Clinical Hot Topic Box: Mobility and Postural Stability
Kristin King, PhD, CCC-SLP
Critical development of anatomy, physiology, swallowing, mobility, and other skills begin in utero and continue from birth through childhood. Immediately after birth, speech, language, and cognition are added to the many areas of development that a child is undergoing. It is well documented that primary speech and language development occurs from birth to age three and during this same timeframe, infants and toddlers are making vast changes in gross and fine motor development. These skills continue to develop throughout childhood but at a slower pace than initially seen in infancy and early childhood. When this process is complicated by medical conditions requiring a tracheostomy, the manner in which the systems interact for development are compromised even further.
When a tracheostomy tube is placed in the trachea, the respiratory system and intrathoracic and intra-abdominal pressures are diminished by having an open system (Massery, 2014). Airflow is redirected through the tracheostomy tube and the patient is no longer using the upper respiratory airway – airflow does not go through the upper airway and glottis (vocal cords). Use of the upper airway and glottis typically provides restrictions that allow for control of exhalation and assists with controlling expiratory lung volumes (Massery, 2014). This loss of pressure may impact gross motor function for mobility and postural stability.
Use of the Passy Muir® Valve during physical therapy helps restore the pressure support in the trunk, allowing for natural increases in intrathoracic pressure (ITP) and intra-abdominal pressures (IAP) in response to increased postural demands. With an open tracheostomy tube and therefore, an open system, thoracic pressures cannot be increased or sustained as airflow passes through the tracheostomy tube and bypasses the upper airway. This difficulty would be observed when a patient needs to crawl, sit, push, or stand up. The typical means of gross motor movement for mobility is to engage the glottis (vocal cords) to restrict the expiratory lung volume in order to stabilize the chest and upper body (Massery, 2013). Placing a Passy Muir Valve on the tracheostomy tube closes the system and restores a patient’s ability to use the upper airway to control expiratory flow and improve ITP and IAP.
Consider that with infants and young children, a tracheostomy could limit or diminish gross motor development. During infancy and early development, children are progressing through the stages of head control, trunk control, sitting, reaching, standing, and walking. Without good ITP and ITA, these functions could be significantly impacted and even delayed. A vicious cycle may begin as fine motor skills related to feeding, self-feeding and other levels of function are directly linked to gross motor development. These delays and limitations can be mitigated by using a bias-closed position no-leak speaking valve to return the young child to a more normalized use of the upper airway with control of expiratory lung volumes and improved trunk control and postural stability
Massery, M. (2014). Expert interview: The role of the Passy-Muir valve in physical therapy. Talk Muir (3 Feb. 2014): 2-4.
Massery, M., Hagins, M., Stafford, R., Moerchen, V., and Hodges, P.W. (2013). Effect of airway control by glottal structures on postural stability. Journal of Applied Physiology, 115(4), 483-490.