Chicago torticollis therapy

Picture Exchange Communication System - Lumiere Children’s Therapy Chicago

Our previous post, Learning to Talk, outlined the typical development pattern for expressive language. Expressive language is the ability for one to communicate wants and needs, socialize, and interact with their environment through words, gestures, and nonverbal communication. For children with a language delay or an expressive language disorder secondary to an underlying diagnosis, a picture exchange system may assist in the development of expressive language. The picture exchange system can offer a bridge between communicating with gestures or signs to verbal communication. It may also help a child develop the necessary skills to operate a high tech Augmentative Alternative Communication Device (AAC).

Picture Exchange Communication System, often referred to as PECS, is a program of picture representations for common objects, actions, and thoughts. A person can initiate conversation using PECS to communicate their wants and needs without verbally speaking. It allows children to communicate with others even if they do not have the necessary verbal skills.



What is Picture Exchange Communication System?

Picture Exchange Communication System (PECS) was developed by Andy Bondy, PhD, and Lori Frost, MS, CCC-SLP in 1985 as a system used with preschool students diagnosed with autism. The goal of the program was to teach children how to self-initiate functional communication. Based on the success of the program, it is used with many learners with various communicative, cognitive, and physical difficulties of all ages. PECS is a six phase program that emerges from single word requests to building of sentence structures. There have been several studies that confirm that implementing PECS can help children develop verbal language, as well as decrease negative behaviors associated with language delays.



Who would be appropriate for PECS?

PECs is an approach used for nonverbal children. If your child consistently uses words, although limited, this system may not be the first choice in treatment. The following would indicate if your child would be a good candidate for a picture exchange system. 

  • Intentional communicator: In order to effectively use a communicate exchange, a child needs to want to communicate with others either through pointing, gestures, bringing caregivers to desired objects, or communicate through facial expression. 

    • Example: Jenny wants a chocolate chip cookies, so she directs dad into the kitchen and points to the cabinet with cookies. 

    • If a child does not involve the caregiver when trying to obtain an object, they may not be ready for a picture exchange program. The first step in this scenario would be to gain joint attention. Joint attention is when the child and caregiver are actively focused on the same object/activity. 

  • Preferences/motivation.  In order to understand the power of a picture exchange system, the child needs to be fully motivated for what they are receiving in return. When first teaching PECs, food, favorite toys, and motivating activities (slide, swing, etc) are most frequently used as motivation to communicate through pictures.

    • Example: Eric loves to build with legos. Parent will hold box of legos and give Eric one lego after every request. Eric is motivated to continue to use PECS to get more lego pieces. 

    • If a child has weak or no preferences, then PECs may not be appropriate. Preferences can be determined through trial and error of different foods, toys, and activities.

  • Discrimination of picture. Although picture discrimination is not a definite prerequisite of picture exchange system, it can enhance progress. As PECs continues to be implemented into daily routines, children will begin to learn which pictures correspond with the matching toys, food, activities, etc. If a child advances quickly with PECS, they may be more appropriate for an AAC high tech device. 



How is PECS implemented?

PECs is taught by a certified, trained speech language pathologist (SLP) but involves a caregiver or teacher as part of the team. The SLP becomes certified in PECS by attending a two day training. The SLP will be the primary PECS program coordinator for a child but it can be beneficial if caregivers attend the two-day training as well. Caregivers may include parents/family members, classroom teachers, and classroom assistants. Here is a list of training workshops available across states. PECS can be taught by the SLP in a therapy clinic, home setting with early intervention, and/or school or daycare. As the child and parent progresses in their knowledge and training of PECs, it should be used in all activities in their everyday activities. During phase stage, the goal is approximately 80 picture exchanges each day. 



Stages of PECS: 

In the early stages of PECs, there are three people in the training situation. The child, the person who receives the pictures (mom or teacher), and the facilitator who assists the child (speech therapist). Eventually, the facilitator is phased out of the training. 

  • PECS PHASE I: How to Communicate 

The first phase lays the foundation for exchanging single pictures for desired toys or activities. Receiver entices the child with the preferred object or food. As the child reaches for the desired object, the facilitator can assist the child to pick up the picture and hand to the receiver. The receiver does not say anything until receiving the picture. Once they receive the picture, they can say “ball, you want ball”.

  • PECS PHASE II: Distance and Persistence 

Phase II continues to target single pictures but in a variety of places, communication partners, and at greater distances from their field of view. It also teaches the child to become more persistent and consistent with communicating wants and needs. The facilitator is still present, and intervenes when necessary, but the child should be more independent in this stage.

  • PECS PHASE III: Picture Discrimination 

In this phase, two or more pictures are used at a time. The caregiver would present two or more pictures for a child to choose their desired object. The pictures are compiled into a communication book such as a ring binder for easy access by the child. 

  • PECS PHASE IV: Sentence Structure

The child learns to construct simple sentences with a sentence strip using “I want” picture with desired picture following.

  • PECS PHASE V: Answering Questions 

At this point, the child can learn to use PECS to answer questions such as “What do you want to play?” or “What do you want to eat”. 

  • PECS PHASE VI: Commenting 

The final phase of PECS is using pictures to make comments or respond to questions in their environment. They learn to create sentences starting with functional phrase strips I see, I hear, I feel, It is a, etc. 



How does PECs help develop verbal language?

In the previous post, Learning to Talk, a list of seven prerequisites to verbal language were described with at-home strategies. Three of the prerequisites align with the foundation of a picture exchange system. 

  1. Adequate attention and joint attention. Joint attention is when a child is focused on the same item or activity as the communicator or parent.

    1. Joint attention is necessary for a child to understand the concept of PECs. PECs requires the child to establish joint attention between the communication partner and their desired object or action. 

  2. Understands words and commands. 

    1. Before a child can effectively use verbal language, they need adequate receptive language skills. Receptive language is the ability to understand and comprehend language. Receptive language involves the identification of pictures. PECs encourages children to identify an action or object with a corresponding picture. It increases the child’s recognition and labeling of common objects and actions, improving one’s receptive language skills. 

  3. Communicates wants and needs with gestures and/or pointing. Children learn to communicate and engage with caregivers before verbal language typically emerges. Children may smile when they get something they want, point towards desired objects, or carry toys to caregiver. These are all forms of expressive language. PECs helps facilitate non-verbal expressive language by giving the child resources to communicate wants and needs to caregivers. It teaches the concept that requesting for an object/action results in receiving desired item. PECS encourages the concept of cause and effect. 



As a child develops these necessary skills through a picture exchange system, they are reinforcing the development of communicating for wants and needs. The caregiver is modeling the verbal production of each picture exchange providing more opportunities for modeling. For example, if Noah brings a picture of a ball to his mom, mom will state “ball, want ball”. Noah is receiving verbal modeling of the word ball to picture multiple times. 

If you feel your child would be an appropriate candidate for a picture exchange system, contact Lumiere Children’s Therapy. At Lumiere Children’s Therapy, we have therapist certified in the program to help your child communicate their wants and needs across all environments.




References:

“Picture Exchange Communication System (PECS)® |.” Pyramid Educational Consultants, pecsusa.com/pecs/.

“The Picture Exchange Communication System (PECS).” The Picture Exchange Communication System (PECS), www.nationalautismresources.com/the-picture-exchange-communication-system-pecs/.

Vicker, B. (2002). What is the Picture Exchange communication System or PECS? The Reporter, 7(2), 1-4, 11.




Torticollis: What is Torticollis?

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Devinf

Torticollis means “wry neck” and refers to the position of your baby’s head and neck.  A common presentation is if your baby prefers to tilt his head to one side and/or look to the opposite side. Parents usually first notice that their baby only prefers to look one way and has difficulty or resists looking the other way. (Note: every baby with torticollis will present differently.)


How can I tell if my baby has torticollis?

Does your baby tilt his head to one side or prefer to look to one side more than the other? Does your baby only reach with one hand? Can your baby look all the way to each shoulder while on his back, belly, and sitting? If you notice some of these signs, you can ask your pediatrician for a physical therapy referral for an evaluation and assessment of your baby’s alignment, range of motion, and strength. An early referral is always best!

What causes Torticollis?

Torticollis can occur for a few reasons. It is commonly caused due to your baby’s position in utero. Some additional factors include a larger size baby, a larger size head, a smaller uterus, or a twin pregnancy. Additionally, if your infant gets accustomed to looking to one way, this can become a habit and cause some muscle tightness that will further compound the head position.

Due to his position in utero or post-birth, your baby can develop muscle restrictions in his neck, trunk or pelvis that cause him to develop a lateral head tilt and rotation preference to look one way. Subsequently, often his trunk and pelvis will also be asymmetrical.

Another factor that can exacerbate the torticollis is your baby’s head shape. If a baby spends too much time on his/her back, especially looking to one side, your baby can develop a flat spot on one side of the head which then will reinforce the head tilt/rotation. This is called plagiocephaly. Sometimes, a shaping helmet is required to address your baby’s plagiocephaly in addition to the torticollis. Your pediatrician can give insight on whether a shaping helmet is required for your baby and will work with an orthotist or plastic surgeon to decide. (Note: Helmets are only needed if a baby’s head shape is moderate or severely misshapen, and also depends on baby’s age. It’s important to note that not all babies with torticollis have plagiocephaly.)


How can physical therapy help Torticollis ?

Every baby with torticollis may present a little differently, and a physical therapist should evaluate your baby in each developmental position (on his back, tummy, sitting, on all fours, crawling, standing, walking) to determine specific positions, exercises and activities that are optimal for your baby to obtain symmetrical alignment and strength.

Physical therapy treatment sessions will incorporate positions, stretches, and exercises that are specific to your baby’s head and neck alignment. Treatment sessions will consist of passive or active stretches, strengthening exercises, and positioning to achieve postural symmetry with symmetrical muscle length and strength. A large part of physical therapy treatment will include parent education and a home exercise program so that the baby’s parents can be empowered to help the baby at home throughout the week to ensure good carryover from physical therapy sessions for optimal results.



Torticollis Treatment: The Traditional Way


My baby has torticollis. What can I do to help?

Torticollis exercises will be specific to your baby’s presentation, alignment, muscular restrictions, and head tilt. At a physical therapy evaluation, your therapist will determine a treatment plan, goals, and home exercises.

Note: all described exercises need to be prescribed and demonstrated by a physical therapist.


Torticollis exercises

Positioning

If you tend to lay your baby down on the crib and changing table the same way each time, try switching it up. Sometimes a child will look more to the right because there is a wall on the left of his crib, and it is more interesting to look to the right. Additionally, if a baby consistently is bottle or breastfed in the same orientation, try switching up the way you hold your baby for feeding to allow your baby a different orientation and place to look around. Your physical therapist can provide further details on this.


Active stretches

Depending on your baby’s muscle length/strength, active stretches can be indicated to gain muscle length and strength. For example, if your baby prefers to look to his left, you can place toys to his right to get him to look further to his right and hold his gaze. During such exercises, always follow your baby’s lead and allow the baby to perform the motion on his own. A physical therapist can help educate you on the best way to help your child to look the other way safely and comfortably. Sometimes passive stretches are indicated however, most babies do not tolerate passive stretching and should only be performed under supervision of a physical therapist and with the baby’s tolerance.



Strengthening

Depending on your baby’s muscle length/strength, strengthening exercises can be indicated to gain muscle strength to obtain symmetrical posture and development. Strengthening is important to make sure both sides of his body are equally strong in order to hold his head, neck, and trunk in the middle and use both arms and legs equally to play and move within his environment. Your physical therapist will educate you on gross motor milestones and will guide you to ensure your baby develops symmetrically, with assisted reaching, assisted rolling, tummy time, assisted sitting, etc., until your baby performs on his own.



Massage

Typically, your baby’s muscles will be tight on one side, so your physical therapist can help educate you on techniques to gently massage your child’s neck.



Home Exercise Program

Your physical therapist will demonstrate and teach prescribed exercises to the baby’s caregiver to ensure good carryover from physical therapy sessions for optimal results.



Torticollis Treatment: Total Motion Release Tots and Teens


What is Total Motion Release?

Total Motion Release (TMR) is a postural release technique founded by physical therapist Tom Dalonzo-Baker over 15 years ago1 to help his adult orthopedic patients with back pain, gain range of motion. These techniques release restrictions in muscle/fascia to encourage improved range of motion and symmetrical alignment in the pelvis/trunk, that leads to functional improvements in patients with pain, decreased range of motion, or atypical presentations. These techniques have been used on generations of orthopedic adult patients. 

Tom connected with a pediatric physical therapist Susan Blum in 2006 to modify these techniques to be utilized for the pediatric population, which is now called TMR Tots and Teens (TMR TNT).2 Susan now teaches TMR TNT courses for physical and occupational therapists in pediatrics all over the United States. You can reference the TMR website at www.tmrTots.com3 for more information!

Who is TMT TNT for?

TMR TNT is indicated for the many pediatric diagnoses including torticollis, Down Syndrome, cerebral palsy, hyptonia, motor control, scoliosis and more, however here, we will focus on using TMR to treat torticollis. It can be performed on babies and children of any age and it will be specific to your child!


Why is TMT TNT different?

While the traditional way to treat torticollis works, TMR TNT is a different way to treat torticollis. Using TMR TNT, therapists look for interconnected areas of limited range of motion elsewhere in the body which are associated with the torticollis. For example, TMR TNT therapists will focus on the entire body, not only the neck, when treating torticollis. Results can often be limited when only the neck is treated. From TMR TNT’s website2, it lists five features that make TMT TNT different than traditional therapy:


1. Focus: “Treatment is precise to get to the root problem and quickly fix it.”

2. Build on What They Know: This builds on your child’s strengths. “We reinforce the patient's successes with positive motor experiences, which aid in motor recruitment.”

3. Empowerment of Caregiver and Child: “Therapeutic activities are incorporated into daily routines at home, school and daycare.  Instead of 1 or 2 hours of therapy a week, treatment becomes 24/7 for even more accelerated results.”

4. No Tears - Parent Satisfaction: “The language of TMR is comfort!”

5. Results: “Many patients with incomplete correction of torticollis achieved full correction once TMR was used to identify and treat the associated restrictions"



What does TMR TNT treatment look like?

It involves placing the child in positions to their preferred/easy side to "unlock" the restriction to gain improved active range of motion, so it does not involve any stretching. It then allows your child to explore in his new range of motion and achieve symmetrical alignment, improved gross motor skills, gain motor control, and more! It is tears-free, feel-good therapy! 

The home exercises are simple and can be worked into the parent's day for two minutes at a time, so allows for easier carryover. For example, positions can occur while being bottle or breastfed, being held, while reading a book, and while playing! This empowers the caregiver!



Who can perform TMR TNT?

A physical or occupational therapist who has taken a TMR TNT continuing education training course seminar can utilize the TMR evaluation tool and protocol to treat your baby or child. There are three levels of TMR TNT. Three physical therapists at Lumiere Children’s Therapy have taken TMR TNT Level 1!



Torticollis Tips, Tricks, and Toys


  • Utilize your pediatrician and physical therapist to help get you started! Don't let the internet or anyone else scare you. We will work with your family for an optimal treatment plan to help your baby.


  • Perform exercises when your baby is the most energized and ready to play, such as after your baby has slept, eaten, and has a clean diaper, to ensure your baby is the best mood to “exercise”!


  • Some babies will need to wait an hour after eating before tummy time to minimize spitting up, especially babies with reflux. Ask your doctor about specifics if your baby has reflux.


  • Utilize toys listed below to help your baby have the most fun during exercises!



Toys

  • Tummy time mat: a comfortable tummy time mat will motivate your baby to stay on his tummy, engage in the toy, and be comfortable!

  • Small rings: small rings are initially easier to grab, so it promotes your baby to reach. Your therapist can show you positions for your baby to reach on his back, belly, and in sitting!

    Bright Starts Lots of Links: https://www.amazon.com/Bright-Starts-Lots-of-Links

  • Music toys: toys that play music will distract your baby to look to one side and keep him focused on the toy, so he maintains his gaze. This toy is a parent favorite because of the soft music, and a baby favorite because of the size, colors, and sounds!: Baby Einstein Take Along Tunes Musical Toy

  • Cause and effect toys: Toys that encourage your child to reach in order to produce a song/sound/movement on a toy will encourage reaching and further gross motor development. Kids and therapists love this spin toy!: Leap Frog Spin and Sing Alphabet Zoo


Next Steps


If you have any questions or require an evaluation or therapy plan for your baby’s torticollis, please contact Lumiere Children’s Therapy.

Written by: Morgan, PT, DPT, a licensed physical therapist at Lumiere Children’s Therapy.