The main manifestations of torsional spastic cerebral palsy.
The child has normal intelligence, speech, and mainly abnormalities of posture (asymmetric neck tension reflex) and movement. The muscle tone of the right upper and lower limbs is higher than that of the left side, and the child’s cooperation during activities is not high.
Manifestations.
(1) The head is habitually tilted to the left in the supine position, while the right upper and lower limbs appear in a flexed position and the left in an extended position.
(2) The child is unable to sit alone in the long-legged and end-legged positions. When sitting with the assistance of the therapist, the child exhibits shoulder joint retraction, right upper extremity flexion, head tilt to the left, entire trunk twisting to the right, and pelvic tilt.
(3) The child was unable to perform functional movements of both hands simultaneously due to asymmetrical cervical tension reflexes, and had difficulty moving in the midline position.
(4) The child has good hand function and can perform some gross and fine movements.
Asymmetrical cervical tension reflexes.
(1) Examination method: The child lies on his back with his head in the median position and the upper and lower limbs straight. The examiner turns the child’s head to one side, and the upper and lower limbs on the face side of the child will appear to be extended, while the upper and lower limbs on the other side will appear to be flexed.
(2) Significance: persistent appearance after 4 months indicates brain damage. The persistence of this primitive reflex can seriously affect the posture and motor development of the affected child. It is a typical feature of cerebral palsy.
Torsional spasm, also known as idiopathic torsional spasm (ITS), torsional dystonia, primary dystonia, is characterized by clinical dystonia and violent involuntary twisting of the limbs, trunk and the whole body.
It is divided into primary and secondary, and primary is more common. Torsional spasms are mainly involuntary spasms and twisting of the trunk and limbs, but the shape of such movements is bizarre and variable. The onset is slow, often starting in one or both feet, with spastic plantarflexion. Once the extremities are involved, the proximal muscles are heavier than the distal muscles, and the cervical muscles are invaded with a spastic oblique neck. Involvement of the trunk muscles and paraspinal muscles causes twisting or spiral movements of the whole body, which is the characteristic manifestation of the disease. The twisting spasm increases during exercise or stress, and disappears during quiet or sleep. Myotonia increases during the twisting movement and becomes normal or decreases after the twisting movement stops, hence the name deformational dystonia. In severe cases, there is slurred speech, restricted swallowing, and mental retardation.
The disease is caused by abnormal muscle contraction and twisting of the head and neck, and the abnormal posture is produced by rotation. Therefore, it is also called spastic squint. The onset of the disease is slow, and the early stage of the disease is characterized by periodic head rotation to one side or forward and backward flexion, and later the head is often fixed in a certain abnormal position. The affected muscles are often painful, and muscle hypertrophy can also be seen, which can be aggravated by emotional excitement, and can be alleviated by head support and disappear during sleep.
I. Incidence
Spastic squint is the most common type of limited dystonia. It can occur at any age and is more common in middle-aged and elderly people and women, with an incidence of 9 out of 100,000.
Clinical manifestations can be clinically divided into four types according to the extent of muscle involvement.
(1) Rotation type: spasticity of the head along the longitudinal axis of the body to one side.
(2) Posterior tilt type: the head is tilted backward toward the back, facing the sky.
(3) Forward-flexed type: head flexed forward with the jaw against the chest.
(4) Lateral flexion type: head deviates from the longitudinal axis to the left or right, with the ear near the shoulder, often accompanied by ipsilateral shrugging of the shoulder. Most patients have head tremors when they try to maintain their head in an upright position.
The most important rehabilitation exercises.
(i) Head control.
The child’s head turned to one side when he appeared in the supine position, so I used to move in the lateral position during training (which could inhibit his abnormal posture), followed by joint movement training, and also actively induced his right upper limb to reach forward to grasp objects (to prevent shoulder joint retraction).
(2) Loosening of the neck joint in the supine position.
1. Massage to relax the tense muscles of the neck.
2.Patient position: supine position with head resting on the therapist’s palm and neutral neck position.
3.Therapist position and manipulation: sitting above the child’s head, one hand holding the back of the child’s head, one hand placed at the jaw, both hands pulling the head along the long axis longitudinally for about 15 seconds, then relax and restore, repeat 3 times.
4.rotation swing: increase the range of motion of cervical rotation swing, therapist position as above, when rotating to the left, the therapist’s right hand is placed on the child’s occiput to drag his head, the left hand is placed on his jaw, both hands simultaneously make the head slowly rotate to the left, and the opposite technique is operated when rotating to the right.
(ii) Turning training.
Use both upper limbs to drive the trunk and pelvis rotation to turn over. Practice: when turning over to the right, the head rotates to the right, the right upper limb is raised to the top of the head, and something is taken to induce the child’s left hand to grasp something, so that it turns over to the right, and the left side is the opposite.
Trunk, pelvic control.
(iii) Training in sitting position.
1. Shoulder control: First, let the child lean on himself, hold the child’s bilateral pelvis with both hands through the child’s shoulders from the front of his body, and then use his upper limbs to put pressure on the child’s shoulders backward. The child’s scapulae will be inwardly retracted and the shoulders will move in the direction of abduction.
2.Torso gyration: While on the method, the therapist moves both hands backward to the waist. While continuously controlling the shoulders, the therapist’s thumbs face outward and hold the child’s torso with both hands to do a slow gyration movement. Care is taken to keep the child’s trunk extended. This can be used to increase the mobility of the trunk and reduce muscle tension repeatedly. Or use both elbows for trunk gyration.
3.Shift the weight: while keeping the shoulder joint abducted and externally rotated, use one hand to carry the weight and induce the child to move the weight to the side. When the child moves to the left, the right trunk is extended and the head is shifted right to keep upright.
4.Inhibit flexion posture and maintain posterior support of weight: The therapist is located behind the child and the child is supported on the bed from behind in the abducted external rotation position with the palm of the hand down and the fingers fully extended to control the shoulder joint from behind.
5.Functional activity of the midline position of both hands: first fix one upper limb and let the other upper limb do the specified movement, repeatedly, and then let both upper limbs do the functional activity at the same time, such as lifting the gymnastic bar together.