February 4, 2013
Mapping A Route To The Land of Oz
Alas, there is no GPS to tell us the best route to take with our clients that will end at our desired destination: efficient postural control. But fortunately, there is beginning to be some research regarding the detours and what we can do to facilitate the journey.
Recent research has outlined that elevated arm posture (on either one side or both) in children with CP is a strategy to maintain balance when walking (1) My clinical experience also tells me children with CP do this when searching for stability in sitting or in transitional movement as well. They also have impaired anticipatory postural adjustments (2,3). Furthermore, older children with CP appear to fall more often than children under the age of 5 with CP (4).
When reading the research on Developmental Coordination Disorder and balance, we see that children have delayed onset of postural adjustments and also decreased balance (5,6).
Finally, the present information on Autism Spectrum Disorder suggests that children with ASD have greater postural instability in quiet standing as well as in gait (7,8).
We also know that typical children rely primarily on vision for postural control under the age of 3 (9) and that some children with disabilities tend to rely on vision for much longer (10).
In my clinical experience, children with disabilities exhibit both the breath holding and altered head position we discussed in the previous blog as compensations for inefficient postural control. Clinicians also know our clients display altered alignment which may serve to stabilize their bodies in the absence of efficient postural control (3,11) although formal research on alignment is sparse.
So what’s the best route to take in treatment? Fortunately we are beginning to see some road signs that can point us in right direction (12).
The respiratory diaphragm is a major player in creating central stability before movement begin (13) but breath holding doesn’t allow it to be used optimally. Ensure that the child is not holding their breath while they move – have them sing, blow a whistle, exhale, talk, phonate, whatever works.
Alignment matters (11). Look closely at the alignment of the rib cage as well as the pelvis (remember that’s where the diaphragm lives) and promote a neutral alignment of the rib cage and pelvis separately and in relationship to one another.
Practice works (12, 14). Have your clients practice reactive and anticipatory balance tasks in sitting and in standing. You can shift their weight to reach the very limit of their base of support and help them to experience balance there. Also, have them actively reach for a toy at the limit of their base and return to the center. But remember, they have to do it in alignment and while they are breathing! As they get stronger, include massed and then random practice into their home program.
Don’t forget the emotional system. Children who are anxious have poorer balance (15). Use strategies that down regulate the child’s anxiety before and during treatment.
Prime the sensory systems. Postural control is a multi-system function. Providing vestibular input as a preparation for balance tasks may assist some children with better outcomes (12)
23 years ago my NDT instructor taught me that giving a child something to hold (distal stability) can improve trunk stability (proximal stability). A study supporting this concept was published in 2012 (16). When treating balance, it may be helpful to give the child something to hold in their hands during the task.
Our clients may be relying on vision for postural control. Begin to practice new tasks giving the child a focal point. Graduate the difficulty of the task by having them practice when possible with eyes closed.
Lastly, don’t forget all the strategies you are already using when addressing many systems. We still have to manage spasticity and range issues. And orthotics can help children manage range and lower extremity alignment even if the jury is still out on whether they directly assist with postural control(17).
I hope this series of posts has shed some light on the typical development of postural control, how our clients compensate and some strategies that we can use in treatment. I’m optimistic that future research, combined with thoughtful clinical practice, will help us map that yellow brick road to efficient postural control more completely.
1. Meyns P, Desloovere K, Van Gestel L, Massaad F et al. Altered arm posture in children with cerebral palsy is related to instability during walking. Eur J Paediatr Neurol. 2012; 16(5): 528-35.
2. Tomita H, Fukaya Y, Honma S. Ueda T, Yamamoto Y, Shionoya K. Anticipatory postural muscle activity associated with bilateral arm flexion while standing in individuals with spastic cerebral palsy: a pilot study. Neurosci Lett. 2010; 479: 166-70.
3. Girolami GL, Shiratori T, Aruin AS. Anticipatory postural adjustments in children with hemiplegia and diplegia. J Electromyogr Kinesiol. 2011; 21: 988-97.
4. Burtner PA, Woollacott MH, Craft GL, Roncesvalles MN. The capacity to adapt to changing balance threats: a comparison of children with cerebral palsy and typically developing children. Dev Neurorehabil. 2007; 10(3): 249-260.
5. Jover M, Schmitz C, Centelles L, Chabrol B, Assainte C. Anticipatory postural adjustments in a bimanual load-lifting task in children with developmental coordination disorder. Dev Med Child Neurol. 2010; 52(9): 850-5.
6. Kane K, Barden J. Contributions of trunk muscles to anticipatory postural control in children with and without developmental coordination disorder. Hum Mov Sci. 2012; 31: 707-20.
7. Fournier KA, Kimberg CI, Radonovich KJ, Tillman MD, Chow JW, Lewis JW et al. Decreased static and dynamic postural control in children with autism spectrum disorders. Gait Posture. 2010; 32: 6-9.
8. Bhat AN, Landa RJ, Galloway JC. Perspectives on motor functioning in infants, children and adults with autism spectrum disorder. Phys Ther. 2011; 91(7): 1116-9.
9. Foudriat BA, Di Fabio RP, Anderson JH. Sensory organization of balance responses in children 3-6 years of age: a normative study with diagnostic implications. Int J Pediatr Otorhinolaryngol. 1993; 27(3): 255-71.
10.Weimer AK, Schatz AM, Lincoln A, Ballantyne AO, Trauner DA. Motor Impairment in Asperger Syndrome: evidence for a deficit in proprioception. Dev Behav Pediatr. 2001; 22(2): 92-101.
11. Cherng RJ, Lin HC, Ju YH, Ho CS. Effect of seat surface inclination on postural stability and forward reaching efficiency in children with spastic cerebral palsy. Res Dev Disabil. 2009; 30: 1420-27.
12. Westcott SL, Burtner P. Postural control in children: implications for pediatric practice. Phys Occup Ther Pediatr. 2004; 24(1-2): 5-55.
13. Hodges PW, Gandevia SC. Activation of the human diaphragm during a repetitive postural task. J Physiol. 2000; 522(1): 165-75.
14. Shumway-Cook A, Hutchinson S, Kartin D, Price R, Woollacott M. Effect of balance training on recovery of stability in children with cerebral palsy. Dev Med Child Neurol. 2003; 45: 591-602.
15. Stins JF, Ledebt A, Emck C. van Dokkum EH, Peek PJ. Postural sway in high anxious children. Behav Brain Func. 2009; 5: 41-51.
16. Claxton LJ, Melzer DK, Ryu JH, Haddad JM. Control of posture in newly standing infants is task dependent. J Exp Child Neurol. 2012; 113: 159-65.
17. Carmick J. Importance of orthotic subtalar alignment for development and gait of children with cerebral palsy. Pediatr Phys Ther. 2012; 24: 302-7.