As I have discussed last week, every pediatric therapy intervention that I am aware of aims, in part, to strengthen the core. And the exercises used should strengthen the core. The sad truth is that in most cases, the exercises are ineffective. The reason is that they are not done enough times every day. In order to properly strengthen the muscle, the child’s body has to be held in alignment by a pair of hands most of the day. This is not meant as a guilt trip for parents. It is a recognition that you have to use some form of support so that the child’s muscles can work within the proper length. Exercise with a lengthened or shortened muscle is just not as effective. I have had a fair number of emails since I started this series of posts and one of the most common forms of confusion is the difference between TheraTogs, Spio and Kinesiotaping.
TheraTogs can, in most cases, prevent and in many more cases, treat biomechanical distortions caused by unequal muscle pull. If the child has a weak core, I believe they should be in a Tog for much of the day until the therapeutic exercises, in the Tog, have strengthened it.
Spio has a full range of compressive garments. These garments give excellent proprioceptive feedback to the child and this is their major benefit. They provide support and can, to a degree, improve alignment. I have been very impressed with the results in children with hypotonia or low tone. The effect of improved proprioception is almost immediate when you put them on. Parents recognize quickly that the child is steadier. As I explained last week, in my practice, I recommend both of these techniques, with the recognition that children with more than mild problems are going to need both systems to optimize function.
Kinesiotape is another good technique that all therapists should have in their toolbox. It is useful in babies to peak performance athletes… watch Wimbledon in June and see how many tennis players have bright blue tape on their bodies. Many more athletes use it, but it tends to be hidden under their uniforms. This tape provides excellent proprioceptive feedback and is useful in providing a small degree of support to a joint. Time for another fact check. You cannot Kinesiotape an entire trunk and pelvis to provide the required support for weak muscles. In most children, trunk support is needed over a very prolonged period of time and the skin will not tolerate it. However, this tape can be used in addition to either of the more supportive core garments and it really excels as a therapeutic adjunct when working on a specific upper or lower limb motor skill.
The problem seems to be recognizing that until the child has some core strength you cannot increase core strength. Every muscle has its own optimum length and strengthening occurs when the muscle is working within its optimum range. Once you have midrange strength, you can work on strengthening in a shortened position and even strengthening in a lengthened position, but you cannot, in my experience, strengthen in a lengthened position first. A child or an adult with a weak core who cannot maintain an upright sitting or standing position, will need some support in order to exercise properly.
Unfortunately, when the core is really weak, it is not just the muscles that are affected. If you think of the child in a “C” shape, all the muscles and tendons at the back of the body are elongated and weak while all the muscles and tendons in the front of the body are shortened and weak. Compressive garments and taping all work to keep the muscles in their normal range.
What about the older teenagers and adults? The major difference here is that these individuals may have suffered the results of muscle imbalance in a growing body. Most of the adults were discharged from active therapeutic interventions before many of these modern techniques were made available. Many, if not most, have significant body issues with shortened muscles and tendons as well as bony alignment issues.
The first step for these individuals is an examination by an adult physical therapist. There is not much point in looking for a pediatric therapist as in most cases, they work in institutions with a finite age limit of 18 or 21 years and frankly, do not have the type of examination equipment that may be needed. I have found the best results with an orthopedic or sports therapist. They understand biomechanics and should be able to provide you a good documentation of muscle strength and range of motion. Before starting any program of therapeutic exercise, you should see a physician to rule out any contraindications or limitations to your exercise program. For those who are in the mild to moderately affected group of adults, a family physician could do this clearance. For those with moderate to severe involvement, I would ask for a referral to see a physiatrist. These individuals are like an internal medicine specialist for people with neuromotor impairments. The American Academy of Physical Medicine and Rehabilitation at www.aapm.org has a useful tool to find a physiatrist in your region. You can find the tool under the family and patient tag on their homepage.
For teens and adults that are up and moving, you might try a sports compressive garment to see the effect of some support. The following links are for two types of sports garments. The first is more supportive, as it was originally designed to help support joints in peak performance athletes. The second is more equivalent to what I have described under the Spio information. There are many other types available and I encourage you to send me information of any you find that are helpful.
All of them give improved proprioceptive awareness, support circulation and some degree of support.
What exercise systems are there in addition to therapy? For the older child, teenager, or adult, Pilates exercise is a good choice. This system was developed with the aim of increasing spinal and pelvic stability. There are practitioners worldwide and a fair number of adult therapy centers have Pilates available as well. In that type of therapy center, you have the best of both worlds in that the Pilates instructor is also a physical therapist. There are a smaller number of pediatric physical therapists who have incorporated Pilates into their programs, but it is always worth asking your own local contacts to see what else might be available.
Yoga floor exercises are also very helpful. Both yoga and Pilates practitioners put a lot of emphasis on improved breath control… a common problem in all adults with limited mobility.
Tai Chi is a martial art form that is also very helpful. Tai Chi centers often have modified programs for adults with injuries or impaired mobility due to age. These programs may offer a series of seated exercises to start. For most people with spasticity, there is less “overflow” to the muscles in a seated position than in a standing position.
All three of these techniques are “out of gravity” to some extent. The movement patterns that you learn are new to your body and challenging to your brain. There are many research studies that now have documented that novel, challenging tasks induce neuroplastic change. As readers of this site understand, many of the movements that affect individuals with an early neurologic injury become ingrained habits. Coaches and athletes will tell you that you cannot change a habit by working a habit. Activities that are out of gravity, on the floor, are particularly beneficial.
Water exercise with a flotation device is an excellent method that improves cardiovascular fitness, allows out of habit practice of reciprocal movements, and strengthens both the limbs and the core. If you are registered on this site, you can download a water program here that is effective for both children and adults who are able to get in and out of the pool.
Remember, the older you are, the more important it is to check with your physician before starting this or any other exercise program.
Of all of these exercise methods, I have seen the biggest gains from water. In a flotation device, in the water, your brain has to rapidly figure out how to move in a totally new environment. Firmly wired patterns of movement on land do not work. It is sometimes shocking to see how much improvement is possible in the water when you take away the habit that is hiding the evidence of neurologic recovery.
There are a series of blog posts about water exercise that document change in both children and adults. This link will take you to a page with all of these blogs. Water Exercise posts.
What else has changed in the last 20 years? There are new and improved methods of spasticity management. Orthopedic surgery has entered an entirely new era with improved selection criteria, intra-operative techniques, and better post surgical rehabilitation. These interventions are not within the scope of this site, but I do think it is worth talking to a physiatrist about your individual case. I believe it is always worth making an informed decision.
For the parents of young children, I encourage you to create a dialogue with adults who have had a similar early brain or nerve injury. I think it is important that you understand the natural history of nonintervention. You are in the position to limit the effects of body malalignment issues in your child. It is a lot of work, but I encourage you to remember that it is easier to prevent a habit than to change a habit.
For the adults who read this blog, the first change for many of you, will be the willingness to investigate the possibility of change. In my experience, most of the adults that I have met, have initially resisted the possibility of change. This is not surprising. You grew up and were treated in an era when human neuroplasticity was denied. It is now an accepted scientific fact that our brains can change and improve throughout life. Equally, dealing with body malalignment issues is a much more advanced science. The first step is the willingness to change.
In closing, my message to parents, adults and therapists is simple. Alignment issues are virtually universal in all people with early neurological issues. Dealing with them is a challenge until the teenager has reached bone maturity at 18+ years of age. Collectively, we have to stop thinking of all the available therapeutic interventions as interchangeable options. We have to support alignment first and foremost. If your practitioner does not have these “tools in their toolbox”, then get a referral to see someone who does have these necessary skills. In my opinion, the alignment supports that each child needs are as necessary for them as insulin is for a diabetic. Next week, I will discuss alignment issues in hands, another almost universally neglected area of alignment management.