Center IMT - Integrative Manual Therapy and Diagnostics

Sitting Postural, Balance, and Endurance Improvements using Integrative Manual Therapy with a Patient Diagnosed with Athetoid Cerebral Palsy, Brainstem Stroke, and Cervical Subluxation/Fusion

Author: Susan J. Leger PT

Abstract: A 45-year-old male diagnosed soon after birth with Athetoid Cerebral Palsy. She was further diagnosed at age 43 with a brainstem infarct with left hemiparesis, and at age 44 with cervical subluxation with right-sided pain, atrophy, and joint dislocations, was status post cervical fusion. He sat independently, without support, with improved posture, balance, and endurance, following 4 hours of Integrative Manual Therapy (IMT).

Key Words:

Pictures demonstrate the significant postural changes from the beginning of the session, after 2 hours, and after 4 hours.

History: This man was referred at 44 years of age, by the out patient physical therapy director at Sheppard Spinal Center (Atlanta, Georgia), where he had been extensively hospitalized for surgical fusion of the 2nd through the 7th cervical vertebra, with bone grafts, plus anterior and posterior metal bar fixation. His life history of severe cerebral palsy with athetosis, more recent left hemiparesis from a brainstem stroke, then right-sided pain, atrophy, and joint dislocations, significantly complicated rehabilitation. The patient wore a halo brace then a rigid cervical collar, and had full, very painful, dislocation of his right shoulder and right knee joints when beginning his treatment sessions one year ago.

Evaluation: The patient was without speech and was hard of hearing, however, he was able to understand and follow simple and even some complex commands. Integrative Manual Therapy (IMT) combined with Neurodevelopmental Treatment (NDT) four hours every other week progressed this patient to this day’s status. At the start of this four-hour IMT/NDT session, the patient was wheeled in by his hired caretaker. He locked his wheelchair independently using lock extensions and his left hand. He transferred to a hi/lo treatment table, set at wheelchair height, with minimal assist primarily using his left arm and leg. He has assisted to as upright a sitting posture as possible for the picture to be taken (Picture A). Eight attempts were taken to take a picture without some one else’s assistance needed in some way. The patient could not maintain sitting independently for more than a few seconds requiring the picture to be taken quickly. His independent sitting posture was with full spinal flexion forward, no head or eye righting. He was also strongly pulled to the left, with associated balance reactions of extremities noted. He did not approximate his feet to the floor, but instead strongly adducted his legs and drew his feet off the ground. Note the picture (Picture A) at the beginning of the session.

1^st Treatment: Treatment for the first two hours focused on the restriction of his aorta, esophogus, and vagus nerves. Techniques proceeded as follows: thoracic and abdominal cavity Jones Strain and Counterstrain techniques, time limited (1); Respiratory Abdominal Diaphragm Compression Syndromes, time limited, (2); Advanced Neural Tissue Tension Techniques, time limited, (3); Disruption of Membrane technique and Resistance Therapy to Immune Deficiency Motility (2,4); and functional integration of pelvic base and thoracic cage balance (5,6) on a gymnastic ball.

1^st Treatment Outcome: Sitting following the first two hours of treatment was significantly improved (Picture B). He sat with less spinal flexion, posturing taller, with head and eye righting. Lower extremity associated reactions were less, however, he was still unable to approximate his feet into the ground. The left cervical and upper thoracic protective muscle spasm was quite prominent as noted in this interim picture. This picture was easily taken. He could sit independently as shown in the picture for two minutes.

2^nd Treatment: Treatment for the final two hours focused on the restriction of his left cervical vessels. Techniques proceeded as follows: left cervical Jones Strain and Counterstrain techniques, time limited (1); thoracic inlet Diaphragm Compression Syndromes, time limited, (2); Disruption of Membrane technique and Resistance Therapy to Immune Deficiency Motility (2,4); Healing Protocol (7,8); and functional integration of pelvic base, thoracic cage, shoulder girdle, and head balance (5,6) on a gymnastic ball.

2^nd Treatment Outcome: Sitting following the last two hours of treatment was again, significantly improved (Picture C). He sat with improved spinal extension, posturing taller, with head and eye righting. Lower extremity associated reactions were significantly less; he was able to approximate his feet into the ground. The left cervical and upper thoracic protective muscle spasm was no longer prominent, with only left cervical rotation remaining. The final picture was taken without concern of assistance being required. He could sit independently as shown in the picture for five minutes. After five minutes the patient began fatiguing, flexing his spine slightly to the left and lifting his feet off the floor again (similar to the interim picture).

Discussion: The patient’s sitting posture, balance, and endurance has been monitored over two months following the final session, and it has only improved. He never returned to sitting as represented in the initial picture. It is evident that the four hour program made a significant impact on this client’s level of sitting function. The IMT was coupled with the functional progression of NDT. I believe the imperative diagnostics for this client was the restriction of the cervical, thoracic, and abdominal vessels and the protections surrounding them. The focus on treating the break downs of Self leading to the need for these protections was essential for allowing the changes to occur.

I feel the full year of IMT/NDT prior to this session prepared a readiness state for changes to occur. Family support and home intervention was nonexistent, except for the hiring of a caregiver to bring him to and from therapy. Therefore, the family did not play a significant part in the improvement this patient gained. I also feel the therapy time in blocks of four hours, allowed for a flow of treatment from IMT, into functional therapy, which contributed to the success attained.

References

3. Weiselfish-Giammatteo, S. © 199?. Advanced Assessment and Treatment of Neural Tissue Tension Techniques. Bloomfield, CT: Dialogues in Contemporary Rehabilitation