Should your child be doing stretches?

For a child with cerebral palsy, physical therapy acts as one of the main components in improving his motor skills and developing his independent daily function.
During this process of learning and improvement, a child is educated about the use of his extremities and trunk in an appropriate / correct way. The normalization of motor function is followed by normalization of the muscle tone.

Each treatment and approach has long and short-term goals, which are based on the child’s condition, age and stage of development. One part of the process, which is widely accepted as a “one of the main treatment components,” is stretching. However, the way your child is stretched can affect his progress and what he will be able to achieve in the long term. There are two totally different types of stretching: active and passive, both of which we will cover in this article.

Explaining changes in tone.

As a neurological disorder, the effects of cerebral palsy originate from damage caused to certain parts of the brain. Depending on the area of the brain that is affected, a child’s muscles and tissues can become either hypertonic (high muscle tone) or hypotonic (low muscle tone). His ability to move properly will be affected as well. Once the child cannot move properly, he will develop compensatory movements, which in turn will lead to increased muscle tone.

There are two processes which are taking place in the brain. The first one is called irradiation, and the other one is called concentration. Irradiation is the process when all the cells are employed for one particular movement. This also includes cells which are not necessary for the function. The concentration process starts when we are becoming acquired with the necessary movement or function. This is when only the cells which are needed to work are working. If a child cannot move properly, he is struggling to perform functions anyway. Therefore, the process of irradiation is taking place. This is when a child will have increased muscle tone. During development, a child starts off by learning how to roll, then sit up, turn onto his knees, and then crawl. This process takes place in a certain order so that a child’s trunk and extremities will be adequately prepared for the different functions.

This process is important because the trunk (also known as the body’s core) acts as the “king” of the body. If a child does not have well-developed trunk control, his tone will increase because of the effort he has to put into keeping his balance, while performing certain tasks with his limbs.

Applying stretches in an active way.

Now, I know that my discussion is going to cause a lot of debate, but it is not my goal to start an argument on this issue. In fact, personally I am in favour of stretching. But, I think that stretching has to be done actively (i.e. with the child’s participation), and not in a passive way (i.e. when you stretch a child and he does nothing). During this “‘passive’ stretch” his brain does not learn movement or function, since he is not actively participating in the task at hand. Moreover, for the body this is an invasion and the brain and nervous system start to fight this invasion.

As a result, the muscle tone can increase more over a certain period of time. In other words, the results of the treatment will not be long-lasting.

So when stretching is being applied in practice, we need to remember that the child has to be an active participant. It means that he should not just work to grab his hand or leg to stretch, but that he needs to be educated in how to perform functions such as rolling, crawling, standing and walking--which are all, in fact, active stretches. During the stages of “normal development,” a child stretches his body as he works his way through each function. His brain learns new movements through his discovery of the world. This is how a child learns to move correctly using every part of his body, which will lead him to develop proper tone and function. A child with cerebral palsy is no different, which is why we need to consider these key components when guiding him through the development process.



Steps to take.

With these differences in mind, there are many tips that you may wish to consider in regards to your child’s treatment. One thing to consider is that your child’s stretches should always start with the trunk. Every limb works in conjunction with the rest of the body, so they cannot be exercised on their own. When the trunk has been introduced to fluid, rotational movements as a part of regular function, your child’s tone will follow and gradually improve. Then, once the tone has been released from his trunk, you will be able to teach your child how to roll properly. This will allow him to progress onto the next stages of regular development.

Like we’ve discussed before, it is important to avoid exercises that do not have a real purpose behind them. This is what differentiates an “exercise” from a “function.” In real life, we do not stand or roll without reason; we perform the actions with a certain intent in mind. So, when you work with your child, give him a functional goal, for example: we are going to crawl to the table to have lunch, etc.

In learning these steps alongside your child, you will lower his tone, improve his movement and help him realize just how much he can accomplish.

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Intensive, Progressive Physical Therapist Exercise Program Plus Educationreduces Disability And Improves Patient Function After Back Surgery

Patients who have undergone a single-level lumbar microdiskectomy for lumbar disk herniation experienced significant improvement in physical function following an intensive, progressive physical therapist guided exercise and education program, according to a research report published in the November issue of Physical Therapy (PTJ), the scientific journal of the American Physical Therapy Association (APTA).

Low back pain continues to be the most prevalent musculoskeletal problem, and one cause is lumbar disk herniation accompanied by sciatica - with many cases resulting in lumbar diskectomy. Up to 35 percent of patients continue to have pain and impaired function after surgery, which may be related to the type of postoperative care that they receive.

"An important goal of physical therapy interventions is to resolve functional deficits associated with low back pain," said physical therapist and lead researcher Kornelia Kulig, PT, PhD, associate professor of clinical physical therapy in the Division of Biokinesiology and Physical Therapy at the University of Southern California in Los Angeles. "There is strong evidence that intensive exercise is effective in restoring functional status in patients who have undergone lumbar diskectomy. The exercise intervention in our study consisted of an intensive, graded strength and endurance training program targeting the trunk and lower-extremity musculature."

In this study, 98 participants who had undergone a single-level microdiskectomy were randomly allocated to receive education only or exercise and education. The education-only group received one session of back care education 4-6 weeks after surgery. The education and exercise group received one back care education session followed by a 12-week USC Spine Exercise Program initiated 2-3 days after the education session. The exercise program consisted of back extensor strength (force-generating capacity) and endurance training as well as mat and upright therapeutic exercises. The back extensor strength and endurance training portion was designed to load the back extensor muscles in a graded manner by varying the time and angle at which the trunk was held against gravity, using a variable-angle Roman chair.

The goal of the program was for participants to be able to maintain a horizontal body position for 180 seconds. The purpose of the mat and upright therapeutic exercise portion of the program was to progressively and dynamically develop strength, endurance, and control of movement by the trunk and lower-extremity musculature.

Testing on all outcome measures began 4-6 weeks after surgery, prior to intervention, and was repeated for comparison after the 12-week program. Participants showed improvement in their ability to engage in activities of daily living as well as performance on the Repeated Sit-to-Stand Test, the 50-Foot Walk Test, and the 5-Minute Walk Test. In addition, some participants opted out of their allocated intervention group to pursue physical therapy care outside of the study, but agreed to remain in the study. This allowed researchers to include a third group. The three-group analysis still showed greater improvement in activities of daily living scores, 5-minute walk distance, and 50-foot walk time in the exercise and education group.

"These results suggest greater effectiveness of the current exercise program in reducing disability and improving walking performance than that expected from usual physical therapy," remarked Kulig. "An intensive 12-week strength and endurance training program of the trunk and lower-extremity musculature is safe and results in a greater reduction in disability and a greater increase in walking performance immediately following the intervention."

This study was funded by a grant from the Foundation for Physical Therapy.

Source: Jennifer Rondon
American Physical Therapy Association