I. Overview of early rehabilitation intervention
In recent years, with the improvement of obstetric technology, perinatal health care medicine and neonatal emergency medicine, neonatal mortality rate and stillbirth rate have gradually decreased, and the survival of high-risk infants such as preterm infants, very low weight infants and perinatal critical illnesses has increased, while the occurrence of adverse consequences has also increased, especially various degrees of neurological developmental disorders, such as cerebral palsy, epilepsy, mental retardation, visual and hearing impairment, etc. The incidence of cerebral palsy decreases with gestational age. The incidence of cerebral palsy increases with gestational age, and the younger the gestational age, the higher the incidence of cerebral palsy; the lower the birth weight, the higher the incidence, and the younger the gestational age (SGA) among preterm infants, the higher the incidence of cerebral palsy than that of the appropriate gestational age. In the United States, morbidity and mortality due to prematurity is a major perinatal problem, accounting for 6-9% of infants born at less than 37 weeks of gestation, but 70% of all perinatal deaths and 50% of all neurological disorders.
Because high-risk infants can lead to severe neurological sequelae, monitoring and early intervention for high-risk infants is particularly important to prevent and mitigate neurological sequelae. In the case of cerebral palsy, for example, the principles are early detection, early diagnosis, and early treatment. Early detection is to provide necessary education to parents of infants and toddlers with birth risk factors, popularize their knowledge of high-risk infants, and conduct corresponding developmental examinations along with regular medical checkups at the pediatric insurance to monitor whether their developmental indicators are within the normal developmental range; early diagnosis refers to the diagnosis of cerebral palsy in infants aged 3 to 9 months, among which the diagnosis between 0 and 3 months is also called ultra-early diagnosis; early intervention refers to the diagnosis of high risk infants whose development deviates from Early intervention refers to the organized, purposeful and comprehensive rehabilitation activities for at-risk infants whose development deviates from normal or may deviate from normal. Early intervention generally refers to treatment within 6 months after birth, and treatment within 3 months is also called ultra-early treatment.
II. Screening of high-risk infants
1. Abnormalities in pregnancy, delivery and neonatal period
Japanese obstetricians, gynecologists and pediatricians consider the following 8 perinatal high-risk films and videos to be the most important.
①Multiple births.
(2) Breech birth position.
③Neonatal asphyxia.
④Abnormal jaundice (serum bilirubin value of 15-20 mg/dl or more).
⑤ respiratory distress, especially apnea attacks.
⑥Spasms.
⑦Lack of nursing power.
⑧Moro reflex (hug reflex) deficiency. Infants with the above high-risk factors should be strictly observed for changes in their developmental course and clinical symptoms. These are also important bases for early diagnosis of cerebral palsy.
2. Developmental delay
The possibility of abnormalities should be noted when the development of the suckling child lags behind the level of the corresponding month of age, such as inability to support the elbow at 3 months, inability to hold the neck upright, indifference to the surroundings, delayed response to teasing, and not reaching out to grasp objects at 5 months.
3. Abnormalities in posture and movement
When the body and limbs are soft or hard, and the activity is clumsy and suspicious compared with normal children of the same age, neurological and developmental examinations should be conducted promptly, and CT and EEG of the head should be performed if necessary.
III. Key points of early clinical observation
In clinical practice, we often see pediatricians, pediatricians (neurologists) or rehabilitation workers telling parents of children with abnormalities at birth that their children have high muscle tone and need early rehabilitation treatment. The term “hypertonia” has caused many normal and developmentally delayed children within six months to undergo unnecessary and excessive treatment that may cause unnecessary harm to the child. One reason for this is the early use of muscle tone to determine if a child is abnormal; another, more important reason is the use of normal primitive reflexes as high muscle tone. This has caused many children 0-6 months to be misdiagnosed and over-treated. To observe whether a child aged 0~6 months has abnormalities, one should not observe from the perspective of muscle tone, but from the aspect of movement, and the main points of observation are as follows.
1. Amount of voluntary movement
Children with abnormalities generally have less voluntary movements and are quieter; normal children have more voluntary movements, like to move, and their arms and legs keep moving.
2, the alternating nature of the movement
Children with abnormalities have few or no alternating movements; normal children often have alternating movements, and the movements are powerful, with hands and feet constantly alternating back and forth.
3. Pay attention to the distinction between postural tension and primitive reflex
Children with postural tension (slowly developing into hypertonia) have few alternating movements and rigid movements, often moving both hands or feet at the same time (common movement), and often have excessive head and trunk extension and flexion due to the influence of ATNR (asymmetrical tense neck reflex) and tense vagal reflex; normal children are influenced by primitive reflexes, and the movements appear to be hypertonic (tense). If we pay attention, we will find that the movements are alternating and coordinated, and the movements are soft, and the ATNR (asymmetrical tense neck reflex) and tense labyrinth reflex are not obvious.
4. Eye dexterity
Children with abnormalities have dull eyes and lack of flexibility, while normal children have flexible eyes, have a bright vision and like to look around.
Correct understanding of “early treatment” in the principle of “early detection, early diagnosis and early treatment
We often have the following misconceptions about the understanding of “early treatment”.
Misconception 1: Children with cerebral palsy (cognitive impairment) can be nipped in the bud through early rehabilitation intervention, and can be restored to normal.
Early rehabilitation intervention cannot make children with cerebral palsy (cognitive impairment) return to normal. Children with cerebral palsy (cognitive impairment) cannot eliminate abnormalities such as postural abnormalities, motor impairment and cognitive impairment no matter what kind of treatment and intervention.
Myth 2: The more treatment programs done in early rehabilitation intervention, the better the child will recover faster.
Early childhood is delicate, so if too many treatment programs are done, the child will not get a good recuperation, which is not conducive to the development of the child’s brain and body. Treatment should be targeted, many treatment programs are ineffective for children, and incorrect methods of motor training will not work for children, early rehabilitation to induce active motor training. Early rehabilitation is not the prime age for children to recover (the prime age is 1-3 years old). Too much treatment in the early stage may drain the family’s financial resources, and when the child really needs rehabilitation, the family no longer has the financial resources to support.
V. Principles of early rehabilitation intervention
1. Step by step, in accordance with the law of early childhood development
2. 0~3 months of age, feeding, induction of automatic movement, and head lifting training are the main focus.
3.4~6 months to promote spinal gyration, coordination of movement and turning over mainly.
4.Supplemented by segmental massage and traditional pediatric tuina
Sixth, motor rehabilitation intervention considerations
Chinese medicine calls children “infantile Yin and Yang body”, which actually means that the child’s body is young and immature. Therefore, we must protect the child during training to avoid injury.
1, careful to use passive expansion of joint mobility training, so as not to cause joint damage.
2.Be careful with pulling to avoid muscle strain.
3.Be careful to use heavy techniques when pushing to avoid muscle
and periosteum damage, or even fracture.
VII. Learning of some training hand techniques
Inducing active stretching of the lower limbs
With the child in supine position, the lower extremity is flexed (hip flexion, knee flexion, ankle flexion) and slightly abducted and externally rotated, and the operator quickly stimulates the thickened muscles above the medial patella (red circle in the figure) with the fingertips to produce an autonomous stretching movement of the lower extremity (figure below).
Induction of active extension of the upper extremity manual technique
With the child in supine position and the elbow joint flexed at 90 degrees, the operator holds the wrist with one hand (the operator’s index finger is passed through the child’s palm for the child to hold in order to inhibit thumb inversion and finger flexion tension), and then uses the fingertips of the other hand to rapidly stimulate the muscle abundance above the hawk of the elbow joint (at the red circle in the figure) to produce voluntary extension movements of the upper limb (as shown below).
Facilitating forward rotation of lumbar spine manual technique
With the child lying on his side, the operator fixes the scapula with one hand and controls the pelvis with the other hand, pulling the pelvis backward to a certain position, and then uses the fingertips (usually the index and middle fingers) to quickly stimulate the lower abdominal muscles (above) to produce voluntary forward movement of the lumbar region (as shown below).
Promoting backward rotation of the lumbar spine
With the child lying on his or her side, the operator fixes the scapula with one hand and pushes the pelvis forward with the palm of the other hand against the hip, and then uses the thumb of the hand against the hip to quickly stimulate (above) the lumbar muscles to produce an autonomous backward rotation of the pelvis (see figure below).
Promotion of forward rotation of the thoracic spine (scapular anterior retraction)
The child is lying on his side, the operator fixes the pelvis with one hand, holds (grasps) the scapular band with the other hand, then pulls the shoulder backward, and after pulling to a certain degree, uses the fingertips of four fingers to quickly stimulate the pectoral muscles below the clavicle to produce an automatic forward retraction of the scapula (as shown below)
Promote automatic turning training hand technique
Turn over training to the left side: the child is in supine position, the operator is on the child’s right side, the child’s left upper limb is flexed (raised) more than 120 degrees, the operator’s left hand controls the shoulder, the right hand controls the pelvis, and then both hands exert force in opposite directions at the same time. Left hand: upward and forward direction (i.e., to the head forward direction); right hand: downward and backward direction (i.e., to the foot backward direction). The child is then induced to turn over to the left side automatically, and care is taken to inhibit excessive head tilting and lower limb hyperextension during the process of inducing the child to turn over automatically (figure below).
Please consult your therapist for head lifting, spinal rotation, and rolling over on the Bobath ball.
Segmental massage techniques
Segmental massage is mainly to promote neural development.
1.Moving method: the operator uses the thumb surface or middle finger finger surface to move up and down. Massage one side when the other side to play a supporting role, massage parts are both sides of the spinous process of the spine, fingers try to touch the vertebral space, and impact movement in this area. The impact of the strength of the drama child’s condition, physical condition (the following chart).
2, drill method: the operator’s thumb and the remaining four fingers on both sides of the spine, with the thumb or middle finger in the spinal nerve root outlet to do circular or spiral movement, from one spinal stage to move another spinal stage, massage fingers and support fingers move at the same time.
3, saw method: hands across the spinal spine, the two fingers between the formation of massage to go to the skin protrusion, hands do pull saw-like movement, a level for 1 to 2 times after moving up a level for.
4, pulling method: the operator uses two fingers of one hand, often the middle finger and index finger, along both sides of the spine from the sacrum until the neck at the same speed pulling method, in order to act powerfully, the other hand to increase the load.
Traditional massage method
Promote the growth and development of children’s health traditional massage method mainly include: press rubbing Baihui, press rubbing the dumb door, press rubbing the large vertebrae, press rubbing the large vertebrae, pushing the spine, press rubbing the kidney Yu, press rubbing the spleen Yu, touching the abdomen, kneading the spine, tonic lung meridian, tonic spleen meridian, tonic kidney meridian, transport water into the water, etc. (Note: it is reported that press rubbing the dumb door and the large vertebrae is beneficial to the blood supply to the brain).
Note: When massaging, put some medium (such as talcum powder) on the child’s skin to prevent skin damage.