Submitted by R. A-N, Physical Therapist
| Before | After |
|---|---|
| Excessive lordosis made transitioning to her wheelchair unsafe; the process often required two people and several attempts | Able to be transferred into her chair with her hips properly positioned, usually on the first try. Less lordosis evident in standing |
| Unsafe alignment when in gait trainers | Able to stand in gait trainer keeping her arms resting forward on the arm rests while stepping forward. She also now stands with her head in more mid-line alignment without external supports. |
My client is a 12 year old girl who has spastic quadraparetic Cerebral Palsy. She is dependent with all movements. She has poor head and trunk control. In order to maintain herself upright against gravity she postures her spine in excessive lordosis with associated scapular retraction and shoulder horizontal abduction. The excessive lordosis and the associated upper extremity posturing interfere with her ability to maintain her head in mid-line for safe transitioning while seated in her wheelchair. It also decreases the ability of her head to stay in midline so that she can visually focus on her communication system and then use the switches that she uses to activate the system. Her family has worked with both medical interventions and equipment supports in an attempt to decrease the lordosis in her spine. They have worked with doctors injecting botox into her spinal extensors to decrease the lordosis with minimal success. They have worked with a variety of chest support and a variety of inclines in the wheelchair, with minimal impact on the lordosis noted.
During her treatment times the excessive lordosis interfered with safe and efficient transfers back into her wheelchair, often leading to prolonged transfers as she required extra supports to properly place her hips in the seating system. It often was a two-person transfer with 2 to 3 attempts required. Based on her excessive lordosis she was assessed for the presence of the Spinal Galant reflex. She demonstrated the presence of the reflex on both sides. Her treatment sessions were then adapted so that the rhythmic movement #1 and #2 [from the Brain and Sensory Foundations course] could be done. Following just the use of the movements her transfers significantly improved. She was able to be transferred back into her chair with her hips properly positioned on the first attempt. She continued to demonstrate ease with transfers with every successive treatment. Her entire body was more relaxed as she transitioned back into her chair.
This young girl is able to ambulate with the assist of a support system that offers her the ability to stand with partial weight bearing. She was initially using a KidWalk gait trainer, which provided her support posteriorly While she was in this gait trainer her lordosis was so significant that she would exceed and laterally flex off of her head rest, placing her body in an unsafe alignment. She was, therefore, transitioned to a different gait trainer, Rifton Dynamic Pacer which provides more support anteriorly, to decrease the stimulation to her spinal extensors. Initially she required extra support posteriorly at her scapulas as she was still posturing in a lordotic position. She continued to receive the combination of rhythmic movements and the isometric activities, done passively in sideline, from March until May. During this time her ability to stand in the gait trainer transformed. She was able to stand in the Rifton Dynamic Pacer keeping her arms resting forward on the arms rests while stepping forward. She was also able to stand with her head in more mid-line alignment without external supports. She was able to stand with less lordosis evident. She still has decreased head and trunk control due to the spastic quadraparesis, but she is able to position with more mid line control so that she can move more efficiently within the limits of her disability.
[Edited for length and clarity, emphasis added]