Abnormal Muscle Tone: Functional versus "Pretty"

When children have abnormal muscle tone such as tight muscles (spasticity) or tremor-like motions (ataxia), then the motions that they make may not exactly look pretty. This is because there is damage somewhere within the neuromuscular system whether it be in the brain such as with cerebral palsy or at the cellular level of the muscles such as with muscular dystrophy.

Back when I had just graduated from therapy school, I went to numerous classes on learning how to improve a patient's muscle strength, tone, and movement patterns. It was my mission to help everyone look typical. That was soon found to not be so realistic. And although a difference can be made with mildly involved persons in a fairly short time, it may take a while for very involved patients such as those who have suffered a TBI- tramautic brain injury. This is because of numerous reasons (medical, neurological, orthopedic, cognitive, behavioral, etc.). So, until their movements look stronger what are we to do? Well, I believe the therapist's duty is to work on functional skills.

For example, I would love for a child with cerebral palsy to hold the spoon perfectly and not spill any food, but that may not be realistic in the short term...for some kids, it may never be realistic. The immediate goal should not be to not let the child feed himself unless he has used the "proper" movement patterns, but instead to make sure the child is functional, even if that means that the movements do not look "pretty". It may mean using a wide handled, curved, or swivel spoon. Although the ultimate goal as a therapist is for the most efficient movement patterns by each muscle group during a functional task, this can take time to develop, and requires daily strengthening. Maybe it can be practiced during snack or at the end of a meal, but it would only frustrate a child to be helping them move "properly" during every single bite. Yet, as a therapist why is it so hard for me to just sit back and watch a sloppy eater? I have had to chill out and realize that I am being a much better therapist by encouraging independence even if the movements aren't the prettiest.

Also, responsibility goes to the parents for carrying out daily activities and exercises to help the child improve. I wouldn't just go to the gym once a week and expect to gain a better figure, so how could we expect that a child with neurological damage is going to improve with tone and strength by only going to therapy once or twice a week? The therapist MUST train the parents to do easy activities and exercises to incorportate into daily routines. Examples include having the child push the siblings stroller to build arm and leg strength, buy toys that encourage manipualtion, carrying grocery bags, "rough house" with parents, taking the child to the park to work on climbing, sliding, and swinging, and the list goes on.

Finally, we as therapists need to know when it is time to discharge a patient from services and guide them to community facilities such as karate or gymnastic lessons. There are some children who have endured years of therapy at a high frequency and although overall they have made gains, there comes a time when those gains aren't so drastic. It could be due to hormones, growth, attitude, needing a change, or that there is just an extreme amount of neurological damage. No matter the reason, I completely believe that it is okay to discharge a child from therapy even if all of his movement patterns are not "pretty". Now, if the child is willing to do all of the work it takes to get stronger and change movement patterns, then I might keep them in therapy longer. But I would still emphasize function. If the child wants to be an artist, then we would work on movements that are made at an easel. If the child wants to be a secretary, then we would work on typing skills whether it be with two hands on a typical keyboard or with a device on an adapted keyboard. I would also work on movement patterns needed to play, cook, clean, dance, or participate in sports.