Neuroplasticity is the good news. Maladaptive habits are the bad. No matter how old your child is, every parent is at the crossroads and the choices you make will affect your child’s destination.
The good news is that upwards of 70% of children with cerebral palsy will walk. (Will My Child Walk? Are We Doing the Right Therapy?) The choice at the crossroads is how well they walk. In the wide world of pediatric physical therapy and the research world of motor control, there are varying theories of the best way to help a child walk well. Many practitioners subscribe to the concept of “movement through function”. In simplistic terms, that means allowing the child to do the function without much attention to form or how they are doing it.
Children are little learning machines and that is why a stimulating, challenging environment enhances neuroplasticity. (Can You Stimulate Baby Brain Neuroplasticity?) The more movement learning opportunities that the toddler or child are exposed to, the more they will learn. This is a scientific fact documented in numerous animal and human developmental studies.
In a normally developing child, they first move, then they practice it and the pattern of movement improves. Think of a toddler’s first steps. They are slow, unsteady and there are frequent falls. Gradually, after many falls and false starts, walking is achieved. Almost as soon as they can walk, they start to run and the sequence of falls and false starts is repeated with gradual correction and development of a steady running pattern. The underlying assumption of the “form follows function” theory above is true for a normally developing child. They are capable of gradually correcting their initial abnormal form to create better function. This is not true in a child with cerebral palsy.
Children with cerebral palsy have impaired motor control systems. When they try to move, they will only achieve function with abnormal compensations. I followed this sequence of development for many years working in the Neonatal Follow-up Clinic at The Hospital for Sick Children in Toronto, Canada. In preterm babies at term and full term infants 3-6 weeks after birth, the most common problem is global low tone…often called hypotonia. Yet the most common form of cerebral palsy is high tone spasticity. The transition from low tone floppy to high tone stiff occurs with attempts at movement over the first 18-24 months. The earlier high tone develops, the more involved is the brain. This is the natural history of untreated “spontaneous” development in children with cerebral palsy.
A good early intervention therapist can easily demonstrate positions and handling techniques that will decrease the tone and improve function. If all parents could be skilled therapists and/or you could take the therapist home for full time treatment while the child is awake, the tone would probably be better. But that solution is neither rational nor possible.
I look at this as two extremes; one is free movement with lots of abnormal compensations and the other is constant attention to correcting or fixing a movement pattern. “Put your heel down”, “Stand straight”, “Lift your foot”, etc., etc., etc. The latter system drives both parents and child crazy. If it worked, I could be convinced to follow this path, but personally I have not been overly impressed with the outcomes of children treated with either of these methods. Abnormal movement patterns interact badly with a growing body and the end result is shortened, tight muscles, bone and joint distortions and chronic, musculoskeletal pain in most teenagers and young adults. (How Much Does It Hurt? , How Much Does It Hurt? Part 2) The available prospective research trials document a gradual deterioration of function with growth.
Now, this is where it gets interesting. Pediatric neurorehabilitation is segmented into specific age groups and the goals for each of those age groups are different.
Early Intervention, commonly birth to 3 years was first developed to enhance social and cognitive development. This system provides a global program working with a diagnosis of Developmental Delay. There are real problems with this type of generic label that limits access to specific cerebral palsy treatments. (Too Little, Too Late)
The age group 3 years to 6 years is covered by preschool programs, with the goal of readiness for academic learning.
School based therapy starts at age 5 to 6 years. Everyone who has had the misfortune of dealing with the school system quickly learns that any and all therapy given in the school must be geared to improve academic function. Correcting the bodily effects of a “Function First” approach is considered a medical problem and not the responsibility of the school system.
Most of the adverse effects of cerebral palsy on body function and movement including progressive spasticity are firmly established by the time the child is 6 to 8 years of age. At this point, the child has firmly wired in maladaptive movement habits.
At this age, there are at least two explanations for why all the years of treatment have produced a child who still has significant movement problems. The explanation most commonly used is blaming it on the child’s brain. These people believe that there is no cure for CP and aren’t you lucky that your child is functional. You should be happy that they are “good enough”. I cannot express how strongly I disagree with that concept. I favor an alternate explanation that traditional therapies are focused on the wrong things and the first and most important ‘wrong thing’ is allowing them to function with poor form. I love this quote from Gray Cook, MSPT, OCS, CSCS in his book, Movement: Functional Movement Systems. With other experts, he developed a functional movement screening tool that is widely used by strength trainers who work with peak performance athletes, including many in the NHL. I love his statement about his philosophy of movement.
First move well, and then move often.
If we want a child to learn to move well we have to teach them to move well first. As abnormal compensatory movements appear, we should block them. The big difference over the last 40 years is the incredibly large toolbox that therapists now have available. Many of these tools are capable of facilitating more normal movement. If you look at all the alignment posts on this blog (Alignment links), you will see numerous examples that range from simply Kinesiotaping a wrist through to invasive spasticity management and Single Event Multiple Level Surgery (SEMLS).
In my experience, and that of coaches and athletes everywhere, it is far easier to prevent a maladaptive habit than it is to replace it. Function must follow form and fortunately the tools are available to help our children achieve their own personal best at every level of severity. Ignoring biomechanical distortion is a short-term solution at best and with many adverse long-term consequences.
The next three posts are going to deal with evidence-informed and best practice interventions for the trunk/hip complex, the upper limb/hand complex and the legs. This series of posts may be considered a bit of a “call to arms”. I believe that parents must demand that their therapy providers offer what is available, not just what they prefer to do. I am of the firm belief that anyone who claims that there is a single intervention or treatment that takes care of all of our children’s problems is misguided at best. I believe parents should have more information so that they can make this choices that best fit their own family situation.
If you have lingering doubts about whether children with cerebral palsy can do better please watch my TEDx talk again. If you think any members of your healthcare team have doubts about this fact, please ask them to watch it and then discuss it with them. Even the most severely involved children can improve their motor functions as their brains mature, but it is harder and takes more work with varied approaches. If there is no change in motor function, it is often the cognitive and visual co-morbidities that restrict progress.