accomplish the task today. You will also see that the ENTRY LEVEL chart has been filled in to reflect the amount of help John is receiving.

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..,......­

This chart allows you to visualize the current prompts so that you know where you are starting. (The sketch, the faded sections, and the explanations in the boxes on this form and all of the rest of the forms are for your clarification and not normally included in the PROMPT REDUCTION PLAN. Amore detailed explanation ofthe PROMPT REDUC­ TION PLAN and prompt values is found in Chapters 5 and 6).

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STANDING OR

ENTRY LEVEL

WALKING

DateJ-18-90

A. TOP DOWN: score: 3 (trunk level) B. CENTER OUT: score: 5 (prompt is on trunk) C. BODY SEGMENT: score: 2 (both sides of the trunk are prompted) D. AMOUNT OF PROMPT: score: 5 (support is being offered) E. TYPE OF PROMPT: score: 5 (mechanical prompt is being used) F. PROMPT POSITION score: 3 (prompt is offered from the front)

39

®

CASE STUDY----------------------------­ STEP 4 - MEASURING PROMPTS (Continued) The second activity John's parents chose was toileting at home. John has been using a potty chair at school but is unable to sit on the toilet at home. Even though John's parents have two bathrooms, one is attached to their master bedroom. The other is situated between John and his sister's bedroom. The bathroom is small and the toilet sits in a little alcove. Adding a potty chair to the bathroom would be almost impossible and certainly inconvenient to John's sister. As you will see in STEP FIVE, John's parents have chosen to use a toilet support which has a removable top and can be used by anyone else when John is not using the tonet. If you look at thePROMPT REDUCTION PLAN - SITTING on the next

page, you will see a sketch ofhow John has been tonetlng at school. You also will see that the ENTRY LEVEL chart has been filled in according to the amount of help John receives.

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If hand or arm use is to be included in the selected activity, use the chart labeled, "PROMPT REDUCTION PLAN­ ARM CONTROL - SITTING, STANDING OR WALKING" in Chapters 5 and 6.

in the section labeled ENTRY LEVEL. This will tell you how much help the student needs in order to perform the task right now. To continue our example, we will deter­ mine the amount of prompting John needs now to accomplish his selected tasks.

Often, a student will have one arm that functions more easily than the other. The arm control prompts, therefore, are scored separately for the right and left arms. Determine which chart or charts you will need to use for the activity you have chosen. In this step, you will be filling 40

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STATIC SITTING

fohn Will sll Oll tl cOllventiol1l1l to'lel {or /I

minimum 0[10 minutes btl restittfhis right /iJreomt Oft tl tmvllt waist height. A slrop wIll be used on his fOrearm /0 assure SI1fi:tv,

ENTRY LEVEL

ACHIEVED

ACHIEVED

ACHIEVED

Dat.e3-18-!J(J

Date____~

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A. HEAD CONTROL B. TRUNK CONTROL C. lUP CONTROL D. FOOT CONTROL

A. Count the number of directions the head must be promplte4 (Count ONE each for BACK. 1'ROlIT, B. Detennlne the amount of trunk control needed: o-vom 01' PROIIPT8; 1-BACK 01' CBAIR C. Count the number of segments of body being prompted: 1l1"l'ER RIGHT; 1l1"l'ER LBJIT; HIPS; I..OWBR D. Detennlne the number of ways the hips need to be o-vom 01' PROMPTS; 1-noaa:

A. HEAD CONTROL: score: 1 (prompt at back of head) B. TRUNK CONTROL: score: 3 (prompt is high on trunk) C. HIP CONTROL: score: 1 (symmetry prompt) D. FOOT CONTROL: score: 5 (foot plates with straps to keep feet positioned)

41

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CASE STUDY.----------------------------­

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STEP 4 - MEASURING PROMPTS (Continued)

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The third activity that John will address is self-feeding whUe sitting at the lunch table with his friends and classmates. Again. by looking at the SITTING PROMPT REDUCTION PLAN found on the next page. you will see a sketch ofthe seating arrangement John uses at school. The ENTRY LEVEL chart helps you see the amount of assistance John requires.

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The page following this PROMPT REDUCTION PLAN shows an ARM CONTROL PROMPT REDUCTION PLAN. Since John is going to be expected to improve his arm use whUe feeding himself lunch. the chart is needed.

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A. HEAD CONTROL

B. TRUNK CONTROL

C. HlP CONTROL

A. Count the number of directions the head must be (Colmt orm eaeh for BACK, 1'IlOI'lT. ';';';''''':'';';''1 B. DetermIne the amount of tnmk control needed: o.VOID OF PROIIPT8; I-BACK OF .................

C. Count the number of segments of body being prompted: 1JPlIBIl1UOBT; 1JPlIBIl LEI'l': BIP8; :t.OWII:Il D. Determine the number of ways the hips need to be o.VOID OF PIIOIIPT8; l-J'I.OOlit; ...._ _

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A. HEAD CONTROL:

score: 1 (prompt at back of head)

B. TRUNK CONTROL: score: 3 (prompt is high on trunk) C. HIP CONTROL: score: 2 (fexton prompt and retainer prompt) D. FOOT CONTROL: score: 5 (foot plates with straps to keep feet positioned)

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fohn will keep his rightjo!'etmn on the

BEGINNING DATE ._,..L2-::.J7'.£8t:::-.:zJ90'L_ _ _ _ _ _ _ __

tahle without prompts while another persOft helps him feed himselfaft

ENDING DATE _ _ _ _ _ _ _ _ _ _ _ __

entire ftII!I11 with his left hond.

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A. 6: B. To detennlne the numerical value, score the right and left arms separately.

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A. RIGHT ARM CONTROL:

score: 4 (controls trunk with forearm support) B. LEFT ARM CONTROL:

score: 0 (can place arm and use hand to purposefully grasp object)

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CASESTUDY----------------------------~

STEP 4 - MEASURING PROMPTS (Continued) The last of John's selected activities requires walking backward. This is a very difficult task for John to attempt at this time. Even though John has enough joint mobllity to allow backward movement ofhis feet, it is almost impossible to even begin the practice without equipment because the instructor cannot support John in a standing position and help him move his feet at the same time. John, therefore, needs the support of a front leaning walker as shown on the following page....

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WALKING

Date3-18-90

A. TOP DOWN: score: 3 (trunk level) B. CENTER OUT: score: 5 (prompt is on trunk) C. BODY SEGMENT: score: 2 (both sides of the trunk are prompted) D. AMOUNT OF PROMPT: score: 5 (support is being offered) E. TYPE OF PROMPT: score: 5 (mechanical prompt is being used) F. PROMPT POSITION score: 3 (prompt is offered from

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STEP 5 - REDUCING PROMPTS Plan a method for reducing the prompts. Define manageable time and/ or distance parameters. In STEP ONE, you tested the student using the TOP-DOWN MOTOR MILE­ STONE TEST. This placed the student

at skill levels in 16 categories (A through P) and gave you a "menu" of current skills as well as a way to select the next skills to be addressed. In STEP TWO, you selected specific

functional activities (such as eating, toileting, riding on conventional buses) for the student to perform. In STEP THREE, you referred back to the TOP-DOWN MOTOR MILESTONE TEST and selected skills that would help the student become more inde­ pendent in performing these specific activities. In STEP FOUR, you charted the amount of assistance needed by the student to perform the selected task. You put this information in the area labeled ENTRY LEVEL of the appropriate PROMPT REDUCTION PLAN.

Now, in STEP FIVE, you will form a "game plan" to allow a systematic re­ duction of the prompts until the stu­ dent performs the task at the skill level you have selected. In this step you will fill in the areas labeled TARG ET GOAL and GOAL AND PARAMETERS of the PROMPT REDUCTION PLAN. "MANAGEABLE TIME AND/OR DIS­ TANCE PARAMETERS" refers to the amount of time or distance that can be allocated for the specific activity. For example, it is not reasonable for a stu­ dent to spend an hour getting from the bus to the classroom. It is reasonable, however, to spend five minutes helping a student accomplish a part of the activity. In the beginning, a reasonable distance to walk might be as little as five feet within a two-minute time pe­ riod. As the student improves, the dis­ tance can be extended and/ or the time can be reduced. Let's look at our example of John Mas­ ters' program and determine the TAR­ GET GOALS we want John to achieve.

47

®

CASE STlJDY

JOHN MASTERS: STEP 5 - REDUCING PROMPTS The first of John's selected activities includes gaining the skill to walk forward. John's ENTRY LEVEL for this skill shows that he needs maximal help {score of 5} in three areas to walk the required 100 feet selected by his parents. We can use the ENTRY LEVEL section to help us decide which prompt or prompts should be reduced to help him accomplish his goals. This goal can be recorded in the area marked TARGET GOAL found on the right-hand side of the PROMPT REDUCTION PLAN•

STANDING .(

OR

WALKING

The first obvious reduction must concern the TYPE OF PROMPT John is using. He has been walking using a front leaning walker. His famUy, however, cannot haul the walker around any easier than his wheelchair so John must learn to walk with the help of another person. (Note: Area E is reduced from 5 to 3.)

po­

-

The second reduction would concern the AMOUNT OF PROMPT John currently is using. He has been leaning on the walker to help support himself. If his parents are going to help him walk without the use of a walker, he needs to learn to use his legs to support his entire weight and have help in maintaining his balance only. {Note: Area D is reduced from 5 to 3.} John's parents would prefer to walk beside him rather than behind him or in front of him because it attracts less attention and looks

51 48

CASE STUDY

STEP 5 - REDUCING PROMPTS (Continued) more normal. So the PROMPT POSITION has been changed. (Note: Area 11' is reduced from 3 to 1.)

Area C (BODY SEGMENT COUNT) remains the same with both sides of John's trunk being prompted. Area A (TOP-DOWN), however, increases in prompt value. When John uses the walker, the highest point of contact is his upper trunk (score of 3). When John's parents help him walk, there is a height difference and the natural contact point is John's shoulder so the prompt has been increased slightly to accommodate the needs of the parents. As John improves his ability to balance, this will be reduced again.

would have to be rewritten within the After the TARGET GOAL is determined. next month or two. Rather than call it is a simple task to fill in the area designated GOAL AND PARAMETERS in another meeting of everyone who works with the the upper right hand comer of child, the \ -..L .L~---;:::;\,..I,"",,~"~~-~~l )J (~~ teacher the PROMPT REDUCTION would select ( GOALS AND PARAMETERS_ G4. /ohfl will move his leg§J~!!!L )_ for miflimum a{IO {i:e/ whilt: /JeOriflg his weight when gnother PLAN. This can a long-term assists. with shifting weigh/and bit/after.. . be written in a goal that variety of forms. meets the The casual needs of the record keeper

activity and simply can select the next higher MO­

can be accomplished within the coming TOR MILESTONE GOAL from the TOP­

year. This requires a somewhat more DOWN TEST. In John's case, the goal

detailed approach to record keeping. As G.4. could be used exactly as it comes the parents explained, one of the spe­ from the test. This method might be cific needs for walking is to enable John practical for parents who are working to visit the yogurt parlor without a with one child but it might not be for wheelchair. This means he will need to teachers who write I.E.P. goals on a walk a minimum of 100 feet without yearly basis. For example, John is close mechanical support. Of course, if he to accomplishing this goal now so it can walk 100 feet to visit the yogurt ...

LU...Ll.,

0W11

t1

~_

m4i!1~aining

pen;()f1

n _ _

C=~=~J-~~~_y

49

--.....-­ -®

parlor, he can walk the same distance to do any number of other activities.

goals naturally emerge. Three blank charts between the ENTRY LEVEL and the TARGET The following GOAL have ~~~lUN/rLAN ~ ~ example shows been pro­ the more de­ vided for use GOALS AND PARAMETERS fohn will WIlli: minimum 0000 as an in­

tailed approach ( when another person helps him mIIi"tal" ba/nnce bv WIIlkingat his Ie/! sitIe, (\ that might be structional ~M~U_'M'''kD-= plan to re­ used by a " " ~ i'~ duce prompts teacher or therapist. More or as a information method of can be added and can include phrases remembering which prompts were that further delineate the skill such as dropped first. "3 out of 4 trials", "gO percent of the time", or "within a five-minute time The following pages show the PROMPT period", etc. Once again, the system of REDUCTION PLANS for all four of the record keeping should fit the instruc­ activities selected by and for John Mas­ tor's needs and can be as casual or ters. These are just examples of a few ways to set up a program. There are as detailed as necessary. many possibilities as there are students and activities. The important thing to

As these decisions are made, I.E.P. remember is to REDUCE PROMPTS.

(~

II

(eet

;

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t ........­

-.--­ p.­

-­

.--­-

~

~ ~

....~ ~

!';: ~ ~

-

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--

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t 50

~

CASE STUDY

STEP 5- REDUCING PROMPTS (Continued)

ARM~

i

I) (

\

CONTROL

ENTRY LEVEL \

FORSITI1NG, STANDING OR WALKING

Date 3-18-90

)

1I

213

0 1 A. ARM CONTROL-RIGHT

I I B.

ARM CONTROL-LEFT

~..

~

_ ,.,

I

.

I

4

15./

,

(

~~

j

When selected activities also require hand and arm use. you can add the ARM CONTROL PROMPT REDUCTION PLAN FOR SITTING. STAND­ ING. OR WALKING. As you can see from the entry level chart for John's activity of eating lunch. John is able to place his own left arm and functionally grasp with his left hand (score of0). He needs help. however, to place and maintain the placement of his right arm (score of 4). NOTE: Detailed use of the hands forfine motor control, such as being able to rotate the wrist to scoop food, etc., is not addressed on this chart. These activities can be individually task analyzed and prompted based on the needs of the student and then the prompts can be reduced. In John's case, it is obvious that he will be able to use his left hand for functional tasks much more easily than his right hand. While he learns to use his left hand for detailed tasks such as manipulating objects, he can learn to use his right arm as a "helper" for maintaining his position.

~U1NLi

)(

ARM CONTROL

FORSITTING, STANDING OR WALKING

A. ARM CONTROL-RIGHT

B. ARM CONTROL-LEFT

,

5 51

~=.....:;~..=.;=-M-=-=_-----t~ ~

PROMPT REDUCTION

________~b~oh~n~A1a~s~t~~~s_________

PLAN ])......_ _ _

A=®

G.4. fohn will mQUe his legs nxiprOCllllv

GOALS AND PARAMETERS

BEGINNING DATE ________--'3.c.-.u18co-g,"'OL-_______

I!!t II minimum 0(10 teet while hearing his own weight when another person

ENDmGDATE _________________________

assists with shifting weight lind 111Ilintllining btllonce..

STANDING OR

ENIRYLEVEL

ACHIEVED

WALKING

Date3-18-90

Date_ _

ACHIEVED

TARGET GOAL

Date_ _

Date_ _

ACHIEVED

o

A. TOP-DOWN: score: 4

(shoulder level)

B. CENTER OUf: score: 5 (prompt is on shoulder) C. BODY SEGMENT: score: 2 (both sides oj the trunk are prompted) D. AMOUNT OF PROMPT: score: 3 (balance only is being offered) E. TYPE OF PROMPT: score: 3 (prompts provided by another person) F. PROMPT POSITION: score: 1 (prompt is offeredJrom the side)

52

1 2 3 4 5

f-+­

-

f-

f-f­

-

r-

r-r­

-

r­

'-'­

-

'-­

!!:

OULUllaiI2l; I5-TOTAL BODY.

......

-

•

:....:.-=-=-=:...-=...----I~ ~AME~~~

______

~EGINNING ~NDING

~~

PROMPT REDUCTION

_____________________

GOALS AND PARAMETERS

~I-_ _----=A=® fah" will sit on a conventionaltoUet &r II

minimum gflO minules btl !!!sting llis righl fi>rlil1n11 on II Inpol waisl

DATE _ ...______--'''-''"'''-''''''-_________

DATE ____________________________

STATIC SITTING

PLAN

height. A sImp will be used on his {iJmtnn 10 "'SU!!! safely.

ENTRY LEVEL

ACHIEVED

Dare 3-18-90

Date_____

A. HEAD CONTROL B. TRUNK CONTROL

C. HIP CONTROL D. FOOT CONTROL

A. HEAD CONTROL: score: 0 (no prompts being used)

B. TRUNK CONTROL: score: 2 (prompt is low on trunk) C. HIP CONTROL: score: 0 (no prompts being used)

D. FOOT CONTROL: score: 0 (no prompts, including the floor, being used)

53

ACHIEVED

ACHIEVED

::...;...:=-:::...=------I[LPROMPT REDUCTION Masters

NAME

PLANl)I--------A

GOAlS AND PARAMETERS

=-@

101m will Won" clnssroomclrair~

BEGlNNINGDATE _ _ _ _-"3'""-1""'8~~~ _ __

I~e witit his peers for (l minimum

ENDINGDATE _ _ _ _ _ _ _ _ _ __

prompt at kis /tips lite floor for !tis feel qndtfu: tnble 10 flIIlintpfn bg/qnce.

[~

STATIC SITTING

ENJRYLEVEL

ACHIEVED

ACHIEVED

ACHIEVED

TARGET GOAL

Date 3-:ta..!JO

Date_ _

Da~

Date_ __

Date_ _

a

o

1 2 3 4 5

1 2 3 4 5

A. HEAD CONTROL

--------~~~H

B. mUNK CONTROL

~-

r-+­

C. HlP CONTROL ··~·-··------+Hm__W:.1

f---~

D. FOOT CONTROL LL

~:

A. HEAD CONTROL: score: 0 (no prompts being used) B. TRUNK CONTROL: score: 2 (prompt is low on trunk) C. HIP CONTROL: score: 1

(retainer prompt)

D. FOOT CONTROL: score: 1

fl/3Q minutes mine.4 reftziner

(feet are onjloor without straps backplate)

54

or

~ ~

o

I 2 345

o

•• • I

:< 3 4 5

~.~ ~

--

--

---

-

r­

1WiiVE'·

::....:;~...:.=-=-==-----1[ PROMPT REDUCTION PLAN

NAME

--Lh~oh~n~M~a='S~t,,,,er,-,,,'S________

BEGINNING DATE ~.1.L:-:Ll-vritten permission.

66

NNiVE ~ Top-Down Motor Milestone T est®

[ W ALKING FORWARD

~

GRAD

LEVEL

LEVEL I

LEVEL II

LEVEL III

G.l. Can walk forward a minimum of 20 feet without assis­ tance.

G.2. Can walk a minimum of 1,000 feet with one hand held. G.3. Can walk a minimum of 300 feet with one or both hands held or with a walker. G.4. Can move legs reciprocally for a m inimum of 10 feet while bearing own weight when another person assists with shifting weight and maintaining balance. G.5. Can move legs reciprocally for a minimum of 20 feet while being supported by a front leaning walker. tolerate fully prompted reciprocal leg movements while being supported in a front leaning walker or by another person. Can tolerate fully prompted extension of hips and knees.

SEE: C.5. Can tolerate being placed in a vertical p osition.

SEE: C.6.

Copyright © 1990, 1999 Kern County Superintendent of Schools, a California (USA) public education agency . All Rights Reserved. May not be reproduced in any format without written permission.

67

NI/iVE' " Top-Down Motor Miles tone

Test®

TRANSITION:

FROM S TANDING TO WALKING

GRAD

LEVEL

LEVEL I

LEVEL II

LEVEL

H.1. Can start walking fro m a s tanding position without assis­ tance . DATE

H.2. Can start walking from a standing position when using a walker or when a n ot her person help s the participant maintain balance on to one or both hands. start moving legs reciprocally from a standing position in a front leaning walker or while another person assists with shifting weight and maintaining balance. Can tolerate folly promp ted reciprocal leg m ovement s while being supported in a front leaning walker or by another person. SEE: G.6.

Can tolerate fully prompted extension of hips and legs. SEE: C.5.

Can tolerate being placed in a vertical position.

SEE: C.6.

Copyright © 1990, 1999 Kern County Superintendent of Schools, a California (USA) public education agency. All Rights Reserved. May not be reproduced In any format without written permission.

68

Top-Down Motor Milestone Test®

TRANSITION:

FROM WALKING TO STANDING

GRAD LEVEL

LEVEL I

LEVEL II

LEVEL

1.1. Can stop walking and maintain a standing position with­ out assistance. 1.2. Can stop walking and maintain a standing position when another person helps the participant maintain balance. 1.3. Can stop moving legs rec iprocally and maintain hip and knee extension for standing while in a front leaning walker or while another person maintain balance. Can tolerate fully prompted reciprocal leg movements while being supported in a front leaning walker or by another person. SEE: G.6. Can tolerate fully prompted extension of hips and knees. SEE: C.5. Can tolerate being plac ed in a vertical position.

DATE

SEE: C.6. DATE

Copyright © 1990, 1999 Kern Co unty Superintenden t of Sch ools, a California (USA) public edu cation age n cy. All Rights Reserved . May n ot be reproduced in any format withou t written permission.

69

#NiiVE ~ Top-Down Motor Milestone T est®

[ WALKING B ACKWARD

~

GRAD LEVEL

LEVEL I

LEVEL

n

LEVEL

J.l. Can walk backward a minimum of three steps while

holding on to a stationary object or with one hand held. J.2. Can walk backward a minimum of t hree steps with both hands held or while using a walker with guidance provided another erson. J.3. Can move feet backward to adjust body alignment when the participant is moved backward while being supported by a front leaning walker or anoth er person. J .4. Can tolerate fully prompted backward r eciprocal leg movements while being supported in a front leaning walker or by another person. Can tolerate fully prompted extension of hips and knees. SEE: C.S. Can tolerate being placed in a vertical position.

SEE: C.S.

Copyright (e 1990, 1999 Kern County Superintendent of Schools, a California (USA) public education agency . All Rights Reserved. May not be reproduced in any format without written permission.

70

-'-- ­

Top-Down Motor Milestone Test®

TURNING W HILE WALKING

] GRAD

LEVEL

LEVEL I

LEVEL .....- - - 4 LEVEL II

m

K. l. Can tum to the left or right in a maximum arc of three

feet while walking independently. K.2 . Can pivot to the left or right while being guided with one hand. K.S. Can turn to t he left or right in a maximum arc of three feet while walking with one h and held. K.4. Can pivot to the left or right while walking with a walker or with both h ands held when another person rotates the walker or the trunk of the participant. Can maintain hip and knee extension while standing while another person rotates the entire body and helps support the participant. SEE: F.3. Can tolerate fully prompted extension of hips and knees. SEE: C.5. Can t olerate being placed in a vertical position.

SEE: C.G.

Copyright © 1990, 1999 Kern County Superintendent of Schools, a California (USA) public education agency. AU Righ ts Reserved. May not be reproduced in any format without \vritten permission.

71

NltiNET" Top-Down Mot or Milestone Test®

WALKING UP STEPS

GRAD

LEVEL

LEVEL I

LEVEL II

LEVEL ill

L.l. Can walk up a minimum of three steps while holding a

railing or with one hand held by another person. L.2. Can walk up a minimum of three steps while another person helps maintain balance and prompts each leg. L.3. Can maintain extension of one leg while another person prompts lifting of other leg and helps the student raise body weight to ascend a minimum of three steps. Can move legs reciprocally for a minimum of 10 feet while bearing own weight when another p erson assists in shifting weight while maintaining balance. SEE: G.4. Maintains hip and knee extension to allow weight bearing for a minimum of three minutes while another person keeps SEE: C.3.

Copyright © 1990, 1999 Kern County Superintendent of Schools, a California (USA) public education agency. All Rights Reserved. May not be reproduced in any format without written permission.

72

Top-Down Motor Milestone T est ®

[ W ALKING DOWN STEPS

~

GRAD

LEVEL LEVEL I

LEVEL

n M.l. Can walk down a minimum of t hree steps with both hands h eld by another person or with hand rails on both sides of the M.2. Can walk down a minimum of three steps with balance provided at the shoulder level and with prompting of each

M.a. Can maintain extension of one leg while another person prompts the flexion of the other leg and helps the partici­ pant lower the body weight a minimum of three steps. Can move legs reciprocally for a minimum of 10 feet while bearing own weight when another person assists with shifting weight and maintaining balance. SEE: G.4. Can m aintain hip and knee extension to allow weight bearing for a minimum of three minutes while another person keeps participant's body in alignment. SEE: c.a.

Copyrighl © 1990, 1999 Kern County Superintendent of Schools, a California [USA) public education agency. All Rights Reserved. May not be reproduced in any format without written permission.

73

-~ - - - . - -- - -- ~

1NiiVE'"

Top-Down Motor Mileston e Test®

ij W ALKING ON UNEVEN GROUND ~

GRAD

LEVEL

LEVEL I

LEVEL II

LEVEL III

N.l. Can walk on uneven surfaces with height variations of three inches or less when one hand is held. DATE

N.2. Can walk on uneven surfaces with height variations of three inches or less when both hands are held. N.3. Can walk on uneven surfaces with height variations of three inches or less when each leg is prompted and partial support at the upper trunk level is offered by another person. Can move rec iprocally for a minimum of 10 feet while bearing own weight when another person assists with shifting weight and maintaining balance. SEE: G.4. Can maintain hip and knee extension to allow weight bearing for a minimum of three minutes while another person keeps the participant's body in alignment. SEE: C.3.

Copyright © 1990, 1999 Ke rn County Superintendent of Schools, a California (USA) public education agency. All Rights Reserved. May not be reproduced in any format without written permission.

74

Top-Down Motor Milestone Test®

[

W ALKING U P SLOPES

~

GRAD

LEVEL

LEVEL I

LEVEL II

0.1. Can walk up a slope of 30 degrees or less with one hand held.

DATE

0.2. Can walk up a slope of 30 degrees or less with both hands held. 0.3. Can walk up a slope of 3 0 degrees or less when each leg is prompted and partial support at the shoulder or upper trunk level is offered. Can move legs reciprocally for a min imum of 10 feet while bearing own weight when another person assists with shifting and balance. SEE: G.4. Can maintain hip and knee extension to allow weight bearing for a minimum of three minutes while another person keeps partic ipant's body in alig nment. SEE: C.3.

Copyright © 1990, 1999 Kern County Su perintendent of Schools, a California (USA) public education agency . All Rights Reserved. May not be reproduced in any format without written permission.

75 -

-----

-------

NItiHE'· Top-Down Motor Milestone Test®

~ WALKING D OWN SLOPES ~

GRAD LEVEL

LEVEL I

LEVEL II

LEVEL

P.l. Can walk down a slope of 30 degrees or less with both hands held. P.2. Can walk down a slope of 30 degrees or less with prompts at the shoulder level. P.3. Can walk down a slope of 30 degrees or less when each leg is prompted and partial support at the shoulder or upper trunk level is offered. Can move legs reciprocally for a maximum of 10 feet while bearing own weight when another person assists with shifting weight and maintaining balance. SEE: G.4. Can maintain hip and knee extension to allow weight bearing for a minimum of three minutes while another person keeps participant's body in alignm ent. SEE: C.3.

Copyright © 1990, 1999 Kern County Superintendent of Schools, a California (USA) public education agency. All Rights Reserved. May not be reproduced in any format without written permission.

76

jA.

Top-Down Motor Milestone Test N~ E

[

S UM M ARY OF TEST RESUL-rS ]

DATE___________________________________

1. Fill in squares r epresenting the c urrent skill levels. 2. Fillln all squar es t o the right of t h e current skill levels. 3. Circle skills to be addresse d next. GRAD LEVEL

LEVEL II

LEVELl

I A.4!A.5! A.6 r-::m A.7

A.I

A.2 A.3

I B. MOVES WHILE SITTING

B.I B.2

B.3 B.4 B.5 B.61 B.7 ! B.sln .... a i:1

I C. STANDS

C. 1

C.2

A. MAINTAINS A SITTING POSITION '-l '-l

___________________________________

In ~nv b'l ..........

..

'T

~ --I

./

C.3 C.4

1 1

~

- Ir:

..j

~

D. TRANSITIONS FROM SITTING TO STANDING

0.1 D.2

D.3 D.4

D.5 D.6

E. TRANSITIONS FROM STANDING TO SITTING

E.1 E.2

E.3 E .4

E .5 E.6

C.5

F. PIVOTS WHILE STANDING

F .I

F.2

F.3

c. s

G. WALKS FORWARD

G.I G.2

G.3

G.4 G.5

G.6

H. TRANSITIONS FROM STANDING TO WALKING

H.I

B.2

B.3

G. 6

C. S

I. TRANSITIONS FROM WALKING TO STANDING

1.1

1.2

1.3

0.6

C. 5

J. WALKS BACKWARD

J.I

J.2

J.3

K. TURNS WHILE WALKING

K.I K.2

K.3 K.4

F.S

L. WALKS UP STEPS

L.1

L.2

L.3 G.4l

M. WALKS DOWN STEPS

M.I

M.2

M.3

0.41 ~

N. WALKS ON UNEVEN GROUND

N.1

N.2

N.3

G.4

C.S

O. WALKS UP SLOPES

0 .1

0.2

0.3 G.4

C.3

P. WALKS DOWN SLOP ES

I P.I I

I

I

I P .2 I

I

I

I P .3

,

0.4

J.4

C.S

I

C.S

PREREQUISITE SKILLS FROM OTHER SECTIONS ARE INDICATED BY ITALICIZED LETTERS AND NUMBERS Copyrlgh t @ 1990. 1999 Ke rn Coun ty S upertnte ndent of Schools. a California (U SA) public edu cation agen cy. All Righ ls Reser ved . May not be reprod u ced In a n y format without writte n permiss ion .

r

! ::

f'

-

--

Step Two: Setting Goals Select specificjunctional activities jor the participant to pe1jorm. By asking the

participant (if the participant has expressive language) and by talking to the par­ ents or caregivers, you can pinpoint activities important to the family both now and in the future. There are three basic categories of questions we like to ask families: 1. Questions that pertain to the activities and desires of the participant at this time. Examples: • (directed to the participant) What do you wish you could do today that you cannot do? OR • (directed to thejamily) What does your child wish slhe could do today that slhe cannot do?, or what does your child like to do? 2.

Questions that pertain to the needs and desires of the family members right now. Examples: • (directed to parenti caregiver) What activity is difficult for you when physi­ cally helping the participant? (Example; helping my child take a bath) OR • (directed to parenti caregiver) What would make life eaSier for you?, or what breaks your heart?

3. Questions that pertain to the future life of the participant and the family. Examples: • (directed to participant) Fill in the blank: The one thing I want to be able to do when i have finished school! therapy is , OR • (directed to parenti caregiver) Fill in the blank: By the time my child is an adult, I want him to at least be able to _ _ _ _ _ __ If general answers are given (Le., I want to walk), then the facilitator should help the person become more specific and talk about well defined activities. An activity is a specific event such as, "I want to be able to walk across the stage to get my diploma." (ask, "To walk where to do what?). Fill i n Step Two on the following Activity Sheet and go to Step Three (page 80).

-

---

-­ -­--­ ---

~

--­ -­-­

--

-

...­

--

--

--

--

78

Participant_ _ _ _ _ _ __

MOVE Activity Sheet

Date._ _ _ _ _ _ __

STEP TWO

Activity 1:

Why is this activity difficult to do now? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Activity 2:

Why is this activity difficult to do now? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Activity 3:

Why is this activity difficult to do now? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

79

Step Three: Task Analysis Select goals to help the participant become more independent in performing the spec!Jlc activities targeted in Step Two.

In Step Two you asked. "Why is this activity difficult for the participant to perform right now?" The answer will usually indicate the most critical skill(s) needed for these activities.

Example One: Mary wishes she could run with her sisters and friends while they are playing at home. Q: What keeps Mary from doing this now?

A: Although Mary can move her legs reciprocally. she can't maintain her balance while walking. Possible conclusions after team discussion: Mary should work on standing (Section C) and walking (Section G). Example Two: John wishes he could toilet himself without assistance. Q: What keeps John from doing this now?

A: John cannot transfer himself from his wheelchair to the toilet without assistance. Possible conclusions after team discussion: John should work on transi­ tions from sitting to standing (Section D). Go back to the Summary of Test Results (page 77 of this Assessment Profile) and circle the next most difficult skills in the appropriate categories. Fill in Step Three on the Activity Sheets and go to Step Four (page 82).

80

Participant,_ _ _ _ _ _ __

MOVE Activity Sheet

Date_ _ _ _ _ _ __

STEP THREE

Critical Skill(s) needed for Activity 1: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

List the skill(s) you circledJor this activity on the Summary oJ Test Results on page 77 oj this Assessment Profrle. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Critical Skill{s) needed for Activity 2: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

List the skill(s) you circledJor this activity on the Summary oJ Test Results on page 77 oj this Assessment Profile.

Critical Skill(s) needed for Activity 3: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

List the skill(s) you circledJor this activity on the Summary oj Test Results on page 77 qf this Assessment Profrle.

81

~ ®

The last three steps of the MOVE Curriculum address the teaching of skills se­ lected in the first three steps.

e r=

t:=

r=

Step Four: Measuring Prompts Chart the amount of assistance needed by the participant to perform the selected activities today.

As a team, discuss how the participant is performing the selected actiVity today (actiVity from STEP TWO). Write your description on the lines of the following

page.

Refer to the Physical Prompts chapters in the MOVE Curriculum (Chapters 5 and 6). Select the appropriate Prompt Reduction Planes) for this actiVity (pages 84-87). Using these plans, determine how much help the participant needs to perform the activity at this time. Remember that you are describing specific actiVities. For example, if a sitting skill is critical to this participant, then put the sitting skill into the context of the actiVity. (To sit where - to do what?) Sitting on a chair in a restaurant to eat is quite different from sitting on a bus seat to travel. Some people find the Prompt Pictures at the bottom of the Prompt Reduction Plans helpful in this step (pages 84-87). Using a colored pen, simply circle the appropriate picture of the prompts currently needed. This information can then be transferred to the Prompt Reduction Plans. (Please note: You will need to use the MOVE Curriculum for explanations of these prompts.) Use a different set of Prompt Reduction Plans for each actiVity.

Fill in Step Four on the Activity Sheets and the Entry Level on the appropriate Prompt Reduction Plans. Go to Step Five (page 88).

t:=

E= E=

~

~

~

~

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-

!:

-­t=

-,...... -,..... -

jiiI­

.".,.­

-r--­ r--­

82

~

=~

~

~ ~

~

­

-­

Participant _ _ _ _ _ _ __

MOVE Activity Sheet STEP FOUR

How does the participant take part in Activity 1 today? _ _ _ _ _ _ _ _ __ The most critical skill(s) needed for this activity: _ _ _ _ _ _ _ _ _ _ _ _ __

We are using the following Prompt Reduction Planes) for evaluating this critical skill: (circle plans used) 1. Sitting Prompt Reduction Plan 2. Arm Prompt Reduction Plan for Sitting 3. Standing or Walking Prompt Reduction Plan 4. Arm Prompt Reduction Plan for Standing or Walking How does the participant take part in Activity 2 today? _ _ _ _ _ _ _ _ __

The most critical ski11(s) needed for this activity: _ _ _ _ _ _ _ _ _ _ _ _ __ We are using the following Prompt Reduction Planes) for evaluating this critical skill: (circle plans used) 1. Sitting Prompt Reduction Plan 2. Arm Prompt Reduction Plan for Sitting 3. Standing or Walking Prompt Reduction Plan 4. Arm Prompt Reduction Plan for Standing or Walking How does the participant take part in Activity 3 today? _ _ _ _ _ _ _ _ __

The most critical skill(s) needed for this activity: _ _ _ _ _ _ _ _ _ _ _ _ __ We are using the following Prompt Reduction Planes) for evaluating this critical skill: (circle plans used) 1. Sitting Prompt Reduction Plan 2. Arm Prompt Reduction Plan for Sitting 3. Standing or Walking Prompt Reduction Plan 4. Arm Prompt Reduction Plan for Standing or Walking

83

1tNi}IE~

~

PROMPT REDUCTION PLAN ]___---A-WD-®

NAME ___________________________________



GOALS AND PARAMETERS _ _ _ _ _ _ _ _ _ _ _ _ __

BEGINNING DATE _______________________________ ENDINGDATE ________________________

r~

~

c~~::~

J J. J. J. J.l 'I \.J

~

ENTRY LEVEL

1

Date

ACHIEVED

ACHIEVED

ACHIEVED

TARGET GOAL

Date_____

Date_ _ __

Date_ _ __

Date_ _ __

0 1 2 3 4 5

A. HEAD CONTROL

r- I-­ 00

B. TRUNK CONTROL

~

C. HIP CONTROL

r

D. FOOT CONTROL

[

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C. HIP CONTROL

B.TRUNK CONTROL

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2 LOW PROMPT

3 HIGH PROMPT

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PROMPT REDUCTION PLAN

NAME ________________________________________

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GOALS AND PARAMETERS ___________________

BEGINNING DATE __________________________ ENDINGDATE _____________________________

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ACHIEVED

ACHIEVED

TARGET GOAL

Date,_ _ __

Date_ _ __

Date,_ _ __

Date,_ _ __

ENTRY LEVEL

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GOALS AND PARAMETERS _ _ _ _ _ _ _ _ _ _ _ __

BEGINNING DATE _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

ENDINGDATE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

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STANDING ENTRY LEVEL

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ACHIEVED

ACHIEVED

ACHIEVED

TARGET GOAL

Date._ _ __

Date._ _ __

Date._ _ __

Date._ _ __

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B. CENTER OUT TRUNK

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C. BODY SEGMENT D. AMOUNT OF PROMPT E. TYPE OF PROMPT F. PROMPT POSITION

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NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

GOALS AND PARAMETERS _ _ _ _ _ _ _ _ _ _ _ _ __

BEGINNING DATE ______________________ ENDINGDATE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

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ACHIEVED

ENTRY LEVEL

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FOR STANDING AND WALKING

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TARGET GOAL Date 0

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5

Step Five: Reducing Prompts Form a plan to allow a systematic reduction oj assistance using the Prompt Reduc­ tion Plan.

Determine the length of the instructional process. Many schools use a yearly I.E.P. (Individualized Education Plan). Other organizations establish service contracts for varying lengths of time. Fill in the appropriate Target Goal Dates on the Prompt Reduction Plans. Note that intermediate target dates are also provided on these plans. * (There are three charts located between the Entry Level Chart and the Target Goal Chart on each Prompt Reduction Plan.) Using the same Physical Prompt Plans you used in Step Four, determine which prompts you will reduce as the participant improves. These decisions should be based on the needs of the participant and the family or caregivers. If you are using the Prompt Pictures, circle the prompts you will reduce by the end of the teaching segment. Use a different color ink than the one used in Step Four. Fill in the Tar­ get Goal Chart of the Prompt Reduction Plan(s).

* Helpful Hint: All of the MOVE forms can be updated during the instruc­ tional process prior to the Target Goal Date. Use a different color pen for each update and for incidental notes. On the cover of the Assessment Pro­ file, log the date and pen color. This reduces confusion if you forget to note the date on any of the forms. You will need to refer to the Physical Prompts section of the MOVE Curriculum (pages 212 through 237) to understand prompts and prompt reductions. Fillln Step Five on the Activity Sheets and go to Step Six (page 90).

--

-88

Participant

MOVE Activity Sheet

Date _ _ _ _ _ _ __

STEP FIVE

Describe the way the participant will perform Activity 1 by the end of the instruc­ tionalprocess. ______________________________________________________

We are using the following Prompt Reduction Plan(s) for evaluating this target goal: (circle charts used) 1. Sitting Prompt Reduction Plan 2. Arm Prompt Reduction Plan for Sitting 3. Standing or Walking Prompt Reduction Plan 4. Arm Prompt Reduction Plan for Standing or Walking Describe the way the participant will perform Activity 2 by the end of the instruc­ tionalprocess. ______________________________________________________

We are using the following Prompt Reduction Plan(s) for evaluating this target goal: (circle charts used) 1. Sitting Prompt Reduction Plan 2. Arm Prompt Reduction Plan for Sitting 3. Standing or Walking Prompt Reduction Plan 4. Arm Prompt Reduction Plan for Standing or Walking Describe the way the participant will perform Activity 3 by the end of the instruc­ tionalprocess. ______________________________________________________

We are using the following Prompt Reduction Plan(s) for evaluating this target goal: (circle charts used) 1. Sitting Prompt Reduction Plan 2. Arm Prompt Reduction Plan for Sitting 3. Standing or Walking Prompt Reduction Plan 4. Arm Prompt Reduction Plan for Standing or Walking

89

Step Six: Teaching Skills Teach the skills using the teaching section in Chapter 4 oj the MOVE Curriculum.

Teaching suggestions are provided in the MOVE Curriculum for every skill tested in the Top-Down Motor Milestone Test. There are many different ways to teach the skills. Teaching methods should be determined by the team while being respectful of individual learning and teaching styles. Decide who will be responsible for teaching the skill(s), who will keep the records, when the skills will be taught, what equipment (if any) will be used, and what teaching methods will be used.

Fill in Step Six on the Activity Sheets found on the next page. When you are writing goals, you might consider a formula similar to this: Goal:

---------------

will -----------------------------------(sit, stand, walk or similar physical skill)

(participant)

(amt. oj time / distance)

(# oj trials

or percentage oj time)

-...--­

-

-,........

(describe activity)

using the following physical prompts: __________

-­

(list prompts)

Goal:

John will independently move his legs in a reciprocal pattern

(participant)

(sit, stand, walk or similar physical skill)

for ten feet while entering the cafeteria (75 percent of the time) (amt. oj time / distance)

(# oj trials

-,..........­

-

or percentage oj time)

when preparing to eat lunch. (describe activity)

Using the following physical prompts: a gait trainer with trunk support. hip prompts. and forearm prompts.

Fill in the Goals and Parameters on the Prompt Reduction Plans.

Establish Aerobics routine (see page 92).

90

­

-

Participant ______________

MOVE Activity Sheet

Date _____________

STEP SIX

(Step Six): List the people who w1ll be responsible for teaching the skill(s) and keeping records, the specified times of the day the skills will be taught. the equip­ ment used. and the teaching methods: Responsible person(s): __________________________ Time(s): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Equipment: ______________________________________________ Teachingmethods: _______________________________________ GOAL (I.E.P. or similar goal)

AEROBICS ROUTINE:

91

---

~

AEROBICS ROUTINES Two basic environments are needed for implementing the MOVE Program. (See Chapter 1 pages 15 through 19 of the MOVE Curriculum.) One environment needs to be protective and closely monitored while participants are acquiring new skills. We use this environment for the Aerobics Classes. During aerobics, participants are introduced to new skills. These are practiced using aerobics routines which are established by chaining the critical skills together. When these skills are fluent (or safe) they can be used in the participant's normal living environment. Example:

Targeted critical skills from STEP TWO: (skills circled on Summary of Test Re­ sults). A.3. Can sit on a conventional classroom chair at least 30 minutes without

prompts.

C.3. Can maintain hip and knee extension to allow weight bearing for a mini­

mum of three minutes while another person keeps participant's body in

alignment.

G.4. Can move legs reciprocally for a minimum of 10 feet while bearing own

weight when another person assists with shifting weight and maintaining

balance.

-,-­.......­

--,......-­ 92

1WiiVE7M

A possible aerobics routine might be: John will sit on a conventional chair appropriate to his size with a hip strap and a chest strap for a minimum of ten minutes. Four bean bags will be placed around the chair for protection. John will then be helped to a standing position and bear his own weight for a minimum of one minute while the instructor blocks his knees and helps sup­ port him under the arms. John will be placed in a forward leaning gait trainer with hip, trunk, and fore­ arm support. He will move his legs reciprocally to help move himself forward a minimum of ten feet. The instructor will help John alternately to the right or the left to return to his chair. John will pivot in place with the help of his instructor while in the gait trainer. John will step back with help from his instructor until his calves touch the seat of the chair. Straps will be removed from the gait trainer and John will help lower himself to the chair. Straps for sitting will be put back in place. This routine will be repeated during the aerobics session as time allows. When possible, aerobics sessions are held for apprOximately one hour or one class period each day. As skills improve, they are incorporated into daily routines. New aerobics routines are then established.

93 ---

- -......

~

--

-

---

-

--

-

-

--

94

CHAPTER THREE TESTING INFORMATION

t=.. TESTING INFORMATION THE FOLLOWING PAGES GIVE YOU MORE DETAILED INFORMATION BE­ HIND THE PURPOSE FOR EACH TEST ITEM AND THE REASONING BEHIND THE SELECTION OF THE PARAME­ TERS.

student is sitting in a "reverse W", cross legged, long sitting, whether the knees are touching the floor, or whether the feet rotate inwardly or outwardly. The question is. Can the student sit com­ fortably and scifely in a bathtub while being bathed?

Developmental models are based on the

sequence of normal infant development which, in turn, is influenced by the environments and furnishings available to the infant. For example, infants often learn to use their motor skills while lying on the floor, crib, or playpen. These environments and furnishings are not appropriate when a person passes the infant stage and therefore should be redefined. The same is true of time and distance parameters. Each of the 74 skills listed in the TOP-DOWN MOTOR MILESTONE TESTID are de­ scribed according to adult uses, adult environments, adult furnishings, and are delineated using parameters needed in an adult society. Please note that you are testing the functional use of the skill only. For example, skill A.I. determines whether a student can sit on a flat surface such as a bathtub for 30 minutes. It does not specify whether the arms can be used to maintain balance, whether the

Function as opposed to perfection is the issue at this pOint. Unless the student can use the skill to function, it will probably disappear when the instruc­ tors or the environments change. Re­ search has shown that our students who learn slowly also have difficulty generalizing their skills. Therefore, in the MOVE Program, we test the func­ tional use of the skill as it will be used in daily living. Then, if necessary, we work to perfect certain aspects of the skill to prevent future deformities, to make it more socially acceptable, or to use it for other activities. The question or questions at the end of each descrip­ tion should help you decide whether the student has perfected the skill enough to use it functionally. If the skill needs to be defined more specifically, the need will present itself as the tasks are de­ fined in later steps and can be written into the student's I.E.P.

96

A.

MAINTAINING A SITTING POSITION

L

GRAD LEVEL

A.l. Can sit on a flat surface such as a bed or in a bathtub for a minimum of 30 minutes. FUNCTIONAL USE OF SKILL: When adults sit on a flat surface as opposed to a chair, it is usually while sitting on a bed or in the bathtub. Sitting on a flat surface is done less than five percent of the time by most adults. It is more difficult than sitting on a chair because a flat surface does not have a backrest. People with motor delays often have tightness in the hips and knees which makes sitting with the legs extended uncomfortable or impossible. For these reasons, sitting on a flat surface is the last of the static sitting skills required in the curriculum. PARAMETERS: The time parameter of 30 minutes was selected because that is enough time to take a bath or get dressed.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Would it be practicalfor this student to sit in a bathtub without back support while being bathed?

LEVEL I

A.2. Can sit on the edge of a bed or on a stool without using a foot or backrest for a minimum of five minutes. FUNCTIONAL USE OF SKILL: A person who can sit on a stool or bed can be dressed more easily than a person lying down, even when tightness is present in the hips and knees. Conventional toilets do not have a backrest and some people are too short to have their feet rest on the floor. Sitting on a bed or a stool without foot or backrests is more difficult than sitting on a conventional chair because there is less support to maintain balance. PARAMETERS: The time parameter of five minutes was selected because that is ample time for an instructor to get a change of clothing and to help the student 97

get dressed. It is also enough time for any toileting needs. To determine the student's proficiency with this skill, ask these questions: QUESTION: Would it be practicalfor this student to sit on the edge of a bed while [ help the student get dressed?

QUESTION: Could this student sit comfortably on a conventional toilet without support?

A.3. Can sit on a conventional classroom chair for a minimum of 30 minutes without prompts. FUNCTIONAL USE OF SKILL: A conventional classroom chair is defined as a solid seat chair with a back but no sides. The chair must be the right size for the individual so that the feet can rest firmly on the floor and the hips can fit firmly against the backrest. The term "without prompts" refers to any additional suppor­ tive devices such as ties or other adaptations. The student should be able to sit on ANY classroom chair of the right size rather than a specialized chair with him. The benefits are obvious. PARAMETERS: The time parameter of 30 minutes was selected because most people become uncomfortable after sitting longer than this and need to change positions. Also, 30 minutes is long enough to eat a meal or participate in almost any educational activity. To determine the student's proficiency with this skill, ask yourself these ques­ tions: QUESTION: Would [feel comfortable walking away while this student is sitting on a conventional chair?

-

--­

QUESTION: Would it be practical to have this student sit on a conventional chair without ties while eating lunch?

-

LEVEL II

A.4. Can maintain sitting balance on a conventional classroom chair for a mini­ mum of 30 seconds without prompts. FUNCTIONAL USE OF

SKIL~ It

may seem odd that the curriculum skips from a

98

­

30 second requirement to a 30 minute requirement for sitting but we have found that almost every student who learned to maintain balance on a chair for a few minutes was able to sit indefinitely. Before the students learned to sit without restraints for extended periods of time, they usually went through a stage of being able to "freeze" for a short period of time and maintain balance. We used this stage of development to everyone's advantage. If the student can maintain a sitting posture for 30 seconds, the instructor has time to walk around the chair to fasten ties or to move so that repositioning of the student is easier. (See: Transferring from Chair to Chair, page 251.) PARAMETERS: The time parameter of 30 seconds was selected because that is enough time for an instructor to adjust safety straps and realign the student. Students who did not have this skill required two adults for placement in a chair: one to support the student and the other to fasten the straps or help with reposi­ tioning.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Would this student be able to saJely maintain a sitting position if I walked around to the back oj his chair toJasten a strap?

A.5. Can maintain an erect head position while sitting for a minimum of 30 sec­ onds with prompts at the trunk, hips, and feet, as needed. FUNCTIONAL USE OF SKILL: A student who can maintain an erect head position can look at people or objects of interest, can indicate choices through visual selec­ tion, and can accept a bite of food while eating. Additionally, practicing an erect head position strengthens the muscles in the neck and trunk enabling the acqui­ Sition of other motor skills. (For chair suggestions, see: EQUIPMENT, page 258.) PARAMETERS: The time parameter of 30 seconds was selected because that was ample time for an instructor to help a student place food in the student's mouth. And it was enough time for the majority of students to make a visual selection when several items or pictures were offered.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Can the student keep the head erect while participating in a short activity

if the

rest qf the body is stabilized?

A.6. Can tolerate sitting in an upright position for a minimum of 30 minutes with prompts at the trunk, hips, and feet as needed. FUNCTIONAL USE OF SKILL: Some students have not had the experience of sitting in an upright position. They may have difficulty allowing hip and knee flexion for extended periods of time. Some students have only experienced reclined or slightly reclined sitting. The gravitational pull when leaning back is totally different than it is when sitting upright. They may need practice lifting the head against gravity and maintaining an erect head position, as well as becoming ac­ customed to this position in space. (For chair suggestions, see: EQUIPMENT, page 258.)

PARAMETERS: The time parameter of 30 minutes was selected because most people become uncomfortable after sitting longer than this and need to change positions. Also, 30 minutes is long enough to eat a meal or participate in almost any educational activity.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Is this student comfortable while sitting in an erect position whUe participating in an activity such as eating lunch?

LEVEL III

A.7. Can tolerate being placed in a sitting position with a minimum of 90 degrees flexion in the hips and knees. FUNCTIONAL USE OF SKILL: If the student cannot flex or bend the hips and knees comfortably, you need to seek medical advice. (Please note ffEligibUityfor the Program" on page 4.) PARAMETERS: There are no time parameters listed here. If the student is com­ fortable having the hips and knees flexed for any amount of time, the student will be able to extend sitting time with practice.

E: E:

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Does the student exhibit any discomfort or pain when the hips or

E:

knees areflexed?

E: ) )

B.

MOVEMENT WHILE SITTING

GRAD LEVEL

B.1. Can pivot entire body a minimum of 90 degrees to the left or right while sitting in a bathtub or on a flat surface such as a bed. FUNCTIONAL USE OF SKILL: As many caretakers will tell you, this skill is needed the most when helping a person get out of bed. Many back injuries occur when leaning over with straight legs and attempting to lift something heavy. There are safe ways to help a person get up but it is a great help when the participant can pivot while sitting. (See: Getting Out of a Bed, page 252.) A small person might want to pivot while sitting in a bathtub but this is a much less common need. PARAMETERS: Usually a 90 degree rotation is sufficient for a person to get out of a bed or similar situation. We have found that students who can pivot 90 de­ grees without assistance can pivot 360 degrees if they choose to do so. To determine the student's proficiency with this skill, ask yourself this question: QUESTION: While sitting in bed, could this student tum sideways without help to place theirfeet on thefloor?

B.2. Can pivot entire body a minimum of 90 degrees to the left or to the right while sitting on a conventional classroom chair. FUNCTIONAL USE OF SKILL: There are a number of situations when a person needs to be able to pivot in his/her seat before standing up. The most obvious is

when getting in and out of a car. Also, the same is true of any kind of picnic

bench. church pew. or in school settings with a table and chair. To be indepen­

dent a person also has to be able to pivot his/her body on the seat after sitting

down.

PARAMETERS: Usually a 90 degree rotation is suffiCient for a person to get out

of a chair, car, or bench seat.

T~etermine the student's proficiency with this skill, ask yourself this question:

QUESTION: if you lEfft this student sitting sideways on a chair. could he/she tum to face a table to eat lunch or participate in an activity? 101

It: ®

J!:

B.3.

It

Can pivot legs a minimum of 90 degrees while sitting when arms are rotated

to the left or right.

It:

FUNCTIONAL USE OF SKILL: It is much easier to help a person get out of a car

or similar type seat if the person can help turn their own legs. The instructor simply holds one or both hands to help maintain balance and the person getting

out of the seat does the rest. PARAMETERS: Usually a 90 degree rotation is sufficient to help a person get out

of a car or bench seat.

t!: J!: J!:

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: lfyou grasped the student's hands and turned the trunk, would the

It:

student be able to pivot the rest qf the body without assistance?

I!: LEVEL I

It:

B.4. Can push self to a sitting position from a reclining position on a flat surface such as a bed or the floor. FUNCTIONAL USE OF SKILL: There are a few situations when a person needs to be able to push up to a sitting position from a flat surface. The most common need is encountered when getting out of bed. Helping another person sit up in bed is awkward because it is difficult to use leg strength rather than back strength while pulling the person to a sitting position. Having this skill not only fosters independence but also is a great help to the caregiver. PARAMETERS: Most adults do not lie on the floor, but getting in and out of bed is a daily occurrence. Some adults lie around the pool or lie down in the bathtub to rinse hair or relax.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION:

if this

student was lying in bed, could the student push himself/herself to a sitting position in order to get out qf bed?

It:

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B.5. Can keep trunk in alignment when legs are pivoted a minimum of 90 degrees to th 1eft or the right while sitting.

7

FUNCTIONAL USE OF SKILL: If a student can maintain an upright trunk posi­ 102

It: f!: f!:

tion while another person turns his/her legs to the side. lifting the student out of a car or similar seat will not be necessary. The student can simply be rotated in the seat and appropriate transfer methods can be used. PARAMETERS: Usually a 90 degree rotation is sufficient to help a person get out of a car or bench seat.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Would you be able to tum this student's legs to one side without help­ ing the student maintain an upright trunk position while the student gets out oj a car or similar seat?

B.6. Can realign trunk to an erect position after leaning forward, to the left, and to the right a minimum of 45 degrees. FUNCTIONAL USE OF SKILL: A person who can bring his/her trunk to an erect position from 45 degrees is able to pick up items from the floor (if chair is correct size), lean across a table to get a desired item, and help get to a sitting position while lying in a bed. PARAMETERS: People rarely lean forward or to the side more than 45 degrees while sitting. If they do, they use their hands to maintain balance and push them­ selves back to a sitting position rather than using the muscles of the trunk alone.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student saJely come back to a sitting position without help if the student leaned over 45 degrees?

LEVEL II

B.7. Can realign trunk to an erect position after leaning forward, to the left, and to the right a minimum of 20 degrees. FUNCTIONAL USE OF SKILL: A person who can regain sitting balance after lean­ ing 20 degrees can move back and forth from functional sitting to leisure sitting at will. This ability to shift sitting positions is extremely important for comfort as well as for functional activities. (For chair suggestions, see: EQUIPMENT, page 258.)

103

iI

PARAMETERS: Leaning forward approximately 20 degrees to eat or work at a table is comfortable for most people.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: While sitting, could this student safely leanfonvard to eat lunch with­ out support at the upper trunk level?

B.S. Can raise head to an erect position when head is tilted back while sitting with upper trunk support. FUNCTIONAL USE OF SKILL: Bringing the head to an erect position when the head is tilted back is the most difficult of head righting movements for most people with physical handicaps. It is important to be able to bring the head for­ ward while sitting for safety reasons as well as for functional purposes. A person who cannot bring his/her head forward while sitting cannot swallow and could aspirate if vomiting were to occur. (For chair suggestions, see: EQUIPMENT, page 258.) PARAMETERS: The phrase "head tilted back" means that the back of the head is resting on the spine while the student's trunk is upright.

To determine the student's proficiency with this skill, ask yourself this question:

if the

student was sitting in an upright position and the student's head lagged backward to rest on the spine, would the student be able to bring the head fonvard if he / she started to choke?

QUESTION:

B.9. Can bring head to an erect, midline position when head is turned to the left or to the right while sitting with upper trunk support. FUNCTIONAL USE OF SKILL: Some students have tight neck muscles which make it difficult to bring the head to an erect, midline position. Others tum their heads in habitual or reflexive patterns as their arms or legs are moved. Eating, drinking, and participating in educational activities are difficult when the stu­ dent's head cannot be properly aligned with the rest of the body. (For chair sug­ gestions, see: EQUIPMENT, page 258.) PARAMETERS: The term "erect" means that the head is not falling either forward, backward, to the left, or to the right. The term "midline" means that the eyes are facing forward and that the head is not turned to the left or to the right.

To determine the student's proficiency with this skill, ask yourself this question: 104

E:

QUESTION: if the student turns his/her head while eating, can the student volun­ tarily bring the head back to midline jor the next bite?

B.10. Can raise head to an erect position from a chin on chest position while sit­ ting with upper trunk support. FUNCTIONAL USE OF SKILL: A student who can raise the head to an erect posi­ tion when the head lags forward can see to respond to the environment as well as perform functional tasks. (For chair suggestions, see: EQUIPMENT, page 258.) PARAMETERS: The phrase "chin on chest" refers to letting the head fall forward as far as possible while the trunk remains in an upright position. To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Can the student bring his/her head to an erect position when some­ thing oj interest such as jood or drink is offered?

LEVEL III -------------------------------------------­

B.11. Can tolerate movement of head and limbs while in a fully supported sitting position. FUNCTIONAL USE OF SKILL: If the student cannot allow movement of the head and limbs without discomfort, you need to seek medical advice. Please note "Eligi­ bilityjor the Program" on page 4. (For chair suggestions, see: EQUIPMENT, page 258.)

PARAMETERS: There are no time parameters listed here. If the student is com­ fortable having the head and limbs moved, the student will be able to increase skills with practice. To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Does the student exhibit any discorrifort or pain when the head or limbs are moved?

A. 7.

is a prerequisite skill for MOVEMENT WHILE SITTING. (See Section A beginning on page 146 for more information.)

105

I

c. STANDING GRAD LEVEL

C.l. Can stand in one place without support for a minimum of 60 seconds. FUNCTIONAL USE OF SKILL: Standing in one place without walking is a neces­ sary skill for safety as well as independence. Our students with disabilities often learn to walk forward independently before they learn to stand for long periods of time without support. A person who cannot stand without help in maintaining balance must either have a walker with them or remain within confined environ­ ments, such as a home. PARAMETERS: A person who can maintain standing balance for 60 seconds can usually maintain standing for an indefinite period of time. Even if the person cannot maintain standing balance for extended periods of time, 60 seconds is usually ample time for someone to come to the person's aid. To determine the student's proficiency with this skill. ask yourself this question: QUESTION: if I turned loose oj this student while standing, would he/ she be able to maintain balance Jor 60 seconds?

LEVEL I

C.2. Can stand in one place with one or both hands held for a minimum of five minutes. FUNCTIONAL USE OF SKILL: People who can maintain a standing position with minimal help in balance can remain standing to have clothing adjusted for toilet­ ing. wait for transportation or elevators. and easily transfer from one chair to another. PARAMETERS: In five minutes, even the most complicated clothing can be ad­ justed for toileting, diapers can be put in place if needed, teeth can be brushed at a sink. etc. It has been our experience that students who can stand with help in maintaining balance for five minutes, can stand for indefinite periods of time. 106

E:

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Would this student be able to stand and waitjor a busjorfive minutes

if I

held his/her hands?

LEVEL II

C.3. Can maintain own hip and knee extension to allow weight bearing for a mini­ mum of three minutes while another person keeps participant's body in alignment. FUNCTIONAL USE OF SKILL: One of the most difficult tasks involving older students is changing diapers or toileting. Public bathrooms do not provide change tables for adults and no one would expect the student to lie on a dirty floor. If the student can maintain hip and knee extension for a minimum of three minutes, the adult in attendance can usually manage to adjust the student's clothing, remove, and replace a diaper while the student is standing. Hip and knee extension is also beneficial for transfering from chair to chair. PARAMETERS: To test this skill, the adult should stand behind the student and help keep the trunk balanced over the hips and encourage head control if neces­ sary. Our experience suggests that many adults may not comfortably be able to help a student maintain standing alignment for more than three minutes de­ pending upon the size of the student, height variations between the adult and the student, and skill level of the student. Also, the time parameter of three minutes was chosen because that is enough time to remove or replace a diaper, transfer from one seat to another, etc.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Would this student be able to maintain hip and knee extension if I helped keep the trunk in alignment while brushing teeth at the sink?

C.4. Can tolerate weight bearing on feet for a minimum of 45 minutes per day when knees, hips, and trunk are held in alignment by a mobile stander or similar standing device. FUNCTIONAL USE OF SKILL: Health is the major reason for requiring prolonged periods of standing. Bones and joints, like muscles, need stress and exercise to

107

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remain healthy. Also, internal organs, the circulatory system, and the excretory system work better if standing is included in the daily regimen. With well sup­ ported standing, tight muscles stretch and muscle tone is improved. In addition to health, standing in an upright position often improves a student's self-image and

the image others have of the student. (For stander suggestions, see: EQUIPMENT,

page 260.) PARAMETERS: The time parameter of 45 minutes was suggested by our ortho­

paedic surgeon as the minimal accumulated time a person over the age of three should stand for bone and joint health each day. Children under the age of three

should stand in very short sessions for approximately the same amount of time as

their non-disabled peers would stand each day. (Please note "Eligibilityfor the Program" on page 4.)

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Can this student corrifortably bear weight on his/herfeetfor a mini­ mum of 45 minutes per day?

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LEVEL III

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C.5.

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Can tolerate fully prompted extension of hips and knees. FUNCTIONAL USE OF SKILL: Obviously, the inability to extend the hips and knees will influence the ability to stand and walk. Also, it is very difficult to dress a person who cannot extend his/her hips and knees. If the student's hips and knees do not naturally extend, then please note "Eligibilityfor the Program" on page 4. PARAMETERS: The term "fully prompted" means that the instructor gently helps the student straighten the hips and knees. (Force should NEVER be used and any sign of pain indicates a need for medical assessment.)

The phrase "extension of hips and knees" means that the student has enough joint mobility to allow the hips and knees to extend (straighten out) to at least 45 degree angles. To determine the student's proficiency with this skill, ask yourself this question: QUESTION: When this student is lying down on his / her back, can the student allow the hips and knees to relax enoughfor the legs to straighten out at least half­ way between a sitting position and a standing position? 108

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C.6. Can tolerate being placed in a vertical position. FUNCTIONAL USE OF SKILL: If the student has any of the symptoms listed in HEligibUityJor the Program" on page 4, seek medical help before attempting to have the student stand. PARAMETERS: The term "vertical position" refers to an upright body position with legs extended.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Does the student show any signs qf distress or pain when placed in a vertical position?

109

~ ®

D.

~

E= TRANSITION FROM SITTING TO STANDING

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GRAD LEVEL

D.l. Can stand up from a sitting position in a bathtub or from the floor with one hand held. FUNCTIONAL USE OF SKILL: A person who can stand up from the bathtub or from the floor with one hand held does not need to be lifted. PARAMETERS: Holding one hand was selected because it is the most natural way to help another person get to a standing position. When helping a person out of a slippery bathtub, however, many people prefer to hold the upper arm of the bather.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student position his / her own legs and push up to a stand­ ing position while sitting in a bathtub

if I

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held one hand or arm?

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D.2. Can stand up from a conventional classroom chair without assistance. FUNCTIONAL USE OF SKILL: In order to be independent, a person has to be able to stand from a chair without assistance. Often our students achieve this skill before they can walk independently. Many of them rotate in their seats and use the back of the chair to maintain balance while they rise to a standing position. We often place a simple walker in front of seated students to encourage independ­ ence and also as a safety measure in case they try to stand while unattended. PARAMETERS: The phrase "without assistance" means without another person having to physically help the student.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student push himself/herself to a standing positionJrom a chair without the physical assistance oj another person?

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LEVEL I

D.3. Can push with legs to raise self from a sitting position in a bathtub or from

the floor when the trunk is stabilized.

FUNCTIONAL USE OF SKILL: It is much easier for the instructor if the person who is getting up does not have to be lifted. PARAMETERS: The instructor may have to help the student position the feet in order to push to standing. The phrase "trunk is stabilized" refers to keeping the trunk aligned over the feet while the student comes up to a standing position. The instructor can either stand behind or in front of the student. The student should not have to be lifted. (See: Bathing, page 246.)

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I helped this student keep his/her trunk balanced, would this stu­ dent be able to use his/her legs to push up to a standing positionfrom thefloor?

D.4. Can stand up from a conventional classroom chair with one or both hands

held.

FUNCTIONAL USE OF SKILL: A student who has the ability to keep his/her own body in alignment while leaning forward and pushing to a standing position greatly reduces the physical strain on the instructor. PARAMETERS: The natural way to help another person stand is to hold one hand to maintain balance. To maintain safety. larger people or people who have diffi­ culty keeping their shoulders square may require both hands to be held.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student push himself/herself safely to a standing position from a chair if I held one or both hands and did not block the knees or help keep the body in alignment?

III

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LEVEL II

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Can extend hips and knees and bear own weight when trunk is lifted from a sitting position in a bathtub or on the floor.

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FUNCTIONAL USE OF SKILL: Most people can be lifted safely from a sitting posi­

tion on the floor by standing behind the person, grasping under the arms and around the chest (See: Chapter 4, page 172.) Once lifted, the student needs to

bear weight on the feet so the instructor does not have to continue holding the

weight of the student. Transfer to a chair or prompted walking can then occur.

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PARAMETERS: Extension of hips and knees should occur instantly so the in­

structor does not have to hold the student in space while the hips and knees are being extended. Weight bearing should be maintained long enough to transfer the

student to another seat.

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To determine the student's proficiency with this skill, ask yourself this question:

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QUESTION: if I help this student get to a Sitting position whUe on ajlat sUrface and then lift the student's trunkfrom thejloor, wUl the student immediately take weight on his I her legs and maintain weight bearing long enough to tran~er the student to a chair?

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D.6.

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Can extend hips and knees and bear weight when trunk is lifted from a sit­ ting position on a chair.

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FUNCTIONAL USE OF SKILL: A student who can bear weight after being brought

to a standing position can be transferred to another chair without having to lift

the entire weight of the student. (See: Chapter 4, page 171.)

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PARAMETERS: Extension of hips and knees should occur instantly so the in­

structor does not have to hold the student in space while the hips and knees are

being extended. Weight bearing should be maintained long enough to transfer the

student to another seat.

To determine the student's proficiency with this skill, ask yourself this question:

~

QUESTION: if I block this student's knees with mine and lift the student's trunk from a sitting position on a chair, wUl the student be able to extend his I her own hips and knees and maintain weight bearing whUe I help the student transfer to

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another chair?

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112

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LEVEL III

C.s. is a prerequisite skUI for TRANSITION FROM SITTING TO STANDING. (See Section C beginning on page 108 for more information.)

C.6.

is a prerequisite skill for TRANSITION FROM SITTING TO STANDING. (See Section C beginning on page 109 for more information.)

A. 7.

is a prerequisite skill for TRANSITION FROM SITTING TO STANDING. (See section A beginning on page 100 for more information.)

113

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E.

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!: TRANSITION FROM STANDING TO SITTING

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GRAD LEVEL

f:

E.l. Can lower self into a bathtub or to the floor by holding a stationary object or with help from another person to maintain balance. FUNCTIONAL USE OF SKILL: A student who can maintain body alignment and lower himself/herself to the floor or bathtub from a standing position with mini­ mal assistance to maintain balance requires no lifting and very little help from an instructor. PARAMETERS: A stationary object could be anything from a wall to a counter or bar. Stationary objects are not always in the right position so an instructor can act in the same capacity. The phrase "lower self' refers to maintaining self-di­

rected control of the body while lowering oneself to the floor or bathtub as op­

posed to dropping or falling.

To determine the student's proficiency with this skill, ask yourself this question:

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QUESTION: Could this student stand in a bathtub and sqfely lower himself/her­ self to a sitting position with minimal help to maintain balance (one arm held, both

hands held. or holding on to a wall or bar)?

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E.2. Can lower self to a conventional classroom chair without assistance.

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FUNCTIONAL USE OF SKILL: The ability to lower oneself to a chair gives stu­

dents options in changing positions. This is conSidered a high level skill because the student has to be aware of his /her own position in relationship to the seat.

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PARAMETERS: The phrase"without assistance" means without another person offering guidance or direction. The phrase "lower self' refers to maintaining self­

directed control of the body while lowering oneself to a chair as opposed to drop­

ping or falling.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I left this student standing infront Qf a chair while holding on to a

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114

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stationary object, would this student be aware oj the position oj the seat and be able to lower himself/herself to the seat saJely without assistance or direction? (if I removed the chair, would the student still attempt to sit down anyway?)

LEVEL I

E.3. Can use legs to lower self into a bathtub or to the floor when the trunk is stabilized by another person. FUNCTIONAL USE OF SKILL: A student who can lower himself/herself to the floor or bathtub from a standing position, with assistance to maintain appropriate body alignment, requires no lifting and minimum physical help from the instruc­ tor. PARAMETERS: The phrase "trunk is stabilized" means that the instructor helps keep the trunk aligned over the feet. This can be accomplished by holding the upper arms and helping the student shift the body weight appropriately. The instructor does not support any of the student's body weight. The phrase "lower self' refers to maintaining self-directed control of the body while lowering oneself to the floor or the bathtub as opposed to dropping or falling.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student stand in a bathtub and saJely lower himself/herself to a sitting position

if I helped him/ her maintain appropriate body alignment?

E.4. Can use legs to lower self to a chair when both hands are held by another person. FUNCTIONAL USE OF SKILL: Students who can lower themselves to chairs with­ out an instructor providing support reduce the possibility of injury to both the instructor and the student. PARAMETERS: The phrase "lower self" refers to maintaining self-directed control of the body while lowering oneself to a chair as opposed to dropping or falling.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION:

if this student were standing inJront oj a

chair and I held his/her hands, would the student be able to lower himself/herself to a sitting position with­ out collapsing into the chair or pulling me off balance?

115

LEVEL II

E.5. Can flex hips and knees when another person supports the trunk and lowers

the participant into a bathtub or to the floor.

FUNCTIONAL USE OF SKILL: Students who cannot voluntarily flex the hips and knees must be lowered to the floor in the same manner one would lower a heavy board. This requires a lot of space and it 1s difficult for the instructor to maintain safety as the student gets close to the floor. If the student can voluntarily flex the hips and knees, the instructor can stand behind the student, grasp under the arms and around the chest, and safely lower the student to a sitting position in the bathtub or on the floor. The student then can be lowered to a reclining posi­ tion or whatever position is appropriate for the activity. PARAMETERS: The phrase "supports the trunk" means that the instructor is supporting the student's body weight by holding on to the trunk. The phrase "flex the hips and knees" means that the hips and knees can be bent enough for the student to be placed in a supported sitting position on the floor or in the bathtub.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION:

if I

stand behind this student and lower the student's trunk toward the floor, can the student relax his/her muscles so that the student can be placed in a sitting position?

E.6. Can flex hips and knees when another person supports the trunk and lowers

the participant to a chair.

FUNCTIONAL USE OF SKILL: Students who are able to voluntarily flex their hips

and knees are easy to position in chairs.

PARAMETERS: The phrase "supports the trunk" means that the instructor is supporting the student's body weight by holding on to the trunk. The phrase "can flex hips and knees" refers to the ability to bend the hips and knees enough to be placed in a good sitting position (90 degree minimum).

To determine the student's proficiency with this skill, ask yourself this question:

if I hold this student under the arms and grasp around the chest while lowering the student to a chair, will the student voluntarily flex the hips and knees so seating is possible? QUESTION:

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LEVEL HI

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C.5. is a prerequisite skill for TRANSITION FROM STANDING TO SITTING. (See section C on page 108 for more information.) C.6.

is a prerequisite skill for TRANSITION FROM STANDING TO SITTING. (See section C on page 109 for more information.)

A. 7. is a

prerequisite skill for TRANSITION FROM STANDING TO SITTING. (See section A on page 100 for more information.)

I

117

F.

PIVOTING WHILE STANDING

t

GRAD LEVEL

F.1. Can pivot while standing in place when holding on to a stationary object or another person's hand without additional prompts. FUNCTIONAL USE OF SKILL: In order to move in small spaces such as bus aisles or toilet stalls, a student needs to be able to pivot in place. PARAMETERS: The term "pivot" refers to being able to change the position of the feet while turning the trunk. For the skill to be functional, the student should be able to pivot a minimum of 180 degrees. The phrase "without additional prompts" means that the instructor does not need to help the student with foot placement or help maintain body alignment while turning.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Would this student be able to tum around in the aisle oj a bus without help if the student held on to the bus seats Jor balance or if I offered a hand?

LEVEL I

F.2. Can reposition feet to pivot in place while standing when another person rotates the participant's trunk and helps the participant maintain balance. FUNCTIONAL USE OF SKILL: If a student cannot turn by himself/herself in a small space, it is fairly easy for the instructor to rotate the student's shoulders and help keep the trunk aligned over the feet while turning. The student, however, needs to be able to reposition the feet to maintain a standing position while turn­ ing. PARAMETERS: The phrase "reposition feet" means to pick up the appropriate foot and place it squarely under the body again so that the student does not get off balance and reqUire support from the instructor.

118

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I held this student's shoulders and slowly rotated the trunk in either direction, would the student be able to move thefeet to keep up with the rotation?

LEVEL II

F.3. Can maintain hip and knee extension while standing when another person rotates the entire body and helps support the participant. FUNCTIONAL USE OF SKILL: If a student can maintain hip and knee extension and therefore remain standing while an instructor rotates the student in place, the student can use public restrooms and go into small areas that would not be accessible to a wheelchair. PARAMETERS: The phrase "helps support the participant" means that the in­ structor shifts the student's weight to one foot while rotating the student and then pushes the student's foot to the correct placement while the student keeps his / her legs extended.

To determine the student's proficiency with this skill, ask yourself this question:

if I stand behind this student and shift the student's weight to onefoot. will the student keep his/her legs extended while I rotate the student's body?

QUESTION:

LEVEL III

C.5.

is a prerequisite skill for PIVOTING WHILE STANDING. (See section C on page 108 for more information.)

C.6. is a prerequisite skill for PIVOTING WHILE STANDING. (See section C on page 109 for more information.)

119

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G.

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GRAD LEVEL

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G.I. Can walk forward a minimum of 20 feet without assistance. FUNCTIONAL USE OF SKILL: The ability to walk this far would assure a student of independent mobility within the household. PARAMETERS: The distance of 20 feet was selected because most rooms in a house are less than 20 feet across.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Would this student be able to walk across a large den without supervi­ Sion or help?

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Can walk a minimum of 1,000 feet with one hand held. FUNCTIONAL USE OF SKILL: A student who can walk 1,000 feet with one hand held does not require a wheelchair for the majority of outings. PARAMETERS: The distance from most parking lots to stores, restaurants, or medical buildings is less than 1,000 feet.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk 1,OOOfeet whUe I held one qfthe student's hands?

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LEVEL I

G.3. Can walk a minimum of 300 feet with one or both hands held or with a walk­ er. FUNCTIONAL USE OF SKILL: A student who can walk 300 feet with one hand held or by using a walker does not require a wheelchair to go out if parking is

close to the destination. PARAMETERS: The distance from a handicapped parking space or accessible curb to a store, restaurant seat, or doctor's waiting room is usually less than 300 feet.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk 300feet while I held the student's hands (or walked beside the student and held one hand and guided one shoulder) or while the student used a walker?

LEVEL II

G.4. Can move legs reciprocally for a minimum of 10 feet while bearing weight when another person assists with shifting weight and maintaining balance. FUNCTIONAL USE OF SKILL: A student who can be prompted to walk 10 feet

can be walked into a restroom stall or to seating areas in public places such as restaurants when wheelchairs don't fit at the table. PARAMETERS: Most places that are too small or crowded to allow wheelchair seating (restrooms, church pews, theater seats, etc.) can be reached in 10 feet so that alternative seating can be used.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I stood behind this student. helped to maintain balance and shift weight, would the student be able to move his I herfeet while we walked a minimum of lOfeet?

G.5. Can move legs reciprocally for a minimum of 20 feet while being supported by a front leaning walker or by another person. 121

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FUNCTIONAL USE OF SKILL: A student who can move his/her own legs inde­

pendently is much easier to help than one who requires prompting of each foot.

The ability to walk this far while being supported allows the student to cross any room in a house without having to use a wheelchair. The front leaning walker

gives the student support for walking while allowing the instructor to adjust cloth­

ing for toileting, etc. PARAMETERS: The distance of 20 feet was selected because most rooms in a house are less than 20 feet across. Students who are not too heavy can be sup­ ported by an instructor. Equipment is recommended for larger students.

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To determine the student's proficiency with this skill, ask yourself this question:

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QUESTION: Can this student take continuous reciprocal steps to walk 20 feet if the student has some support and guidance?

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LEVEL III

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G.6. Can tolerate fully prompted reciprocal leg movements while being supported

in a front leaning walker or by another person.

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FUNCTIONAL USE OF SKILL: If a student cannot move his/her own legs inde­ pendently, the student can still be prompted to walk short distances with support.

This alleviates the need to constantly transfer in and out of wheelchairs for activi­

ties such as going from the bed to the bathroom.

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PARAMETERS: The term "tolerate" means that the student is free of pain or dis­

tress while flexing the hips and knees. (please note "Eligibilityfor the Program" on page 4.)

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To determine the student's proficiency with this skill, ask yourself this question:

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QUESTION: When I help this student move his/her legs in a reciprocal pattern, is

the studentfree of pain?

C.s. is a prerequisite skill for WALKING FORWARD. (See section C on page

~ ~

108 for more information.)

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C.6.

C

is a prerequisite skill for WALKING FORWARD. (See section C on page 109 for more information.)

122

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B.

TRANSITION FROM STANDING TO WALKING

GRAD LEVEL

:I

B.l.

J

Can start walking from a standing position without assistance. FUNCTIONAL USE OF SKILL: The ability to start walking without being prompted allows the student independence and encourages decision making. PARAMETERS: The phrase "start walking" means that the student can shift the body weight forward while standing and take the appropriate reciprocal steps. The phrase "without assistance" means without direction from another person and without the use of a walker or supporting device.

To determine the student's proficiency with this skill. ask yourself this question: QUESTION: if I left this student standing at a counter or doorway, could the stu­ dent walk away without any help or encouragement?

LEVEL I

B.2. Can start walking from a standing position without leg prompts when using a walker. FUNCTIONAL USE OF SKILL: The ability to start walking without being prompted when using a walker allows the student independence and encourages decision making. PARAMETERS: The phrase "without leg prompts" means that the student can start walking without someone having to help the student take the first step or move the walker so that the student is off balance.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I leave this student standing with a walker. will this student start walking without any assistance?

123

LEVEL II

H.3. Can start moving legs reciprocally from a standing position in a front leaning walker or whUe another person assists with shifting weight and maintaining balance. FUNCTIONAL USE OF SKILL: A student who can move his/her own legs inde­ pendently is much easier to help than the student who requires prompting of each foot. If a walker is used, the instructor can stand in front of the student and pull the walker along. If the instructor is helping support the student while walking, it is easier if the student moves his/her own feet than if the instructor has to push each foot forward. PARAMETERS: The phrase "start moving legs reciprocally" means that the stu­ dent automatically moves the non-weight bearing foot forward when the upper body is prompted.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: When this student is standing and is moved in afonvard direction, will the student automatically step fonvard with the appropriatefoot?

LEVEL III

G.6. is a prerequisite skUI for TRANSITION FROM STANDING TO WALKING. (See section G on page 122 for more information.)

C.5. is a prerequisite skill for TRANSITION FROM STANDING TO WALKING. (See section C on page 108 for more information.)

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C.6.

is a prerequisite skill for TRANSITION FROM STANDING TO WALKING. (See section C on page 109 for more information.)

124

Iij;­

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I.

TRANSITION FROM WALKING TO STANDING

J

GRAD LEVEL

1.1. Can stop walking and maintain a standing position without assistance. FUNCTIONAL USE OF SKILL: Personal safety requires that a student must have the ability to stop walking and maintain standing balance Without help. PARAMETERS: The phrase "maintain a standing balance" means to stand in one place Without support and Without falling down.

To determine the student's proficiency With this skill, ask yourself this question: QUESTION:

if this

student was walking into a dangerous situation, could the stu­ dent stop and maintain balance long enough to change direction. sit down, waitfor help or do whatever was appropriate to the situation?

LEVEL I

1.2. Can stop walking and maintain a standing position if another person helps the participant maintain balance. FUNCTIONAL USE OF SKILL: For the safety of the instructor and the student, the student has to be able to stop walking or the student and the instructor can be pulled off balance. PARAMETERS: The phrase "stop walking" means to stop moving the feet in a reciprocal pattern and to square the feet in relationship to the body and allow the student to be balanced while standing.

To determine the student's proficiency With this skill, ask yourself this question: QUESTION:

if I

am walking with this student and I stop, wUl the student also stop and bring thefeet to the appropriate positionfor standing?

125

-

r-

--

LEVEL II

r

1.3.

-­

Can stop moving legs reciprocally and maintain hip and knee extension for standing whUe in a front leaning walker or whUe another person helps main­ tain balance. FUNCTIONAL USE OF SKILL: For the safety of the instructor and student, the student must be able to stop moving the feet in a reciprocal pattern and extend the hips and knees of both legs to maintain standing support. PARAMETERS: The phrase "stop moving legs reciprocally" simply means to freeze and not move. Squaring the feet for standing balance may require prompting from the instructor. The student, however, must not collapse.

......

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To determine the student's proficiency with this skill, ask yourself this question: QUESTION:

­

if I

am helping this student walk and we stop. will the student main­ tain enough hip and knee extension to remain standing as opposed to allowing the legs to collapse?

--

LEVEL III

G.6. is a prerequisite skUI for TRANSITION FROM WALKING TO STANDING. (See section G on page 122 for more information.)

C.s.

is a prerequisite skill for TRANSITION FROM WALKING TO STANDING. (See section C on page 108 for more information.)

C.6.

is a prerequisite skUI for TRANSITION FROM WALKING TO STANDING.

(See section C on page 109 for more information.

,.......

-

­

-

126

-

-

....-

J.

WALKING BACKWARD

GRAD LEVEL

J.l. Can walk backward a minimum of 3 steps while holding on to a stationary object or with one hand held. FUNCTIONAL USE OF SKILL: Many situations require backing up rather than turning around. Even when turning around is possible, backing up a few steps often is more convenient. For example, backing up is more convenient when standing in line, in avoiding moving obstacles, or in making room for other people in crowded places. PARAMETERS: People seldom back up more than three steps. If they need to back up more, they usually pivot and walk forward. To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I was holding this student's hand and walking in a crowded area, would this student be able to step back three steps to get out oj the way oj another person without guidance or being told to move?

LEVEL I

J.2. Can walk backward a minimum of three steps with both hands held or while using a walker with guidance provided by another person. FUNCTIONAL USE OF SKILL: Students should be able to step back for safety as well as convenience. People are not safe walking independently unless they have the ability to step back and "catch" themselves and thus regain their balance. PARAMETERS: People seldom back up more than three steps. If they need to back up more, they usually pivot and walk forward. The term "guidance" means that the instructor initiates the movement but does not prompt the foot place­ ment.

127

--,.-.. -To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I stand infront of this student. holding both hands, and guide the student in a backward direction, will this student take a minimum qf three steps backward?

_.

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--­

LEVEL II

J.3. Can move feet backward to adjust body alignment when the participant is moved in a backward direction while being supported by a front leaning walk­ er or by another person.

--­--­r-­

FUNCTIONAL USE OF SKILL: Stepping back is necessary because it is not al­ ways possible to turn a walker around. Also, a student needs to step back to get away from a front leaning walker when in small areas such as the bathroom. PARAMETERS: The phrase "adjust body alignment" means that the body is moved slightly backward. The student then moves the legs one at a time so that the feet are directly under the trunk.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION:

if I

move this student backward while the student is being supported in a standing position, will the student pick up the appropriatefoot and realign his / her bodyfor standing?

.-­ -

--r-­

r-­

LEVEL III

J.4. Can tolerate fully prompted backward reciprocal leg movements while being supported in a front leaning walker or by another person. FUNCTIONAL USE OF SKILL: If a student cannot move his/her own legs inde­ pendently, the student can still be prompted to step back with support. This alle­ Viates the need to drag the student back when in small areas. PARAMETERS: The term "fully prompted" means that the instructor physically picks up the student's foot when the student is in a front leaning walker or rotates the hips when supporting the student without a walker. The term "tolerate" means that the student is free of pain or distress while flexing the hips and knees. (Please note "Eligibiliiyfor the Program" on page 4.) 128

­ -

­

--

--

M/iiVE'.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: When I help this student move his / her legs in a backward reciprocal pattern, is the studentfree qfpain?

C.s.

is a prerequisite skill for WALKING BACKWARD. (See section C on page 108 for more information.)

C.6.

is a prerequisite skill for WALKING BACKWARD. (See section C on page 109 for more information.)

129

K.

TURNING WHILE WALKING

GRAD LEVEL

K.l. Can turn to the left or right in a maximum arc of three feet while walking independently. FUNCTIONAL USE OF SKILL: A person has to be able to tum and change direc­ tions to be independent and make decisions about which direction to move. PARAMETERS: An arc of three feet was chosen because most small areas such as restrooms, hallways, and convenience kitchens have at least three feet of turn­ ing space. Also, a person who could turn within a three foot diameter could stay on most sidewalks. To determine the student's proficiency with this skill, ask yourself this question:

r-­ -

QUESTION: if given a minimum of three feet to tum. could this student change direction without help?

K.2. Can pivot to the left or right while being guided with one hand. FUNCTIONAL USE OF SKILL: Being able to pivot while walking with one hand held is helpful because the instructor can walk side-by-side without having to physically tum the student's shoulders which becomes awkward for both the student and the instructor. A person who is walking forward should be able to pivot while walking without having to stop, regain balance, and then turn. This is a high level skill, however, and independence is usually achieved after graduation from the program. PARAMETERS: The term "guided" means that the instructor initiates the tum and provides minimal balance to the student with one hand. The turn creates no interruption in walking. To determine the student's proficiency with this skill, ask yourself this question:

QUESTION: if I guided with one hand. could this student walk down a narrow aisle and pivot in either direction without losing his / her balance and without stop­ ping or my giving additional help? 130

--

•

LEVEL I

K.3. Can turn to the left or right in a maximum arc of three feet while walking with one hand held. FUNCTIONAL USE OF SKILL: In most instances, sharp turns can be avoided when students have not acquired the skills needed to pivot while walking. When turning in an arc, the student is making a series of small pivots which makes maintaining balance easier. PARAMETERS: An arc of three feet was chosen because most small areas such as restrooms, hallways, and convenience kitchens have at least three feet of turn­ ing space. Also, a person who could tum within a three foot diameter could stay on most sidewalks.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I held one hand of this student, could I walk down a sidewalk and turn in a three foot arc in either direction without having the student lose his / her balance and without stopping or giving additional help?

K.4. Can pivot to the left or right while walking with a walker or with both hands held when another person rotates the walker or the trunk of the participant. FUNCTIONAL USE OF SKILL: A person who can pivot while walking with support does not have to stop at every comer to regain alignment. PARAMETERS: The instructor initiates the tum and rotates the student's trunk either by turning the walker or the student's shoulders. The student then brings the legs into alignment without additional prompting.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could I walk with this student and help him/her turn to the left or the right by simply turning the student's trunk in the desired direction?

LEVEL II

F.3. is a prerequisite skill for TURNING WHILE WALKING. (See section F on page 119 for more information.) 131

c··· r=.. .

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LEVEL III

C.5.

is a prerequisite skill for TURNING WHILE WALKING. (See section C on page 108 for more information.) ~~.

C.6.

is a prerequisite skill for TURNING WHILE WALKING. (See section C on page 109 for more information.)

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132

L.

WALKING UP STEPS

GRAD LEVEL

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L.l. Can walk up a minimum of three steps while holding a railing or with one hand held by another person. FUNCTIONAL USE OF SKILL: Walking up steps is necessary for boarding buses, getting into some buildings, stepping up on curbs, and many other situations. The ability to raise the foot and place it forward is necessary to get in a bathtub and most showers. PARAMETERS: A minimum of three steps was chosen because most buses have three steps. In addition, height variations at the ground floor seldom require more than three steps. The ability to climb stairs to reach the second floor is a high level skill that usually is attained after graduation from the program. The first step on most buses is 18 inches off of the ground. The height of most bathtubs is simi­ lar. For a tall person. 18 inches can be managed. For a small child, shorter steps can be used.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk up three steps by holding the railing or with one hand held in order to sit on a conventional bus?

LEVEL I

L.2. Can walk up a minimum of three steps while another person helps maintain balance and prompts each leg. FUNCTIONAL USE OF SKILL: A student who can ascend stairs does not need to be lifted, can ride on conventional buses, and help get in the bathtub. PARAMETERS: A minimum of three steps was chosen because most buses have three steps. Height variations at the ground floor level seldom reqUire more than three steps. The phrase "prompts each leg" means that the instructor stands behind the student and helps the student lift one leg and place the foot on the 133

step. The student pushes himself/herself up the step with minimal help from the instructor. To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I stand behind this student, help maintain balance. and place the student'sfoot on the step. can the student use his/her own strength to push up to a standing position and preparefor the next step?

LEVEL II

L.3. Can maintain extension of one leg while another person prompts the lifting of the other leg and helps the participant to raise body weight to ascend a minimum of three steps. FUNCTIONAL USE OF SKILL: A student who can maintain body position while being helped to ascend stairs does not need to be carried, can ride on conven­ tional buses, and help get himself/herself into the bathtub. PARAMETERS: A minimum of three steps was chosen because most buses have three steps and because height variations at the ground floor level seldom require more than three steps.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I stand behind this student, help maintain balance, and place the student's foot on the step, can the student maintain his / her own body position while I help the student lift his/her body weight up the step?

LEVEL III

G.4.

is a prerequisite skill for WALKING UP STEPS. (See section G on page 121 for more information.)

-r-

­

C.3.

is a prerequisite skill for WALKING UP STEPS. (See section C on page 107 for more information.)

-..­

-

134

-

M.

WALKING DOWN STEPS

1

GRAD LEVEL

M.l. Can walk down a minimum of three steps with both hands held by another person or with hand ralls on both sides of the participant. FUNCTIONAL USE OF SKILL: Walking down steps is necessary for getting off of buses, getting out of buildings, stepping down curbs, and many other situations. PARAMETERS: A minimum of three steps was chosen because most buses have three steps and because height variations at the ground floor level seldom reqUire more than three steps. The ability to descend stairs to reach a lower floor of a building is a high level skill and usually is attained after graduation from the program. Learning to descend steps usually takes more practice sessions than learning to ascend steps because the student must flex the weight bearing leg to lower themselves while extending the non-weight bearing leg. This is the opposite of the skill required to walk forward. For this reason, more help (both hands held or two rails) is required for the student to descend stairs.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk down three steps by holding two railings or with both hands held to get off a conventional bus?

LEVEL I

M.2. Can walk down a minimum of three steps with balance provided at the shoul­ der level and with prompting of each leg. FUNCTIONAL USE OF SKILL: A student who can help in descending stairs does not need to be lifted, can ride on conventional buses, and has access to any ground level buildings. PARAMETERS: A minimum of three steps was chosen because most buses have three steps and height variations at the ground floor level seldom require more than three steps. The phrase "prompts each leg" means that the instructor stands

behind the student and helps the student remove the appropriate leg from the step and place the foot forward. The phrase "balance provided at the shoulder level" means that the instructor holds the student's shoulders while prompting the flexion of the weight bearing leg. This usually can be accomplished by placing your knee in the back of the student's knee until the student's knee flexes. The student then lowers himselfIherself and takes weight on the extended leg. To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I stand behind this student, help maintain balance, and prompt the student's legs, can the student safely descend three steps?

LEVEL II

M.3. Can maintain extension of one leg while another person prompts the flexion of the other leg and helps the participant lower the body weight for a mini­ mum of three steps. FUNCTIONAL USE OF SKILL: A student who can help in descending stairs need not be lifted. can ride conventional buses. and has access to any ground level buildings. PARAMETERS: A minimum of three steps was chosen because most buses have three steps and height variations at the ground floor level seldom require more than three steps. The phrase "prompts each leg" means that the instructor stands behind the student and helps remove the appropriate leg from the step and place the foot forward. The phrase "helps the participant lower the body weight" means that the instructor holds the student and takes the responsibility for lowering the body weight to the next step. The student's responsibility is to maintain extension of the leg receiving the weight while allowing the other leg to be flexed by the in­ structor.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: if I stand behind this student, prompt the student's legs and help lower the student to the next step. can the student allowflexion of one leg whUe extending the otherfor a minimum of three steps?

E: 136

LEVEL III

G.4.

is a prerequisite skill for WALKING DOWN STEPS. (See section G on page 121 for more information.)

C.3. is a prerequisite skill for WALKING DOWN STEPS. (See section C on page 107 for more information.)

137

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N.

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f= f=

GRAD LEVEL

N.l.

f=

Can walk on uneven surfaces with height variations of three inches or less

with one hand held.

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FUNCTIONAL USE OF SKILL: A person who can walk on uneven surfaces such

as grass or gravel is not limited to man-made environments. Walking independ­ ently on uneven surfaces is a high level skill and is usually accomplished after

graduation from the program.

PARAMETERS: Most parks, playgrounds, driveways, etc. do not vary in height more than three inches.

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To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk safely across a playground if I held the stu­

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dent's hand?

E= E=.

LEVEL I

N.2. Can walk on uneven surfaces with height variations of three inches or less when both hands are held. FUNCTIONAL USE OF SKILL: A person who can walk on uneven surfaces such as grass or gravel has gained additional access. If a person can walk on uneven ground with both hands held, the student can go to parks or playgrounds. Wheel­ chairs often are not practical on uneven ground. So the ability to walk with both hands held makes more environments accessible. PARAMETERS: Most parks, playgrounds, driveways, etc., do not vary in height more than three inches. The phrase "with both hands held" means that the in­

structor prompts both sides of the body so that balance is maintained.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk safely across grass to have a picnic if I held both hands?

138

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LEVEL II

N.3. Can walk on uneven surfaces with height variations of three inches or less when each leg is prompted and partial support at the upper trunk level is offered by another person. FUNCTIONAL USE OF SKILL: Sometimes a wheelchair cannot be pushed across uneven ground. A student's environment can be expanded if the student can be prompted to walk across short spans of uneven ground. PARAMETERS: The phrase "each leg is prompted" means that the instructor helps the student shift weight and pushes each foot forward at the appropriate time. The phrase "partial support" means the instructor stands behind the stu­ dent, has a firm grasp in case the student should lose his/her balance and helps the student shift weight. To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Would this student be able to walk at leastflvefeet across grass if I helped him/her shift weight and moved the feet in order to feed animals at a petting zoo?

LEVEL III

G.4.

is a prerequisite skill for WALKING ON UNEVEN GROUND. (See section G on page 121 for more information.)

C.3.

is a prerequisite skill for WALKING ON UNEVEN GROUND. (See section C on page 107 for more information.)

...139

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GRAD LEVEL

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0.1. Can walk up a slope of 30 degrees or less with one or both hands held. FUNCTIONAL USE OF SKILL: A person who can walk up slopes can go to parks, zoos, and attend other events. Walking independently up slopes is a high level skill usually accomplished after graduation from the program. PARAMETERS: Most parks, playgrounds, ramps, etc., do not have slopes that are greater than 30 degrees. If they do, there is usually an alternate route that is not as steep.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk safely up a slope qf 30 degrees to get to an­ other room

if I walked backward and held both of the student's hands?

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f= LEVEL I

f=

0.2. Can walk up a slope of 30 degrees or less with both hands held. FUNCTIONAL USE OF SKILL: A person who can walk up slopes can go to parks, zoos, and attend other events. PARAMETERS: Most parks, playgrounds, ramps, etc., do not have slopes that are greater than 30 degrees. If they do, there is usually an alternate route that is not as steep. The phrase "with both hands held" means that the instructor is helping control both sides of the student's body.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk safely up a slope qf 30 degrees to get to an­ other room if I walked backward and held both of the student's hands?

140

t=

E:

t:: E:

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LEVEL II

0.3. Can walk up a slope of 30 degrees or less when each leg is prompted and partial support at the shoulder level or upper trunk is offered. FUNCTIONAL USE OF SKILL: Floors inside buildings are not always level. A person able to walk up slopes with assistance can have access to more environ­ ments without depending on a wheelchair. PARAMETERS: Most parks, playgrounds, ramps, etc., do not have slopes that are greater than 30 degrees. If they do, there is usually an alternate route that is not as steep. The phrase "each leg is prompted" means that the instructor helps the student shift weight and pushes each foot forward at the appropriate time. The phrase "partial support" means that the instructor is standing behind the student, has a firm grasp in case the student should lose his Iher balance and is helping the student shift weight. To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk safely up a slope of 30 degrees to get to an­ other room

if I walked behind the student and prompted each leg movement?

LEVEL III

G.4.

is a prerequisite skill for WALKING UP SLOPES. (See section G on page 121 for more information.)

C.3.

is a prerequisite skill for WALKING UP SLOPES. (See section C on page 107 for more information.)

141

---

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P.

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WALKING DOWN SLOPES

GRAD LEVEL

- _ ......

__

........

P.l. Can walk down a slope of 30 degrees or less with one or both hands held. FUNCTIONAL USE OF SKILL: A person who can walk down slopes can go to parks, zoos, and attend other events. Walking independently down slopes is a high level skill and is usually accomplished after graduation from the program. Walking down slopes is more difficult than walking up slopes so the student may require more instructional sessions. PARAMETERS: Most parks, playgrounds, ramps, etc., do not have slopes that are greater than 30 degrees. If they do, there is usually an alternate route that is not as steep. Because walking down slopes is more difficult than walking up slopes,

the instructor offers more assistance. The phrase "with both hands held" means

that the instructor is helping control both sides of the student's body.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk safely down a slope of 30 degrees to enter a building if I held the student's hand?

LEVEL I

P.2. Can walk down a slope of 30 degrees or less with prompts at the shoulder level. FUNCTIONAL USE OF SKILL: A person who can walk down slopes can go to parks, zoos, and attend other events. PARAMETERS: Most parks, playgrounds. ramps, etc., do not have slopes that are greater than 30 degrees. If they do, there is usually an alternate route that is not as steep. The phrase "with prompts at the shoulder level" means that the instruc­

tor is walking behind the student and grasping both shoulders to assure that the

student is able to maintain balance.

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To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk sqfely down a slope of 30 degrees to enter another room if I walked behind the student and held both of the student's shoul­ ders?

LEVEL II

P.3. Can walk down a slope of 30 degrees or less when each leg is prompted and partial support at the shoulder or upper trunk level is offered. FUNCTIONAL USE OF SKILL: Floors are not always level even inside buildings. A person who can walk down slopes with assistance can have access to more envi­ ronments without depending on a wheelchair. PARAMETERS: Most parks, playgrounds, ramps, etc., do not have slopes that are greater than 30 degrees. If they do, there is usually an alternate route that is not as steep. The phrase "each leg is prompted" means that the instructor helps the student shift weight and pushes each foot forward at the appropriate time. The phrase "partial support" means that the instructor is standing behind the student, has a firm grasp in case the student should lose his/her balance and is helping the student shift weight.

To determine the student's proficiency with this skill, ask yourself this question: QUESTION: Could this student walk sqfely down a slope of 30 degrees to enter another room if I walked behind the student and prompted each leg movement?

LEVEL III

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G.4. is a prerequisite skill for WALKING DOWN SLOPES. (See section G on page 121 for more information.) C.3. is a prerequisite skill for WALKING DOWN SLOPES. (See section C on page 107 for more information.)

143

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CHAPTER FOUR

TEACHING THE SKILLS

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--[ TEACHING THE SKILLS ]

-

r-­ TEACHING SECTION A

Maintaining a Sitting Position

r-­

­-

-r-

trated on acquiring movement patterns rather than inhibiting existing move­ ment.

Sometimes in the past, we have as­ sumed that by simply stopping inappro­ priate movements, our students with disabilities would acquire the appropri­ ate moves needed for independent movement. These assumptions came from watching the progression of the neurological development of non-dis­ abled infants. As primitive reflexes "stopped", voluntary movements took over.

We simply placed the student in the desired position and kept correcting movement patterns until the student learned the appropriate movement. In education, we refer to this as shaping. Sometimes we did not have enough hands or we were not strong enough to help the student practice the skills for extended periods. When this happened, we developed equipment to help sup­ port the student and take some of the physical strain off of ourselves. We did not use the equipment as a substitute for teaching or learning.

Most of us are aware of the automatic motor reactions found in newborn in­ fants. These are referred to as reflexes and, although some reflexes stay un­ changed for the entirety of our lives, others, called primitive reflexes, are INTEGRATED into our voluntary move­ ments as the cortex of the brain ma­ tures.

It is especially difficult for us to change

our thought processes with respect to maintaining a sitting position. We tend to think of the process as a non-move­ ment activity. In actuality, all physical activities, including sitting, require muscle activation.

In an infant without disabilities, the reflexes are not "stopped", "inhibited", or "broken up" but are used as a foun­ dation for voluntary movements. Children with motor delays often exhibit these primitive reflexes far longer than infants without disabilities. When we began the MOVE Program, we concen­

Historically, we have paid a great deal more attention to stopping inappropriate movement while sitting than teaching

146

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appropriate movement. This is evidenced by the number of "chair-shaped" people we have produced. Our intentions were good. We wanted to make sure that inappropriate movement, which often resulted in dislocated hips and scoliosis, did not occur. Unfortunately, we have not always balanced restriction with the acquisi­ tion of appropriate movement. Even though it is important that our students do not practice movements that cause deformities, it is equally crucial that we systematically teach them the move­ ments that lead to health and inde­ pendence. In the MOVE Program, we found we

need a minimum of four seating op­

tions: a conventional classroom chair of

the appropriate size, a chair to be used

for functional activities in the classroom

which offers varying degrees of support,

support for toileting, and seating for

transportation.

1. CLASSROOM CHAIR OF APPRO­ PRIATE SIZE: We need to empha­ size the acquisitional phase of sitting which involves MOVING into the appropriate position and main­

taining the muscle balance that is

required to sustain that position.

To begin teaching independent sitting, a chair of the appropriate size must be obtained. The chair should meet the following criteria:

is to either get a chair with ad­ justable legs or, if the chair is too tall, cut the legs off to the correct height. A much less satisfactory solution is to put something SOLID un­ der the student's feet. This solution usually proves to be inconven­ ient because the foot rest must be moved with the chair and the student is unable to walk to the chair to be seated. Chairs that are too short allow the student's legs to twist around and do not pro­ vide a solid foundation for sit­ ting.

b. The length of the seat (front to back) should extend from the student's hips to within a few inches of the back of the knees. Seats that are too long will cause the student to recline rather than sit up straight. Seats that are too short will not stabilize the thighs to keep the legs in place. c. The back rest of the chair should be straight up and down (not lean­ ing back) and should be tall enough to at least reach the student's shoulder blades. Often, it is difficult to find class­

a. The student's feet should firmly touch the floor. The best solution

147

that students use their skills func­ tionally after the acquisition and proficiency phases are addressed.

room chairs that do not lean back slightly. If this is the case, you may have to add firm padding to the back of the chair.

Because it takes a tremendous amount of staff time to constantly readjust chairs, we suggest that chairs be purchased or constructed with the expectation of improve­ ment. Prompts should be easily removed or lessened as the student gains skills. (For chair suggestions, see: EQUIPMENT, page 258.)

We begin addressing independent sit­ ting by placing the student on a con­ ventional classroom chair without ties or supports for short periods of time. The instructor stays with the student and constantly corrects movements so the student can maintain a sitting position. We usually spend three to five minutes per session and have as many sessions as time allows. Some of these sessions are ad­ dressed during aerobics session or while waiting for buses or for lunch to be delivered. Although every school situation is different, there are always times when we must wait for something.

3. SUPPORT WHILE TOILETING: Before we began the MOVE Pro­ gram, we were spending a great deal of time and energy keeping data on each student's toileting cycle. We were then trying to place the student on the toilet at the apprOximate time that the student urinated or defecated the previous day.

The time schedules were a night­ mare. Often we would miss the target time to put the student on the toilet or, worse, forget to take the student off at the appOinted time. This resulted in our giving up and just changing diapers rather than attempting to toilet every student.

2. CHAIR WITH PROMPTS THAT CAN BE EASILY REDUCED AS THE STUDENT GAINS SKILLS: When the students are performing functions such as eating, toileting, or working at a table, we need to use a different prompting system than when students are gaining acquisitional skills. Obviously a student cannot struggle to main­ tain sitting while learning to self­ feed.

When we elected to focus on the acquisition of motor skills, we de­ cided to teach sitting rather than toilet training. We placed students on the toilet when they arrived at school and repeated toileting every three hours.

But all too often we establish one seating arrangement and do not reduce the prompts as the student gains skills. It is very important 148

experiences to permit the acquisi­ tion of skills.

Amazingly enough, voiding in the toilet dramatically improved simply by enabling our students to main­ tain a comfortable functional sitting position and having consistent opportunity to use the toilet. (See next section: MOVEMENT WHILE SITTING for explanation of func­ tional sitting position.)

Also, when we try to make one seating system work for all situ­ ations, we use such complicated mechanisms that an untrained person might be unable to quickly remove the student from the chair in the event of an accident. Some­ times in our efforts to keep stu­ dents safe. we do just the opposite. In the MOVE Program, we usually modify wheelchairs to serve the needs of transportation and not the classroom.

4. SEATING ARRANGEMENT FOR TRANSPORTATION: Often, the most supportive seating arrange­ ment is used while the student is being transported in a car or bus. This is true for everyone regardless of the disability. Even though most of us can sit independently, we wear seat belts and have supports behind our heads in case of an accident, but sometimes we use one set of logical conclusions for ourselves and another for our stu­ dents.

For the most part, our wheelchairs are used only for transportation and are parked all day while the student is at school. We have sev­ eral "transfer" wheelchairs that we use when a student has to move quickly or farther than the student can be walked. These transfer chairs were donated to the school by people who no longer needed them. We stripped off all supportive devices including foot rests.

For ourselves, we do not carry over sitting restraints from the car to our work or leisure activities. We do for our students. Whatever re­ straints are needed for transporta­ tion are then used in all settings whether the student needs them or not.

The students practice helping to seat themselves and use only a seat belt while being moved from one place to another. If the student cannot maintain an erect trunk position, the adult in attendance holds one of the student's shoul­ ders while pushing the wheelchair.

This has evolved because we have tried to make one seating system work for all situations due to the expense involved in proViding seat­ ing systems. We therefore need less expensive seating options for the classrooms and home so the stu­ dent can be provided a variety of

Before we adopted this system, we transported students in their own supportive chairs. It took time and

149

®

energy to strap in the students. We found ourselves leaving the stu­ dents with the fewest skills in the chairs until we could "get to them". Because they were safe and didn't demand our attention, we usually didn't "get to them" for a long time. These were the very students who needed the most help and ended up getting the least.

concept that primitive reflexes are often habitual patterns that change

when new, more functional move­

ments are learned. Rather than stopping the movement of the stu­ dent, we ask the student to move to a position where habitual reflexive patterns do not interfere with the functional activity. It is important that we understand

Using non-supportive transfer chairs made us address these stu­ dents first. As is true for most of our program, changing the habitual patterns of the staff is just as im­ portant and difficult as helping the student change habits.

this concept as we begin to address maintaining a static sitting posi­ tion. In reality, we are asking the student to "move" opposing pairs of muscles in a coordinated manner so that sitting can be maintained. This is an active skill not a passive one. Independent sitting is not achieved simply by relaxing.

The MOVE Program is based on the

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A. 7. Can tolerate being placed in a sitting position with a minimum of 90 degrees flexion of the hips and knees. These are 90 degree angles:

seek medical help before going any further. Students who have not been weight bearing may have brittle bones which could break with very little stress so you never want to force any kind of movement.

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Can tolerate sitting in an up­ right position for a minimum of 30 minutes with prompts at the trunk, hips, and feet, as needed.

If your student cannot comfortably

bend the hips and knees to 90 degrees, something is wrong and you need to

If your student cannot tolerate sitting in an upright position for 30 minutes, you need to determine the reason. Of course, if the student is in pain or looks

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to be in any danger (difficulty breathing or turns pale), you will need to seek medical advice.

the extensor thrust, the student will usually relax and, if the hips go back to the deSired position, the rest of the body will follow suit.

The student should be able to tolerate both leisure sitting and functional sitting for a minimum of 30 minutes. (See next section: MOVEMENT WHILE SITfING for explanation of leisure and functional sitting positions.) Leisure sitting is often reqUired for transporta­ tion and leisure purposes, and, of course, functional sitting is required for most classroom activities.

Look at the hip control prompts in the section titled PHYSICAL PROMPTS-SITTING for a menu of possibilities. Remember to use only what is necessary and then work to reduce the number of straps and pads you are using. This skill reqUires tolerance and duration so you want to keep the student aligned as much as pos­ sible. The last thing you want to do is have the student "practice" sit­ ting with the spine curving to one side, sitting with the hips in a windblown position, or sitting on the tailbone instead of the hips.

Some of the common reasons for lack of tolerance are: 1. The student is accustomed to peri­

odically extending the hips and knees. This is com­ monly referred to as extensor thrust and usually involves "straightening" the entire body including the arms and legs and pushing the head back at the same time.

2. Students who have the opposite problem (low muscle tone) might become uncomfortable while sitting because they sag or droop.

Once again, we usually begin by having these students practice func­ tional sitting with a front leaning chair. We use forearm prompts to help the student maintain alignment and for comfort. When the student has the forearms placed solidly on a support, head control is possible and the student strengthens the muscles needed for future independent sitting.

When we have students who have practiced extensor thrust for a long time, we begin our teaching with func­ tional sitting because the hip flexion often helps inhibit the extensor pattem. Keeping the hips in place is the key to success because, after

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student with low muscle tone in alignment than one with high mus­ cle tone. Remember, however, that you want the students to gain strength and control. Simply tying them in place will not accomplish your goal. Only use as many prompts as you need and then work on reducing those prompts. 3. Occasionally. you may have a stu­ dent who simply does not like to be placed in any new position. Pa­ tience and pleasant experiences while sitting will eventually solve these problems. Start with short sessions (whatever the student can tolerate) and then expand the time.

When the student can tolerate sitting in a supported functional position for 10 minutes, use the skill for toileting. When the student can tolerate sitting in a supported functional position for 30 minutes, use the skill for lunch and other classroom activities. Even though transportation usually reqUires more restraints than classroom sitting, prompts should be reduced as much as possible (while still ensuring student safety) because transportation time gives the stu­ dent a chance to practice skills in the generalization stage.

A.5.

Can maintain an erect head position for a minimum of 30 sec­

onds while sitting with prompts at the trunk, hips, and feet as needed. When students cannot maintain an erect head position, we place them in a supported sitting position but without head rests. We sit behind the student and use our hands as a loose "cervical collar". We help the student balance the head in an erect position. As the stu­ dent begins to lose control, either letting the head lag or pushing backward (ex­ tensor thrust), we gently push the head back into position and remind the stu­ dent to hold your head up. This works best when the student has a reason to hold the head up such as an activity or entertainment. Often, our students learn this skill while learning to bear weight and take reciprocal steps. As the student gains skills, we reduce the prompts by giving fewer and fewer physical cues. We have used the parameter of 30 seconds even though our students who lack head control generally will not demonstrate this skill conSistently.

Food is often a strong motivator but we caution against using food inappropri­

ately. We, like many people, went

through the candy phase where we produced students who would not do anything without a food reward. Today food is used as a motivator only during meal times. When the student has gained enough strength and control to hold the head in an erect position for a few seconds. it is

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time to use this skill functionally while the student is eating. Even if the stu­ dent allows the head to drop between bites, it is still practical for one person to help the student eat lunch and is a pleasant way to practice skills. If you are using manual jaw and lip control proce­ dures, you may have to wait until these techniques are no longer needed before asking the student to maintain head control while eating.

We sit behind the student and use our hands to continually reposition the student (including straightening the spine) in an erect sitting position (spine perpendicular to the floor, not leaning back). As the student gets out of posi­ tion, we gently push the student back, saying something like sit up straight. We do not hold the student in position and, therefore, are constantly moving our hands. The purpose of this exercise is to help the student understand what is expected and give the student a chance to strengthen the muscles need­ ed for independent sitting. Students who constantly pull to one side are at risk for developing scoliosis. Restriction of movement may prevent the rotation of hips or the curvature of the spine from getting worse. We have not found that it improves the Situation unless the student learns to move in a different way.

Students just learning to maintain an erect head position often benefit from the use of forearm prompts. Depending upon the student, we often use one or both forearm prompts at lunch or while drink­ ing. If manageable, we use one forearm prompt to help keep the student in align­ ment and have the student help hold the The session should end when the stu­ spoon or cup with the other arm. dent tires or time runs out. We usually have several short sessions (three to five minutes) per school day. This skill can be used functionally as soon as the A.4. Can maintain sitting balance on a conventional classroom chair for student learns to sit for 30 seconds. We use the skill to transfer from chair a minimum. of 30 seconds without to chair (or toilet). Although we always prompts. maintain a grasp on the student with one hand, when the student is able to We usually place the student on a con­ sit for a few seconds, we are free to ventional classroom chair of the right reach for straps or supportive equip­ size (feet on the floor, hips snugly ment with the other hand, which re­ against the backrest). We do not use duces the amount of personnel needed straps or pads for positioning. to help an individual student.

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A.3.

make some absolute rules about the use of bean bags or you may have to simply get rid of them and use something else.

Can sit on a conventional classroom chair for a minimum of 30 minutes without prompts. As stated in the TESTING INFORMA­ TION (Chapter 3), students usually gain sitting skills rapidly once they have learned to "freeze in space" on a chair for 30 seconds. Independent leisure sitting usually develops before inde­ pendent functional sitting because the student has more prompts or support when balancing against the back of a chair. A small percentage of students, however, learn to maintain sitting bal­ ance by leaning slightly forward and propping on their hands. We have stu­ dents practice both positions whenever possible because they need a variety of skills as they use their sitting in func­ tional ways. Have the students practice sitting skills in a protected environment in as many situations as possible. For example, place a classroom chair on a mat and put bean bags or similar pads around the student while sitting. When sitting at a table, put bean bags or similar padding around the chair. Or you can use a safety strap if an adult is not continually with the student. NOTE: Bean bags are excellentfor pad­ ding the environment but people have a

tendency to place children in the bean bags 'Just for a minute". It is easy to do and, of course, the children who are the most d!tJkult to seat are the first to be placed in the bags. You may have to

A.2. Can sit on the edge of a bed or on a stool without using a foot rest or a back rest for a minimum of five minutes. Begin teaching this skill by using a conventional classroom chair with the back removed for a stool. This provides the student with the stability of having the feet resting on the floor while learn­ ing to sit without back support. When the student achieves this, we have them practice on a higher seat (still solid) but with the feet dangling. Finally, we ad­ Gress sitting on a padded surface such as a bed because it is much harder to maintain sitting balance when the seat is soft. Once again, have the student practice in a protected environment until the student can safely use the skill without supervision.

A. 1.

Can sit on a flat surface, such as a bed or the bathtub, for a mini­ mum of 30 minutes without prompts.

This is by far the most difficult of the static sitting skills. Those who have high muscle tone may never be able to sit comfortably on a flat surface for 30 minutes.

154

Begin teaching this skill by having the student sit in the position that is most comfortable. Next, modify the position until it meets the functional needs de­ scribed in the selected activity. Long sitting or sitting cross- legged are two common ways to sit on a flat surface. For years, "W" sitting was discouraged because of the strain on the knees and

LONG SITTING

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the inward rotation of the hips. Some authorities are now suggesting that "W" sitting does not do as much harm as once believed. It certainly provides the most stable balance for hand use with some students. The amount of time the student spends in any position seems to be the important factor.

SITTING

CROSS-LEGGED SITTING

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TEACHING SECTION B Movement While Sitting

1. We enjoy leisure sitting ourselves and we want our students to be comfortable.

There are two sitting postures common to most people which we refer to as LEISURE SIITING and FUNCTIONAL SIITING.

2. A reclined sitting position takes pressure off of the spine and hips of people at risk for scoliosis. 3. We can see our students' faces and therefore establish eye contact while we talk to them.

LEISURE SIITING

4. Most wheelchairs and seating sys­ tems are made with the support at the back only.

FUNCTIONAL SIITING

A LEISURE SIITING posture is used when resting or at leisure. The person leans against the back support of the chair with the arms at rest. A FUNCTIONAL SIITING posture is used to perform an activity such as eating, writing, or toileting. The person leans slightly forward from the hips and does not use the backrest for support. In the past, we have placed students who do not have the ability to sit inde­ pendently almost exclusively in leisure sitting positions. Often, we even recline the back of the seat to make sure they are leaning back. There are several reasons for this:

People use leisure sitting almost exclu­ sively for receiving information (watch­ ing teleVision or listening to a speaker). When we give information by speaking or performing a function such as eating or writing, we almost always lean for­ ward. There are three major mechanical rea­ sons for developing functional sitting skills: First, it is much easier to lift the head from a chin on chest position than when the head is tilted back. For stu­ dents who are just beginning to estab­ lish head control, the functional sitting position offers a chance to practice head

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them in bean bags. Unfortunately, this is a common practice. From experience, we know that it is easier to maintain a sitting position on a solid seat than on a shifting or sling seat, just as it is easier to walk on a solid surface than on a padded one.

A second reason for practicing func­ tional sitting is for arm and hand use. When in a back leaning or leisure sit­ ting position, it is extremely difficult to use the arms. It takes a lot of strength to pull against gravity. It is next to impossible to feed oneself or do table work while leaning back. When we lean slightly forward, the shoulders and arms are free for use. The third major reason for developing functional sitting skills is to facilitate speech. When we lean forward it is easier to contract the diaphragm and push air through the vocal cords. If you start coughing while leaning back, you quickly become aware of how the dia­ phragm works. The body reflexively pulls forward to allow the contraction of the diaphragm so that coughing can occur. Coughing is a common need in children with chronic congestion.

Only a strong, physically able person can get up from a bean bag and, even then, it is difficult. It is almost impos­ sible to assume an erect sitting position even for a person without disabilities. Invariably the student is placed in a semi-reclining position and therefore sacral sitting with a rounded spine is encouraged. Head control cannot be practiced. The arms are not in a posi­ tion for easy use. If our goals are to improve motor skills, we need to discon­ tinue the practice of placing students in bean bags.

clear their lungs, develop language skills, or use their arms and hands while sitting, then we need to teach them to maintain a functional sitting position. If our goal is to have them listen to a lecture or watch a program, we need to help them assume a leisure sitting position. The ideal situation would be one where the student could go quickly and easily from one position to the other without changing seats.

Before sitting positions can be ad­ dressed, you must determine the func­ tions the child will perform. Then, ana­ lyze normal body alignment. A very common example of abnormal body alignment concerns toileting needs. Most children who lack independent sitting balance are placed on a toilet in a leisure sitting or even reclining posi­ tion. This is not the normal pOSition for urination or defecation. And it is not conducive to learning to use public rest rooms where back rests are not avail­ able.

. We have found that the most incapaci­ tating thing we can do to children with severe physical disabilities is place

NOTE OF INTEREST: It is commonfor students who have severe disabilities to vomit, spit up, or cough up a great deal

If our goals are to help our students

157

t:: offluid and phlegm. This is often the result of a vicious cycle that begins with lack of head control and an uncoordi­ nated swaUow pattern. To facilitate feeding, the adult often tilts the child's head back so that gravity pulls the food to the back of the mouth. Usually the swallow reflex in the throat then takes over. The food then moves to the stomach. (This is often a carry over from bottle feeding.) Sometimes, how­ ever, the student is taking a breath when the food slides to the opening of the throat. This pulls the food into the lungs.

were breaking the vicious cycle that had plagued us for so long. He suggested we begin with short sessions every day and extend the sessions as the lungs began to clear. We found this approach to be successful. For these reasons, the MOVE Program addresses leisure and functional sitting skills. Please note that in the MOVE Program some movement while sitting is taught before independent static sitting is achieved. Also, keep in mind that skills acquired while learning to bear weight and take reciprocal steps help students achieve movement while sitting.

We, the adults, think we are helping by reclining the child even further, puree­ ing the food, adding liqUids, and serving Generally speaking, we teach movement it at room temperature. This, of course, while sitting from the top of the body down. In other words, we work on head reduces the stimulation and the food is movements, then trunk movements, more likely to "sneak up" on the and finally hips and legs. We begin by esophagus and therefore be inhaled. limiting the student's parameters so The food in the lungs often causes that success is probable. Then we ex­ infections which can cause scar tissue pand the parameters as strength and Which, of course, causes mucous, skill are acquired until the student has coughing, and food inhalation. mastered the reqUirements for move­ When we first started putting our stu­ ment while sitting. dents in front leaning chairs, we were appalled at the amount of mucous they In summary, functional and leisure sitting positions are important. Prior to were coughing up. We called in a respi­ ratory therapist and asked him what we MOVE, we put most of our energies into developing maintenance systems for were doing wrong. When he stopped leisure sitting alone. We practically laughing, he explained that we weren't ignored the need for functional sitting doing anything wrong. Probably for the positions. For various reasons, we first time, we were doing something placed many students in reclined posi­ right. tions which did not allow them to prac­ The students were in a position where tice skills needed for any kind of inde­ they could cough and, by doing this, we pendent sitting and did not allow them

158

to use their hands or bodies effectively. We cannot help but wonder whether this has had an influence on our stu­ dent's ability to form communication systems. As stated before, almost all

our students have more receptive than expressive language skills. That may be due to poor positioning for speech production as well as a lack of motor skills.

B.11.

functional use of the head and arms, rather than restraining movements.

Can tolerate movement of head and limbs while in a fully sup­ ported sitting position.

The two most common reasons that a student cannot tolerate the movement of the head and limbs are:

B.10.

Can raise head to an erect position from a chin on chest posi­ tion while sitting with upper trunk support.

1. The student has tight muscles or

deformities that prevent movement. 2. The student is a slave to primitive or abnormal reflex patterns.

A general rule to follow is use gentle, consistent pressure to help a student move. Stop the pressure when the joint resists movement. Patiently wait for compliance. NEVER force or jerk a student. People who have not been weight bearing or using their muscles often have brittle bones that can easily break. If the student's joints cannot be moved easily or if the student exhibits any kind of pain or discomfort, seek medical advice. If the student is simply reacting to habitual reflexive patterns, then the habit needs to be changed. Remember, you are asking the student to MOVE INTO a position that will allow

You can start teaching this skill by placing the student in a functional sitting posi­ tion. At rest, the head falls forward, which is a safe position. Any activity or noise encourages the stu­ dent to lift the head to see and hear what is taking place. Therefore, the stu­ dent increases strength in the neck. If the student is too weak to raise the head from a chin on chest position, for supported sitting when direct supervision is not possible, pad the trunk support of the front leaning

159

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chair so that the chin barely drops. The student then only has to move the head an inch or so to see what is going on. As the student becomes stronger, we thin the padding until the student is picking the head up from the chest. For the acquisition phase, we use forearm prompts and actively encourage head movements. A student without head control and placed in a leisure sitting position usually has to have a headrest (support at the back of the head) to insure safe­ ty. Should the student vomit with the head back, the student could aspirate. Once there is a back support, the stu­ dent usually allows the head to rest against it. Because the student lacks strength, the head lolls to one side. This encourages the adults in charge to add side supports to the head rest. Then the student often fights the side supports so the adult adds a neck collar or similar device. The student then is unable to move. Obviously, this does not increase mus­ cle strength or skill. Therefore, we have students practice head control in front leaning chairs as often as possible. Of course, leisure sitting is necessary for transportation. But we do not fool ourselves into thinking we are teaching the students anything while they are immobilized. The answer is to increase head and upper trunk control as quick­ ly as possible.

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B.9. Can bring head to an erect, midline position when the head is turned to the left or to the right while sitting with upper trunk sup­ port. If the student gets "stuck" and cannot bring the head to midline after the head turns to the side, the problem is proba­ bly habitual reflexive pat­ terns. Usually these stu­ dents are demonstrating asymmetrical tonic neck reflex (ATNR). This is com­ mon with students who have severe motor disabili­ ties, a condition often referred to as the "fencing position". Flexing the extended arm and bringing it to the center of the body usually frees the head move­ ments. Remember, when moving the limbs do not use force. Move slowly and steadily, and stop when joints resist movement. When you have students who demon­ strate these reflexes, you may want to start them in a front leaning chair with forearm prompts. This keeps the arms in alignment while the student has the option of moving the head. If the stu­ dent exhibits pain or discomfort, seek medical advice. If you are not familiar with primitive and abnormal reflexes, consult a physical therapist.

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B.8. Can raise head to an erect

B. 7. Can realign trunk to an erect

position when the head is tilted back while sitting with upper trunk sup­ port.

position after leaning forward, to the left, and to the right a minimum of 20 degrees.

This is not the most common head move­ ment of people without disabilities be­ cause people do not generally sit with the head tilted back. To protect the disabled child's welfare, it is important that stu­ dents demonstrate the strength and abil­ ity to right the head from a tilted back position. A student too weak to bring the head forward could vomit and choke to death if left unattended. Therefore, NEVER leave a student when the head is tilted back. When you teach this skill, work in short sessions. Don't allow the student to remain with the head back more than a second or two. Use your finger tips to help draw the head forward until the student has enough strength to accomplish the skill unaided. Once again, you want the student to have parameters that make the skill possible without substituting the skill. Often, we see children with so much support that they couldn't move if they wanted to. This will not increase skills. It is a substitute for the skills the stu­ dent lacks. Without practice sessions to increase muscle strength and skill level, the student will become weaker and lose what skills have been acquired. Substitution for head control is neces­ sary when a student is unattended, but practice should be incorporated into as many activities as possible.

You can start teach­ ing this skill by using forearm prompts without trunk control prompts. A student with low muscle tone will usually lean forward without prompting. We then use pressure on the shoulders to help the student come back to a leisure sitting position. As the student begins taking over some of the movement, we use less and less pressure until the student can change from a leisure to a functional pOSition, then back to leisure without help. A student with high muscle tone might try to extend the hips rather than lean forward. In this case, we use a pelvic strap or knee blocks to keep the hips in alignment and help the student lean forward to assume a functional sitting position. Usually, when the student leans forward, the high tone is reduced. The student reacts in the same way as the student with low tone. We just keep practic­ ing in short sessions until the student increases skills. When you leave the student without direct supervision during this phase of

161

B.5. Can keep trunk in alignment

learning, You can place a strap on the trunk to keep the person from "getting stuck" in a forward leaning position. As the person gains independent skills, we place the strap lower and lower on the trunk.

when legs are pivoted a minimum of 90 degrees to the left or right while sitting.

Mter the individual has gained the ability to lean forward and come back to an upright position, remove the forearm prompts. Have the person practice leaning to one side, then come back to sitting. We have found that once people learn to control leaning forward, they rapidly learn to control the side to side movements as well. Often it is just a matter of practice in a safe environ­ ment.

B.6. Can realign trunk to an erect position after leaning forward, to the left, and to the right a minimum of 45 degrees.

Once the student has mastered trunk control while sitting, the stu­ dent should be able to maintain sitting balance when the legs are rotated by anoth­ er person. This . . skill usually takes only a few prac­ tice sessions. The instructor simply rotates the legs slowly in one direction or the other giving the student enough time to adjust the trunk to maintain sitting balance. As the student becomes more proficient, the instructor can speed up the movements.

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This is the phase we refer to as "creative B.4. Can push self to a sitting posi­

tion from a reclining position on a chair sitting". Once students have mas­ flat surface such as a bed or the floor.

tered moving within a 20 degree pa­ rameter' they usually start experiment­ ing. This is when you really need those Students who have tight muscles in the discarded bean bags. Students often get hips and knees may not be able to sit very brave and begin sticking their feet on a flat surface in the air, scooting to the very edge of comfortably. Be­ the seat, or leaning wa-a-a-a-a-y over. ing able to push Experience becomes the teacher at this to a sitting from a pOint. Needless to say, a protected lying down posi­ environment is a necessity until the tion can be ac­ student learns the parameters of grav­ complished in ity. several ways. It does not necessar­

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ily require straight leg sitting. For ex­ ample, getting out of bed can be accom­ plished by swinging the student's legs over the edge of the bed and then ask­ ing the student to sit up.

Start teaching this skill by rotating the student's arms to one side, then gen­ tly nudging the leg closest to the in­ structor until the student moves. As the skill is devel­ oped, less and less physical prompting is used on the legs until the student can move the legs independently. This saves the back of the person who is helping the student get out of cars or off benches.

Depending upon trunk strength and arm use, begin teaching students to push to sitting by haVing them turn partially to one side and then push up. Once a student has learned to come back to an upright sitting position after leaning forward, to the left, or to the right a minimum of 45 degrees, it is usually a simple matter to push to a sitting from a reclining position. Since most adults do not spend time lying on the floor, pushing up to a sit­ ting position with legs straight would have a low priority for skill develop­ ment.

B.2. Can pivot entire body a mini­ mum of 90 degrees while sitting on a conventional classroom chair.

B.3. Can pivot legs a minimum of 90 degrees while sitting when arms are rotated by another person to the left or to the right. Usually learning to turn sideways in a chair when the arms are rotated takes a number of practice sessions. This skill is very important in adulthood if the student is to use conventional transpor­ tation such as cars and buses. In any situation where the seat is fixed and cannot be moved to allow the student to stand up and walk forward, the student has to learn to turn in the seat.

Once the student can move the legs independently in order to pivot in the seat, it is a matter of reducing prompts given on the arms. Start by rotating both arms in the desired direction, then reducing the prompt to simply pulling one arm across the chest. Finally, re­ duce this prompt to a touch on the shoulder or visual and auditory re­ quests only.

B.l.

Can pivot entire body a mini­ mum of 90 degrees while sitting in a bathtub or on a flat surface such as a bed.

163

This skill usually has a low priority because it is used infrequently by adults. Most students who can sit com­ fortably on a flat surface and have learned to pivot on a chair need very little instruction to pivot in a bathtub or on a bed.

If the parents or care-takers see this as

a needed skill, it is simply a matter of giving and reducing physical prompts until the skill is performed independ­ ently.

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TEACHING SECTION C

Standing

In this section we will discuss ways to help students learn to extend their hips and knees to bear weight on their own feet and learn to stand as independently as possible. Before we begin to discuss the ways of teaching bearing weight, we need to understand why weight bearing is im­ portant for physical health as well as skill attainment.

Children gain height because of growth in the long, tubular bones. At the ends of the long bones, there is a growth plate consisting of cartilage cells which are constantly being invaded by bone forming cells called osteoblasts. These cells contain calcium and eventually transform the cartilage into bone, mak­ ing the bones longer and longer.

Gravity plays a large role in the lives of all living things. Not only does it keep us from flying off the surface of the earth but it helps bone and muscle development and proper functioning of internal organs. Gravity can be a friend or enemy. Gravity is friendly when a person is properly aligned against the pull. We have already discussed how a func­ tional sitting position can help gain head and arm control. When placed in a slightly forward-leaning standing posi­ tion, the person has these same bene­ fits as well as increased bone health. Bearing weight is extremely important to bone health and muscle strength. Everyone understands the need for exercise to strengthen muscles. But we

tend to think of bones as inanimate, stony structures that remain constant regardless of use. In truth, bones are made of tissue much like muscles. Just as we can build up muscles, we can also build up bones.

The other kind of bone cell, the osteo­ clast, is the one that constantly re­ shapes existing bones throughout our lives. While the osteoblast puts calcium in the bone, the osteoclasts remove it and put it back in the blood stream. The stress put on the bones will dictate the shape of the new bone tissue. Through this process, a child's bones are replaced an average of once a year. An adult's bones last about seven years. Understanding this process will help us realize how quickly deformities can

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develop. For example, children with cerebral palsy often have an uneven pull from the muscle groups in the hips and legs. The adductors (muscles on the insides of the legs) will pull the legs together constantly while the abductors (muscles on the outsides of the legs) remain stretched. The stress of the constant pull will reshape the hip joint until dislocation is a possibility.

even muscle pull) placed on the bones rather than a genetic predisposition to bone deformity. Knowing how quickly bones can change in children, it is easy to understand how damaging it is to allow children to spend vast amounts of time "resting" on bean bags, reclining chairs, or the floor.

Imagine the change in bones being similar to the change in muscles. If you have ever had a cast on an arm or a leg, you will notice how quickly the muscles shrink and weaken with disuse. Bones, too, are living tissue that can change just as rapidly through lack of exercise or improper stress. If bones and joints are constantly being pulled in one direction, they will form and grow ac­ cording to the stress. It is therefore very important that children be placed in weight bearing positions with the joints aligned properly. We are all too familiar with children who are born with perfectly normal skeletal systems but become grossly and painfully deformed with time. This is almost always due to the stress (un­

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C.6. Can tolerate being placed in a vertical position. H the student becomes pale, has difficulty breathing, or shows other signs of being unable to tolerate a vertical position, seek medical help.

We sometimes have older children enter our program who have not been placed in a vertical position for many years. It is common among these students to have circulation problems at first be­ cause the heart and Circulatory system are not accustomed to pumping blood all the way up a vertical body. 166

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The first symptom that usually appears is a mottled discoloration of the legs. Sometimes the face becomes pale. This is because gravity is pulling the blood supply to the feet and the heart is not strong enough to pump it back up. If we see any of these signs, we ask for medi­ cal clearance for standing activities. We then begin standing activities by placing the student in a vertical posi­ tion for short periods of time. We moni­ tor the activity closely. If we see any signs of circulatory problems, we take the student down. As the circulatory system improves, we are able to extend the periods of time spent in a vertical position.

We do not believe that it is necessary to inflict pain on students and prefer a gentler approach. Contractures have to be corrected surgically. Tight muscles often can be coaxed into relaxing. We use friendly gravity to do the job by placing students in a supported vertical position and letting the legs dangle. As the student begins to relax, gravity pulls the feet down. Eventually, the student gets straight enough to begin bearing weight. Sometimes it takes several months before the muscles have stretched enough to allow weight bear­ ing.

The main points to remember are that there should be no pain and that you should never use force.

C.5. Can tolerate fully prompted extension of hips and knees.

C.4. Can tolerate bearing weight on If a student cannot extend the hips and knees comfortably so that the body is fairly straight, you need to seek medical help. The term "contracture" refers to the permanent shortening of muscles and tendons. Some children come to you with con­ tractures. If you try to force the joint to straighten out, you could rip tendons apart or break brittle bones. Even if you do not damage the muscles, tendons, or bones, the pressure can cause excruci­ ating pain. Any stretching should be monitored by a therapist or other medical personnel.

feet for a minimum of 45 minutes per day when knees, hips, and trunk are held in alignment by a mobile stan­ der or similar standing device. There are four common reasons why a student cannot tolerate bearing weight for 45 minutes. One is that the body cannot easily be straightened; two, the circulatory system needs to be strength­ ened; three, the student has joint or bone deformities that do not allow total weight bearing (completely dislocated hips, brittle bones, etc); and four, the student isn't used to being in an up­ right position.

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We have already discussed the first two reasons. The third problem (bone or joint deformities) requires medical supervision. If you have any reason to question the integrity of the student's skeletal system. seek medical help. The fourth problem is common among our children with physical disabilities. They have been subjected to so much pain. surgery and frightening situations that they are often leery of anything new. When we first get students. it is sometimes difficult to differentiate be­ tween a cry of pain and one of appre­ hension. Parents ALWAYS know, so if you are having trouble deciding whether a stu­ dent is uncomfortable. go to the ex­ perts. If that isn't possible, try diverting the student's attention. If the student can be diverted, then it is most likely the fear of a new situation that is caus­ ing the problem.

C.3. Can maintain hip and knee extension to allow weight bearing for a minimum of 3 minutes while an­ other person keeps the participant's body in alignment. When we first start asking our students to bear their own weight, we either stand behind them and support them under the arms or we stand in front of them and use our knees to block theirs while holding them around the trunk. We use both methods during the day because functional use will re­ quire support from dif­ ferent directions.

At first, the student may not bear any weight at all. We keep encouraging the students while gently and slowly "bobbing" them up and down. Depending upon the size of the student, this exer­ If there are no medical problems, simply cise can be as short as expand standing time a little each day one or two bobs or as long as three until the student grows accustomed to minutes. As the student starts volun­ the new position. The 45 minutes per tarily taking weight on the feet, the time day can be broken up into short ses­ can be expanded. sions. Keep in mind that this is the minimal time and for the best bone. joint, and Circulatory health, the time spent standing should approximate the time that non-disabled peers stand each day.

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C.2.

Can stand in one place with one or both hands held for a mini­ mum of 5 minutes.

C.l.

Using the physical prompts for teaching standing and walking, begin reducing prompts to maintain standing.

Once the student can stand in place with one hand held, begin working on independent standing. When the stu­ dent can stand safely with one or both hands held, further reduce the prompts by lowering the prompts to the hip level. In order to do this safely, try standing behind the student and hold the hips only (the student must main­ tain trunk balance without assistance). When stability is achieved, kneel and hold lower and lower on the legs.

Can stand in one place with­ out support for a minimum of 60 seconds.

In the early stages of learn­ ing to stand, the instructor often stands behind the student and provides sup­ port by holding the stu­ dent under the arms. When the student can maintain extension of the hips and knees, begin reducing the prompts. Instead of holding the student up, simply help the student maintain balance. When the student can demonstrate proficiency at maintaining hip and knee extension for a period of time, further reduce the prompts by standing in front of the student and holding the student's shoulders. As the student gains skills, place your hands on the upper arms, elbows, and forearms. Finally, simply hold the stu­ dent's hands. When the student is comfortable with this, drop one hand and start expanding the time param­ eters until you reach 5 minutes.

It is extremely im

portant to practice this in a protected environment espe­ cially with large students. Sur­ round the student CUSHIONS with bean bags or OR BEAN BAGS similar cushions. Keep reducing the prompts (See: PHYSICAL PROMPTS­ STANDING AND WALKING) until the student stands independently. It should be noted that safe, independ­

ent standing will not be achieved until the student can walk forward and step back without prompts.

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TEACHING SECTION D

Transition from Sitting to Standing

Joints are made of bone and cartilage. Like all bones, joints are dependent upon stress and proper use for strength and conformation. There are three types of jOints: 1. Hinge, which moves back and forth like a door. 2. Pivot, which can rotate like a door knob. 3. Ball and socket, which can move in all directions like a joy stick.

the leg contract to straighten the knee out again. While one of the muscles in the set contracts, the other one should relax. The child with cerebral palsy usually begins life with perfectly normal bones and muscles but the messages sent from the damaged portion of the brain cause the muscles to contract inappropriately and involuntarily.

Bones are either tied together with liga­ ments or attached to muscles with ten­ dons. Ligaments and tendons are made The knee is a good example of a hinge of similar fibrous tissue which is fleXible joint because it can only move back and and reacts a little bit like a rubber band. forth. The elbow is a combination of a If a tendon or ligament is torn, the two hinge and pivot joint. You can move it ends snap away from each other and back and forth as well as rotate it. The cannot get back together to heal prop­ hips have a ball and socket that allows erly. Once torn, they have to be surgi­ the greatest movement but also requires cally repaired. Children with high mus­ the most muscular control. It is no cle tone sometimes develop contractures great wonder that many children with (permanent shortening of the muscles motor delays have the greatest prob­ and tendons) due to constant messages lems controlling their hips. Of course, from the brain telling certain muscles to the hips are often the first joints to contract. Joint mobility is lost when the develop deformities. tendons and ligaments are "remodeled" in a shortened pOSition. Surgery is usu­ Muscles come in matched sets and a ally required to lengthen them again. muscle can only contract. The contrac­ tion of a muscle causes the joint to When a person chooses to change posi­ move. In the knee, for example, muscles tion, the brain sends signals which in the back of the leg contract to make activate certain muscles. This, in turn, the knee bend. Muscles in the front of makes the joints move. For example, the

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simple act of standing up from a chair requires a whole series of coordi­ nated muscle move­ ments. The person leans forward from the hips so that weight can be taken on the feet. The feet are separated to provide a standing base that is approximately the same width as the shoulders. As the person rocks forward, the but­ tocks comes up off of the chair. The entire body weight is then balanced over the feet. During this stage, the shoul­ ders are as far in front of the person as the buttocks are behind the person. To maintain balance, this ratio must continue during the entire transition from sitting to standing. If the move­ ment is not coordinated, the person will lose balance and fall.

Because we are taller than most of our students, we often get into the habit of using the "water ski" technique to help students come to standing. In other words, the student simply stiffens the knees, leans back, and waits for the instructor to pull him or her up, much like getting up on water skis. Even though this movement pattern can be changed as the student becomes more independent, it is much easier to teach it correctly first. In this section we will be discussing transition from sitting to standing, which can be de­ fined as getting up from a seated posi­ tion.

It is important to get in the habit of

helping students practice the balance that will be needed when independence is addressed.

D.6.

Can extend hips and knees and bear own weight when the trunk is lifted from a sitting position on a chair.

To start teaching this skill, we stand in front of the student and block one of the student's knees with your own

knees. Depending upon the size and the weight of the student, either grasp the student around the trunk or under the arms and slowly help the student come to standing. Verbal instructions such as stand up or push with your legs should always accom­ pany movement.

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Once in a standing position. ask the stu­ dent to maintain standing for a few seconds before allow­ ing the student to return to the chair. As the student gains strength and starts extending the hips and knees voluntarily. we give less and less support.

lifted using leg strength rather than back strength. Once the trunk has been lifted from the floor. expect the student to straighten the legs and bear weight. Once again, the size of the student makes a big difference. If the student is not un­ bearably heavy. we hold the student up for a few seconds in the hope that grav­ ity will help the student remember where the legs belong.

If can physically manage it. we start using this skill to transfer from chair to chair even before the student starts voluntarily extending the hips and knees. Remember that a student cannot learn to stand if the feet never touch the floor. So often. we get in the habit of simply lifting the student instead of expecting the student to help.

D.5.

Can extend hips and knees and bear own weight when trunk is lifted from a sitting position in a bathtub or on the floor.

If the student is large, use two people to help the student come to standing: one person lifts the trunk while the other person helps the student straight­ en the legs and take weight on the feet. As the student gains skills. the time between the lifting of the trunk and bearing weight should decrease until leg extension is achieved instantaneously.

D.4. Can stand up from a conven­ When you first start teaching this skill. tional classroom chair with one or concentrate on having the student both hands held. straighten the legs and take weight on the feet once you have done the lifting. -Mter a student has learned to maintain Begin by standing behind the student hip and knee extension to stand, it is (after helping the student to a sitting time to learn to push with the legs to position) and then wrap your arms come to standing. Many students want around the student's chest. The in­ to extend the knees and use the "water structor should have knees spread and ski" technique of coming to standing bent so that the student's weight can be which means you are doing all of the 172

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grasp from the trunk to the upper arms, the elbows, the forearms, and finally to the hands. If possible, ask the student to come to standing using only one hand (the preferred hand of the stu­ dent).

work. (See introduction to this section.) Instead, the student should lean for­ ward (functional sitting posture) and take weight on the feet as the buttocks come off of the chair. Then the student should straighten the knees and hips while raising the trunk to an upright position.

D.3.

Begin teaching this skill by standing in front of the student with your arms wrapped around the trunk. Use your knees to block one of the student's knees. As you rock the student forward, ask the student to stand. Congratulate the student for even partial participa­ tion. As the student gains strength and un­

derstanding, do less and less lifting of the trunk. Eliminate using knee blocks when the stu­ dent can help come to stand­ ing without allowing the knees to twist to one side or the other. The chil­ dren who have trouble keeping their legs aligned are usually the ones who have a wind-blown pelvis or very low muscle tone. As the student takes on more responsi­

bility for pushing to standing, reduce the prompts on the trunk moving your

Can push with legs to raise self from a sitting position in a bath­ tub or from the floor when the trunk is stabilized. Once a student learns to extend the hips and knees to raise the body weight from a chair, it is a matter of gaining strength to use the legs to raise the body from the floor. You may want to begin by having the student come to a sitting position on the floor. Stand behind the student and help flex the hips and knees so the feet are flat on the floor in front of the buttocks. Then rock the student forward onto the feet, help maintain balance while the stu­ dent pushes with the legs to come to a standing position. Reduce the prompts by doing less and less of the lifting until you only help maintain balance and the student does all of the work. When the student is fairly stable with this method, move around so that you are prompting from in front of the stu­ dent.

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Once the student is strong enough to use the legs to push up, have the stu­ dent roll to a prone position, bring the knees up under the body, come to knee standing, lift one foot and then raise the body weight on the extended foot. If possible, the

student should learn to come to standing from a kneeling posi­ tion, but muscle tightness or weakness on one side of the body might delay or prohibit this part of the skill. The main point is that students should be able to help get their body weight from the floor to a standing position without hurting themselves or the peo­ ple who are helping them.

D. 2.

Can stand up from a conven­ tional classroom chair without assis­ tance. You can teach your students to turn side­ ways on a conventional classroom chair, steady themselves on to the back of the chair, and then stand up. We have found that this is the easiest way to reduce prompts because we

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help the student either grasp the back of the chair with one hand or use the forearm if the student does not yet have functional grasp. You can then prompt the other shoulder until the student comes to standing. Prompting can be reduced as the student learns the skilL Eventually, the student can be encour­ aged to place a hand or forearm on the back of the chair without assistance. Students who do not have arm use can lean straight forward from the chair and slowly stand. In this situation, the instructor will have to be careful about the methods used to prompt the stu­ dent. The natural inclination for the instructor is to push the trunk forward and then keep the hand on the back while the student pushes to standing. Often, the student will want to use the instructor's hand as leverage and push against it. Once the instructor's hand is removed, the student has no way to become independent. Instead, the instructor can help the student lean forward and then place one hand on the student's upper chest.

As the student gains balance and be­

gins to come to standing, use the hand to help the student lift the chin and therefore straighten the trunk. In this ~ way, the instructor's hand can be re­ moved and the student will have independence.

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D.I. Can stand up from a sitting position in a bathtub or from the floor with one hand held. This is a difficult skill for many people with disabilities and is often the last skill that students learn. Since the skill is used mainly for getting out of a bath­ tub, it is a skill that can be circum­ vented in a variety of ways if it is too difficult or uncomfortable for the stu­ dent. Most students have difficulty raising one foot while kneeling on the other knee, even when balance is provided by another person. Weak hips, tight muscles, and lack of coordination of motor movements make it difficult to learn the skill. You can begin to teach the skill by standing in front of the kneeling stu­ dent, hold one arm or shoulder, and prompt the lifting of one foot. If the student is large or has much difficulty

allowing the lifting, two people may be required in the early sessions. One person helps the student maintain balance while kneeling. The other per­ son prompts the lifting of the leg. As the student gains skills in moving the knee forward while balancing on the other knee, the prompts are reduced. Eventually, the student should be able to bring one knee forward without help and push to standing while the in­ structor holds both arms. One arm can then be dropped and the instructor can stand beside the student rather than in front. At this point, the student should be able to use the skill functionally while bathing.

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TEACHING SECTION E

Transition from Standing to Sitting

on a narrow ledge barely leans forward, so the hips drop almost vertically.

In the early part of this section, you want the student to allow sitting to occur. For students with normal or low tone, this will be automatic because gravity does the work. The real chal­ lenge will begin when you expect the student to maintain control during the entire transition from standing to sit­ ting. For students with high muscle tone, the challenge will begin when you ask for hip flexion. At first the progress will seem slow but it evens out in the long run. Mter the students with high muscle tone learn to flex the hips, they usually gain controlled sitting quickly. The students with low muscle tone spend more time learning to maintain muscle tone as they lower them­ selves to a seat.

A person who is going to sit in a deep chair leans farther forward. To maintain balance, the hips protrude in the back and a deeper seating position is achieved. Those of us who have had experience taking a seat do not realize that we are making decisions on how far to lean forward before we sit down. Very young children or people with little experience need practice before these considera­ tions will become automatic.

If you observe

people as they prepare to sit, they lean forward and bend the knees slightly to maintain balance. A person who is going to sit

Since students with severe disabilities do not generalize their skills easily, you need to pay attention to helping them lean forward correctly even in the early stages of skill development. Doing so will result in fewer mistakes once inde­ pendence becomes a reality. In this section we will discuss transition from standing to sitting which can be defined as moving from a standing position to a seated position.

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E.6.

Can flex hips and knees when another person supports the trunk and lowers the participant to a chair.

TIVELY participating in this skill. Stu­ dents with low or normal muscle tone should easily be able to accomplish this skill.

Usually the only students who will have difficulty with this skill are those who tend to stiffen the whole body while extending the hips and knees. These students not only want to straighten the legs but also arch the back and neck, and stand on the toes. Usually, the position of the head will determine whether a student will re­ main in full extension. If the head bends forward, the body will relax. If the neck arches backward, the rest of the body will go into extension. Unfortu­ nately, trying to force the head forward usually increases the muscle tone be­ cause the student wants to push against the support. Depending upon the size and the weight of the student, you can stand beside the student with one arm around the shoul­ ders and place the other hand on the student's abdomen. You then help the student bend forward at the waist and gUide the hips to the chair. If the stu­ dent is large, you can sometimes use two adults to teach the skill. If this system does not work without having to use force, contact a physical therapist for sug­ gestions for normal­ izing tone while the student is AC­

E.5. Can flex hips and knees when another person supports the trunk and lowers the participant into a bathtub or to the floor. Once again, the students who will find this task difficult are the ones who have high muscle tone. When you first start teaching this skill, you can generally stand be­ hind the student and have the student lean slightly forward from the hips. This usually enables the student to relax enough so that the knees bend. Allow the stu­ dent's hips to slowly lower to the floor using your own bent legs as guides. If the student has very high muscle

tone and you must use force to help the student bend, contact a physical thera­ pist for suggestions for normalizing tone while the student ACTIVELY partici­ pates in this activity. Students with low or normal muscle tone should be able to accomplish this skill easily.

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E.4.

Can use legs to lower self to a chair when both hands are held by another person.

After a student has learned to maintain hip and knee extension to maintain standing, it is time to learn to use the legs to lower the body into a seat. At first, the student will probably want to collapse to get to a sitting position. Begin teaching this skill by having the student stand in front of a conventional classroom chair for varying amounts of time (a few seconds) before beginning to sit. This keeps the student from devel­ oping the habit of collapsing the mo­ ment the chair is reached. You can then have the student lean slightly forward from the hips. Next, gUide the hips to the chair seat.

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knees until the buttocks reach the chair. Reduce the prompts for this skill by offer­ ing support at the trunk if needed, then move your hands to the upper arms, elbows, forearms, and finally to the hands as the student gains strength and control.

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E.3.

Can use legs to lower self into a bathtub or to the floor when the trunk is stabilized by another person.

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Once the student has control in lower­ ing the body weight to a chair, it usu­ ally requires only strength and experi­ ence for the student to learn to lower the body weight to the floor. You can begin teaching this skill by standing behind the student. Help the student lean slightly forward from the hips (no more than 20 degrees) and then prompt their knees to bend. Use your own bent legs as gUides for the stu­ dent's hips. If the student leans forward

more than 20 degrees, the student

tends to lock the knees and eventually collapses.

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It is often harder to train ourselves (the

instructors) than teach our students this skill. We have a tendency to allow the student to lean against us (like a plank), step back, and lower the stu­ dent's trunk to the floor until the hips give way and bend. This is expedient and fairly easy on the instructor but does not lead to independent move­ ment.

Many students want to simply lean back while being supported by the instructor (like a plank), then flex the hips and knees simultaneously. This method will not al­ low the instructor to reduce the prompts as the student becomes stronger. And it will not lead to independence. The stu­ dent should lean slightly forward flexing the hips first and then slowly flex the After the student learns control in low­

178

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ering the body to the floor. stand in front of the stu­ dent holding the student's upper arms. This re­ quires the stu­ dent to control the hips as well as the knees.

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seat and place the calves against the seat to maintain balance, then lower the body weight to the chair. This is a more difficult skill for the student. It is more difficult for the instructor to reduce prompts.

E.I.

Can lower self into a bathtub or floor by holding a stationary ob­ ject or with help from another person to maintain balance.

E.2.

Can lower self to a conven­ tional classroom chair without assistance. You can start teaching this skill by having the student stand to the side of the chair and use the chair back to maintain bal­ ance while lowering themselves into the chair seat. This method allows you to reduce the prompts as the student gains independence. You can begin by helping the student place the arm or hand, hold the arm in place. and gUide the hips to the seat. As the student gains experience, stop gUiding the hips and reduce the amount of help you give to keep the arm in place. Finally, ask the student to place the arm without help.

This skill is used mainly by adults when getting in and out of the bathtub. After the student has learned to lower the body weight to the floor with the upper arms held. move your grasp to the elbows. the forearms. and if possible. the hands. The ideal situation would be for the student to be able to lower the body weight with one hand held be­ cause this is the most convenient way to get in and out of a bathtub.

Most students have some arm use even if they do not have a strong functional grasp. Students who do not have func­ tional arm use can back up to the chair

179

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TEACHING SECTION F Pivoting While Standing

Pivoting while standing is less compli­ cated than many of the other skills. It is essential even in the early stages of skill acquisition because it is needed to transfer from chair to chair. To be suc­ cessful, the student needs to maintain hip and knee extension while rotating the body. The leg closest to the destina­ tion bears the weight of the body and acts as the pivot point.

Students who have difficulty with this skill usually have low muscle tone and weak hips. As the body starts to rotate, the hips and knees get out of alignment and the student collapses. For these reasons, concentrate on helping the student maintain alignment in the early stages of skill acquisition.

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Can maintain hip and knee extension while standing when an­ other person rotates the entire body and helps support the participant. You can start using this skill function­ ally when a student can maintain hip and knee extension even momentarily. If you are helping a large student (who is just learning to bear weight on the feet) transfer from chair to chair, you may want to stand in front of the stu­ dent, hold around the trunk, use a knee block to prompt knee extension and to help maintain foot placement while getting the student to stand. Then help the student pivot by step­ ping back with one foot and rotating the trunk in that direction. The stu­ dent is then in front of the other chair.

Encourage the student to bear as much weight as possible during the entire transfer. As the student gains strength and understanding of what is re­ quired, reduce your support. Some students have a ten­ dency to col­ lapse when the body begins to pivot. The hips get out of alignment and they cannot maintain knee extension. For very large students, begin teaching this skill using two instructors. One uses the method above. The other sim

180

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ply gUides the hips and keeps them in alignment.

place when holding on to a station­ ary object or another person's hand without additional prompts.

F. 2. Can reposition feet to pivot in place while standing when another person rotates the participant's trunk and helps the participant maintain balance. As the student begins to maintain align­

ment, you can eliminate the knee block (See above). Continue to reduce the prompts by holding the upper arms instead of the trunk. Then hold the elbows, the forearms, and finally the hands. By this time, the student is doing most of the work. While the in­ structor is turning the student, the student is able to keep the body in alignment and can keep the feet from getting tangled while turning.

After the student has learned to reposi­ tion the feet while being turned, the student needs to learn to initiate the movement. You can teach this skill by having the student hold onto a rail, counter top, or other stationary object, while you prompt by turning the shoul­ ders. Give less and less prompting until the student is capable of turning at will. You can use a stationary object to teach this skill because it is too tempt­ ing to give the student additional cues when you are using your hands to help them maintain balance. This skill is used most often by adults when getting in and out of a bathtub or when turn­ ing in close quarters such as a bath­ room stall.

As the student gains experience, you

can expect maintenance of hip and knee extension with one leg while you pick up the other foot for placement. You can teach this skill by helping to shift weight to the pivot leg as you tum the student. Some prompting of the non-weight bearing foot may be neces­ sary as the student learns to reposition the feet. At this point, the student should be able to maintain a standing position and keep from tangling the feet regard­ less of where the instructor stands in relation to the student (behind, in front, or beside).

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TEACHING SECTION G Walking Forward

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they would walk in Circles. Eventually, everyone who learned to walk independ­ ently also learned to stand in one place

though not always in the same se­ quence.

had one wish, I would wish that my child could walk, is the most common

statement we hear from parents of children who are non-ambulatory. The ability to walk does indeed change a person's life. Environments expand and learning experiences become self-di­ rected. Money spent on substitution equipment like wheelchairs, lifts, and speCialized transportation can be re­ directed. Medical care costs go down as health improves. Children are able to live at home longer. When out-of-home placement occurs, the cost is less. Meaningful employment opportunities in adulthood increase.

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Walking is a complicated task requiring the coordination of a number of skills. The baSic skills required to walk inde­ pendently are listed below. Some of these skills are found in Section C: STANDING. Others are found in the current section: WALKING FORWARD.

They have been combined and se­ quenced here to show the learning patterns of the majority of students.

Keep in mind that some students Will learn in a different sequence.

The skill acquisition sequence of stu­ dents With disabilities is quite different from the sequence of skills normally acquired by non-disabled infants. Al­ though standing is one component of walking, students do not usually learn to stand in one place Without holding on to anything until they begin their first independent steps.

1. Maintains the extension of hips

and knees to allow weight bearing on feet for a few seconds With support offered either by another

person or a walker.

We have had several students who learned to walk independently many months before they learned to stand still. They would simply walk from a door frame to a counter to a wall. If they couldn't find anything to hold on to,

182

2. Allows legs to be moved in the reciprocal pattern to walk while being supported by another person

or a walker.

3. Voluntarily maintains extension of

one leg while alloWing flexion and forward movement of the other leg

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while supported by another person or a walker. 4. Moves own legs in a reciprocal walking pattern while being sup­ ported by another person or a walker.

10. Stands independently after being helped to gain balance.

5. Helps keep trunk and head erect while walking with some support. (you can usually prompt from behind and offer some support under the arms.)

11. Walks independently. 12. Stops walking and stands by grasping a table, wall, or similar structure.

6. Moves legs and supports own

weight while another person helps maintain balance and shift weight from side to side. (You can usually prompt from behind touching only the shoulders and help the student rock from side to side while taking steps.)

13. Turns while walking independ­ ently. 14. Starts walking away from sta­ tionary object without being prompted.

15. Stops walking and stands without support.

7. Shifts own weight from side to side while walking when both hands are held by another person or when using a walker without trunk support (forearm supports or hand grips only).

This sequence is quite different from the developmental sequence of typical in­ fants. It must be noted here that any sequence that results in independent walking is a good sequence. This has only been included as a general refer­ ence.

8. Walks with one hand held. 9. Walks with intermittent prompts.

G.6.

Can tolerate fully prompted reciprocal leg movements while being supported in a front leaning walker or by another person. We do not believe that pain or force is necessary to gain skills. If the student is unable to tolerate reCiprocal move­

ment of the legs due to pain, something is probably structurally wrong and you need to seek medical help. If it is a matter of high muscle tone, patience and slow movements may be all that is needed. Mter you have determined that the

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G. 5. Can move legs reciprocally for a minimum of 20 feet while being supported by a front leaning walker or by another person.

student is capable of flexing and ex­ tending the hips and knees without pain, you can begin teaching this skill either by placing the student in a front leaning walker or supporting the stu­ dent yourselves. If the student is in a front leaning walker, kneel behind the stu­ dent and help the student shift weight to one leg by pushing the hips slightly to the weight bearing leg. You can then prompt the movement of the non-weight bearing leg either by moving the foot or helping the knee flex and pushing the foot forward. Mter taking a step, help the student shift weight to the leg in the forward position by shifting the hips for the student and then repeat the process with the non-weight bearing leg. When you teach reciprocal movements without using a walker, you stand behind the student and offer support under the arms. Once again, the first consideration is to help the student shift weight to one leg. When the weight is shifted, you can use your foot to nudge the student's foot forward on the non­ weight bearing leg. You can then help the student shift weight to the leg in the forward position and repeat the procedure.

When you are teaching this skill. you want the student to learn the separate roles of each leg while walking. In other words, the weight bearing leg always remains extended while the non-weight bearing leg is moving forward. Shifting weight from one hip to the other allows one leg to take the weight while the other one is moving. Many walkers either support the user at the hips (with a seat which encourages paddling around rather than walking) or the walker requires well-developed arm and hand use (with handles on a three-sided frame). Look for walkers that provide support for TEACHING skills.

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Unfortunately. many people want to simply place students in supportive walkers and leave the student to their own devices rather than teach the skills required. As previously stated. our students had not demonstrated the ability to automatically learn motor skills. We must concentrate on teaching the movements rather than assuming that learning will occur. You can start by giving the students as much support as necessary to keep them aligned in an upright position without encumbering the hips. At this point, two major components must be addressed:

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1. Rhythm and speed control. Gen­ erally, you can teach this by walk­ ing behind the student and prompting each leg for reciprocal movements. Concentrate on estab­ lishing a rhythm at an acceptable speed. If the student moves very slowly. you can speed up the gait. If the student bolts forward or has an uneven gait, work on con­ trolled. even steps.

happily walk all day if we would prompt them.

G. 4. Can move legs reciprocally for a minimum of 10 feet while bearing own weight when another person assists with shifting weight and maintaining balance. In the previous skill. you provide some support for the student. You can start by totally supporting the student either with equipment or by hand while you prompt leg movements. As the student becomes stronger and more experi­ enced, you continually reduce that support until the student is bearing weight and taking reciprocal steps while you help shift weight from one leg to the other and maintain body alignment.

2. Independent movement of legs for taking reciprocal steps. Part of the practice sessions are spent on reducing the prompts needed in order for the student to continue with the rhythm needed for walk­ ing. You can practice rhythmic movements for a few minutes then reduce the amount of prompting to the feet. The gait of the student usually changes when you reduce the prompts. During this part of the session. you are looking for self-movement of each leg. You can keep repeating this sequence until the student demonstrates rhythm and self-initiative while you provide some support (either with a walker or by hand) and help the student shift weight. The length of the sessions and the number of sessions per day usually are limited by time constraints rather than the endurance of the students. Origi­ nally we believed that our children tired quickly. When we looked at the situ­ ation more closely. we found that WE tired quickly. Most students would

Generally speaking, you start teaching this skill by standing behind the stu­ dent and holding the student under the arms. The method of offering support should be determined by the size differ­ ence between the stu­ dent and the instruc­ tor. The most difficult students to prompt are the ones who are much shorter than the in­ structor or the ones who are very large. If the student is short, you may want to lean over the student (your knees slightly bent) and grasp the student un­ der the arms from the

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front of the shoulders. If the student is tall, you may want to slip your arms under the student's arms to offer sup­ port. Several things should be noted when helping students. Be careful not to put strain on your lower back. This usually happens when prompting very small children. If the child is tiny, you may want to wear knee pads and walk on your knees. You will have to make these decisions individually based on your own needs and those of the stu­ dent.

dent needs to be leaning slightly forward over the pelvic structure so that there is some forward momentum. This also al­ lows for the shifting of weight from leg to leg. As your students begin to bear their own weight on one leg while moving the other leg forward, you can often move your hands from under the arms to the outside of the upper arms (you are still standing behind the student). This allows you to help the student maintain balance and shift weight without offer­ ing any support. It also provides a natu­ ral transition for when you move to the front of the student.

It is always tempting to help very small

children start walking by holding their hands up in the air. Some of our stu­ dents have very loose shoulder joints and it is possible to pull a shoulder out of the socket if you are holding the student's entire body weight by the hands alone. If you can manage to prompt the student with the arms down, it is much better for the student because it is a more natural position.

As soon as the student is stable enough

You should be aware of the student's feet in relationship to the trunk when you are prompting walking. You can't always see the feet. You may have to get someone else to help in the obser­ vation. The most common mistake people make is pulling the student's shoul­ ders back so that the student has to walk like a German soldier. The stu­

to keep the hips in alignment, we begin prompting from the upper arms while standing in front of the student, then work down to holding the hands. This prepares the student for using a walker with forearm prompts or, if possible, a

conventional three-sided walker with handles.

G.3. Can walk a minimum of 300 feet with one or both hands held or with a walker. If a student can walk a short distance

with both hands held, that distance can be lengthened with practice. An easy way to assure that this will happen is to park the student's wheelchair a certain distance from the destination of the student. At first, that distance may only be a few feet. As the student gains

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strength and skills, start parking the wheelchair farther away.

they start walking forward, intermit­ tently let go and they continue to take a few steps forward independ­ ently.

As the student improves, we periodi­

cally (throughout the day) drop one hand and have the student walk with one arm held. At first. the student and the instructor find this difficult but the skill improves with practice. Once the student can walk with one hand held, it is easier on the instructor to help the student walk long distances.

G.2. Can walk a minimum of 1.000 feet with one hand held. This skill just requires an increase in distance from the previous skill. Walk­ ing with one hand held usually evolves over a period of time and requires many practice seSSions. When the student (or instructor) is energetic, the student walks with one hand held. When the student or the instructor tires, the prompts are increased again until en­ ergy is restored.

G.1. Can walk forward a minimum of 20 feet without assistance. Independent walking requires a combi­ nation of skills as stated in the intro­ duction to this teaching segment. Once the student starts walking with one hand held, you can often increase the prompts again by walking behind them and gently grasping their shoulders. As

Pay particular notice to the stu­ dent's body align­ ment while practic­ ing this skill. The trunk must lean slightly forward or the student will not maintain forward alignment. Be careful while practicing this skill because inexperienced students can pitch forward quickly. We often begin teaching this skill with a spotter in front of the student just in case the prompter can't grab the student. When your students acqUire enough independent walking skills to begin relaxing while they walk, most of them start experimenting with the skills and automatic learning begins to occur. This is the same phenomenon that occurs when you teach sitting skills. The students go through a stage of "creative chair sitting" once they ac­ quire enough skills to feel confident in experimentation and they go through a "creative walking" stage that keeps finger nails chewed to the nub. This is a difficult stage for both parents and instructors. Inevitably the student will push just a little too far and fall down. This is all part of learning but it

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is difficult for everyone concerned. Unfortunately students often get tied down during this learning period in the name of safety and the skills do not continue to develop. It is important that parents and instructors find time to help the student practice independence. The faster the students gain skills, the safer they will be and future independ­ ence will be assured. With older students, you are often faced with learned helplessness or depen­ dence. You must repeatedly give per­ mission to the student to become inde­ pendent. Remember that the student's whole life has revolved around another person's helping hand or piece of equip­ ment. You not only need to give the student permission but you must also convey to the student that you expect independ­ ence. Often you can "wean" the student away from the helping hand by having the student hold on to one end of a

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cloth while you hold on to the other end. Or you can barely hold on to the back of the student's shirt.

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You can, therefore, vary your prompting methods from seSSion to session. At this point, anything is fair game. We were not above tricking our students into taking those first scary steps. Use your imagination. A favorite trick is to have a dance and get the student involved in twisting to the music. Prompt them from behind and when they aren't paying attention to you, quietly remove your hands. The student already has the rhythm of swinging from side to side so stepping forward often occurs. Then, of course, we shout and applaud (and sometimes cry) and congratulate the student.

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\ TEACHING SECTION H

Transition from Standing to Walking

Although stepping forward while stand­ ing sounds like a simple task, many students need a great deal of practice before they will self-initiate movement, especially when they reach the stage of near-independence. There are probably several reasons for their reluctance.

gained independent sitting. standing. or walking skills. they started demon­ strating these reflexes.

First, some students, especially the older ones, have spent years believing that someone or something had to be attached to them before they could move. Moving without help is not within the scope of their experiences. Second, most of the students have passed the age when falling is natural. They did not have the experience of plopping down when they were only a few inches off the floor. Since they are older. falling is much more frightening because they are taller, less padded. and have developed few protective skills. Third. almost all the students we have worked with do not initially demon­ strate reflexes such as the stepping reflexes, righting reflexes, or any of the protective reflexes like extending an arm to break a fall or pulling the head forward when falling backward. Inter­ estingly enough, AFTER these students

Because of the simplicity of stepping forward, it is often overlooked in the teaching model. Then, when independ­ ent walking is addressed, the student is unable to walk away from a counter or wall without prompting. The component skills required for stepping forward are: 1. Shoulders must be balanced

slightly forward of pelvic structure. 2. Weight must be shifted to one leg. 3. Non-weight bearing leg moves

forward (knee bends).

Later, after the student has mastered weight bearing while walking, the shoulder on the same side as bent knee should shift slightly backward to main­ tain balance. This shift in the shoulders as we walk is what makes our arms swing opposite to our leg movements. Many people concentrate on the arm swing to balance walking but in reality it is the shoulder movement that main­ tains trunk balance over the feet. For these reasons, when a student is

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ready to take their first independent steps, you can often increase the prompts initially by standing behind the student and prompting the shoulder positions. When this pattern is established, you then lower the prompts to the hips (still prompting from behind so the student will keep hands free). You

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can also prompt the hip movement asking the student to control the shoul­ ders and maintain balance while walk­ ing. When a rhythm is established, you release the hips for a few steps.

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With practice, the steps increase until the student has the confidence to walk alone. Once this is well established, it is a matter of coaxing the student to step forward, away from a wall or counter.

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H.3. Can start moving legs recipro­ cally from a standing position in a front leaning walker or while another person assists with shifting weight and maintaining balance.

You can usually start teaching this skill by fully prompting the leg movement. Stand behind the student and help the student shift weight, and then prompt the non-weight bearing foot forward. As the student gains some movement skills, reduce the amount of physical help by prompting the bending of the knee rather than the foot movement. You want the student to complete the movement after you initiate it. You then reduce the prompting to the hips and help the student shift weight only. If you are standing behind the student without using eqUipment, you support

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the student, shift weight by physically moving the student from side to side and use your foot to prompt the stu­ dent's foot forward. As the student improves, use your knee to prompt the knee forward and eventually, just help shift weight. At first when you ask students to ini­ tiate their own movement, you start with one of the student's feet in the forward position. You move the student's trunk over the feet. Mter the student has learned to start moving the legs from this position, have the student start with the feet placed side by side. This is important when the student later begins making decisions about when to walk and when to stop walking. Continue to help the student shift weight but refrain from prompting the legs or the feet.

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H.2. Can start walking from a standing position when using a walk­ er or when another person helps the participant maintain balance by holding on to one or both hands. Obviously the next step is to help the students learn to shift their own weight in order to initiate the first step. Once again, begin by placing one of the student's feet in a forward position. Then help the student lean slightly forward. If the student does not take a step, prompt the leg slightly. As skills improve, we move around to

the front and help the student lean slightly forward. If the student does not step out, pull the knee forward and then continually reduce the amount of physical assistance. Balance is still being provided by another person or by a walker.

H.l. Can start walking from a stand­ ing position without assistance. This is usually one of the last skills the students learn. You can be pragmatic and use anything that works. Some­ times the old "step away from the wall" routine is all the student needs. Other students learn this skill by stepping away from a counter or a table. Many students are reluctant to give up the security of support. You can help them establish standing balance in the middle of the room and have one person in front encouraging them to walk while another person stands behind them in case they start to fall. Plan on spending some instructional time with this skill. It is often frustrating simply because we think it should be automatic. It is not.

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TEACHING SECTION I

Transition from Walking to Standing

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Most students easily learn to stop mov­ are side-by-side. ing their legs reciprocally and stand still when using a front leaning walker or 4. Standing balance is then main­

when prompted by another person. tained.

When they start taking their first inde­ pendent steps, however, it is difficult to teach them to stop walking and main­ tain standing balance even though they have mastered each skill individually. The transition from one skill to the other must be taught and often takes a lot of practice. The inability to stop walking and stand in one place can cause many tumbles. So plan to spend 1 2-3 4 some time helping the student master this skill. The student is not safe until it The difficulty in teaching this skill in is m astered. the latter stages is probably due to the fact that the students have always been

The basic requirements for the transi­ dependent on another object such as a tion from walking to standing are: walker or another person to help main­ tain balance. When you ask the stu­

1. The body is balanced over the

dents to stop their forward momentum forward weight bearing leg while

by pulling the shoulders back. they do the non-weight bearing leg is be­

not have anything to push against. hind the body.

You can teach this skill by walking 2. The head and shoulders are drawn behind the student. Mter asking them slightly back while in this position to stop walking, prompt the shoulders so that forward momentum is back so that standing balance can be stopped. achieved. Reduce the amount of prompting until the verbal command 3. The non-weight bearing leg is then can be obeyed without physical assis­ brought forward so that both feet tance.

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1.3.

Can stop moving legs recipro­ cally and maintain hip and knee extension to stand while in a front leaning walker or while another per­ son helps maintain balance.

standing position without assistance.

In order for the student to stop walking and stand still, maintaining a standing balance, the student has to stop the This is usually a fairly easy skill to forward momentum by aligning the teach when a student has support. At trunk over the feet in an erect position. first, some students will want to let the In the previous skill, the instructor knees flex when they stop walking. Mter began by physically helping the student the student learns to maintain hip and align the body to maintain standing. As the student becomes more independent, knee extension, begin teaching the student to bring the feet side by side the physical prompts are reduced until when walking stops. This is important the student can stop walking and stand as the student learns to maintain bal­ still independently. ance. Once again, this is accomplished by prompting the feet and then reduc­ ing the amount of physical help you are giving.

1.2.

Can stop walking and maintain a standing position when another person helps the participant main­ tain balance.

As the student becomes stronger and acquires skills, support will not be necessary. The instructor should be able to cue the student to stop walking by helping the student bring the trunk directly over the feet. If the instructor is walking behind the student, it is simply a matter of pulling the shoulders back slightly. If the instructor is walking in front of the student, the cue can be given by pushing the arms back until the trunk is aligned over the hips.

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r­ TEACHING SECTION J

Walking Backward

We are notoriously neglectful in ad­ dressing walking backward especially in smaller children. It is easier to pick them up rather than teach them to step back. As they get older and heavier we can no longer lift them. By then it is more difficult to initiate the learning sequence because prompting a large student takes much more energy than a smaller one. Walking backward a few steps is used more often than most people realize. We step back a step or two every time we work at a counter, sink, or similar structure; when we open doors that swing toward us and when we seat ourselves on a chair. It is not always convenient to pivot while standing, especially when a student is being prompted by another person. Many parents and teachers repeatedly place strain on their lower backs while help­ ing students get into wheelchairs simply because they do not expect the student to step back to help seat themselves.

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Stepping back is a fairly simple proce­

dure to task analyze. But it is seldom easy to teach the student. The baSic components of stepping back are:

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1. Shift weight to one extended leg.

2. Flex the opposite leg. 3. Bring the shoulders back over the plane of the pelvic structure. 4. Bring the flexed leg back and ex­ tend the knee and hip so that weight can be taken on this leg.

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Perhaps one of the reasons we are reluctant to teach this skill is because it is difficult to teach. We have not placed enough emphasis on its importance. Walking backward, however, is a vital skill and the students will not be safe walking independently until they learn it.

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You can use a supportive walker to teach this skill because it is awkward to backward reciprocal leg movements while being supported in a front lean­ support a student and move the legs in ing walker or by another person. a backward direction. If the student is

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tall enough, the instructor can "dance" with the student. This means that as the instructor walks forward, the stu­ dent steps back. If a walker is used, the instructor can kneel down and move the legs in a backward direction. Tight­ ness in the hips can make this move­ ment difficult. When the student is walking forward, the weight on the extended leg helps stretch the muscles of the hips as a step is taken. When the student is stepping back, the foot must be lifted and the muscles in the hips must be stretched to purposefully place the foot behind the body without the benefit of leverage. At this stage, we ask the student to allow the movement rather than initiate it.

while you prompt the leg movements. Push the walker backward a few inches and while kneeling, physically prompt the backward movement of one foot and then the other so that the feet are di­ rectly under the student. When the student starts participating in the movement. reduce the physical prompts by helping pick up the foot while allow­ ing the student to place the foot appro­ priately. The instructor must be careful not to let the walker move so far back that the student cannot realign the feet.

J.3. Can move feet backward to

Once the student has learned to bring the feet back to "square them up". it is time to teach the student to step back using a reciprocal pattern. This is a good time to "dance" with the student because you can establish a rhythmic pattern and help shift weight from leg to leg. At first. you will probably have to prompt the student's foot with your foot while moving the shoulders back and helping to shift weight. As the student gains skills, you should be able to distance yourself from the body and have the student step back with only the hands held.

adjust body alignment when the participant is moved in a backward direction while being supported by a front leaning walker or by another person.

Mter the students are accustomed to allowing backward movements of the feet, ask them to realign their feet as you move them backward. This is sim­ ply a matter of pulling one or both feet back so that the trunk is balanced over the feet. Many of our students who lack walking experience do not know where their feet are in relationship to their bodies.

J.2. Can walk backward a minimum of three steps with both hands held or while using a walker with guidance provided by another person.

You can teach this skill using a walker. It is awkward to support the student

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A. J .1.

Can walk backward a minimum of three steps while holding on to a stationary object or with one hand held.

As the student becomes more proficient, you should be able to drop one hand while still remaining in front of the student. As this becomes easier, you should be able to move to the side. Eventually, the student should be able to step back while holding on to a counter or wall for balance.

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TEACHING SECTION K

Turning While Walking

Turning while walking is a somewhat different skill than pivoting while stand­ ing even though the two skills use some of the same component parts. To turn while walking, the person must keep the center of gravity toward the inside leg, take a short step with one foot and a long step with the other foot. You can start teaching this skill by having the student walk forward (either in a walker or with another person) and then help them pivot to the right or left without stopping to stand up straight first. This requires the maintenance of hip and knee extension on the weight bearing leg while the other person ro­ tates the student's trunk. Mter this is mastered, we start requir­ ing the student to continue to walk while turning slightly to the right or left. You can then work on having the stu­ dent turn in smaller and smaller circles until they can keep the forward momen­

tum while turning in a three-foot circle in either direction. Some students easily accomplish this skill while others find it difficult to keep the trunk aligned with the hips when using a walker or when both hands are held by another person. When independent walking is first achieved, have the students practice turning first in one direction and then the other. Students who have more involvement on one side of the body than the other generally will find it easy to turn in the direction of the involved side because short steps are required of the tighter leg. They require much prac­ tice to turn the opposite direction. The students who usually have the most difficulty in learning this skill are the ones who display athetosis or atax­ ia. They have difficulty maintaining balance and coordinating their body movements. For these students, many practice sessions may be required.

K.4. Can pivot to the left or right Mter a student has learned to maintain while walking with a walker or with hip and knee extension while standing both hands held when another person and pivoting, the student needs to learn rotates the walker or the trunk of the to pivot while maintaining forward participant. momentum. This requires the student 197

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Keeping the body in alignment so that balance can be maintained is usually the main skill that needs to be taught. Often, the students want to lean too far forward as they tum and then they lose their balance and pitch forward, bend­ ing at the waist. Usually just helping the student keep the trunk aligned over the feet will solve the problems. As they gain experience, give fewer and fewer physical cues.

K.2. Can pivot to the left or right while being guided with one hand. The term "guided" means that the in­ structor initiates the tum and provides minimal balance but does not have to support the student or help the student realign the body during or after pivot­ ing. You can teach this skill by walking beSide the student, hold one of their hands, and use your other hand to prompt the opposite shoulder to bring the trunk into alignment.

K.3. Can turn to the left or right in a maximum arc of three feet while walking with one hand held.

As the student gains skills, simply reduce the prompting of the shoulder until the stu­ dent can walk and pivot either direction easily.

One would think that this skill would be easier to accomplish than pivoting all at once, but usually the students find it more difficult to walk in an arc than to pivot. The reason for this is that walk­ ing in an arc requires a series of short steps with one foot and long steps with the other foot. When students first start learning this skill, they lose their balance easily and cannot control the small pivots. Usu­ ally, they want to continue turning because they are off balance and cannot bring the body back into the alignment needed for walking straight forward. First, have them walk in big Circles and help them maintain alignment while they tum and decrease the amount of help you give as they gain skills. You

K.l. Can turn to the left or right in a maxi­ mum arc of three feet .~ while walking inde­ pendently. Once students begin taking steps inde­ pendently, they usually tum in one direction or the other, not because they made a conscious deciSion to do so, but because they got off balance. Turning keeps them from falling. Many students tum to the more involved side easily but

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fmd it difficult to tum to the stronger side. Also. many of the students will walk in circles because it is difficult for them to stop walking and maintain a standing position without support. When a student reaches this level of independence. we have found that they begin to demonstrate automatic learn­ ing. Usually. experience and encourage­ ment is all that they need. Pivoting while walking independently is not a skill that we address in the MOVE Program. We have found that students will automatically learn this skill after they leave the program. But it usually takes a certain amount of experience before the skill is accomplished.

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E: TEACHING SECTION L Walking Up Steps

It would not be harmful to motor stu­

dents through the process of stair climbing at any skill level. However, we find it is not practical until the student volunteers to bear some weight on the feet. It is simply too difficult to support the student and move the feet from step to step. The duration of maintaining hip and knee extension could be anywhere from a split second to three minutes depending upon the size of the student in relation to the person who is doing the prompting. A very small student is easy to catch if the knees buckle. A large student is another story. It is nessesary, therefore, to use common sense to determine when to begin stair climbing. A NOTE ON ARM USE

Leg use is explained in the steps follow­ ing this explanation but arm use while ascending the steps varies with each student and the physical characteristics of the stairwell. For practice steps, it helps to have handrails on both sides even though most buses only have rails on one side. If the student can comfort­ ably extend the arm, we help the stu­ dent grasp the hand rails on one side only. The weight is then shifted to that side.

While holding the student's hand on the railing, prompt the student to lift the non-weight bearing knee high enough for the foot to rest on the first riser. Then, help the student lean slightly forward over the bent knee. This is extremely important because you want the student to push forward and up, not back against you. Next, prompt the student under the arm to push with the flexed leg to ascend the riser. Most students then bring the feet to­ gether on the same riser rather than walking up the steps using a reciprocal pattern. Mter the first step is taken, release the hand that is holding the rail and place the other hand on the oppo­ site rail. Repeat the process with the other leg. We continue to do this until the student has climbed to the top of the steps. Do not attempt to keep both of the student's hands on the railings at all times for three reasons:

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1. Most railings are too far apart for

the students to comfortably hold both sides. 2. You cannot hold both the student's hands and prompt the non-weight

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bearing leg while you also help the student shift weight.

ping on each riser) whenever possible.

3. Most staircases in the community are designed for using one railing at a time.

If the practice staircase is too wide to use this method and you are working with a large student, you may have to begin the early sessions using two peo­ ple. As the students gain skills, you may want them to practice ascending and descending steps using one railing only. Practice using the railing that is avail­ able on buses (left hand rail when fac­ ing the interior of the bus). You can also teach reciprocal stepping (without stop­

L.3. Can maintain extension of one leg while another person prompts the lifting of the other leg and helps the participant raise body weight to as­ cend a minimum of three steps. It is good to begin teaching step climb­

ing as soon as you can physically man­ age to do so because the inability to walk up and down steps will limit ac­ cess to environments. Start teaching this skill by standing behind the stu­ dent and helping the student shift weight to one leg. Next, physically prompt the other leg up to the first riser on the step. You can then help the student shift weight to the flexed leg by manipulating the hips; then help the

When a student is not able to extend the arms comforta­ bly, you can teach the skill by bracing the student's shoul­ der on the weight bearing side. It is more difficult to help the student maintain balance using this method. Independ­ ence will take longer to achieve but once again, it is far better to have a student who is capable of bearing their own body weight while being helped to ascend stairs than one who must be carried.

student push with the flexed leg, either by boosting the hips up or by holding the student under the arms. The in­ structor must be careful, however, that the student is not leaning back to get up the step. The student's trunk should be leaning slightly forward while the student ascends the steps. If possible, prompt first one leg and

then the other as the student climbs the steps. Some students, however, have one leg that is much weaker than the other. They cannot raise the body weight with the weak leg. In these cas­ es, teach the student to continually lead with one leg rather than use reCip­ rocal movements. Ideally, the student

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should eventually gain enough L.l. Can walk up a minimum of strength in the weaker leg to use recip­ three steps whUe holding a raUing or rocal steps. Should this scenario not with one hand held by another per­ develop, the student will still have son. access to additional environments and can ride on conventional buses. If these The next thing to eliminate is the students can't be perfect, then at least prompting of the legs. Once again, let them be functional. reduce the amount of help you are giving until the student needs only a touch to lift the leg. Next, eliminate the touch and just cue the student by help­ L.2. Can walk up a minimum of ing shift weight to one leg. Eventually three steps whUe another person just the presence of the steps should be helps maintain balance and prompts enough cue to start ascending the each leg. steps. The first prompt you want to eliminate is lifting the student. Once in position (with one foot on the next riser) you want the student to do the lifting of the body weight. Continue to prompt the placement of the foot and boost the student until the student starts push­ ing with the flexed leg. At first, it may be only the last few inches. As the student gains strength and skill, the student should take on more and more responsibility for the body weight. If the student has arm use, we encourage the student to hold on to a handrail while pulling up.

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IWiiVETM TEACHING SECTION M

Walking Down Steps

Walking down steps is much more difficult for most people than walking up. The main difference is that the student has to lower the body weight by slowly flexing the weight bearing leg while the other leg hangs in space until the lower riser is reached. This uses a different motor sequence than walking forward or climbing stairs. Most stu­ dents are apprehensive about stepping off into space. When this skill is first practiced, be prepared to raise the prompt level by giving support as well as helping the student maintain bal­ ance. Once again, arm and hand use varies with each individual student and the physical characteristics of the stairwell. You can begin teaching this skill by standing behind the student and hold­ ing the shoulders. If the student is very large, have a spotter stand in front of

the student. After the student has learned the me­ chaniCS of moving the legs, try to have the student hold one handrail. Then, start prompting from the front and hold the upper arms (or hold one upper arm and one hand on the railing. if pos­ sible). Be careful, however. because many students will want to lunge forward and you can end up supporting the stu­ dent's entire weight. If this is a possibil­ ity, you may want to station a spotter behind the student to pull the shoul­ ders back into alignment if necessary. The arm prompts can then be reduced as safety permits until the student can descend the steps with little or no help. The methods for prompting the legs are described in the next steps.

M.3. Can maintain extension of one leg while another person prompts the flexion of the other leg and helps the participant lower the body weight for a minimum. of three steps.

This is a difficult skill to start teaching. You can start by standing behind the student at the top of the stairs. While holding the student securely around the trunk, help the student shift weight to one leg (use the stronger leg at first).

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Push the other foot off the step while helping the student lean slight­ ly forward. The student will probably bring the foot right back because you taught him to do that in the first stages of walking backward. You have to be fast and coordinated to make this next step work. As you ease the foot off the step, quick­ ly flex your own weight bearing knee to make the student's knee bend. Then lower the student to the next step. If this doesn't work, use two people to start teaching the skill. One helps sup­ port the student and the other one manipulates the student's feet.

M.2. Can walk down a minimum of three steps with balance provided at the shoulder level and with prompt­ ing of each leg.

Mter a while, the student will stop resisting and allow the foot to dangle off the step once you have pushed it for­ ward. It is then a matter of prompting the weight bearing leg to bend so that the student can be lowered to the next step. When this becomes fairly smooth, encourage the student to use leg mus­ cles to lower the body weight as op­

posed to clumping down. You can move your hands from under the student's arms to cup the shoulders. This gives you enough control to keep the student from falling but does not offer support. About this time, many students start stepping forward without prompts, but please use caution. The students often want to take a giant step and end up going down two risers at a time rather than one. If you aren't expecting it, it can throw you off balance.

M.I. Can walk down a minimum of three steps with both hands held by another person or with handrails on both sides of the participant. There is a big difference between stand­ ing behind a student to prompt de­ scending steps and standing in front of the student. When you change posi­ tions, the student is in charge of main­ taining body alignment. The instructor has very few ways to prompt the move­ ment. For the first few times you at­ tempt this while working with large students, you will probably want to have one instructor in front of the stu­ dent holding both hands or one hand, while having the student hold the rail with the other hand. If necessary, an­ other instructor stands behind the student and prompts the feet. These prompts are reduced until one person can safely help the student descend the steps.

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TEACHING SECTION N

Walking on Uneven Ground

Walking on uneven ground takes pa­ tience rather than a change of tech­ nique. Many students simply freeze and refuse to move at all. Often, it seems like you are starting over. There is a tendency to skip the training sessions because of the difficulty. If a student is unable to walk on grassy or uneven ground, many environments such as parks and beaches will be excluded from the student's life.

Often, you will have to increase the prompts to the level you used when the student first started walking! Please remember that most students do not generalize their skills easily and virtu­ ally start over when new elements are added. The number of trials needed for success decreases with each new expe­ rience. Just keep practicing and reduce the prompts as the skill improves.

N. 3.

Walking on uneven surfaces is a good way to help a student learn to correct the body alignment and generalize walking skills. In the beginning, you will need to increase the prompts. Then gradually reduce prompts as the stu­ dent increases the ability to adjust body alignment.

Can walk on uneven surfaces with height variations of three inches or less when each leg is prompted and partial support at the upper trunk level is offered by another person.

You can start teaching this skill by walking behind the student and offering support around the trunk. At first, the student will probably have difficulty in maintaining any kind of balance. Begin teaching the student to adjust the body alignment with each step. The instruc­ tors usually are the ones who get frus­ trated because walking is slowed a great deal.

N.2.

Can walk on uneven surfaces with height variations of three inch­ es or less when both hands are held.

This skill simply requires a reduction of prompts with the instructor moving from behind to the front of the student.

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Once again, it is usually frustrating to the instructor because the student has forgotten everything. Keep in mind that walking on uneven ground requires much higher skills than walking on solid surfaces. Students with severe disabilities usually have difficulty gen­ eralizing skills from one situation to another. Walking on uneven ground requires change and continual adjust­ ment. It is particularly difficult for stu­ dents with limited experience in align­ ing the body.

N.1. Can walk on uneven surfaces with height variations of three inch­ es or less when one hand is held. After the student has learned to adjust the body alignment with both hands held, reduce the prompts and hold one hand only. By this time, the student should be able to walk on a variety of surfaces with varying amounts of help. For example, walking on rocky ground may require more prompting than walking on sand. Sand usually slows a student but the consistency of the surface requires less adjustment to maintain body alignment than sporadic rocks that slant first one way and then another. Most of the time, when walk­ ing in a community, a fairly even sur­ face for walking can be chosen. There are occasions, however, when people will have to walk across uneven grass or broken sidewalks.

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TEACHING SECTION 0

Walking Up Slopes

Walking up a slope is somewhat differ­ ent than walking on even ground. The student must lean forward and bend the knees slightly to maintain an erect position. This is fairly easy to prompt when standing behind the student but more difficult when standing in front or

beside the student.

0.3. Can walk up a slope of 30

For these reasons, walk short distances (three to 10 feet) in the beginning and expect the movement to be very slow. If we remind ourselves that this is going to happen, we don't become nearly as frustrated. At first, it seems like the student has forgotten everything; but with practice, the prompts can be re­ duced.

Be careful not to allow the student to either push back against you or be pulled up the slope. Future independ­ ence will not occur if this is allowed to continue.

degrees or less when each leg is prompted and partial support at the shoulder or upper trunk level is of­ fered. Prompts need to be increased when introducing this skill to the student. The first problem is aligning the body against gravity when the feet are on a slant. You can begin by standing be­ hind the student, prompting the stu­ dent's legs with our legs and concen­ trating to help the student adjust to the new alignment. We are always amazed at the difficulty of these first few trials. Usually, the students feel so insecure that they tend to freeze. When we prompt movement, they either want to push back against us or collapse forward.

0.2. Can walk up a slope of 30 degrees or less with both hands held. Usually when you move to the front of the student to offer help, the student wants to pull back and use you for leverage to maintain balance. Special attention should be paid to help the student lean far enough forward so that the body is balanced against gravity.

207

-­ This is awkward for the instructor be­ cause the student's arms or hands must be held low to allow forward lean­ ing. If the arms are held high in the air, the student will not be able to lean forward to align the body against grav­ ity.

0.1.

Can walk up a slope of 30 degrees or less with one hand held. Everyone is usually relieved when the stu­ dent can walk up a slope using these prompts. It is much less awkward for the in­ structor. You can begin by standing beside the student and placing one arm around the shoul­ ders while grasping the opposite upper arm with your other hand. When the student becomes stable using this method, start releasing the shoul­ der intermittently until the student can walk with one arm held. Next, reduce that prompt by holding the elbow, then the forearm, and finally, just the hand.

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TEACHING SECTION P

Walking Down Slopes

ward. Once again, it is a matter of help­ ing the student learn to align the body against graVity in an erect position.

Walking down slopes often is more difficult to teach than walking up slopes. The student wants to pitch for-

P. 3.

Can walk down a slope of 30 degrees or less when each leg is prompted when partial support at the shoulder or upper trunk is offered.

You can begin by standing behind the student and pulling the student's shoulders back to help maintain body alignment. At first, the student will probably freeze and not want to move either leg. Help the student shift weight to one leg and prompt the other leg forward. Unlike walking up the slope, graVity will help pull the leg forward and a step can be taken. As the student steps forward, the stu­ dent will probably want to bend at the waist. This will throw the instructor off balance. Be prepared for this movement and concentrate on helping the student compensate for graVitational pull by bending the knees rather than pitching forward.

Once again, start with short distances (three to 10 feet). Expect the movements to be slow and awkward for both of you.

P. 2.

Can walk down a slope of 30 degrees or less with prompts at the shoulder level.

Mter the student has learned to move the feet reciprocally while walking down a slope, the instructor should be able to stand behind the student and hold the shoulders back to help maintain bal­ ance against the graVitational pulL Some instructors find it easier to move to the front of the student and brace the shoulders while the instructor walks backward. Both methods work well as long as emphasis is placed on helping the student keep the trunk in an erect position.

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The major problem students have at this point is keeping the shoulders erect and square while walking down a slope. There are several ways to prompt this skill depending upon the size of the student and preference of the instruc­ tor. The instructor can stand in front of the student and start reducing the prompts to the shoulders by lowering the grasp to the upper arms, elbows.

and forearms, and finally the hands. Or the instructor can stand beside the student holding one shoulder and up­ per arm. This can be difficult to control with students who are large and tend to lurch forward. Usually when they do this, they swing in front of the instruc­ tor. This makes it difficult or impossible to maintain balance. This method, however, is much less awkward for the instructor if safety can be maintained...

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CHAPTER FIVE PHYSICAL PROMPTS - SITTING

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A systematic approach to providing physical prompts is essential to teaching people with physical disabilities to sit. The purpose of this chapter is to:

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2. Provide a system for reducing prompts until independence is achieved. 3. Provide a system for measuring progress.

The physical prompts for teaching sitting have been divided into four categories and labeled as: A. B. C. D.

Head Control Trunk Control Hip Control Foot Control

Each category is further divided into degrees of assistance. These degrees have been given numerical values ranging from the most intervening (5) to independ­ ence (0). Therefore, a student who requires total assistance in all categories could have a cumulative prompt level of 30. A student who has reached complete inde­ pendence would have a prompt level of O.

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BACK PROMPT

FRONT PROMPT

CHIN TUCK

RIGHT SIDE

LEFT SIDE

PROMPT

PROMPT

PROMPT

To determine the numerical value of the HEAD CONTROL PROMPT, count the number of different directions that need to be prompted in order for the person to perform a specific activity. (Count one each for back, front, chin tuck, left and right.) If the head is held in place either mechanically or by another person, use a score of 5 (total control). a. BACK PROMPT - If the person needs a prompt to bring the head to an erect position from a backward pOSition or to keep the head from moving back­ ward, score as 1 prompt. (The prompt can either be mechanical such as a headrest or it can be help from another person.) b. FRONT PROMPT - If the person needs a prompt to bring the head to an erect position, from a chin on chest position, or to keep the head from falling forward, score as 1 prompt. c. CHIN TUCK PROMPT - If the person needs a prompt to keep the chin from protruding and the neck from hyper-extending, score as 1 prompt. d. RIGHT SIDE PROMPT - If the person needs a prompt to keep the head from resting on the right shoulder or to bring the head to an erect position from the right side, score as 1 prompt. e. LEFT SIDE PROMPT - If the person needs a prompt to keep the head from resting on the left shoulder or to bring the head to an erect position from the left side, score as 1 prompt.

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4 SYMMETRY PROMPT

5 RECLINING

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To determine the numerical value for TRUNK CONTROL prompts, look at the type of control needed in order to maintain a sitting position. O. VOID OF PROMPTS - If the person can sit on a backless seat without any prompts, use a score of O. 1. BACK PROMPT

If the person can sit with trunk support proVided at the back only, use a score of 1.

2. LOW PROMPT - If the person needs a tray, seat belt, waist strap or similar

deVice to maintain trunk control, use a score of 2.

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3. HIGH PROMPT - If the person needs a prompt high on the TRUNK to ei­

ther maintain a sitting position or to prevent slumping while sitting, use a

score of 3.

4. SYMMETRY PROMPT - If the person needs prompts to keep both sides of

the back symmetrical, (body brace, side pads, or similar deVices) use a score

of 4.

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5. RECLINING PROMPT - If the person is reclining (even slightly) count as

total support and use a score of 5.

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( C. HIP CONTROL]

a FLEXION PROMPT

b RETAINER PROMPT

c SYMMETRY PROMPT

d PULL IN PROMPT

e SEPARATION PROMPT

To determine the numerical value for HIP CONTROL prompts, count the num­ ber of prompts needed to keep the hips properly placed for sitting. a. FLEXION PROMPT - If the person needs a prompt to keep the hips in flex­ ion, score as 1 prompt. (Wedges that slope down toward the back of the seat, raising the knees, are often used for this purpose. Leaning forward to do table work, however, serves the same purpose and is typical behavior of people without disabilities.) b. RETAINER PROMPT - If the person tends to sit on the tailbone (sacral sitting) rather than on the buttocks, a T-strap or Similar prompt is needed to keep the hips firmly retained at the back of the seat. Any prompt used for this purpose scores as 1 prompt. c. SYMMETRY PROMPT - If the person needs a prompt to keep the pelvic structure symmetrically placed (not windswept), score as 1 prompt. (NOTE: knee blocks pushing the hips into alignment serve the same purpose.) d. PULL IN PROMPT - If the person needs a prompt to keep the thighs prop­ erly placed on the seat, score as 1 prompt. e. SEPARATION PROMPT - If the person needs a prompt to keep the legs separated evenly, score as 1 prompt.

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VOID OF PROMPTS

FLOOR PROMPT

BACKPLATE

FOOT STRAP PROMPTS

PROMPT

To determine the numerical value of FOOT CONTROL prompts, look at the amount of control the person needs in order to keep the feet in place while maintaining sitting balance.

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O. VOID OF PROMPTS - If the person can use their feet to maintain sitting

balance but can sit without the floor or any other part of the body being

prompted, use a score of O.

1. FLOOR PROMPT - If the person can use their feet to maintain or regain

sitting balance with only the floor as a prompt, use a score of 1.

3. BACK PLATE PROMPT - If the person only needs a back plate to use the

feet to maintain sitting balance or to keep the feet properly placed, use a

score of 3.

5. FOOT STRAP PROMPTS - If the person needs foot straps or Similar con­ straints to use the feet to maintain sitting balance or to keep the feet prop­ erly placed, use a score of 5.

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BEGINNINGDATE ______________________________ ENDING DATE __________________________________

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STATIC SITTING

ENlRYLEVEL Date

ACHIEVED

ACHIEVED

ACHIEVED

TARGET GOAL

Date_ _ __

Date_ _ __

Date_ _ __

0 1 2 3 4 5

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A. Count the number of directions the head must be prompted in order to accomplish the stated goal: Count 1 each for BACK, FRONT. CHIN TUCK. RIGHT SIDE, and LEFT SIDE. S. Determine the amount of trunk control needed: O-VOID OF PROMPTS; l-BACK OF CHAIR ONLY; 2-LOW TRUNK; 3-HIGH TRUNK; 4-SYMMETRY; 5-RECLINING C. Count the number of ways the hips need to be prompted: Count 1 each for FLEXION. RETAINER, SYMMETRY. PULL IN. SEPARATION D. Determine the amount of control needed to keep the feet in place: O-VOID OF PROMPTS; l-FLOOR; 3-BACK PLATE; 5-FOOT STRAPS.

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To determine the numerical value of ARM CONTROL FOR SITTING PROMPTS, score the right and left arms separately.

O. VOID OF PROMPTS - If the person can place the arm and use the hand to

purposefully grasp an object, use a score of O.

1. PLACES ARMS - If the person can purposefully place the arm to maintain

balance, for protection while falling, or to help realign the sitting position, use

a score of 1.

2. MAINTAINS ELBOW EXTENSION - If the person can maintain elbow exten­

sion after the arm has been positioned, use a score of 2.

3. MAINTAINS FOREARM PLACEMENT - If the person can maintain the place­

ment of the forearm on a table, tray, or similar structure in order to maintain

or align the sitting position, use a score of 3.

4. CONTROLS TRUNK WITH FOREARM SUPPORT - If the person can lean

forward and then straighten the trunk to resume an erect sitting position

while the forearm is supported and held in place, use a score of 4.

5. NEEDS HELP TO FUNCTION - If the person CANNOT lean forward and then

straighten the trunk to resume an erect sitting position while the forearm is

supported and held in place, use a score of 5.

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BEGINNING DATE _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

ENDING DATE ________________________

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ARM CONTROL FOR SITTING, STANDING OR T,

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