The In-Between Time
Studies demonstrate that the most common frequency of therapeutic intervention is 1x per week. This ‘frequency’ is no match for the vastness of all the ‘in between time’ a child spends outside of the intervention. This current delivery system is failing our children; true measurable change in function is not being seen because movement is not only omnipresent in development, it is literally as basic to life as breathing. Our bodies are designed to move. The child that is unable to move, spends the majority of his or her time ‘in-between’ therapy sessions not moving, standing to reason that what the child is doing with that ‘in-between time’ determines the outcome. If most of the time is doing nothing, then we develop nothing.
The emphasis of the intervention needs to shift to this ‘in-between time’. Shifting the emphasis WILL produce measurable changes. To help understand this, let’s look at the beginning of movement during infancy, this will offer a glimpse into how important this ‘in-between time’ truly is. Movement is perhaps the most ubiquitous, ever-present, universal, pervasive and fundamental of all psychological activity. Self-initiated movements of the eyes, head, limbs and body provide the largest source of infants’ perceptual experiences. By the time that infants are 12 months old, they have likely experienced over 110,000 bouts of wiggles, waves, kicks, and flaps of 47 different types of spontaneous rhythmical stereotypically movement in their legs, arms, head, and trunk (Thelen, 1979, 1981b). In sum, an infant’s everyday waking experience resembles a type of practice regimen that would be highly conducive to motor learning: massive amounts of variable and distributed practice largely free from aversive consequences for errors (Gentile, 2000; Schmidt & Lee, 1999). An infant accumulates, over the course of a normal waking day, the quantity and variety of experiences that are truly massive. Each day, a toddler will take more than 9,000 steps and travel the distance of more than 29 football fields. They will travel over nearly a dozen different indoor and outdoor surfaces varying in friction, rigidity, and texture. This self-produced locomotion organizes the emotional, cognitive, and social development. This self-produced locomotion or movement in early development represents a ‘setting of events’ for the development of other skills. That is, an infant’s new mobility greatly increases the probability of their encountering a host of other skill-enhancing experiences. Self-produced movement mediates important developmental changes for a better understanding of the development of the self.
Given that each new movement skill enhances the development of other skills, ‘milestones’ are expressed, and are seen to develop in a sequential fashion. This means that a child will need to develop some skills before he or she can develop other new skills. Children usually acquire developmental milestones or skills during a specific time frame or “window”, thus predicting when most children will learn different skills. Each milestone that a child acquires builds on the last milestone developed. Within each milestone, there is a specific set of skills that will need refinement and a tenacity of exposure second to none, before a new skill emerges, no compensation can occur within the segments of that skill, otherwise it will impact the development of any new future skill that comes. This is why the ‘in-between time’ is so important in the physically disabled child. Not only does there need to be frequent practice and exposure to movement, as we know from normal development, but the prevention of compensations within each skill is also as vitally important in the development of functional movement patterns.
Continuing with the relevance of the in-between time, the frequency and duration of intervention, we can look at a well-cited specific statistical analysis to see further evidence of the importance of this ‘in-between’ time. It is seen that the prognosis regarding ambulation is dependent on the type and the severity of the motor dysfunction. The research states that overall, children with hemiplegia will walk by 18 months to 36 months, that 80-90% of children with diplegia, and 70% of children with dyskinesia, will walk with or without an assistive device, and that 50% of children with quadriplegic may achieve some limited degree of ambulation. In Taft LT Cerebral palsy. Pediatric Review 1995; 16(11): 411-418, it is also stated that children with hemiplegia almost always develop independent ambulation, whereas a majority of those with quadriplegia do not. If you really look at what these statistics are saying, it actually demonstrates the failure of the intervention, its not the intervention that achieves the goal of walking, it is the spontaneous and independent movement during the in between time that leads to the child learning to walk (recall the immense amount of motor practice it requires for our typical children to learn to walk). Since children with hemiplegia have the highest ability to move independently and spontaneously outside of intervention, and the adult assistance is the least, they have the greatest number of compounding movements and repetitions in their day that encourages many trials and errors, resulting in a life that mimics a typical developing child. They put in the time daily that is needed to walk. In contrast, a child with quadriplegia or diplegia has less independent movement proportional to the level of involvement of the disability, with greater adult assist needed, so the statistics actually just demonstrate the fact that the intervention is not the factor creating independence, it’s the child’s self movement. Why it is so disturbing is that it has been mentioned that children with Cerebral Palsy respond to therapeutic exercise and movement in the same manner as typical peers, which lends it self also to the fact that Cerebral Palsy is non progressive and that they can train like there typical developing peers. Given these facts the result should lead to better outcomes in independence, but they don’t, and the main reason is that they do not get the movement practice needed for independent success in terms of frequency and duration.
Here is another typical scenario being played out in clinics and schools, a child with Quadriplegic Cerebral palsy, in a wheelchair, gets out of his or her wheelchair only during therapy, (typically 2 times a week for 30 minute sessions) and works on core strength to improve sitting—but then the child is placed back in the wheelchair after therapy and this work on strength will not be worked on again until the next session. The child will then spend most of his in-between time not using or practicing this newly trained muscle. This timing will never achieve the goal of independent sitting; the exposure is simply too limited and too spread out. At TMS, the same work done on core strength to improve abdominals and surrounding muscles of the trunk and pelvis will be used daily in a functional way. In other words, at TMS, we want to continue to use this new trained strength within ever increasing challenges that will lead to movement skill attainment. So instead of putting the child back in the wheelchair where its all stability, we place the child in a chair that offers support, but most importantly, gives the newly exposed and trained segment of the sitting skill ever increasing challenges to become fully incorporated in the body, and thereby coming closer to eliciting independent sitting, so the in-between time is now being used by the body working. As you can see, the next therapy session is then beginning at a higher level of work- so each time the therapy and out-of-therapy time is being used to make sure adequate time, frequency and duration is being applied to the skill in order for independence, resembling an environment proportionally equal to that of a typical developing child.
Another example of an individual who, like Temple Grandin, found that motivation, deliberate practice, frequency and duration and the in-between time were the critical factors that he attributed his success to later in life was Gregg Mozgala and his experience with dance. Mozgala, 30, recently stared in a documentary highlighting a man with cerebral palsy overcoming the accepted limitations of a neurological disorder to become a dancer despite the initial reservations of a veteran choreographer, Tamar Rogoff. Rogoff had no experience in working with a person with cerebral palsy, however, decided to take on this young man using typical tools all inspiring dancers would utilize, those of motivation, daily intensive practice, multiple repetition of body segments and movements. In an interview, Mozgala was quoted as saying:
“The work with the choreographer and the exercises we did worked different muscles, creating an urgency in the body that allowed for the underutilized and underserved muscles to be ignited. I felt the place beyond the tension and then utilized that place into the ARTS and into my everyday life”. Mozgala goes on to say that working with his choreographer was such a shift from his experience with traditional Physical therapy when he was younger. Growing up, he would have a slough of therapists (PT, OT, SP) coming to his house for at most an hour, where he would do the same battery of stretching- getting some relief from his tightness, leading to a slight improvement in his walking. Mozgala states that “the therapists would leave, and within 15 minutes due to the neurosystem of Cerebral Palsy, my brain would reset back to before my session – this reinforced the prognosis that CP would not get better. I literally was evolving through my compensation, whereas the new movements I learned from my choreographer served to de-clunk my body. With my traditional therapy, I did not have knowledge of my body’s independent parts, or control over my individual muscles outside of my very rigid patterns, I basically moved through life falling through space in one piece”. Mozgala felt, as a result of training as a dancer, that he started gaining jurisdiction over his body, he started becoming his own expert of his body, he felt that he had not put his foot on this earth until he was 30 years old, believing now that change can happens at any age, even if you have Cerebral Palsy. The choreographer is quoted saying “This really proves neuroplasticity”.
This film portrays TMS’s fundamental principles that are neither radical nor innovative, for why Mozgala made improvements in his motor capabilities and his functional abilities outside the studio. These key principles are important to understand and apply to any person or child across all domains, they are as follows: