POSMODEV Who are we Main markers of the postural development Questions, definitions Central Coordination Disorder (C.C.D.).
Cerebral Palsy (C.P.) motor education : myth or reality..? the Vojta concept More about reflex locomotion Documentation and training


FITTING FOR C.P. CHILDREN



The C.P. child may have severe postural and motor gaps that compromise the acquisition a stable symmetrical posture as sitting, but also the manipulation and the different forms of locomotion. This handicap needs frequently use of equipment of adaptation in order to:
- facilitate essential functions of the daily social life
- prevent a possible orthopaedic degradation of the child without neglecting his comfort

These equipments bring an assistance concerning:
- the motor uprighting action
- the corporal symmetry (a persistent asymmetry is a pathological invalidating vector)
- the maintenance of postures, movements

In each country, different materials to reach these objectives can be found; it would be impossible and useless to enumerate them or to present them all. It is more interesting to specify:
a) what are the fundamental postural needs of the child according to his development level,
b) which equipment are the best to satisfy these needs,
c) in accordance with these two preceding points, what kind of adaptation fitting to choose.

REMINDER:
1) In an optimal development, the corporal symmetry is the result of a muscular tension balance acting on the corporal axis (spine essentially). A deficit of coordination, an unilateral deficit of muscular force, induce an asymmetrie. A majority of muscles and muscular groups have an oblique situation as compared to the corporal axis, they induce necessarily during their action a corporal rotation component, symmetry and rotation are therefore inseparable notions.

2) Symmetry in the course the development: at the age of 3 months, the corporal symmetry in prone and supine position is acquired thanks to the active construction of support points delimiting a support polygon:

- in the prone posture when the child is able to support on his 2 elbows with a weight transfer on the pelvis, he can then maintain the head , symmetrical and free to orient it in the space (according to the optical need), the spine can be well aligned. The simultaneous support on 2 elbows and the pelvis contribute therefore to the head liftcontrol.

- In the supine posture the support polygon is a triangular surface from the two scapulae to the sacrum, lower limbs are lifted; the head is in contact, but it is not really a support point to stabilize the body because it has to remain adjustable, to satisfy the optical function.

( normal evolution of the postural automatism, table, click here: table).

The active symmetry of the corporal axis contributes to the appearance of the prehension at the age of 4 months.

The installation of a young C.P. child during the daily life has to take these fundamental development principles into account. Fittings has therefore to use the same support points as long as the postural development level of the child corresponds to the end of the first trimester, although the child is older. It is frequently the case of C.P. children. The choice of the installation is based on the real postural abilities of the child, rather than on his age. In fact, choose the installation according to the civil age, means take the risk to pose to the child an insoluble postural problem because of his low motor performances; in this situation, the child is constrained to use a stereotyped compensation primary pattern, almost always asymmetrical and to fix himself in a stiff posture.

(definition of a compensation pattern , click here: substitute pattern)


3) Development of the coordinate vertebral rotation:
- During the 2nd trimester, in supine position, the control of the vertebral rotation produces the contro - lateral prehension: the child can grasp on one side with the opposite hand and vice - versa. This action will end, at six months in the first spontaneous turning from the supine to the prone position .

- during the second trimester (prone position), the support on one elbow and the opposite knee to catch an object is the sign of this new ability to control the vertebral rotation (4,5 months). A 6 months child can also raise by a symmetrical support on his 2 hands.



NB: at the age of 6 months no aligned and stable sitting is still possible. Sitting with lateral protection reactions of hands exists only in the middle of the third trimester; stable sitting, without support on the upper limbs is completely controled at 9-10 months, that means when the child can pass from the horizontal posture to the sitting posture by a succession of support points on the upper limbs, and thus to hoist the trunk until the vertical position, by transferring the weight of the trunk on the pelvis.


Simultaneously, appears the first creeping, because it uses the same postural components: differentiated support on the limbs to transport the trunk, crossed coordinate motor pattern (definition of the motor pattern, click here: pattern). The same crossed pattern persists and constitutes later the fundamental architecture of walking...

All these operations necessitate a mastered twist of the trunk, that means a precise control of the vertebral rotation. It appears thus clearly that a good quality sitting is impossible if a child does not turn over , or has not still developed a consequent support ability on the upper limbs. In a normal development this support ability is largely used to straighten the trunk and to maintain it, and we know that the simplest form of support, but already very efficient, is the support on 2 elbows (ventral posture, 3 months)

INSTALLATION AND POSTURAL DEVELOPMENT LEVEL :
- Objectives:
- Facilitate the access to the social life despite postural gaps of the child.
- Complement the physiotherapy to create conditions of emergence for the main motor functions: symmetry, orientation, prehension, locomotion, etc...
- Prevent the orthopaedic degradation.
- Two necessities: comfort and physiological use of the body according to the level of postural development, and to the possible orthopaedic alterations.

Means:
- Inventory of the child's most physiological postural elements (postural checkup).
- Choice of support points in accordance with these patterns.
- Adaptation of life modes to appeal in priority most physiological patterns (adapt the equipment to the person).

In practice:
Standing, going and sitting, are 3 main situations where fittings can bring a constructive assistance
. The postural development level of the C.P. child never corresponds to a fourth homogeneous trimester (if such was the case, these children would be spontaneously more autonomous). Postural activities of the third trimester (creeping, sitting , possibly verticalisation attempt) represent for these children the maximum performance level, sometimes with severe compensation patterns during their realization: rolling "en bloc", stiff crawling, cyphosis, etc...
Essential activities corresponding to the second trimester are generally insufficient or impossible. A very simple test allows to verify it: ask a C.P. child, in the supine posture, to catch rapidly its 2 feet with 2 hands and to remain in this position hands - feet coordination according to V. Vojta). A lot children do not get there, others get there very briefly but fall rapidly on a side or the other because they can not stay in balance on the dorsal support polygon of a 5 months healthy child, when he begins to catch his feet...
The postural patterns that a C.P. child can use in relatively physiological conditions are the patterns that a healthy child exploits at the end of the first trimester, possibly at the beginning of second trimester.

If we want to help a C.P. child to stand, to sit, and to discover a first form of going with help of fittings, it is therefore always preferable to make sure that the child is able to stabilize his body by support on the two elbows.

This double elbow support contribute also , by the peripheral irradiation of muscular games, to:
- head control and free orientation of the head for the visual function,
- alignment of the wrist and adjustment of the hand segments in the prehension posture(extension of the wrist, unfolding of fingers etc...)

The durable and effective stabilization of the trunk only with support on the pelvis and the lower limbs is impracticable (therefore absolute impossibility to master correctly a normal sitting). This posture is therefore not to research in priority, on the contrary we have to imagine an other social posture.

The installation modes follow from the previous elements:

1) Standing : Rather than to research on the one hand a form of " helped standing" and on the other hand a " helped sitting", all two utopian, because the active neuromuscular control means are failing , imagine a posture appealing in priority postural mechanisms of the end of the first trimester, much more accessible for the C.P. child.
The typical material to realize this " functional social posture" has to apply the following principles:

- Ventral board, slightly inclined forwards (15 degrees). It induces a support reaction on the upper limbs. A larger incline forwards increases the weight transfer forwards and imposes more rectification of the head to keep the look horizontal. This risks activating the hyperextension of the nape (deviant pattern).
- Anterior support on 2 elbows: a horizontal shelf is to place at sternum height, under nipples; it seems to be very high, nevertheless this height is necessary in order that elbows come naturally to make there a support; if the shelf is lower (at the last coasts level , for example) it cannot play this role. The shelf is carved in order to surround the trunk of the child. That avoids the loss of supporting on the elbows when the child moves his upper limbs. When the child takes support on his elbows, there is a muscular traction upwards on its spine, what contributes to align it.

- Pelvic saddle : this almost vertical position would be in contradiction with what has been previously told if we demand from the child that he lifts his own weight on his lower limbs. The equipment has therefore a saddle to sustain directly the pelvis (contact under the ischiatic bone). It can be constituted of a simple stuffed cylinder, passing between the thighs, under the pelvis. This support under the pelvis, associated to the moderated incline forwards, and to the support on the elbows practically calls only on the automatic components acquired during the first trimester of a normal development, and able to insure the balance of the trunk and of the head.

- Lower limbs are moderately spread (angle :40 to 60░ between the two lower limbs) to center the hips without stretching the possibly stiff adductor muscles . The foot-bases are adjustable, but it is important to remind that the essential of the corporal weight is not found there since this weight is distributed on the two elbows, the pelvis, and the ventral board, because of the incline forwards.

- A rigid posterior board is applied on buttocks, whereas the back is free. Applied without exaggerated pressure, it is situated in the frontal plan, it avoids the pelvis rotation and limits the hips flexion . The support on the ventral board and on the horizontal shelf surrounding the trunk avoids the lordose that could create the buttocks pressure.

Summarized::
This posture that looks like standing (with a light anterior incline) can as well be considered as a form of sitting, because of the support under the pelvis, but it really calls on postural automatisms that generate head control, vertebral alignment, segmental adjustment of the hand preliminary to the prehension. The realization, and the long term utilization by C.P. children of fittings respecting these principles, has shown that this installation could be comfortable, and contributes to symmetrical head control, development of the manipulation, such as graphics, and to the safeguard of hips at spastic children.

2) Sitting:
At this level of postural development (3-4 months), sitting has no chance to be actively controlled, because it corresponds to a pattern of the third trimester. Sitting finds a relative justification only for social reasons; it is necessary therefore to use it with parsimony ( the ventral board is preferable).

- During sitting, to be almost at the postural level 3-4 months, it is necessary to recreate the dorsal support polygon (2 scapulae - pelvis ) whose active construction is linked to the simultaneous stabilization of both scapulae by muscles such as, "trapezius", "rhombo´dei", "serratus anterior". Sitting in a posterior incline of 30 to 45░ will contribute to the creation of this dorsal polygon; an incline over 45░ favors too much support on the head (deviant pattern, substitute).

- In the supine position, the action of the "serratus anterior" and "pectoralis" muscles is prolonged by the abdominal oblique muscles to stabilize the pelvis. During sitting these muscular chains have to function from a pelvic support point to stabilize the trunk, the weight of the trunk will contribute to fix the pelvis to provide this support point, it is the second reason not to increase the posterior incline over 45░. No illusion: even in a perfect shell-seat the pelvis is never efficiently maintained, it is therefore essential that the dorsal support contributes to stabilize the body.

- When a headrest is indispensable , this contact has however not to become a support point which creates a deviant "hyperextension pattern" (frequent with too much posterior incline); the support polygon has to be dorsal (scapulae - pelvis), but the head has to remain mobile. As soon as possible the incline will be reduced and the headrest suppressed.

- Hips, knees and ankles are at 90░ (middle position = 3 months development level ), corresponding to a moderate muscular tension.

- Hips abduction: a too large passive "correction" of the adduction is useless and dangerous, particularly when there is an asymmetrical "gust of wind" attitude (deviation to the same side of the two lower limbs). Indeed, the exaggerated stretch of the adductor muscles, inhibits the abdominal activity, compromises the stabilization of the trunk, increases the previous lumbar lordose or cyphose. On the other hand, the presence of an abduction wedge between the thighs, can contribute, when adductor muscles are very spastic, and have an unequal force, to increase the obliquity of the pelvis and to create a scoliosis.

- Child with hyperextension tendency: the passive forwards roling up of shoulders (too often recommended to the parents ) is to avoid; it creates a cyphosis, incompatible with the construction of the posterior support surface. The round back rolls on the back of the seat and increases the lateral instability.

- Child with cyphosis, have difficulties to create the posterior support surface on scapulae, front straps passing ahead shoulders (used to "straighten" the child) are to avoid; they favor the research of an anterior support on shoulders and increase therefore the cyphosis and the instability.

- During a normal development, at the beginning of the second trimester, in the supine position, the trunk is perfectly stabilized on its dorsal support polygon , all four limbs are lifted in middle position; shoulders and hips are centered by a balanced muscular activity, that's why the prehension is going to appear; that is also the reason why, in the course of the following trimester, lower limbs gradually become support points able to stabilize the pelvis and the trunk; sitting and standing can appear. Sitting with adaptation fittings is therefore essentially devoted to the social life and to the prehension; the upper limbs are not used for the stabilization of the body; there are much more risks of deviant patterns during sitting than on the ventral board with anterior incline and support on elbows.

Summarized: adapted sitting , and installation on the ventral board , used according to the previous described modes, aim to launch essentially a postural activity corresponding to the 3-4 months level; such an activity is relatively affordable by the C.P. child. The ventral board creates a postural context closer to the physiological functioning than an adapted form of sitting. All two allow the prehension, but the ventral board is more propitious to a physiological posture of the hand because of the muscular irradiation induced by the support action on the elbows. That's also the reason why the correct head balance is facilitated by anterior incline of approximately 15░ with support on the elbows.

3) The autonomous locomotion:

postural advantages of the anterior incline with support on elbows can also be exploited for strolling: it is the principle of the quadricycle. This simple device uses the same support points that the healthy child of 3 months in the prone position .

- The quadricycle comprises different adjustments:
* height , back-forwards moving of the cylindrical saddle
* height and incline of the handlebar (optional)
* distance between 2 elbows
* forearm rotation
* by a combined adjustment of the saddle (back - forwards) and of the handlebar (height), it is possible to dose the trunk incline: in no case the trunk of the child has to be totally vertical, because the anterior incline favors the elbow support.

- The quadricycle can be made by a good handyman for a moderated price.

- At a very young child, who has still great difficulties to control his posture, it is possible in the beginning to replace the handlebar by an identical carved shelf as the ventral board (see previous text), with handles that the child can seize.

The upperlimbs are immobilized on the handlebar whose form enables a steady support on the two elbows. Thus, the propulsion and especially the direction of the quadricycle activate a rotation work of the trunk (without visible movements of the chest), with a coordinate action from the muscular chains of the trunk. That's the reason why, only the front casters of the quadricycle can swivel .

This activity of the trunk comprises many common elements with normal activities such as rolling , creeping , crawling, lateral step. This dynamic process increases the physiological irradiation to the musculature of the neck, hands, lower limbs; it contributes therefore to promote not only strolling or walking, but also head control, prehension, the sitting quality and support on the lower limbs. The regular use of the quadricycle is a functional and play continuation of the therapy.

More info to make by oneself a quadricycle


POSMODEV Who are we Main markers of the postural development Questions, definitions Central Coordination Disorder (C.C.D.).
Cerebral Palsy (C.P.) motor education : myth or reality..? the Vojta concept More about reflex locomotion Documentation and training