June 18, 2012
Dynamic Core for a child with spastic quadriplegia
I often get questions about how we can use the Dynamic Core for Kids approach with children who experience more severe motor involvement. I thought my answer might be helpful to some of you who also work with this population. Please share your comments and experiences!
I’ve been truly amazed at how well your concepts of breathing/inner core activation have worked with my kids. I have one particular child that I feel would benefit from this approach, but I’m not sure how to get there. She is 6 years old and has spastic quadriplegia with very poor postural and head control. She is cognitively very aware. I’ve tried umbrella breathing in supine but she produces minimal force on the exhale. She has a lot of difficulty even vocalizing. Blow toys are difficult for her because of lip closure. This child has just started using a communication devices with head switches on her wheelchair, so I feel that improving her core stability and head control will be crucial for her in this and other functional ways. How do you approach dynamic core breathing for these kids?
Answer:Thanks for such a great question. I absolutely agree that the best place to start with your client is in supine. However, because of her level of motor involvement, it is necessary to totally support her in the neutral rib cage and pelvis position. I encourage you to experiment with various pillows, rolled towels etc. to get her fully into neutral; a small rolled towel at the top of the pelvis is often necessary to maintain the neutral pelvic position along with several pillows under the knees. Then continue to work with the umbrella breathing. If flexion for mouth closure is challenging (as it often is for our kids with lots of extensor tone) then don’t use the whistles. Engage her cognitively and use proprioceptive cues with your hands at her rib cage. “Can you breathe in to my hands?”, “Can you take a breath in and make my hands move?” are often cues I use. As her activation of flexion improves in supine, the activity of the orbicularis oris will also improve and you can try whistles again. However, it may be that you don’t want to take the time to treat that specific component – perhaps you can team up with her SLP and discuss the connection between quality flexion throughout the body and lip closure. Once she can get the umbrella breathing, you can slowly introduce the postural synergist work. however we need to be careful of overwhelming the core with too much resistance. Remember, strategy before strength!Also we can acknowledge that her progress will be slower than some of your other kids. There are so many levels for our children with more motor involvement. Any retention of developmental reflex patterns (Moro, TLR, ATNR, etc) will mean that the primary sensory and motor wiring has not been laid down in the brain in early development. Therefore, the organization of movement is more challenging from this perspective.
I am so glad to hear that you are having success with the concepts. I just wanted to tag on a thought to all of Shelley’s feedback. Her “minimal force on exhale” made me think you may need to get her a better inhale first, which might be better achieved with some gravity. Diaphragm and pelvic floor really love to be up against gravity, the proprio and vestibular input are both enhanced too! This may improve her inhale excursion, which would carry over to a stronger exhale. I would try a wedge of some kind….managing alignment will be the trick. You will have to play with that element. But my sense is she might need to get out of supine to initiate that connection. Worth a shot to see how she responds, let us know how it goes!