Girl / Cheer

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	The Girl Who Has Something to Cheer About *By Karlene Cantrell, RPT* Published in "Physical Therapy Forum" Week of November 12, 1990 Laura not only caught the pillow I threw to her, she also remained standing. Ordinarily this would not be a great feat, but Laura is a nine-year-old child with spastic quadriplegic cerebral palsy. When I evaluated Laura just four months prior, she had difficulty even trying to stand still without swaying or falling over. She began a physical therapy treatment program with me, utilizing primarily myofascial release techniques, three times per week, as well as a traditional developmental treatment program with an occupational therapist, one time per week. Lara was born thirteen weeks premature, weighing only two pounds, eleven ounces. Shortly after birth she had a cerebral hemorrhage resulting in brain damage to the areas controlling motor function of the muscles. From one year to five years of age, she attended an area preschool where she received physical and occupational therapy, including neurodevelopmental treatment. Surgeries included right eye surgery at two years of age, left eye surgery at three years of age, and a left heel cord release at six years of age. At six years of age, Laura entered a regular private grammar school and maintained an A/B grade average. She attended tumbling and swimming lessons, but not therapies. When I evaluated Laura, she ambulated independently with modified AFOs, however, her gait was very precarious. She threw her upper body, head and arms in attempts to balance herself. She was up on her toes with her feet and legs turned in, so she looked like she would trip over her own feet. Dynamic AFOs (AFOs that allow ankle dorsiflexion and a few degrees of plantar flexion which were developed by Nancy Hylton, RPT) were ordered to replace her outgrown AFOs. The accompanying chart outlines selected results from Laura's initial evaluation and six-month re-evaluation.

Initial Evaluation

Six-Month Re-Evaluation

Reflexes

1) Tonic Labyrinthine Prone - positive and strong.

2) Neonatal Body Righting - positive and obligatory.

3) Asymmetrical Tonic Neck Reflex - Positive in test position and observable in resisted movements.

4) Symmetrical Tonic Neck Reflex - Positive especially in hands/knees and kneeling, interfered with movements, especially hip dissociation.

1) Tonic Labyrinthine Prone - only mild influence in stressful activity.

2) Neonatal Body Righting - integrated.

3) Asymmetrical Tonic Neck Reflex - integrated/no evidence even with stressful resisted movements.

4) Symmetrical Tonic Neck Reflex - only slight influence in hands/knees.

Range of Motion

1) Straight Leg Raise - (R) 35^o (L) 40^o

2) Thomas position - (R) 35^o (L) 40^o

3) (L) hip external rotation - 35^o

4) (L) shoulder flexion and abduction - 135^o

1) Straight Leg Raise - (R) 70^o (L) 50^o

2) Thomas position - (R) 20^o (L) 40^o

3) (L) hip external rotation - 50^o

4) (L) shoulder flexion 160^o ;(L) shoulder abduction 155^o

Muscle Strength

1) Prone extension - unable to assume or maintain even after being placed in position.

2) Supine flexion - unable to assume or maintain.

1) Prone extension - independently assumes and maintains two to three seconds.

2) Supine flexion - independently assumes and maintains thirty seconds.

Gross Motor

1) Log rolls - pulling upper extremities into flexion at chest.

1) Segmental rolling - able to keep upper extremities extended over head.

Sitting

1) Pelvis severely posteriorly tilted with weight posterior to ischeal tuberosities.

2) Independently assumes and maintains sidesitting with legs to left, heel sit and "W" sit.

3) Reaching only in heel sit and "W" sit.

1) Pelvis somewhat posteriorly tilted; but with verbal cueing can correct to weight bearing on ischeal tuberosities.

2) Independently assumes and maintains Indian sit, long sit and sidesitting with legs to either side.

3) Reaches in all positions except sidesitting with legs to right.

Hands / Knees

1) Independently assumes and maintains - on fingertips and hips overflexed.

2) Forward progression - decrease in excursion of all movements.

3) Backwards progression - very difficult, especially left extremities.

1) Hand flat and hips aligned over knees.

2) Forward progression - normal excursion of movements.

3) Backwards progression - minimal difficulty.

Kneeling

1) Assumes with assistance and maintains independently.

2) Bilateral hip flexion 30^o.

3) Wide base of support.

4) No lateral weight shift.

5) Knee walk forward two to three feet before falling.

1) Independently assumes and maintains.

2) Bilateral hip flexion 10^o.

3) Moderate base of support.

4) Good lateral weight shift to right and beginning to left.

5) Knee walk ten feet.

1/2 Kneel

1) No way! Even with two therapists assisting.

1) Independently assumes and maintains either foot up. Increased hip flexion and head forward. Independently assumes standing from 1/2 kneel.

Standing

1) Unable to stand still without support or assistance.

2) Minimal spinal extension.

3) No lateral weight shift to left.

1) Stands still.

2) Moderate spinal extension.

3) Good lateral weight shift to left.

Gait

1) Bilateral internal rotation of legs.

2) Toe strike bilaterally.

3) Sideways - walks at 30^o angle - tiny steps.

4) Backwards - extremely difficult.

5) Running - exaggeration of gait deviations with arms at high guard.

6) Single limb balance - 0 seconds bilaterally (unable to stand still).

1) Internal rotation of left leg.

2) Bilateral flat foot strike.

3) Sideways - easily on a straight line with normal size steps.

4) Backwards - easily.

5) Running - slight increase in hip internal rotation, arms at low guard.

6) Single limb balance - right three seconds and left two seconds.

Other

1) Unable to hop.

2) Unable to duckwalk.

1) Hops on both feet, two to three inches.

2) Duckwalks five to seven feet, placing hands on floor between steps for balance.

Balance

1) Tilting - present and reliable through sitting.

2) Equilibrium reactions - none.

1) Tilting - present and reliable through kneeling and beginning in standing.

2) Equilibrium reactions - present through standing.

Just after evaluating Laura, I took my first course in John Barnes' myofascial release approach. This approach to treatment is based on the fascial system, a greatly overlooked system of the body. The importance of the role of the fascial system was explored and documented by Dr. John Upledger, chief of research at Michigan State University. The fascia surrounds every cell of every system in the body including bones, muscles, organs, nerve and the brain' forming a three dimensional web from head to toe. This makes the fascia the immediate environment of each cell. This environment should be gelatinous in form, giving it the ability to absorb shock and cushion the cells. When an injury occurs to the body and/or postural malalignment occurs, the fascia binds down causing pulling throughout the system. Imagine a loosely knit sweater, and that you are pulling on one corner of it. Depending on the direction you are pulling, the fibers throughout the sweater pull and realign along the lines of tension. This is what happens in the body. When bones are pulled out of normal alignment due to injury, stress or tight muscles, and the fascia pulls in a three dimensional pattern throughout the body. In this way an injury to the thigh can unbalance the pelvis causing other bones, muscles, etc., to unbalance in an effort to compensate.

Think of the body as a bag of blocks stacked neatly in a well-balanced tower – if one block is moved out, another block must be moved in to counterbalance or the tower falls down. This also occurs in the body. With a tensile strength of two thousand pounds per square inch, the fascial system cannot correct itself back into normal alignment without help. This constant pulling is responsible for many chronic pain problems, postural deviation, etc. Children born with handicaps often have fascial restrictions from the body's attempts to compensate for abnormal muscle tone and movement patterns, as well as from birth trauma.

I decided to use a myofascial release approach in Laura's treatment. I began with CV-4s and transverse plane releases. Next, I tried arm and leg pulls which she tolerated with minimal discomfort, so her parents were instructed in these techniques as a home program. I gradually introduced deep releases, releasing all aspects of the legs, trunk, shoulders, arms and neck. The psoasis and anterior hip joints were very restricted. After several releases over the anterior hip joints and continuing into the legs and/or the trunk, lumbo-sacral decompressions, lower back releases, and hamstring releases; the pelvis began shifting into a more normal position. This shift in her pelvis and the increased mobility of her muscles allowed for a decrease in muscle tone, since now the muscles didn't have to "fight" gravity to maintain an upright posture. Her movement patterns, therefore, became more fluid, her balance improved, and the influence of abnormal reflexes began diminishing. I continued releasing areas of fascial restrictions I found throughout her body and utilizing various cranial-sacral techniques, as well as unwinding.

By the time Laura's six-month re-evaluation, she made significant progress. Not only could she now stand still and maintain her balance, but she could actually catch an object thrown to her without falling. Laura continues to progress in her treatment program. Last school year, she tried out for the cheerleading squad, and made it. Maybe she can't do the splits or cartwheels yet, but she can stand still and maintain her balance while performing the cheers and stomp her feet and move side to side.

Laura's case is not an isolated one. All of the children (and adults) I treat have made significant progress in shorter periods of time since the addition of myofascial release techniques to my treatment program. I routinely teach parents arm and leg pulls as home programs for gaining and maintaining range of motion, while releasing fascial restrictions. Most children tolerate deep releases and cranial-sacral techniques readily, and most children love unwinding.

I believe the children deserve the chance to experience normal posture and muscle mobility, which is possible with the addition of myofascial release.

( Reprinted with permission. )


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