(A) Foot drop
Foot drop is caused by 3 reasons: the primitive reflexes have not disappeared, normal reflexes have not been established, and abnormal force and contracture.
Solution: ①Relieve the contracture of ankle joint by massage, and move the ankle joints on both sides more than 50 times every morning, each time for half a minute, so that the ankle joints are dorsiflexed at least 90 degrees. (2) Due to the tension of the gastrocnemius and plantar flexor muscles caused by abnormal force, can be solved by pulling the gastrocnemius and plantar flexor muscles, that is, support squat, put a stick under the forefoot of both feet, or squat on a 30-degree slope, pulling the plantar flexor muscles and Achilles tendon, each squat 10 minutes, three times a day. Or hold the child’s ankle joint with one hand and the palm of the child’s foot with upward pressure so that the ankle angle is less than 90 degrees, and then fix the pull for 3-5 minutes. ③ For reflex problems, the therapist should manipulate the stimulation to trigger active dorsiflexion of the ankle joint, 50 strokes per side each time. Wang Hui, Department of Pediatrics, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine
(2) Inward turning of the foot, outward turning of the foot, inward eight, outward eight of the foot
(1) The solution for inversion of the foot: First, the child’s outer calf skin is stimulated from the bottom to the top with hands, small brushes, and ice cubes, which can induce the appearance of active foot valgus action. Second, stimulate the lateral side of the child’s foot with manipulation to trigger the foot valgus. Third, put a board on the outside of the foot, so that the inside of the foot is fully on the ground, stimulating the medial force; if necessary, practice standing on one leg and put an inclined board on the outside of the foot. If the child has one foot inversion and one foot valgus, put a board on the inside of the valgus foot and a board on the outside of the valgus foot. If the foot is inwardly turned bilaterally, a board can be placed on the outside of each foot, so that the inside of both feet are forced to correct the inward turning.
(2) solution of foot valgus: If one side of the foot valgus, a board can be placed on the inside of the foot, so that the outside of the foot is fully on the ground, stimulate the outside force, if necessary, single-leg stand, the inside of the foot put a board. If the two sides of the foot exostosis, you can make a board high in the middle, low on both sides, so that the child’s feet on the board, so that the outside of the feet fully force, correct foot exostosis. If the lateral side of the child does not exert force, the foot thumb often hooked inward, or to the second toe overlap, then you can use gauze to gently wind up the thumb pad high, so that the thumb normal force, which is conducive to the improvement of foot valgus.
(3) the correction of the foot inside the octagon: the cause of the foot inside the octagon is the relatively poor muscle strength of the outer calf muscle group, the inner calf and the inner edge of the foot muscle tension. The main correction methods are.
①Stimulate the lateral calf muscle group with your hand to improve the lateral muscle strength. ② Fix the ankle joint with one hand, hold the forefoot of the foot with the other hand and slowly pull outward to fix it, so that the muscles of the inner calf and the inner edge of the foot can relax. ③Practice squatting with the child’s heels together and toes outward, squatting in an outward figure of eight, or support squatting for about 10 minutes. ④Standing (or standing against a wall) with heels together and toes pointed outward in an outward-focused position for about 10 minutes. ⑤When pulling and walking or walking alone, in severe cases, the therapist can passively kick the child’s toes outward with the foot or verbally stimulate the toes to push outward.
(4) training of the external foot: the cause of the external foot is the tension of the outer calf muscles, the inner muscle strength is weak. Training methods are: ① using techniques to stimulate the medial calf muscle groups, triggering the medial foot force. ② Fix the ankle joint with one hand and hold the front part of the foot with the other hand to slowly pull inward and fix it, so that the lateral calf and the lateral foot can relax. (③When the child takes a stool sitting position, supports squatting and standing, the therapist makes his or her toes oppose each other and the heels separate, and insists on fixing for 10-18 minutes time.
(iii) Knee hyperextension
Knee hyperextension is caused by: (i) bony changes in the knee joint itself, resulting in abnormal knee joint position. (ii) Poor knee joint control under weight bearing, as evidenced by loss of knee proprioception, laxity of the periarticular ligaments, and weak or non-normal ratio contraction of the quadriceps and N cord muscles. (iii) Contracture of the soleus flexor or high muscle tone. ④ abnormal massage, excessive force, resulting in medically induced injury.
Training methods.
①Improve quadriceps muscle strength training: boarding sitting position to standing position transfer. Exercise the therapist hands to control the child’s double knee joints, so that they do not overextend; or sitting on the edge of a chair or bed, hands held on the edge of the chair or bed, kick the leg straight, last 3-6 seconds to put down, if completed easily, you can apply appropriate resistance on the child’s wrist.
② Training to improve the muscle strength of the N cord muscle: the child is in a prone position, the parent fixes his thigh with one hand, holds the child’s ankle with the other hand, and helps the child to do the flexion and extension of the leg. When the child completes this movement independently, the hip may buckle when the leg is flexed with force. Parents can use both hands to fix the hip and apply appropriate resistance on the calf as appropriate.
③ Training to improve the strength of the plantar dorsiflexors. This training is important for children with plantar dorsiflexor muscle contracture or high tone, which leads to knee hyperextension: when the child is sitting or supine, the therapist holds the child’s ankle with one hand and the upper third of the foot with the other hand, and does the dorsiflexion of the foot at 90 degrees or slightly over, or when the child is prone, the therapist fixes the ankle with one hand: the other hand holds the upper third of the foot and does the pulling activity. Hold the upper third of the foot and pull downward (note: 90 degrees of knee flexion). Or put a board in front of the child’s feet and let the child squat for 10 minutes, or let the child squat on a 30-degree slope for 10 minutes, 3 times a day, this method can pull on the gastrocnemius and soleus muscles.
Knee control training: First, use stockings or elastic bands to fix the knee joint to control knee hyperextension. Second, the child’s hands are placed on the therapist’s shoulders, and the therapist places both hands on the outside of the child’s knee joint to control the knee joint, allowing the child to squat slowly downward with a straight trunk and then slowly stand up. Note that when the child is upright, the knee joint should be controlled in the neutral position, never overstretching, and the magnitude of the squat should be determined by the child’s ability to control the knee joint. Third, when standing or squatting the child, the therapist should be careful to control the knee hyperextension with words. Fourth, control while the child is walking: the therapist is behind the child and uses his or her hands to restrain the child’s knee flexion and control knee hyperextension with verbal stimulation.
(iv) Knee flexion
The causes of knee flexion are: (1) due to the child’s own bony changes. (ii) Contracture of the knee joint due to prolonged inactivity or the joint being in a fixed position for a long time. Poor control of the knee joint and poor muscle strength of the quadriceps. (iv) Abnormal force of the plantar flexors and gastrocnemius muscles and high muscle tone.
Training methods.
① The child is in the supine position, the therapist holds the knee joint with one hand and the ankle joint with the other hand to do pulling passive activities, so that the knee joint is fully straightened for a few seconds, then flex the hip and knee, and then pull, each time pulling 50 times. Be careful not to use too much force too fast and too hard to avoid knee hyperextension.
②Standing position of the child, the therapist’s hands support the child’s hip fixed, the therapist’s knees aligned with the child’s knee joints (the child’s knees together) parents in the back fixed heel, so that the child’s knee joints try to straighten, try to straight back, pay attention to the appropriate force.
③ therapist in the back, the child to take a standing position, therapist in the back hands fixed double knee joints child feet double knees together, so that the knee joint straight, then the child bent forward down hands touch their toes, the N rope muscle to pull, if necessary, with the help of the child’s parents to support the child’s hips forward force, so that the knee joint fully straightened.
(E) poor quadriceps muscle strength
Training methods.
①Sit on the stool and transfer to the standing position. Let the child lower his head, lift his hips, straighten the knee joints of both legs when standing up, and then sit down. 30-50 exercises each time, which can be increased slowly according to the child’s strength and ability to bear.
②When standing against the wall, the therapist helps the child with both knees with both hands, try to make the child’s legs straight, pedal upwards, insist for a few seconds, then pedal upwards until straight, then bend and pedal straight again, 20-30 times each time, or slowly increase according to the child’s strength and ability to bear.
③When the child pulls and walks, the therapist is in front of the child, one hand pulls the child’s upper limb on one side, one hand supports the knee joint on the opposite side, language stimulates walking one step and stirring a little later before taking a step, after taking a step, make the knee joint straighten as much as possible before taking the next step.
④When the child walks on his or her hip, the therapist is behind the child and uses one hand to hold the child’s left knee joint to stimulate the child verbally and manually, straighten the left leg and then take the right leg, and then use the same method to hold the right leg and take the left leg.
⑤ If the child can walk alone, the therapist should verbally stimulate the child to straighten the leg as much as possible, take one step, straighten the stirrup, and go slowly so that the child can make full use of the quadriceps muscle strength to straighten the knee joint.
(6) Hypertonicity of the hip flexors
The abnormal posture caused by the tension of the anterior flexors is: the child’s hips are upturned, the waist is not straight, the body is leaning forward, and the heels do not reach the ground or do not exert force.
Training methods.
① The child is in a prone position, the hip may be slightly raised, the therapist can use one hand to press the child’s side of the hip, the other hand to bend the corresponding leg, put the hand on the upper part of the knee joint, and then slowly lift upward, pay attention to the first time to do this pulling action, not eager, it will bring pain to the child, or due to excessive force caused by strain or fracture.
②The child is in prone position, lying on the therapist’s legs, then the therapist presses the left elbow joint on the waist of the child, and puts the right hand on the back of both thighs, then slowly presses the left elbow downward and gently lifts the right hand upward, paying attention to the force not to be too violent, and slowly increases the force of pulling.
The child is in a prone position, and the therapist supports the child with both hands to apply pressure at the bilateral hip joints to keep the child’s joints off the ground. Cue or help the child to straighten the arms with force for 1-2 minutes, then get down and straighten again with force.
The child’s legs are spread apart so that they are sitting on the therapist’s lap and the therapist’s hands are holding the child’s pelvis bilaterally, then the child is bent over on his or her back to touch the toys on the floor, then gets up again. (Note that the child’s lumbar vertebrae are placed on the therapist’s knees and thighs.) This pulls the flexor muscle groups with high hip muscle tone and improves muscle strength. Each time the number of training, depending on the child’s physical strength, or make the child lie on the edge of the bed, legs on the bed, the body above the waist lying on its back under the bed, to complete this action.
(G) poor muscle strength of the low back muscle caused by the waist can not be straightened
Training method: let the child lie flat, legs flexed, parents use both hands to fix the child’s feet, let the child try to raise the hips, pelvis up; to the body stem, pelvis, lower limbs of the thighs in a straight line is appropriate, if too much lifting will appear lumbar back muscle compensation is often seen in the “jerk” phenomenon.
(H) Hip extensor muscle group muscle tone is high
Hip extensor muscle group muscle tone is high, the hip joint forward flexion range of motion is limited, the child will appear to tummy phenomenon.
Training methods.
① The child takes a long sitting position, the therapist kneels behind the child, hands fixed knee joints (such as knee hyperextension do not force downward pressure or put a ball of paper under both knee joints to control knee hyperextension), then the therapist uses chest strength, slowly downward pressure, but not too fast and too hard, for 1-2 minutes, the child’s hands can touch their toes.
②The child is in a standing position, the therapist fixes his knee thighs with both hands, fixes the child’s feet with his own feet, and then allows the child to slowly bend forward and downward to touch his toes for 1-2 minutes.
③When practicing standing and walking, language stimulates the child to stand and walk with head down and stomach tucked.
(ix) Hip joint inversion and internal rotation
Internal rotation of the hip joint will cause muscle shortening and the “scissor step” posture of internal rotation of both lower limbs.
Training methods.
①Passive training of joint range of motion to maintain normal joint movement and expand the restricted joint range of motion, pulling on the hip abductor and external rotator muscles, or stimulating the lateral thigh muscles. ②When squatting, the child put his hands between his legs to separate them and then stand up. ③When standing against the wall or alone, place a towel roll between the legs to separate the knee joints. ④When the child is sitting, make a stool with a backrest to sit backwards and put the legs on both sides of the small stool. ⑤ Hold your hands on the backrest and pull on the adductor muscles. Or sit on a small stool and do the action of hip abduction and external rotation.
(X) Hip abduction and external rotation
The reason for hip abduction and external rotation is low muscle tone, the posture of abduction and external rotation, the knee joint can hardly maintain the flexion position, also known as “frog-like posture”.
Training method: The child’s lower extremities are flexed in the standing position, and the trainer applies resistance from the lateral side of the knee joints inward, so that the child can force the leg to the lateral side, which is the action of abduction and external rotation. The therapist then moves both hands to the medial side of the knee and applies resistance outward, allowing the child to resist this resistance while performing the internal rotation activity.
Note: Whether doing resisted abduction and external rotation or resisted internal rotation, the resistance should be applied evenly throughout the process. In addition, the resistance should be appropriate, so that the child can train evenly under the resistance.
(XI) Internal rotation of the hip joint on one side of the child
The abnormal posture caused by internal rotation of the hip joint on one side, resulting in internal rotation of the knee joint, foot valgus and lateral bending of the trunk.
Training methods.
①Passive internal rotation, abduction and external rotation of one side of the hip joint, so that the knee joint is abducted and externally rotated to the horizontal plane, the action should be slow.
② single-leg stand, stand, inward internal rotation side of the foot inside a 2 cm board, so that the outside of the foot force to correct the valgus, and then the therapist lift the normal side of the leg, so that the inward internal rotation side of the single-leg stand. When standing, the entire weight is shifted to the lower limb of the inwardly rotated side.
③When walking, one side of the hip joint is side-bent, the hip joint can be righted with the help of hands, and try to make the child stir straight with force on the inwardly inwardly rotated side.
④ Perform trunk lateral bending, in which case one side of the hip joint is laterally bent.
If the hip is protruding to the right side, the child should be passively bent to the right side, so that the left hip is protruding. Similarly, if the left side is protruding, the child should be bent to the left side to make the right side protrude. The correct method is to fix the hip joint with both hands and then bend it to one side. Then, the therapist moves the child’s legs to one side.
(XII) Upper limb and hand training
I. Upper limb training is mainly for the movement of the shoulder, elbow and wrist joints.
(A) Shoulder joint movement limitation
1. Do passive pulling exercise. Take a supine position, the therapist holds the upper arm of the child with one hand and the forearm with the other hand, then slowly lift upward along the midline of the body, and continuously induce with words: “Lift your arm up with force”. This can last for 6-10 seconds at a time until it is close to the edge of the ipsilateral ear. Or hold the palm of one hand, tap the shoulder k point with the other hand, and keep stimulating with words, “Lift, lift, lift” until you lift to the maximum.
2.Manual guide training. Take a sitting position, first let the child’s restricted upper limb rest on the therapist’s shoulder, when the arm cannot be raised, the therapist should squat down to adapt to the position where the affected arm can be raised, hold the child’s elbow joint with one hand, rub the thumb on the Quchi point, hold the shoulder with the other hand, and use language to suggest relaxation, meanwhile, the therapist slowly straighten the body, so that the child’s shoulder is raised unconsciously with the relaxation of the shoulder muscles, until the shoulder joint cannot be When the shoulder joint can no longer be raised, the lifting action can be stopped. Do this repeatedly and use rhythmic language to induce spontaneous activity in the child.
(ii) Shoulder joint inversion
1. With the child in the supine position, the therapist holds the child’s upper arm with one hand and his forearm with the other hand, then moves to 90 degrees horizontally, turns the palm of the hand upward, and then continues to move upward to the base of the ear.
2. In a sitting position, the therapist presses the shoulder well point with one hand while holding the child’s hand with the other hand. The therapist’s thumb and the child’s thumb are crossed so that the thumb is abducted and the palm of the hand is turned downward, and the therapist’s hand is held hard with verbal cues, then a small shaking is done, and the shaking should make the child’s shoulder, elbow and wrist joints shake up at the same time, and it is done repeatedly for 1 to 5 minutes.
3. Take a sitting position with the affected arm on the chest, the therapist faces the child, holds hands with the child and does clockwise and counterclockwise rotations of the shoulder and elbow joints (if this cannot be done, more help and traction should be given). To induce shoulder joint movement, take a sitting position, the therapist puts one hand on the child’s shoulder joint in a fixed position and holds the child’s forearm with the other hand, and then does a large rotation movement with the shoulder peak as the axis to increase the range of motion of the shoulder joint.
4.Take a sitting position with both feet flat on the ground, the therapist stands behind the child and grasps his two wrists, then slowly opens them upwards, at this time the child should be reminded to lift upwards on his own, the force used by the parents should be gradually reduced until the child can complete this action independently; you can also let the child hold a wooden stick with both hands in a sitting position, slowly lift it over his head and then put it down again, but the distance between the child’s hands should be wider than the width of his shoulders.
5, the child to take a sitting position, feet flat on the ground, the therapist stands behind the child, one hand to hold the child’s side of the arm, and induce him to slowly stretch to the side, the other hand behind the child, to play a protective role. If the child can complete this action independently, parents can put a toy far to his side for him to touch, which not only achieves the training purpose, but also increases the fun of the training program.
(C) elbow flexion and extension
1, the child to take a sitting position, feet flat on the ground, the therapist grasp the child’s elbow to fix the elbow joint, the other hand to hold the child’s hand (both thumbs interlocked), first the child’s forearm passive in a flexed position, and then let the child will straighten the forearm, repeatedly. When doing this action, the child’s forearm should be passively flexed, and the child should not be allowed to do flexion, especially in children with high muscle tone; when the child is able to complete this stretching exercise, the therapist should give appropriate resistance to the child’s hand.
2, take a sitting position, feet flat on the ground, the therapist grasp the child’s elbow with one hand, fix the elbow joint, the other hand holding the child’s hand (both thumbs interlocked), and then, rotate the forearm back, push up for flexion, and then pull down for extension, and repeat the exercise. For those with high muscle tone and heavy spasticity, the child should be slowly, balanced and continuously inhibited from exerting force and induced to do spontaneous activities of extension and flexion by the situation.
3, passive activity extension, flexion method: first make the forearm rotate forward, with the shaking method, with both hands or one hand hold the child’s forearm, gently force to do a small up and down continuous shaking, so that the muscles around the joint relax, and then one hand to grab the wrist to pull flexion and extension exercises.
4, the child’s elbow joint is flexed position, the main focus on the elbow off, hands straight, force to push the parents’ hands or mirrors, walls, etc., so that not only can induce the child to gradually straighten the arm, but also to improve the muscle strength of the elbow joint extensors (triceps brachii). You can also do arm weight training, that is, let the child take a sitting position, feet flat on the ground, one hand naturally on one side of the body, and keep the elbow joint fully extended, the other hand across the body, to reach the other side of the hanging toys, alternating sides; arm weight training can also let the child sit on the bed, put both legs on the side of the bed, one hand five fingers apart, parents will fix the child’s elbow joint, so that it is fully straightened, and then put the hand on the bed, the parent will fix the child’s elbow joint, so that it is fully straight. Then place the hand on the bed and shift the child’s trunk weight to this arm, holding it for about 1 minute each time, repeatedly and rotating both sides. Arm weight training can also be accomplished by means of quadrupedal stance, crawling training, etc.
(D) Wrist joint activities
Wrist movement training is mainly a palmar flexion and dorsiflexion exercise.
During the training, the therapist first makes a demonstration, and then should continuously induce the child to “straighten the fingers and lift the back of the hand upward” and actively complete the palmar flexion movement. Then let the child “palm down”, to guide the child to complete the dorsiflexion of this action spontaneously. If the fingers are not straight, let the child make a fist to complete dorsiflexion, palmar flexion; or the therapist can hold the child’s hand, so that the thumb is abducted, the wrist joint passive activities into 60 degrees, palmar flexion, dorsiflexion activities, in order to achieve the purpose of flexible wrist joint movements. When the child does palmar flexion or dorsiflexion training, let the child’s hand bend naturally.
II. Hand training
Due to the unique structure of the hand, it allows us to make precise hand movements such as grasping, straightening, flexing, and palming freely. Under the control of the cerebral cortex, each finger can move flexibly individually, and most of the skillful work relies on close cooperation between the hand and the eye. However, when cerebral palsy occurs, the rhythm and coordination of movements are disturbed, growth is stunted, and some simple movements cannot be completed accurately, which hinders daily life movements and learning. This requires special ways to help the affected children and guide their hands to move normally, so that they can perform daily life movements and learning like normal children.
(i) Hand grip
For hands that have been held together for a long time and cannot be extended: the therapist presses the child’s inner guan point with one hand and induces the child to grasp with words or presses the child’s outer guan point to make the child’s fingers open. Slowly spread the child’s fingers apart, and the therapist rubs his fingers on the patient’s palm, followed by flatly pushing the finger extension point (from top to bottom), or slowly rubbing back and forth along the child’s fingers, forearm, and finally up and down to the elbow joint. This training method can stimulate the skin and sensory organs of the child’s cell phone and forearm through the therapist’s palm and fingers, and guide the child to stretch his palm. The most common problem in pediatric cerebral palsy is the difficulty in palmar flexion or grasp of the hand joints, and the hand joint grasping action should be trained. The excessive flexion of fingers is common when grasping, so the child should be instructed to hold large objects first and then small objects later to correct the problem.
Training method: Guide the child to slowly separate the clasped hands and then place them in front of the body with the elbow joint straightened, allowing the child’s hand to gradually exert pressure downward, maintaining a continuous and even force. At the same time, you should constantly use toys to guide and prompt each part of the force, and tell the child what toy it is, and then the child himself to grasp, so as to enhance the child’s ability to identify the outside world, but also passively bend or palm bend the child’s hand, and then release the hand, prompting the child’s fingers to release naturally. This action is repeated several times in a row, and then the child is guided to throw away the toys held in his hands, which can prompt the fingers to stretch.
(B) extension spasm can not grasp
1, training, with the help of some moderate size, light and heavy, easy to grasp toys for the child to complete. When grasping, help the child bend his fingers so that he can grasp the toy, and after a few seconds, slowly reduce the help to the hands, while pushing and pulling the toy laterally to enhance the grasping ability. When grasping, induce the child to separate the five fingers and force them evenly, slowly put them down after grasping, and then pick up …… at the same time to induce the child how to force, grasp and release. When grasping, first let the child’s fingers flex, then grasp with force; when put down, try to let the hand straight, but also to force the child a sense of time, with “one, two, three, four ……” to prompt him to quickly complete this action. Repeat this action to strengthen the child’s grasping ability. Full extension