Neuro Peds - 03 - Therapy Balls

Question 1

considerations for treatment using therapy ball:

Answer 1

• tool vs outcome of treatment
• who is patient
• type of muscle tone of patient

Question 2

considerations for tool vs outcome of treatment:

what functional outcome am i looking for?

Answer 2

Goals:
•	ROM
•	Strength
•	Balance - Postural control/adjustments for righting and equilibrium responses
•	Sensory system effects	
--Vestibular – rotary and linear 
--Can be used to stimulate or calm CNS

Question 3

considerations for who is the patient:

Answer 3

Who is this individual and what is the most suitable treatment for them?
Is the ball fun and are they attracted to using it?

Question 4

considerations for the type of muscle tone:

Answer 4

Hypotonia
• Helps activate the postural system by varying and de-stabilizing the base of support and center of mass,
• Arouses the CNS

Increased stiffness/Spasticity
• Decrease stiffness
• Increase PROM

Question 5

what are the basic characteristics of the therapy ball?

Answer 5

Size
Firmness
Textures

Question 6

considerations of therapy ball Size:

Answer 6

Depending on size of child –so can sit with feet on floor, hips 90/90 with femurs parallel.

To increase weight thru feet, try a taller ball.

Feet off floor (prone, supine or sitting), the size of the ball changes the size of the support surface. Desirable to have sufficient horizontal surface for support.

Height of the ball can be changed by adding cushion under ball if too small.

What size is best for you to treat? Protect your body, know your limitations. A bigger ball can raise level of child for clinician’s biomechanics.

Question 7

considerations of therapy ball Firmness:

Answer 7

Activities change dramatically by either inflating or deflating the ball to change the firmness.
Good to bring pump.

The more firmness, the more sensory input, but decreases size of BOS and thereby increases demands for control.
Best used for hypotonia.

The more deflated, the more the size of base of support increases and thereby decreases demands for postural system.
Best used for hypertonia.

Question 8

considerations of therapy ball Textures:

Answer 8

now have ball covers with variety of textures.

Question 9

what are the ABC’s of therapy ball activity?

Answer 9

A= Alignment
B= Base of Support
C= Center of Mass

Question 10

describe the Alignment for sitting activities on therapy ball

Answer 10

ALWAYS SCAN ENTIRE BODY FIRST

a) Spine erect with chin tuck
Neutral spine= better breathing!

b) Head/neck, mouth balanced over spine, ears over shoulder girdle, easy lip closure
c) Eyes – free to move ie horizontal plane.

d) Shoulders and arms
1) Clavicles horizontal,
2) Arms at sides (if arms forward, increases flex of spine, if arms back extension of spine is increased).
3) Elbows, wrists hands quiet and at rest

e) Pelvis 90 degrees to femurs and neutral.
1) Can’t get weight shift if pelvis locked in ant or post tilt!

f) Femurs supported by ball and parallel to floor
g) Legs with equal weight distribution, knees over feet (feet should disappear) with tibia directly over foot.
h) Feet parallel and close together

Question 11

describe Base of Support for sitting activities on therapy ball

Answer 11

a) Feet,
b) Thighs
c) Ischial tuberosities (sitting bones), not the sacrum!

Question 12

describe Center of Mass for sitting activities on therapy ball

Answer 12

a) Over BOS
b) Move toward at edges of BOS
1) Shift weight all directions
2) Lateral weight shift very important.
a) Problem with the shape of the ball is it promotes more primitive weight shift, with shortening, rather than elongation of the weightbearing side used for mature weight shifting.

Question 13

What are purpose, precaution and variations for sitting activities on therapy ball?

Answer 13

PURPOSE:
Activation of postural muscles in lower extremities and trunk.
Perception of lower body as BOS with upper body free for movement.

PRECAUTIONS:
Foot placement with LE internal rotation
Rounded or hyperextended back

VARIATIONS:
Vary size of ball, surface for feet
Vary surface for feet
Peanut instead of ball

Question 14

how does therapist Assist for sitting activities on therapy ball?

Answer 14

• From front - below eye level, (eye contact can be reassuring).
• From behind- spinal alignment
• From the shoulders (cup) to correct rounding or retraction
• From pelvis for stability (glutteus medius- add fingers and squeeze)
• From knees to compress to floor or pelvis (input just above or below the knees)
• From length of femur for spinal alignment (forward, back, side to side)
• From front at rib cage – intercostals spaces, fingers between the ribs
• From behind at rib cage (hands change in direction of ribs)
• From the feet at the talus (inversion, eversion, PF, DF)

Question 15

what are some sitting activities on therapy ball?

Answer 15

Lateral weight shift in sitting
Circle hips both directions
Bouncing in sitting

Question 16

Lateral weight shift in sitting -

describe Activity, Purpose, Precautions, Assist, Variations

Answer 16

ACTIVITY: Shift weight side to side

PURPOSE: To increase reciprocal movement of scapulae, forearms, shoulders (abduction/adduction), elbows

Requires co-contraction and mobility of spine– cannot rotate in hyperflexion or hyperextension due to spine mechanically locks.

PRECAUTIONS: Primitive versus mature weight shift due to shape of ball.

ASSISTANCE: Elongate weightbearing side.

VARIATIONS: Sitting on end of peanut.
Sitting on your lap with their side to peanut, with both arms reaching to or pushing peanut to roll back and forth in small excursions or to hold for weightbearing on arms.

Question 17

Circle hips both directions -

describe Activity, Purpose, Precautions, Assist, Variations

Answer 17

ACTIVITY: Circle hips both directions

PURPOSE: Increase mobility in:

• Spine all planes (flexion, extension, lateral flexion, rotation)
• Hips all planes (flexion, extension, abduction, adduction, internal or external rotation
• Ankle and foot
• All of above

PRECAUTIONS: Client tries to do from upper body
Client increases mobility in only hypermobile regions
Watch for breath holding

VARIATIONS: Size of ball
Feet on or off floor

ASSISTANCE: Typically in lower body (pelvis, femurs, lower leg).
Input to upper body is to align trunk or minimize excessive movement.
Work for control of trunk in flexion, extension, flexion/rotation, extension/rotation).
Look at the relationship between the pelvic girdle, shoulder girdle and the head.
Sustain downward pressure through ball.

Question 18

Bouncing in sitting -

describe Activity, Purpose, Precautions, Assist, Variations

Answer 18

ACTIVITY: Bounce while remaining sitting on ball then stop.

PURPOSE: Increases proprioception for postural control.
Can increase cardiovascular and respiratory demands.
Can influence the regulatory system.

PRECAUTIONS: Client can activate from the upper body.
Carefully monitor spinal and pelvic alignment.
Use small compressions so can sustain alignment. If spinal alignment not able to be corrected, compression from below that level. Don’t bounce to hard or too big and be sure they are able sustain the posture rather than flopping around.

VARIATIONS: Vary size and number of bounces.
Do with music or clapping to rhythms.
On peanut or ball.

ASSISTANCE: Verbal instruction, music, etc.
Most often from lower body, but can try upper body to assist in alignment and postural activation.
Sustain downward pressure through ball.

Question 19

ABC’s of Prone on therapy ball

Answer 19

1. Alignment: Spine straight, hands under shoulders with palms flat on floor and hands/fingers pointing straight ahead. Elbows extended, but not locked. Hips are extended fully and slightly apart and externally rotated.
2. Base of Support: Size variable and depends on placement of hands and distance of hands from base.
3. Center of Mass: COM moves over BOS. Can also shift BOS under COM

Question 20

Activity in Prone

describe Activity, Purpose, Precautions, Assist, Variations

Answer 20

1. Prone on peanut with weight on hands

ACTIVITY: Walk forward on hands until ball supports only feet.

PURPOSE: Increase dynamic postural stability in shoulder girdle and arms in weightbearing and weight shifts. Improves proximal stability with cocontraction. Requires symmetrical work. Increase hip extension.

PRECAUTIONS: Spine should not be in excessive lumbar lordosis or thoracic rounding. Be sure be joints are not locked.

VARIATIONS: Vary difficulty by how far hands are from the ball. Hardest if feet supported on ball. Easier if knees are supported. Lift one hand to wave or reach.

ASSISTANCE: From side or behind. Can place their hands on your legs. Can keep your legs mobile (takes good abdominal strength).

Question 21

Sidelying on Therapy Ball -

describe Activity, Purpose, Precautions, Assist, Variations

Answer 21

ACTIVITY: Sidelying isometric holding with resistance.

PURPOSE: Strengthen transverse abdominals which helps with reflux, constipation. Coactivation over decreased base of support, with low COM for client with decreased control in upright postures. Elongates rib cage.

PRECAUTIONS: Support at hips, shoulders, and/or trunk versus distally.

VARIATIONS: Vary resistance. Roll to prone. Roll to supine. Can vary gravity assist/resist. Bend top leg with hip rotated externally, foot on surface of ball for weight bearing.

ASSISTANCE: Key points usually either weighted shoulder and pelvis, or just pelvis, just shoulders.

Question 22

Transitions on Therapy Ball -

describe Activity, Purpose, Precautions, Assist, Variations

Answer 22

ACTIVITY: Prone to sit with assistance.

PURPOSE: Increase trunk rotation. Integrate shifts in posture and movement. Initiate movement transitions from the lower body. Increase mobility in the lower extremities.

PRECAUTIONS: Clients with laxity in the knees should be assisted above rather than below the knees.

VARIATIONS: Can do with a large ball with no contact of feet on floor. Smaller ball. Change firmness of ball. Can hold in different parts of the range. Either leg bent.

ASSISTANCE: Clinician holds lower extremities by crossing under to hold opposite leg.

Question 23

Quadruped on Therapy Ball -

describe Activity, Purpose, Precautions, Assist, Variations

Answer 23

ACTIVITY: Client transitions to all fours from prone.

PURPOSE: Co-contraction of trunk, shoulder girdle, pelvic girdle. Learning to shift weight and control center of mass over base of support in more upright postures.

PRECAUTIONS: Check alignment of elbows, hands/wrists, shoulders, spine, hips, and feet.

VARIATIONS: Client placed on ball Climb up on ball to quadruped, Reach with one hand to wave or grasp toy.
Tall kneel propped peanut, then transition to side sit.

ASSISTANCE: From behind child. Guide weight shift and assist as needed. Provide small excursions for weight shifting all planes. Tilt ball so child is oriented more upright to decrease gravity resistance, increase field of vision, increase arousal level. Tall kneel to side sit onto your leg so only lower ¼, ½ range.
Lower tone: best to work in end ranges first, as more muscle feedback.

Question 24

Rolling on Therapy Ball -

describe Activity, Purpose, Precautions, Assist, Variations

Answer 24

ACTIVITY: Child rolls on ball.

PURPOSE: Increase rotation, coactivation of trunk. Improve segmental rolling skills.

PRECAUTIONS: Be cautious of laxity in the shoulders, hips and knees.

VARIATIONS: Start supine, prone or sidelying. Stop and hold isometrically.

ASSISTANCE: Upper or lower extremities usually at shoulders and hips for child with low tone. Can give more support at trunk and pelvis if needed. Ball rolls in opposite direction of child so child stays on top.

Question 25

Supine on Therapy Ball -

describe Activity, Purpose, Precautions, Assist, Variations

Answer 25

ACTIVITY: Client place supine on ball for lateral weight shifting

PURPOSE: Experience lateral weight shifting in with a large base of support and low center of mass which is an important skill in early development. Can be used as a more stable posture when working with vision or reaching.

PRECAUTIONS: Watch alignment of head, neck, shoulders and rib cage. Be sure they are well supported. Eye gaze is focused slightly downward and midline. Spine is in good alignment and hips supported.

VARIATIONS: Can transition to supine to side to sitting. Can vary resistance.

ASSISTANCE: Sit facing client supporting their hips with your lap or hands. To transition to sit stabilize opposite hip and shift child laterally in that direction. Hold their opposite shoulder (most support), elbow or wrist.