What is the problem, and what should we do about it?
Well, that depends on how we understand and define a symptom.
Today, we often talk about “spasticity” as if it is something in itself — almost like a muscle or a part of the skeleton. But there is no “spasticity organ.” Instead, we need to talk about a spastic movement pattern — a way of moving that occurs when a person lacks motor control.
Why should we talk about a spastic movement pattern? Because it changes the way we think about intervention — and can lead us towards very different, and better, approaches.
A spastic MOVEMENT PATTERN in the legs resembles the stepping pattern of a newborn baby when you hold the baby upright: the legs cross, the baby stands on the toes, and there is a lack of hip extension and weight-bearing through the whole foot.
Just like the newborn baby, children with a spastic movement pattern need to change, develop and improve the way they move.
This shifts our focus towards improvement and towards striving for normal motor ability. The child needs to learn what is missing: how to bear weight, extend the hips, externally rotate the legs, and much more.
Many current interventions do not address the actual problem — the movement pattern itself.
Botox weakens the child — it affects muscle strength. We do not want to weaken children; we want to make them stronger.
Rigid ankle-foot orthoses reduce loading and restrict joint movement. We want to increase loading and increase joint mobility.
Passively moving the legs of a child who is lying down and assessing “spasticity” tells us little about the child’s movement pattern in standing. It assesses resistance to passive movement without the influence of gravity — not what the movement pattern looks like when the child is actively moving under the influence of gravity.
If many of the interventions commonly used today were applied to typically developing children, they would impair their motor function.
We create a sense of “threat” that things may become “even worse” unless we lock the foot or weaken the muscle.
But what happens if, instead, we think about the movement pattern?
What if we aim, in every possible way, for improvement, learning and successful performance of movement — and through this, work towards normalizing the movement pattern?
If I learn the movements that I initially cannot perform, the spastic movement pattern decreases — and may even disappear.
There may still be resistance when my leg is moved passively.
But what does that matter if I can walk normally?
What I have learned from clinical practice is that walking aids can either reinforce or reduce the spastic movement pattern, depending on how they are designed and adjusted.
Just the other day, I saw a young boy who had walkers of different sizes at home and at preschool. His walking pattern was significantly better with the smaller walker. When we reduced the distance between the handles on the larger walker, his movement pattern immediately improved. It can improve even further when the child is able to walk in a fully upright position.
So, in addition to practising the movements the child cannot yet perform — such as walking backwards, standing with the feet turned outwards, and actively pushing the feet into the floor — we also need to think carefully about walking aids and how they influence the child’s movement pattern.
We also need to assess and analyse the movement pattern itself.
What movements can the child perform? To what extent? Which movements can the child not yet perform? How can I create tasks and activities that encourage those missing movements to emerge?
The earlier we start, the better.
We know how children learn to walk and gradually develop control of their movements. For children with disabilities, we should use that knowledge from the very beginning — creating appropriate tasks, opportunities for learning, and well-designed assistive devices that support the development of movement.
And we need to understand that the walking aid itself is part of the training. An assistive device is not neutral. Depending on how it is designed and adjusted, it can either reinforce the child’s spastic movement pattern or create the conditions for a more functional and more developed walking pattern.
That is why it is not enough to ask: Can the child get around using the walking aid? We also need to ask: How does the walking aid make the child move — and is that the movement we want the child to learn?
Does this way of thinking make sense to you?
