How much do range of motion exercises and positioning help the child with cerebral palsy?
Of course, normal range of motion and normal body alignment are desirable goals; but, historically, we have not always been successful in achieving these goals with our students who require help to move. Range of motion exercises that are practiced twice a week for 15 minutes cannot have much effect on a student who practices non-range of motion for the other 5,010 minutes of the week. The question we need to ask is, "Range of motion to do what?"
Campbell, 1987, states that management programs for students should be coordinated with any active intervention program that the student is receiving. In other words, an active intervention program designed to develop pelvic mobility could be carried over to other situations where management is necessary.
We have found that range of motion exercises have little or no effect unless they are used in daily functional activities and they have the best effect when they are self-directed by the student.
Positioning or proper body alignment requires the same questioning: "Positioning to do what?" The most common questions about positioning are related to sitting. Why do we need to sit? The most obvious answer is that standing all of the time is too tiring and we cannot function well when lying down. That leaves sitting. As we mentioned before, there are two basic sitting positions; leisure sitting which involves leaning against the backrest and functional sitting which involves leaning forward from the hips to perform a function.
For some reason, we use leisure sitting almost exclusively for receiving information (watching television or listening to a speaker). When we give information by speaking or when we perform a function such as eating or writing, we almost always lean forward and assume a functional sitting position.
In the past, we have placed our students who do not have the ability to sit independently almost exclusively in leisure sitting positions. Often, we even recline the back of the seat to make sure that they are leaning back. There are several reasons for this:
1. We enjoy leisure sitting ourselves and we want them to be comfortable.
2. A reclined sitting position takes pressure off of the spine and hips of people who are at risk for scoliosis.
3. We can see their faces and therefore establish eye contact while we talk to them.
4. And, of course, that's the way most wheelchairs and seating systems are made.
There are two major mechanical reasons for developing functional seating systems: One, is for arm and hand use. When in a back leaning position, it is extremely difficult to use the arms. It takes a lot of strength to pull against gravity and it is next to impossible to feed oneself or do table work while leaning back.
The other reason is speech production. It is easier to speak when we lean forward because it is easier to contract the diaphragm and push air through the vocal cords. If you start coughing while leaning back, you quickly become aware of how the diaphragm works. The body reflexively pulls forward to allow the contraction of the diaphragm so that coughing can occur, which is a common need in our children with chronic congestion.
If our goals are to help our students clear their lungs or to develop language skills then we need to help them assume a functional sitting position. If our goal is to have them listen to a lecture or watch a program, then we need to help them assume a leisure sitting position. The ideal situation would be one where the student could go quickly and easily from one position to the other without changing seats.
In summary, both functional and leisure sitting positions are important; but, in the past, we have put most of our energies into developing maintenance systems for leisure sitting alone. We have practically ignored the need for functional sitting positions. For various reasons, we have placed many of our students in reclined positions which do not allow them to practice the skills they need for independent sitting and do not allow them to use their hands or bodies effectively.
C.M. Mulcahy, et al, 1988, noted that even a small five degrees of recline can have a negative effect on a child's posture and physical ability which can delay or prohibit the acquisition of independent sitting. According to Mulcahy, a reclined sitting posture can promote extensor thrust and cause the arms to be held in a high guard position which reduces functional arm and hand use. Additionally, the student often tries to counteract an insecure feeling of falling by straining forward. This reaction is often perceived as a further indication of lack of head control requiring even greater restraint.
The study also notes that a reclined sitting position alters the line of vision for the student and often results in the student staring at the ceiling rather than observing life. The normal sequence for learning sitting balance is to recover a sitting position from a forward prop, then from a side sitting position, and lastly, from a reclined position because it requires greater strength and coordination. Complex tasks requiring orientation and cognitive ability are performed better in an upright sitting position, according to an investigation into sitting postures referenced in the study.
Before positioning can be addressed, you must determine the function the child will be performing and then analyze normal body alignment. A very common example of abnormal body alignment concerns toileting needs. Most children who lack independent sitting balance are placed on a toilet in a leisure sitting position or even in a reclining position. This is not the normal position for urination or defecation and it is not conducive to learning how to use public restrooms where back rests are not available. Simple prompts can be constructed from PVC pipe to help the student practice functional sitting skills while performing specific activities such as toileting.
The same is true of all positioning whether it involves sitting, standing, or walking. The position must not only be as normalized as possible, but must also meet the functional needs of the activity. Activities without functional purposes such as side lying, rolling over balls, propping on wedges, etc. have not proven effective in helping children with severe disabilities gain independent motor skills. There are other reasons for the lack of success. A few obvious ones are:
1. The students are not motivated to increase their skills. The staff encourages the child to pick up the head, extend arms, or whatever for a short period of time but when the adult loses interest, so does the student.
2. Often, the positioning of the student is considered the entire program. Students with severe disabilities usually do not acquire skills without direct intervention and even when they are taught skills, they do not generalize them from one situation to another without more direct intervention. For example, a student who practices reduced muscle tone while side lying is unlikely to recall that muscle tone while sitting in a chair for lunch.
3. Tired or busy people only do what they have to do. Students with severe disabilities have to get on and off the bus, eat/drink, and be toileted (or have diapers changed). Skills associated with these tasks will be performed every day regardless of the busy schedule. Other programs or activities can be shelved when necessary.
4. It is almost impossible to set goals for or to measure the progress of side lying, wedge propping, or similar passive exercises. Without goals, there can be no success.
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