This webinar is a half-hour introduction to the philosophy and practice of MOVE™ presented by Julie Sues-Delaney, Program Manager at MOVE™ International.
What is MOVE™?
(Slides 1 – 3)
Okay so I'll go ahead and get started. MOVE™ stands for Mobility Opportunities Via Education/Experience. If you were to come to a training, these would be the objectives we would want you to walk away with – that you have a thorough understanding of the principles and the philosophy behind MOVE™; be able to complete all Six Steps; be able to complete an assessment profile and know how to use the equipment that we promote within the MOVE™ training.
MOVE™ was started in 1986 by a special education teacher, Linda Bidabe. Linda would be the first to tell you she was bored. She was bored in her classroom, because back then the kids were considered beanbag kids and it was glorified babysitting and she wanted to do something more. So she felt if she could get the kids up and moving that their world would broaden.
Results with MOVE™
(Slides 4 – 8)
In 1986, she convinced her school district to do a summer pilot program. It was not a study and we’re very careful today, (being that everything has to be research-based and evidence) that we don't call it a study, because it was really what she did is - in California they had a six-week summer school program - and over the six/seven weeks, and over that time, she did heavy gross motor type activities.
She started with four kids who could sit in chairs. At the end, nine could. And we're talking about the type of chairs you're sitting in now. So, these are kids that were originally thought that they couldn't sit in anything except in an activity chair with everything on it and yet after the short period of time they were sitting in typical chairs like you are. Three could bear weight; at the end ten could bear weight - and that's huge when you're talking about having a child at home whether they can bear weight or not, because parents go through a lot. Most parents are working, so by the end of the day they are tired let alone having to pick up their child. Two were standing with assistance; eight at the end. Two were taking steps in a walker (and a walker really would have been considered what we call a gait trainer today but back then “walker” was the term that was given to it); eleven at the end. Nobody was walking and at the end one was walking twenty feet independently and Linda would be the first one to tell you that that person was well on their way to walking anyway. But again, it shows that over a short period of time if you really put a lot of emphasis on mobility that the kids can achieve these skills.
In 2004 to 2007, doctors Keith and Stacy Whinnery out of University of West Florida did a pilot study at Chesapeake Care Resources. They came in and they said you know we'd like to do this pilot program - do you have a group of people that we can work with - and the administrator was very much on board. Now, not all the people at Chesapeake Care’s workers were on board and they very much wanted to pick the six people who were going to be in the study. Well, you can't pick your people who are going to be in the study, that kind of makes your study invalid.
This was what the population looked like that was in the adult study and these were the results at the end of it. Nobody was sitting in a typical chair and that was probably due to lack of opportunity because many of these people were able to. Sitting on an adaptive toilet; six at the end. Being able to do sit-to-stand and stand-to-sit transitions; all six at the end. Walking independently in a walker (and again this would be a gait trainer); all six people at the end. Now that is huge and the problem person (who the adult program was originally fashioned after) ironically did very well walking in a gait trainer from very early on. They put her up in a gait trainer, and she walked directly to the coffee pot and everybody said, “Oh do you think she wants coffee? But we can't give her something hot to drink? What if she spills it?” And one of the workers said, “Well why not? Maybe she wants her morning coffee?” Ironically, this woman got on her transportation bus at 6 a.m. in the morning. She was given a cup of water before she went to her Adult Day Program and then nothing till they had breakfast at the Adult Day Program. Now, how many of you guys came in here and hit the coffee? So, why wouldn't these adults want their coffee?
At Chesapeake, they also had to track toileting with their individuals for state documentation, so these - this is just incidentals they came up with during the study, but all six at the end were able to void on the toilet. Making choices, all six were making choices. (Example, “I want my coffee.”) And interfering behaviors. This woman who initially spent most of her day twirling string; if you got too close, was spitting or biting at you or hitting you, no longer did any of those things. She kind of became the little “mother” of the facility. So, again, giving her wings, letting her get up and MOVE™ about and be independent, doing what she was choosing to do, was huge.
Foundations of the MOVE™ Approach
(Slides 9 – 11)
We are a top down approach, which is still pretty unique. We want to start at the top. What skills do our individuals have? Let's work off of their strengths. If we know that they can stand, let’s work on standing and move forward. Let’s not worry if they can roll. The majority of the population that the MOVE™ program works for has some type of brain abnormality. That’s just the fact.
Benefits of physical activity - this is brand new to MOVE™. In last few years (this is by the Center for Disease Control - and this came out with childhood obesity) this is what they are teaching in regular gen-ed buildings as important characteristics for why you want physical activity. If you think about it they're just basic general healthy lifestyle comments so that you're able to live into old age and be healthy.
In MOVE™ we used to teach that we wanted people to do MOVE™ to get up and get moving to prevent contractures, for pressure sores, respiratory issues, GI, and cardiovascular. I now challenge everybody at my trainings is why aren't we looking at these? These are still very important but they're too minimal we need to look broader for our population. Our population is now living considerably longer due to all the advancements in health and we need to keep that in mind.
MOVE™ Principles. So, this is probably the slide that is extremely important for you guys to take away today, because this is the nuts and bolts of MOVE™;. Our number one thing is to have high expectations for our individuals. If we don't have high expectations for them who is going to? We want to shoot for the stars. Isn't that what we want for the general population, for everybody here who has children, isn't it what you want? Going to shoot for the sky?
So, that's one of the prime principles of MOVE™ and one of the first things we have to get across to our audience is to have high expectation. Our population of people has potential. Does it mean if they're all going to walk without equipment? Possibly not, but they all have potential that we should work towards.
Plan programming throughout the day. We talked about how MOVE™ has to do with activities; everything should be an activity, so you have to consider: What is this individual typically going to do it in a school day or their Adult Day Program and how can we include more gross motor opportunities into that day? If you think about it, they come in in a wheelchair, 90% of our population enters the building, they're going to be out of the day in a wheelchair. They have the opportunity to do a sit-to-stand transition out of their wheelchair. Typically, they're placed in another chair or in a walking device. If they're in another chair, there's another opportunity to do a sit-to-stand transition when they get out of that chair.
All our individuals have to be toileted twice a day. If they're allowed to sit on a commode, there's two more opportunities for sit-to-stand transitions, so without even trying I have four opportunities that have to happen in a day. Why not use those opportunities as our training opportunities instead of sitting them down saying, “Okay let's do five sit to stand transitions for no purpose?” Doesn't make sense. So, we want people to put in the gross motor activity when it should be happening in the day. We know that all our individuals are going to be toileted twice a day, hopefully in a bathroom, so why not walk them to the bathroom? It's going to have to happen anyway. Walk where to do what - makes a lot more emphasis than just putting them in a room and saying welcome - one end of the room to the other for no purpose.
Teach skills in different environments. Really important. Teach it where it's going to be happening, because that's where they're going to need to be able to use it. If you only teach it in an isolated room they may only adapt to that room. I can only walk in this room because that's where all my practice has been at. So they need to walk where it's happening.
Safety is important, but you need to have the element of risk. The other example I love to use is driver's education. How many of you have had the pleasure of teaching somebody how to drive? OK, you want to talk about element of risk and that's for the parent not for the kid driving. But, if you think about it, we have risks all the time in our lives. Why should we take them away from our population? We're not saying to let them get hurt, but what's wrong with tightly holding on to loosely holding on? What's wrong with hands-on, hands-off? What's wrong with loosening a strap on a gait trainer; allowing them to be more responsible for their own body? We're not talking about big huge risks, but we have to introduce some of the risk in a safe and controlled environment.
Choose equipment for active participation and you will see this word active. If you're doing the (MOVE™) Basic Provider Training, you would see it come up at least twenty times and that's very intentional because MOVE™ is all about active on the part of the individual. They need to be the person doing it. We don't need to passively do for them.
Choice making. We take away the choices from our population all the time. We tell them what they're going to do. A lot of times people will say, “No, we give him a choice. We show them red paint and blue paint.” OK, we've given them a minimal choice. They can pick red or blue, but do they know where that paint came from? No, it just magically appears. We took the choice away from them walking and getting the paint. Very often we limit what their choices are going to be. If you have a typical five-year-old; let's even make it older so that we're appropriate; let's say a ten-year-old and you're doing an art lesson. Do you think they're going to be happy if you give them two color markers to pick from or two paints? What are they typically going to do? How are they going to show us? They're going to walk to the paint cabinet and they're going to say I want purple. OK, that's typical age-appropriate.
That's what we should be doing for our population - opening up the choices. What is it that you would like, going through the cafeteria? Does our population get to go through the cafeteria line and pick what they want for lunch or does staff pick it and put it in front of them? So we don't even realize very often how often we limit choices for individuals.
And everybody learns if we know how to teach. Putting somebody in a piece of equipment does not teach them what to do with that equipment. Now every now and then there's a great pleasure of putting somebody in the gait trainer and they do start walking. Do they really start walking? Walking assumes that you have direction. Or do they start reciprocating steps? They basically start reciprocating steps - and believe you me I take advantage of it every time I get it - but we need to realize we need to have them have purpose to those steps. You're taking these steps to get somewhere for some purpose. You're going to figure out how to get through the doorway so that you're not stuck in one room.
Dr. Keith Whinnery often said this: “The greatest barrier for individuals with severe disabilities is not their disability, but rather the limitation that others impose on them.” We decide they can't do it. OK, I think the individual needs to prove to me they can't do it. We shouldn't limit them.
Early Onset Brain Injury and Neuroplasticity
By the way, have you noticed that I haven't talked about a diagnosis before now? It’s because MOVE™ doesn't care what the diagnosis is. The diagnosis isn't important. That's not the individual. MOVE™ is all about what the individual can do.
So, neuroplasticity has been around for a hundred million years. It used to always be thought of with the geriatric population that grandpa had a stroke and we need to get grandpa in rehab right away, because whatever he gets back in the first two weeks is the most critical. OK, that's discussing neuroplasticity and if you think about it, a lot of our kids have brain trauma at birth or in utero and it's the same thing as grandpa having a stroke. So why it took so long for this to come down to a pediatric population who knows? But basically, what it is saying is that there is some abnormality in the brain. The brain has the ability to regenerate. OK, it can form new pathways. It's not just that “relearning.” You actually form new pathways and you form those pathways through practice. It’s well established: through practice.
It's basically the practice and the problem solving - letting the individual problem-solve for themselves. That's really important instead of always telling them what to do.
The Six Steps of MOVE™
These are the Six Steps of MOVE™ and to do the MOVE™ Program properly, you need to go through all Six Steps. In a typical training, this takes at least six hours for me to go through all Six Steps.
Step One: Testing
Step one is testing. This is where we have an assessment profile. It's a data collection booklet. You’re going to see some slides of it.
We use a top-down motor milestone test which is an interview test where we discuss with the parents. MOVE™ is very much family-orientated. If you can have the parents there, you want to have an open discussion with the parents on a very friendly basis. But, the bottom line is, we want to know what does the individual do at home. You talk to the school staff: What do they do at school?
If the family is not involved (and it does happen quite frequently in the school's program and the Adult Day Program they don't want to come to school to do this), we encourage people talk to them on the phone, send them an email, get an idea of what's happening.
This is a category page in the MOVE™ profile. OK, can the child maintain a sitting position? So remember, we talked about top-down? This is a perfect example. So, we would start at the top here. Can the individual sit on a flat surface for thirty minutes? The reason we want them sitting on a flat surface is can they take a bath in a bathtub? Can they sit in the middle the living room to watch a TV show like a typical kid? If they do not have this skill yet, we use the term “not yet” in MOVE™. And I can't tell you how important that is, not to say “no.” “Not yet” gives a parent hope. “No” means out of the question. So it would be a “not yet.”
So, then we drop down to another skill. Again, if it's a “not yet” we drop down and we keep dropping down until we get to the point where the family says, “Yes, they can do that.”
That's how we would go about filling out the assessment. There are sixteen pages like this. At the end, they take the information that's on this page (because, let's say that here was where – yes, they can do that), we would tell them to put the date and their initials because that indicates this is the skill level they're at. Then we take the information and transfer it onto this summary page.
This just shows the progress of a student year to year. Green was the first time. Then red, then blue. As you'll notice it looks like it's all over the place and that's OK, because usually the most progress is in the area of where there is a goal for that year. And we're going to talk about goals next, but just to give you an idea of how they track using the assessment profile.
Step Two: Setting Goals
Step Two is goals. Step Two is definitely the most important step and it's the most important step because we're finding out what is important to the family into this individual - asking questions like: What would you like the individual to do now? What would they like to do now? And if our individual has the ability to communicate, we strongly encourage them to ask the individual. At a training I did, I had the… I never picked the kids who are coming to the training I don't meet him before they come in the door, so all I knew is that I was going to have a teenager coming to my training and when we got to the goal part I asked the young man what do you want to do? And in his own way he communicated he wanted to dance at prom. OK, a high school student. Is that reasonable? Absolutely. I thought was a great goal.
We also teach the audience how to take the goal the family said in common language and turn it into something that will be accepted on school paperwork. And I would have to say 90% of our trainers will agree with me that they can find a way of turning a family goal into a goal for the school without a whole lot of difficulty.
Step Three: Task Analysis/Plan Activities
Step Three. How do we get there? How do we get from what skills the student has to what the family wants to happen? That comes up in Step Three and what we do in Step Three is we try to figure out what exact skill. Now in MOVE™, we call the exact skills “motor milestones.” OK, we don't call them a gross motor skill, because we have subdivided them down into such small little parts, so they're considered a motor milestone. What do they need and what activities are we going to use and how are we going to break those activities down? So, not only, but what does the student need? But, what part of the activity are they going to practice that in.
And we need to come back and remind people that when you do a task analysis, are the motor milestones you're picking - do they make the individual work towards their goal or have you gotten off-track? Does it increase the individual's independence? Because that's what it was all about; increasing their independence. Is it something you can practice often? Does it allow for opportunities of integration? And that's huge. More and more schools are decentralizing. They're taking their center-base and they're sending kids to their neighborhood schools. Anyhow, does it allow for more integration and is it active participation of the skill? When you pick those activities are you actually practicing the skill in it.
Here are just a couple of examples of activity-based instruction; practicing sitting, circle time - it's a preschool classroom. If it's a true activity, you're also working on cognition, communication, social. But what are we practicing? What's the MOVE™ part of this? Sitting. Mom needs the individual to sit. Eating in a restaurant. Again, huge. You can practice a lot of motor components when you think about eating at a restaurant. OK and you can incorporate all of these into a school program in one shape or form. You can also do the fine motor communication, social and cognition. In our MOVE™ training we have different slides we go through and show them how you can take a family goal and bring it back into the classroom.
Step Four: Measuring Prompts
Step Four is measuring prompts. Remember I said if you're walking through the door that you might be supporting him at the trunk, you might be supporting him at the shoulders? OK, we have prompt plans. These are Step Four and this is the grid of what it looks like. So, basically, we're looking at what type of physical support are we giving to the individual to make them more successful in the activity? We go through each one of these individually, we'll talk about trunk control, what level the trunk are we dealing with, arm control - where are the arms? How much support are we giving them? Same thing with hip and foot. We go through each one. Steps Four and Five take two to three hours to get through so you guys are going to just trust me on this one.
Step Five: Prompt Review
Step Five is a journey with what we started with to where we're going.
We look for more independence. Prompts should be seen as temporary. Again, you need to always state when are you going to look at this? Are we going to look at it in three months? Are we going to look at it at five or six months? And the reason for that is because we want the high expectations. If we don't go back and review what we've done, we're not keeping those expectations up. We're going to a maintenance program and we don't want maintenance.
We really stress working on independent skill advancement. With Step Five, you always want to address when are we going to look at it again? We just updated it when are we going to do it again? This is what it would look like once was completed. This would have been Step Four, your initial scores. This is Step Five.
Step Six: Teaching Skills (Learning)
OK, Step Six. We talk about the stages of learning and this is very intentional because we have a lot of teachers in our program. And they are taught the stages of learning in great lengths. These have changed in the last four years. We've updated the program to show the change.
Basically in a nutshell: Acquisition stage is when we're introducing MOVE™. We're introducing the skills the first time. Fluency is you're becoming more proficient. Generalization: You're doing it in different environments. Adaptation: The individual adapts on their own. And that's the biggest change with the stages of learning. It goes hand in hand with problem solving.
Acquisition stage is the most critical stage. You have to reduce the other demands. The real key thing here is this: Just Manageable Difficulty Level. It's really important especially for MOVE™ because we don't want a maintenance program in MOVE™. Remember we talked about the rate of learning is one of the problems for our individuals? If we have them doing the same thing every day without any change, without boosting those expectations, it's a maintenance program. So just manageable difficulty: just keep stepping everything up just a tad. If we're walking through the doorway and mom is holding on to Matthew’s trunk, maybe mom wants to go from holding on to the trunk with both hands to a trunk and a shoulder. That's less support. OK, now Matthew is doing great with that. Maybe we want to get rid of the trunk at all. Let's do both shoulders. Just keep edging it up a little bit. It's really important to keep it that just manageable difficulty. You don't want to step it up so much that they're not successful. We want our individuals to be successful, but we also want to keep the high expectations.
OK, then again in the program we go ahead and we reiterate what we've been telling people: that you have to have planning. MOVE™ doesn't happen on the fly. You have to know when you're going to put in the skill development. If you don't, it's not going to happen. You want to make sure you're always dealing with the family goals. You want to make sure you're dealing with the motor skill you picked. Are you really working on the motor skill you picked that you wrote on the goal sheet? And have you increased your practice opportunities?
Now, who do you think gets the most practice? We have ten students - out of those ten students who would you guess gets the most practice? (They're all considered severely multiply impaired.) The most able. The one who communicates the most; the one who’s the most fun to work with. Who do you think needs the most practice? The least able. And that's the one who gets the least amount of practice. And that's research-based.
So, we talk to our audience a whole lot about how they have to distribute it across the board; not just the kid who's always willing to do it. And again going through Steps Four and Five and then the cycle returns back up to Step One again. So, MOVE™ is just an ongoing and continuous, which is why it can work from early on up to geriatric.
Active Participation is the Key
We also start talking about the active participation needs because these are things that people don't even think about. Is the individual engaged in the activity?
Active participation: research even states it improves communication. It also improves socialization.
OK, now sometimes we do have to work on just partial participation and this happens a lot in the MOVE™ program where our individual needs to be able to break it down to be successful.
We have Trenton here and Trenton loves to feed the fish at his school, but his classroom is 300 feet away from the fish tank and he can't walk 300 feet. So, what do we do? We shorten the distance, so that he's going to be successful. We bring his wheelchair out to 200 feet away and that's where we start the activity. “Trenton, you want to feed the fish?” We're already 200 feet away. Trenton is able to get up and walk the last 200 feet and then we bring… (remember it's an activity), so now Trenton has to unscrew the fish food now he has to shake it in there, gets to watch the fish come up and eat it. He has to rescrew it put it down. He has to check off that he fed the fish to make it an entire activity. Again, we took away the barrier. Now, unfortunately, at his school all the fish died within two weeks, because all the kids wanted to feed the fish. And if you over-feed the fish they die, so the school put (I thought this was really good) so one of the people came up with putting saran wrap across the top of it so only a few flakes fell in, so the kids could watch them - - feed the fish - - and then they recycled it. They take the saran wrap at the end to pour the food back in the food thing. Pretty cool.
Conclusion: Benefits of MOVE™
MOVE™ definitely provides a way of combining therapy and education and works on the three problems of (1) time, (2) rate of learning, and (3) generalization, and offers record-keeping. And that is huge. No school system allows a program in there anymore, that does not have a record-keeping system to show progress.
A framework builds confidence. That's huge. People don't realize our individuals need to build confidence. They really do. I don't know why we think that they don't have the insecurities that we all have, so that part is huge. And it also allows them in multiple environments, and less stress on the family and caregivers.
If we teach an individual to stand momentarily, let's say for 30 seconds to a minute, it is not very long, is it? But what does that entitle them to do? Can they now be in a bathroom and propped up against the vanity to brush their teeth? Do you think parents literally brush their kid’s teeth for two minutes? No, probably like 30 seconds. So gets them into a bathroom that they can be in the appropriate environment for brushing their teeth even combing their hair, for girls maybe getting to put on some makeup before school. For boys - maybe getting to shave in the bathroom. Huge. And again, all we taught was standing for seconds to a minute.
OK, let's go out to the car: What about if mom could help the child pivot in the car seat and the child could stand up and be propped against the car momentarily? I mean, literally, just propped against the car momentarily. Mom can re-get her balance and then help him move into his wheelchair. That may be the whole basis of that individual getting in and out of the house and going to family events. If mom can't get him in and out of a car independently… Do you ever think about what it's like to get a grown adult in and out of a car? How many of you guys have taken kids in car seats in and out of their cars and as they get bigger does it get more difficult? And how does your back feel as you're wrenching yourself from here to get out and put them down? So can you imagine how much easier your life would be if a parent could take the individual from sitting in the car to standing up and you know take you’re propped, let me get my bearings, okay now let's go from here to here. Huge. And again, all we're working on is standing for 30-60 seconds. Do you see how one simple motor milestone can impact so many parts of an individual's life and the family's life?
This is an example: We have somebody practicing sitting on the edge of a mat table with no support, and now we’ve put him in an Activity Chair. That's a lot more support. The purpose right now is self-feeding and he needs all the support he can get to be able to keep himself in a position to self-feed. So it's a balancing act. It goes back to that planned programming. Our big goal here: increasing his strength, getting him to sit independently. Our big goal here: self-feeding.
OK, teaching upright toileting. Allows individual to toilet in an appropriate area.
It also allows for practice mobility skills. We can do a sit-to-stand transition we can practice in standing we can do a stand-to-sit transition. We can practice pivoting. Now, we are not a toilet training program, so MOVE™ does not tell you that you have to do toilet training. We highly encourage allowing every individual the opportunity to sit on a toilet or a commode; to be able to practice voiding. The majority of our population that is continent or does void on a toilet - it is scheduled. Basically they know that they go on the toilet at this time, at this time, at this time. But to a family that is still huge, because that diaper bag is gone.
Definitely easier on family and caregivers even at home if an individual can stand up at home where they don't have support stations we encourage putting a pad on top of a low dresser. If they can't do it in the bedroom we even will say you might want to use a couch, so that you can still have them stand up and lean over it. We would prefer to be in the bathroom. In the bathroom we encourage them to put their elbows in the sink and to give them a pad but anytime that they are upright in the home - we really problem solve in the home, however we can, so they can practice it at home too. Really important.
This is when I told you about Frannie, the woman who made the coffee. This is what she was like at the beginning of the study; look at how heavy she is. This was just three years later; how much weight she had taken off and the only thing that changed was she was getting up and moving.
That's what MOVE™ is all about. So, you guys just got two days of training really condensed down.
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