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Suggestions needed - November 14, 2000 5:04:00 PM
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Kristen Snarski
Posts: 2
Joined: October 26, 2000
From: Erie, PA USA
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I am currently working with a 17-month old with mild hemiplegia secondary to schizencephaly. Things have been going along fairly well...she sits independently with minimal asymmetry and her quadruped creeping paattern is now including some weight bearing on her involved side. She will rotate in and out of sitting and quad over either side. She pulls to stand with her uninvolved leg forward. Once standing she is not weight bearing well on her left (involved) leg and instead is pushing into extension, is up on her toes and maintains the hip abducted and externally rotated. When cruising she is using this leg more as a prop than as a weight bearing limb. During handling/facilitation she tends to "dump" weight to her upper extremities rather than accept weight on the left leg. When we work without upper extremity support she is extremely fearful and will just collapse into flexion.
I work on sit-to-stand and stand-to-squat activities where she tolerates more handling and will take more weight on her left leg, but she is pulling to stand and cruising more and more on her own and I am plum out of ideas to facilitate better weight shift/bearing on that left legt
Any words of wisdom out there?
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Re: Suggestions needed - November 15, 2000 8:08:00 AM
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Bobcat
Posts: 493
Joined: July 13, 1999
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How much control does she have of the involved lower limb, and are there any known perceptual impairments?
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Re: Suggestions needed - November 15, 2000 10:44:00 AM
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Dana D
Posts: 142
Joined: September 18, 1999
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How is she when cruising to the left? Does she still use her leg as a "prop" support? or does she simply refuse to do it? If she is at a couch she could easily "dump weight" on her arms... but if you try a less supportive surface, as a refrigerator with magnets to the left of her, she may be forced to weightbear on her left leg.
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Re: Suggestions needed - November 15, 2000 1:13:00 PM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
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Okay, I've got a few ideas, but first, you'll need a crash course in normal motor development a la NDT. If you need more help with this, take a look at the full presentation on my website at [URL=http://www.geocities.com/drewpt]www.geocities.com/drewpt[/URL] or get your hands on a copy of Lois Bly's Motor Skill Aquisition through the First Year of Life. It is a MUST HAVE for any pediatric therapist.
Anyway, you will need PowerPoint2000 or the free viewer in order to take a look at my free continuing education information. That said:
Consider what happens between the 4th and 5th month of development . . .
Hip flexors lengthen
Lower extremity AB and IR is reduced
Child gets up into prone on extended arms. This allows for weight to be shifted posterior. Obliques & Glut Max develop
Serratus Anterior develop. Note that if the Obliques don't develop well in the 1st through 3rd month (keep in mind that head control starts at the OBLIQUES), then head control is compromised, and the child compensates in the 5th month and never develops good control of the serratus anterior. If the serratus anterior does not develop correctly, then the child does not work the gluts when reaching from prone extension.
Your patient with hemiplegia therefore, is likely to have very poor control of the gluts because way back in the 5th and 6th month, she didn't reach from this position and never fully strengthened the gluts.
If the gluts don't kick in, then the Illiopsoas does not lengthen, what happens next?
TFL tightens (Flex,AB,IR)and when child brings foot to floor in standing, hips ABD, and Adductor Magnus, Brevis, Longis and Gracillis shorten and tighten.
APT worsens
Why is your patient on toes? Because the OBLIQUES ARE WEAK AND OR POORLY CONTROLLED. As a result in order to maintain trunk stability in vertical, be it sitting or standing, the child must compensate.
In your patient, the Lower Traps and Serratus Anterior did not develop in prone. As result, the Rhombioids Compensate.
Arms are retracted and weight is shifted from heels to ball of feet.
Stand up and try it!!
I didn't give you cerebral palsy, so what happened? There is NO Gastroc spastically here!!! The “tone” is created by postural compensation.
So . . . . .
What to do?
You'll need to begin by re-training the poorly developed musculature. Starting with the obliques. Weight shifting Quadruped is not the greatest idea because a child who is already moving by compensation will continue to do so. Try putting the child in a runner's stretch (Quadruped with one leg flexed and the other extended). This will lock the pelvis into a neutral postion in the saggital plane and allow for movement in the frontal plane. Facilitate by having the child reach for puzzle pieces, leggos, etc. Your hand SHOULD NOT BE ANYWHERE NEAR THE OBLIQUES. You should have one hand facilitating from the sternum. Remember, you are facilitating movement, NOT transfering the child. For a change of pace, have the child reach above 45 degrees to reach for toys or play a fishing game with velcro fish . . . this will work the gluts, which your child needs some serratus work on too.
The serratus needs work too, because in order to access a functional change, you'll have to change the child's center of mass. The patient needs the oblique control first, so that the scaps can be released from the postural system and used for functional purposes. Sitting on the floor and rolling a ball back and forth works well for this, but the patient MUST USE TWO HANDS AND FULLY EXTEND THE ARMS.
When the obliques begin to control trunk balance in lieu of the upper girdle, gait will improve provided that you've prepared the lower extremities as described above.
Finally, remember to facilitate the child from prone on extended arms to 4-sit to quadruped using one hand only. Your hand should remain on the sternum and the child does not need any additional support (if you MUST put another hand somewhere, it should be used for LIGHT assistance on the thoracic spine on the contralateral side to the one that you are facilitating from. If your hands are on the obliques or the hips, or the pelvis, then you're robbing the child of an opportunity to strengthen the very muscles that are giving you a problem in therapy. In other words, you're TRANSFERRING THE CHILD, when you should be FACILITATING THE CHILD.
There's more, but that's enough to chew on for now I think.
E-mail me directly at Drewpt@e-machines.net if you would like more help.
Drew
By the way, this is tough stuff to master, and NO ONE should feel bad, novice therapist or experienced, for not fully understanding the above information. So don't feel bad about asking for additional clarification.
[This message has been edited by Andrew M. Ball, MS, PT (edited November 15, 2000).]
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Re: Suggestions needed - November 15, 2000 7:33:00 PM
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Bobcat
Posts: 493
Joined: July 13, 1999
Status: offline
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Uh, Dana --...are you suggesting that magnets be used to help her weight-bear on her involved limb? Isn't that completely, like, employing MAGNET therapy??
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Re: Suggestions needed - November 16, 2000 4:44:00 AM
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Dana D
Posts: 142
Joined: September 18, 1999
Status: offline
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Thanks for the laugh [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
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