case_images: PMC10235686_01
case_images: (A) Timeline from onset of injury at 5 years of age. Patient initiated activity-based restorative therapy (ABRT) at 6 years, 6 months old. Arrows indicate the therapies patient was receiving and the number of times per week they participated. AFM, acute flaccid myelitis; SATCo, segmental assessment of trunk control. (B) Timeline from onset of injury at 8 years of age. Patient initiated activity-based restorative therapy (ABRT) at 9 years, 6 months old. Arrows indicate the therapies patient was receiving and the number of times per week they participated. (C) Timeline from onset of injury at 4 years of age. Patient initiated activity-based restorative therapy (ABRT) at 7 years, 5 months old. Arrows indicate the therapies patient was receiving and the number of times per week they participated. (D) "I can see the ground and around my chair better". This was reported by patient 1 with the transition of external head support from passive capital extension via a headrest (D1) to the implementation of an external head support device promoting midline cervical positioning and the initiation of cervical rotation (D2). (E) Initial vs. final mobility. (E1) Initial mobility presents as seated in power wheelchair in a forward flexed, kyphotic posture, with left lateral cervical flexed positioning. (E2) Final mobility with patient independently controlling posterior walker with bilateral upper extremity platforms. Patient presents with a more upright posture and head toward the midline position. (F) Independent sitting without trunk support vs. manual facilitation of trunk support at the head, trunk, and pelvis. (F1) Without head, trunk, or pelvic support, the patient presents with left lateral cervical flexion, uneven shoulder elevation (left above right), right kyphosis of the rib cage, left lateral trunk flexion, and a left pelvic obliquity. (F2) Manual facilitation was provided at the head, trunk, and pelvis, positioning the patient as close to the midline position as possible. Maximal assistance is required to achieve the positioning in image (F2). (G) Patient demonstrates ambulation with maximal manual facilitation for head support. Without trunk support, he is unable to maintain the trunk and pelvis in midline alignment. Able to ambulate for over 2 min with head support. (H) Able to hold head without manual facilitation at head, trunk, and pelvis in sitting and standing for 2 min each, transitioned from sitting to standing without manual support with inappropriate kinematics of head, trunk, and pelvis.
case_images: fresc-04-1063724-g001.jpg
case_images: PMC10235686_03_fresc-04-1063724-g001.jpg
case_images: F1
case_images: AFM diagnosis. At the initial evaluation, the patient was ventilator-dependent and was treated by an outpatient pulmonary rehab team once a week to address sprinting/weaning (Figure 1C). With manual head support, the patient could sit, perform sit-to-stand, and ambulate, though with an asymmetrical trunk posture (Figure 1G).
case_images: Initial and final outcomes across all three patients for head control, scoliosis, SATCo, timed sit, timed stand, sit outside base of support, and sit to stand.
case_images: fresc-04-1063724-g002.jpg
case_images: PMC10235686_01_fresc-04-1063724-g002.jpg
case_images: F2
case_images: With full support and alignment of the pelvis and trunk in the neutral position, the patient could not control his head, resulting in cervical flexion or extension (Figure 2).
case_images: PMC10235686_02
case_images: (A) Timeline from onset of injury at 5 years of age. Patient initiated activity-based restorative therapy (ABRT) at 6 years, 6 months old. Arrows indicate the therapies patient was receiving and the number of times per week they participated. AFM, acute flaccid myelitis; SATCo, segmental assessment of trunk control. (B) Timeline from onset of injury at 8 years of age. Patient initiated activity-based restorative therapy (ABRT) at 9 years, 6 months old. Arrows indicate the therapies patient was receiving and the number of times per week they participated. (C) Timeline from onset of injury at 4 years of age. Patient initiated activity-based restorative therapy (ABRT) at 7 years, 5 months old. Arrows indicate the therapies patient was receiving and the number of times per week they participated. (D) "I can see the ground and around my chair better". This was reported by patient 1 with the transition of external head support from passive capital extension via a headrest (D1) to the implementation of an external head support device promoting midline cervical positioning and the initiation of cervical rotation (D2). (E) Initial vs. final mobility. (E1) Initial mobility presents as seated in power wheelchair in a forward flexed, kyphotic posture, with left lateral cervical flexed positioning. (E2) Final mobility with patient independently controlling posterior walker with bilateral upper extremity platforms. Patient presents with a more upright posture and head toward the midline position. (F) Independent sitting without trunk support vs. manual facilitation of trunk support at the head, trunk, and pelvis. (F1) Without head, trunk, or pelvic support, the patient presents with left lateral cervical flexion, uneven shoulder elevation (left above right), right kyphosis of the rib cage, left lateral trunk flexion, and a left pelvic obliquity. (F2) Manual facilitation was provided at the head, trunk, and pelvis, positioning the patient as close to the midline position as possible. Maximal assistance is required to achieve the positioning in image (F2). (G) Patient demonstrates ambulation with maximal manual facilitation for head support. Without trunk support, he is unable to maintain the trunk and pelvis in midline alignment. Able to ambulate for over 2 min with head support. (H) Able to hold head without manual facilitation at head, trunk, and pelvis in sitting and standing for 2 min each, transitioned from sitting to standing without manual support with inappropriate kinematics of head, trunk, and pelvis.
case_images: fresc-04-1063724-g001.jpg
case_images: PMC10235686_03_fresc-04-1063724-g001.jpg
case_images: F1
case_images: AFM diagnosis. At the initial evaluation, the patient was ventilator-dependent and was treated by an outpatient pulmonary rehab team once a week to address sprinting/weaning (Figure 1C). With manual head support, the patient could sit, perform sit-to-stand, and ambulate, though with an asymmetrical trunk posture (Figure 1G).
case_images: PMC10235686_03
case_images: (A) Timeline from onset of injury at 5 years of age. Patient initiated activity-based restorative therapy (ABRT) at 6 years, 6 months old. Arrows indicate the therapies patient was receiving and the number of times per week they participated. AFM, acute flaccid myelitis; SATCo, segmental assessment of trunk control. (B) Timeline from onset of injury at 8 years of age. Patient initiated activity-based restorative therapy (ABRT) at 9 years, 6 months old. Arrows indicate the therapies patient was receiving and the number of times per week they participated. (C) Timeline from onset of injury at 4 years of age. Patient initiated activity-based restorative therapy (ABRT) at 7 years, 5 months old. Arrows indicate the therapies patient was receiving and the number of times per week they participated. (D) "I can see the ground and around my chair better". This was reported by patient 1 with the transition of external head support from passive capital extension via a headrest (D1) to the implementation of an external head support device promoting midline cervical positioning and the initiation of cervical rotation (D2). (E) Initial vs. final mobility. (E1) Initial mobility presents as seated in power wheelchair in a forward flexed, kyphotic posture, with left lateral cervical flexed positioning. (E2) Final mobility with patient independently controlling posterior walker with bilateral upper extremity platforms. Patient presents with a more upright posture and head toward the midline position. (F) Independent sitting without trunk support vs. manual facilitation of trunk support at the head, trunk, and pelvis. (F1) Without head, trunk, or pelvic support, the patient presents with left lateral cervical flexion, uneven shoulder elevation (left above right), right kyphosis of the rib cage, left lateral trunk flexion, and a left pelvic obliquity. (F2) Manual facilitation was provided at the head, trunk, and pelvis, positioning the patient as close to the midline position as possible. Maximal assistance is required to achieve the positioning in image (F2). (G) Patient demonstrates ambulation with maximal manual facilitation for head support. Without trunk support, he is unable to maintain the trunk and pelvis in midline alignment. Able to ambulate for over 2 min with head support. (H) Able to hold head without manual facilitation at head, trunk, and pelvis in sitting and standing for 2 min each, transitioned from sitting to standing without manual support with inappropriate kinematics of head, trunk, and pelvis.
case_images: fresc-04-1063724-g001.jpg
case_images: PMC10235686_03_fresc-04-1063724-g001.jpg
case_images: F1
case_images: AFM diagnosis. At the initial evaluation, the patient was ventilator-dependent and was treated by an outpatient pulmonary rehab team once a week to address sprinting/weaning (Figure 1C). With manual head support, the patient could sit, perform sit-to-stand, and ambulate, though with an asymmetrical trunk posture (Figure 1G).
case_images: Outline of the steps developed over time to address and progress head control as patient control increased across time..
case_images: fresc-04-1063724-g003.jpg
case_images: PMC10235686_03_fresc-04-1063724-g003.jpg
case_images: F3
case_images: During overground and activity-based occupational therapy, an external head device called a HeadPod assisted in providing head support (Figures 3, 4A). Graded manual facilitation was introduced via a segmental approach at the C1-C7 vertebrae (Figures 3, 4A).
case_images: (A) Progression of head control. Passive manual facilitation provided at the head due to no head control outside of chair/headrest. External head support device in place providing maximal assistance at the head. External head support device allows for patient initiation of cervical flexion, extension, and rotation. Posterior head support was provided to the head and trunk to address upright stabilization of head control in a vertical position with maximal assistance at the trunk and pelvis for midline positioning. As midline stabilization was achieved with posterior support, the patient transitioned to addressing cervical lateral flexion, flexion, and rotation with posterior support. Graded manual facilitation from C1 to C7 with improved head control initiation, graded from distal to proximal until support was able to be removed from head/neck. With increased activation of cervical musculature, increased head control was observed with support; the posterior support was removed and training transitioned to head control without manual facilitation. Assistance was graded over time pending each patient's progress and strengths. Grading included moving from distal to more proximal support until head and/or trunk support could be removed. (B) Progression of trunk control. Initial SATCo demonstrated no head control across all three patients. Patients 1 and 3 required manual facilitation at the head for initial SATCo. Final SATCo demonstrated increased head control across all three participants, with a change in the scores of patient 2, demonstrating static head control. Patients 1 and 3 presented with emerging control toward static head control. Patient 1 demonstrated head control without manual facilitation at the final SATCo.
case_images: fresc-04-1063724-g004.jpg
case_images: PMC10235686_03_fresc-04-1063724-g004.jpg
case_images: F4
case_images: During overground and activity-based occupational therapy, an external head device called a HeadPod assisted in providing head support (Figures 3, 4A). As cervical musculature activation progressed, head control facilitation transitioned from maximal manual facilitation to the implementation of a posterior surface in sitting/standing (Figure 4A). As head control progressed, the posterior support was removed (Figure 4A) and the head control goal shifted to achieve midline positioning without occipital support. Graded manual facilitation was introduced via a segmental approach at the C1-C7 vertebrae (Figures 3, 4A).