Occupational Therapy News OTnews November 2019 | Page 47

CHILDREN’S SERVICES FEATURE the therapy centre, while the other sessions were carried out by parents and/or carers at home. ‘All the relevant information and suggestions about one- handed play “toy boxes” that could be made up for the sessions was given out on an information sheet,’ she says. ‘Parents and therapists needed a box with one-hand activating toys, such as a small ball, a push and pop up vehicle, a push spinning top, pop-up wooden men, a rattle/drum, stacking cups/ bricks/switch toys, a child’s piano/musical push or press toy, pop- up animals using push/twist and turn buttons and push down lids afterwards.’ The first session was used to assess and set goals and on the final session a comparison of the child’s use of that limb was made with week one. This was done from a weekly tick sheet and verbal/observed progress. ‘Ongoing discussion between myself and colleagues in the early years team regarding helpful ways of carrying out this treatment resulted in the development of some informal guidance, • placing or asking the child to lie over a ball on their tummy and which has been found to be helpful when carrying out Modified Constraint Therapy in this setting,’ she reflects. Sarah’s top tips include: always start by discussing MCT with the parent first and follow • this up with an exciting first session with the therapists/therapy assistants in the clinic, where choice of toys are likely to be greater and the whole procedure can be demonstrated to the parent; • support parents/carers carefully at the start of the intervention and explain the process well; • therapists need to be flexible, alternating home visits with the child visiting the clinic; the • child must be tolerant of the constraint, otherwise the tone increases in the affected limb and contraindicates the whole benefit of the intervention; compliance and the ability to maintain some awkwardness • and manage some frustration when using the affected arm is essential for success; • each session needs to be formally ‘timed’ and ‘noted’ in some way, whether by writing down baseline points on the first session or taking note of starting skills and changes as they happen for six weeks. essential’, with ‘lots of variety and passive movement to help the child achieve play success’, as well ample opportunities for active movements and play. ‘Remember, the child is here to play and have fun and the parent needs lots of ideas to help their sessions at home go well and with as little stress as possible on both sides,’ she stresses. ‘We allow the child to lead the session and indicate time limit and use a sand timer, as once they have had enough the positive work carried out can be undone if the child becomes distressed or unhappy, or feels trapped when not allowed to get up from the table,’ she says. ‘Videoing the first and last sessions is practised in some clinics, but locally we had difficulties with being given consent to use video, so written evidence and noting observed changes worked best in this situation,’ she says. ‘Parents of course can and did take video evidence themselves on their phones for their use only.’ She adds: ‘The important information concerns the changes that have taken place in the use of the affected hand after six weeks of sessions, which the therapist or therapy assistant and parents need to document and agree on in the last session of each block of treatment’. ‘We recommend that you always feedback relevant information to other therapists and therapy assistants, or other professionals, involved with child’s care or treatment in the team. ‘After a break of six to eight weeks we review the child’s progress and carry out a second set of sessions, if this is assessed to be of value to the child. ‘Finally, listen to the parents’ feedback, as they are the child’s most informed expert when it comes to behaviour and routine.’ Her ideas for activities to use during the sessions include: • songs requiring arm movements at the shoulder, for example ‘Row, row, row the boat’, ‘Wind the bobbin up’ and ‘Head, shoulders knees and toes’; move both arms with the child through movements passively • and to the greatest range of movement possible; • encourage the child to copy a commando crawl with bent elbows, using forearms as propellers, resulting in both shoulder joints being moved through full or larger range of movement without that child being aware of the ‘exercise’ the affected arm is performing; • stimulate both arms by rubbing or gentle tapping to music; and gently rolling the child so they have to place both hands down on floor, where possible with fingers open and flat. This can be made fun with music and the parent or therapist activating toys in front of child to take their mind off the discomfort of the stretch of affected side. Sarah goes on: ‘It is vital to ensure the child is relaxed and happy before placing tubigrip on their unaffected arm, as this moment is crucial to the constraint part of the treatment. Positioning for the child works well in a small chair up to a table, with the parent sitting to the side of them and the therapist or therapy assistant sitting opposite. ‘When siting on a parent’s lap, there is more opportunity for a child to wriggle and twist out of useful sitting posture crucial for play. At home, a high chair has been found to be as useful for this part of the session.’ Sarah asserts that ‘lots if encouragement and praise is Sarah Grimshaw, paediatric occupational therapist, Kent Community Health Foundation Trust Children’s Resource Centre, Dartford, Kent. Email: [email protected] OTnews November 2019 47