Irregular-motor cerebral palsy is caused by damage to the extrapyramidal system and is a common type of cerebral palsy, accounting for about 10% to 30% of cerebral palsy. The common causes are bilirubin encephalopathy, severe hypoxic-ischemic injury, prematurity, low weight, etc. Clinically, the main manifestations are increased involuntary movements due to disorders of random movements, common torsional spasms, dystonia, chorea, tardive dyskinesia, residual primitive reflexes, reduced head and trunk tone, postural control defects, etc. Most children have poor treatment results, severe motor disability, difficulty walking, and are moderately or severely disabled.
Early abnormalities in children with cerebral palsy often appear first in the head. If the child cannot adequately control his head, he will be prevented from learning higher motor functions, and abnormal posture and movement of the head will lead to abnormal posture and movement of the whole body. In the developmental process of children with non-random-motion cerebral palsy, the control of head posture is the most easily obstructed, so it is important to discuss the analysis of the causes of poor head control and physical therapy methods for non-random-motion cerebral palsy.
1. Importance of head control
Head control is the first milestone gross movement in the development of children. Children who cannot control their heads have difficulty in completing other movements, therefore, head control plays an important role in the overall motor development of children and the development of advanced motor functions such as daily life activities.
It takes about 3 months from the time a child is born until he or she lifts his or her head to complete. The general term head control refers to the slow tilting of the child forward, backward, left, and right while the head can remain in a vertical position when supported by holding the child’s chest tightly by hand. Only when the intermediate position of the head and neck is well controlled, can a good foundation be laid for the completion of the turning movement and trunk control. Therefore, the control of the head is often given the highest priority when functional training is carried out.
2. The main reasons for poor head control in non-random cerebral palsy
The conditions that need to be met for stable head control are: symmetrical extension of the spine, body axis gyration, support and protective extension of the upper limbs, establishment of the balance response in supine, prone and sitting positions, and disappearance of the hugging reflex. The common factors that hinder head control in children with cerebral palsy are: insufficient muscle strength of the neck muscles, coracobrachialis, abnormal postural reflexes, failure to establish cervical erect reflexes, inability to complete elbow support, and impaired trunk gyration. In contrast, involuntary movement type of cerebral palsy, because of mainly extrapyramidal lesions, abnormal muscle tone and involuntary movements are often manifested as generalized. The main reason for poor head control movement is due to the effect of abnormal posture and abnormal movement of the whole body. The abnormal posture inevitably produces abnormal movements, which affect and control the development of normal movements. The main abnormal postures that lead to poor head control are
2.1 Asymmetrical posture Due to the existence of asymmetrical tension neck reflex, it is difficult for the child to maintain the neutrality of the head when tension exists, mostly manifested as the head twisted to one side, the limbs are flexed on one side and extended on the other, in a “bow and arrow” or “teapot-like” posture.
2.2 Hyperextension in supine position In supine position, the child’s spine and hip joints are extended, the head is dorsiflexed, and the head and two shoulders are asymmetrically posteriorly extended; in lateral position, the head and neck trunk are excessively posteriorly extended, and the posture is angularly inverted.
2.3 Flexion pattern in prone position Under the influence of the tense vagal reflex, the child cannot raise his head, the spine and hip cannot extend, and the upper limbs cannot be supported. This posture controlled by the primitive reflex of low head, hip flexion, and knee flexion in the prone position is present even at a very young age.
2.4 Posture of hypotonia Some children with hypotonia, especially in the quiet state, show weakness, such as the drooping of the head in the sitting position.
2.5 Poor postural stability Due to the opposite innervation disorder, there is a lack of ability to maintain postural tension, joint fixation, and simultaneous contraction of the proximal end of the body, thus failing to maintain a gravity-resistant posture and an intermediate position, especially the head has the worst control regulation and cannot maintain a stable posture.
In Chinese medicine, the disease is considered to be due to the congenital deficiency of endowment, and the deficiency of kidney water cannot contain wood, resulting in the hyperactivity of liver yang, which causes the internal movement of false wind and the appearance of symptoms such as limb twitching. If the child’s spleen qi is weak, the spleen loses its yin, the earth is deficient in wood, and the liver is hyperactive and windy. The deficiency of heart and spleen, deficiency of Qi and blood, deficiency of liver blood, loss of liver nourishment, and the onset of wind and dark movement. The kidney is the master of water, and the liver is the master of tendons. It can also develop due to the deficiency of liver and kidney yin, water does not contain wood, wood is not nourished, and the yin deficiency and wind move the limbs, head and neck instability. The lesions are mainly in the liver, spleen and kidney. The origin is the deficiency of the spleen and kidney, and the symptoms are the excess of liver hyperactivity.
3.Physical therapy for poor head control of involuntary motion cerebral palsy
Due to the specificity of its lesion mechanism and clinical manifestation, the treatment of involuntary movement cerebral palsy is different from other types. In the rehabilitation treatment, we should follow the treatment principles suitable for this type of cerebral palsy and adopt corresponding treatment methods to achieve better treatment effect, and the same is true for head control training. Because the abnormal muscle tone and involuntary movements of children with involuntary movement cerebral palsy are often generalized, only on the basis of generalized treatment can the control of the head make progress. Many children with cerebral palsy have been treated for a long time without obvious results, often due to the failure to master the characteristics of their lesions and treatment principles.
3.1 Motor therapy A comprehensive treatment approach based on neurodevelopmental therapy is used for motor rehabilitation [5]. The manipulation should be gentle and soft, with the aim of relieving muscle tension, reducing muscle tone fluctuations, and controlling dystonia. Autonomous, random movements can be completed and head control can be achieved only if the child is treated in a relaxed, relaxed manner and no longer has significant muscle tension and dystonia during active movement. Therefore, any therapeutic techniques that aggravate stimulation and induce tension in any case should be disabled.
Inhibiting abnormal posture and breaking the control of the primitive reflexes is the basis for producing normal movement. Postural control is essential to maintain stable support, to avoid abnormal posture during treatment, in daily life and in various positions, and to maintain the symmetry of the child’s body and the normal position of the head. Only when the abnormal posture is controlled can normal voluntary movements be produced.
For children with surviving asymmetric tense neck reflex, the therapist can hold their shoulders with both hands in the supine position to make their head and neck flexed, their hips elevated, and their limbs symmetrically flexed, or the child can sit with his back against the therapist’s chest while the therapist controls his upper limbs to make his head and neck flexed and his limbs symmetrically flexed, like holding a ball, in order to suppress the asymmetric tense neck reflex or coracoid pattern and promote the neutral head position placement and control.
The therapist may also encourage the child to do spontaneous head flexion and extension based on the ball hold to enhance the stability of head control. The therapist may also sit on the bed with both lower extremities extended and close together, with the child’s back to the therapist, legs apart, and sitting on his or her legs. Depending on the child’s condition, the child’s head is placed against the therapist’s shoulder and chest so that the child’s upper extremities are held flat and the hands are interlocked in the middle position, then the trainer holds the child’s hands and pulls the child’s upper extremities forward and downward, when the child’s center of gravity moves forward and downward and the head and neck are bent forward. The asymmetrical posture can be suppressed at the same time.
For children with tense vagal reflex hyperactivity, to correct this abnormal posture do not put your hand behind the child’s occiput and lift the head upward, this will be counterproductive, making the spasm worse, making the head back even more. The correct method of operation is: the child to take the supine position, the operator with both hands to hold the child’s head on both sides, first make the child’s neck stretch, and then gently lift the head upward with both hands, at the same time, the therapist with two forearms lightly press the child’s shoulders.
Repeated training can make the child’s abnormal head posture be properly corrected. The child can also be placed prone on the therapist’s lap or on a wedge-shaped mat, with the therapist helping to support the child’s shoulders, elbows, arms, etc. The other leg can be pressed against the child’s buttocks to suppress the child’s tense vagal reflex. For children with poor postural stability and partial neck weakness, the therapist can improve muscle tension by compressing and resisting the trunk in its sitting position, and on this basis, provide appropriate resistance training to the head to enhance head stability.
For children with non-tensive hand-foot-movement cerebral palsy, the therapist can place the child in a supine position, bend the lower limbs toward the abdomen, and have the child grasp his or her feet with both hands while the therapist holds both sides of the wrist and ankle and pulls the child up to 45° or 90° to promote forward head and neck flexion and head uprightness, as well as to promote a balance response. The therapist may also have the child lie prone on the large Bobath ball, changing from a prone position to an elbow-supported prone position, and then, alternately, holding both upper extremities toward the front for support. The ball is moved to the front and the child’s body is then moved to the front, using the effect of promoting the corrective response of the head to induce head lifting movements.
3.2 Tui-na massage Among the traditional treatment methods, tui-na massage has an important role in relieving muscle tension, reducing excitability, promoting the disappearance of primitive reflexes and improving muscle strength. The tui-na treatment for cerebral palsy with involuntary movements focuses on unblocking the meridians, improving motor functions and suppressing abnormal postures. It is advisable to master the principles of lightness, gentleness and slowness, and avoid overly strong stimulation of the limbs.
On the basis of relaxation of the whole body massage, both sides of the thumb can be used to push down the foot solar bladder meridian and the cervical meridian at the same time. Rub the Fengchi, Fengfu, neck pinch points, shoulder well, Dazhi, Tianzong and other acupuncture points to relieve tension in the neck muscles; head and neck soft can be heavy stimulation point press, percussion of the back of the neck and upper back muscles, popping the sternocleidomastoid muscle.
3.3 Chinese herbal bathing
Drugs: 30g of Radix Rehmanniae, 30g of Radix Chrysanthemum, 20g of Angelicae Sinensis, 20g of Eucommia, 30g of Paeoniae Alba, 30g of Radix Achyranthes Bidentatae, 30g of Radix Papaya, 30g of Peach kernel, 30g of Safflower, 30g of Crotalus, 30g of Paeoniae Alba, 30g of Dilong. ～The bath is administered 1~2 times a day for 30~45 minutes each time, for 1 course of treatment per month.
In addition, under the effect of buoyancy, the joints of the limbs and the spine of the child will not be directly impacted by the reaction from the ground in the movement, which is conducive to correcting bad habits and postures. Under the effect of relaxation of the whole body muscles and the resistance of water, the involuntary movements of the child with involuntary cerebral palsy are reduced, and some head control training can be done at this time, which will achieve twice the effect with half the effort. The child’s motor function is better improved.
4.Experience
Cerebral palsy is a chronic neurological disease with a high prevalence and disability rate, which seriously endangers the physical and mental health of children.
Head control is the first step in the treatment of cerebral palsy. The maturity of head control plays an important role in the development of advanced motor functions such as overall motor development and daily life movements of children. Unlike other types of cerebral palsy, the treatment of non-random motion cerebral palsy must be based on a holistic approach, where the control of the head is based on the relaxation of the whole body muscles and the stability of the trunk. Any techniques that stimulate the child and increase tension should be disabled. Only in this way can we achieve the desired results in the actual treatment process.