DISCLOSURE

Mary McLaurine, M.SP., CCC-SLP Lisa Sheff, OTR/L Amanda Drawbaugh, PT, DPT

Speech Tree, LLC 2020

© All rights reserved

In an effort to comply with the

appropriate boards and

associations, We declare that we do not

have any affiliation with or financial

interest in a commercial

organizations that could pose a conflict of

interest with our presentation

TANDEM A Different Approach to

Verbal Apraxia

Mary McLaurine, M.SP., CCC-SLP Lisa Sheff, OTR/L Amanda Drawbaugh, PT, DPT,CIMI

Speech Tree, LLC 2020

© All rights reserved

1983

Intro to NDT

(Neurodevelopmental

Treatment)

1985

Washington D.C.

NDT Techniques

1991

Daughter is

born

2003

Lisa Sheff

enters the

picture

Conduit to Tandem

Lisa Sheff & Amanda Drawbaugh

Let’s Look at Apraxia in a New Way

Review of the Integrated Treatment Modalities used by Tandem

Tandem has integrated selected treatment principles and therapeutic strategies of :

Neurodevelopmental Treatment (NDT)

Occupational Therapy Treatment Strategies,

Sensory Integration, and Manual Therapy

Physical Therapy

Myofascil Release

Kinesio Taping

APRAXIC KIDS DISRUPT THE BASIC PRINCIPLES OF MOVEMENT THEY CHOOSE SELF GENERATED CREATIVE MOVEMENT PATTERNS

INTERRUPTING THE ORDERLY EMERGENCE OF SPEECH AND LANGUAGE

STABILITY BEFORE MOBILITY

STUCK IN LINEAR PLANE

(STRAIGHT PLANE)

SEPARATION OF MOVEMENT ANTIGRAVITY

POOR DEVELOPMENT OF ANTIGRAVITY MUSCLES

ROTATIONAL SKILLS

HAVE DIFFICULTY EMERGING APRAXIC KIDS STUCK IN LINEAR PLANE

(STRAIGHT PLNE)

TRANSITION OF MOVEMENT REQUIRES CO-CONTRACTION

RESPIRATION AND BREATH SUPPORT FOR SPEECH

DISRUPTED UNABLE TO SUPPORT MOVEMENT AND SPEECH

( If you Can't Breathe you can’t function Mary Massery DPT)

MUSCLE TONE IS WEAK MOVEMENT MUST BE BALANCED

MUST HAVE BALANCED

BASE OF SUPPORT.

STABILITY AND ALIGNMENT WORKING FROM THE BASE UP

DO NOT PRESENT OR REQUEST A MOTOR PLAN TO BE PERFORMED IN THE SAME MANNER CONTINUOUSLY.

THIS ON;Y REINFORCERS INAPPROPRIATE MOTOR PLANS

NEW MOTOR PLANS CANNOT EMERGE OR BE ESTABLISHED IF ONLY USING A PREFERRED MOVEMENT ALL THE TIME.

APRAXIC CHILDREN WILL APPEAR STRONG BECAUSE THEY HAVE

LEARNED TO LOCK MUSCLES TO GIVE THE ILLUSION OF STREGNTH

DIFFICULTY WITH SENSORY REGULATION

Speech Tree, LLC 2020

© All rights reserve

Let’s review a few movement

principles that Apraxicchildren circumvent disrupting speech

THREE PLANES OF

MOVEMENT

Stuck in Sagittal Plane

Apraxic Children turn Movement

muscles into Postural muscles

Thus the Tin Man posture

Apraxic Children have difficulty

Transitioning from

Sagittal Plane

to Frontal Plane,

to Transverse Plane

The Tinman

LINEARLINEAR PLANE (STRAIGHT PLANE) can be

either in

A side to side movement or forward/backward

movement

Children who show signs of Apraxia also

demonstrate movements that are

limited to the LINEAR PLANE

Apraxic children have little to no

TRANSVERSE PLANE

(Rotational Plane)

incorporated into daily transitional/play

activities

Amanda Drawbaugh, PT, DPT, CMI

SAGITTAL PLANE

Apraxic children are stuck in

Linear Plane (Straight Plane) causing muscles to shorten and become

immobile.

This immobility is due to their creative body fixing to support gross and fine motor movements which then disrupt

orderly emerge of speech and language skills

Apraxic children use Linear Plane (straight plane)

as their compensatory

Plane of Choice

When Apraxic children use

prolonged “fixing”, the muscle

becomes tight, rigid, and

shortened

The Specific Muscle or Muscle

Groups being contracted are at

risk for reduced flexibility.

APRAXIC CHLDREN LOVE TO SKIP REQUIRED

DEVELOPMENTAL STAGES TO ACCOMPLISH THEIR

MOVEMENT GOALS

Question 1 for the Parents: Do you remember if your baby was able to pull their knees to their chest

when on their backs (FLEXION)?

Question 2 for the Parents: How well can your child perform this sustained flexion pattern NOW despite

their age?

This is 4-6 month

old skill that

Apraxic children

avoid.

APRAXIC CHILDREN LOVE TO STAY IN EXTENSION

OR LINEAR PLANE

EXTENSION

Specifically

Supine Extension

This is an extension posture noted in a child

approximatley

2-3 months of age

From Early Infancy and beyond Apraxic children

continue to use extension to support movement

HOW TO AVOID USING

FLEXION

JUST TAKE A STAND

Or keep those legs

straight out in Sitting

Extension is a compensatory strategy Apraxic Children use very frequently

The Apraxic Child’sDiaphragm is used to support standing and/or extension vs using the Diaphragm to Support Breathing and Speech

Abdominal Muscles

”BOOTY SQUAT”Using Joints and Ligaments not

Abdominal Muscles among others to Squat

o Apraxic kids use their joints and ligaments and not abdominal muscles to squat.

o Apraxic children bypass weaker or locked/immobile muscles and find other muscles to solve their movement issues

o This position allows for shifting to play with “pseudo” moving across midline

YOU CANNOT TALK USING JOINTS AND LIGAMENTS

If you see your children doing this pattern, make the child sit on their sit bones (ischial tuberosity)

How To Stop the “BOOTY SQUAT”

LINEAR PLANE CHEAT

HYPEREXTENSION PATTERNS

Standing to avoid flexion and to Avoid

using Abdominals

Leaning back vs taking head out of

upright to look at the toy.

Pulling on neck muscles to support his

head during his chosen activity vs using

arms and aligning his shoulders to play in

midline

Lateral leaning posture the neck and no

rotation of the trunk

Posturing his right shoulder for support

so he can use his left hand and retrieve a

toy.

FIGHT EXTENSION WITH

FLEXION

This is Lisa placing a little guy we had at least 10 years ago into sustained flexion.

This is a position Lisa uses frequently

Apraxic children over work their extension

muscles and extension patterns and need to practice more flexion

According to NDT, Speech is a FLEXION ACTIVITY

Flexion is required to help activate the diaphragm

W SITTING

W-sitting is when a child sits on their bottom with bent

knees and their feet are resting on either side of their

body.

It is called ‘W-sitting’ because from a bird’s eye view,

the child’s legs form a “W.”

This position provides a wider base of support and

increased stability to the child’s trunk and core when

sitting. This is a major “Fix”

This is just a flat “Booty Squat”

It is often used to compensate for decreased trunk

strength or increased flexibility© 2020 Chicago Occupational Therapy.

All Rights Reserved.

W Sitting should be avoided

W sitting provides a larger base of support

allowing the child to use ligaments and bony

structures for stability and decreasing the

amount of work required for the core muscles

Posterior pelvic tilts disrupts the Diaphragm

Poor trunk positioning allows the child to

compress the Diaphragm

POSITIONS TO CONSIDER TO COUNTERACT W SITTING

Apraxic kids must sit on

sit bones (Ischial Tuberosity)

A true sitting pattern with sustained flexion must be

integrated into your Treatment and everyday activities

Flexion is required to help activate the diaphragm and

abdominal muscles

This is a foam stair used to help encourage sustained flexion

FRONTAL PLANE

Frontal Plane Movements

Divides the body into the front and the back and is seen as a side bend

The Apraxic Child

Is “fixing” because of overusing frontal plane so a more complete and complex movement pattern does not develop.

ENCOURAGEMENT OF

FRONTAL PLANE

ECOURAGMENT OF LATERAL

PLANE

CHILD WITH ELEVATED

SHOULDERS TRYING

TO INITIATE

FRONTAL/TRANSVERSE PLANE

A LAUNDRY BASKET IS GREAT TO

HELP ENCOURAGMENT FLEXION

AND POSTURAL STABLITY

TRANSVERSE PLANE

TRANSVERSE PLANE

The Third and Final Plane of Movement

TRANSVERSE PLANEIS A MOVEMENT PATTERN IN WHICH AN OBJECT MOVES AROUND A FIXED AXIS INA CURVED PATH

TRANSVERSE PLANE is a 6-8 MONTH OLD DEVELOPMENTAL SKILL

• Rotation is difficult and disorienting for Apraxic children, since they are not

moving their heads out of the upright position. Apraxic children continue to

use straight plane positions

• You can observe Hanging Obliques

• Restricted Separation of Movment or Disassociation of upper extremities

and lower extremities have not emerged (Tin Man)

APRAXIC CHILDREN

HAVE POOR

TO

NO Transverse Plane Skills

(rotational plane)

No Elongation

of the

Internal and External Intercostals

in the Ribcage

Disrupts

TRANSVERSE PLANE

ED SULLIVAN NECK

Ed Sullivan is showing his

hyperstable or elevated

shoulder patterns which are

helping to shorten his neck

HYPERSTABILITY OF THE NECK

Apraxic children tend

to hyperstabilize with

neck, shoulders, and

hip flexors to move

from supine to sit, sit

to stand, and

everything in between.

LINEAR PLANE PATTERNS THAT PERSISIT

►Transverse skills begin with babies preparing to roll over

►Typically, developing children will use head and neck to initiate the rolling and evolve to using the flexion (knees to chest) and the abdominals (belly muscles).

►Children with motor planning issues will continue to primarily alry use movement with their head and neck beyond the infant stage (Ed Sullivan neck).

►This will disrupt rotation through elevating and hyperstabilizing the neck and shoulders and disrupting respiration to support speech and especially oral motor skills

The Dreaded Pretzel

Lisa helping to facilitate Transverse

Plane movements

This Pool Floatie has been

The best piece of equipment for

encouraging rotation

And movement in general

Stairs

►Great to Encourage Transverse Plane in Daily Activities(Rotational Skills)

►Transverse Plane movements (Rotation) support airgrading for word, phrase, and connected speech through increasing core strength therefore you are able to use the diaphragm as intended for breath support and speech

►Transverse Plane supports balance reactions

►Transverse Plane supports crossing midline

TRANSVERSE PLANE CHEATS

Not progressing through

the 3 planes of movement

tends to obstructs the

Orderly Emergence

and Development

Speech/Language

in Apraxic Children

RESPIRATION IS THE FOUNDATION OF SPEECH

PRODUCTION

Apraxic children attempt to initiate and sustain speech with “Quiet Respiration” skills vs

“Forced Respiration” skills for speech.

Apraxic Children tend to present with weak core strength

Playing to their strength leads to creative muscle locking or

“Fixing”

These are compensations disrupting

respiration for speech

SODA POP MODELDeveloped byDr. Mary Massery PT, DPT, DSc

Dr. Mary Massery is a Physical

Therapist who is a National and

International Expert on

Respiration

SODA POP MODEL

Respiration for Speech

and the

Soda Pop Can Theory

Developed by

Dr. Mary Massery PT, DPT DSc

Dr. Massery Teaches a Respiration

Course

If you Can’t Breathe you Can’t

Function

Dr. Massery explains respiration skills

using a

Soda Pop Can

(She is a diehard Chicago Girl)

DR. MASSERY DIVIDES THE

BODY INTO TWO CHAMBERS

THORACIC

AND

ADOMINAL CHAMBERS

DIVIDED BY THE

DIAPHRAGM

SODA POP MODELUpper Chamber

Vocal Cords

Thoracic Cavity

The Upper

Diaphragm

SODA POP MODELThe Lower

Chamber

Lower Diaphragm

Abdominal

Cavity

Pelvic Floor

SODA POP CAN MODEL

Aluminium Can Skelton

Aluminium Around the Can

Does not provide Strength to

Can

Skelton does not

provide strength to body

SODA POP CAN MODEL

Vocal cords

Pelvis

Carbonation

In the Can

Trunk Pressure

of Chambers (Upper and Lower Chambers)

Internal Carbonation

Pressure Maintains the Can’s shape and

strength

Air Pressure

Upper and Lower ChambersPressure supports Posture and Strength

SODA POP MODEL

FOR RESPIRATION

The Soda Pop Can looses strength when opened (pressure is compromised)

The can is easy to deform into different configurations

PRESSURE ISSUES ARE EFFECTED BY CHALLENGES WITH MOTOR PLANNING

VOCAL CORDS

AS

CHAMBER

REGULATORS

IMPORTANT AREA NOT ADDRESSED WITH

APRAXIC CHILDREN UPPER CHAMBER

VOCAL FOLDS

THORACIC CAVITY

UPPER DIAPHRAGM

THORACIC CAVITY

Apraxic Kids are

unable to build,

sustain, and grade

pressure in the

Upper and Lower

Chambers to support

speech

LOWER CHAMBER

LOWER DIAPHRAGM

ABDOMINAL CAVITY

PELVIC FLOOR

NEW DEFINITION OF “CORE”by Dr. Mary Massery

CORE STABILITY EXTENDS FROM THE

VOCAL FOLDS ON TOP

TO THE PELVIC FLOOR ON THE

BOTTOM

AND INCLUDES EVERY MUSCLE

IN BETWEEN

ABDOMINAL BINDER

TO SUPPORT ABDOMINAL AREA AND DIAPHRAGM

Please discuss wearing these options with your Therapist.

Smart Knit Kids Compression

-Deep Pressure Sensory

Compressions Undershirt

Depending on the

Size costs $15.71-$22.46

Amazon sells this product

www.smartknitkids.com

].

CUSTOM ABDOMINAL BINDER The American Sewing is the Company recommended by

Dr. Massery. You can google Custom Abdominal Binder to review all the companies providing

Binders

Dr. Massery recommends only wearing the Binder

8 hours per day. You will need to determine the

best protocol for your child

The Top of the Soda Pop Can Vocal Folds

and Supporting Structures

are the

Gate Keepers of Pressue Regulation

Then Dr. Massery Asks

Are YOUR vocal folds really

related to postural demands ?

STAND UP

The Vocal Cords Considerations for Verbal Apraxia

Stability for Mobility

Yes, Apraxic children have difficulty with Voicing

The Breath Holding is a major issue when the vocal cords should be in neutral

In Sitting or playing with the Apraxic Child you can hear multiple breath holding and releases

“uh” ”uh” “uh” of varying intensity and frequency or something similar

The Apraxic child is attempting to regulate pressure and support their body movements.

Stability (holding my breath and trunk muscles) before Mobility (using my arms and fingers)

Not enough strength and stability to add speech to the motor plan

PRESSURE ISSUES

DURING INFANCY

Apraxic children are often described as the

“Good Babies” who rarely cried or made any

sounds

Babies should be loud and raucous

Research Summary

This is Tandem’s partial list of the muscles to assess in Children with Motor planning issues.

The following muscles are helping to disrupt the orderly emergence of speech and language

Shoulders

Intercostals

Paraspinals

Diaphragm

Abdominals

Pelvic Floor (Hips)

TANDEM’S ADDITION to Dr. Massery’s

List of muscles above

Eyes

Feet

Dr. Massey confirms through research

The trunk muscles are simultaneously

supporting

Respiratory

And

Postural Systems

SODA CAN MODEL

Dr. Massery says

“Appropriate Balanced

Pressure allows

talking, walking, and

chewing gum”

PITCH PLAY

Respiration Issues with Thoracic and Pelvic Pressure

Upper and Lower Chambers

YELLINGWHISPERING

GRUNTING

OR

BUILDING VALSALVA

Issues with Thoracic and Pelvic Pressure

Sneezing/Blowing Nose

Laughing

Apraxic children can have difficult with these pressure patterns to varying degrees

More Pressure

Sensitive

Requirements

Sniffing

Raspberries

Sniffing is something that Apraxic

Children have difficulty producing.

You must activate your facial muscles and respiratory

skills. For example, Making a pig face and sniffing in

and out quickly.

This is a pattern seen at approximatley

6-7 months of age.

Apraxic children of all ages have trouble with this

pre-linguistic pattern due to restricted pressure play

Apraxic children of all ages

have difficulty with

producing raspberries

DECREASED PELVIC AND THORACIC PRESSURE

Can’t Blow out Candles?

Not building, sustaining, and grading

pressure to support blowing

IT IS NOT ABOUT THE INABILITY TO

ROUND THE LIPS

SOME OF THE MOVEMENT

MUSCLES USED TO SUPPORT SUSTAINED

LINEAR PLANE PATTERNS

In Correct Usage of the Primary

Muscle for

Respiration:

Postural Muscle Stability

►The Diaphragm controls forced and quiet inhalation and exhalation

►The Diaphragm is unable to function as a primary muscle for respiration (Quiet and Forced) because Apraxic children use the Diaphragm as a postural support muscle not for breath support for speech

Feet Turning Blue from Hyperstabiliy

Patterns or Severe “Hanging On”

On Occasion, Lisa and I have treated children whose

feet are blue from hyperstable patterns of the feet. These

children are attempting

to sit, play, stand, and walk with hyperstable feet

patterns disrupting circulation

Although, this is generally a sign of heart issues

in children but can be a hyperstability pattern

Please check with your pediatrician and/or cardiologist

MOVEMENT PATTERNS VIOLATED

EXTERNAL INTERCOSTALS SUPPORT

INHALATION

▶ The rib cage provides core stability and support that

helps with dynamic movement and appropriate

static placement

▶ Apraxic kids lock and hold the external intercostals

disrupting quiet and forced respiration

▶ It will be difficult for the rib cage to move side to

▶ small shifts in the rotational plane are also difficult

to facilitate

▶ Intercostals must elongate to support inhalation

▶ The intercostals are not elongated in children with

Verbal Apraxia

STABILITY BEFORE MOBILITY

QUIET RESPIRATION

MUSCLES OF FORCED EXHALATION

Apraxic children have significant

difficulty with forced exhalation skills

Internal Intercostals helps to form the

chest wall

The intercostal muscles are

between your ribs and help

enlarge the chest cavity. The

Intercostals contract to pull your

rib cage both upward and outward

when you inhale.

STABILITY BEFORE MOBILITY Muscles of Quiet and Forced Respiration

The Apraxic children will generally present with elevated ribcages and or asymmetrical ribcages

The chest might look boxy

You might see the bottom portion of the ribcage flaring out

You will also see a divot in the middle of the chest that resembles the beginnings of pectus excavatum

We call this Pseudo-pectus excavatum

A DIAGNOSTIC INDICATOR

What you might see in our Apraxic Children

APRAXIC

Pseudo Pectus Excavatum

True Pectus Excavatum

USING THE RIBCAGE

FOR STABILITY vs MOBILITY

DISRUPTS SPEECH PRODUCTION

Flaring Ribcage

Elevated ribcage which means restricted

elongation of the intercostals

This floppy belly is also an indication of Poor

core stability

Flaring at the bottom of the ribcage signifies

weakness through the abdominals and

ribcage

The wrinkle in the belly signify inactivity

Might observe diastasis recti

WEAK MUSCLES IN THE EXTERNAL AND INTERNAL INTERCOSTALS

POT BELLY

NOTHING SAY WEAKS ABDOMINALS

LIKE A

POT BELLY

Separation of Movement

Disassociation

T

This Photo by Unknown Author is licensed under CC BY-NC

ANOTHER MYSTERY SOLVED BY

PHYSICAL THERAPY AND OCCUPATIONAL THERAPY

Apraxic kids do not have separation of movement of the eyes from the head, neck, jaws, tongue,

lips, tongue, and jaws.

Apraxic children are unable to move their eyes into various positions to support processing the

world around them.

Apraxic kids will use their eyes to support head and other body movements.

The eye movements between Apraxic children and Autistic children should be researched.

This could be an important differential diagnosis between the two disorders.

Hyper Stability of the Eyes disrupting

pending Rotational Skills

This is Noah at 1 month. He is hyper stabilizing his head and shoulders using his eyes to support elevation of his head. When Amanda saw this picture and stated his cervical flexion strength is poor. Cervical extension is being overused and control against gravity is poor.

Hyperstability with the eyes can disrupt his motor development and overall development of head control

This is the normal posture of a

1-2 month old child.

NoahI saw Noah for only Six Months. He was

2.5 years when I started treating him through Early

Intervention. Mom showed me this picture on our last

session

Here is the Baby as at almost 3 years old. Look at the the upper and lower pictures Noah is having difficulty transitioning to his right side. He is hyper stablilizing and overusing his right side for support

Look how he has his tilted to the right so he can use his eyes to review his environment. Remember he uses his eyes to support his head

The Coshee Seat (Blue seat that Noah is sitting on) is trying to disrupt his W sitting. He postures to right which is his preferred position

SEPARATION OF MOVEMENT OF EYES FROM HEAD

AND NECK, TONGUE, AND JAWS

INFANT EYE DEVELOPMENT

THE EYES MUST BEGIN TO DEMOSTRATE

SEPARATION OF MOVEMENT OF HEAD, NECK,

TONGUE, LIPS, AND JAWS FOR ORAL MOTOR

SKILLS TO EMERGE

IN the first few weeks of life an

infant Infant’s eyes are fixed.

Approximately 3 months later,

Children begin to move their eyes

independently of their head

SEPARATION OF MOVEMENT OF EYES FROM

HEAD AND NECK, TONGUE, AND JAWS

INFANT EYE DEVELOPMENT

Apraxic children have NO to PARTIAl SEPARATION of Movement or Disassociation

of EYES from the head and neck

Apraxic childen have much difficulty moving and

Holding the eyes in the far quadrants

One way to observe this Eye Movment pattern is with a platform such as Zoom

You will have enlarged view allowing for better observation of the eyes, head, neck, and chin

SEPARATION OF MOVEMENT VISUAL DEVELOPMENT

By 6 months of age

Separation of movement of

EYES from the …

Head

Neck.

Jaws.

Tongue is necessary

so the Babbling can begin to

emerge

Son of Michaela Gahman from Apraxic Kids

Mom posted this picture and asked

about Apraxic children’s ability to

eat with their mouth closed. The

Lip smacking was driving her crazy

You might also see Apraxic

children counterbalancing with

their eyes

Lids will be half closed

chin slightly elevated

using the lower quadrant of the

eyes to view the world

STABILITY BEFORE MOBILITY Counter Balancing

the Head with their Eyes Will not be be able to shift eyes without moving

the head

(no separation of movement )

You can see this posture in varying degrees

Also look the right hand. It is fisted and resting

on the chair for stability. Sign of poor core

strength

This is one of the tricks that you might find

Apraxic Children using. They have masterful

compensations that go unnoticed

Look at River’s eyes. He was

positioned on the foam stairs to

provide better stability through his

shoulder girdle and he was able to

move his eyes to the far quadrant

without moving his head

Hyperstable Neck The Valley of the Neck

You will see overactive capital (head) extensors

As separation of movement of the eyes improve, you will hear the speech improve

HYPERSTABLE NECK

THE VALLEY OF THE NECK

This is dip in the neck is from using eyes

muscles for head control and this is an effort of

counterbalance the head.

Speech can be difficult to initiate because of

the lack of separation of movement of the eyes

from the oral motor system.

You might also note that the Occiput can also is

elevated

The back of the neck should be smooth

indicating appropriate balance of the head, neck

and shoulder muscles

The back of the neck should be smooth

indicating appropriate balance of the head, neck

and shoulder muscles

Separation of MovementEyes from the Head, Neck, and Oral-Motor system

Emerging verbal language sample can/will:

Be dominated by nouns

Some Apraxic children can/will Have difficulty with visual processing movement in their environment

This is because of restricted separation of movement of the eyes from the head and neck

They view items and events that are static

WHY LOOK AT THE FEET FOR

VERBAL APRAXIA

Deviations in Feet Positions Can Effect Alignment Which

Can….

INFLUENCE POSTURES AND GAIT

DISRUPTS THE LOWER CHAMBER NEEDED TO SUPPORT

RESPIRATION SKILLS FOR SPEECH

Lindsay Haycraft

Lindsay Haycraft, PT, DPT Helped to unravel another Apraxicmystery

I had been asking this question for years (25 years) with no supportive answer for the observed patterns; I had noted over the years with Apraxic kid’s feet

“Lindsay, what is up with Pronation and

Supination in my kids ??” Pronation or Supination of the

feet is noted consistently in Children Verbal Apraxia

Sign of reduced core strength and children actively seeking support by any means necessary

Supination (walking on the outside of the feet forming a soup bowl (Learned from Lisa)

Pronation (walking on the insides of the feet and or the ankles). You might also see uneven wear of the shoes depending on the posture used

And Dr. Haycraft said……

THEN LINDSAY SAID…….

How about

a

Patti Bob

PATTI BOBS

Primary goal of foot orthosis: to create a neutral position to allow for more optimal function

MAIN AREAS OF DOCUMENTED VALUE FOR BRACING IN PEDIATRIC POPULATION:

Prevention of deformity

Correction of positioning deformity

Promotion of a Stable Base

Facilitating development of skills

Improving efficiency of gait

-Campbell et all

COMPANY IMFORMATION IN REFERENCES

SUBTALAR JOINTArticulating surface of talus (ankle bone) and heel (calcaneus)

https://reembodyme.files.wordpress.com/2014/05/img_0281.jpg

PRONATION /SUPINATION IN APRAXIC CHILDREN

Without changing from supination and/or pronation for the

push off, Apraxic kids are stuck in the initial phase of gait development

Pes Planus: foot that exhibits no arch and an ankle that is everted*can also be called flat foot or pronatedhttps://file.scirp.org/Html/4-2100559/ec2bce50-e8f3-4139-a59d-c812fc84ed60.jpg

ATYPICAL FOOT POSITION

Let’s

Take a Brief Look at Typical Gait

Development!

(Approximately 12-15 months)

Gait’s Progress

Movement patterns are refined

Around 18 months a heel strike

2 years more bend in the knees

Gait pattern matures and the

feet strengthen and develop

3 years walking pattern is maturing and looks more like adult

TAKE HOME MESSAGE

When walking first emerges, stability reigns

supreme over efficiency.

Your child is more concerned with falling than

being fast.

As the child gets more comfortable efficiency

states to take over

Changes in patterns emerge

Get to where they’re going fast

HOW DO I KNOW IF FLAT

FEET ARE A PROBLEM

So how do I know if my child’s flat feet are a problem? Here are some questions to ask yourself:

Does my child seem anxious/nervous about standing/moving?

Is my child is late with walking or can walk but not keep up with peers?

Does he/she falls a lot either over his/her own feet or when presented with obstacles or varying surfaces?

Alignment or gait mechanic deviations could be happening

This Photo by Unknown Author is licensed under CC BY-ND

Support emergence of Speech

These shoes inserts or

Patti Bobs have made

the greatest difference…

Helping to build pressure

lower chamber pressure

Extinguishing pronation

and/or supination

Increasing separation of

movement of upper and

lower extremities

Tandem Theory Patti Bobs

assist Apraxic Kids

sustaining and grading pressure

in the Pelvis/Lower Chamber to support

speech

“

”

Learning new skills is difficult for anyone

with Praxis issues.

YOU CANNOT BUILD A SOLID HOUSE ON A WEAK

FOUNDATION

WHY FIX IT. IT

AIN’T BROKEN

Apraxic kids can present as Stubborn

but this a protective response

Apraxic Kids do not like to have their

preferred motor plan disrupted

through touch, facilitation, or words.

The slightest change introduced

outside their neurological system, can

be met with retreat, avoidance,

and/or tantrums of varying levels.

Apraxic Children lock their favorite parts of the body

disrupting the interconnected

systems needed to support the

emergence of Speech and

Language skills.

Circa 2010

USE WALKING MUSCLES FOR WALKING

AND SPEECH MUSCLES FOR SPEAKING

Lindsay Haycraft, PT, DPT

Hope to be able to present

this information to you in

person at the Apraxic Kids

Conference next year 2021

Cascade

Maker of Patti Bobs

800.848.7332

+1 360 543 9306(international)

dafo@dafo.com

Smart Knit Kids Vests

www.smartknitkids.com You want the

vest a little snug to provide the support to the trunk

muscles. Kids might not like the vest initially as you

are changing their base of support which is

disorienting for the Apraxic Child

1.Wasserman JB, Abraham K, Massery M, Chu J, Farrow A, Marcoux BC: Soft Tissue Mobilization Techniques Are Effective in Treating

Chronic Pain Following Cesarean Section: A Multicenter Randomized Clinical Trial. In: Elkwood AI, Kaufman M, Schneider L, eds. Rehabilitative

Surgery: A comprehensive Text for an Emerging Field. Switzerland: Springer; 2017:129-137

2.Massery MP. Physical Therapy Following Phrenic Nerve Graft Surgery: Implications Far Beyond Breathing. In: Elkwood AI, Kaufman M,

Schneider L, eds. Rehabilitative Surgery: A comprehensive Text for an Emerging Field. Switzerland: Springer; 2017:129-137

3.Kaufman M, Bauer T, Massery MP, Cece J. Phrenic Nerve Reconstruction for Diaphragmatic Paralysis and Ventilator Dependency. In:

Elkwood AI, Kaufman M, Schneider L, eds. Rehabilitative Surgery: A comprehensive Text for an Emerging Field. Switzerland: Springer; 2017:115-128.

4.Massery MP. Asthma: Multisystem Implications. In: Palisano R, Orlin M, Schreiber J, eds. Campbell’s Physical Therapy for Children. 5 ed. St.

Louis, MO: Elsevier; 2017.

5.Massery M. Breathing and Postural Control: It’s all about Pressure! The Gas Exchange. Vol Summer. Ottawa, Canada: Canadian Physiotherapy

Association – Cardiorespiratory Division; 2016:6-9.

6.Frownfelter D, Stevens K, Massery M, Bernardoni G. Do abdominal cutouts in thoracolumbosacral orthoses increase pulmonary function?

Clin Orthop Relat Res. Feb 2014;472(2):720-726.

Massery M, Hagins M, Stafford R, Moerchen V, Hodges PW. Effect of airway

control by glottal structures on postural stability. J. Appl. Physiol. Aug

2013;115(4):483-490.

Massery M. Multisystem clinical implications of impaired breathing mechanics

and postural control. In: Frownfelter D, Dean E, eds. Cardiovascular and

Pulmonary Physical Therapy: Evidence to Practice. 5 ed. St. Louis, MO: Elsevier-

Mosby; 2012:633-653.

Massery M. Asthma: Multi-System Implications. In: Campbell S, Palisano R, Orlin

M, eds. Physical Therapy for Children. 4 ed. St. Louis, MO: Elsevier; 2012:815-

844.

Massery M, Sweeney JK. Commentary on “Expiratory Flow Increase Technique

and Acid Esophageal Exposure in Infants Born Preterm With Bronchopulmonary

Dysplasia”. Pediatric Physical Therapy. 2011;23(4):333-334.

Massery M. The effect of airway control on postural stability (doctoral

dissertation). Provo, UT: Rocky Mountain University of Health Professions; 2011.

Massery M, Cahalin L. Physical Therapy Associated with Ventilatory Pump

Dysfunction and Failure. In: DeTurk W, Cahalin L, eds. Cardiovascular and

Pulmonary Physical Therapy. 2 ed. New York: McGraw-Hill; 2011:643-693.

Massery, M., Breathing and Upright Posture: Simultaneous Needs, in 26th

International Seating Symposium, Vancouver, BC. March 11-13, 2010;25-28.

Massery M. The Linda Crane Memorial Lecture: The patient puzzle – piecing it together. Cardiopulmonary Phys Ther J. 2009;20(2):19-27.

Massery M. Referred by the Cystic Fibrosis Clinic’s PT: Treatment of Posture and Pain. Pediatric Pulmonology, Supplement. 2008;31:112-114.

Frownfelter D, Stevens K, Massery M, Bernardoni GP. Comparison of respiratory function while wearing a thoraco-lumbar-sacral orthosis (TLSO) with and

without an abdominal cutout (Abstract). Cardiopulmonary Phys Ther J. 2006;17(4):141.

Massery M. Magee, C. Asthma: Multi-System Implications. In: Campbell S, Palisano R, Vander Linden D, eds. Physical Therapy for Children. 3 ed. Philadelphia,

PA: Elsevier Health Science; 2006:Chapter 28:851-879.

Massery M. Multisystem Consequences of Impaired Breathing Mechanics and/or Postural Control. In: Frownfelter D, Dean E, eds. Cardiovascular and

Pulmonary Physical Therapy Evidence and Practice, ed. 4. 4 ed. St. Louis, MO.: Elsevier Health Sciences; 2006:695-717.

Frownfelter D, Massery M. Body Mechanics – The art of positioning and moving patients. In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary

Physical Therapy Evidence and Practice, ed. 4. St. Louis, MO: Mosby & Elsevier Health Sciences; 2006:Chapter 42:749-758.

Frownfelter D, Massery M. Facilitating airway clearance with coughing techniques. In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical

Therapy Evidence and Practice, ed. 4. St. Louis, MO: Mosby & Elsevier Health Sciences; 2006:Chapter 22:363-376.

Nuzzo NA, Bronson LA, McCarthy T, Massery M. Respiratory muscle strength and endurance following a CVA. Neurology Report. 1999

1999;23(1):25-27.

Feldman D, Ouellette M, Villamez A, Massery M, Cahalin L. The relationship of ventilatory muscle strength to chest wall excursion in normal

subjects and persons with cervical spinal cord injury. (Abstract). Cardiopulmonary Physical Therapy Journal. 1998 1998;9(4):20.

Massery MP, Dreyer HE, Bjornson AS, Cahalin LP. Chest wall excursion and tidal volume change during passive positioning in cervical spinal

cord injury. (Abstract). Cardiopulmonary Physical Therapy. 1997;8(4):27.

Nuzzo NA, Bronson LA, McCarthy T, Massery M. Ventilatory muscle training effect on respiratory status and functional mobility following a CVA:

a case study. Cardiopulmonary Physical Therapy Journal. 1997;8(1):15-18.

Bronson LA, Nuzzo NA, McCarthy T, Massery M. The effect of VMT on post-CVA pulmonary function and functional mobility. (Abstract).

Cardiopulmonary Physical Therapy Journal. 1997 1997;8(4):25-26.

Massery MP, Frownfelter DL. Facilitating Airway Clearance with Coughing Techniques. In: Frownfelter DL, Dean E, eds. Principles and Practice of

Cardiopulmonary Physical Therapy, ed. 3. St. Louis, MO: Mosby-Year Book; 1996:367-382.

Massery MP, Frownfelter DL. Facilitating Ventilatory patterns and Breathing Strategies. In: Frownfelter DL, Dean E, eds. Principles and Practice

of Cardiopulmonary Physical Therapy, ed. 3. St. Louis, MO: Mosby-Year Book; 1996:383-416.

Massery MP. The patient with neuromuscular or musculoskeletal dysfunction. In: Frownfelter DL, Dean E, eds. Principles and Practice of

Cardiopulmonary Physical Therapy, ed. 3. St. Louis, MO: Mosby-Year Book; 1996:679-702.

Massery M. Manual breathing and coughing aids. In: Bach J, Haas F, eds. Pulmonary Rehabilitation. Philadelphia, PA: WB Saunders; 1996:407-422.

Massery MP, Frownfelter DL. Facilitating Airway Clearance with Coughing Techniques. In: Frownfelter DL, Dean E, eds. Principles and Practice of

Cardiopulmonary Physical Therapy, ed. 3. St. Louis, MO: Mosby-Year Book; 1996:367-382.

Massery MP, Frownfelter DL. Facilitating Ventilatory patterns and Breathing Strategies. In: Frownfelter DL, Dean E, eds. Principles and Practice

of Cardiopulmonary Physical Therapy, ed. 3. St. Louis, MO: Mosby-Year Book; 1996:383-416.

Massery MP. The patient with neuromuscular or musculoskeletal dysfunction. In: Frownfelter DL, Dean E, eds. Principles and Practice of

Cardiopulmonary Physical Therapy, ed. 3. St. Louis, MO: Mosby-Year Book; 1996:679-702.

Massery M. Manual breathing and coughing aids. In: Bach J, Haas F, eds. Pulmonary Rehabilitation. Philadelphia, PA: WB Saunders; 1996:407-422.

Massery MP, Frownfelter DL. Assisted cough techniques – there’s more than one way to cough. PT

Forum; 1990:1-3.

Massery MP, Frownfelter DL. Consider the gravity of gravity. PT Forum; 1989:1-3.

Massery M. Respiratory rehabilitation secondary to neurological deficits: understanding the deficits.

In: Frownfelter D, ed. Chest Physical Therapy and Pulmonary Rehabilitation: An Interdisciplinary

Approach, ed.2. Chicago: Mosby-Yearbook; 1987:499-528.

Massery M. An innovative approach to assistive cough tecniques. Topics in Acute Care and Trauma

Rehabilitation. 1987;1(3):73-85.

Massery M. Respiratory rehabilitation secondary to neurological deficits: treatment techniques. In:

Frownfelter D, ed. Chest Physical Therapy and Pulmonary Rehabilitation: An Interdisciplinary Approach, ed.2.

Chicago: Mosby-Yearbook; 1987:529-562.

APTA. (2001). Guide to Physical Therapist Practice, ed 2. Physical Therapy 81:.

Bach, J.R., Baird, J.S., Plosky, D., Navado, J., & Weaver, B. (2002). Spinal muscular atrophy type 1:

management and outcomes. Pediatric Pulmonology 34:16-22.

Bach, J.R., & Bianchi, C. (2003). Prevention of pectus excavatum for children with spinal muscular atrophy

type 1. American Journal of Physical Medicine and Rehabilitation 82:815-819.

Bach, J.R. & Saporito, L.R. (1996). Criteria for extubation and tracheostomy tube removal for patients with

ventilatory failure. A different approach to weaning. Chest 110:1566-1571.

Bly, L. (1994). Motor skills acquisition in the first year. San Antonio, Tex: Therapy Skill Builder.

Borowitz, S.M., & Borowitz, K.C. (1997). Gastroesophageal reflux in babies: impact on growth and

development. Infants and Young Children 10:14-26.

Borowitz, S.M., & Sutphen, J.L. (2004). Recurrent vomiting and persistent gastroesophageal reflux caused by

unrecognized constipation. Clinical Pediatrics 43:461-466.

Bouisset, S., & Duchene, J.L. (1994). Is body balance more perturbed by respiration in seating than in standing

posture? Neuroreport 5:957-960.

Button, B.M., Heine, R.G., et al. (2003). Chest physiotherapy in infants with cystic fibrosis: to tip or not? A five-

year study. Pediatric Pulmonology 35:208–213.

Button, B.M., Heine, R.G., et al. (2004). Chest physiotherapy, gastro-esophageal reflux, and arousal in infants

with cystic fibrosis. Archive of Diseases in Childhood 89:435–439.

Cala, S.J. (1993). Abdominal compliance, parasternal activation, and chest wall motion. Journal of Applied

Physiology 74:1398-1405. Cherniack, R.M. & Cherniack, L. (1983). Respiration in health and

disease, ed 3. Philadelphia, Pa: W.B. Saunders Co.

De Looze, D., Van Laere, M., De Muynck, M., & Elewaut, A. (1998). Constipation and other chronic

gastrointestinal problems

in spinal cord injury patients. Spinal Cord 36:63-66.

De Troyer, A., Gorman, R.B., & Gandevia, S.C. (2003). Distribution of inspiratory drive to the external

intercostal muscles in humans.

Journal of Physiology 546:943-954.

de Ybarrondo, L., & Mazur, J.L. (2000). Sandifer’s syndrome in a

child with asthma and cerebral palsy. Southern Medical Journal

93:1019-1021.

Deem, J.F. & Miller, L. (2000). Manual of voice therapy, ed 2.

Austin,Tex: PRO-ED, Inc.

Demir, E., Saka, E., et al. (2001). A case of Sandifer’s syndrome

with hand tremor. Turkish Journal of Pediatrics 43:348-350. Dodd, M.E. (2004). Incontinence in cystic

fibrosis. London: Presented at The Royal Society of Medicine Conference on

Cystic Fibrosis.

Gandevia, S.C. Butler, J.E., Hodges, P.W., & Taylor, J.L. (2002).

Balancing acts: respiratory sensations, motor control and human posture. Clinical and Experimental

Pharmacology and Physiology 29:118-121.

Gorrotxategi, P., Reguilon, M.J, et al. (1995). Gastroesophageal reflux in association with the Sandifer

syndrome. European Journal of Pediatric Surgery 5:203-205.

Grimstone, S.K. & Hodges, P.W. (2003). Impaired postural compensation for respiration in people with

recurrent low back pain. Experimental Brain Research 151:218-224.

Han, J.N., Gayan-Ramirez, G., Dekhuijzen, R., & Decramer, M. (1993). Respiratory function of the rib

cage muscles. European Respiratory Journal 6:722-728.

Hayama, S., Honda, K., et al. (2002). Air trapping and arboreal locomotor adaptation in primates: a

review of experiments on humans. Zeitschrift fur Morphologie und Anthropologie 83:149-159.

Hodges, P.W. & Gandevia, S.C. (2000). Activation of the human diaphragm during a repetitive postural

task. Journal of Physiology 522:165-175.

Hodges, P.W., & Gandevia, S.C. (2000). Changes in intra-abdominal pressure during postural and

respiratory activation of the human diaphragm. Journal of Applied Physiology 89:967-976.

Hodges, P.W., Gurfinkel, V.S., Brumagne, S., Smith, T.C., & Cordo, P.C. (2002). Coexistence of stability

and mobility in postural control: evidence from postural compensation for respiration. Experimental

Brain Research 144:293-302.

Hodges, P.W., Heijnen, I., & Gandevia, S.C. (2001). Postural activity of the diaphragm is

reduced in humans when respiratory demand increases. Journal of Physiology 537:999-

1008.

A02775-Ch39.qxd 10/26/05 1:03 PM Page 716

39 The Patient with Multisystem Impairments Affecting Breathing Mechanics and Motor

Control 717

Langman, H., Orr, A., et al. (2004). Urinary incontinence in CF: why does it happen?

Eighteenth Annual North American Cystic Fibrosis Conference, St. Louis, Mo. Pediatric

Pulmonology 27(Suppl):154-155.

Lanini, B., Bianchi, R., Romagnoli, I., Coli, C., Binazzi, B., Gigliotti, F., Pizzi, A., Grippo,

A., & Scano, G. (2003). Chest wall kinematics in patients with hemiplegia. American

Journal of Respiratory and Critical Care Medicine 168:109-113.

Lissoni, A., Aliverti, A., Tzeng, A.C., & Bach, J.R. (1998). Kinematic analysis of patients

with spinal muscular atrophy during spontaneous breathing and mechanical ventilation.

American Journal of Physical Medicine and Rehabilitation 77:188-192.

Massery, M. (2005). Asthma: multisystem implications. In Campbell, S., Palisano, R., &

Vander Linden, D., (Eds). Physical therapy for children. Philadelphia, Pa: W.B. Saunders.

Massery, M.P. (1991). Chest development as a component of normal motor development:

implications for pediatric physical therapists. Pediatric Physical Therapy 3:3-8.

McGill, S.M., Sharratt, M.T., & Seguin, J.P. (1995). Loads on spinal tissues during simultaneous lifting and

ventilatory challenge. Ergonomics 38:1772-1792.

Nava, S., Ambrosino, N., Crotti, P., Fracchia, C., & Rampulla, C. (1993). Recruitment of some respiratory

muscles during three maximal inspiratory manoeuvres. Thorax 48:702-707.

Noreau, L., Proulx, P., Gagnon, L., Drolet, M., & Laramee, M.T. (2000). Secondary impairments after spinal cord

injury: a population-based study. American Journal of Physical Medicine and Rehabilitation 79:526-535.

Papastamelos, C., Panitch, H.B., & Allen, J.L. (1996). Chest wall compliance in infants and children with

neuromuscular disease. American Journal Respiratory Critical Care Medicine 154: 1045-1048.

Pierce, R.J. & Worsnop, C.J. (1999). Upper airway function and dysfunction in respiration. Clinical and

Experimental Pharmacology and Physiology 26:1-10.

Primiano, F.P. Jr. (1982). Theoretical analysis of chest wall mechanics. Journal of Biomechanics 15:919-931.

Rimmer, K.P., Ford, G.T., & Whitelaw, W.A. (1995). Interaction between postural and respiratory control of

human intercostal muscles. Journal of Applied Physiology 79:1556-1561.

Rimmer, K.P. & Whitelaw, W.A. (1993). The respiratory muscles in multicore myopathy. American Review of

Respiratory Disease 148:227-231.

Sapsford, R.R., Hodges, P.W., Richardson, C.A., Cooper, D.H., Markwell, S.J., & Jull, G.A. (2001). Co-activation

of the abdominal and pelvic floor muscles during voluntary exercises. Neurourology and Urodynamics 20:31-42.

Senocak, M.E., Arda, I.S, et al. (1993). Torticollis with hiatus hernia in children. Sandifer syndrome.

Turkish Journal of Pediatrics 35:209-213.

Serway, R., & Faughn, J. (1992). College physics. Orlando, Fla: Harcourt Brace Jovanovich.

Skjodt, N.M., Farran, R.P., Hawes, H.G., Kortbeek, J.B., & Easton, P.A. (2001). Simulation of acute

spinal cord injury: effects on respiration. Respiratory Physiology 127:3-11.

Sobus, K.M.L., Horan, S.M., et al. (2000). Respiratory management of neuromuscular diseases in

children. Physical Medicine and Rehabilitation: State of the Art Reviews 14:285-299.

Sumarez, R.C. (1986). An analysis of action of intercostal muscles in the human rig cage. Journal of

Applied Physiology 60:690-701.

Toder, D.S. (2000). Respiratory problems in the adolescent with developmental delay. Adolescent

Medicine 11:617-631.

Werlin, S.L., D’Souza, B.J., et al. (1980). Sandifer syndrome: an unappreciated clinical entity.

Developmental Medicine and Child Neurology 22:374-378.

Wilson, T.A., Legrand, A., Gevenois, P.A., & De Troyer, A. (2001). Respiratory effects of the external

and internal intercostal muscles in humans. Journal of Physiology 530:319-330.

Winslow, C., & Rozovsky, J. (2003). Effect of spinal cord injury on the respiratory system. American

Journal of Physical Medical Rehabilitation 82:803-814.

Wood, R.P. 2nd, Jafek, B.W., & Cherniack, R.M. (1986). Laryngeal dysfunction and pulmonary disorder.

Otolaryngology Head and Neck Surgery 94:374-378.

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Muscles of Respiration

Inhalation Diaphragm

Pectoralis Major

Pectoralis Minor

Subclavius

Serratus Anterior

External Intercostal

Levators costalis

Serratus posterior superior

Sternocleidomastiod

Scalenus anterior

Latissimus Dorsi

Sacrospinalis

Expiration Internal Intercostals

Serratus posterior inferior

Quadratus Lumborum

Abdominal Muscles

Transverse Abdominis

REFERENCES