Proximal Stabilization

Alternative Therapy for Cerebral Palsy

D. G. Kamath, Proximal Stabilization Centre

Surrey, B.C., Canada

INTRODUCTION:

The majority of Cerebral Palsy Children with Quadriplegia are wheelchair bound, totally dependent, and often develop contractures in spite of everything that is said and done for them. The Proximal Stabilization programme is likely to change it. But it needs to be monitored carefully for long term effects.

BACKGROUND:

Cerebral Palsy is mainly a motor disorder. The children afflicted with it have poor postural security in anti-gravity positions, such as crawling, sitting, etc. The Postural Insecurity is caused by imbalance between the spastic limbs and the flaccid trunk of the child (1) and fear for safety. Sometimes both neck and trunk are weak among some of them. The imbalance develops due to the inability of the trunk muscles to hold the body up-right against gravity. The increased effort by the child results in recruiting muscles of the extremities and tone increases in the large muscles of the limbs (2). The effects of imbalance can be minimized by appropriate support to the trunk or neck and trunk (3).

PRACTICAL CONSIDERATIONS:

All Cerebral Palsy Children may be helped by Proximal Stabilization in future. However, presently some children make better progress than the rest of the subjects.

Children between the ages of 15 months to four years of age seem to make significant improvements in their motor skills compared to other age groups.
Severely mentally retarded children do not respond to the programme.
The programme usually has been a success if parents are committed.

PROGRAMME:

Orthosis and equipment.
Parent training.
Follow-up.

The programme is conducted by an experienced physiotherapist and an occupational therapist who pioneered the programme. The children are referred by physicians.

Orthosis and equipment: - The commercially available trunk and neck supports are too rigid to allow badly needed movements of the trunk and neck. A flexible trunk orthosis has been designed as illustrated in Fig. 1. If neck and trunk need to be supported a circular inflatable tube is attached to the trunk support in front which supports the neck like a collar.

An ambulator is the other equipment the child needs. It has a rectangular wooden base mounted on 1 inch casters in the back and 1 ½ inch casters in front. The body of the ambulator is made out of half-inch PVC pipe. It has a rectangular front and triangular sides. The pipe is heat moulded. The front is covered by fiberglass mesh. The child leans against it while standing as shown in figure 3. The back end of the base, which has rubber pads, digs into the floor and the ambulator is stable in this position. Hence the leaning child is safe.

Parent Training: - Before commencing the parent training programme, the child is assessed for his functional level and equipment needs. The assessment and the planned programme are discussed with the parent, with special emphasis on the role of the parent in the programme. Because the parent has to conduct the programme after training, it is important that the parent understands the programme correctly, tries it out at home, and provides feedback. The training includes:

How to put the support on the child, the air pressure to be maintained in the tubes, and precautions to be observed.
How to monitor the effects of therapy, orthosis and the ambulator
How to advance the child, and achieve quality movements.

Usual steps to improve postural security are:

Instead of a chair use the ambulator seat
Consistent use of the seat for play, which is likely to get the child used to it. Hence fear for safety is reduced.
The child is encouraged to stand with total extension. He is helped to put the weight on his feet, while standing.
Improving weight bearing on feet by play in standing position.
Feet are used while sitting on the ambulator seat to move forward.
Achieving change of direction of ambulatory movements and speed control without external help, are likely to make the child confident in maintaining balance on a moving object.
When fear of a fall is minimized by better balance and the ability to control movements, the child is encouraged to stand and take steps.
Lastly, an adult supports the child from behind, instead of the ambulator. Gradually, the helper decreases assistance, and the child eventually becomes independent of the walker.

Follow-up: - The entire programme takes 10 to 18 months and is provided free of cost to Cerebral Palsy victims and their parents. Depending on their individual needs the parents make arrangements to treat their children at home and bring them to the Centre to review progress. During review most of the time has been devoted to advising the parents how to advance their children. Also, to upgrade the orthosis and ambulator to meet continually changing needs of these children.

CASE STUDIES:

Seven Cerebral Palsy children were referred to the programme. Among them four are less than four years of age. The other three children are between seven and thirteen years of age. All are Quadriplegics. The thirteen year old boy gained head righting ability. The other two from the third group did not improve due to severe retardation. Three younger children achieved the ability to walk independently. One child discontinued the programme early.

REFERENCES:

1. Kamath, D.G., ‘The Neck and Trunk Functional Support for Cerebral Palsied Children.’ Proceedings, 8^th International Congress, World Federation of Occupational Therapists, p. 751-2.

2. Lundervold, ‘Electromyograph Investigation in Position and Manner of Working in Typewriter.’ Oslo, Bragger and Boktrykka, 1951, p. 171.

3. Kamath, D. G., ‘Proximal Stabilization and It’s Effects on Function of Cerebral Palsy Child.’ 1985 Annual Meeting, American Academy for Cerebral Palsy and Developmental Medicine, p. 103.