In the bad old days, a child with cerebral palsy who attained any level of independent function was considered “Good Enough”. Fortunately, times have changed and the standards must be set higher for all children with Cerebral Palsy.
The image on the left is the most common type of neurological problem seen in an NICU Follow-up Clinic. The infant is being supported in a sitting position and simultaneously offered some beads to play with. Now here is Infant Development 101:
- The head is held extended backwards because the neck muscles are too weak to support the heavy head
- The shoulders are hunched up and the tone in the arms increased to try to help support the head
- The back is rounded and the baby is balanced on the posterior pelvis – again because the muscles are weak
- The effort of trying to get to the sitting position tightens all the muscles, bringing the knees up – if we could look inside the cute shoes, the ankles would be up and the toes curled
All of these signs are common with low tone hypotonia. Over the first year or so of life, this pattern of movement will either resolve completely or progress to spastic CP. The best you can say about this baby’s performance, at this point in time, is that there is evidence of reasonable vision and interest!!!
Remember, as I said last week, (Do You Want Your Child to Walk or to Walk Well?) babies are little learning machines and they will respond to novelty with great interest – this little baby is trying so hard to get at those beads. Unfortunately, whatever they do and however they move, will wire in as their own, unique movement pattern. I vote for the position on the right hand side!
The changes in tone in the photo on the left are “activity dependent” at this point in development. The image on the right is on the same day, a few minutes later. The only change is putting on a Wunzi from TheraTogs. With the extra trunk support, the infant can sit with a good base of support. The activity dependent tone is gone!!!! The head is central, the arms, hands and legs are relaxed and the infant is actively exploring a toy, using both hands. You do not need to have a MD, PT or OT degree to tell that the position that has good form will allow the child to develop good functional habits. The position that has bad form can only lead to progressive increased tone and abnormal functional patterns. Children with cerebral palsy have damaged motor control and this means that they cannot, on their own, self-correct bad form.
Bad function follows bad form and good function follows good form. The common therapy philosophy of thinking that function is the most important goal is outdated and incorrect. I was discussing this with my trainer and he came up with a great line.
“You cannot expect someone who has dysfunctional movement to simply do functional movement.“
Garrett Tandy, M.A.Ed., CSCS, Titleist Performance Institute CGFI, CES
Garrett has degrees and certifications in sport, strength training and conditioning and employs corrective exercises for folks like me with dysfunctional movements (form), before working on sport specific training (function). For older children and adults with cerebral palsy or other early neurological problem, correcting the underlying dysfunctional movements is important. We cannot expect children to do focused, isolated muscle training, but we can support them in alignment so that they can move and strengthen in as close to normal form as possible. As they gain in strength and function, the amount of additional support can be lessened. If you look at YouTube searching for TheraTogs, Spio or DMO, there are many before and after videos that demonstrate change in children of all ages from toddler to teen.
All functional skills start with the trunk. In my experience, supporting the trunk in infants and toddlers is a necessary part of minimizing maladaptive habits and maximizing neuroplasticity. For children and teenagers with established maladaptive habits, correcting trunk alignment and working to strengthen in alignment is the best starting point to improving function. Maladaptive habits are not changed. They are replaced with new, more functional movements. I have listed below the trunk garments that I know. I have personally had the most experience with TheraTogs and the Spio vest, but which one is best for your child should be discussed with your physician and your therapist.
Unfortunately, there are still some professionals that do not “believe” such garments are useful, arguing that there is little experimental evidence of their value. Not all observations need a Randomized Controlled Trial or RCT to prove effectiveness. Print this blog and ask which child is learning good movement habits? My closing point is that all of exercise science agrees that function follows form. Form can be managed and improved in children with early neurologic problems. I would ask, “What evidence is there that form follows function in growing humans?”
Trunk Compressive Garments -please let me know if I have missed any that you have used.
For Teens and Adults – Some of the better-known sports brands designed for athletes. Your healthcare team may find some of these useful for independent walkers. Check with your PT and MD for any contraindications first.
Hi Dr Pape,
I showed this email re the compressive garments to one of Ella’s doctors. He said that the child needs to do the ‘work’ and not the garment. Is that true? And does it matter?
I respectfully disagree. When the child is slumped over, all of the trunk muscles are in a sub-optimum position. They cannot strengthen from this position.This is true for an athlete with a great body as much as a baby. That is one of the reasons that form is stressed in all strengthening programs. The baby has the additional problem that they do not have any experience of normal position. The compressive garments allow them to attain that position. Then they can strengthen. As they gain control….and the spastic tone decreases, then the garments can be loosened. Hope this helps explain it.
Yes it does. Thank you.
What are your thoughts about Benik garments? http://www.benik.com/peds/trunk/v-100
As more people start to understand the importance of a stable trunk, there has been an increase in the available options. Benik is one company that has a great line of products. However, the choice of the most appropriate garment and the fitting of it is the responsibility of the therapist. The nice thing about compressive garments is the change is immediate.