Motivating a child during an Ax and Rx session

Yesterday, on my paediatrics placement, I encountered a 13yr old boy who had suffered from osteomyelitis 3 yrs ago which affected his bone growth so that he now has residual skeletal deformity. A severe varus deformity in the distal 1/3 of both his tibias is his most prominent impairment. In standing, it causes the entire weight of his body to be focused through the lateral aspect of his tibia and his feet to be forced into inversion. This disenables him to weight bear through his legs for long periods of time due to pain in his subtalar joint. Therefore he is currently unable to walk and relies on a wheelchair for ambulating both short and long distances.

His orthopaedic surgeon has indicated he will be eligible for surgery to correct this deformity and align his tibias so they are straight enough for him to evenly weight bear through his tibial shaft and to align his feet flat on the ground in subtalar neutral position. However there is a catch. His bone density is currently too low to conduct surgery. Therefore he must increase it. However, this can only be achieved through weight bearing, of which the boy cannot achieve without pain.

My clinical supervisor has issued him a Kaye Walker to promote walking short distances around the home. This is aimed to encourage him to walk, thus weight bear through his tibias which in turn will increase bone density.

The home visit aimed to assess his ability to use the frame around the household. He was very reluctant to use the walker and chose not to comply with the instructions my supervisor gave him, nor did he listen to his mum. He was given a kicking exercise to improve his quad strength. He took about 3 kicks and then gave up, refused to do any more exercises and hid his head under his t-shirt so he didn’t have to see or listen to anyone. His mum and the physio understandably gave up and began discussing other things. I sat next to him and asked him if he wanted to play a game. He chose cards. We played for about 5 minutes. Then I asked if he would like to play soccer. He was interested this time. So we set up a goal between a chair and the TV cabinet and he kicked the ball through the goals as I attempted to block them. We played for 5 minutes. I found by acting as a playmate he was motivated to do the exercise. He was given the opportunity to initiate play (with my guidance) and our aim, to promote kicking, was achieved.

In Neuroscience 351 Paediatrics it didn’t occur to me that telling a child an instruction would actually have a negative effect on them. I could understand that by being their playmate, you would in turn enhance the Ax/Rx session. But I always assumed if you acted in an authoritative manner, they would listen to you. But this case study made me realise that acting authoritatively can have a detrimental effect on a child. In this instance he became scared and confused from all the instructions he was being given. He was upset that he could not achieve the task he was being asked to do. He was overwhelmed by all the criticism.

I feel acting as a playmate in conjunction with being an instructor, is an effective way to communicate with a child. If an exercise can be adapted into a game of some sort, then it is much more interesting for the child, less intimidating and doesn’t feel like a chore.

In the future I anticipate adapting every paediatric assessment and treatment to some form of game. Augmented feedback should focus not only on errors, but successes as well.