Pediatrics and Range of Motion Exercises

Posted by Nurse Linda in Life After Paralysis on October 28, 2020 # Health

Your child's body is capable of movement and sensation. In spinal cord injury, the message to move or to feel is not being transmitted at the level of injury. If this input can be overcome, movement and sensation would be possible. Even though movement may be limited, the body still craves it. Therefore, providing movement to all parts of the body, affected by spinal cord injury or not, is critical to the health of your child.

The range of motion is the most basic exercise for the body. In this process, every joint of the body is repetitively moved in every direction that the joint normally moves. The range of motion should always be performed carefully and gently. Sometimes, when sensation is decreased, people get a bit aggressive with movement because there is little notice that you are overdoing it. This is especially true with children who may have decreased to no sensation in addition to the developmental level to notice the aggressive movement.

Before starting an exercise program for your child or adolescent, be sure to check with their healthcare provider to make sure there are no contraindications for doing so. If a child has a joint problem or undiagnosed or diagnosed deep vein thrombosis, significant healthcare issues can arise. You will also want to seek education and hands-on instruction with a therapist or nurse to understand how the joints move and how far they should be moved. Smaller children should not be moved as adults or teens.group of children

Children have slightly different range parameters than adults, especially for those under two years. The bones are still growing until the child reaches puberty, so you need to be cautious when doing a range of motion. Care should be used as you do not want to cause a fracture (breaking) or displacement of the joints or bones. You cannot use the range of your adult joints as an example of how far to extend or flex the child's joint.

If a child has the ability to move their own body, they should be taught to do a range of motion exercises, moving their body on their own where they can and moving the parts of the body that need assistance if they are able. While they are doing these movements, they should be thinking about that part of the body moving, even if someone else is doing the motions. This gives input from the brain that the body part is moving and input from the body while it is being moved. In both directions, the message is coming from the brain and from the body part to the location of the spinal cord injury. This coordination might stimulate some leap of nerve messages that could lead to nerve connections.

The range of motion should be performed gently only in the direction that the joint moves. Here is a chart of how the joints move:

Joint

Forward

Back

Sideways

Circular

Neck

Shoulder

Elbow

Wrist

Fingers

√ slightly

√ slightly

Trunk

Hip

Knee

Ankle

√ slightly

Toes

√ slightly

√ slightly

You will need education on how to move the joints, what to do if there is resistance, and how to know if a contracture is forming. Some healthcare providers will recommend putting paraffin over a sock that covers the joint to help loosen it. If this is needed, you will be directed by your healthcare professional. Most of the time, it is not necessary, so only use this technique if instructed. Otherwise, you could be over moving the joint.

Some of the joints can be moved at one time. For instance, you can move the shoulders and elbows together as with the knee and hip. Fingers and toes can be moved up and down in one movement.

Most movements can be done in bed, which might be more accommodating if someone is doing the child's movements. However, in the bed or sitting can impede the movement of some joints, such as moving the neck, shoulder, or hip toward the back because the bed is in the way. These can be accomplished by placing the child on their side rather than on their back. When the child is sitting, the movements might be more accessible, except hip movement cannot be done due to positioning. Most people find doing some exercises in bed and some in the chair to be easier, but this will be established in your own routine.

The range of motion should be done at a minimum of two times per day, with at least ten movements in each direction of every joint. You can work in a few extra sessions, such as doing the arms before meals and the legs at catheterization times. Any extra movement is a benefit.

An important warning is not to extend or move the neck back above the natural eye-line. This can cause vascular issues.

After spinal cord injury at the cervical or thoracic levels, tone (spasticity) can be an issue. Aggressive range of motion can stimulate tone in the form of a spasm. Slower, more careful ranging needs to take place. Moving body parts affected by spasticity can fatigue the muscle. This leads to less spasticity if done gently. Autonomic dysreflexia can also be stimulated with aggressive or overstretching the child's body. Check out the Reeve Foundations wallet cards for more information.

At the lumbar or sacral levels of spinal cord injury, the body is more flaccid. Often, you will see the muscles of the legs become smaller due to the lack of tone in the body. The range of motion can help at these levels of injury to supply input to the nerves and muscles of the lower extremities as well.

Moving the body has a variety of benefits. Think about when you move your body. It feels good. Even if your child has decreased sensation, the body likes the stimulation and input of movement. In other words, it still feels good to that part of the body even if it is not perceived by the individual. It can help with breathing, bowel function, reduction of urinary tract infections (UTI), stimulation of the nerves and muscles below the level of injury, reduction of spasticity and contractures, help prevent pressure injury and deep vein thrombosis (DVT) by stimulation of circulation and improve overall health. There is a great deal of benefits for relatively little work.

Performing range of motion exercises before a therapy session is also beneficial. We all know about doing warmups prior to exercising. The range of motion exercises provides this warm-up before therapy. More benefits from each therapy session can be gained if a range of motion occurs prior to therapy.

Your child may have the opportunity to participate in some advanced therapies such as functional electrical stimulation (FES), aquatic therapy, or other treatments. Some of these therapies will also provide some range of motion to the joints. Look to see how the therapy is affecting the joints. Your child may be receiving back and forth movement but not the circular range of the joint. Or perhaps the hip, knee, and ankle are moving up and down but not back in the full range of the joint. Or the toes are missed.

It is a good habit to begin a routine of range of motion at an early age or as soon as possible after the injury. This way, it becomes a natural part of the day and a natural part of life for the child. It gets the child involved with their care from the start. As soon as you think the child is ready, have them do the range of motion on their own as a part of their development. This is their body, so they will need to care for themselves in their adult life. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.