Early intervention refers to organized and purposeful comprehensive rehabilitation treatment activities for high-risk infants whose development deviates from normal or may deviate from normal. Since neonates and small infants have imperfectly developed brain functions, even with brain injury, neurological symptoms do not necessarily appear soon. Regular follow-up examinations of high-risk children can detect certain abnormal neurological symptoms early and guide brain-injured children to start intervention treatment as early as possible.
Intervention purpose: to seize the critical period of brain development and intelligence development, to reduce or repair brain tissue lesions by means of drugs or environmental stimulation, to block apoptosis of nerve cells, so as to reduce or prevent neurological sequelae and to improve the future quality of the population.
Intervention content: including pharmacological and non-pharmacological interventions.
Pharmacological interventions Commonly used are hyperbaric oxygen therapy, brain activation drugs such as cerebral activator and cytophosphorylcholine, neurotrophic factor drugs, compound salvia injection, various vitamins, trace elements and traditional Chinese medicine, etc.
Non-pharmacological interventions 1. Early education: Based on the developmental rules of physical, motor, perceptual, language, attention, memory, thinking, emotion and emotion of infants and toddlers from 0 to 3 years old, individualized and targeted educational training is provided to infants and toddlers in stages. 2. Doman-Delecato therapy: Created in the 1970s by Doman, a physical therapist, in cooperation with Delecato, an educational psychologist. 3. Vojta Induction Therapy: Created and applied by Dr. Vojta, it has two basic techniques: reflexive turning and reflexive belly crawling, which are effective in promoting normal motor reflexes and correcting abnormal postures. 4. Traditional medical treatment, orthopedic appliances, surgical treatment, physical factor therapy and other methods.
Intervention therapy: The recovery of brain injury depends on the plasticity and compensatory of brain cell function, and the recovery of motor function and intelligence also depends on the recovery of neurological function, which can only be achieved with long-term rehabilitation therapy.
Early treatment of cerebral palsy
Cerebral palsy is one of the main causes of motor dysfunction in children, and is often accompanied by mental retardation, epilepsy, visual and hearing impairment, and speech impairment. Therefore, when cerebral palsy is diagnosed, treatment should be started immediately, and early treatment can minimize the degree of brain damage and obtain the best treatment effect. Early treatment refers to treatment within 6 months after birth, and treatment within 3 months is also called ultra-early treatment.
Objectives: To promote the development of brain cells and myelin formation; to develop normal postural reflexes and muscle tone of anti-gravity muscles, to promote the formation and development of normal motor functions, to prevent the development of abnormal postural reflexes and abnormal muscle tone; to prevent secondary damage caused by postural and motor abnormalities joint contracture, muscle atrophy, limb deformation,.
The importance of early treatment: children are growing organisms, brain tissue is not mature at birth, the cerebral cortex is thin, cell differentiation is poor, nerve myelin is not fully formed. 3 years old when the basic differentiation of nerve cells is complete, nerve fibers to 4 years old to complete myelination. The brain is in the stage of rapid growth and development within 6 months after birth, the number of nerve cells does not increase much, but mainly the volume increases, the dendrites increase, and the formation and development of neuromyelin, while the brain injury is also in the early stage, abnormal posture and movement are not yet fixed, and the motor function is easily restored after treatment; timely treatment in this period can get the best therapeutic effect.
Methods: At present, comprehensive rehabilitation therapy is used at home and abroad, mainly including physical therapy, somatic training therapy, pharmacotherapy, massage therapy, rehabilitation care, etc.
Physiotherapy is based on gross motor and lower limb functional training, using mechanical and physical stimulation to carry out a series of training for various motor disorders and abnormal postures left behind by cerebral palsy. The purpose is to improve function, suppress abnormal postural reflexes and induce normal motor development. The main methods commonly used at home and abroad include: physical therapy PT, occupational therapy OT, speech therapy ST, and music therapy. Music Therapy (Music Therapy)
Drug therapy Western medicine treatment mainly uses drugs to nourish brain cells and improve brain metabolism; Chinese medicine treatment mainly uses drugs with the effects of soothing the tendons and opening the channels, awakening the brain and opening the orifices, strengthening the spleen and benefiting the kidneys; Chinese medicine preparations can also be used to conduct a medicinal bath to regulate muscle tone, promote muscle strength improvement and relieve muscle spasm.
Massage therapy is based on the traditional Chinese medicine meridian theory, using the method of massage treatment by following the meridian to take points. The main techniques include segmental massage method, chiropractic treatment method, muscle strength promotion massage method, joint mobility massage method, abnormal posture correction method, etc.
Motor development intervention for cerebral palsy
Abnormal motor development is the main obstacle of cerebral palsy, and also affects the development of intelligence, language and other functions. Motor development intervention can effectively promote the recovery of motor function and the overall development of the child’s physical and mental health.
The Bobath Method was co-founded by British scholars Karel Bobath and Berta Bobath. It is a method of treating cerebral palsy by inhibiting abnormal postural movements and promoting normal postural reflexes and motor development according to the laws of neural development in children. The concept is that the rehabilitation treatment of pediatric cerebral palsy is a neurodevelopmental treatment. The brain injury hinders the normal development of the brain, thus causing the motor development to lag behind and stagnate; the abnormal posture and abnormal movement patterns appear due to the release of abnormal postural reflexes and stunt the normal motor development. Therefore, the focus of treatment is to inhibit abnormal reflex activity and promote the emergence of normal movement.
Objectives: 1. To improve the ability to resist gravity, maintain normal posture and control motor posture. 2. To control the growth of abnormal postural reflexes and abnormal postural tension. 3. To develop the child’s ability to perform movements on their own in daily life by means of play and training. 4. To prevent joint contractures and deformities so as to achieve rehabilitation.
Methods: Bobath therapeutics considers the presence of abnormal posture as the greatest obstacle to normal motor development, and the basic principle of its treatment is to inhibit abnormal postural movements and promote normal motor patterns. It is advocated that rehabilitation should be carried out throughout the daily life of children with cerebral palsy, paying attention to every posture of daily care, around the midline of the spine, and keeping symmetrical centering at all times.
Inhibition of abnormal postural movements consists of three main areas. Suppression of abnormal postural reflexes, such as asymmetric tense neck reflex (ATNR), symmetric tense neck reflex (STNR), and tense labyrinth reflex (TLR); suppression of abnormal postures, such as eliminating excessive tension and alleviating pointed foot and scissor gait; suppression of abnormal movement patterns, such as anterior kneeling extension support pattern of both upper limbs, rigid straight pattern of both lower limbs, and overall movement pattern of coracoid pattern
Facilitation of normal movement patterns refers to the methods that enable the child to obtain normal responses and spontaneous movements and to induce the maximum potential ability of the child. The main objective is to promote the emergence of upright reflexes such as sitting upright, standing upright, and balance reflexes in order to achieve the basic movements of turning, sitting, crawling, standing, and walking.
Motor development intervention program (motor function rehabilitation training according to the law of development)
Zero to three months old.
Main Objectives Visual, auditory and tactile development, vestibular function training, body turning, head control, and hand grip.
Main methods Visual, auditory and tactile information stimulation Visual and auditory stimulation with language, toys, picture cards and music when waking up; gaze with affectionate eyes, always accompanied by verbal communication is also the basis for all future training; for those who do not look at the red ball well, use red light flashlight to guide gaze several times a day; strengthen sound stimulation for poor auditory response; tactile stimulation mainly uses touch, chiropractic and baby gymnastics. Visual, auditory and tactile information stimulation is not only an important method to improve intelligence and establish good mood, but also the basis of motor function training.
Vestibular function training can be used to hang the sheet inside the left and right flip, swing, lift high, cradle / bouncer, swivel chair, inflatable ball training, etc.. At this age, the inflatable ball training can be performed on the prone and supine balls. The child is prone on the ball, and the handler presses down on both thighs, or an assistant can help support both arms. Bounce the ball while communicating with the child, and after the child relaxes, roll the ball up and down, left and right, clockwise and counterclockwise for 3-5 minutes, then turn into supine at the same time. Bouncing and turning on the prone/supine ball not only feeds the vestibular system with information about horizontal head orthostatic rotation in all directions, but also promotes head control and antigravity stretching of the trunk.
Body rollover and head control Support the legs/arms to roll from supine to lateral, use words and toys to guide the child to roll to prone, alternating between left and right; after rolling to prone, guide elbow support and head control. Head control training can also be used to pull sitting and hold standing position. Hand grip objects Support hands touching each other in the middle line, put small objects in the hands to promote hand grip and release.
Can support standing stepping training 5-10 minutes daily.
Related research: vestibular function training The proportion of children with sensory integration disorder is high in China, for example, 12.9% of 1622 school-aged children with severe sensory integration disorder were reported. The percentage of sensory integration disorders is even higher in people with brain injury and cerebral palsy. Sensory integration training is often combined with games, which is not only willing to accept normal children, but also an ideal way for children with brain injury and cerebral palsy who need long-term training. Euphoric play can motivate children to relax and participate in repeated training. In recent years, monographs on cerebral palsy published in the United States have included sensory integrative therapy as one of the main treatment programs for cerebral palsy.
Sensory integration disorders are multifactorial, and inadequate input of various sensory information early in infant development is one of the main factors. In scientific infant rearing, we are now paying more attention to visual, auditory, tactile and proprioceptive information stimulation, but the input of vestibular information is not enough, so we should strengthen the input of vestibular information in infant rearing. The vestibular system consists of two vestibular receptors in the inner ear, the brainstem, the cerebellum, and the vestibular nucleus, and is also closely related to the brain. The two vestibular receptors in the inner ear are the gravity receptors and the motor receptors. When the position of the head changes, the small calcium carbonate crystals in the gravity receptors leave their original position, and the fluid in the three pairs of semicircular canals in the motor receptors flows and transmits information to the cerebellum and brain. If there is sufficient vestibular information input about the various position changes of the head during infancy, the brain’s integrative function will be strong and the child will have good balance and other functions. Vestibular perception is not only related to balance, but is also involved in the improvement of many functions of the body. For example, in children with poor vestibular function, the eye and neck muscles are also impaired, the eyes cannot gaze well and move with objects, and hand-eye coordination is poor. It has also been reported that electrophysiological testing reveals syndromes characterized by impairments in reading, writing, and spelling inversions, primarily due to dysfunction or lesions of the cerebellar-vestibular system. Studies have also shown that vestibulo-cerebellar function also affects emotional and cognitive refinement, and that vestibulo-cerebellar deficits are responsible for emotional instability, poor attention span, learning disabilities, language deficits, and autism.
A number of studies have confirmed that the input of vestibular information not only enhances balance but also promotes multifaceted development in infants. It has been observed with infants held in a swivel chair that after 4 weeks of swivel chair stimulation 4 times a week, the group was more responsive and better motor development than both the non-sitting and sitting without swivel control groups, especially in sitting, crawling, standing, and walking. It has also been shown that preterm infants who received additional vestibular stimulation gained weight faster, were less likely to cry, and slept better. The various exercises assisted by the large inflatable ball can input vestibular information about various body positions and movements, including head-down position, as well as tactile, proprioceptive, visual, and auditory information, which is an ideal way to improve infants’ vestibular function, sensory integration, and motor function. In infancy, no other sensory program can safely input vestibular information in the head-down position, which makes large ball movements even more valuable.
Stepping training Some scholars started a study on children 1 week after birth. Group 1 practiced stepping reflexes by holding in an upright position with their feet on the table for 10 minutes every day; Group 2 measured stepping reflexes once a week; Group 3 did leg pulling stepping gymnastics on their backs every day; Group 4 did not have any examination or intervention. The results were that the stepping reflexes of groups 2 and 3 decreased at week 8; group 1 maintained the stepping reflexes and increased the number of steps, walking 1 month earlier than groups 2 and 3 and 2 months earlier than group 4. It was observed that after the disappearance of the stepping reflex in infants aged 2-6 months, the stepping reflex was induced again when the infant was held in position and the trunk was immersed in the bath; before the stepping reflex disappeared, the weight on the foot could disappear; statistics also showed that the stepping reflex disappeared early in those with relatively high body weight, indicating that the disappearance of the stepping reflex was related to weight gain. We have observed clinically that early stepping training in children with cerebral palsy can induce early exposure of pointed foot and scissor step in children with hypertonia, but simultaneous massage and pulling can suppress abnormal gait, and stepping training can direct the trend of tonic-like tightening of lower limbs to stepping action. We have learned that early exposure to abnormalities is easier to control than late exposure, which not only prevents secondary damage to muscles and joints, but also makes it easier to replace incorrect patterns with correct patterns in the brain. Foreign scholars have also suggested that early intervention of incorrect patterns can help correct pattern formation. They observed that children who started training at 3 months walked earlier and with a stable gait. Although delayed fading of the stepping reflex can be one of the signs of cerebral palsy, studies have confirmed that many primitive reflexes are associated with certain functions later in life, and the stepping reflex is the basis for later walking, and delayed fading in cerebral palsy is associated with factors such as hypertonia. For children with brain injury and cerebral palsy who have low muscle tone, stepping movements are often not induced, so it is advisable to do stepping gymnastics with supine support for both lower legs.
From April to June
The main goal: to roll over actively, to promote sitting alone, to reach out and grasp objects, to continue vestibular and other sensory training, to start the development of good habits and emotions and to implement them in the future training.
Main methods: Using language and toys to guide rolling over. If you can’t turn over with language and toys, add acupuncture point stimulation to promote turning over. After holding the baby in a lateral position, press and push the double Fengchi points, or press the upper side shoulder well or the ring jump point. Pull both arms from supine to sitting position, train head control and sit alone; support sitting or sit alone when the bowed back is more obvious, press the double lumbar eye points. Use small toys in front of the child’s hands and eyes to guide them to reach out and grasp. Hold position hip flexion and extension training. At five months of age, you can hold the child’s pelvis in an upright position facing forward, and use toys and language to guide the bending and lifting movements. Sensory training exercises on the ball added to the previous movements: side lying up and down rolling: side lying on the ball, holding the thighs and shoulders up and down rolling, alternating left and right. Rolling on the ball in lateral recumbency not only feeds the vestibular system with information about horizontal head lateral rolling, but also promotes the lateral bending function of the trunk. Six months plus prone back and forth roll with toys, language to guide the hands alternately forward to reach the object, not only can input information to the vestibular system of the head down position, but also promote the formation of protective parachute reflex. Support cushion bouncing and leaning forward to guide the protective support of hands when leaning in sitting position. Six months plus support the child’s double armpits into an upright position, bouncing on the sphere, training the lower limbs to hold weight and knee and hip flexion and extension movements, laying the foundation for walking and jumping.
Related research: roll over compared to crawl, is the action after adulthood, is the focus of this stage of the project. If you can’t roll over beyond this age, the abnormalities that cause rolling over often form a more fixed pattern in the brain and are more difficult to be replaced by the correct pattern. It is important to counteract the abnormalities early on and guide normal movement when it is time to emerge, as is the case with turning and other functions.
Seven to September
Main goals: prone crawling, knee-handed crawling, start of standing training, position change for transition to standing, thumb/index finger pinching of small objects, chewing and articulation training, new items added to sensory training.
Main methods: using language and toys to guide the crawl. Acupoint stimulation to promote prone crawling Prone elbow support position, a forearm slightly forward hand back up, fix the hand while pressing the shoulder well point on that side, triggering the upper limb force; at the same time or slightly backward flexion of the opposite side of the lower limb, supporting the thumb stirring the ground while pressing the Yongquan point on that side. Alternating left and right, stimulating prostration crawl. Push the foot/push the position/top crawl mode to promote the top crawl. After you can crawl, you can crawl over your mother’s thighs and other methods to transition to knee-hand crawl. Exercise the lower limbs to hold weight by supporting bouncing, holding and standing. If you can’t hold weight, use the standing board to help you stand: after a period of standing training, use toys to guide you to bend down and fetch things, and train hip flexion and extension movements. Sit up training exercises hip, knee flexion and extension, lower limb weight holding, sitting and standing position conversion. Poor completion of the available sit-up chair. Squatting training. Squatting posture is abnormal or poorly completed, should be supported, 1 person to support the arms to help do squatting, up action, the other two people sitting on the mat with both feet, hands to support the fixed ankle, knee joint in the correct position movement. Support step heel not on the ground plus support squatting foot before and after the weight shift. Guide/support the transition from lying/sitting position to semi-kneeling-standing position. Guide/support the thumb/index finger to pinch small objects. Oral exercises Face-to-face demonstration of articulation and chewing, use hands to help jaw movement, press and rub chewing muscles and related points or use fingers to do massage in the mouth, use “teething cookies” to promote chewing, swallowing, articulation, etc. Sensory training in the ball movement increased. Support the child to sit upside down and lean from side to side, and guide the child to lean as a protective support for the hands. Hold the child’s armpits in a self-supporting position, bouncing on the ball surface, training the lower limbs to hold weight and knee and hip flexion and extension movements, laying the foundation for walking and jumping. When lying on the side and bouncing the ball, one hand holds the pelvis, one hand holds the shoulder, alternately doing shoulder and pelvis pulling in the opposite direction, alternating left and right side lying, exercise body axis rotation. Support the child squatting on the ball surface, bouncing the ball while doing the heel-to-foot weight shift, to promote the correct heel-first correct action when stepping.
Related research: Crawling is not only the foundation for more coordinated movement, later standing movement and other coordinated movements, but also contributes to cognitive improvement and emotional improvement. The Harvard area of the United States surveyed, more late walkers did not go through crawling. The clinical conclusion is that it is not easy to crawl too much after crawling, on the one hand, because this stage is also the beginning of the standing training months, time is limited; on the other hand, too much knee-hand crawling can lead to wrist joint deformation. For children who can’t crawl or walk after 1 year old, they should be trained mainly in standing position.
Ten to twelve months
Main goals: Stand alone, walk by hand/walk alone, reach and grasp objects with hand-eye coordination.
Main methods: standing alone with support, leaning, and under protection; walking holding hands, walking with parallel bars, and walking alone under protection. If you can’t stand alone, help walk or help walk with abnormal posture, continue the above training, and add bundle stand straddle stand, bundle stand kick objects, etc. When carrying out the above training, there are foot in/out turn with appropriate wedge plate correction, with pointed foot wedge plate pad in the forefoot; there is knee reversion when the bundle stand behind the knee pad; sit up chair training when the knee arch between the knee pad. Stand training must be based on the correction of abnormal posture, stand training and correction at the same time can not only enhance muscle strength and bone and joint stability, but also help to correct abnormal posture. Sensory training increases the movement on the ball. Stand with the back against the ball pillow and neck against the ball, slowly withdraw the ball and use language to guide the head to tilt forward and stand straight. Standing/supporting with the ball facing the ball, holding the ball with both hands, rolling the ball forward to guide the protective reflex of reaching forward to support the ball.