U-Turn Approach to Independent Sitting

ABR is a technique that addresses weaknesses within the connective tissue skeleton and brings architectural and structural  improvements to children with muscular skeletal and movement disorders. The following explanation is given in order to create a basis for understanding how these structural improvements translate to improved function.
The child cannot sit independently. What stages does she have to go through to attain independent sitting? How will we be able to mark and to notice the improvements when they start to appear?

The speed of transitions from one step to another will depend upon the severity of the child. A mildly affected child will progress through these stages in such a way that the parent may not even notice it. The parents will notice the appearance of more dynamic functions like rolling and crawling and creeping, as well as the emergence of transitions from one position to another. In the case of a more severe child, these stages will show up more gradually.

In the description given below, sitting is used as an example, but this example could equally be applied to most other movements and functional complexes as well.

What ABR demonstrates repeatedly is that, when the direct road to the achievement of independent sitting is closed for the child, one can take the U-Turn approach and still come to independent sitting.

On the other hand, if the child does not show any spine movement, if the thorax is excessively weak, and the entire body responds as one block in respect to changes in positioning – the child will not learn to sit independently, regardless of how much external training and brain stimulation the child receives.

The U-turn approach describes the functional steps that will show up along the way that lead the child to the attainment of the function of independent sitting.

Normally the problem is analyzed as follows:
If we were to put the child into a sitting position on a stool and go away the child would fall. One could say: “Well her brain is damaged and the brain is sending poor signals to the body. Therefore she cannot sit.”  One then goes on to try to train her to sit anyways –  and this is the basis of most training programs.

But this will not help the child to come further. We need to look deeper to find the elements of independent sitting that the child is missing, and then make a strategy as to how to attain them. We can see that she seems to initiate the fall  often through some kind of full body stiffening or protective reactions.  Many children appear to “throw themselves backwards”. But, if she initiates a fall she is not able to stop or to brake the fall. Movement in the healthy person is not only constituted of the ability to initiate a movement, but a controlled movement is also made up of the ability to stop or brake the movements in any and every position and at any and (almost) every acceleration.

Initially, if the child starts to fall, she will do this with the accelerated fall. She does not have a simple fall that follows the gravitational pull, but will fall with an increasing velocity. This is due to the fact that when we put her into a sitting position we do this against inherent bodily resistance. This resistance is a result of a combination of factors such as backline spasticity and fascial shortening  – which are brought into an elongated tension when she is put in sitting position. As soon as the external support is taken away, the tightness along her back re-contracts and returns to the neutral position, making the velocity of her fall accelerate. We can observe the “snap back” reactions.

At the same time the child has not been able to “index” the variety of positions which a healthy person has in respect to the sitting position.  This huge variety is an  “unknown unknown” for the child.  The bottom of the child cannot grip the surface she is sitting upon and then the entire body goes into a protective reaction.  When the full body stiffening occurs, the child shoots.

When she does this, she is simply unable to brake the fall.

1. If we want her to improve we need help her to go through several phases.
   The first thing that needs to happen is that she can begin to fall with a simple, floppy and loose fall. This will appear when spasticity and fascial tightness in the trunk begins to release and is – never the less – a result of connective tissue strengthening and remodeling. This is a deep and important improvement, but not necessarily yet a functional improvement.  The parent may not even notice when the child goes through this stage.
2. The next step is that she will be able to begin to slow down the fall. She may not yet have achieved the strength needed to brake the fall entirely, but if we – for example – initiate a change of position, the child will begin to show us that she is trying to slow down the fall.
3. Thereafter the child will move on to having control of the fall in some positions, but not yet in all of them. The child still cannot really sit alone, but if we change the sitting position, the child will not helplessly go into the falling mode, but will be able to stop the fall at some of the positions between being upright and being completely horizontal.
4. After arriving at this stage, the next really big step is when the child begins to perform the counter balancing movements. A counter balancing movement is a movement that balances out another bodily movement in order to avoid distortion of the body or the loss of balance. We make the stages of counter balancing development visible by initiating a movement through the utilization of one segment – for example the head or the upper trunk or pelvis for this. If the child can start to return part of the body towards the initial position whilst another bodily segment stays or still moves in the counter direction, then the counter balancing movements are starting to appear. In effect all of our changes of positioning and especially walking involve a highly developed complex of counter balancing movements. With respect to a child who has not yet attained free and independent sitting, the achievement of some counter balancing movements show us that the child is getting close to being able to sit without support.  Often at this stage the child can begin to sit alone or with support on his or her arms when placed in the sitting position.

On the way to achieving the counter balancing movements, the child will of course have improved significantly in respect to trunk strength and stability, pelvis positioning, the strength and mobility of the vertebral column as well as to increasing bodily segmentation. The child will begin to show mobility in the upper body that is independent of the movements of the extremities, i.e. arms and legs. The head will have to become independently mobile with respect to the trunk, and the thorax needs to be independently mobile in respect to the abdomen, etc.

In this way one can understand how the ability to perform segmented movements of bodily parts in respect to each other is essential for the attainment of independent sitting.  As long as the different segments – be it head, neck, chest, abdomen, arms or legs – are all fused together as one movement unit, then the possibility for both “braking” a movement and also for the counter balancing movements are not available to the child.

In order to summarize one can say that the child will go through the stages of:

1. A simple and loose fall
2. Slowing down of the initiated fall
3. Stopping an initiated fall
4. Counter balancing movements
5. Maintaining the sitting position for shorter or more extended periods –  on the way to the attainment of a free and independent sitting.

This describes the “U-Turn” approach that is possible to achieve through ABR work in conditions where the progress has otherwise shown to be impossible.

 

Diane Vincentz
Director
ABR Denmark Aps