Therapist is seeking your suggestions and strategies for treating an autistic patient with JRA, and Total Hip Replacement


Samantha Posts:

DEAR ERI COMMUNITY: I am a relatively new physical therapist and have an interesting patient that I would appreciate tips/suggestion for treatment techniques. I work in an acute care setting. I typically work with orthopedic patients (adults), those both who have recent TKA/THA and orthopedic trauma patients. I have a new pediatric patient, age 8 accelerated and progressive JRA and a history of hip dysplasia. This patient had received prior physical therapy prior to surgery, although I do not have assess to the notes as it was at another facility, so I am not sure of what interventions the previous therapist performed. The patient had dislocated her hip x2 prior to admission. The patient underwent a total hip replacement. Secondary to the age of the patient and the surgical intervention, the patient is currently TDWB, strict posterior hip precautions, and a Hip Spica Brace that is to be worn at all times. The patient is to be seen BID for a stay of 1 week to 1.5 weeks. Along with the significant orthopedic history, the patient has a past medical history of autism. With regards to the autism spectrum, this patient is nearly non-verbal, somewhat resistant to touch, and displays a lack of interest in general. I have had one treatment session with this patient which was very difficult for the patient to focus and she was very agitated throughout the treatment session with an obvious lack of interest in the treatment session. She had a extreme difficulty with maintaining WB status and ambulation with use of assistive device. As far a “play” therapy or activities to engage the patient, do any experienced therapist have suggestions/strategies for interventions allowing for minimal agitation and overall compliance with WB and hip precautions in order for a successful session? Thank you for your help.

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21 Responses to Therapist is seeking your suggestions and strategies for treating an autistic patient with JRA, and Total Hip Replacement

  1. Jill Madej says:

    I would talk to the parent about what interests/motivates her and use that in an activity or as a reward for participating. Provide frequent rewards and if possible respect the patient’s tolerance and attention span and schedule shorter sessions more frequently. Children on the autistic spectrum are a challenging patient population. Best of luck

  2. karen says:

    The child really needs to see a pediatric physical therapist. She may not be a candidate for ambulation due to limited cognition and inability to follow instructions. There are gait training devices for pediatrics that can be used to reduce wb (i.e. the Lite Gait) but as far as ideas for engaging the child, that is a very complex issue and should be passed on to a peds therapist familiar with autism. IF that isn’t possible, the key would be to talk with the parent/caregiver and find out what motivates the child, what calms her, and what triggers her to be upset. From there you can find activities that will help her to participate in the session. Again, this is going to be very difficult to do in a clinic that is set up for adult rehab.
    🙂

  3. Hi, I recently worked with a one year old with severe hip dysplagia who underwent hip surgery and was casted for 18 weeks, long time for a 14 month old to be casted! Anyways, I did a lot of research and found an amazing site/woman that makes combined seats/tables for little ones in these casts. http://www.ivyrosespicachairs.com/ The family/child can customize the seat any way they want to. They are made to order and range in price from 150-300 pending the painting style the family chooses, some are quite extraordinary. From a PT perspective seating and positioning can be a great undertaking for little ones with these casts. In turn by enabling good positioning sitting at a table top you can then engage the child in many different motor/cognitive tasks. Hope this helps!

    Olivia

  4. Trish says:

    Hi
    Agree with the idea to find out what motivates her. She might not be able to use the Lite Gait due to the hip precautions. Do you have access to a pool? that would really help

  5. Diane says:

    Was the patient ambulatory prior to the surgery? If so, with or without a device?
    I agree that at d/c, a referral BACK to a pediatric PT is in order, but it sounds like you have 1.5 weeks in acute care to work with the patient.

    I would involve the caregivers immediately, to start spica care and ensure they have the room at home to manage this. I woukd also consider a fall back plan of pt NOT being ambulatory at d/c, if he cannnot maintain TDWB status. Be careful of “not interested in therapy”…he may be very interested but unable to communicate. “Lazy” can be low tone or low arousal, after all…
    I would also be sure to have a conversation with the surgeon or PA to be sure they know of the challenges, and find out how strict TDWB must be and for how long.
    find out what the goal is for the caregivers-transfer training and bed mobility will require lots of family teaching which does count for your BID sessions. With a spica, ROM and strength might not be on the agenda. Your goals might also need to include consistency, compliance, return demonstration etc…
    Find out from care givers what has been calming for the patient and try to re create that environment.
    Good luck!

  6. Coleen says:

    Hopefully you have access to a Wii Fit somewhere in your facility- if video games are motivating, this might be a good way to get TDWB (from being perched on a large therapy ball). If you figure out a way to engage the child, then a large therapy ball could be very useful. Ask the family what the child’s strengths are- you may find music or books on tape, or looking at books or puzzles will keep the child engaged enough to be safe. If someone is handy & could adapt a scooterboard for the casts, that could also be useful.

  7. Peggy says:

    I am a parent of a child with autism and a peds. therapist. I would engage parents to find out an area of interest and use that. Example, blowing bubbles that she must pop with her foot for hip/knee exercises. Or balloons to kick. Use very simple one word phrases. Use first, …then approach with a desired item/activity after the patient does an exercise or activity that you want her to do. Find out from parents what should be expected. She may only be able to do 5 minutes of an activity before getting a preferred item or she may be able to do 15 minutes. You can build from there. Be consistant in what you have her do daily and she will begin to understand what is expected. The weight bearing is going to be tricky. If she has sensory issues, you could remove her sock so she does not want to step down on the floor. Again, each child is unique and parents are going to be your best bet for information. Music is usually a motivator and singing what you want her to do may work as well. A video may get her attention and you could video a person or child doing what you want her to do and have her watch it. Just throwing out several ideas. Hope something is useful. Good luck 🙂

  8. Stacey D says:

    Everyone on here has given very good points. As we know ambulation is so important for this patient regardless of co-morbidity as we are fully aware that we get our patients up with a THR that have dementia. Autism and dementia are not the same but you are dealing with barriers that interfere with your ability to do your job and that is to have the pt move. Speaking with the family is a great start to find out what motivates this person. Toys and rewards are great motivators and having the pt work towards that toy/reward may help. If your facility has one of the older standing frames that assist to standing with use making sure the pt is not placing too much wt through that LE. Speak with the physcian as well and see what they might allow and given cognition (TDWB) is not ideal. I would also try some sensory integration for this pt and see if that might help. Good luck and keep up informed on your progress.

  9. Evelyn says:

    Although your experience with pediatric is limited, one can tell you feel very uncomfortable treating this 8 year old THR patient with a Hx of hip dysplasia, dislocated hip X 2, autism, and having to perform a miracle with low confidence with this 8 year old having a short hospital stay time. You can still accomplish education to the family on Hip Precautions and Contraindications, Transfer Training, Education on TDWB, Home Exercise Program, and Education on Positioning with a Hip Spica Brace. As far as activities, try to perform all activities and treatments from a different view like in front of a window to see the outdoors instead of the hospital ceiling. Maybe the 8 year old has been in an isolated environment without socialization for so long that the taught response is display a lack of interest and resistant to touch. Working with pediatric patients is a love to do job. One is always creating ideas, shaping ideas, sharing ideas, and, most importantly, being there to help other therapists when they run out of ideas.

  10. Adam Castiglione says:

    I may have missed it but i did not read anything about working with this child’s sensory system. Children with autism are challenging, i work with them during the day, I am also a very new therapist. My department head who is an OT, very much stresses how much people with autism need to regulate their sensory system. It was new information to me after 3 years of PT school. This is generally done with joint compression (especially hands, wrists, elbows, shoulder and unfortunately hips), and light or moderate stroking. Generally anything that is a calming activity. These can help the child to be organized and thus receive information. It may also help them be more receptive to touch. We also try to decrease stimming, which is any activity they do routinely (spinning, flapping) as this can send their sensory system into overdrive and prevents organization.

    Secondly i agree with almost everyone that in this case TDWB is irrelevant and should be adjusted to NWB. Similar to the way you would not allow a non-compliant patient to walk and would sit them back down and do other exercises.

    Lastly in the perhaps 6 months i have been working with these kids i have become quieter. I am not their speech therapist so (especially with the non-verbal ones) i do not talk, or only use single words. More often then not I get more out of demonstration and facilitation and gesturing. Have extreme patience with their responses to your commands. As everyone else said having a preferred activity is a great way to increase cooperation but it may have to be used as a reward. Individual activities and even individual positions may have to be limited to 5min or less if you want to maintain their full attention.

  11. Paula Passi McCue says:

    HI Samantha,
    It’s great that you are reaching out for help and ideas for this complex patient. There are a lot of great ideas and suggestions to consider. If you are still in need of ideas or support, I’d be happy to connect via email or we could chat on the phone.
    Besides parents, teachers might be great to contact for ideas on what works best for this kiddo.
    Hang in there
    Paula Passi McCue, PT
    paula_passimccue@wayland.k12.ma.us

  12. Marie Johnson says:

    I would start with a visual schedule to let this pt. know what the plan or steps are for the therapy session. You can talk to a SLP to help you with this. Pictures will help with communicating what you want the patient to try to do. I agree if she is not following weightbear precautions you may need to hold up on any ambulatory training until it is healed better! You don’t want to risk dislocation. Vibration may help with calming pt. prior to session. Also may help engage the exercises that you are working on. Get family involved as much as you can. A visual timer may help with getting the patient to work with you for longer periods of time. Kicking at balloons and bubbles are a great idea for this population! Good luck! Hope these ideas helped!

  13. Sam says:

    Do you have access to pet therapy dogs?
    I have kids ‘walk’ the dogs all the time.
    This may be hard with TDWB but I pt can walk WITH the dog it may be motivating.
    Ask parents first!!

  14. Andi Finkelstein says:

    If she receives OT, contact them and ask what sensory issues need to be addressed if any. Addressing this first may help you to reduce her agitation.

  15. Heather says:

    I would suggest a co treatment with your OT. As well as probably taking your therapy objectives down a notch and just trying to form a bond with this child. Good luck!

  16. Suzanne Siu says:

    Samantha-

    I come from a background as a ped’s PT with JRA kids and as an ortho background with adults and currently with under three population. You CAN do this!!! Be creative like the Mom/ped’s PT above suggested: kicking balloons or bubbles or some sort of target- stuffed animal you dangle above. How about attaching a self inflating Whoopie cushion under the foot of the TDWB leg and tell him NOT to let it make a sound. Or how about a small stuff animal that has a long tail- place it on top of that foot with the tail underneath and tell him NOT to step on the tail. Cause and effect like kicking a tambourine or making something light up if you touch it. I like the suggestion about taking off the sock if that sensation of the floor might be offensive. You don’t need special training as a ped’s PT- just be creative! Good Luck!
    Suzanne

  17. Julie R says:

    Check to see if this child has a school based OT or PT that you can share information with. I am an OT in a school setting, and Autistic individuals usually respond very well to visual supports, such as pictures of a desired exercise, or a video which simply models what she needs to do. See if they are using pictures or visual supports in her school or at home. The first/then idea (with pictures) can also be used….for example, first, the exercise (shown with a picture model), then her preferred task or motivator, such as bubbles, or a preferred task such as an iPad. Having a picture or video of someone using a walker with touch down weight bearing may be helpful. You can find all kinds of videos on you tube, or make one yourself and show it to her on an iPad. Hope this helps.

  18. Julie R says:

    Another thought, for those who are resistant to touch, be sure to use firm touch for your hands on guidance, light touch can send one through the ceiling as children with Autism can be very tactually defensive. Some children respond well to pressure vests or weighted vests as a calming and organizing input. These are usually worn for 20 -30 minutes at a time and are typically 3 to 5% of body weight. Playing or digging in sand or putty can be calming. One other organizing input can be swinging or rocking in a linear, slow movement pattern. Keep in mind the lights, and noises in the clinic, which can cause distress. If there is a quiet treatment area where you can dim the lights, that may help as well. Keep in mind that children with Autism prefer structure, predictability and routine. Keep things predictable and routine during your tx sessions. Without knowing this child, it is difficult to assess and make recommendations. Are there any OT’s in your facility you can talk with?

  19. Mandy says:

    Dawn Heino, OT Posts:

    Dear Samantha,
    You have already gotten quite a few helpful suggestions including: talking to the family about the child’s likes and dislikes, and what motivates her and using this information to design your intervention. I would also ask the family how she communicates her wants and needs. Is she familiar with a visual schedule and could you use one for your sessions? A visual schedule is a picture schedule of what you are going to do in your session and it helps the child know/predict what is going to happen since it is likely that she does not understand verbal language. You could use a reward for the final picture-i.e. the child participates in the session activities in the picture schedule and then gets a reward which is pictured last. Children with autism thrive on routine so the flow/order of your sessions should be similar each time.
    Hope this is helpful!
    Dawn Heino

  20. Stephanie Menendez says:

    Hello,
    Just as everyone have said, finding out what motivates the child and using a visual schedule could help with the child to engage. As far as mobility, a physical therapist I know suggested the following:
    It makes me think of the teekos harness for the swing or partial weight bearing gait trainers or a Pacer that has pelvic supports and forearm troughs that allows arms to help. It also makes me think a roller-skate
    under her operated foot.
    First impressions. I can think more later
    I will post more as I get more ideas

  21. Samantha says:

    Thank you for the numerous responses regarding this specific patient. I read over all of the ideas that were presented while treating the patient which were all very helpful! As far as treatment was concerned, the parents were heavily incorporated into the session, which they apprecipated greatly. I was informed, from the parents, that the use of the Ipad was a large motivator for participation from the child. The use of the Ipad gave the patient interest in ambulation. The use of the visual/audio stimulus was also helpful with education regarding hip precautions. As far was weight bearing status was concerned, I spoke with the primary orthopedic team and the surgeon who performed the surgery regarding the difficulties that were encountered during therapy session, he decided that NWB would be more appropriate at this time secondary to difficulty maintaining TDWB. We were able to faciliate NWB status through the use of a pediatric walker and with the help from parents when ambulating. The patient was to follow up in OP PT with a pediatric orthopedic PT with long-standing experience in the realm of complex patients. As far as maintaining NWB per the time frame of the surgeon, the plan is for OP PT to faciliate the use of the device that is more appropriate for the patient. Thanks again for all your help! It was pleasure to read through responses from such experienced therapists and begin to intregrate these ideas into my own repertoire of treatment techniques.

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