Lisa8
5 posts
Jun 09, 2008
6:55 PM
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I have a 14 month old with arthogryposis. She has global low tone and mm weakness. She is not walking. She can roll short distances but can not assume supine to sit. She sits alone with a severe lordosis. It is flexible, so she can assume a normal curve, she goes in and out of it. There is little motion in C and T spine. She can not extend head in prone or do much of anything. In supported stand she goes into such a severe lordosis, she looks like she will break in half. Mom is concerned about this. I pushed her into it more and tried to make it unilateral as much as I could. By the end of the session she did seem to correct it a little and I think I saw some increased extension of the upper spine. IT was hard to compare since I did not have her shirt off when I started. Does anyone have any more suggestions. I also push her to her side to get a right total sidebend since she is so weak on the other side. There is mild torticollis, perfers right sidebend/left rotation. This helps to correct it to and corrects some left dorsiflexion. But I am not getting the WOW results I usually get. Could it be she is so involved physically and I need more intensity. But not sure how to get that.
Last Edited on 9-Jun-2008 6:58 PM
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SusanPEDPT
14 posts
Jun 11, 2008
2:43 PM
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Not to sound like I don't hear you, but my focus with such a child as you present is to ask myself "What CAN she do" As I read your post I got myself really confused. This was something I used to do to myself thinking "he can do this, he can't do that , but he can do the other part way....." I now ask myself "which way is he trying to move?" "where is the strength?" "where is the motion?" and then make up a position to enhance that starting with expanding on the motion first so the child can discover new movement options.
Does this help?
Susan
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Lisa8
6 posts
Jun 11, 2008
7:12 PM
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I think I just added too much info. and I explain better than I write. Basically she has a severe flexible lordosis in sit and supported stand and a neck/trunk weakness into left sidebend. I do enhance these motions but only seeing slight improvements. I push her into more lordosis in sit and not sure how to increase the intensity. Pushing her into right sidebend is working well. It is the lordosis I am trying to treat and correct. Prone is not an option since she can not lift her head and all movement happens in the TL junction. I want more extension in the total spine. Maybe I will have her reach for toys in front of her because this does increase the lordosis and will be more active than me just pushing her into it. Do you think I am on the right path here?
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SusanPEDPT
15 posts
Jun 12, 2008
5:16 AM
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This is one to brainstorm! I wonder what Mickey would have to say as he works with people w/ TBAs that are very immobile?
For my own take on this I just use the area that is super flexible to jump start motion EG: Child w/ torticollis want to side bend to right. I look at it as 1) Relax 2) Release for range 3) play in new positon
1) have them relax to right making entire body melt into worst possible looking posture to quiet and reboot 2) have them do a release to the right as it is the side of ease, but then ( delete (3) do isometric holding against gravity )
NOTE: edited version eliminated 3 as originally posted
and changed to hold child upright so he can see the world with new found range. Bounce on a ball or on your lap to help reinforce the posture as you would be sitting on a therapy ball yourself and gently bouncing in place to feel yourself wanting to sit up straighter.
If you apply this approach to this child you are just using the extension as a starting point because she ultimately needs abs to work. I think you're on the right track with bringing the arms in. I'd put toys high, low, to the side first in the direction or angle that comes easy and so she can discover other movement options. I'd also work a lot in propped sidelying so that she can use her trunk without fighting gravity. This is a very challenging case I don't have to tell you as we really don't know what's going to happen with her joints if they are really stuck or might get more range. Let's keep chatting on this!
Last Edited on 12-Jun-2008 6:03 PM
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Lisa8
7 posts
Jun 12, 2008
5:24 PM
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I have to interject that she is not immobile. But with that diagnosis, I know it sounds that way. She really does not have a lot of joint restricition. She is more of a developmentally delayed or low tone CP type of child. Very flexible, too flexible, espeicially into hip flexion. Just sever mm weakness in abs., hip extension. She can bear weight with a lot of support to keep her out of the severe lordosis. I have her tomorrow and will try active increased lordosis by reaching forward, sideways, high/low and then see what happens.
One question, why work on left neck overstretch weakness??? Wouldn't I work on the strong side. I keep putting her into right sidebend and then test the other side for improvements.
Thanks for chatting
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SusanPEDPT
16 posts
Jun 12, 2008
5:51 PM
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Good question! You are really thinking! I was slipping back into my old ways and am NOT going to do that as that would be working the wrong side. After having the child relax to the right and then actively flex to the right why would I want them to flex to the left? Actually I just got off the phone w/ a mother and we were discussing the very same thing. She is very much on board with this approach. We are now going to sit the child on a small playball (the basketball size one from the dollar store) and gently bounce to provide some sensory input to help them realize that NOW this is neutral.
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SusanPEDPT
17 posts
Jun 12, 2008
5:55 PM
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BTW the kids I've had w/ that Dx have been so immobile that I assumed that you were dealing w/ the same thing. Another consideration is what is the actual issue? Is it pain or is it lack of motion?
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Lisa8
8 posts
Jun 13, 2008
7:14 PM
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Yeah, she is unlike others I have worked with with that diagnosis that I actually forget. She has most restriction in her wrists and fingers. Born with severe club feet but casting took care of that problem. I worked on reaching today but she does this anyway herself. She will sit and lean trunk all the way to the floor and then resume sit without assistance. She puts herself into a severe lordosis, so how much could I do. Working is right sidebend is working nice to increase left sidebend, but it took several weeks to see a significant difference. I think I need to be more patient when the child is so involved. Since she has hip flexion and next to no hip extension but not enough flexion to lift from sit for a SLR, she can flex easily in supine, so I may put a light weight (like a bean bag) in her sock and try to figure out stronger leg. Then I will have her lift leg with a bean bag. She loves to lift her legs in supine and put her feet by her ears. This weight will increase intensity where she can work. I will let you know how this pans out.
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Lisa8
9 posts
Jun 13, 2008
7:27 PM
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I have another child with torticollis, right sidebend/left rotation. He is 12 months and started PT at 4 months. PROM/AROM is WNL but a slight head tilt remains. Kids are usually discharged by now. He will not tolerate any handling, he is very stubborn, mom has no more success than me. We have tried everything. Just can't permanently get rid of that head tilt. I think if he let me touch him, he would not be on program any more. He gets to the point where he stops breathing and he writhes so much, it is not worth it. He wants what he wants. So I may try kinseotape on the strong side. I tried on the weak side two months ago with little success. He did tolerate though. I have nothing else to try. Have you ever had a child like this. I really thought once I started TMR (in May) he would be OK but he does not care. He does not want to be touched and no technique is good if you can not use it.
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SusanPEDPT
18 posts
Jun 14, 2008
7:17 PM
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Some of the kids w/ torticollis have such profound restrictions in the pelvis that I think it keeps pulling into the neck. Until we get the foundation straightened out and in balance it's going to be a challenge. I have a child I've been seeing once every few weeks for a year now. Often times w/ torticollis there's about 50% improvement in one session. With this boy we started doing TMR in November. Even though remaining tilt isn't huge it's persistant and the doctor was talking surgery several months back. Parents are on board w/ using TMR and gradually he's been getting better. Like the child you are seeing he doens't want to be touched. If the child previously saw a therapist that was trying to stretch the area he may be anticipating pain and tightening more if he thinks he's going to hurt. Some of the kids who have been through this type of PT seem to have increased sensitivity and don't even want their ear washed on the involved side. I wouldn't be surprised if the tightness in the fascia was giving them tinnitus. Anyhow for this child we have been placing him in a 3D position on mother's lap helping him relax and melt into the trunk twist, side bend combo position of ease. We follow thig by him sitting on mom's lap with his legs to the side and twisting his trunk forward to see the TV to do a release. Finally they are placing him in the same 3D position to work against gravity to reach up for a toy while twisting. Every time I see him he is a little bit better and mom is delighted. Photos show his head more upright. We are tracking how long he sits at a meal before he fatigues and starts to tilt as a measure of progress. Inch by inch, but always better!
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Mickey
7 posts
Jun 14, 2008
8:36 PM
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Lisa and Susan,
First of all, let me commend both of you on your choice to work with peds! I definitely don't have enough patience and definitely have too much compassion to work with this population.
After reading your posts I keep getting the sense that you are focusing on one set issue and not the body as a whole. Not that this is a bad thing, because sometimes you need to address one issue to get everything working better. Positional releases and PROM work wonders but the real magic begins with active movements and sometimes with applied resistance. Even using the visualization technique, the patient is imagining active movements.
If I were to treat a patient that wanted to sidebend to the right I may start them with a "melting" motion to that side to get a release on the left. If I see some improvement I would continue until there is no more improvement and then add active movement. Such as have them lay on their back and have them try to actively bend to the right as much as possible and hold it as long as they can. Then I would re-check to see if there are any changes. I tell a lot of my patients that this is learning by example. I am trying to show the "bad" side what it is supposed to do by working the good side...actively.
When I work with patients with brain injuries I try to stay away from good side vs bad side thinking, particularly if one side is flaccid and the other side is contracted. I may treat the flaccid side a couple of visits to decrease the contractures and then treat the side with tone to increase tone on the flaccid side.
The post about the child that hold his breath and pitches a fit made me wonder...what if that is what he NEEDS to do?! If it is an automatic response maybe his body is telling him that is what it wants. The concept is listen to what the body wants to do and do more of it. This applies to to the girl with the loose hip/ tight hip issue. Does the body want to tighten the loose hip or loosen the tight hip or a combination of both.
It never ceases to amaze me how working an area as far away from the "issue" as possible can sometimes fix the issue. It goes against everything our profession is currently built upon and what our professional instincts have been "honed" to address.
I hope I haven't muddied the waters with my rambling. Basically what I wanted to say was, if what you are trying to do isn't working then go somewhere else in the body and try a different approach.
Mickey
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Lisa8
12 posts
Jun 15, 2008
4:49 PM
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Mickey, I hear what you are saying. But I feel I am trying everything. I TRY to check for limited motion everywhere if he lets me. Yes he throws a fit just playing with him like you would any child. I did treat him for 5 months traditional and maybe he is just angry and working the weak/ tight side and wants no more. But mom says he is like this for everything. She says he just can not take "no" for an answer. He tantrums all the time when he does not get his way. He is a little young for this terrible two behavior. Mom admits she does not get to carry over anything due to this behavior and I feel she is not trying hard enough. I can only do so much twice a week. Do I just let him cry to the point of exhausion? He is so strong that it is hard to control his position. So that is why I am trying kinseotape on the strong SCM, the right side. WIll check with mom next visit. I may try mcconnell tape to hold him in that right tilt for maybe a day or so just to see what happens if the kinseotape fails. He improves in one visit but the next visit he is the back to the same mild head tilt. So please keep giving me your thoughts, anything will help at this point. Susan thanks for your suggestions as well.
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SusanPEDPT
21 posts
Jun 15, 2008
4:53 PM
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Mickey thanks so much for input. That's actually how I am working with the child trying to look at the whole child, but it's easy to slip back into looking at one part. So glad for your input as I was hoping that you'd chime in to share your experience since you have worked w/ some pretty complex cases. Actually my approach is 3 fold. One have them melt w/ gravity in a combination such as arm reach, trunk twist and side bend, next do the the Fab5 w/ the family , and finally go back to the melting position to make them work against gravity. The challenge is to initially leave a parent w/ a home program that zeros in on one area so they can get a handle on the system while at the same time treating the whole child as we work with them until they have a better handle on it. Any thoughts on this?
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Mickey
9 posts
Jun 24, 2008
4:18 PM
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Lisa,
Sorry for delay! Hectic lately!!
I would definitely let him tantrum! In fact, I would encourage him to throw a bigger tantrum, in a safe place of course. I might even try to help him exagerate his movements. Make sure it's okay with mom and tell her it could help in two ways. First, physically it could start an unwinding and help his issues. Second, it could help decrease the tantrums. When my 22 month old throws a fit, I encourage him to throw a bigger fit. The result usually is the tantrum stops within seconds and doesn't re-occur over same issue. I say, try it once and see what happens. If it breaks the cycle and allows mom to treat him at home, then it is worth it! Let me know the outcome if you attempt.
Mickey
P.S. - Tell mom this might not be do-able in public!!
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Lisa8
13 posts
Jun 24, 2008
7:18 PM
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Mickey,
Thanks for your input. I will try this approach again. I have done this but with traditional treatment. I would let him cry vigorously while I worked him on weak side. Mom gave her consent but always appeared disturbed and would grab him often for a hug. This is why I am resistant to do it now. However I am getting at that point again because nothing is getting accomplished. I will keep you updated
Lisa
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Lisa8
19 posts
Aug 08, 2008
3:40 PM
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This is in response to the torticollis child in the last post. He is doing very well. There are still imbalances in left arm raise and right trunk rotation. They are the strongest and others are mild. He has active equal range to both sides but turning to right is still harder. Strength is still mildly weak into left sidebend. Still a mild head tilt to the right. Mom tries to work with him but she is not steady with it. Usually kids are discharged after this much PT, it has been 8 months and 3 months using TMR techniques. I work through his tantrums regularly. There is improvement since I have done this. I am constantly pushing him over to the left in sit in order to have him actively sidebend trunk/neck right (into deformity). I also do passive left trunk twist and active/passive right arm raise. After tons of sitting up to the right I test left neck sidebend and feel the change is mild. The progress has been so slow.
Any suggestions!
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SusanPEDPT
31 posts
Aug 10, 2008
6:34 PM
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Just got a child w/ similar situation. He was seen by another PT for almost a year. Mom says there was no improvement in all that time. Because of the child's very strong will he resists holding. I have found that the best thing is to have his dad involved. We put a toy out of reach off to the side so that when dad holds him on his lap with his legs draped over dad's right thigh the child turns to the left reaches up and back with left hand and strains to get a toy that is out of reach. He put so much effort into reach that he moves deeper into the movement. Rather than doing multiple reps for 20-30 sec, we get a couple of big forceful twists and reaches. When he gets upset and wants the toy he reaches harder. I don't know if this helps. We have made some gains. I' m not counting the time he did the other PT in the picture. The typical child is taking much less time than other children on whom I had used a traditional approach.
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SusanPEDPT
32 posts
Aug 10, 2008
6:44 PM
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Some more thoughts on torticollis_ Here's what the typical case has been:
I just saw a child who was seen weekly for 3 weeks, then every other week for 8 weeks. I will be checking in w/ parents in 4-6 weeks to see if he can be discharged. The parents are on board w/ techniques and have provided feedback to reflect their understanding of TMR. (I know they have it under their belts when they apply it into situations I haven't mentioned -shows they are taking the ball and running w/ it) They have incorporated the movements into play activities. We have discussed the implications of the stress of future developmental milestones possibly causing him to bend his neck to stabilize. They understand that he may do this instead of using his tongue to stabilize through motor milestones all the way up to cursive writing. They plan to check for symmetry in future skills and make sure he has equal use of both sides EG: cruising , using sit n spin, on steps etc,
Sometimes kids seem to regress when ill and they know to recheck his motions when he has been sick. (Most important seems to be the twist in supine)
I keep the case open for a month or so to make sure they are set for the future, but doubt I'll need to treat him again.
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Geetha Bharathan,PT
Guest
Mar 08, 2009
7:30 AM
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very interesting concept of TMR. I normally use kineisotape on the weaker side to stabilize scapula and relax upper trapezius since child not only has wekaness in SCM but also imbalance in teh traepezius-upper upper trepezius compensating and mid and lower traepezius significantly weak.Thus stabilizing scapual has been very helpful.
I also use craniosacarl approach and being totally painless it appears very helpful.Childern who throw too much tantrums may have a genueine issues at the cranial base causing problems with their autoregiulation as well as vestibular system . Thus touching their neck-ear area increases their apprehension .
I hope I am helpful.I have alarge clientage of childern with Torticollis and plagiocephaly.
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SusanPEDPT
65 posts
Mar 10, 2009
3:12 PM
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Hi Geetha, Glad to see your input here. I totally agree that you are on the money looking at apprehension associated with cranial base etc. and the value of taping. It is my belief that this just gets worse when you try to stretch the area (which would account for why children seem to shut down when passively stretched. I had one boy who 3 years later didn't want his ear washed or hair brushed on that side. As far as the taping is concerned despite having taken 2 taping courses I still ran into children with skin issues with the tape. Also with TMR when I get the pelvis level the scapula typically glides into the correct position. In the days that follow when the child plays with the shoulder in good alignment he develops strength as he uses it (as in typical development)
One reason I love TMR is because it is user friendly and duplicatable. In the past I posted that even a mom that was diagnosed as mentally retarded was herself able to determine which side was the good side and treat her child. Perhaps she didn't understand the mechanism, but she did understand the process - find the side with ease and go the easy way.... child gets better.
The 2nd reason I love TMR is because it treats the whole child when we look at the pelvis. Granted craniosacral does this too, but the % of therapists that have the skill to do this is limited and the family is dependent on the therapist to be available to fix the child, rather than being educated to manage the current issue as well as associated problems (like tilting the head to stabilize when learning cursive writing)
Finally what is really neat is the fact that when a child falls asleep in your arms (or the parent's arms) and is getting treated at the same time, it is a priceless moment. We have lots of those with this approach.
Happy to continue to chat about this. Hoping to post some video clips on this site soon so keep checking back as there will be more information to share.
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Geetha Bharathan
1 post
Apr 04, 2009
8:25 PM
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HI Susan, Lost the web address and could not read your response. Regarding taping I am with you. Not all kids tolerate tape but it is very valuable when it works. I just watched your video and have few Q's . What do you mean by by Fab5 releases? Would you say that all your kids regained their nekc symmetry after 5 visits? I see so many variety of asymmetry and cannot convincingly claim to gain symmetry in 5 visit specially when symmetry is more generalized with low tone & core muscle weakness. I would like to get mor e info on your pediatric approaches .
Thanks
Treating kids is a joint venture. I eduacte my parents and all of them are eager to work with their kids .
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SusanPEDPT
68 posts
Apr 05, 2009
6:03 PM
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Geetha, Some of the children have been discharged after 4 or 5 visits when the parents were quick to learn and implement the instructions I provided. Other children have been seen for months because they have associated issues which keep feeding back into the neck. these include but are not limited to asymmetry in pelvic posture or lower extremity posture.
What I mean by Fab 5 releases is using the Fab 5 positions which Tom discusses on this site, but modifying them to treat the developmental level of the child eg: Sit to Stand performed in supine. You may want to watch Tom's videos and try some of these on yourself (the adult version of the exercises) When the parent is taught to hold the child in a specific position the range and symmetry improve. This indirectly increases range in the neck.
Think about a tower of blocks, move one of the blocks near the bottom out of position and an upper block has to move to keep the tower up. Asymmetry in the trunk effects the neck.
These positions are taught on my webinar for torticollis and will be taught for a wide variety of pediatric neuro and ortho problems at the October seminar. Check back soon to the TMR home page where I'll be postiong additional information.
Feel free to write back or call me with further questions!
717 309-1354
Susan
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MARIJO50
1 post
Jul 18, 2009
10:08 AM
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THE LINK TO THE PEDS WEBINAR DOWNLOAD APPEARS TO BE BROKE-HOW CAN I PURCHASE THE WEBINAR -MARIJO
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Tom Dalonzo-Baker
120 posts
Jul 19, 2009
7:21 PM
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When did you purchase the webinar? If you purchased it a while back, shoot me an email at totalmotion@gmail.com. If it is a new purchase let me know - the link should be working. If not email at the address above so I can fix it.
Tom
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