A Chance to Shadow in the Home Environment

I had the chance to shadow PT today as she worked with the two previous children in their home environment- both children come from the same household. It was great to be able to see them in their natural environment as they work with their physical therapist. As I watched their interaction and spoke to Janet, some key information stood out to me that might influence my future design.

Child A – 9 months old; low muscle tone

PT started out working with Child A on a carpeted floor. She explained to me that she starts off on carpet because it will cause resistance when he tries to move and she will then put him on the hardwood floor to help him turn on his own more easily. He begins lying down on his back with his arms reaching above him. PT holds out two small plastic toys that he is able to grab from her and bang together; this simple act shows the improvement that has occurred over the past few months thanks to the physical therapy sessions.

When the physical therapist turns him on to his stomach, he still struggles to hold his head up on his own but is making slow progress. He also has trouble lifting his body into a sitting position, so she will put him in a hands and knees position (think of when you’re leaning on all fours) and slowly shift him into a sitting position from there. One fun thing that she does is place a mirror in front of him when he is finally sitting up. It completely grabs his attention and he is so distracted that he can sit up on his own, even if just for a little bit.

One drawback to the hardwood floor is that even though it is easier for him to move himself, the hard surface will cause him to hit his head harder if he gets more tired and his head drops downward. Also, he can flip onto his side more easily but the slippery surface makes it extremely difficult for him to transition from that position onto his stomach.

Child B – 2 years old; high muscle tone

PT proceeds to work with Child B using a device that she brought with her. She sets him up in a suspension walker, a physical therapy device used to aid children who have struggles walking on their own:

suspension walker

The walker holds him in place with a detachable harness and holds him up from above, but it gives him a little freedom to use his own leg strength to stand and walk. He is very hesitant to walk forward so the physical therapist stands in front of him with an object, such as a toy or an iPad playing a song that he loves, to coerce him to move forward. He takes a few steps in her direction but quickly gets frustrated and starts crying. It does help him with his strength but he is clearly not enjoying it at all.

I asked PT if his crying was caused by pain. She told me that even though he is visibly struggling, it is most likely not due to pain caused by the act of walking. It is just that he is not used to doing these sort of movements so it is uncomfortable and even scares him a little bit each time he progresses.

After giving him a little break to calm down, PT sits on the floor with Child B so that they are facing each other with their legs open and their feet touching. They hold hands and she slowly moves back and forth, pulling him towards her and then slowly letting him lean back. All of this is happening while she is singing a song that he loves so he is not as much paying attention to the act of moving as he is to the singing. She uses this technique as they go through different activities, either singing a song that he likes or making a song on the spot about the action they are doing at that very moment. Her voice seems to be calming him, causing him to have a momentary distraction from what they are working on.


Since this shadowing session was a home visit, it gave me the chance to speak to one of the child’s mother while I was there. She has been really supportive in my design pursuit since my last visit and it has been helpful to be able to bounce ideas off of a parent of children with abnormal muscle tone. When I explained my overall thesis goals to her, she agreed that if I could find a way to enhance their motor skills, keep them engaged, make it more meaningful for her, and make it fun for them then that would be an extremely impactful in-home design.

This visit gave me inspiration for a few general design elements that I might incorporate into my design:

Design Idea #1

A device that can alter the amount of resistance the child needs to exert in order to cause something to happen. One that can take more force and pressure in the beginning and gets progressively easier as the child plays and gets tired, but it can also start off easy to use and get harder as the child plays in order to build endurance.

It can be gone about mechanically using mechanisms or adjustable parts, or I can use some sort of material that naturally possesses the quality of tension and resistance, such as water, air pressure, or sand. Maybe these can be used inside of the product to create a cause an effect that will engage the child in different ways.

Design Idea #2

A voice-recording element in which the parent can sing while playing with their child and having fun, but it can be recorded for them later and be replayed when the child is playing on their own. Perhaps an order of actions that have to be done, such as pulling a lever or pushing a ball through a hole, that is then rewarded with a recording of their parent singing the song that they love. Knowing it is something that will happen once the actions are completed can be persuasive.

Design Idea #3

A transitional material for a floor mat or play space. Material and textures are important sensory triggers that can be manipulated and used during certain actions to provoke specific outcomes. Smooth and hard textures or soft and bumpy texture surfaces might be able to be combined in some way. Maybe even removable pieces, such as those individual bath mat pieces for children that cause traction, can be used on a smooth surface so that there are multiple options.

The opportunities are endless.


Basics of High Tone and Low Tone

Some more information that the physical therapist told me while shadowing:

Tone is defined as tension of the muscles at rest. Low tone is when the child’s muscles feel soft and doughy, while high tone is when the child’s muscles are more rigid and stiff due to higher tension. On both ends, range of motion is a big concern. Both types make it hard for the child to move against gravity.

A really big problem that physical therapists have to counter-act is what is known as the ‘W-Sitting’ position:

Screen Shot 2014-09-11 at 2.15.19 PM

W-sitting is an easy position to sit in for a child with abnormal muscle tone since it increases the area of support outward due to the ankles and feet being on either side. It takes significantly less effort than sitting in other positions since it shifts the weight onto the pelvis area and outright feet instead of on the child’s bottom. It is not good for the child’s hip and knee areas since it puts a lot of pressure on them in the wrong direction. It also does not promote weight shifting, good pelvic strengthening, and movement in and out of sitting.

I will continue to shadow therapy sessions to learn more techniques from the physical and occupational therapists that can help me with my design.

First Observation/Shadowing Session

On September 9th, I had the opportunity to shadow PT on two physical therapy visits with two different boys. These were my observations:

Child A – 9 months old; low muscle tone

PT  has been working with Child A for the past few months. He was born with extremely low tone and when visits began three months ago, he was unable to lift his head, hold himself up, or hold a toy on his own. His only possible position was lying flat on his back with arms laid flat out on either side of him due to his inability to lift his arms upward. A good tactic to help him was ‘side-lying’, which positioned him on his side. It forced his legs together and his arms were in a better position in front of him.

Positioning of the child’s toys are important as well. For example, placing a toy forward in front of the child’s head will make him move his head forward, strengthening the neck muscles. At first, on his stomach, Child A could not pick his head up. It would fall down and he would get frustrated; slowly over time, he had gained the strength to lift it up.

PT uses toys to motivate Child A to reach forward, especially ones that are colorful and noisy to grab his attention- the toys or objects that are used as motivation make all the difference. She helps to hold him up a little bit but tries to get him to do it mostly on his own. One of the issues associated with his low muscle tone is that when he loses his balance and falls over, he makes no attempt to lift himself back up. Also, when he is held up in a standing position his legs collapse. There is no attempt at all to stand or keep them straight.

One product that PT uses with children with low muscle tone is called a gertie ball, which comes in sizes of 9″ or less. It is a ball that comes in different textured surfaces and you are able to blow it up as firm or as loose as you like, which makes it easier to grab and adjust. The child is placed on top of the ball in a sitting position which enhances his posture and gives him the opportunity to bear some weight on his feet. The 90 degree sitting position is really important for them to learn to do on their own- it is great for leg strength, waist strength, and neck/head strength.

Child A can go from his back to his side, but once he is on his side, he lacks arm and shoulder strength to lift himself up on to his stomach. Also, Child A struggles to lift his head so with every turn his head shakes a little, representing how unstable the movement is.

Child B – 2 years old; high muscle tone

PT has been working with Child B for the past few months. He can only stand if he is held since he struggles to stay upright, so she is working with him on lifting off the ground to get into a standing position. His high muscle tone causes him to keep his hands fisted and all of his ligaments brought in close to his body. Instead of crawling, he scoots around with his right leg in front of him and his left leg behind him, using his right leg to pull his entire body forward like this:

crawlingTo help him try to walk in the upright position, PT aids Child B in using a toy with a handle and wheels that he can use to support his weight. Even with the help, he is very wobbly when using the toy for support. He has problems with motor planning and has only figured out how to sit up 2 months ago with the help of physical therapy. Up until this point he can only sit up using the right side of his body; he still struggles to use his left side as support.

Child B is gaining strength in his leg muscles and learning how to move from sitting to a standing position. PT is hopeful that he will eventually be able to walk on his own in a couple of years with continued therapy. Another method she uses to help him stand is supporting him with her arms and leaning him up against a wall cushioned with gym mats to help him gain balance. It is easier for him to stand when he is distracted by visual cues, such as a video on an iPad that is held up in front of him. He is not thinking about what he is doing at that point, but as soon as the video ends and he is no longer distracted, he ends up falling instantly.

Gaining Some Professional Input

I sought out pediatric physical therapists in order to gain some more insight about my thesis topic. While the internet and library have been great resources so far, I really needed to meet with someone in person for additional guidance and to find out if I would be able to observe multiple physical therapy sessions. My searching brought me to a local pediatric outpatient therapy center made up of experienced pediatric physical and occupational therapists that primarily focus on early intervention. That is how I got in contact with the physical therapist (who I’ll be referring to as ‘PT’) who agreed to help me throughout this process.

PT has already given me some general guidelines when it comes to toys and objects used to work with children with abnormal muscle tone. All of the human senses are targeted during physical therapy sessions:


Vision leads to all movement. One big visual stimulation for children is color; black and white are early visual cues. For newborns, their visual field is best within 8-9 inches. Their initial visual field is not so strong.

Vision can also be used as an incentive to help them gain physical strength. For example, positioning of a toy or object can be key. Placing it forward in front of the child will cause him to move his head forward as well, strengthening the head and neck muscles.


Children respond to voice, physical touch, heartbeat, and rhythm of breathing. If the child gets worked up, speaking soothingly or breathing rhythmically helps calm them when you hold them. (also applies to Touch)


Children with lower muscle tone do not have great movement. They are unable to crawl or move around to explore and touch objects in their surroundings. Incorporating texture into the designs they interact with is highly important to expose them to what they otherwise would be missing out on. Materials in their surrounding environment are also important for them to get used, such as the furniture around them and different floor textures. For instance, being able to feel the difference between hard/soft and warm/cold gives them a better sense and awareness of their body.

Within our first meeting, PT gave me really helpful advice that has altered the path of this thesis topic. Hypotonia is very specific and can limit the amount of users for my product, as well as making it incredibly difficult to create a universalized design. Instead of just focusing on children with hypotonia, I will be designing for newborn to 3 year old children with abnormal muscle tone, including both high muscle tone and low muscle tone.   A design will be created that can cover both extremes since they actually have many similarities.

August Visit to Adaptive Design Association

In the beginning of August, I had the chance to spend the afternoon at Adaptive Design Association, a spectacular non-for-profit located in Manhattan that focuses on creating custom adaptations for children with disabilities. I was taken around the facilities to learn more about the materials they use, the children that require their help, and how they design custom pieces for the children that they work with.

My thesis seeks out to design products to work alongside the sessions that an occupational and/or physical therapist would conduct with the child. They would be products designed for the home environment; products that parents could use during play, mealtime, and other times throughout the day to help advance the work being done by the therapist.

Adaptive Design Association designs custom pieces for individual children. For each piece, the designer works with the child’s therapists, usually the physical therapist, to figure out exactly what the child needs in order to help them with their physical development. The custom pieces have very specific details, such as knee-blockers to prevent overextension outwards, head pillows to prop their head up and prevent them from having it faced downward due to lack of strength, and soft body straps to hold the child in place where it is necessary. All of their designs are made out of tri-wall, which is essentially layered cardboard that is low in cost yet sturdy enough to create long-lasting results.

Rocio Alonso, an Adaptive Designer and Fabricator at ADA, told me that it is possible to add too many details to each product. She told me to remember that adding too much support will cause the child to become less likely to work on his own at all and he will not be able to advance at the expected pace. If there is too much help, the child will not be able to experiment with movements and try things out for himself.

As I’ve already explained, ADA creates custom pieces catered toward individual childrens’ needs. With my project, mass production has to be taken into account. Therefore, I have the intentions of observing at least one child with hypotonia to help base my designs on, but then I will continue to carefully add on to those specific features in order to universalize the design for a much larger market with slightly less specific needs.

A small chair designed to be adjustable with the child's growth.

A small chair designed to be adjustable with the child’s growth.

Some of the many children that ADA has designed for.

Some of the many children that ADA has designed for.

Soft, adjustable straps.

Soft, adjustable straps.

ADA's 'Tippy Stool' design.

ADA’s ‘Tippy Stool’ design.