Activity-Based Therapy in Pediatrics
Improvement in the neuromuscular system is the aim of Activity-Based Therapy (ABT). The goal is to improve and stimulate plasticity in the nervous system. Neuroplasticity is the nervous system’s ability to heal itself. The process has been more successful in the pediatric population, most likely due to growth and development where activity-based therapies not only help regeneration but in pediatrics, generation of the nervous system. Creating motor and sensory function is needed for improvement.
Activity-based therapy has been used in pediatrics with diagnoses such as spinal cord injury from trauma or disease, cerebral palsy, transverse myelitis, acute flaccid myelitis, tumors of the spine and other neurological issues. It has also been used as therapy for specific health issues such as to improve respiration or breathing ability.
Activity-Based Therapy is an alteration in the process of traditional therapy. Historically, children with spinal cord injury from any cause are taught to overcompensate movement by replacing function with parts of the body that have power for those body parts that are not functioning well. This concept is flipped in ABT with therapies that stimulate function in the less active parts of the body. The issues of requiring joints to do activity for which they are not constructed (compensation) is altered to stimulation of the body to conduct the tasks it was designed to do. The classic example is transferring the body to a different location by use of the arms for which the joints and muscular structure is not designed for the load. Instead, stimulation to the lower body is designed to allow neuroplasticity to restructure so the legs can lift and propel the body (activity).
Repetition of activity below the level of spinal cord injury is the key to ABT. The area of the body below the level of injury is still capable of function, however, messages for movement and sensation cannot progress beyond the spinal cord lesion area. Therefore, continuous repetitive movement and sensation is supplied, often with electrical stimulation.
Four principles of locomotor training have been outlined by Howland, et al., 2016 (p. 404). These include maximization of load bearing by the lower extremities while decreasing load bearing in the upper extremities, optimization of sensory cues for walking, optimization of kinematics for trunk, pelvis and extremities, and maximization of recovery strategies while minimizing compensatory strategies.
Treatment Strategies used in Activity-Based Therapy
Therapies used in ABR encourage use and inclusion of affected body areas. Naturally, this does not mean that children are thrust into activities that they are not prepared to do. Therapies begin where the child is functioning. Some of the specific strategies are:
- Strengthening exercises to promote stabilization of joints.
- Movement with elastic bands to help build muscles and to strengthen limited movements.
- Positioning strategies to allow functional movement and reduce restriction. This may include new seating, reduced use of restraints for positioning of head, body, and limbs. Use of the SATCo can help devise some positioning guides.
- Load bearing coordinated movements gradually building motion.
Aquatic Therapy which uses the buoyancy of water to reduce gravity restrictions which can enhance small movements. Once a small movement is found, therapies to enhance the function and transition it to land are implemented.
Electrical stimulation to supply function to nerves and muscles below the level of injury. This can be used as with functional electrical stimulation applied for bicycling to produce repetition in the lower body.
Constraint-induced therapy may be a strategy if the body has differing levels of function on each side of the body. In this case, the more functional side of the body is constrained to make the less functional side improve.
Locomotor training using challenged practice and weight bearing. Weight supported walking with or without leg assist, on a treadmill, around the gym, or outdoors depending on the level of function of the child. Much of the principles of ABT focus on the use of locomotion training as it captures the repetition principle of the lower limbs.
There are many studies of locomotor training, however, two are highlighted here as examples of the research documenting success of the therapy. There are additional studies as well.
Locomotor training demonstrated improved trunk and neuromotor capacity regardless of age or chronicity in 26 children with spinal cord injury, average age of 5. Assessments were measured by use of the Pediatric Neuromuscular Recovery Scale (NRS) scale and the Segmental Assessment of Trunk Control (SATCo). Incidentally, parents reported transfer of abilities into the community setting with improved quality of life (Berman, et al., 2019).
In a systematic review of published research of locomotor training in children aged 1- 17 years, gains were found with therapy including walking capacity, speed, and distance. An increase in the number of therapy sessions improved outcomes (Gahandi, et al., 2017).
Assessment of Activity-Based Therapy
With a new and novel concept of providing restorative treatment to individuals with spinal cord injury, a new assessment instrument was developed called the Neuromuscular Recovery Scale (NRS), 2009. As opposed to other previously developed functional assessment instruments, the NRS assesses function without use of compensatory actions. Test-retest reliability of the instrument in adults is Spearman correlation coefficients of 0.92-0.99. Interrater reliability is Kendal coefficient of concordance ≥0.90. (Basso, et al, 2015). A pediatric version of the NRS was translated from the adult version. Titled the Pediatric Neuromuscular Recovery Scale Peds NRS was developed, reviewed by Delphi technique and is currently under analysis for psychometric effectiveness.
Outcomes
Outcomes have been greatest in the pediatric population. Across all age groups, individuals with incomplete injury (ASIA Impairment Scale [AIS] C and D) have demonstrated the most improvement. Individuals with AIS classifications of A and B have demonstrated changes but have yet to achieve independent functional walking.
It should be noted that all pediatric rehabilitation centers do not offer Activity-Based Therapy. Most offer traditional therapies, however, as ABR becomes more mainstream, more treatment centers are providing it. Some recommend traditional rehabilitation followed by ABT in a specialty center although combining both traditional and ABT at the same time is possible. There is some time needed to educate healthcare professionals about the theories and techniques. More Activity-Based Therapy strategies and techniques will become mainstream as healthcare makes the shift in philosophy from compensation therapy to neuroplasticity-focused treatments.
Written by Linda M. Schultz, PhD, CRRN.
References
Argetsinger, L.C., Singh, G., Bickel, S.G. et al. Spinal Cord Injury in Infancy: Activity-Based Therapy Impact on Health, Function, and Quality of Life in Chronic Injury. Spinal Cord Ser Cases 6, 13 (2020). https://doi.org/10.1038/s41394-020-0261-1
Basso DM, Velozo C, Lorenz D, Suter S, Behrman AL. Interrater Reliability of the Neuromuscular Recovery Scale for Spinal Cord Injury. Arch Phys Med Rehabil. 2015 Aug; 96(8):1397–403. Epub 2014 Dec 27. DOI: 10.1016/j.apmr.2014.11.026 [PubMed: 25546720]
Behrman AL, Ardolino EM, Harkema SJ. Activity-Based Therapy: From Basic Science to Clinical Application for Recovery After Spinal Cord Injury. J Neurol Phys Ther. 2017;41 Suppl 3(Suppl 3 IV STEP Spec Iss): S39-S45. doi:10.1097/NPT.0000000000000184
Butler PB, Saavedra S, Sofranc M, Jarvis S, Woollacott M. Refinement, Reliability, and Validity of the Segmental Assessment of Trunk Control. Pediatr Phys Ther. 2010 Fall;22(3):246–57. DOI: 10.1097/PEP.0b013e3181e69490 [PubMed: 20699770]
Gandhi P, Chan K, Verrier MC, Pakosh M, Musselman KE. Training to Improve Walking after Pediatric Spinal Cord Injury: A Systematic Review of Parameters and Walking Outcomes. J Neurotrauma. 2017 May 1;34(9):1713-1725. doi: 10.1089/neu.2016.4501. Epub 2017 Jan 13. PMID: 27869534.
Howland DR, Behrman AL, Thompson JE, (Eds. Vogel LC, Zebracki K, Betz R, Mulcahey MJ). Activity-Based Rehabilitation in Young Children with Severe Spinal Cord Injuries: From Science to Clinical Practice, American Academy for Cerebral Palsy and Developmental Medicine, 70th Annual Meeting, 2014 Mac Keith Press, London. https://www.aacpdm.org/UserFiles/file/IC1-Behrman.pdf
