I have been involved in the diagnosis and management of children with cerebral palsy for over 30 years and I can say, with confidence, that every child I have seen demonstrates some variation in their skill set. They have a habitual way of walking, but occasionally, they walk better. They may have enormous difficulty communicating in a new situation, but can speak fairly clearly at home. They may need to be fed by a parent at home, but eat snacks and school lunches with minimum difficulty. All of us – parents, therapists and physicians – have seen this range of behavior in children, but we generally fail to act on it. The lower range of skills is what the child learned early, with a damaged, immature brain. They are comfortable habits for the child. Further, they feel “normal” to the child….it is the way their body moves. The higher range of skills was learned later, when there had been some recovery and the brain was more mature.
Currently, much of the focus in therapy involves trying to change early abnormal movement patterns. In my opinion, this is the wrong focus. The early walking pattern is a firmly entrenched habit and we all know how hard it is to change a habit! All my training in medicine and all my experience in the diagnosis and management of children with early neurological problems failed to teach me how to change habits. My tennis pro was the first to teach me about motor habits and how to change them. Coaches and exercise scientists understand that to change a habit, you have to challenge the brain in a different way. Working within a bad habit does not change the habit. It actually strengthens it. It “wires” the incorrect motor movements more firmly into the brain. Putting a child who can only walk badly on a treadmill will not teach the child to walk normally. Walking badly in a treadmill only teaches the child to “walk badly better”. It is as if a golf pro told a person with a chronic slice that they should go out and practice hitting a few hundred slices.
“Practice does not make perfect. Only perfect practice makes perfect.” Vince Lombardi
The first step in developing an effective therapy program is to determine what you have to work with. Doctors and therapists rarely see children “at their best”. Parents get to see the full range of performance and it is your job to document it. “Catch them doing it right” and make a list. Take a photo or a short video with a smart phone and show your child’s entire team. The point of all this is that if a child with CP can pull together 3-4 normal heel-toe steps at anytime, you know they have sufficient neurological recovery to ultimately walk well. If the child with an involved upper limb can occasionally pick up small objects or play on an iPad, hand function will follow when they are old enough to work hard at it. The amazing changes seen with just 3-4 weeks of focused practice using Constraint Induced Movement Therapy (CIMT) prove the point that neurological potential is present, but not used without a focused intervention.
I hope you will find the posts interesting and will send me your questions and comments. I would love to hear more examples of Habit Hides Recovery, so send me a description of “best” and “habitual worse” performance that you see in your child or patient. Recently I gave a talk in California to a group of therapists and families of children with early neurological problems. When I described this range of behavior idea, one of the mothers showed us her sons on her smart phone. The twin boys were walking, side by side, at the head of their Boy Scouts pack. Each boy carried a flag and both walked normally. One boy had hemiplegic cerebral palsy, but in this situation, he walked with his “best walk” and it was normal. Translating the occasional great performance into a habitual great performance takes years of practice, but it is possible.