The Importance of Movement for Children With Disabilities
by Monica Silva, MSC in Neuro Rehabilitation
Introduction
“Use it or lose it”, this is the fundamental conclusion of recent neuroscience studies, with the concept of neuroplasticity underpinning a new paradigm in rehabilitation. The literature highlights that in children, neuroplasticity capacity is at its highest and young children experience critical periods for brain development which rely on the interaction and input from their environments. Therefore, early intervention to facilitate this in children who may be impacted by other factors that restrict their ability to freely move, is key.
For these children, there may well be multiple professionals each with distinct roles in their early rehabilitation process. It is crucial that the team surrounding the child, work together to promote opportunities to feel, touch, hear, see, taste and enjoy meaningful activities. Enhancing and preserving a child’s movement skills is key, of course, but movement is not a static and isolated skill. It is dynamic. It thrives and develops within a complex neurological network involving various aspects such as sensation, previous experiences and motivation. As such, it is crucial for clinicians to consider timely interventions to achieve optimal motor, cognitive and functional outcomes.
Below, the following will be discussed:
- Essential aspects regarding early motor development
- Functional implications and challenges resulting from movement deprivation
- Approaches to support movement skills within the paediatric population
Essential Aspects Regarding Early Motor Development
Movement drives and reflects development.
The literature suggests that the development of movement repertoires, motor control and body representations in sensorimotor circuitry are achieved through early spontaneous movements, sensorimotor experiences and proprioceptive feedback in children. It is now known that brain development and the refinement of the motor system continues postnatally, and it is driven by motor cortex activity.
In normal infant development, the refinement of movement allows the acquisition of other essential skills such as supporting early visual and later hand-eye coordination by moving the eyes separately to the head to fix and follow objects of interest. As primitive reflexes are reduced, and voluntary movement emerges, infants progress in their ability to reach and grasp objects, support their body weight and dissociate their lower limbs movement in preparation for crawling and walking.
Movement allows the sensory exploration of the infant's own body and of the immediate environment. By touching and manipulating objects, humans create an internal representation of that physical stimuli within our somatosensory cortex, which allows us to learn the properties of these and manipulate them successfully. Furthermore, this learning is modulated by the overall experience and both intrinsic and extrinsic factors such as pleasure, fatigue, pain, a sense of mastery or motivation. It is plastic, and therefore consideration for the child’s sensory experiences within the context of early occupations such as bonding with parents and play is paramount to childrens' motor development.
In summary, active movement in young children influences the development of their motor cortex and consequently to generate intentional, controlled and dexterous motor actions.
Cerebral Palsy is the Most Common Cause of Motor Impairments in Children
Within childhood physical disabilities, cerebral palsy (CP) is most common, with a prevalence of 2.1 cases per 1000 in high-income countries (Oskoui et al 2013). Cerebral palsy is “a group of permanent disorders relating to the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the foetal or developing brain“ (Rosebaum et al, 2007). A CP diagnosis is typically given between 12 and 24 months of age, with current recommendations for clinicians to give an interim high-risk of cerebral palsy if diagnosis not certain to optimise access to early intervention (Novak et al, 2017). CP may result from various causes including genetic, stroke, brain mal-formations or hypoxic ischaemic encephalopathy (HIE). The most frequent motor type is spasticity (85%-91%) which can affect present unilaterally as a hemiplegia (38%) or bilaterally which can present as diplegia (lower limbs more affected in 37%) and quadriplegia (four limbs affected in 24%) (Report of the Australian Cerebral Palsy Register, 2016).
Being aware of the child’s birth and early medical history and diagnosis is helpful to both case managers and therapists, as it will help them to understand the complexity and severity of a child’s motor impairments, associated co-morbidities and future functional considerations. It is also worth finding the child’s Gross Motor Function Classification System (GMFCS) (https://www.canchild.ca/en/resources/42-gross-motor-function-classification-system-expanded-revised-gmfcs-e-r) and Manual Ability Classification System (MACS) (http://www.macs.nu/), and including these in communications for a shared overview of the child’s motor and functional abilities. Questionnaires and literature are available on the websites above to help determine these in discussions with parents and/or carers.
Other Causes of Motor Impairments in Children
Motor impairments may also be found in older children with previous normal development subsequently to acquired brain injury with traumatic brain injury, brain tumours or meningitis being common causes. As mentioned above, it is beneficial to understand the cause of injury as specific diagnosis have distinct recovery trajectories, co-morbidities and prognosis which can impact their motor performance. For example, there is a proportion of children with traumatic brain injury who significantly recover from their motor impairments and have the capacity to actively mobilise from a motor perspective but lack the cognitive and behavioural skills to do so independently and safely in community. For example, by showing impulsive behaviours and reduced safety awareness when crossing roads.
Functional Implications and Challenges Resulting from Movement Deprivation
Recent international recommendations highlight that early active movement and intervention are essential as infants who do not use their motor cortex risk losing cortical connections and resulting function (Novak et al 2017). Conversely, early intervention maximises neuroplasticity and minimises harmful modifications to muscles, bone growth and overall development.
The International Classification of Function, Disability and Health (ICF) (https://www.who.int/classifications/icf/en/) is a helpful framework to guide and support communication within all professionals involved in the child’s care. Its classification clearly describes the various components contributing to a person’s function and environmental factors.
As described above, according to the ICF framework, body functions, activity and participation can influence each other, although it is not known to what extent. Therefore, when planning and providing interventions to support and/or maintain motor development, these should be considered in the context of facilitating engagement in meaningful activities for children and young people. Some examples include facilitating age appropriate play, participating in school and leisure activities. In order to achieve some of these, therapists may use a rehabilitation approach (treat the impairment), a compensatory approach (adapt the environment or activity in order to facilitate the child engaging in the task) or both. Often, a child’s trajectory will fluctuate between both approaches depending on the severity of their presentation.
For example, a young baby who suffered a hypoxic ischaemic encephalopathy (previously known as birth asphyxia) may likely initially benefit from intensive intervention to encourage their active movement. This is done by encouraging them to touch toys, roll to their side or engage in tummy time. However, the baby may not be able to maintain a side lying position to look and touch toys or push through their upper limbs to support their body and require this activity to be adapted by using equipment such as a Leckey Squiggles Early Intervention System (http://www.leckey.com/products/squiggles-early-activity-system/) which can help compensate for the baby’s motor weakness and facilitate their ability to engage in age appropriate play. In this example, by encouraging movement and compensating the lack of which results in the facilitation of not only active movement but facilitation of visual and cognitive milestones.
As mentioned above, being aware of the child’s individual functional abilities (using the GMFCS and MACS levels) can also aid case managers and therapists with intervention planning. For example, children with a GMFCS of level IV or V (more severely affected gross motor function) may need prioritising the assessment and provision of 24 postural management care such as orthotics, specialist seating or standing frames. Conversely, a child with a MACS level of II-III (less severely impacted manual ability) may benefit from engaging in an intensive block of upper limb rehabilitation for improvement of their independent functional skills to engage in play, school activities or self-care.
Approaches to Support Movement Skills Within the Paediatric Population.
Best practice: Supporting client-centred approaches and meaningful functional outcomes.
Novak et al (2020) have identified clear aims for intervention for children with cerebral palsy. Whereas some of these may not be relevant with children presenting with other diagnosis that limit movement, it remains a clear guidance to consider, which can support intervention planning. For the purpose of this article, the focus below will be on the interventions relating to movement only.
- Optimise motor, cognition and communication outcomes using interventions that promote learning and neuroplasticity.
All children with cerebral palsy have motor impairments, with varied degrees of severity and presentation as described above (spasticity, dyskinesia, ataxia and hypotonia).
According to the literature, therapists are encouraged to focus their intervention on child-initiated movement, task-specific practice and environmental adaptations which stimulate independent task performance. These should take place in the context of meaningful occupations such as play, sleep, eating, bonding with parents, engaging in school activities. Case managers and therapists can also consider the input of other professionals such as teaching assistants or support workers to increase the opportunities for the child/young person to engage in therapy programmes.
Examples of upper limb evidence-based interventions include modified-constraint induced movement therapy, bimanual therapy or goal-focused therapy for children with hemiplegia (Novak et al, 2020). These techniques are underpinned by neuroplasticity paradigm and focus on the learning of movement skills by offering increased opportunities for movement repetition at just the right level of motor demand in the context of meaningful activities. For a baby, this could be to focus on holding a rattle, for a toddler to hold a spoon in their hand to feed themselves during mealtimes and to a teenage girl to hold and place their sanitary pads when menstruating. The therapist will select the most appropriate model of treatment based on the individual needs of the child and their family, the outcome of their assessment, other treatments the child maybe undergoing; and their own levels of experience and training and in collaboration with the wider MDT. A list of international recommendations for early intervention for children with CP from 0-2 years of age has also been recently been published to assist with evidence-based practice (Morgan et al, 2021).
Motivation is key, therefore knowing parent and child’s interests and preferences can optimise the effectiveness of chosen interventions also. This can be as simple as finding out the best time of the day for the parent and child to carry out sessions, knowing whether a child prefers to play with musical or light toys, or even who is their favourite superhero or tv programme and include these in any aspect of intervention.
Further whole body well established interventions, although less evidence-based, include provision of casting, orthotics, taping, CO-OP, electrical stimulation, hippotherapy (see next months Expert insight article for more information on hippotherapy) and hydrotherapy. Recent recommendations against include passive forms of NDT and Sensory integration (Novak et al 2020).
Other resources to be aware of are charities such as MERU (https://meru.org.uk/what-we-do/bugzi/) which provides customised and ready-made products to support children with disabilities in engaging in daily life and leisure activities. Of note is the Bugzy loan scheme, through which children with disabilities can access an electric indoor wheelchair to develop their early mobility independence. A similar option is available through Designability (https://designability.org.uk/meet-wizzybug/about-wizzybug/) which is also available for toddlers as young as 14 months old and can be used outdoors. Another charity well worth knowing about it Remap (https://www.remap.org.uk/) which creates bespoke equipment not available elsewhere in the market. This resource is of interest if aiming to facilitate motor performance and/or independence in functional tasks. A great example of this is found on their website ( https://www.remap.org.uk/2426/zoes-new-reacher/).
- Prevent secondary impairments and minimise the influence of complications that worsen function or interfere with learning
It is well known the prevalence of co-morbidities in the CP population which include chronic pain (75%), epilepsy (35%), intellectual disability (49%), musculo-skeletal problems (such as hip displacement) (28%), behavioural disorders (26%), sleep disorders (23%), functional blindness (11%) and hearing impairment (4%) as well as bladder control problems (1 in 4), and tube feeding (1 in 15) (Novak et al, 2020).
Although the complications above may not immediately be considered in movement impairments, they can all contribute to movement deprivation in a functional context and must be addressed timely for treatment planning and provision. For this, multi-disciplinary team communication is key.
Summary
Promoting early movement in children with motor impairments is essential for overall development in the first years of life. It offers optimal opportunities of brain development, including recovery and/or acquisition of new skills following an acquired brain injury. Children with cerebral palsy or acquired brain injury can present with varied levels of impairment, activity and participation difficulties and benefit from individualised interventions to meet their needs. Consideration of best-practice guidelines and multi-disciplinary work and facilitate intervention planning and meeting children and young people holistic health needs which can impact on motor outcomes. The literature also recommends that the management of movement difficulties is planned, developed and implemented in partnership with children, young people and their parents or carers, using meaningful and goal-specific approaches to meet their individual needs.
References
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