How “The Boy Who Could Run But Not Walk,” by Karen Pape changed our practice.
Karen Pape, MD, is a pioneer, rightly demanding that colleagues integrate the new science of brain plasticity as it applies to children with neurological disorders. She speaks of starting a REVOLUTION… that following a stroke up to 30 percent of adults with a first-time, mild stroke may have a complete recovery, and their outlook is improving all the time. Yet a baby with a similar stroke, with a brain injury in the same area of the brain as the adult, is expected to have the abnormal movement patterns that we associate with cerebral palsy (CP) for life. The medical profession still maintains that cerebral palsy is a permanent disorder of movement and a condition with no cure.
“It makes no sense: an adult with a mild stroke may recover completely, but a baby with a similar mild stroke will not recover and instead have a permanent disorder of movement and posture called cerebral palsy. Changing the name of a condition from stroke to cerebral palsy does not change the reality that a young, growing brain should have a better chance of full recovery than an old, deteriorating brain.”
The book was titled ‘The Boy who Could Run but not Walk,’ as she had a young patient through her neonatal unit born at twenty six weeks, she had diagnosed him with left side hemiplegia after a major bleed on the right side of his brain. Several years later she had him walk up and down the hallway to confirm that he still had the typical gait of a child with mild spastic hemiplegia. He did. Though his mother mentioned that he played soccer like a regular kid….
Then she asked him to run.
And, to her astonishment, he ran like a normal little boy, with an easy, balanced stride and reciprocal arm movements. “He performed tight pivot turns, at speed, on both legs. Even the left leg, which had a limp when he walked, performed perfectly when he was running.”
THIS SPARKED HER INTO ACTION …. When he learned to walk, his brain was still damaged, so he developed an awkward walking gait. Yet by the time he learned to run, the parts of his brain that controlled both walking and running had healed and matured. So he could run like the other boys could. He could run, but his walking was still hampered, not by brain damage but by bad habits.
This is the power and beauty of neuroplasticity, the brain’s amazing ability to change and heal.
Focused, purposeful practice of the new motor pattern is needed to change what feels like an awkward movement into a new brain-body habit. If you want to fully engage the power of the brain to alter behaviour, you have to give it something new to do. Neuroplasticity is stimulated by novel, challenging tasks. Without novelty and challenge, well-established habits always d
ominate.
Between three and six years, there’s a significant development in all children: the cerebellum comes online. The cerebellum can be thought of as a backup system for the rest of the brain. It coordinates and refines motor movements, particularly rapid, alternating movements. The child with mild to moderate cerebral palsy, who up to this point has been somewhat clumsy with poor balance, can now learn to run, jump, and climb with a very different brain from the one he was using in the first two to three years of his life. The brain has had time to recover and it is now considerably more sophisticated.
Neuroplasticity is a game changer for the rehabilitation world, and it demands a radical shift in our approach to rehabilitation and our expectations for recovery.
Her thinking at the time was ‘At least three different processes contribute to the final disability: first is the primary lesion to the nervous system, affecting the child’s ‘control’ system; the second is a disturbance of muscle and bone growth; and the third is a learned response, as the child develops abnormal movement patterns to compensate for the neural damage.’ The child in this condition, having no concept of normal movement, learns to move abnormally. In designing a treatment plan for improvement, each component—the brain damage, the spasticity and body distortion, and the maladaptive habits—needs attention and a very different therapeutic approach.’
“Practice Does Not Make Perfect. Only Perfect Practice Makes Perfect.”
—Vince Lombardi
After good body alignment is achieved, the child must practise, practise, practise. We know that abnormal movement patterns develop as the child tries to move against gravity. This is easily demonstrated. The infant may have perfectly normal four-point movements lying on her back on the floor but have increased tone as soon as she is first put into a sitting or standing position. The arms and hands tighten up automatically as she tries to balance to protect herself from falling. This is the early stage of spasticity.
“The best therapists find ways to use the out-of-gravity principle, combined with their knowledge of neuroplasticity, to develop techniques that successfully prevent or replace maladaptive habits. ”
“If I am working on walking and I see a pattern that I don’t like, I am not just going to work on walking. I am going to come up with new ways to have that body move,”
She advocates for a Universal exercise unit – “[Sometimes] I would take bungee cords and attach them to my cage at a height that is like parallel bars; only it is giving her a lot less support than parallel bars. It is only a bungee cord and it is very dynamic, so it challenges her to put the work back into her legs and learn balance. It might be similar to walking in the water. ”
“Another technique that I’ve mentioned previously is water exercise. I know of no other form of therapy that is better for all-around strengthening and improving cardiovascular fitness in children and adults with a neurologic problem. Tone increases as the child moves against gravity and it decreases when he is in a gravity-reduced environment. For toddlers and young children, water is a fun-filled play environment where they can escape from the negative pull of gravity.” Karen Pape.
At the Centre of Movement we incorporate both the Universal exercise unit and hydrotherapy using the Wet Vest into our intensive rehabilitation programs.
A Wet vest – a neutral buoyancy vest that allows children and adults to walk and jog in deep water with their heads held out of the water.
“A child with diplegia who walks on his toes with knees together on the ground gets into the water, vest on, and after an awkward start, he’ll start to move fluidly in the water, in just a few minutes.
A teen with hemiplegia will quickly discover that he has to use both arms and legs reciprocally to move forward in the water. If he relies on the old spastic pattern of depending upon the better-functioning side, he will just be able to go around in circles. Our brains love a challenge, and it always surprises me to see just how quickly the old negative feedback loop can be bypassed in the out-of-gravity environment.”
Learning how to stay upright and then move about a pool was a novel challenge that rapidly took the child “out of habit” and revealed underlying recovery. It was not unusual to have a child who walked with difficulty learn to jog in the water within minutes, moving all four limbs in a reciprocal pattern.
This book is a must have for any parents or specialists that are working with children suspected or diagnosed as having cerebral palsy or any brain related changes. Norman Doidge, MD, author of The Brain’s Way of Healing and The Brain that Changes Itself, calls it ‘compelling, engaging and essential.’
It goes on to explain of many more innovative approaches including active resistance exercises, electromyographic (EMG) biofeedback, neuromuscular electrical stimulation , training substituation, gait training, intensive therapy models, constraint induced therapy and the new standards for botox, selective posterior rhizotomy, orthopedic surgery and most importantly having a personal plan that includes muscle strengthening.
Karen Pape sadly passed away in 2018 but her incredible work continues to offer real hope for some of the world’s most vulnerable children and a better understanding of how babies brain can grow and recover.
"Alone we can do so little; together we can do so much"
– Helen Keller
