By Rita Watson, MPH
Children and adults who have disorders or injuries that affect movement or coordination are often referred to physical therapists. While most people with epilepsy do not need physical therapy (PT), those persons who have limited mobility or are injured may be appropriate candidates for PT. In these cases, physical therapists can help enhance mobility and coordination through various approaches, including stretching, exercise, and skills development.
We talked with physical therapist Lori LaFrance who works with children and asked her to describe her work at Hasbro Children's Hospital, which is a part of the Brown University group of hospitals in Providence, Rhode Island. We wanted to know how children with epilepsy react to physical therapy and were interested in parental expectations for their children.
Can you describe your work in general with regard to children and physical therapy?
I evaluate and treat children up to the age of 18 with physical disabilities. I provide treatment for children in acute care and outpatient settings. In the past I have traveled to the homes of families through the Early Intervention and home care programs to treat the children. We work to help the children achieve age appropriate range of motion and strength in their trunk and extremities and age appropriate function. This can range from a child learning to hold his or her head up, roll over from back to stomach, sit up and play, or walk - and everything in between.
You also work with children with epilepsy. What is your goal for each child?
The overarching goal for each child is to maximize their functional level and this includes children with epilepsy. By function I am referring to daily activities such as getting out of bed, eating breakfast, brushing their teeth, getting dressed, and using the toilet. And in fact we also often have to help children learn to sit down, stand up, walk, run, get into a car, or eat at the table. Because the most important function in the child's eyes is play, we work with children to develop the physical mobility and strength needed to participate in play activities with their peers.
But it is important to realize, and we often must remind parents, that functional potential is different for every child. With some disabilities and with epilepsy, two children with very different ages may have a similar functional level.
How do different types of seizure activity impact on physical therapy sessions?
Physical therapy intervention differs from child to child based on their specific deficits and challenges. The factor that varies with different seizures is the recovery time required after a seizure. Some seizures are mild and the child will even attempt to play during the seizure. In this situation we continue therapy as before.
Other seizures, even though they are not severe in intensity, are long in duration. The children I work with who have seizures lasting greater than five minutes typically require Diastat to be given and rescue called for transport to the emergency room for monitoring and possible admission to the hospital. Obviously, the current therapy session is ended at that point. Even if transport to the hospital is not needed, the current session is ended because the child is typically fatigued and needs a break to recover.
I can generally tell if a child is stressed with the therapy and I will have the child rest and try to calm down before proceeding. The child's caregivers are very valuable in sharing with me the cues the child will give when he or she is stressed or unable to tolerate certain activities. I very much respect that a child's caregiver knows the child much better than I do and the caregiver is ideally the child's best advocate.
What do you do to calm a child who has a seizure during physical therapy?
Regardless of the type of seizure a child experiences, we continue to talk to the child during the seizure to offer them comfort. It is typical that after a seizure a child will be more lethargic and have decreased tolerance to physical therapy challenges.
We see some children in the intensive care unit who are in status epilepticus. Therapy for these children must be gentle and very cautious, constantly monitoring their vital signs and tolerance to any type of movement.
There are physicians who believe physical exercise helps with seizure control. Does this happen with physical therapy?
I have not conducted any studies to test this theory. I have observed in my 14 years working with children who have seizures that there are some times in which PT actually induces a seizure. For example, seizures in some children are triggered when they become excited or very active, and excitement and activity are common to pediatric PT sessions. Also in the situation of the very acute child in the ICU the least amount of added stress to the body systems associated with PT can induce seizures. At this point we stop the PT and assess on a daily basis if the patient is stable enough to receive PT.
What is the benefit to treating a child in the ICU?
We see children in the ICU due to their immobility. Once a child is medically stable, the effects of prolonged immobility can be their biggest enemy. It is important to promote full range of motion at the joints and as much strength as possible during the ICU stay. We do this through whatever means is appropriate for the specific child from basic positioning in bed to sitting and standing with support – all, of course, if the child is stable enough to tolerate such activity. Another important role is to train the child's parents or caregivers in positioning and exercises as appropriate. The caregiver is often with the child many hours out of the day if not around the clock and is very valuable in helping the child ward off the effects of immobility. I have treated some children in the ICU for months and even greater than a year. Now years later after the crisis these children are going snow skiing and playing soccer on their local teams.
What are parental expectations for their children in terms of physical therapy?
Parental expectations are as various as the number of parents. Some parents are very realistic about their child's disability and potential. However, I would say that many parents are guarded to the reality of the situation and have unrealistic expectations for their child's potential.
We never want to take a parent's hope away but at the same time it is vital for a parent to recognize a child's limitations if they are going to truly support the child in growing in the next phase of development/mobility.
We try to support parents by helping them face the reality of their child's functional level so that we can all work together for success to help that child improve at whatever level that may be. I have never encountered a parent who expects that physical therapy will cure or "treat" a child's seizures.
How do you help parents and/or children ascertain realistic goals?
We tell parents what our plan is for the child. Then we break down tasks into tiny parts and work to meet each of those smaller goals. We create a detailed "problem list" that would prevent function for each child and then set ourselves to address the problems.
For example, to achieve the goal of sitting at a desk at school, the child will need to:
- use many different muscle groups,
- have balance and motor control to maintain their trunk at midline,
- develop strength enough to support his or her head upright, and
- have the necessary motion in their trunk and extremities.
With the family's input as to each of the goals, we write smaller (short-term) goals for each of the items on the problem list that will help to achieve the long-term (larger) goal.
We also make an effort to focus on what it is that a child does well and is capable of doing rather than on what they can't do, while at the same time addressing the various challenges.
What other ways do physical therapists help children gain independent movement?
Helping each child become as independent as possible oftentimes requires our assessing them for appropriate bracing, equipment, therapy interventions, and a significant amount of parental or caregiver education and training. The real progress is made when children work day by day, following through with recommended therapeutic activities with the help of their caregivers.
Lori LaFrance, PT is in the Pediatric Rehabilitation Department at Hasbro Children's Hospital, where she is also the Inpatient Coordinator.
Submitted on June 27, 2008
Edited by Steven C. Schachter, MD