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Andrew M. Ball MS MBA PT -> Re: CP, ambulation, and ligamentous laxity (January 9, 2002 2:06:00 AM)
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I agree with Mark. PWBTT should be your first approach in this situation considering the following:
1. Gait improvements will be realized MUCH sooner with PWBTT than with anything else in the PT toolbox.
2. Likelihood of compliance with orthotics is low considering parental perceptions of disability.
3. Applied, controlled, stress loads applied to the ligaments will be in functional positions and ranges, not compensated ones.
Also, (and this is from my NDT background), consider WHY the child got into W-sitting in the first place. Usually, it's a cascade of compensations that can be traced back to poor development of the lower trunk (obliques and rectus ab), as well as the serratus anterior. In the absence of appropriate equipment (PWBTT), working ONLY on the functional level, trying to remind the parents and child not to w-sit will likely be unsuccessful unless you the PT ALSO work on the impairments that lead to the dysfunction and disability. A few suggestions:
1. Try placing the child into a runner's stretch position (dissociated LE's), and encourage weight shifting through facilitation (at the sternum) and/or play (picking up legos from one side and building with the other). This will target the RA and obliques while locking out the saggital plane, allowing movement in the frontal plane only. Getting the child to reach forward and above eye level will elicit tetanic contractions of the glut-max (which may also be important to prevent and reduce the crouched gait pattern characteristic of spastic di CP in particular. Also (and I personally find this the greatest benefit), the dissociated position will lock the pelvis in neutral so that there is not movement compensation related to APT or PPT.
2. Some therapists like to use a swiss ball or bolster with kids like the one you describe. I usually opt for a bolster over a swiss ball because I (and the child) only has to control one degree of freedom. Anyway, most therapists who've not been trained in pediatric handling, tend to place the child on the ball, and move the ball around in the hopes of improving balance. To do so is, in my opinion, a waste of time at best, and counterproductive at worst. Be very careful not to reinforce unwanted movement compensations (such as facilitation of the illopsoas to control balance in sitting as opposed to the lower trunk --- a compensation that will also lead to crouched gait). Be sure, therefore, that when working the obliques, that the ball moves minimally as your hands rest on the child's pelvis, your forearms run down the child's femurs, and the child is facilitated so as to LENGTHEN ON THE WEIGHT BEARING SIDE, concaving on the contralateral side.
Drew
[This message has been edited by Andrew M. Ball MS MBA PT (edited January 09, 2002).]
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