Based on the methodological recommendations on how to use the Adeli Suit alongside with other rehabilitation techniques for patients with various forms of cerebral palsy, written by Professor Oleg V. Bogdanov, director-general, Institute of Medical Rehabilitation, St Petersburg.
The load at the start of Adeli Suit treatment is minimal, to be added gradually from session to session, depending on the patient’s condition. The length of treatment is raised gradually from 25 or 30 minutes at the start of the course till 45 to 90 minutes at the end (including breaks for rest). Prior to each Adeli Suit session, each patient undergoes a round of preparations. The aim of this prior workout is to render less pronounced those posture-tone reflexes which will be handled during the Adeli Suit treatment program.
Preparations prior to Adeli Suit treatment
It is advisable to do the following at this prior stage:
When the condition is mild, all the ways needed to relax as much as possible the spastic muscles and stimulate the hypotonic muscles (including various kinds of massage, such as general massage, segmentary massage, nerve-point massage, etc., postisometric relaxation, microresonance therapy, etc.) combined with correcting drug therapy, and homeopathic and homotoxicological therapy;
When the condition is severe or nearly so, the above mentioned procedures should be supplemented with a course of micropolarization of the brain and the spinal cord and/or a course of neuropeptide arginine-vasopressin—that is, the procedures aimed, above all, to improve the functional state of the brain, normalize the cortex-to-subcortex exchange and the supraspinal effects, activate the trophic process in the nervous system and augment neuronic sprouting.
In all cases, it is advisable to undertake a course of psychological correction with a psychologist to heighten motivation and develop in the child (and in his parents) the right outlook on treatment and expected outcome.
Although passive movements are crucial in Adeli Suit workout, they should be incorporated in the exercises aimed to manage individual elements of a single motor action. They will help to develop kinetic and visual sensations of the pattern of movement in progress, retard any concomitant reactions, and stimulate the development of isolated and reciprocal movements.
Adeli Suit Therapy Sessions
The following tasks should be in view when performing the main stage of Adeli Suit rehabilitation:
- normalizing the tone of the muscles (correcting the posture-tone reflexes);
- correcting the faulty patterns of the support-and-motor apparatus (the extremities, sections of the spinal cord, and others);
- improving the mobility of the joints;
- managing the weakness (hypotrophy, atrophy) of individual groups of muscles;
- forming vestibular and antigravitational reactions and static-and-dynamic steadiness (balance and spatial orientation);
- improving muscle-and-joint sensation (kinesthesia and proprioception) and tactile sensations;
- improving the general support of the extremities and the support of their individual segments;
- developing dexterity of the arms and hands (minor motor management);
- improving the functions of the cardiovascular, respiratory and other systems.
Given infantile motor development influences greatly the development of speech, mental responses, intellect and analyzing systems and that an increased afferent flow has an activating effect on the central structures of the brain, it is important to keep watch of how speech is developing under motor management, how spatial and time perceptions are being formed and how various physical properties of materials and things are being recognized in the course of Adeli Suit treatment.
In training motor functions, it is important to keep in mind the principle of ontogenetic sequencing. The order in which movements are formed should be quite definite: starting from the head, from the upper sections of the trunk towards the lower sections and from the trunk towards the extremities. It is not at all necessary that one function should be made to work perfectly before proceeding to training another. The reason for doing so is that, even when man develops quite normally, a more complex kind of activity is usually taken over before the preceding kind becomes perfect. All kinds of activity, including standing and walking, should be trained simultaneously, and attempts should be made to model the dynamic sequence of movement development during the course. For example, the more the patient acquires the habits of sitting, standing and walking, the more attention should be paid to training equilibration and coordination.
Individual movements should not be worked out in isolation for a long time, especially if the child is unable to perform them with normal coordination. Should this be done, a pathologic pattern of movement could be firmly set in and the development of general motor activity could be delayed. It is important to avoid movements which are more likely to make pathological reflexes more active and, for that matter, make the muscles more spastic.
Rounds of correcting exercises in an Adeli Suit – I
In severe cases, Adeli Suit exercises should be started by developing the right motor pattern in lying position. During each exercise, special attention should always be paid to arresting faulty synkinesis and synergy and to the position of the head.
It is important to train first the position of the head in order to manage the erecting reactions. This is because normally movements and the upright position of the trunk are developed in the craniocaudal direction. When lying on the back, the patient should be taught to raise and turn the head. This will help, at a later stage, to learn to make turns, sit without anybody’s help, and actively interact with the surroundings. Next, the patient, when lying prone, should be taught gradually to be able to hold the head and straighten the chest section of the spine.
When tone (asymmetrical and symmetrical) reflexes appear in the neck, the position of the extremities, as determined by a change in the tone of the flexors and extensors, will also depend on a certain position of the head. To get rid of this faulty pattern, it is highly important to train the child’s ability to make isolated movements of the head and extremities without anybody’s help (by training to move the head movements while the extremities are fixed and the other way around).
When the head and the upper part of the trunk are straightened, the flexory spasticity of the hands grows lower because the tonic neck and labyrinth reflexes get retarded. By training the ability to rest on the forearms it is possible to stimulate movements in the legs, first in their proximal and later in their distal segments. Further training the ability to rest on the palms will make it possible to teach the child to stand and crawl on the hands and knees. Along with developing the supporting reaction of the hands, the righting reaction on the shoulders is stimulated and balancing reactions are trained.
Next comes restoring movements in the hip joint. Special attention should be paid to make sure that the pelvis is symmetrical and the lumbar section of the spine has moderate lordosis. Usually, functions of the thigh are found weakened, such as extension, lead, external rotation and steadiness control. Of all thigh extensors, the most afflicted is major gluteus. When it stays extended for a long time, its function as contractor suffers badly. Whenever faulty positions and flexor synergies are in evidence, thigh-extending exercises should be carried out with the leg bent at the knee joint at right angle, with the shin resting on a support or held in position. Making major and medium gluteus function better as flexors will help the trunk to stay in correct upright position. For a start, the thigh is trained to extend, bend and make external rotation before proceeding to training thigh extension.
When the muscle sense is found to show persistent disturbances, it is necessary to incorporate, at all stages of workout, some exercises aimed to restore it to normal.
Rounds of correcting exercises in an Adeli Suit – II
The further stage (or the initial stage when the disorder is mild) is sitting training. What is most important here is to learn to keep the correct posture with head, shoulders and pelvis in symmetric position. For a patient to be able to sit, balancing reaction and protective reaction of the arms must work well. In training these habits, special attention should be paid to correcting any pathologic postures, as these are most likely to make it difficult for the patient to restore the ability to sit and, besides, may lead to the development of secondary deformations and contractions. It is important that the motor habits should be trained alongside with correcting the wrong trunk and limb positionings. After the child has learnt to sit while keeping balancing control by resting on the hands, he must start training balancing reaction without hand support, and, at a later stage, go on to do so while making different movements, while being jolted, and so on.
Making free movements by the arms helps to keep the trunk steady while sitting. It will be worthwhile, therefore, to start training various manipulatory habits and fine coordinating movements as well. (It is useful to manipulate with household articles set on a rack, or pass through a labyrinth of varying complexity with a feeler, or simulate isolated movements of the index finger by tapping, and so on). To make the muscles work better and train the upper and lower extremities to perform correct consensual movements, it is essential to doze loads and monitor the pulse during Adeli Suit exercises.
After exercises aimed to make head and trunk position steadier, correct the faulty positions of the lower extremities and render the joints more flexible have been finished, it is possible to go on to standing control exercises.
It is important to train the feet to rest uniformly and take care to keep the upright posture control while maintaining balancing reactions. Special attention should be paid to training balancing reactions, because without them it would be impossible to assume a steady upright position and start walking. The correct posture is first trained while standing with a support, before proceeding to trunk turns, leg bending at hip and knee joints, straightening of the leg, performing external and internal rotations, performing various movements with one arm (with the other arm resting on a support). Next, the same movements should be practiced while standing without any help or support (but beside the support). To secure a firmer foothold, some other exercises will be useful, such as standing with no support at the center of the room, standing with the eyes closed, performing movements with the arms, head and trunk in upright standing position.
In training walking habits, the patient should be trained to:
- keep head and trunk in the correct upright position with respect to the supporting surface;
- shift the center of gravity of the upper part of the trunk on to the supporting leg;
- shift the non-supporting leg;
- set the foot in the right position at the end of the leg-shifting phase;
- able to keep on standing while resting on each of the legs in turn;
- distribute the weight of the body on both feet equally;
- control movement and rhythm.
First of all, the child should be taught to walk while being supported. At this stage of locomotion reaction development, the instructor’s hand, parallel bars, a rope, crutches or anything else may be used to assist the child. But it is important to bear in mind that, if such appliances are used too long in walking, the child may grow feared of falling. So it will pay to learn to walk without any supports. It will be better to use supports only for a short time, when changing from standing to walking. Special attention should be paid to developing the correct gait. To do this, individual elements of footstep should be worked out with care, such as shifting the load on the heel, then on the whole foot, then on the toe, and, finally, carrying over the foot itself.
After the child has learnt to walk all by himself, ambulatory skills should be improved by working out the length of footstep, walking with different rhythm, starting and stopping quickly on request, walking with turns and performing other exercises.