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Pediatric Rehabilitation

Asmaun Nadjamuddin, md Physical and rehabilitation medicine, fkuh-rsws

Pediatric Rehabilitation
Pediatric Rehabilitation Introduction PR Motor development during early childhood Development of Postural Control Postural Adjustments are Anticipatory

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Pediatric Rehabilitation
Postural Adjustments are Task and CEREBRAL PALSY Etiology Pathology Classification

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Pediatric Rehabilitation
Different to Spastic,Rigidity,Athetoid HYPOTONIC CP SPASTIC CP ATHETOID CP ATAXIC CP

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Pediatric Rehabilitation
Medical Treatment Rehabilitation Management Surgical Complications..

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PEDIATRIC REHABILITATION

Introduction
Some 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.
Pediatric Rehabilitation

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Introduction PR
Do 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.

Introduction PR

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Introduction PR
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 weakened extremities, compared to the strong stimulus for bone growth in extremities with normal muscle 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

Motor development during early chilhood

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Development of Postural Control

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

Development of postural control

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Development of Postural Control

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 )

Development of postural control

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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

Postural Adjustments are anticipatory and

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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

Postural adjustments are task and context

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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...

Cerebral palsy

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Etiology
Have changed through time More frequent disease in undeveloped countries, but prevalence hasnt 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)

Etiology

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Etiology
NATAL AND PERINATAL Incidence in this period is dropping Intrapartum asphyxia POSTNATAL PERIOD Infections (mengitis, sepsia) Intoxications traumatism

etiology

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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

pathology

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Classification
Bobath, 1976

classification

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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

Classification

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Different to specific,, rigidity,, athetoid

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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

Hypotonic cp

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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
Hypotonic cp

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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

Spastic cp

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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

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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
Spastic cp

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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

Athetoid cp

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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

Ataxic cp

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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

Ataxic cp

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Sit to stand

Ataxic cp

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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

Medical treatment

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Rehabilitation Management
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.

Rehabilitation management

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 Three to Seven Years of Age

Rehabilitation Management

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.
Rehabilitation management

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 Eight Years of Age to Adulthood

Rehabilitation Management

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
Rehabilitation management

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Surgical
Selective Posterior Rhizotomy : This is a surgical procedure that reduces excessive muscle tone in spastic cerebral palsy.

Surgical

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Complications
The obvious Motor dysfunction Mental retardation Speech and language problem Visual problem Diminished hearing Dental problems

Medical treatment

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