Use of a Lycra-based Garment in Facilitating Postural Stability in Children with Cerebral Palsy

 

Clare CHENG, Senior Physiotherapist, Superintendent

Iris CHAN, Occupational Therapist

Jockey Club Marion Fang Conductive Learning Centre of SAHK

 

  Begin with a Story

  Literature Review

  Clinical Trial of the Dynamic Postural Garment (DPG)

  Subjects

  Wearing Regime and Training

  Data Collection

  Results

    CYX showed functions improved immediately after wearing the DPG

    NKT also showed improvements in the following functional activities

  Conclusion

  References

 

 

Begin with a Story

Truncal, pelvic and shoulder girdle instability is often a big hurdle to the development of independent mobility and upper limb functions of children with cerebral palsy. Some years ago, we observed an unexpected “side-effect” of a pressure garment worn by a schoolboy with spastic quadriplegia after accidentally scorched his groin region by hot water during bathing. The pressure garment covering the lower trunk and hips gave some stability to his “wobbly” pelvis and allowed him to free one hand from support while standing. This task was impossible for him before wearing the pressure garment. The “side-effect” aroused our interest in looking into the use of lycra to tackle the problem of proximal stability in children with cerebral palsy.

 

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Literature Review

In reviewing the literature, it was found that Blair, et al.1 had experimented on lycra material to make a lycra-based dynamic total body splint called UPsuit. They reported that the splint provided joint stability and tone inhibition. The best result was achieved in children with hypotonia or dystonia. This splint consists of multiple layers of lycra fitted next to the skin with plastic reinforcement to provide the required dynamic pull and support. The difference between the UPsuit and the conventional rigid orthoses is that it provides support and control whilst allowing movements. Hence, it allows active learning of more normal functional movements. However, the splint was complained to associate with significant practical problems such as inconvenience of putting on and keeping hygiene.2 In considering the climate in Hong Kong, comfort and tolerance would be another issue.

Other versions of dynamic splint based on the concept of UPsuit was tried by other investigators such as in Hylton and Allen’s case study3 where they use a thinner lycra material to make what they called the stabilizing pressure input orthosis (SPIO). It was again a whole body garment.

Gracies, et al.4 investigated the mechanical effect of these lycra-based garments. Their experimental garment consisted of a series of circumferential lycra segments sewn to form a sleeve tightly fitted to the whole upper limb with a pull in the direction of supination. They demonstrated that a low-tension sustained torsion was exerted to the arm and forearm in the desired direction.

 

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Clinical Trial of the Dynamic Postural Garment (DPG)

Based on the literature review and the observation of the child mentioned in our story, we selected two cases from the Jockey Club Conductive Learning Centre of the Spastics Association of Hong Kong for a clinical trial on a lycra garment which we called the Dynamic Postural Garment (DPG) (Figure 1). The garment consisted of a single layer of lycra covering the shoulder region, the trunk, the pelvic region and the thighs to produce circumferential and compression pressure to the axial and proximal joints. This is similar to the effect of approximation given manually to elicit an active cocontraction of the axial musculature so as to gain truncal and pelvic stability.


Figure 1.
Child NKT having DPG on.

 

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Subjects

One case (CYX) selected was a four-year-old boy with hypotonic CP and moderate mental retardation. He demonstrated a generalized hypotonicity and the tone was only slightly raised in exertion. He was a supported sitter with good head control but poor truncal stability and with kyphotic back. Propping with the upper limbs was weak even with arm gaiters and the grasp was also weak and not sustained. In supported standing with a ladder frame and manual assistance, there was a constant sway of the pelvis to either side and locking of the pelvis in the posterior tilted position showing the poor cocontraction of the axial musculature. The DPG was expected to elicit more active muscle work of the axial joints.

The other case (NKT) was a 3 year-old girl with athetoid CP and normal to limited intelligence. Her basic muscle tone fluctuated from normal to slightly hypotonic. She sat with support and occasionally could prop both hands on floor to maintain sitting balance. However, she got little confidence to sit independently without adult beside her. She showed little attempt to reach out with both hands. She tucked her elbows to the side of the body for stabilization when doing manipulative tasks. This limited her use of the hands in a more functional position as well as limited her ability to push the ladder frame (the walking aid she used) in assisted walking. The DPG was expected to give her more proximal fixation around the shoulder girdle and the trunk giving her confidence to attempt sitting independently and releasing the fixed posture of the upper limbs for reaching and pushing.

 

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Wearing Regime and Training

CYX started the trial in September 2000 and off the garment in June 2001. In the first week, the garment was worn for one hour as an adjustment period. The duration was gradually increased to 2.5 hours per day thereafter. The garment was off during mealtime and sleeping time.

NKT started the trial in June 2001 and off in August 2001. The DPG has been worn for 5 weeks. The duration of wearing the garment was increased gradually from one hour per day to 2.5 hours per day. The much shorter duration compared with CYX was due to less skin tolerance in NKT.

Both cases continued their training in Conductive Education programmes which include learning in transfer skills, hand tasks, play skills, self-care skills and daily routine of walking, toileting and feeding. All the activities emphasized active movements and participation as well as understanding of the task and good postural requirements. The flexibility of the DPG material allowed movements and it did not hinder the active learning part of the programmes.

 

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Data Collection

Video on gross and fine motor activities was taken in the natural environment during the training programmes and daily routine. Video was taken before wearing DPG, immediately wearing it and at the end of the trial period. The content was analyzed according to activities including rolling, prone on elbows, 4-point kneeling, sitting on floor, sitting on stool, standing, sitting on stool to standing, walking, reaching with the upper limbs and basic grasp and release of the hands.

 

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Results

CYX showed functions improved immediately after wearing the DPG:

1.   The frog position of the legs in lying was reduced;

2.   The upper limb actively took part in the assisted rolling with the shoulder showing more self- controlled movement;

3.   The head could maintain in the upright position in the forearm-supported prone position for a longer time and the head could turn from side to side to follow toys with sound;

4.   Hands could prop on the floor without arm gaiters to maintain sitting for a second and with arm gaiters, sitting balance could be maintained up to 2 minutes;

5.   In sitting, the trunk maintained in the upright position more frequently;

6.   Sideways and forward sway of the pelvis was reduced in supported standing.

 

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NKT also showed improvements in the following functional activities:

1.   She could sit on the floor on her own without support for an increased period of time;

2.   She showed confident to sit on a stool without adult beside her;

3.   She could reach out with both hands in different directions in the sitting position;

4.   She could maintained a 4-point position which was not achieved before;

5.   Her shoulders were more forward with elbows extended in standing pushing onto a ladder frame;

6.   Athetoid dancing” of the legs was reduced in standing position;

7.   Walking was improved with better pushing of the ladder frame and weight shifting between the two legs.

 

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Conclusion

The project was a very preliminary trial of two cases on the lycra-based garment. Encouraging results were seen in both cases indicating an improvement of proximal stability on wearing the garment. The investigation will be continued to work for a more systematic assessment for correlating the findings. Colleagues who are interested to try this garment out are reminded to some contraindications. Subjects with uncontrolled epilepsy and poor respiratory function should be excluded. Skin sensitivity to the lycra material should be observed before a longer wearing regime is adopted. Reduced muscle strength in prolonged wearing is also theoretically possible. Constipation and urinary frequency is also some complications mentioned in some investigations.

 

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References

1.   Blair E, Ballantyne J, Horsman S, Chauvel P. A study of a dynamic proximal stability splint in the management of children with cerebral palsy. Dev Med Child Neurol 1995;37:544-54.

 

2.   Hanson C. How effective are lycra suits in the management of children in cerebral palsy. J Assoc Paediatr Chart Physiotherapists 1999;90:49-57.

 

3.   Hylton N, Allen C. The development and use of SPIO Lycra compression bracing in children with neuromotor deficits. Pediatr Rehabil 1997; 1:109-16.

 

4.      Gracies JM, Fitzpatrick R, Wilson L, Burke D, Gandevia SC. lycra garments designed for patients with upperlimb spasticity: mechanical effects in normal subjects. Arch Phys Med Rehabil 1997 Oct;78 (10):1066-71.

 

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