CP, ambulation, and ligamentous laxity (Full Version)

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zkatlinda -> CP, ambulation, and ligamentous laxity (January 8, 2002 3:12:00 PM)

I have only been working as a peds PT for a few months now. I work at a school for children with CP. I got into this field because I have a daughter with CP. I have a passion for trying to help kids with CP gain motor function. I read everything I can get my hands on -- old and new from the Bobaths to Leonard to Shepherd.

This is probably only the first of many requests for help I will be sending out.
I have a student with spastic diplegic CP, about 12 years old, with a long history of sitting inside of his LE's ("W-sitting").
He ambulates with an Ottobock Bugsy walker, but his gait pattern is painful to watch.
His hips, knees and ankles move excessively in every direction. To say that he suffers from ligamentous laxity would be an understatement. I have asked the parents to remind him not to "W-sit." (Although I think its a little late for this.) I have been trying to work on activities that will help increase muscle strength in LE's to help with support and stability at the involved joints. While doing this I have to provide manual support at the knees and hips to get a somewhat normal alignment.

From what I've been able to find in the literature, I'm afraid his ligaments are going to eventually snap -- they've been
permanently deformed and if immobilized they would change in physical properties so as to become more brittle.

I haven't been able to find any literature about surgical procedures to repair this type of damage. I thought of using orthopedic knee and ankle braces during therapy (mom and dad don't like orthotics --they think it makes their son look disabled). I thought maybe if I showed them what he looked like walking with more stability at the knees and ankles they might reconsider. Maybe I could try the SWASH for the hips?

Andrew, I would appreciate any guidance or
suggestions.

Thanks,

Linda Z.




Mark Hirsch -> Re: CP, ambulation, and ligamentous laxity (January 9, 2002 3:56:00 AM)

Hi Linda,
Do you have access to a treadmill with partial body weight support at your school?
Mark




Andrew M. Ball MS MBA PT -> Re: CP, ambulation, and ligamentous laxity (January 9, 2002 8:06:00 AM)

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).]




zkatlinda -> Re: CP, ambulation, and ligamentous laxity (January 10, 2002 2:35:00 PM)

Thanks for the advice. Unfortunately, we do not have access to a treadmill. Most of the funding for the CP Center School comes from sending school districts and United Way. The equipment we have here is minimal.

Thanks for the NDT based suggestions -- I'll
use them in future treatment sessions.

By the way, we got very little NDT clinical exposure in school. Can you recommend a first NDT continuing ed course for a new peds PT?

Thanks again.

Linda Z.




Andrew M. Ball MS MBA PT -> Re: CP, ambulation, and ligamentous laxity (January 10, 2002 5:00:00 PM)

I'm a big fan of Lois Bly's week long introductory course. It's heavy on physiologic theory and developmental kinesiology (with which, if you have a firm grasp - NDT isn't all that usefull), and uses her book (essentially a qualitative study of over 1000 infants), to guide the evidence-based aspects of the course. This is followed by a day or two of treatment techniques.

Drew




Mark Hirsch -> Re: CP, ambulation, and ligamentous laxity (January 9, 2002 3:56:00 AM)

Hi Linda,
Do you have access to a treadmill with partial body weight support at your school?
Mark




Andrew M. Ball MS MBA PT -> Re: CP, ambulation, and ligamentous laxity (January 9, 2002 8:06:00 AM)

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).]




zkatlinda -> Re: CP, ambulation, and ligamentous laxity (January 10, 2002 2:35:00 PM)

Thanks for the advice. Unfortunately, we do not have access to a treadmill. Most of the funding for the CP Center School comes from sending school districts and United Way. The equipment we have here is minimal.

Thanks for the NDT based suggestions -- I'll
use them in future treatment sessions.

By the way, we got very little NDT clinical exposure in school. Can you recommend a first NDT continuing ed course for a new peds PT?

Thanks again.

Linda Z.




Andrew M. Ball MS MBA PT -> Re: CP, ambulation, and ligamentous laxity (January 10, 2002 5:00:00 PM)

I'm a big fan of Lois Bly's week long introductory course. It's heavy on physiologic theory and developmental kinesiology (with which, if you have a firm grasp - NDT isn't all that usefull), and uses her book (essentially a qualitative study of over 1000 infants), to guide the evidence-based aspects of the course. This is followed by a day or two of treatment techniques.

Drew




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