Uso de la Compresión de Lycra SPIO

The development  and use of SPIO Lycra compression bracing in children with neuromotor deficits – NANCY HYLTON and CHERYL ALLEN

Summary

The use of flexible compression bracing in persons wüh neuromotor deficits offers  improved  possibilitíes  for  stability and movement control without severely  límiting  joint  move­ ment options. At the Children’s Therapy Center in KenL Washington, this treatment modality has been exp!ored with increasing apptication in children with moderate rn severe cer­ ebral palsy and other neuromotor de:ficits over the pasi: 6 years, with good success. Significant functiona1 improvements using Neoprene  shoulderitrunk/hip  Bracing  led  us  to   experimem with much lighter compression materials. The stabi1izing pres­ sure input orthosis or SPIO  bracing  system  (developed  by Cheryl AJlen, parent and Chief  Designer,  and  Nancy  Hylton, PT) is custom-fitted to the stability, movement control  and sensory deficit needs of a specific individual. SPIO bracing developed for a specific child has  often  become  parr  of  a rapidly increasing group of flexible  bracing  optíons  which appear to provide an improved base of support for functional gains in- balance, dynamic stability, general and specific move­ ment control with  improved  postural  and  muscle  readiness.

Introduction

Numerous years of experience with very flexible ankle/foot bracing has led to further professional expioration  of  mher  flexible  bracing  as therapeutic aids to stability, balance and movemem control. Our earliest  expenences  with  lightweight  compression bracing in children with cerebral palsy was in the mid- 1980s. Though these experiences were confined to two or rhree children for whom parents were willing w fabricate pant ·gárineiits·ollt of Ilyfoll ·or Lycra·:rnatefjalS, they all accompanied functional improvements in reduced hypertonus, and improved stability and movemenr con­trol.

Four years ago, after 1-2 years of positive experience usmg Neoprene shoulder/trunk/hip  compression bracing, primarily with children who had athetoid quad­ riplegia or severe low tone, a deeper exploration of this therapeutic medium began at our centre in Keot, WA. Spurred by the needs of her son, Brian, and therapisI Nancy Hylton, Cheryl Allen began t’abrícaling compression therapy shorts and.pants’ ofvarious mate­ rials. These were used in therapy and at home, with improved movement and weight-bearing control noted in the trunk and lower extremities in conjunc.tion with dynamic Foot Orthotics. This endeavour was limited to her son Brian until Chery!’s younger son Tan was 10 months old.

Ian had received weekly physical therapy with Nancy Hylton from 3 months of age for significant early sen­ sorimotor difficulties, íncluding increased extensor pos­ turing,   significant   movement    and   postural  control difficulties and marked hypersensitivity to typical envir­ onmeiii:af stimuJi. ·By “JO montfis orage·1ari”··was”·-hegin­ ning to sit independently, but was stíll unable to manage functional weight-bearing in prone. One morning, in therapy, Nancy decided to try wrapping Ian with a 6- inch elastic bandage. The elastic wrap went from each shoulder to between his legs several times, and rhen around rhe Irunk from the underarms to the hips. His response was immediate and quite unexpected. He pushed up on his hands, balanced and  looked  around the room, and rhen began to scoot forwards on his stomach. Cheryl went home and fabricated a customized body suit out of Lycra, in an attempt to duplicate this effect. Wearing this suit daily, within a week Ian was crawling reciprocally and rockíng on hands and knees. The transformation was truly fascinating and amazing. When we took  the Lycra off he could remain somewhat organized for a few minutes. but was no longer able to move or maintain his balance and progression skills. As we discussed the phenomenon more extensively during Ian·s therapy sessions, we wanred to cover ran·s arms and legs \VÍth Lycra as well. A design with overlapping pieces to give double compression to the trunk and hips, and specific downward compression over rhe shou1ders. was   fabricated,   Not  only  did  Ian ‘s  funcüon steadily improve,  but  he was  less hyperexcirable and  less easily overstimulated by noiscs,  visual action and body touching. He began to explore his environmen,t in a more ordered and secure way . The experience with Ian brought a new dimension to the development of Lycra compressio4 bracing or stabi­ lizing pressure input orthosis (SPIOJ.+ Severa! children in therapy at our centre were wearing a Neoprene shoulder/trunk:hip  vest  full-time  during  the  day. In child, movement control and balance were signifi­ cantly improved wíth use of  the  Neoprene  compression vesi:.  Parents  and  therapists  were  concerned   about  the comparison figure photographs were taken wíthin moments of each other, and no therapeutic intervention occurred between them. Often SPIO photos were taken first  and then the bracing was removed for the comparison ability of these children to continue to wear these as sununer weather approached, They were equally con­ cerned about the loss of function that these children might experience if they were unable to wear the Neoprene shoulder/trunk/hip brace that was assisting each of their functional movement  skills and  balance, A two-piece double-layer Lycra vest was fabricated for these children, We expected that the less mechanically supportive Lycra would decrease the usefulness of the brace, but hoped that it would provide sorne helpful compression support. Much to our surprise these chil­ dren with quite severe shoulder/trunk/hip invo!vement did as welI, or better, in the SPIO vest.

Our curiosity about both the mechanical effects of compression and the use of new sensory  input  from the system stimulated greater use of SPIO vests and wraps during therapy sessions, We found them generally he!pful ín children with moderare to severe stability and proprioceptive deficits, For sorne the SP!Os provided a very powerful aid to dynamic stability, movement orga­ nization and movement control.

Current use and protocols for use of flexible compression bracing

The styles and types of Lycra bracing are continuine to evolve, Because of our long-tenn and typical use of dynamic AFOs and FOs these became a protocol to the use of this type of bracing, Children were first assisted with a stable base of support and foot/ground contact before a SPIO was  uied, Different styles of shoulder/trunkíhip  wraps  and vests, two- and three-layer compression wraps for limb segments and trunk, cornpression thumb/wrist splints have been adde.d to the basic two-piece suit design described above,

We are continuing to explore the use of double and triple layering, lt appears that, for sorne individuals, an additional !ayer of material leads to significant func­ tional improvement  For  others  the  single  !ayer  is very helpfuL Double and triple layering, though more difficult to doff and don, provide greater mechanical stabi!ity, and probab!y alter externa! torque forces in ways that we do not yet understand. AH of these new innovations, though  originally  designed for  a  particular  individual,  have  proved  quite helpful for others with similar dynamic stability and sensory deficits. We are using flexible compression bracing in combination with other deep sensory input systems, namely vibration and subcontractile functional electri­ cal stimulation.

Styles of SPIOs and patient selection

As mentioned above, the number and styles of SPIOs have changed dramatically in the past 18 months, even though the original two-piece shoulder/trunk/hip flex­ ible compression brace covering arms  and  legs,  and the flexible shoulder/trunk/hip vest-type brace  have been used in children and adults with a variety of neu­ romotor deficits since they were first fabricated. The Lycra material used has eight-way multidirectional stretch, with excellent  memory and rebound into its ori­ginal shape. It provides a steady stretch tension with excellent breathability and a very pleasant tactile sensory feedback.

Even though this very thin and flexible bracing system has the appearance of a standard shirt and unitard com­ bination, the combination of the natural characteristics of the construction material and the specific compres­ sion ratios provides very precise sensory infonnation, which appears to be quite helpful and organizing to children with several different sensorimotor involve­ ments. Double circumferential trunk compression is achieved from a region under the arms to over the hips, as well as across the shoulders, Vertical compression is achieved between the over-the-shoulder straps and the buttocks, and between the legs area of the unirard. Cylindrical compression of limbs is tolerated very well, and appears to help the wearer’s position-in-space a\Vareness.

Spio: Shoulder, Trunk, Hip Vest Compression Brace

With a Velero sensitive Neoprene back panel, two- or three-layer compression tension is readily adjustable and permits significant growth potential for longer wear life of the brace. This is a very useful problem-solving style for a rherapy clinic tria!.  Over-the-shoulder straps can be custom-made with varying widths and cap over the tip of the shoulder. Circumferencial trunk cornpression can be varied easily between thorax, lumbar and pelvic regions. The vest can be made with or without anchor strapping between the legs to enhance compression over the shoulders.

Spio has  been  used  successfully in children with quadriplegic involvement. Among the chil­ dren responding with improved stability and function to SPIO no. l there is a 7-year-old-boy with mixed athe­ toidiataxic cerebral palsy, who is also deaf and blind; a 2-year-old boy with mixed athetoid/spastic quadriplegia from severe birth asphyxia; a 4-year-old boy who is independently ambulatory but very unsteady wírh mild athetoid/ataxic-type involvement; a 2-year-old girl with recently acquired moderate to severe cerebellar ataxia; a 2-year-old boy with marked sensory difficulties  and poor grading and movement control with a history of gestatíonal drug exposure and infant pertussis; a 3-year­ old boy with Angelmann·s syndrome and ataxic-type motor  ínvolvement,   and   numerous   children   aged -years–and·older wirh–motor  discoordination-and sensory integration-type problems. Immediate and ongoing functíonal improvements while  wearing  the  SPIO brace include improved ability to maintain stationary balance in prone, sittíng, hands and knees, and standing; improved grading of movement and dynamic balance in transüíonal movemenrs; active weight shifting away and back to midline; walking, running and more complex upright skills; improved level of muscle activaüon and postura} readiness (increased activation in children with low tone and decreased tension in children holding the body stiffly to manage stability and sensory deficits) at rest; improved protective extension and active weight­ bearing on extended arms or legs and improved toler­ ance to extraneous sensory stimulation, such as auditory or visual overstimulation.

This type of SPIO brace has proved very helpful for children with cerebral palsy or spastic diplegia involve­ ment.

Spio: No compression Wraps

These compression wraps are being used successfully in severa! children around the upper arm, to improve active stability, weight-bearing and quiet flexor spasti­ city in the bíceps (Figures 4c,d and 5b). They are also being used to assist the quality of lower extremity weight-bearing and muscle control, and occasionally :.i.s more generic trunk/hip wraps.

SPIO NO. 5: COMPRESSION THUMB, HAND, WRlST SPLINT

Lycra compression bracing on hands and forearms is being used on children with hemiplegia or quadriplegia involvement. In sorne cases this appears to provide a primary deep sensory input while screening out bother­ some light tactile input. The combin?J,tion permits immediate and ongoing improvement in weight-bearing on extended arms. precision of finger/hand control and manipulation/play skills. Suspected neural and biomechanical mechanisms Though the insights shared here can certainly be con­ sidered highly speculative, they-are offered as possible mechanisrns for the functional changes which we have observed in hopes of stimulating more thought and exploration in  this area. At  a  wonderful  3-day course in February 1996, cal!ed ‘The brain in three-dimen­ sions’, inscructor Shelby Clayson, MS, OT, casually shared sorne information with me  durlng  a  break, which has profoundly stimulated my thinking. My question to her was whether there was any neurophysío­ logical connection between deep pressure and proprio­ ception. Her response both astounded and excited me. Not only were proprioception and deep pressure specific somatíc inputs to an organization within the CNS designed for environmental exploration and  learning, but this system also íncluded vibration  and  precise touch as additional somatic inputs. An alternative orga­ nization designed for survival and protective functions included inputs of light touch and pain. Could it be that persons with poor proprioceptive feedback, whether because of a primary deficit or because of inconsistent and poorly coordinated muscle activation dísrupIÍng the feedback loop, could obtain helpful inforrnation from vibratory and deep pressure receptors that could ímprove functional movement control? Is this the link that makes flexible compression bracing change func­ tional concrol rather miraculously for sorne individual{‘ If thís is so, and my experience and intuition makes a strong connection to this piece of infonnation, then one possible mechanism for the functional improvements that we have seen wüh Lycra is bm:h direct deep pressure from contact wlth the skin, and increased internal soft­ tissue pressure impacring both mechanicai stability and pressure receptors. As the deep pressure receptors give more usable inforrnation to the proprioceptive feedback syste·rh, pósitional’límb ánd bbdy· awareness i’s irriproVed and rhe person is able to direcr movement and specific muscle activation more precisely. In the case of Kalen. a little boy with Angelmann ‘s syndrome, he appeared ro have very little idea ot’ where the edge of his body ended and the air began. Lycra bracing from wrists to ankles, wíth double compression through the trunk and across the shoulders. perhaps perrnírted h1m to better ‘place his body ín space’. Increased light touch from  the donning of the top and bottom portien of the brace, caused a hypersensitive ·fidgety’ and ;disorganized’ response. This response was, however, temporary, and changed quickly to a more artentive, interactive and deliberate demeanour within a few minutes. The latency response time for body righting to weight displacement on the therapy bail was reduced almost immediarely from a 15-20 second average down to 5-10 seconds. Kalen opened his eyes wider, gave me  direct  visual  regard and smiled. lt was as if the Lycra suit ‘gave him better ownership of bis body’. Sorne of the mechanica1 mechanisms are fairly easily seen. Overstretched abdominal muscles cannot contraer as easily as those which are being heid in a less-stretched mid:.:fange. ·Neo-¡:irene cj!indfical wraps around· “arms. legs and trunk exert a direct  force  against  collapse from gravity in weíght-bearing and  upright.  Though the dírect effect may be more subile, Lycra must also have sorne dampeníng effect on external force vectors which are acting across joints, especially those with mul­ riple degrees of freedom. This permírs a slightly longer reaction time, and contains overshooting, so that the system has the possibiiity to become increasingly more predictable rather than less predictable. Increased stabílity, assisted by increased internal pres­ sure on soft-tissue structures, in sorne cases also prob­ ably plays a role ín rhe improved loading of joints which is seen. It is a well-known facr that increased intra­ abdominal pressure provides improved anterior spinal stabilization. Abdominal musde sets are taught for mis reason ro be used befare and during lifting, to sup­ port and protect back structures. It makes sense that similar increased soft-tissue pressure around shoulder and hip/pelvic girdle areas could be equally helpful in improving joint stabilization and reducing troublesome vector forces. The effect seen in a young girl with spastic diplegia in Louisiana might be an example of the mechanism.   An   independent walker \Vith forearrn crutches, her unstable hips snapped and popped wirh cach step. Double-thickness Lycra comprcssion bracing. from the leve! of rhe lower ribs ro the knees. ímmediately stopped the popping and clicking sounds and excessive hip luxation movement. and improved borh gait comfort and efficiency.

Another mechanical mechanism which may be con­ tríbuting to the funcrional improvement  seen. relates to  a commenr recently made to me by Gad Alon. PhD. PT and biomechanist. He said that. among all of the force vecrnrs acting to make life difficult for persons wírh movement control problems, external vector forces probably cause the biggest problems. By dampening external force vectors, containing movement, yet ailow­ ing it, persons may be assisted to  redirect force vectors to a more even force generation. thereby improVing their functional movement control. Such a factor may allow them to combine muscle activation  in a greater variety of combinations. and with greater predictability. This may partially account for the  ínitial  and  continued more rapid learning curve for movement. stability, con uol and balance seen with the addition of flexible com­ pression bracing to an already-established therapy intervention programme. It may also account for the observation that. even though  function  is  improved with compression bracing on, irnproved control gener­ alizes over time to siruations without brace wear. The dependency curve appears to lessen with  wear, instead Of “inGreasirii.

Conclusion 

Though it is still a relarively uncharted area of exploration, our preliminary experiences using Lycra compress10n bracing show consístent functíonal improvements in children with sensorimotor deficits. Other compression bracing systems which have devel­ oped simultaneously. such as the Up-Suit from Perth, Australia[]], ail appear to be made with less growrh and rherapist discretion to adjustability, out of  materials with less ease of multi-directional srretch. The SPIO system developed in this area, and in this  regard, appears to have sorne dístinct advancages.

At the same time it is crucial that we forge ahead with therapeutically helpful tools to improve function  in daily living for individuals with sensorimotor deficits. Fabrication of bracin_g.  and  suppon systems  which both contain inirial costs and permü significant growth. is especially important for children and young farnilies. Certainly more exploration and specific data collec­ rion 1.,vith different popu!ations of children and adults with neuromotor deficits needs w be done in all areas of therapeutic imervention. Flexible compression bracing is no exception. From our experience, it does show excellent promise for ongoing improvement in daily function, especiall:y in !-hose in whom proprioceptive deficits and/or stability deficits are major concems. Great care must be exercísed, however, that this is not the latest ·carrot’ dangled in front of parents and  per sons with neuromotor deficits. Initial problem-solving \Vith 6-inch elastíc wraps. which are often available in the therapeutic serting, can provide valuable immediate feedback as to the potential value of such bracing for specífic individuals.