Minimize Maladaptive Motor Habits

Whatever you do, your body will learn to do better. If you are walking badly, your body will learn how to do badly better. Over a long period of time I have asked parents why they go to physical therapy. In one form or another the answer is nearly always “So that he/she can walk normally.” Here are some facts. Regardless of what you do or how you do it, all children with Hemiplegia will walk. If they do not walk, it is caused by another problem, not early onset Hemiplegia. The vast majority of children with Diplegia also walk. Walking is more delayed in children with four limb involvement, either Spastic or Athetoid Quadriplegia. But even in these more severely involved children, I expect all children with mild to moderate levels of severity to walk. This takes us down to less than 10 to 20% of children with early onset brain lesions that will not walk. The more severe the brain problem, the more interventions they may need to get up on their feet and moving. The point is that the majority of affected children will walk. The choice that both parents and therapists face is whether they learn to walk badly or they learn to walk well. In my experience, the earlier they walk, the more likely they are to develop significant maladaptive movement habits.

The stark reality is that the quality of movement that our current therapeutic interventions are producing is not “good enough” for the majority of children. Many attain function without alignment and that means pain later in life. (see: Is Malalignment Malpractice? and Poor Alignment Equals Chronic Pain) Next time you are at a doctor’s office or at your regular therapy center, look at the older children.

In the beginning, I was taught that cerebral palsy was caused by a permanent, irreversible brain injury. In the presence of a permanent brain problem, functional independence seemed to be a reasonable goal. Working under this paradigm, we have collectively settled for distortions of the body’s alignment in children with cerebral palsy. Then along came Human Neuroplasticity…a true game changer. As I got older, and my patients got older, I found more and more evidence that they were capable of complex motor movements. (The Boy Who Could Run Better Than He Could Walk) Once I worked out the difference between neurologic potential and early learned habit, I had to question the ethics of setting such low outcome parameters for children who would have demonstrable recovery later in their lives. (Recovery In Cerebral Palsy Takes Time and Fresh Thinking)

It is common wisdom that it is easier to prevent a habit than to change a habit. Older children, teenagers, and even adults can change these early maladaptive habits, but it takes a lot of work and a lot of interventions and a lot of time. So, the goal is not to walk early, but it is to walk well. I would like you to stop and look at this YouTube video. http://www.youtube.com/watch?v=uUgtzfvXr9g

It was filmed with an annoying radio commercial in the background, so turn down the sound. As you watch it, notice that at first he falls frequently and is not using his hands. He requires close supervision. Then he is filmed with a TheraTogs system in place. With the suit on, he is able to walk rapidly with better balance. He no longer falls, he gets farther away from supervision, and he is actually able to hold a toy and walk at the same time. You decide which gait you think the child should practice…the one with the TheraTogs system or the one on his own?

When a child has the base of a stable trunk, they are able to activate and strengthen the core muscles. It is hard for anyone to properly strengthen a muscle if it is either too short or too long. When children slump into a “C” shape, the muscles on the back are stretched and elongated and the muscles on the front, particularly the hip flexors, are shortened and weak. The reason professional athletes have strength training coaches and weekend warriors have personal trainers is to make sure that the body is in the correct position when the muscles are strengthened. It may be harsh to say it, but I think anyone who believes that they can be successful strengthening a baby’s muscles in an abnormal position is working in an alternate reality system.

I posted Billi Cusick’s letter to parents and therapists about postural control and its development. Please read it. The link is at the end of this post. She developed the TheraTogs system and is owner of the company that distributes it. This means that she can’t be quite as forceful as I can be about encouraging its use. I am in the fortunate position of having no competing biases. I am not a consultant to Billi’s companies nor do I profit from the sale of her equipment. The same disclaimer holds true for any other technique or technology that I recommend. All I can do is give you my views based on over 35 years of dealing with children with early neurologic injury. I have now retired from clinical medicine and my “work” is writing.

You can read more about the TheraTogs system at www.theratogs.com

Billi Cusick’s teaching schedule, books, videos, and research results are available at www.gaitways.com

I also think it is worthwhile to Google the images for TheraTogs and look through them. It is obvious that all these children have achieved proximal stability for distal mobility in their suits. With a stabilized trunk/core, they are in a good position to learn to use their hands or feet.

What else is available? Athletes use variable levels of support depending upon the amount of stress that is being put on their body. I believe that children should also have variable levels of support available for their bodies. This opinion is in direct contrast to common practice in pediatric neurorehabilitation where most children are offered only one level of support. I have seen countless children with one set of ankle foot orthoses and nothing else. They go from the AFO to bare feet or flip-flops. Most do not even wear supportive shoes. I would hazard that 90% of the children I have seen with abnormal wrist/hand positioning either have no support for the joint or they do not use the supports. My goal for children with mild or moderate injury is a straight body that moves well by their late teen years. I do not accept the concept of allowing their bodies to deform and their brains to learn abnormal movement patterns.

TheraTogs, like AFO’s, are rarely worn throughout the waking hours. Fortunately, variable support is available. The Spio group of products are similar in many senses to the compressive garments used by athletes. You can see these products at www.spioworks.com

There are a group of in-course videos to see at www.youtube.com/watch?v=bGIJ9VmuC2w

I personally have had less experience with the Spio products than the TheraTogs. However, they are obviously effective with low tone and much easier to use with infants and young toddlers. I think they could also be used effectively as a “step-down” from the TheraTogs in older children. I guess the simple answer is that you should use the equipment that allows your child to have a steady core. From that position, the child can do all the therapeutic exercises and various techniques that are available to strengthen the core muscles in their proper alignment. Putting on a compressive garment does not put a muscle at rest and cause disuse muscle atrophy. It actually improves the activation of the muscle by improving the sensory or proprioceptive feedback to the brain of the body’s position in space. This is one of the reasons athletes use compressive garments! We should stop expecting children with damaged brains to be able to do things that peak performance athletes, with perfect brains and excellent neuromotor skills, cannot do.

These two techniques are the ones I am familiar with and feel comfortable recommending. Others may also work. As ever, I appreciate feedback. For any techniques the most important principle is that the trunk muscles are in the proper alignment. Exercise out of alignment is harmful, not helpful. If your child “works” better with your therapist’s hands on for support and guidance, then you should consider sending a set of hands home with the right compression garment.

I close this post as I started…the core is the starting point for all movement. The list of other techniques and technologies used in the small child with Cerebral Palsy is fairly long and many of them discount the core…some even go so far as to push parents to only use their particular program. Everyone is entitled to their own beliefs, but it helps if the belief is based on a few important realities. All movement starts with the core. Look again at the first YouTube video http://www.youtube.com/watch?v=uUgtzfvXr9g

With an unstable core, the child learns a maladaptive movement pattern. With a TheraTogs system, properly fitted, his gait is great. Your choice.

My parting words are “Properly Fitted”. There are a lot of trained, certified TheraTogs therapists. On the two sites given above, there is a wealth of helpful information for people who are not as experienced. The Spio website also has information about their product, research reports and some helpful information on fitting the garments. My advice to parents and therapists is to contact these sites directly for information about trained practitioners in their area. Adults should contact both sites for information about larger sized products.

My next post will be about exercises for the core in older children, teenagers and adults.

See Also
Movement Starts with the Core
Billi Cusick’s Thoughts on Managing Children with Diplegic Cerebral Palsy


7 Responses to “Minimize Maladaptive Motor Habits”
  1. Suzanne says:

    Hello Karen

    Hope you can open this! 🙂 And pray all is great with you.

    http://www.youtube.com/watch?v=DvxpXylwE4I&feature=share&list=UUAOTkZiedcAsntydugqlMJQ

    Thank you Suzanne.
    Watching the dolphins is good for the soul.
    Karen

  2. Vikki Currier says:

    Hi Karen,

    I just wanted to share a good news story with you. My son was diagnosed with hemiplegic CP at 7 months old. He is now 15 months. I have been an avid follower of your blog after listening to your TED talk and have been applying your principles as much as possible.

    My son started to commando crawl at 10 months, he basically dragged his body weight around using his left arm to pull himself along – I knew this was bad. What was worse, is that I taught him to do it!! Our physio convinced me that it was more important for him to be mobile (to prevent other developmental delays) and said that we will focus on getting him up and walking sooner than later, so he is not doing this bad patterning for too long. I agreed, but was nervous.

    I did not give up on the possibility that he would crawl properly, even though pretty much every therapist etc told me not to worry about it and that it was not a developmental milestone!. Every day I got him up on his hands and knees and would manually move and adjust all 4 limbs in a crawling action, so he would get the hang of it.

    I’m thrilled to tell you that just before he turned 14 months he started to crawl!!!! He has now absolutely mastered it and has completely abandoned the old commando style. He is doing a beautiful, even, reciprocal crawl and I couldn’t be happier.

    Thank you for your knowledge and helping me to help my son. I’m sure this will have a significant impact on his future progress.

    • kpape says:

      Dear Vikki, I appreciate good news stories. In his case, your hard work paid off. The other process that was obviously going on was his brain was recovering sufficiently to allow him to produce a normal, four-point reciprocal movement. Check that his affected hand and ankle are not tightening up while he is crawling at speed. I wish you every good luck getting him up and moving on his feet. Just as he had difficulty figuring out how to crawl properly, he may need some help in the upright position. Talk to your therapist about whether he needs bilateral AFO’s to give him more stability through the initial learning process. In my experience, all children with hemiplegic cerebral palsy walk… The question is whether he walks well or not. It’s fairly easy for a young brain to figure out that a reciprocal, hands and knees crawl is easier to maintain and less work than a commando crawl. However, once he is upright, it is hard for the toddler to appreciate the difference between walking with one foot up on the toe and both feet flat. That is why I am an advocate of bilateral AFO’s as they get started in the walking process. Thank you for your comment, Karen

  3. Nicole Allen says:

    Hi Karen! Absolutely one of your biggest fans! We love everything you write in the FB group, Mild CP Parent Support Group. Do you have any posts you can share on FB that talk about gait trainers and walkers and when in your professional opinion are appropriate, or not. Lots of parents having inquiring minds! TIA

    • kpape says:

      Thanks for the boost Nicole,I do post all the blogs on my FB page and am glad to hear that you find them helpful. I think walkers and gait trainers have a place in the child’s rehabilitation to aid learning in the upright position. The key to their use is to think of them as an aid, not an answer. I strongly support the water program available on this site as another way to train reciprocal leg movements out of gravity. Are you being told not to use them?

  4. Lida Thompson says:

    Hi Karen,

    I read your blogs and I am a fan. My nephew is 2.5 years old and he has been diagnosed with spastic diplegia. He has just started to crawl somewhat reciprocally. He mixes his crawl with bunny hops. In your reply to Vikki above, you mention, “… The other process that was obviously going on was his brain was recovering sufficiently to allow him to produce a normal, four-point reciprocal movement. Check that his affected hand and ankle are not tightening up while he is crawling at speed.” I would like to know what you mean by that. I see my nephew fist his affected hand when he crawls.

    • Karen Pape says:

      Thanks for your comment Lida. Read Chapter 10 in my book The Boy Who Could Run But Not Walk: Understanding Neuroplasticity in the Child’s Brain. The cild often fists the hand(s) when working hard or learning a new task. This is an example of the “bully muscles” taking over. We want to block this reaction so that it does not become a maladaptive habit.Your sister should ask for a light splint, like a McKie thumb wrist splint to use when he is doing an activity that causes his hand to fist tightly.https://mckiesplints.com/