This is one of the most common question parents have asked me when they learned that their child has some form of brain damage. In my view, it’s the wrong question. It should be “How well will my child walk?” The answer is that it is largely up to the choices parents and therapists make in the time leading up to independent walking.
Most children with cerebral palsy walk. When and how they walk varies with the severity of damage and their pattern of abnormal movements. All children with hemiplegia end up walking and up to 80% of children with diplegia also walk with or without aids. In children with triplegia or quadriplegia, walking takes longer and they may need more interventions. However, all of those in the mild category should walk and in my experience well over 50% of those with a moderately severe form of CP can have useful household ambulation or better. With modern spasticity management techniques, the odds are much higher for all children to walk. Overall, close to 75% achieve this goal.
My view is not whether they will walk or not but whether they walk well. The push to try and have a child walk early is not based on good outcome measures. The vast majority of children, who learn to walk early, do so by learning to walk badly. As I’ve discussed in “The Boy Who Could Run Better Than He Could Walk”, a child’s walking pattern does not necessarily reflect the degree of brain recovery. We walk and run with the same parts of our brain, yet most children with hemiplegia and a good number with diplegia run better than they walk. My view is that if a child can run reasonably well, there is sufficient corticospinal system recovery for them to walk well.
One of my favourite tests with children who are up and walking independently, but badly, is to give them some hand support and ask them to walk backwards. It’s shocking to see how much better their backwards walking is than their forwards walking. Why? Because the forwards walk is a habit. The backwards walk reflects more accurately the brain recovery.
What can be done in the early years to improve this dismal record of abnormal walking habits?
Abnormal movement patterns develop as the child tries to move against gravity. The child may have perfectly normal four point movements lying on their back on the floor but has increased tone as soon as they are first put into a sitting or standing position. The arm(s) and hand(s) tighten up automatically as they try to balance to protect themselves from falling. Some call this overflow reaction “dynamic tone”, but basically it’s the early stages of spasticity. Skilled therapists can show you how to minimise this tone with handling techniques.
These are the problems…
- The therapist’s skilled hands do not go home with the parent.
- One or two hours a week in therapy is useless as a sole intervention. No athlete has learned a sport, no musician has learned to play an instrument, and no dancer has gone on America’s Got Talent without a sufficient amount of practice. An hour a week at the gym does not strengthen the body or improve skill levels. How on earth can we expect a baby with a damaged brain to learn movement only in therapy?
- No parent I know has the time to keep “hands-on” all day, every day. But that is exactly what is needed. So, if you can’t put hands on all day, every day to normalise and facilitate normal movement patterns, something else is needed.
- If your child cannot easily maintain a position against gravity or there is overflow tone when they do move up against gravity, the answer is trunk support. Fortunately, there are a variety of options to help. I strongly suggest that parents discuss them with their therapist. My rule is that if a pair of hands on the body can improve function, the child needs more core support. If as a therapist, you would like an additional pair of hands during treatment, then the child needs core support during treatment.
- This is against some theories of therapy that believe the small child has to be in a natural state to learn to activate the appropriate muscle groups. The problem is that it does not work. Core strengthening should start “out of gravity”, lying on a mat on the floor. For the older child, water exercise with a Wet Vest or other neutral buoyancy device works well. Parents are often surprised to see normal reciprocal arm and leg movements when the child is “out of gravity”.
- Once the child can sit or even get to standing, they need to work on their balance. Here’s a test for you to try. Stand next to a supporting counter or piece of furniture and put your arms out to the side. Now shut your eyes. Most people suddenly realise that they have to work a bit to balance. Now repeat the same process but up on your toes. Again, most people will find that they have even worse balance on “tip toes” with their eyes shut. Don’t panic. All you have to do to improve your response to this simple test is to practice it.
The reason people find it difficult when they shut their eyes is that you turn off the visuomotor control system, which is more efficient than your own proprioceptive system. There are two facts that you should know about children with CP. The first is they all have some degree of impaired proprioception. So this task is even more difficult for them. Secondly, their tone tends to put them up on their toes and push them into a forward falling position. Both children and adults find it difficult to balance without a stable base. Talk to your physician and therapist about what is needed to give your child a stable base for standing. This ranges from supported standers through AFO’s, plus or minus Botox or other forms of spasticity management. You have to do whatever is needed to give the child a stable base so that they can learn to do sit to stands and stand to sits. They need to do hundreds, if not thousands of repetitions of this simple exercise to strengthen their muscles and learn the balancing and supportive reactions that they will need to independently walk. Think of the able-bodied child learning to stand and walk. They get up…on flat feet…and fall down…over and over again. The child with CP has to do it too!
I know this goes against current practice in many areas and in truth most children will learn to stand on their toes. But the cost of pushing early walking, without core strength and a stable foot, is that the child “wires in” bad movement habits that “once formed” are much more difficult to change.