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The development and use of SPIO Lycra compression bracing in children with neuromotor deficits – NANCY HYLTON and CHERYL ALLEN
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.
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 2 -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.
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.