Abstract: Knee anteversion is one of the typical gait patterns of children with cerebral palsy, and its treatment mostly adopts exercise therapy and massage, which has achieved certain results, but the clinical operability varies significantly. Orthoses can improve the child’s ability to sit, stand, and walk by limiting abnormal movements, maintaining the stability of the joint, strengthening the weight-bearing capacity of the limb, and correcting the deformity of the limb or preventing the deformity from worsening through the two-point mechanics. In recent years, orthoses have been widely used in clinical practice and have achieved good results due to the continuous introduction of new production materials and the continuous improvement of production levels. Clinical application results show that the use of rigid ankle-foot orthoses can provide children with good hip and knee alignment and alignment, increase the stability of the ankle joint, and reduce muscle tension. It relieves spasticity and effectively improves gait function. Zhang Jiankui, Department of Pediatrics, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine
Keywords: knee anteversion; cerebral palsy; orthosis
Abstract: Knee hyperextension is one of the typical gait of cerebral palsy which is treated by Physical therapy and Traditional massage.However,the However, the clinical operation was poor.gait.Based on three-point mechanics principle, orthosis can correct deformity or prevent deformity progression. The most important thing is to improve sitting, standing and walking abilities and promote deveIopment of parlents through limiting abnoml motion, keeping joint stabisty, and Recurrently, ankle-foot orthotics has been widely used for clinical The clinical treatment due to its development of manufacturing materials and manufacturing technique. Clinical appliication jndicates that ankle-fool orthosis provides well alignment and paratope of hip and knee, enhances stability of ankie joint, relieves muscular tension and spasm, and effectively The use of the fluoroscopic technique is a key component of the treatment.
Keywords: knee hyperextension, Cerebral palsy; Orthopaedic implement
0 Introduction
Cerebral palsy (CP) is a syndrome caused by non-progressive brain injury and developmental defects from conception to infancy, mainly manifested by motor and postural abnormalities [1], often accompanied by mental retardation, speech impairment, epilepsy and other complicating disorders. The incidence rate is 1.80/00 to 4.00/00 [2]. Currently, there are about 5-6 million children with cerebral palsy in China, so cerebral palsy has become a major limb-disabling disease after polio control, seriously endangering the physical and mental health of children. The onset of cerebral palsy is a brain injury or developmental defect caused by various reasons before and after birth, among which premature birth, nuclear jaundice, low weight, neonatal asphyxia, hypoxic-ischemic encephalopathy, congenital brain developmental malformation, and birth injury are its main causes. The clinical manifestations vary due to the different sites of injury. Cerebral palsy is often accompanied by many abnormal postures, such as head dorsiflexion, upper limb flexion and fist clenching, hip flexion, knee dorsiflexion, foot inversion, foot valgus, and pointed foot. Knee dorsiflexion is one of the typical gait patterns of cerebral palsy and has a relatively high incidence in cerebral palsy. It seriously affects the walking ability of the child and even causes the child to lose the ability to walk if he or she is already able to walk. The main clinical manifestations are low muscle strength of the lower limbs, increased muscle tone, and knee hyperextension. At present, a comprehensive rehabilitation measure based on movement therapy is mainly used, which includes the application of orthoses [3].
Orthotics are devices used in the human limbs and trunk and other parts of the body to prevent and correct deformities, treat and compensate functional deficiencies through the action of biomechanical principles. With the development of rehabilitation engineering technology and rehabilitation concept, the application of orthoses in cerebral palsy rehabilitation is becoming more and more widespread, and the number of users is increasing year by year. This paper intends to discuss and analyze the causes of knee dystocia in pediatric cerebral palsy, traditional physical therapy methods, and the application of orthoses in the treatment of knee dystocia.
1 Problem
Question 1: What are the causes and clinical manifestations of knee dystocia in children with cerebral palsy?
Question 2: What are the clinical applications and effects of orthoses in the treatment of knee dystocia in children with cerebral palsy?
Question 3: What are the traditional physiotherapy methods of knee dystocia in children with cerebral palsy?
2 Solution of the problem
2.1 Causes of knee dystocia in children with cerebral palsy Knee dystocia, also known as Knee overstension or hyperestension or knee dorsiflexion deformity, is a phenomenon of knee overstension when standing upright or walking at rest. The maximum knee extension is close to zero degrees when normal, but exceeding zero degrees is considered knee dystocia. In pediatric cerebral palsy, knee dorsiflexion is due to the lack of control of the quadriceps muscle between 0° and 15°, which does not actively maintain the stability of the knee during the support phase, so that the body will immediately lean forward after the foot follows the ground, causing the line of gravity to fall in front of the knee, while the hip extensors and ankle plantar flexors contract to passively straighten the knee to compensate, thus forming knee dorsiflexion. On the other hand, gastrocnemius spasm prevents the affected leg from producing the ankle dorsiflexion necessary for weight transfer when bearing weight, and in order to “walk”, the patient tries to flex the hip so that the affected hip is posteriorly convex, thus also forming knee dystocia. Common causes of knee dorsiflexion in children with cerebral palsy are [4, 5].
Due to quadriceps paresis or hypotonia, the N cord muscle is weakened and the knee joint is unstable in the extended position, forcing it to walk in the posterior extension position when carrying weight. It is commonly seen in ataxia type and hypotonia type cerebral palsy.
Posterior knee paralysis or hypotonia The N cord and triceps are paralyzed or hypotonic, and the posterior knee, including the joint capsule and ligaments, is relaxed, causing knee dystocia. It is common in spastic and hypotonic cerebral palsy.
Poor control of the quadriceps and N cord muscles Poor selective motor control of the muscles of the knee joint and lack of simultaneous contraction, resulting in knee instability, mainly seen in tardive dyskinesia type cerebral palsy.
Spasticity of knee muscles in support phase extension Hypertonicity of the quadriceps, especially the rectus femoris, leads to stiffness in the standing or support phase, with the trunk flexing forward during advancement and the line of gravity falling in front of the knee joint, prompting the knee joint to extend backward to maintain balance. It is commonly seen in spastic and tonic cerebral palsy.
Knee hyperextension due to plantar flexor spasm or contracture Knee anteversion is compensated for by the line of gravity falling in front of the knee joint due to triceps calf spasm or contracture, commonly seen in spastic cerebral palsy.
Knee proprioception impairment and poor knee control Knee hyperextension occurs when the knee is locked in the posterior extension position to increase joint stability, mainly in ataxia and tardive dyskinesia.
In addition, long-term flexion deformity of the knee joint leads to patellar ligament laxity, and knee anteversion occurs when the N cord muscle is released, which is also a common cause of knee anteversion in cerebral palsy.
2.2 Measurement of knee valgus The maximum extension of the knee can be measured using standard lateral radiographs. The line between the greater trochanter of the femur and the external ankle passes slightly below the Ludloff triangle when normal, and if it passes in front of it, then the knee valgus is confirmed and the angle between the long axis of the femur and the long axis of the tibia can be measured. The measurement should be performed with the femoral epicondyle as the axis, with the fixed arm parallel to the longitudinal axis of the femur and the mobile arm parallel to the longitudinal axis of the tibia, and any angle exceeding 0° is considered to be knee varus [6].
The degree of knee varus can be classified as mild below 10°, moderate 10° to 30°, and severe above 30° [2].
2.3 Clinical application and effect of ankle-foot orthoses The main functions of orthoses are:① relative or strict braking to protect the lesioned area. ②Prevent the development of deformity or diaozheng deformity. ③Support the paralyzed muscles and stabilize the joints to facilitate movement or improve gait. ④Share the gravitational load to reduce the force on the joint, protect the joint and facilitate movement [7]. Children with cerebral palsy cannot maintain correct standing posture due to conditions such as increased muscle tone, knee dystocia, knee flexion, pointed foot, foot inversion and scissor gait, which reduce their stability and motor function. Treatment of children with cerebral palsy with orthoses mainly inhibits abnormal postural reflexes, promotes normal postural movements, stimulates superficial receptors and intrinsic receptors, thus improving gait, facilitating walking, improving standing balance, correcting knee hyperextension, expanding foot-ground contact, stabilizing talocrural joints, facilitating weight-bearing, reducing energy expenditure, and promoting the improvement of intrinsic factors in children [8]. The design of the orthosis mainly uses the principle of three-point mechanics to control the complex motion of the ankle and foot throughout the gait cycle, to stabilize the joint, and to control the lower extremity using ground-acting force control, which uses the torque generated by contact with the ground. Nowadays, orthoses are made and designed according to the human biomechanical three-point force principle and dynamic mechanics requirements to prevent and correct deformities and contractures [9].
Some studies have measured the walking cycle of children before and after wearing ankle-foot orthoses, and showed that the walking speed and stride length of children before and after wearing ankle-foot orthoses significantly increased, and the walking speed after wearing ankle-foot orthoses was significantly faster than before wearing ankle-foot orthoses, and the stride length significantly increased and the stride frequency decreased [10,11]. Zhang Xiaochao et al [12] studied the effect of lower limb orthoses on 61 children with cerebral palsy, referring to the qualitative assessment of the “Japanese Olden’s functional walking classification” and developed an operational “comparison of the results of the Japanese Olden’s functional classification before and after the use of orthoses” as an evaluation criterion, and their results also confirmed that lower limb orthoses The results also confirmed that the lower limb orthoses had the effect of reducing the muscle tone of the lower limbs, controlling knee reversion and knee flexion, correcting abnormal gait, and maintaining the correct standing and walking posture. Li Runjie [13] and Ren Shuxin [14] studied the use of ankle-foot orthoses in children with spastic cerebral palsy using the “Self-designed Evaluation of Motor Function before and after Wearing the Pedal Foot Orthosis” and the “Evaluation Criteria of Pointed Foot before and after Wearing the Pedal Foot Orthosis”, respectively. The study also concluded that the use of ankle-foot orthoses in children with spastic cerebral palsy could improve the motor function of the limbs and enhance the rehabilitation efficacy to different degrees with the help of the orthoses in a timely manner based on functional training. One study compared children with delayed cerebral palsy with and without the use of an ankle-foot orthosis for the first 3 months of treatment. There was no significant difference in the ability of the two groups to acquire crawling to standing support, and after 3 months of treatment, the walking ability of children with cerebral palsy with ankle-foot orthoses improved significantly, suggesting that ankle-foot orthoses are helpful in the acquisition of walking ability in children with delayed cerebral palsy [15]. The ankle-foot orthosis provides reasonable motor control in the sagittal, coronal, and horizontal planes of the ankle-foot of the child. It can also better control plantarflexion, enhance ankle stability, reduce muscle tone, and improve gait function [10]. Zhu Mei [16] treated 53 children with cerebral palsy combined with knee valgus using massage and exercise therapy with ankle-foot orthosis, and the total effective rate reached 94.3%. She suggested that most of the children with knee dystocia could achieve normal or significant progress through regular treatment, but the course of treatment was relatively long, usually more than 3 months to be effective and more than 6 months to be cured.
2.4 Physiotherapy for children with cerebral palsy The most prominent clinical manifestation of cerebral palsy knee varus is increased muscle tone, low muscle strength, and excessive knee flexion. Therefore, improving the muscle strength of quadriceps and N cord muscles, reducing their muscle tone, relieving gastrocnemius spasm, and suppressing knee flexion are the keys to promote the improvement of motor function in children with cerebral palsy. There are many treatment methods for pediatric cerebral palsy, and massage and exercise therapy are adopted for knee anteversion, but the principle of comprehensive rehabilitation is the main one.
Commonly used sports training are as follows [16]: ① Squatting training, knee flexion about 90° when squatting, knee should be 140°-160° when standing to avoid knee hyperextension. ② prone position calf flexion and extension training to improve the N cord muscle strength and increase knee stability. ③ single and double leg kneeling training, which helps to improve the control of the knee joint. ④Crawling training with knee flexion and flexion position is beneficial to correct the antalgia, while increasing the control ability of the knee joint and coordinating its motor function. Knee flexion and extension, foot dorsiflexion training, improve the strength of the extensor muscles and coordinate the tension of the antagonist muscles. ⑤ Calf triceps retraction and muscle strength training, let the child’s forefoot on a small step, heel on the ground, mainly to train the child to put down the heel (pull gastrocnemius) and lift the heel (improve gastrocnemius muscle strength), for the swing period the most needed strength training. (6) Bridge training to enhance the strength of the extensor muscles, promote hip extension and correct trunk forward flexion. (7) Up and down step training, which has a greater effect on correcting knee dystocia and coordinating gait, but attention should be paid to keeping the knee joint slightly flexed. (8) Weight-bearing standing training, which can be combined with straps or braces to fix the child’s lower limbs to avoid knee hyperextension, which helps to improve the stability of the knee joint and increase proprioception.
Different training can also be done in different positions according to the child’s different motor abilities, and the specific procedures are as follows [17]: ① Supine training of hip flexion and knee flexion. Emphasize selective flexion and extension of the hip and knee joints, and maintain full ankle dorsiflexion. The hip joint is not abducted and externally rotated, and the knee extensor spasm is inhibited. ② Training knee flexion in the supine position with the hip extended. Emphasize knee flexion, and full ankle dorsiflexion, and control ankle plantarflexion. (③Train active knee flexion in the prone position. Emphasize the non-flexion of the affected hip joint. ④Knee four-point kneeling position, knee two-point kneeling position: knee four-point kneeling position emphasizes hip inversion, knees one shoulder width apart, hip flexion, knee flexion, knee weight bearing, and ankle dorsiflexion. The upper limb maintains forward flexion of the shoulder joint, extension of the elbow joint, rotation of the forearm and full dorsiflexion of the wrist joint. The knee two-point kneeling position emphasizes one shoulder width apart, hip extension and knee flexion, and knee weight bearing. ⑤ In the sitting position, train to actively cross the affected leg over the healthy leg, emphasizing hip flexion and knee flexion, and ankle dorsiflexion. The affected leg should not be pulled by the healthy hand. ⑥In the standing position, train the affected leg to step with the knee flexed without lifting the hip and with the knee joint relaxed. Emphasize knee flexion without lifting the pelvis. (7) During the standing period, train the affected leg to extend the hip and bend the knee, and stand with the healthy leg. Emphasize hip inversion, hip extension and knee flexion. (8) During the standing period, train the patient to stand with the legs crossed. Emphasize that the affected leg is in front and slightly flexed against the healthy knee.
Exercise therapy should pay attention to the training of muscle strength and posture correction. Posture correction, such as pointed foot and trunk flexion, should not be performed until the posture is corrected and the extensor spasm is relieved, and orthotics should be worn to ensure knee stability if necessary. For knee anteversion below 10°, it is beneficial to stabilize the knee joint and no correction is required. The treatment should not be focused on each muscle or joint activity, but rather on functional training.
Massage is mainly based on point pressure, the knee is the capital of tendons, the liver is the main tendon, and the kidney is the main bone. The principle of acupuncture points for knee dystocia is to follow the meridian and local acupuncture points. The commonly used acupuncture points are Thigh Pass, Fu Hare, Liang Qiu, Calvary, Sea of Blood, Yin Ling Quan, Yang Ling Quan (tendon meeting), Wei Zhong, Cheng Shan, Foot San Li, Hanging Bell (bone meeting), etc. Use the thumb to press the above points, and use discretionary force according to the strength of the muscle and muscle tension. For points with low muscle strength, use heavy stimulation; for points with high muscle tension, use light techniques to relax and activate the tendons. Operation is as follows [18]: the child supine, lower limbs slightly flexed, a soft pillow under the knee, the threaded surface of one thumb and the remaining four fingers flexed into an arch, pinch or meat around the patella, the soft tissue around the knee. The force is repeated from light to heavy and then from heavy to light for 2-3 minutes. The thumb pushing method is then used to apply the surgery around the knee joint in the circumference of the foot Sanyang meridian and the foot Sanyin meridian, and the operation is repeated 3-5 times. The child then straightens both lower limbs and holds the bad not with both hands or one hand, pushing or squeezing towards the knee joint for 1-3 minutes. The rubbing method can also be applied, starting from the N fossa, rubbing the bilateral collateral ligaments, rubbing the bilateral knee eyes and the circumferential edge of the patella, to the extent of heat penetration.
3 Discussion
Children with cerebral palsy have nonprogressive, permanent central motor disorders triggered by injury and trauma to the brain at an immature stage, which affects the longitudinal growth of muscles due to muscle spasm and lack of muscle balance, resulting in deformities such as fixed muscle contractures, muscle and bone deformities, joint deformities, motor dysfunction, abnormal motor development of posture, abnormal reflexes, and abnormal muscle tone signs [19]. . The continuous pulling and holding action of the orthosis stimulates the proprioceptors of the skin, muscles, muscle cavity, and ligaments, so that the cerebral cortex constantly receives proprioceptive shocks, and the brain center thus sends messages to excite nerves, promote growth and development and recovery of motor function, eliminate and prevent contractures of muscles, muscle health, and joints, improve joint mobility, thus helping to relieve antagonistic muscle spasm of the limbs and trunk, reduce muscle tension, inhibit the primitive reflexes of the foot, increase flexibility, restore muscle function, and facilitate the emergence of uprightness, turning down, and balance reflexes [12]. A suitable orthosis can reduce the tension of the muscles of the joints of both lower limbs, improve the solidified movement patterns, enhance compensatory and auxiliary lost functions, maintain the support and stability of the body mass, and control involuntary and involuntary joint movements,
The massage for pediatric cerebral palsy knee dystocia mainly uses the Chinese medicine massage method of pinching, pushing, holding, popping, plucking and percussion to relieve the tense muscles, reduce muscle tension and improve muscle strength, and also applies different techniques to the relevant parts of the child’s body surface, based on the direction of muscle movement in the meridian circulation area, and carries out massage along the circulation area, which causes physiological changes through reflex action, and plays a role in unblocking the meridians, activating the meridians and correcting abnormal posture. Through reflex action, it causes physiological changes, which can unblock the meridians, activate the meridians, correct abnormal posture and promote normal movement. Tui-na massage has no side effects, is easy for children to accept, painless, easy to use, and is currently an ideal treatment method.
Exercise therapy is mainly based on knee four-point kneeling, knee two-point kneeling training, supine hip and knee flexion training and knee control training, etc., to suppress abnormal posture and promote the development of normal posture. All of these methods are used to promote the recovery of knee function in children with cerebral palsy. In addition to the above mentioned techniques, long-term exercise therapy and occupational therapy should also be used to improve the child’s motor ability and living ability. In addition to the above manipulative therapy, long-term and extensive exercise therapy and occupational therapy should be used to improve the motor ability and life skills of the child.
4 References
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