The rehabilitation of children with cerebral palsy requires the participation of multiple disciplines and offers a wide variety of treatments, including: movement therapy (neuromotor therapy, postural control and postural activities, walking exercises, etc.), activities of daily living training, therapeutic play, speech therapy, psychotherapy, massage therapy, acupuncture, guided education, orthotics, assistive device therapy, pharmacotherapy, orthopedic surgical treatment, selective cremaster heel resection, education and social rehabilitation, etc.
Exercise therapy
Movement therapy plays an important role in the rehabilitation treatment of cerebral palsy. The purpose and the main part of movement therapy is to train walking, control head, sitting and standing postures, and to train active and passive activities of the limbs and trunk through the application of easy-to-use techniques, i.e. neuromotor therapy techniques. The content includes Bobath method, Vojta method, Brunnstrom method, Rood method, PNF method, Ueda method, guided education, and Domain method. Principles.
1.Follow the laws of children’s motor development;
2. Inhibit abnormal movement patterns and induce normal movement patterns at the same time;
3.To enable the child to acquire the ability to maintain normal posture;
4.Promote right and left symmetrical posture and movement;
5. induce and strengthen the desired fixed movement pattern, and gradually complete the coordinated movement from single movement to multiple movements; 6. relieve the muscle tone before rehabilitation training. Key points.
1.Head control;
2.Support lifting training;
3.turning training;
4.Sitting training;
5.Knee-hand standing and high climbing training;
6.Standing and standing training;
7.Walking training;
8.Progressive and practical training of walking.
The various neuromotor therapies used to treat cerebral palsy share a common basis, which is the attempt to trigger the desired appearance of limb movements, or to alter muscle tone (antispasticity), or to inhibit the appearance of primitive reflexes and abnormal responses, by means of some stimuli (sensory, verbal, postural, specific body positions or movements), in accordance with neurodevelopmental principles. The therapist may use both conventional general movement therapy such as joint mobility exercises and 1-2 neuromotor therapies simultaneously. However, to date, there is much debate about the value, rationality, and efficacy of each type of neuromotor therapy, and further research is needed.
Postural control and postural activities: For the training of young children, the mother or other family members perform such postural therapy or holding activities at home after the therapist has demonstrated and taught them, or through the child’s own activities from one position to another.
Walking exercises.
1. Walking support: For children with bilateral lower limb paralysis, the supporter should stand in front of the child and let the child hold both arms in a straight forward position, with the supporter holding the child’s elbow or hand, giving support and guiding the child’s body weight forward and stepping out. For those with lower limb palsy or hemiplegia, the supporter should support the upper limb (in the straight position) on the affected side at the elbow and hand.
2.Walking with walkers: Walkers for children with cerebral palsy have the following characteristics: stable and sturdy, can support part of or even most of the weight, with armrests or platforms for arm placement; easy to move around, no obstruction in moving forward and turning, but not slippery and difficult to control.
3, wearing orthotics walking: Although wearing orthotics walking consumes more energy, easy to tired, as a practical functional walking its value has some limitations, but because both the lower limb weight-bearing support role, but also to a certain extent to correct the lower limb deformity unfavorable to walking, the patient can open step, encourage its exercise and rehabilitation confidence, so wearing orthotics walking as a therapeutic walking contact, has its positive significance.
4.Walking exercises to correct abnormal gait: suitable for children with cerebral palsy with a mild degree of dysfunction, who have a certain degree of independent walking ability, but have an incorrect gait and poor endurance. Through corrective walking guidance and exercises, with the help of lightweight lower limb orthoses, walking running tables and weight-reducing walking equipment, gait can be improved to a certain extent and walking ability can be enhanced.
5.Walking exercises combined with training of balance ability: Improving balance ability by controlling the support surface of the feet on the floor and other balance training, combined with walking exercises, is helpful for developing independent walking ability.
Conductive education and activities of daily living training
Conductive education is a comprehensive treatment method founded by Peto in Hungary in 1945, which was created by integrating the knowledge of neurology, psychology, education and rehabilitation techniques. In other words, the guide assumes the role of a professional in education and therapy, so that functional exercises can be integrated into education and the child can learn the activities of daily life within 24 hours. For this purpose, the teaching and training contents are programmed to integrate the skills of various specialties such as physical therapy (movement therapy), occupational therapy, speech therapy, education, psychotherapy and social work services to promote the development and development of the various functional areas of children with cerebral palsy. Conductive education focuses on the active participation of children with cerebral palsy in learning and training to overcome the motor and postural abnormalities caused by brain dysfunction, and then repeating the steps of each functional activity with the support of a special environment and training devices, with the aim of achieving independent living and learning without the help of others. The goal of Conductive Education is to develop the character of the child with cerebral palsy, with a focus on the child’s learning and education. It requires active participation and self-motivation, and strives to ensure that the child is interested and enthusiastic in the learning process, which are formulated according to the child’s age. At the same time, it allows for the simultaneous development of physical, language and intellectual activities.
Principles of Conductive Education.
(1) Centering on the child’s needs: Centering on the child’s needs is the core of the Peto Method principles. All therapeutic measures must be centered around addressing the child’s walking and daily living abilities first, based on the child’s immediate needs. However, the educational end point waist be changed at any time according to the different functional disabilities of each child and with the different stages of the child’s growth and development.
(2) Guidance to induce and stimulate children’s motivation to learn: encourage and guide children to think actively, aspire to goals, and aspire to success; use environmental facilities, learning practices, and group dynamics to induce motivation to learn; stimulate children’s interest and sense of active participation with recreational and rhythmic intentions, maximize guidance to mobilize children’s potential for independent movement, and stimulate children’s motivation to learn, to meet challenges, and to solve the practical problems they face (3) Holistic awareness and comprehensive development
(3) Holistic awareness and comprehensive development: It is important to have a comprehensive understanding of each child, set some common goals and apply the same methods to train the child according to the expectations and needs of the majority of the children in the group. The viewpoint of comprehensive rehabilitation should be insisted on, and the children with cerebral palsy should be combined with education and training in language, intelligence, emotion, personality, interpersonal relationship, will, daily life function, physical ability and cultural study, etc. The education and training should be combined with various other treatments and active participation in society, so that they can get comprehensive development in all aspects, and these developments will help them to overcome their behavioral disorders.
(4) Grouping by nature and optional classes: Children with similar functional disability nature and Chengdu are formed into groups so that the learning objectives, contents and teaching methods can be more relevant to the needs of the majority of children. If necessary, classes can also be selected according to the level of intelligence and individual needs, such as cultural classes in groups according to the level of intelligence, sometimes divided and sometimes combined, but to maintain relative stability, so that each child can get the maximum degree of learning training.
(5) Step by step, integration and coherence: start training with simple movements, or break down difficult movements into several small movements for training, and then train in tandem when the small movements are skilled, so that children can easily gain a sense of success and increase their confidence, combine education and training with the usual life process, reasonable choreography, combination of movement and integration and coherence, so that children with disabilities can easily and happily Complete each exercise procedure so that every moment of life is an opportunity for children to learn and encourage them to continue this awareness throughout their lives in order to improve and consolidate the rehabilitation effect.
(6) Extreme responsibility and teamwork: The Conductive Education Team (auxiliary facilitators, physical therapists, speech therapists, nurses and other staff), which is headed by a facilitator, is fully responsible for the life, learning, functional training and various therapies of the children in the group. The guided education team must have a high sense of responsibility and love, understand and care for each child’s problems and needs, plan the goals, design the methods, arrange the curriculum and organize the implementation, etc. The team members must work closely with each other and play the team spirit, demonstrate and guide the children in the group to help and encourage each other and play the team spirit.
Orthotics and assistive device treatment
Role of orthotics.
(1) It can prevent and correct the contracture and deformity of the limb. Orthotics can help protect normal limbs, such as ankle foot orthotics on the stabilization of the ankle joint; can also inhibit spasticity and prevent contracture deformation of the limb, such as horseshoe deformity; can also maintain the postoperative correction position. The appropriate orthosis can reduce the tension in the joints of both lower limbs, including around the pelvis. Orthotics also inhibit the primitive reflexes of the foot, which tend to persist in children with cerebral palsy and lead to abnormal posture and poor balance. However, inappropriate orthotic wear can cause the side effect of persistent muscle traction contractures in children with spastic cerebral palsy, thus enhancing spasticity and joint responses and worsening dysfunction.
(2) Improvement of dysfunction. Improving the type of movement that has been immobilized, improving function as well as enhancing compensatory and adjunctive loss of function. The use of orthotics in children with cerebral palsy has a bias toward improving dysfunction, and thus more orthotics are used for short periods of time and less for long-term use as an adjunct to improving ability, which is a difference from the use of orthotics in adults. In addition, orthotics are rarely used for children with tardive dyskinesia because involuntary movements of the whole body are difficult to control with local orthotics. In order to ensure the therapeutic effect of orthoses, it is necessary to combine them with exercise therapy.
(3) Other roles. Maintenance of weight support and stability, as well as control of involuntary movements and involuntary joint movements. Most children with spastic cerebral palsy have increased muscle tone in both lower extremities and walk with a scissor gait and inward turning of the feet, which limits the walking function of the child. The ankle and foot are the largest weight-bearing support parts of the body, and maintaining the stability of the ankle and foot and maintaining its biomechanical characteristics is one of the keys to walking.
Types of orthoses often used for children with cerebral palsy: The most commonly used orthoses in the treatment of children with cerebral palsy are hard ankle plastic ankle-foot orthoses, which can fix the ankle joint of spastic clubfoot in the corrected position as much as possible, which can relieve the triceps spasm and improve the gait. There are also elastic ankle plastic ankle-foot orthoses, which have good dorsiflexion assistance and plantarflexion resistance and are suitable for people with drooping feet. Children with pointed feet, pronated feet or deformed pronated feet can apply a short lower limb orthosis with metal brackets on both sides when walking. Depending on the direction of inversion and valgus, padding can be added to the outside and inside of the sole to flatten the foot. Knee flexion deformation can be applied to the long lower limb orthosis, so that the knee joint to maintain a straight position. Hip abduction orthoses can be used for the deformation of the thighs to keep the legs in an external position. Other functional aids include sitting chairs, standing tables, crutches, walkers, wheelchairs, etc. Assistive devices for the upper extremities include self-help devices that are commonly used in self-care activities and life-related activities to assist the child’s hand grasp and manipulation abilities.
Issues to be noted in the use of orthotic treatment.
(1) Care should be taken to prevent pressure injuries to the limb from the orthosis during use and should be checked at all times.
(2) To be constantly adjusted and updated with age.
(3) Functional assessment should be performed regularly.
Chinese medicine rehabilitation treatment
Including acupuncture therapy, tui na therapy, and Chinese medicine treatment. Acupuncture therapy: general head acupuncture and body acupuncture are carried out simultaneously, with acupuncture treatment 5 times a week, and the efficacy of acupuncture treatment is generally evaluated in about 3 months. Tui-na therapy includes head, trunk, upper limb and lower limb tui-na techniques. For children with spastic cerebral palsy, multiple techniques of tui-na should be used to relieve spasticity and coordinate muscle strength; for children with tardive dyskinesia, attention should be paid to controlling the stability of the whole body during tui-na; for children with hypotonia, slightly stronger stimulation should be given during tui-na to improve muscle tone. Chinese medicine steam bath is a long-established physical therapy used to reduce the muscle tone of children with spastic cerebral palsy. The steam generated by heating the medicinal solution is used to fumigate the skin surface, with the dual effect of heat and medicine in the bath. On the other hand, the heat of the steam makes the tiny blood vessels in the skin expand, promotes blood circulation, accelerates the metabolism of the body, strengthens the regeneration ability of local tissues, softens and loosens the spastic muscles, facilitates the softening and repair of nerve cells, and makes use of the characteristics of the muscle shuttle conduction affected by temperature, so as to relieve muscle spasm and reduce muscle tone, and on this basis, to be rehabilitated and trained to promote the development of motor function of the child, which can be achieved This can be achieved with half the effort.
Orthopedic surgery
Among children with cerebral palsy, those who are older and have not received early treatment, especially those with severe spasticity, may have their spasticity further aggravated due to abnormal posture and movement patterns for a long time, eventually leading to irreversible tendon contractures and bone and joint deformities, and in such cases, orthopedic surgery should be considered as part of the comprehensive rehabilitation treatment.
The purpose of orthopedic surgery is to contact the soft tissue spasticity and correct the bone and joint deformity, and also to create stable conditions for other rehabilitation treatments in order to restore and improve the muscle balance, enhance the motor function of the limb, and return to society. Surgical principles: Upper limb surgery focuses on making the upper limb play or reconstruct the role of grasping, pinching and holding the hand, while lower limb surgery mainly restores the standing posture and walking ability of the lower limb, with the principle of choosing the surgery with the least trauma and the best effect.
Postoperative attention issues.
(1) Postoperative plaster fixation is of great significance to the surgical result. Good plaster fixation can avoid wound bleeding and prevent the occurrence of metastatic tendon stop avulsion or fracture end displacement. Tendon surgery is fixed for 5-6 weeks and osteoarticular fusion for 3-4 months. During this period, pay attention to close observation, if there is severe pain in the limb, pallor or bruising of the limb end, numbness or loss of sensation, cold skin and obvious swelling occur, the cause should be examined and dealt with promptly by loosening the cast or other treatment. For longer time with plaster, pay attention to protect the plaster from damage and loosening.
(2) Postoperative anti-inflammatory, analgesic and hemostatic treatments are the same as for other surgeries.
(3) Postoperative physiotherapy and functional training are equally important, such as the use of ultrashort wave to prevent wound infection and strengthen passive exercise to promote blood circulation, which is conducive to the improvement of limb function and enhance the surgical effect.
(4) Early physical therapy and functional training after removal of plaster fixation.
Selective posterior crestal nerve rhizotomy for treatment of spastic cerebral palsy in children
A key issue in the treatment of spastic cerebral palsy is to release or reduce muscle spasm to facilitate active motor exercise, improve gait, and enhance the ability to care for oneself in daily life. Since all kinds of non-surgical treatments cannot achieve the above purpose satisfactorily, the medical profession has explored the method of selectively cutting the posterior roots of the cremaster nerve to relieve the muscle spasm of the lower limbs based on the knowledge of cremaster neurophysiology for many years, and so far the procedure and the effect have been improved and this surgical treatment has gradually become popular. Indications for surgery.
(1) Only for spastic cerebral palsy, other types such as tardive dyskinesia, ataxia and ankylosis are not suitable for surgery.
(2) The age is 4-8 years old, IQ is above 80, and can cooperate with rehabilitation training to have good results.
(3) There is no deformity of the crestal spine.
(4) The ability to move actively, such as standing in a squatting position, is confirmed by the evaluation before surgery. Only those who meet the indications for surgery will have satisfactory results with rehabilitation training after surgery.
Drug therapy
Drug therapy is mainly based on drugs that promote brain metabolism, gangliosides, brain activator, cytidylcholine, nerve growth factor and other brain nerve cell nutrients, gangliosides are a class of diabetic nerve sheath esters containing sialic acid, which is an important component of human nerve cell membranes. Tetracosyl monosialate ganglioside is one of the important gangliosides and is the only one of them that can pass the blood-brain barrier, which can promote nerve regeneration, repair damaged nerves, restore nerve function and promote nerve remodeling. Gangliosides accelerate the regeneration of nerves. For the spastic type, balufin and botulinum toxin can be used to reduce muscle tone, and for the tardive dyskinesia type, dopamine drugs such as Antan and levodopa can be used in combination. Medication should be used only when necessary, and it cannot replace functional training.
Prevention and health care of cerebral palsy
The current treatment of cerebral palsy focuses on the remedial treatment of behavioral-motor disorders and cognitive decline, so that the child can improve his or her physical and psychological social functions and enhance his or her life.
Quality treatment for cerebral palsy is based on a comprehensive rehabilitation approach, including physical therapy, occupational therapy, speech therapy, acupuncture, acupuncture injections, tui-na therapy and Chinese herbal medicine. In recent years, many biological treatments have also been developed, including nerve growth factor and stem cell transplantation for cerebral palsy. Although the current treatment methods for cerebral palsy are rapidly changing, they still only improve the life status of children with cerebral palsy, but do not cure the disease. Therefore, the fundamental treatment for cerebral palsy is to understand the risk factors for its development, to prevent and control it, and to reduce the incidence of cerebral palsy. Some studies have shown that family history of parental cerebral palsy, prematurity, placental insufficiency, intrauterine distress, neonatal whistling distress syndrome, neonatal ischemic-hypoxic encephalopathy, neonatal intracranial hemorrhage, neonatal brain infection, and neonatal ABO hemolysis are all risk factors for the occurrence of pediatric cerebral palsy. Targeted intervention of risk factors for cerebral palsy by relevant medical and health institutions is important to prevent and reduce the onset of cerebral palsy and guide the treatment of children with cerebral palsy.