YAI 2013 May 9, 2013 1

YAI 2013 May 9, 2013 2

Matheny Medical & Educational Center

Matheny’s main campus is located in Peapack, NJ. Matheny is home and school to 101 adults and children with developmental disabilities. In addition to their primary diagnoses many children and adults, have a long list of associated clinical conditions such as vision and hearing deficits, seizure disorders, cognitive impairments and dysphagia, with resulting aspiration problems.

YAI 2013 May 9, 2013 3

About Matheny

Middle States accredited school JCAHO and CARF accredited School and

Hospital Multidisciplinary team approach

Brynna 3 years of experience with the

developmentally disabled population Speech Pathologist at Matheny Medical

and Educational Center Certifications and Licensure

New Jersey State Speech Language PathologistNew Jersey Board of Education Speech

Language SpecialistAmerican Speech Language Hearing

Association Certificate of Clinical Competence

YAI 2013 May 9, 2013 4

YAI 2013 May 9, 2013 5

Christine

11 years of experience with the developmentally disabled population

Senior Speech Pathologist at Matheny Medical and Educational Center

Certifications and Licensure New Jersey State Speech Language Pathologist New Jersey Board of Education Speech Language Specialist American Speech Language Hearing Association Certificate of

Clinical Competence Rehab Engineering Society of North America certified Assistive

Technology Professional Certified Pediatric Neuro-Developmental Treatment therapist PROMPT trained

Erin 10 years of experience with the

developmentally disabled population Physical Therapist at Matheny Medical

and Educational Center Certifications and Licensure

New Jersey State Physical TherapistNew Jersey Board of Education School

Physical TherapistCertified Pediatric Neuro-Developmental

Treatment therapist

YAI 2013 May 9, 2013 6

YAI 2013 May 9, 2013 7

The Rule for Today

Every time you hear the word ‘movement’, stand all the way up, then sit down.

YAI 2013 May 9, 2013 8

Why is respiration important

The process of Respiration: Diaphragm contracts &

moves down Ribcage expands in 3

directions as lungs fill with air

Diaphragm relaxes, the ribcage contracts, expelling air from the lungs

The function of respiration: Getting oxygen to the

tissues and organs of the body

Removes carbon dioxide/waste

YAI 2013 May 9, 2013 9

How respiration is important in daily functioning

Gives endurance Feeds brain cells Promotes better health Promotes improved attention Necessary for everything!

YAI 2013 May 9, 2013 10

The Basics-Anatomy of the ribcage

Structure Cage like part of the

body comprised of bones, muscles and cartilage

Function Protect the internal

organs such as lungs, heart, kidneys, liver

Additionally, it supports the head, neck and upper extremities

Brynna Cunningham, M.S., CCC-SLPChristine Mayercik, M.S., CCC-SLP, ATP, C/NDT

Erin Meineke, PT, DPT, C/NDT

YAI 2013 May 9, 2013 11

Structure-Bones

• Bones– 12 pairs of ribs, with origin at the

thoracic vertebrae and insertion at the sternum.

– Ribs 1-7 are known as “True” Ribs, meaning they have individual origins and insertions

– Ribs 8-10 are known as “False” Ribs, meaning they have unique origins on the vertebrae, but articulate with rib #7 at the sternum

– Ribs 11 and 12 are known as “Floaters”…they have origins on the vertebrae, but do not connect to the sternum.

– The sternum is comprised of three parts…the manubrium, the body and the xyphoid process. Ribs attach to the manubrium and the body, but not to the xyphoid process.

YAI 2013 May 9, 2013 12

Structure-Muscles and Cartilage

• Muscles and cartilage• Intercostals…in the space

between ribs. On inhalation, the intercostals contract, lifting the ribcage up and out.

• Sternocleidomastoid, Scalenes, Pectoralis…assist in respiration by lifting the ribcage.

• Diaphragm…forms the base of the rib cage. On inhalation it flattens and contracts, pulling the lungs down and allowing them to fill.

• Cartilage connects the true ribs to the sternum. It allows movement of the ribs during inhalation and exhalation.

YAI 2013 May 9, 2013 13

The Diaphragm

The muscle that forms the floor of the ribcage. Maximizes inhalation Contributes to postural

control Supports gastro-

intestinal function Aids venous return

YAI 2013 May 9, 2013 14

Movement of the Ribcage

Typical During respiration, the

ribcage moves in 3 planes:○ Up/down (vertical)○ Front/Back

(anterior/posterior)○ Around (Transverse)

YAI 2013 May 9, 2013 15

Movement Break!

YAI 2013 May 9, 2013 16

Normal rib cage development

• Infant ribcage:– Triangle shape– Whole cage is elevated

and ribs are horizontal – High respiratory rate and

low tidal volume– Diaphragmatic nose

breatherMassery, M. 1994

YAI 2013 May 9, 2013 17

Normal ribcage development

• 3-6 months– anterior chest wall

significantly opens– Ribcage configuration

begins to look more rectangular

– Respiratory rate decreases as tidal volume increases

6-12 months Child is now upright against

gravity Breathing is no longer

posturally inhibited by contact with supporting surface

Gravity and developing abdominal muscles rotate the ribs and begin to pull them downward which results in an elongated chest wall

12 months + Downward rotation of ribcage

continues

YAI 2013 May 9, 2013 18

Typical Breathing Patterns

Normal Breathing PatternsClavicularThoracicDiaphragmatic

YAI 2013 May 9, 2013 19

Typical Breathing-Toddler

YAI 2013 May 9, 2013 20

Typical Breathing- 5 year old

Bench sitting Supine

YAI 2013 May 9, 2013 21

The Basics- Atypical development

How we end up with kids who are not breathing well

Muscle tone Neurological

impairment Physical abnormalities

YAI 2013 May 9, 2013 22

Atypical Ribcage Development

What we see: Decreased head and neck

control

Poor Control of Shoulders and Upper Extremities

Poor Control of Pelvis and Lower Extremities – due to low tone

Poor Control of Pelvis and Lower Extremities – due to high tone

Effect on Respiration: Open mouth positioning Increase thoracic kyphosis (flexion) and lumbar flexion Decreased oral motor control – baby is unable to bring

hands to mouth Scoliosis

Increased thoracic kyphosis

Rib flaring Poor rib cage and intercostal movement – the rib cage

moves as a whole unit to produce body movement, movement occurs between T12-L1 spinal segment

Increased thoracic flexion in sitting

Decreased use of abdominal obliques, which become elongated and weak

Increase in thoracic and lumbar flexion Fixing with rectus abdominis which can contribute to rib

flaring

YAI 2013 May 9, 2013 23

Atypical Breathing Patterns

ParadoxicalDiaphragm and upper accessory musclesUpper accessory musclesAsymmetricalLateral or gravity eliminatedShallowRib FlareNon-rhythmical breathing

YAI 2013 May 9, 2013 24

Atypical Breathing Patterns

Rib Flaring Minimal ribcage movement

S/P Spinal stabilization

YAI 2013 May 9, 2013 25

Other Factors Impacting Respiration Posture Position GERD Asthma Genetic conditions Vents, trachs,

intubation Scoliosis Spinal Stabilization Other surgeries

YAI 2013 May 9, 2013 26

The effects of Posture

• A chronically slumped posture can lead to kyphotic posture– Shortened anterior ribcage

wall, shortened rectus abdominus,

– Forward head position– Shoulders are elevated and

adducted(protracted scapula and internally rotated humerous)

– Accessory muscles are not available to aid in respiration

– Posterior pelvic tilt

YAI 2013 May 9, 2013 27

The effects of positioning

Sitting positioning Slumped posture Head position Lateral leaning Pelvic tilt Visual issues Body awareness Lacking the ability or

understanding to reposition themselves

YAI 2013 May 9, 2013 28

Improved respiration=Improved health

Respiratory problems are some of the sequela of neurological diagnoses, causing excessive loss of work or school days and numerous hospitalizations

Massery, M., 1994

Maintaining a healthy respiratory status should be a top priority for a neurologic population.

Massery, M., 1994

YAI 2013 May 9, 2013 29

How to improve respiration

Introduce movement Setting up the classroom/or day

YAI 2013 May 9, 2013 30

There is some evidence that physical exercise improves mental sharpness

“What’s happening in the body is their heart rate is increasing and blow flow is changing, and they’re actually activating the brain differently than when they are sitting down”

○ John Ratey, Harvard University

YAI 2013 May 9, 2013 31

Support for Movement Breaks

“In 2008, the U.S., Dept of Health and Human Services issued physical guidelines for Americans ages 6 and older. These guidelines recommend that children and adolescents participate in 1 hour or more of physical activity daily. Physical Activity should take place throughout the day to meet this recommendation.”

National Association for Sport and Physical Education

“Physical activity improves general circulation, increases blood flow to the brain, and raises levels of norepinepherine and endorphins-all of which may reduce stress, improve mood, induce a calming effect after exercise, and perhaps as a result improve achievement.”

Taras, H., 2005

YAI 2013 May 9, 2013 32

More support

According to Betts, et al. (2006), elementary school students’ sustained attention is not fully developed. They suggested that elementary students need breaks during their school day because they cannot stay focused for extended periods of time

YAI 2013 May 9, 2013 33

Benefits of Movement Breaks and Respiration

Children are often more attentive, behave better, and perform as well or better scholastically after participation in physical activity through recess or physical education.

Mahar, M., et al, 2006

Because of budgetary constraints and growing pressure on administrators and teachers to increase academic achievement scores, opportunities for physical activity are being reduced or eliminated.

Mahar, M., et al, 2006

YAI 2013 May 9, 2013 34

Movement Break!

YAI 2013 May 9, 2013 35

Its easy to make changes

Easy, fast, brief Get it into your day

with minimal disruption Fun and motivating Make it something

everyone can do

YAI 2013 May 9, 2013 36

Suggestions of activities

Busy City Get Up and Move Over/Under Relay

Benefits: Communication Social skills/awareness Sensory/Spatial awareness Creativity Increasing respiration!

Other resources 10 simple activities to

encourage physical activity in the classroom○ www.YourTherapySource.com

Integrating Physical Activity into the Complete School Day○ www.naspeinfo.com

YAI 2013 May 9, 2013 37

Ways to introduce movement

Pairing movement with respiration

Movement breaks in the classroom

Alternate positioning Short yoga breaks Incorporating more

reaching tasks into lessons

YAI 2013 May 9, 2013 38

What we came up with

Respiratory boxes: One per classroom A bag for each student Some items are shared

by the class

YAI 2013 May 9, 2013 39

Respiratory Boxes

Some ideas:

Have contests to see who can make the loudest noise, longest noise, most attempts at noises, etc.

Keep track and see if you can do better than your last attempt.

Use the magic mics to participate in short songs: staff sings/speaks a line and allows each student to finish it (any vocalization is acceptable here), kind of like playing karaoke. Let students pick songs out of a hat by reaching to the sides or diagonally to get to the hat.

Bubbles: See how many bubbles you can blow initially. Have contests to see who can blow the most, biggest, etc. Try to blow more at the end of respiratory play. Between the first attempt and last attempt, have students help by dipping the wand, grabbing paper towels to dry hands, etc. Have students reach in every direction (up, down, across body, out to the sides, etc), especially laterally.

Pinwheels: See who can get theirs going fastest, longest, or most often. Between first attempt and last attempt, have students pass the pinwheels around the circle by reaching laterally to their friends. Play games where one person starts, and when they stop, the next person starts.

YAI 2013 May 9, 2013 40

Video of 301

YAI 2013 May 9, 2013 41

Your turn!

YAI 2013 May 9, 2013 42

Questions

References Aubrey, A. Deskercise: Staying Jazzed and Focused at School. 2009.

www.npr.org/templates/story/story.php?storyID=101149470 Bly, L. (2011). Components of Typical and Atypical Motor Development. Laguna

Beach, CA: NeuroDevelopmental Treatment Association, Inc. Bachman, J.E. and Fuqua, R.N. Management of Inappropriate Behaviors of Trainable

Mentally Impaired Students using antecedent exercise. Journal of Applied Behavioral Analysis, vol. 16, No. 4, pp. 447-484, 1983.

Dwyer, T., Sallis, J.F., Blizzard, L., Lazarus, R. and Dean, K. Relation of Academic Performance to Physical Activity and Fitness in Children. Pediatric Exercise Science, Vol. 13, pp.225-237, 2001.

Eddy, M. Movement in the Classroom. www.wellnessCKE.net. Move for Health of Body and Mind.

Kerby, A. Effects of Breaks on Elementary Students’ classroom Behaviors (master’s thesis). St. Mary’s College of Maryland.

Mahar, M.T., Murphy, S.K., Rowe, D.A. , Golden, J., Shields, A.T. and Thomas, D.R. Effects of a Classroom-Based Program on Physical Activity and On-Task Behavior. Med. Sci. Sports Exerc. Vol. 38, No.12, pp. 2086-2094, 2006.

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.

YAI 2013 May 9, 2013 43

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

International Seating Symposium, Vancouver, BC. March 11-13, 2010;25-28. Massery M. The patient with multi-system impairments affecting breathing mechanics

and motor control. 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 39:695-717.

Massery MP. What’s positioning got to do with it? Neurology Report. 1994;18(3):11-14. Schroeder, R. Importance of Respiration.

www.ehow.com/about_5390615_importance-respiration.html Taras, H. Physical Activity and Student Performance at School. Journal of School

Health, Vol. 75, No. 6, pp. 214-218, 2005. Winslow, K.C. Movement Activities for the Classroom.

www.ehow.com/print/info_7871679_movement-activities-classroom.html Integrating Physical Activity Into the Complete School Day. www.naspeinfo.org 10 Simple Activities to Encourage Physical Activity in the Classroom. 2001.

www.therapysource.com

YAI 2013 May 9, 2013 44