December 2013, Week 1: To crawl or not to crawl

The session I wish to reflect on in this entry was with patient JF, a 4 year-old female with the medical diagnosis of CPSQ. The patient’s primary means of mobility was wriggling her pelvis while in ring or long sitting position. She has no other means of independent mobility, such as creeping, crawling or cruising. This current means of mobility was obviously not typical (in the sense that it is not included on the long list of motor milestones) so the first goal I came up with after seeing her in person was for her to learn how to crawl (quadruped mobility). I did not immediately deem cruising as a goal, being a more advanced skill than crawling, which she was unable to do. At the back of my mind, however, I felt that something was amiss with my goal: the patient is a 4 year-old female and a child of her age is already expected of walking. After a quarter of the session's hour had elapsed, the patient still was not showing the slightest hints of improving in crawling despite manual guidance. Maybe, if I were to train mobility, I might as well train her to walk. The impairment, however, that kept me from choosing walking as the goal for that session was the severe lower extremity extensor spasticity of the patient. When assisted to walk, she presented with hyper-extended knees and plantar flexed ankles, which only went to neutral after short duration of rest (<30 seconds). I thought that by training how the patient to crawl, I was training her to move out of this extensor spasticity. I might have, but the carry-over of reduced spasticity would probably limited to activity of crawling. Again, I should remember that spasticity will never be completely resolved so I might as well just work with it with the skill I want her to develop. The lesson now is that first, I should try to be more specific with the activity. From then on, I can apply Motor Relearning principles (now appropriately called motor learning principles for the pediatric setting). In JF’s case, it is probably impractical to religiously subscribe to the neurodevelopmental approach of training motor milestones because doing which would perhaps prevent me from progressing my goals. What I can think of right now is to incorporate training of these "earlier" motor milestones on training walking alone. For instance, maintenance of quadruped position for JF would be used to promote weight-bearing on his lower extremities.