Newer research confirms that having children participate in functional
activities early on can help to curb inactivity and subsequent medical costs.
Getting children involved in those functional activities, however, can be
especially challenging where there are physical impairments present.Often the
path of least resistance is taken when functional activities may be too
challenging. Fortunately, therapists are becoming involved in the early stages
of infancy with more emphasis being placed on reaching developmental milestones
at a more appropriate time. Infants with disabilities create a patient
population that – we as orthotists – may not be involved with due to
the traditional orthotic designs that often limit function or impede motion.
These interventions can be contradictory to the goals the medical team is
hoping to accomplish. Children with more obvious disabilities or known medical
conditions would likely benefit most from early intervention with a focus on
functional activity. It should be noted, however, that a child with delayed
development does not necessarily mean that this child will have long-term
disabilities, but impaired quality of movement, athleticism and coordination
may also be the residual effects of this delay. Minimizing the delay in proper
intervention helps to minimize negative residual effects and limits the level
of disability for all children. An orthotist is a key team member in a
child’s life by the decisions and designs of the devices that we fit.
Maintaining a systematic approach for this population’s intervention will
assure the most positive outcome. Successful intervention for this population
should be structured around the following guidelines.
Evaluation
The evaluation process for children can be challenging. Manual muscle
testing is not valid for children at a very young age. Additionally, some
children will become hysterical when an examiner gets close enough to touch
them. Observation is often the best tool when trying to judge active motion.
Understanding if there is no function, some function or a functional amount of
movement is key in determining the design and level of support that is
necessary to achieve the medical team’s goals. When the orthotist’s
focus is shifted more in these terms, then a strategy of support and stability,
assistance or alignment can best be determined.
In correlation, the child who has no strength in a particular direction
needs to be supported in that direction, someone who has some strength needs
assistance, and someone with functional strength may require alignment without
restriction to motion. Take, for example dorsiflexion strength. In cases where
dorsiflexion is absent, plantarflexion is blocked. When there is still some
dorsiflexion but difficulty with clearance the orthotist may consider an assist
joint without the use a plantarflexion stop, and when dorsiflexion strength is
there, but clearance is still an issue, the focus should be toward alignment
for optimization of the dorsiflexion muscle group.
Hands-on evaluation
Eventually, hands-on evaluation is necessary. The skilled practitioner
will use this part of the evaluation process to gain insight into the
patient’s condition.
First, understanding the tonicity involved with a specific child’s
neuro-muscular system should influence your design. Part of this is
understanding the available passive range of motions, and the difference
between Reflex Point 1 (R1) and Reflex Point 2 (R2) positions. R1 is defined as
the first catch position and the R2 is the end range position. Individuals with
hypertonicity may have significant differences between those
two positions. Lawrence D. Lieber, MD published in 1993 that R1 is the optimal
position of contractile force generation for spastic muscles.
 |
|
| © 2011 Marcin Sadowski/Dreamstime.com |
The modern therapist records these positions with hopes of improvement
as strength is gained. Additionally,
hypertonic children often also present a clonus response to a
fast stretch. Children with hypertonicity have shown functional improvements
when a management strategy has involved increased stability and positioning the
patient in more functional positions of the muscles versus being placed at an
end range.
Children with hypotonicity have shown greater functional improvements
with more alignment oriented dynamic orthosis. These orthoses primary goal is
alignment while still allowing for joint mobility. Hypertonicity is generally
associated with profound weakness, which some theorize could be why the
development of the tone occurred initially. On the contrary, hypotonic children
tend to be strong, as a result of a large range with poor resting positions.
Understanding this important aspect of the clinical evaluation helps to improve
the decision-making process and the outcome so that the strength of these
children can be best used. Passive range of motion (PROM) is also important.
Fabricating an orthosis in a position that someone is not capable of achieving
can lead to pressure, limited function and reluctance to comply. It is also
important to understand where a neutral alignment is occurring throught the
passive range.
The clinical evaluation is the key skill of an orthotist and the roadmap
to a successful outcome.
Over bracing and under bracing
Regardless of the decision to brace or not to brace, there is a
functional goal that is being challenged. If goals are not being met, the
design of the orthosis should be reconsidered. In the case where too much
motion is being blocked, the orthoses may not be dynamic enough and a child is
not able to generate the forces to create movement, a lesser device or more
dynamic design should be considered. Sometimes, situations arise where
inadequate bracing has been used. Often there is a therapist who fears blocking
function so they want a device that may be insufficient. Usually these children
present with more proximal weaknesses of the trunk, hips or at the knee. By
providing the appropriate distal control, more proximal strength can be
developed and appropriate motor planning can begin so that further progression
can be developed.
Validate approach
A child’s movement and progression of milestone development occurs
on a daily basis by every motion he or she makes. Children exercise against
gravity and the development of motion helps to determine motor patterns they
will continue to use throughout life.
Think about crawling and the development of hip and trunk strength from
that activity, and then think about those children who are unable to crawl. Not
being able to crawl can influence that child’s ability to advance his or
her leg when it is time for that child progression to walking. Reaching a
milestone is a concrete goal, that when accomplished, can help to validate the
approach that was taken.
In conclusion, the orthosis that a practitioner chooses for early
intervention should meet established functional goals and so enables the child
to reach developmental milestones in a more timely manner. Reaching these goals
requires intense repetition and progressive overload of the neuromuscular
system.
With the proper design and implementation, an orthosis has great
potential to assist in reaching these developmental goals.Making sure that the
goals are understood and the devices that we are fitting are achieving those
goals remains to be of paramount importance.
|
