I had to put my thoughts down in response to a post from Karen Pape, MD. In her blog "Revolutionize Your Approach to Therapy this Summer" she advocates for "splinting" the more affected limb of a child with CP to encourage them to use their good side better. My first reaction to the idea splinting the more affected side to allow increase work of the stronger side was...
Many of the kids I work with will naturally use their stronger side to the detriment of the weaker side and their overall postural alignment. In fact – most times, use of the stronger side “switches off” the weaker side, or worse – actually increases tone and harmful alignment.
I’ll describe 2 kids to illustrate:
1. Jamie is a 13 year old child with spastic diplegia (GMFCS IV).
Using Dr Pape's descriptions, upper limbs would be 70% of normal function, lower limb would be 20% – 30%.
When Jamie pulls to stand using his hands, he does so with his legs “locked” in a spastic pattern of hip adduction, knee and hip flexion and ankle planterflexion. Typical diplegic stand in other words. He can move from sitting to standing without his hands if well supported at the pelvis. Although it is harder work for him if you take the hands away – standing without pulling with his hands ‘switches on” his glutes and quads resulting in much improved alignment of the legs and Jamie is able to stand up with neutral hips and knees. So letting him use his stronger limbs (arms and hands) results in more spasticity in his lower limbs and worse function.
2. Marc is also a 3 year old child with diplegia (GMFCS IV). He has a stronger right hand (50% of normal function) and will use that hand for play, fixing the left hand (40% of function) in a flexor pattern as a postural stability strategy, which pulls his whole trunk to the left.
Constraining the right hand with a soft splint encourages the left hand to come to the party. When Marc uses his left hand, the flexor tone in his left trunk relaxes, resulting in better body alignment. So Marc naturally "splints" his worse hand without anyone having to do it for him when he is busy with his right hand – which he does all the time to the detriment of developing skills in his more affected, but functional left hand.
So, with this in mind, just as I was thinking I finally disagreed with Dr Pape, right at the bottom of this blog I read a sentence or two about constraint and alignment – and the penny dropped for me.
The penny being ALIGNMENT!
What Dr Pape is proposing is not revolutionary, but quite old school NDT. By splinting the more affected limb in a position of good alignment, what you are actually doing is using a tone influencing pattern (TIP) or really old school “reflex inhibiting posture” (RIP). NDT therapists use this all the time to decrease effort and help kids move out of a spastic pattern into a functional movement skill with good alignment.
I love when "revolutionary" is really just a rehash of NDT!
Maybe what is more revolutionary – is the idea of practicing this during the summer holidays :) .
So overall – good therapy advice as usual and a reminder that whenever we think about constraint in young kids it is so important to remember that as well as encouraging use of the more affected limbs, kids need time to develop good skills in the less affected limbs, which is enhanced by keeping the worse limb in a good TIP.So thanks once more to Dr Pape for taking the time to write down your excellent advice and provide a place to encourage more specific conversations about what therapists do and why we should do it.