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Matheny Medical & Educational
Center

Matheny’s main campus is
located in Peapack, NJ.
Matheny is home and school to
101 adults and children with
developmental disabilities.
In addition to their primary
diagnoses many children and
adults, have a long list of
associated clinical conditions
such as vision and hearing
deficits, seizure disorders,
cognitive impairments and
dysphagia, with resulting
aspiration problems.
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About Matheny
Middle States accredited school
 JCAHO and CARF accredited School and
Hospital
 Multidisciplinary team approach

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Brynna
3 years of experience with the
developmentally disabled population
 Speech Pathologist at Matheny Medical
and Educational Center
 Certifications and Licensure

 New Jersey State Speech Language Pathologist
 New Jersey Board of Education Speech
Language Specialist
 American Speech Language Hearing
Association Certificate of Clinical Competence
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Christine



11 years of experience with the developmentally
disabled population
Senior Speech Pathologist at Matheny Medical and
Educational Center
Certifications and Licensure
 New Jersey State Speech Language Pathologist
 New Jersey Board of Education Speech Language Specialist
 American Speech Language Hearing Association Certificate of
Clinical Competence
 Rehab Engineering Society of North America certified Assistive
Technology Professional
 Certified Pediatric Neuro-Developmental Treatment therapist
 PROMPT trained
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Erin
10 years of experience with the
developmentally disabled population
 Physical Therapist at Matheny Medical
and Educational Center
 Certifications and Licensure

 New Jersey State Physical Therapist
 New Jersey Board of Education School
Physical Therapist
 Certified Pediatric Neuro-Developmental
Treatment therapist
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The Rule for Today

Every time you hear the word
‘movement’, stand all the way up, then sit
down.
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Why is respiration important

The process of
Respiration:

The function of
respiration:
 Diaphragm contracts &
 Getting oxygen to the
moves down
 Ribcage expands in 3
directions as lungs fill with
air
 Diaphragm relaxes, the
ribcage contracts, expelling
air from the lungs
tissues and organs of the
body
 Removes carbon
dioxide/waste
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How respiration is important in daily
functioning





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Gives endurance
Feeds brain cells
Promotes better health
Promotes improved attention
Necessary for everything!
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The Basics-Anatomy of the ribcage

Structure

 Cage like part of the
 Protect the internal
body comprised of
bones, muscles and
cartilage
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Function
organs such as lungs,
heart, kidneys, liver
 Additionally, it supports
the head, neck and
upper extremities
Brynna Cunningham, M.S., CCC-SLP
Christine Mayercik, M.S., CCC-SLP, ATP, C/NDT
Erin Meineke, PT, DPT, C/NDT
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Structure-Bones
•
Bones
–
–
–
–
–
12 pairs of ribs, with origin at the
thoracic vertebrae and insertion at
the sternum.
Ribs 1-7 are known as “True” Ribs,
meaning they have individual origins
and insertions
Ribs 8-10 are known as “False”
Ribs, meaning they have unique
origins on the vertebrae, but
articulate with rib #7 at the sternum
Ribs 11 and 12 are known as
“Floaters”…they have origins on the
vertebrae, but do not connect to the
sternum.
The sternum is comprised of three
parts…the manubrium, the body
and the xyphoid process. Ribs
attach to the manubrium and the
body, but not to the xyphoid
process.
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Structure-Muscles and Cartilage
•
•
•
•
•
Muscles and cartilage
Intercostals…in the space
between ribs. On inhalation, the
intercostals contract, lifting the
ribcage up and out.
Sternocleidomastoid, Scalenes,
Pectoralis…assist in respiration
by lifting the ribcage.
Diaphragm…forms the base of
the rib cage. On inhalation it
flattens and contracts, pulling
the lungs down and allowing
them to fill.
Cartilage connects the true ribs
to the sternum. It allows
movement of the ribs during
inhalation and exhalation.
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The Diaphragm

The muscle that forms
the floor of the ribcage.
 Maximizes inhalation
 Contributes to postural
control
 Supports gastrointestinal function
 Aids venous return
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Movement of the Ribcage

Typical
 During respiration, the
ribcage moves in 3
planes:
○ Up/down (vertical)
○ Front/Back
(anterior/posterior)
○ Around (Transverse)
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Movement Break!
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Normal rib cage development
•
Infant ribcage:
– Triangle shape
– Whole cage is elevated
and ribs are horizontal
– High respiratory rate and
low tidal volume
– Diaphragmatic nose
breather
Massery, M. 1994
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Normal ribcage development
•
3-6 months
– anterior chest wall
significantly opens
– Ribcage configuration
begins to look more
rectangular
– Respiratory rate decreases
as tidal volume increases





6-12 months
Child is now upright against
gravity
Breathing is no longer
posturally inhibited by contact
with supporting surface
Gravity and developing
abdominal muscles rotate the
ribs and begin to pull them
downward which results in an
elongated chest wall
12 months +
 Downward rotation of ribcage
continues
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Typical Breathing Patterns

Normal Breathing Patterns
 Clavicular
 Thoracic
 Diaphragmatic
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Typical Breathing-Toddler
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Typical Breathing- 5 year old
Bench sitting
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Supine
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The Basics- Atypical development

How we end up with
kids who are not
breathing well



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Muscle tone
Neurological
impairment
Physical abnormalities
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Atypical Ribcage Development

Effect on Respiration:


Open mouth positioning
Increase thoracic kyphosis (flexion) and lumbar flexion
Decreased oral motor control – baby is unable to bring
hands to mouth
Scoliosis

Increased thoracic kyphosis
Poor Control of Shoulders and
Upper Extremities

Poor Control of Pelvis and Lower
Extremities – due to low tone

Rib flaring
Poor rib cage and intercostal movement – the rib cage
moves as a whole unit to produce body movement,
movement occurs between T12-L1 spinal segment
Increased thoracic flexion in sitting


What we see:



Decreased head and neck control




Poor Control of Pelvis and Lower
Extremities – due to high tone
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

Decreased use of abdominal obliques, which become
elongated and weak
Increase in thoracic and lumbar flexion
Fixing with rectus abdominis which can contribute to rib
flaring
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Atypical Breathing Patterns

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
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


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Paradoxical
Diaphragm and upper accessory muscles
Upper accessory muscles
Asymmetrical
Lateral or gravity eliminated
Shallow
Rib Flare
Non-rhythmical breathing
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Atypical Breathing Patterns
Rib Flaring
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Minimal ribcage movement
S/P Spinal stabilization
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Other Factors Impacting Respiration
Posture
 Position
 GERD
 Asthma
 Genetic conditions
 Vents, trachs,
intubation
 Scoliosis
 Spinal Stabilization
 Other surgeries

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The effects of Posture
•
A chronically slumped
posture can lead to
kyphotic posture
– Shortened anterior ribcage
–
–
–
–
wall, shortened rectus
abdominus,
Forward head position
Shoulders are elevated and
adducted(protracted
scapula and internally
rotated humerous)
Accessory muscles are not
available to aid in
respiration
Posterior pelvic tilt
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The effects of positioning

Sitting positioning
 Slumped posture
 Head position
 Lateral leaning
 Pelvic tilt
 Visual issues
 Body awareness
 Lacking the ability or
understanding to
reposition themselves
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Improved respiration=Improved health

Respiratory problems
are some of the
sequela of neurological
diagnoses, causing
excessive loss of work
or school days and
numerous
hospitalizations

Maintaining a healthy
respiratory status
should be a top priority
for a neurologic
population.
 Massery, M., 1994
 Massery, M., 1994
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How to improve respiration

Introduce movement
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Setting up the
classroom/or day
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There is some evidence that physical exercise improves mental
sharpness

“What’s happening in
the body is their heart
rate is increasing and
blow flow is changing,
and they’re actually
activating the brain
differently than when
they are sitting down”
○
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John Ratey, Harvard University
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Support for Movement Breaks

“In 2008, the U.S., Dept of
Health and Human Services
issued physical guidelines for
Americans ages 6 and older.
These guidelines recommend
that children and adolescents
participate in 1 hour or more of
physical activity daily. Physical
Activity should take place
throughout the day to meet this
recommendation.”

“Physical activity improves
general circulation, increases
blood flow to the brain, and
raises levels of
norepinepherine and
endorphins-all of which may
reduce stress, improve mood,
induce a calming effect after
exercise, and perhaps as a
result improve achievement.”


Taras, H., 2005
National Association for Sport and Physical
Education
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More support

According to Betts, et al.
(2006), elementary
school students’
sustained attention is not
fully developed. They
suggested that
elementary students
need breaks during their
school day because they
cannot stay focused for
extended periods of time
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Benefits of Movement Breaks and Respiration

Children are often
more attentive, behave
better, and perform as
well or better
scholastically after
participation in physical
activity through recess
or physical education.
 Mahar, M., et al, 2006

Because of budgetary
constraints and
growing pressure on
administrators and
teachers to increase
academic achievement
scores, opportunities
for physical activity are
being reduced or
eliminated.
 Mahar, M., et al, 2006
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Movement Break!
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Its easy to make changes
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Easy, fast, brief
Get it into your day
with minimal disruption
Fun and motivating
Make it something
everyone can do
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Suggestions of activities



Busy City
Get Up and Move
Over/Under Relay

Other resources
 10 simple activities to
encourage physical activity
in the classroom
○

Benefits:

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
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
Communication
Social skills/awareness
Sensory/Spatial awareness
Creativity
Increasing respiration!
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www.YourTherapySource.com
 Integrating Physical Activity
into the Complete School
Day
○
www.naspeinfo.com
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Ways to introduce movement

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Pairing movement with
respiration
Movement breaks in the
classroom
Alternate positioning
Short yoga breaks
Incorporating more
reaching tasks into
lessons
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What we came up with

Respiratory boxes:
 One per classroom
 A bag for each student
 Some items are shared
by the class
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Respiratory Boxes

Some ideas:

Have contests to see who can make
the loudest noise, longest noise,
most attempts at noises, etc.

Keep track and see if you can do
better than your last attempt.

Use the magic mics to participate in
short songs: staff sings/speaks a
line and allows each student to
finish it (any vocalization is
acceptable here), kind of like
playing karaoke. Let students pick
songs out of a hat by reaching to
the sides or diagonally to get to the
hat.
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
Bubbles: See how many bubbles you can
blow initially. Have contests to see who
can blow the most, biggest, etc. Try to
blow more at the end of respiratory play.
Between the first attempt and last attempt,
have students help by dipping the wand,
grabbing paper towels to dry hands, etc.
Have students reach in every direction (up,
down, across body, out to the sides, etc),
especially laterally.

Pinwheels: See who can get theirs going
fastest, longest, or most often. Between
first attempt and last attempt, have
students pass the pinwheels around the
circle by reaching laterally to their friends.
Play games where one person starts, and
when they stop, the next person starts.
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Video of 301
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Your turn!
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Questions
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References
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Aubrey, A. Deskercise: Staying Jazzed and Focused at School. 2009.
www.npr.org/templates/story/story.php?storyID=101149470
Bly, L. (2011). Components of Typical and Atypical Motor Development. Laguna
Beach, CA: NeuroDevelopmental Treatment Association, Inc.
Bachman, J.E. and Fuqua, R.N. Management of Inappropriate Behaviors of Trainable
Mentally Impaired Students using antecedent exercise. Journal of Applied Behavioral
Analysis, vol. 16, No. 4, pp. 447-484, 1983.
Dwyer, T., Sallis, J.F., Blizzard, L., Lazarus, R. and Dean, K. Relation of Academic
Performance to Physical Activity and Fitness in Children. Pediatric Exercise Science,
Vol. 13, pp.225-237, 2001.
Eddy, M. Movement in the Classroom. www.wellnessCKE.net. Move for Health of Body
and Mind.
Kerby, A. Effects of Breaks on Elementary Students’ classroom Behaviors (master’s
thesis). St. Mary’s College of Maryland.
Mahar, M.T., Murphy, S.K., Rowe, D.A. , Golden, J., Shields, A.T. and Thomas, D.R.
Effects of a Classroom-Based Program on Physical Activity and On-Task Behavior.
Med. Sci. Sports Exerc. Vol. 38, No.12, pp. 2086-2094, 2006.
Massery M. Multisystem clinical implications of impaired breathing mechanics and
postural control.
In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical Therapy:
Evidence to Practice. 5 ed. St. Louis, MO: Elsevier-Mosby; 2012:633-653.
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References
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Massery M. Asthma: Multi-System Implications. In: Campbell S, Palisano R, Orlin M,
eds. Physical Therapy for Children. 4 ed. St. Louis, MO: Elsevier; 2012:815-844.
Massery, M., Breathing and Upright Posture: Simultaneous Needs, in 26th International
Seating Symposium, Vancouver, BC. March 11-13, 2010;25-28.
Massery M. The patient with multi-system impairments affecting breathing mechanics
and motor control. In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary
Physical Therapy Evidence and Practice, ed. 4. St. Louis, MO.: Mosby & Elsevier
Health Sciences; 2006:Chapter 39:695-717.
Massery MP. What’s positioning got to do with it? Neurology Report. 1994;18(3):11-14.
Schroeder, R. Importance of Respiration.
www.ehow.com/about_5390615_importance-respiration.html
Taras, H. Physical Activity and Student Performance at School. Journal of School
Health, Vol. 75, No. 6, pp. 214-218, 2005.
Winslow, K.C. Movement Activities for the Classroom.
www.ehow.com/print/info_7871679_movement-activities-classroom.html
Integrating Physical Activity Into the Complete School Day. www.naspeinfo.org
10 Simple Activities to Encourage Physical Activity in the Classroom. 2001.
www.therapysource.com
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