Hands-On Therapy

It’s that uncomfortable moment in our professional development where they talk about not touching students. You know, that you shouldn’t really hug or touch students, and specifically not below the waist and above the knee.

I know the point of the training (and am not in any way minimizing the need for our children to be safe in school), but I can’t help but feel that it doesn’t apply to me. My hands are frequently on my students. Because it’s my job.

Whether it’s providing joint compression or deep pressure or joint mobilization or myofascial release, I need to be using my hands. My hands, and actually my whole body for that matter, are a tool in my toolbox. They help to provide the necessary modality to address impairments that are leading to dysfunction in my students. This dysfunction is the focus of my treatment. Especially in school-based therapy, the goal is to improve function.

Take, for example, the child who enters Kindergarten with great functional goals, like reciprocal stair navigation, ball play, cutting, and manipulating the zipper on his backpack. Yes, these are all the things a Kindergartener should be doing or working toward. But in this case, the child has a right hemiplegia, has not worn his hand splint or AFO in months, and basically does not use his right side (other than in ambulation). He is plagiocephalic and has a history of extensive abdominal surgery.

Range of motion limitations prevent the child from putting his foot flat on the floor. Muscle tone issues prevent spontaneous ease of use. Limb-neglect is present. Motor control and motor planning also stand in the way.

Based upon the child’s presentation, it’s apparent that extensor development is lacking. This impacts mid-range postural control and is another complicating factor in his overall functional deficits. While outside modalities (such as medical management and bracing) are often needed, we have some tools in our toolbox to start addressing some of these concerns. Going back to the developmental sequence, using an NDT frame-of-reference can help to address some of those skills that have been missed. Developing extensor and then flexor control through prone and quadruped will improve balance and stability for fine and gross motor tasks.

For example, positioning in prone prop while attending to an activity, for this child, can provide the following benefits:

  1. Development of strength and endurance in the upper back, scapular, and neck extensors.
  2. Elongation of the hip flexors and abdominal muscles that are often shortened due to frequent sitting.
  3. By flexing the non-involved leg (in this case left) slightly, weight bearing through the right hemibody is occurring to improve proprioception.
  4. Shoulder girdle strengthening.
  5. Right shoulder proprioceptive input through joint approximation, which can help maintain capsular integrity as well as decrease muscle tone through weight bearing.
  6. Work on visual tracking, convergence and divergence.
  7. Extension of the head and neck activates the reticular activating system, which increases attention and arousal.

But, passive positioning, especially in this case, isn’t quite enough. Hands-on techniques such as joint mobilization, range of motion, PNF, and myofascial release are often needed to inhibit muscle tone and lengthen muscles to achieve neutral alignment. Once in neutral, strengthening and motor control can be developed.

While we often think about these techniques as clinical skills that aren’t used in school, they’re often a valued resource in improving overall function within the school environment. If you’re interested in learning more about how to use NDT and MFR to treat moderately to severely involved children in the school environment, check out Barbara Hodge’s seminar, The Moderately-Severely Involved Child: Integrating NDT and MFR into a School-Based Program at the Sixteenth Annual Therapies in the School Conference.

~Kathryn Biel, PT, DPT