pediatric rehabilitation

Pediatric Rehabilitation

Asmaun Nadjamuddin, md

Physical and rehabilitation medicine, fkuh-rsws

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Introduction PR

Motor development during early childhood

Development of Postural Control

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Postural Adjustments are Anticipatory…

Postural Adjustments are Task and…

CEREBRAL PALSY

Etiology

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Pathology

Classification

Different to Spastic,Rigidity,Athetoid

HYPOTONIC CP

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SPASTIC CP

ATHETOID CP

ATAXIC CP

Medical Treatment

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Rehabilitation Management

Surgical

Complications..


PEDIATRIC REHABILITATION

IntroductionSome of the more frequently encountered disabling conditions of childhood are :• Cerebral palsy• Muscural dystrophy• Spina bifida• Developmental delays• Hypotonia

Keep in mind the following aspect of rehabilitation that are unique to treating children.

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Introduction PRDo not treat children as trough they are little adults ; • It is the job of parents in society to help children, including

those with handicaps, grow into mature adults capable of independents living.

• This responsibility should be shared by the health professional concerned with their care.

Because children are largely products environment ;• Educate parents about would constitute therapeutic

environment for their children.Rehabilitation of children, in contrast to that of adults ;• Often does not mean relearning low skills, but rather,

learning appropriate motor and social skills for their age or• Developmental level under adverse conditions.

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Knowledge of normal motor learning, growth, and development is essential for the

therapeutic intervention in the growing child• Understanding the emotional needs of the child at various

ages is equally important.Treatment must take into consideration decelerated bone

growth in weakenedextremities, compared to the strong stimulus for bone growth

in extremities with normalmuscle activity.

Introduction PR

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Development of postural control :• Bobath ( 1964 ) response aspects of postural adjustment

used for evaluating child• Reflexes are part of assessment but role in MD not

known • Woollacott (1986) Role of postural control ignored• Perin (1989) Emphasis on treatment as being moved by

the therapist

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BALANCE– Needed:

• Set segmental alignment before limb is moved voluntary• Respond to movement of surface in which we are• Withstand displacement by some outside force

– Both internal and external forces• new findings

– Postural adjustments are anticipatory and preparatory– Postural adjustments are task and context specific– Vision has a propioceptive role in postural control

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Development of postural control :

• Gahery and Massion (1981) areas of the brain that control voluntary movement also activate postural adjustement

• Treatment = self initiated movements made by the infant and not postural adjustaments in response to movements imposed on the infant by therapist

• Postural adjustments vary ( task, enviroment, individual )


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Postural Adjustments are Anticipatory and Preparatory

• Shepherd ( 1994 ) Lower limb postural muscles activated before prime mover arm

• Bouisset and Zattara (1981) activation associated with joint rotation and changes in centre of pressure

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Postural Adjustments are Task and Context Specific

• Cordo and Nasher (1982) muscles can vary their main function, from stabilizing to active movement

Nashner and Woollacott (1979) distal to proximal activation

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CEREBRAL PALSY

• Non-progresive group of brain disorders resulting from a lesion on development in fetal life or early infancy

• Pathological CNS mechanisms not progressive but clinical features do appear to change as infant grows older, due to infant experiences

• Abnormal movements due to– Motor control deficits– Cognitive abilities– Enviroment where movement takes place

• Experiences direct maturational changes in nervous system, so position and movements practiced are important

• CP child need multidisciplinary team: neuroly, psycology, social work, PT, speech therapy, education, OT, orthotics...

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Etiology• Have changed through time• More frequent disease in undeveloped countries,

but prevalence hasn´t cut down due to improvements in obstetric management and perinatal cares (low prematures survivance)

• Classification according to periods– PRENATAL

• Mother infections in the first gestational trimester• Circulatory ( anoxia, anemia, hypertension) • Metabolism (diabetes mellitus, fenilketonuria)• Rh incompatibility• X-Rays exposure• Premature periventricular leukomalacia related to spastic

diplegia (Kitchen 1987)

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Etiology

• NATAL AND PERINATAL

Incidence in this period is dropping– Intrapartum asphyxia

• POSTNATAL PERIOD– Infections (mengitis, sepsia)– Intoxications– traumatism

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Pathology

• Haemorrhagic lesions– More common in premature infants, less 32 weeks– Origen at thalamic groove

• Hypoxic ischaemic lesions – Select neuronal necrosis– Focal or multifocal ischaemic lesions– Intracranial haemorrhage– Hyperbilirubinaemia

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Classification

Bobath, 1976

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Classification

• SPASTIC showing characteristics of UMN involvement• ATHETOID showing signs of extrapyramidal

involvement, with involuntary movements, dystonia, ataxia and sometimes rigidity

• HYPOTONIC severe depresion of motor function and weakness

• ATAXIC cerebelar involvement, ataxia• MIXED

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HYPOTONIC CP

• Often transient to spasticity or athetosis(dystonics attacks)

• Evidencied:– Floppiness when picked up– Inability to generate muscle force to move body against gravity

• Differencial diagnosis: Tay-Sachs, Werdnigg-Hoffmann, premature infants and Down syndrome

• Examiner can produce some activity, but child has little spontaneuous movement ( even respiratory)

• Possition decubit: arms and legs ABD, ER and F

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HYPOTONIC CP

• Pull to sit: head lag

• Prone protective side turning of head absent

• Sitting/standing will colapsed• No kicking nor effective cough• Dificulty eating and drinking due to

muscle weakness

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SPASTIC CP

• Resistance to passive movement and abnormal patterns not evident in young infants

• Tone increases as infant develops ( Bobath 1975)• 2 groups

– Initial hypotonus• Spasticity due to effects adaptive neural and mechanical events that

reflects organization of CNS and MSS• Hypertonus result of

– Structural changes on muscle and soft tissues– Neural recovery process at spinal level

– Dystonia for severe extensive brain dysfunction afecting cortex and spinal cord

• Little ability to move in any position (changing influated by tonic reflexes), resistance to passive movement

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SPASTIC CP• Spasticity =

– Hyperreflexia– Changes in muscle structure

and function– Abnormal muscle activity by

change of position• Major barrier to development is

negative features• Abnormal patterns of movement:

– flexion upper limb at elbow, wrist and fingers, shoulder IR & ADD

– Extended lower limb: IR&ADD hip, plantiflex and inversion ankle

– Trunk for intersegmental attachment of limbs muscles: latissimus dorsi


SPASTIC CP

• Associated movements in response to stimuli

• Behavioural adaptations

• Contractures skeletal deformity

• Main problem= inhability to activate muscles and control muscle force to produce intentional movement


ATHETOID CP

• Choreiform movements, dystonic posture• Involuntary movement both rest and volitional move• Infants typically trunk and head extension• Strategies for dealing w motor dyscontrol• Control of head position slow to develop=

vision=reaching• Grimacing face= breathing and swallowing• Joints hypermobile• Hip and jaw dyslocation• Scoliosis due to muscle imbalance

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• Uncommon in CP, associated with hydrocephalus, head injury, encephalitis or cerebral tumor

• Dificulty with movement: rate, range, direction and force• Amplitude and velocity no functional actions (reaching)• Uncoodinated wide base locomotion ( no balance) so

use hands• Lack of braking joint dislplacements = overshoot

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• Movement dysfuncion– Impaired motor control– Minimal brain dysfunction: clumsiness

• Reaching and manipulation• Floor-sitting

– Diplegia

• Sitting on a chair– IR and flexed hips


• Sit to stand


Medical Treatment• Baclofen

– Antispastic agent– Reduces hyperactive of

• Mono- and polynaptic stretch reflex• Arachnoyd space• Lessens involuntary spasm and spasticity ( Cambell 1995)

• Botulinic Toxine– Inhibit presinaptic release of Ach in neuromuscular space– 1-4 months– In muscles

• Prone to contractures• Spasticity interfers in its function

– Triceps, hamstrings, hip flexors and ADD– Co-adjunment to PT

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• Birth to Three Years of Age– For the nurmal child, this is the age period when

intense motor learning and basic language development occur.

– Accordingly, this is the time that intervention by physical therapy, and / or speech therapy can be most beneficial in promoting the development of normal motor patterns (gross, fine, and oral), and perhaps inhibiting abnormal patterns.

– With a good program of early intervention, surgeryis rarely necessary in this age group.

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• Three to Seven Years of Age– Brancing rarely is required before 3 years of age,

unless the child is standing or ambulating with severe leg, ankle, or foot deformity.

– Bracing is used to augment weak muscles and oppose strong muscles, thus preventing deforming forces on bones and joints.

– For severe adductor spasticity causing scissoring during ambulation, long leg braces with a pelvic band.

– It functional ambulation without or with minimal bracing has not been achieved by 5 to 7 years ago, refer the child to orthopedic for surgical release.



• Eight Years of Age to Adulthood– Physical therapy should be limited to a

maintenance program for preventing contractures and deformity and promotion independence at the wheelchair level.

– Occupational therapy may still be necessary to enable the child to rich an optimal level of independence in activities of daily living in accordance with abilities and limitations.

– If speech has not developed by age 8, further speech therapy is probably not indicated



Surgical

Selective Posterior Rhizotomy :

• This is a surgical procedure that reduces excessive muscle tone in spastic cerebral palsy.

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• The obvious Motor dysfunction

• Mental retardation

• Speech and language problem

• Visual problem

• Diminished hearing

• Dental problems

Complications

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pediatric rehabilitation

Documents

rehabilitation of children

therapistmotor development

propioceptive role

rehabilitation medicine

little adults

adverse conditions

appropriate motor

social skills