Baby brains and nerves have an exuberant amount of neuroplasticity in the first 3 to 4 years of life, but in many cases, doing our current therapy interventions in an ineffective way wastes this potential. Many children at risk are not receiving regular therapy from a trained therapist until they outgrow the local 0 to 3y Early Intervention Program. These programs are of great value with respect to cognitive development, but most do not have either the training or the techniques to initiate early good tissue management. In too many areas, the focus is on creating function at the expense of quality of movement.
One of the key differences between a similar brain or nerve injury in an adult, compared to a baby, is growth. The adult has a normally grown body while the baby undergoes ballistic growth, achieving half of their adult height by 2 to 3 years of age. This is important because an arm and hand affected by a brachial plexus injury do not grow as well as the opposite side. With decreased movement, there is decreased growth. For the child with a brain injury, leading to cerebral palsy, spasticity develops over the first years of life. Uncontrolled spasticity causes an even greater distortion of body growth. Spastic muscles are shorter and weaker than normal. The non-spastic antagonist muscles are longer than normal and even weaker than the spastic muscles.
There are a wide variety of techniques that help both the child with cerebral palsy and the child with a brachial plexus injury. I will start with the common accepted therapies, and medications that have a primary goal of “allowing” the child to move in a more normal fashion. The first and simplest is regular stretching and massage. In my experience, stretching is frequently taught to parents as a first step in rehabilitation, but I question if they are truly taught the importance of this first intervention. I focus on parents understanding because over the years I have met so many people who either failed to stretch enough, or do it incorrectly. What is the correct way to stretch? I think we should be looking at how athletes take care of their muscles for some clues to effective stretching. The athlete who is training for a peak performance sport stretches many times a day and they never stretch their muscles “cold”. They either stretch after a warm-up exercise or after a passive warm-up like a warm shower or bath. A heating pad to troublesome muscle groups can be used for more localized tightness. One very smart mother taught me about whole bed heating pads, commonly used by massage therapists to keep their clients warm during a massage. She put one in her son’s bed and turned it on for 10 to 15 minutes in the morning before helping him out of bed. She found it far easier to stretch him after this “warm-up” period.
I have been a pediatrician for over 30 years and I can confidently say that a vanishingly small number of parents manage to stretch their child after warming, twice a day. If you are not sure about a stretching technique or how to warm up the muscles in your child, speak to your physical therapist. He or she may refer you to a good massage therapist … they are the true experts in tissue management.
The muscles of a peak performance athlete tighten up after exercise. They know that stretching and massage improves their recovery from the exercise as well as maintains their flexibility. Most adults automatically stretch when they get up from a long period of time hunched over a computer. My dog, a very intelligent German Shepherd, stretches every time she gets up from a nap. Babies stretch as they wake up from a nap in the same way. Children who have an early neurologic injury cannot do it on their own. In addition, they have unbalanced tone and muscle pull on their growing bones and joints. It seems obvious to me that we should be doing this work with them.
In my view, it is the first and most important thing you can do for your child. It should be done at least twice a day, every day…just like brushing your teeth! If athletes stretch after exercise, why are most therapists not stretching the child at the end of a hard therapy session? Equally, do children not deserve a relaxing massage of their tight stiff muscles after a day at school? Dentists have done a much better job convincing all of us the importance of daily brushing. Tissue management with massage and proper stretching should be part of the daily routine of all children with any form of early muscle imbalance that limits their own ability to stretch. Twice a day, every day, until they stop growing.
I expect to get a lot of negative feedback for this post, as I do when I teach it to a group of therapists and/or parents. The fact is that this treatment is boring and difficult to do on a daily basis. It does not fit easily into our lifestyle, but in terms of the child’s growth and development, it is an important first step.
For parents who are following these posts, I hope you have made a list, for your own use, of the therapies that you do that are “how to” therapies that “allow” better movement. For therapists, I hope you will check that your families are doing the “allow” treatments while you focus on the “how to” component. Daily stretching and massage should be at the top of everyone’s “allow” list? If not, why not?
In This Series…
What about Spasticity?