Observation/Shadowing & Product Scale Testing

On February 5th, I was able to shadow PT on two physical therapy visits with Child A and Child B once again. Having a period of one month in between these two visits allowed me to see even further progress that they have made over a short period of time. These were my observations:

Child A – 15 months old; low muscle tone

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PT spent the beginning of this physical therapy session working with Child A to stay in a hands and knees position. Instead of this being his usual way of moving around, he uses his head to scoot across the carpet while he lies on his back. In this position, he also arches his back and pushes off of the ground to gain movement. PT works with him on lifting upright on his arms and stomach so that it will transition into him moving around on his hands and knees as opposed to the position he currently prefers. She helps support him while she has him slowly move forward on his hands and knees.

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PT places a mirror underneath Child A and holds him in the same hands and knees position that he was in before. Looking down at his reflection, Child A is interested enough to push upright in order to see his face, helping him stay held up on both of his outstretched arms for a longer period of time than usual. He enjoys looking at his own reflection but he needs to be a little further away from it to see it, so this helps keep him from laying down flat on top of it. In addition to the support that she is giving him with her own hands, PT has wrapped a “super wrap” around his hip and upper thigh area. It is a stretchy, bandage-like fabric wrap that holds his legs together and helps him stay a little more rigid.

Child B – 2 years (+ a few months) old; high muscle tone

2-5-15acopyPT started the therapy session by taking out a product called Theratogs and carefully putting it on Child B. Theratogs, designed by a physical therapist for children with neuromotor issues, is a garment that physically aids the child when it is worn. It comes in different parts so that it is easy to put on and remove, as well as so that it can be used on the areas of the body that require it most.

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PT uses the medical device with Child B since it keeps him grounded, which allows him to be more patient during the physical therapy session. He is able to work for a longer period of time and it helps increase his stability throughout the session. It also helps him with his hip rotation alignment when he is put in to a kneeling position.

Product Scale Testing. 

In addition to just observing this session, I was also able to bring my first full-scale foam prototype of the first of the three final designs to test it for scale. The model was created the same way my previous scaled model was made; I designed the form on CAD, split it into stackable layers using Autodesk 123D Make, then used the CNC router to cut the shapes out of 1″ thick sheets of pink foam. I stacked the piecess together using spray adhesive then proceeded to carve and sand it into its final form.

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Child A, who is 28.5″ tall, is the perfect age and size to use as a scale reference for the model, so I brought it to the physical therapy session for him to interact with. Once I placed it next to him, I immediately saw that the model was a lot smaller than I had anticipated it to be. Although I was still happy with the form, I knew that there were a few modifications that were to come so that the scale could be perfected towards its user.

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The first modification to the full scale piece was that the thicker end, which is the end that the child’s head would be leaning on, needed to be widened. This would create a larger surface area that would be resting on the floor, increasing the design’s stability and making it sturdier and safer for a child to interact with. In addition, the entire piece need to be both lengthened and widened so that it could accommodate a child. Seeing it not only in full scale, but also next to a child in the age range of my user group, allowed me to gain a better sense of scale.

One great part of seeing Child A interact with the foam model was when he started crawling around it and playing with it. He was interested in its inviting, curvy form and continuously grabbed on to it. This made me see that although it is designed based on a specific developmental stage, its minimal form allows it to be used beyond that for different purposes during playtime.

Follow-Up Observation/Shadowing Session

On January 6th, I had the opportunity to shadow PT on two physical therapy visits with two different boys. I had already shadowed these two boys twice in September, so having a few months in between visits allowed me to really see the progress that they have made with her. These were my observations:

Child A – 14 months old; low muscle tone

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At this point, Child A is now able to sit upright unsupported, which is a huge step forward from where he was just a few months ago. He can also reach for objects while sitting upright and even bang two objects together. Once in a while he gets back into a side-lying position, so PT slowly aids him as he pushes to lift back into an upright position. When he plays upright with a toy, Child A mainly uses his left hand to play while he uses his right hand to stabilize himself to stay sitting up.

A big challenge that PT is dealing with now is getting him to move onto his stomach. She shakes a small toy near him that makes subtle noises, such as a plastic maraca or a ball with a smaller ball inside. When he hears and sees it, he slowly moves towards it by reaching his arms outward while lying on his back. From his left side, Child A does not need much support to sit upright when he is lying on the floor. He has to work a lot harder reaching up from his right side.

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PT holds up a plastic ring stacking toy while he is sitting upright. She has him reach towards it and pull off the rings one at a time, then has him put them each back one by one. Child A puts on and takes off each one that PT tells him to and stays sitting upright the entire time. After this activity, she puts Child A on her lap while she sits on a floor mat. She places his legs in a 90 degree position and gently keeps them in this position with his feet planted firmly on the ground. As she holds him in this position, PT uses her other hand to place toys in front of him so that he reaches forward and grasps the toys with his hands.

Seeing this progress from the first session I observed really made an impact on me. It showed me that with enough time, patience and attention, children with hypotonia can progress at a steady pace and advance physically over time.

Child B – 2 years (+ a few months) old; high muscle tone

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PT holds him and tells him to carefully lean forward into a hands and knees position. He leans forward slowly so that his hands are touching the ground and she carefully lifts him back up. They proceed to do this activity multiple times so that Child B gets used to it.

After this, PT puts Child B’s orthotics on, followed by his sneakers. The orthotics give him added support in the ankle and knee areas. Having a more stable base helps keep the rest of him stable. She then places a weight around his left ankle before trying to get him to walk across the room. He walks across the room towards an iPad playing a favorite song of his while she stabilizes him and slowly guides him there. Once he reaches his goal, Child B sits down on the floor and PT adds a weight to his right ankle. With both weights on, he is aided back across the room and goes into sitting position once again when he gets to the iPad. PT does this exercise multiple times with him, going from one end of the room to the other.

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PT pointed out that Child B works more with his right side during every activity. If he pushes off the ground, he always uses his right side as support since it is currently his dominant side. PT is working with him to use his left side too in order to strengthen it so that he has no dominant side and uses both of them equally. Getting rid of this current dominance will help him use both sides during activities.

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PT carefully sets him into his walker. He holds on to both sides and walks without the support of PT, but uses the walker to help him. He is able to walk out a fairly long distance on his own. He does not tire easily and pushes himself to keep moving forward for a fairly long time.

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Throughout this entire time he has been looking around and taking in his surroundings. As he gets tired, Child B’s legs get less stable and the bottom of his feet are no longer planted firmly on the ground. He uses the walker to hold most of his weight towards the end of his walk. Once he starts fatiguing it is difficult for him to stand up straight. PT makes sure to take short breaks while walking once he gets tired. She continues to give him encouragement and support, telling him that he is doing a great job. She also makes sure that he is holding up his weight with not only his right hand, but his left one as well.

Once again, I was grateful to be able to see theses stages of progress with my own eyes. It showed me that although it might be difficult at times, these children want to progress physically for themselves but do not know how to do so on their. The help of a PT and development tools makes an extremely noticeable difference and I am hoping that my design will have the opportunity to aid in these milestones as well.

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

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.

Hearing

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)

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.