1.Rehab training 4-6 hours a day, separate training in the morning and afternoon.
2.Training items: passive joint activity training, upper limb and hand function training (separation movement, fine activity, movement stability), kneeling position training, standing balance training, walking training.
3, training methods and essentials.
(1) passive joint activity training: the principle is slow, gentle, in order not to cause tension and pain to the patient, in short, to be carried out with the cooperation of the patient
(2) Upper limb and hand function training (detachment movement, fine activity, movement stability).
During the long process of biological evolution, humans evolved from crawling to walking upright, which freed our hands and enabled us to make tools and perform advanced and complex labor. It can be said that all complex manipulation and labor activities in our daily life are inseparable from the function of the upper limbs and hands. Functional training of the upper limbs and hands in children with cerebral palsy is not only important for the rehabilitation of life and work in the future, but also allows the child to perform the functions of other parts of the body with the assistance of the upper limbs and hands. Before training, it is important to understand what are the important motor functions of the upper limbs and hands under normal conditions.
The main motor functions of the upper limbs and hands: structurally and functionally, the movement of the upper limbs is achieved mainly through the movement of the shoulder, elbow and wrist joints. The shoulder joint allows the greatest range of motion of any joint in the body, such as forward, backward, inward, outward, forward and backward rotation of the entire upper extremity, as well as circular movements around the shoulder joint. The function of the elbow joint allows for the extension, flexion, internal and external rotation of our forearm. The wrist joint is similar in orientation to the shoulder joint, except that the range of motion is relatively small. Functional training of the upper extremity should include functional exercises for all three joints in all directions. The joints of the fingers are relatively complex in composition, but in terms of motor function, the thumb has a larger range of motion, such as internal retraction, abduction, flexion, extension, internal rotation, external rotation, and palmar movement of the thumb. The orientation and range of motion of the other four fingers are relatively small, mainly extension, flexion, adduction and abduction. In the rehabilitation of hand function, we should focus on the functional development and practice of each joint of the thumb. In daily life, the function of the thumb accounts for almost half of the function of the whole hand. The thumb, in conjunction with any of the remaining four fingers, can replace almost all of the functions of the entire hand. In the functional areas of our cerebral cortex, the functional representation area of the thumb is larger than the functional representation area of the entire lower extremity.
The main content of functional training of the upper limbs and hands: 1.
1. Training of joint motor function. In the upper limb and hand motor function training, according to the specific situation of the child’s dysfunction, we should develop effective training methods to correct and exercise their motor functions for each joint and the corresponding lesions of the muscle groups attached to the joints at all levels. Some children’s motor dysfunction may not only be due to muscle spasm or muscle tone abnormalities, but may also be due to joint deformity or subluxation based on muscle spasm or muscle tone abnormalities, and may therefore require surgical treatment. In the training, we should analyze the causes first, then carry out targeted training, and correct the various incorrect movements and postures of the child in the training at any time.
2. Training of compensatory functions. The purpose of the upper limb and hand function training is to lay the foundation for future life and work. Therefore, in the training, we should not only focus on the normal motor function of the joints and muscles of the child; at the same time, we should make full use of the structural and functional characteristics of each joint, and develop corresponding measures to enable the child to establish certain aspects of motor function through various compensatory mechanisms. In addition to the two groups of muscles that confront each other, there are also other synergistic muscle groups that are involved in the movement of the human joints in all directions; in addition, each of the
In addition, each muscle is almost simultaneously involved in the movement of a joint in one or more directions.
3, the upper limbs and hand function training procedures and methods. According to the rules of children’s motor development, the procedure of upper limb and hand motor training for children with cerebral palsy can follow the principles of gross motor first and then fine motor, proximal first and then distal. In terms of specific methods, the upper limbs can be trained in all directions of the shoulder joint first, followed by the elbow and wrist joints; for finger function training, the proximal knuckle joints should be trained first, followed by the distal knuckle joints. The training of a specific joint function is followed by the functional training of other adjacent joints, and then the training of the distal knuckle function. When training a specific joint function, the function of that joint can be practiced individually and then combined with other adjacent joint functions for overall training. In this way, a specific joint can be targeted and reinforced for a specific joint impairment in motor function. For example, when a child lifts his or her hand to reach for something high, he or she tries to lift the entire upper extremity to grasp it because of poor wrist extension. In this case, we should focus on strengthening the training of wrist joint function. In terms of the requirements for training movements, the training of fine and large movements can be carried out first, followed by the training of fine movements. At the same time, there is also focus on the standardization and coordination of each movement of the child training.
4, in the training of the child’s finger movement function, not only according to the movement characteristics of each finger joint functional exercises, but also combined with the practical functions of the fingers in daily life to train. For example, you can first apply some toys that are large and easy to hold, through the child’s lifting, grasping, holding, relaxing, patting, pushing, pulling, lifting and other actions, in order to train their fingers thicker and need strength movements. Then apply some small, smooth or manipulative toys such as small beads, electric toys with buttons, etc., and let them perform finer and more dexterous movements such as pressing, tapping, flicking, hooking, pulling, and pinching, in order to train their individual finger mobility and the ability to coordinate and cooperate with other fingers.
(3) Kneeling position training: At the early stage of training, if the child cannot independently maintain the kneeling position, parents can assist him/her in stabilizing the pelvis.
(4) Training of standing balance.
Just because a child with cerebral palsy can rise from a sitting position to a standing position does not mean that he or she is ready for walking training. In addition, since the contact area between the body and the ground is obviously reduced in the standing position, the child can maintain the balance and stability of the body mainly through the support of the feet and the curvature of the crest, which increases the weight of the lower limbs. This is a serious challenge and test for children with cerebral palsy, especially those with bilateral lower limb spasticity. Therefore, at least one aspect of the standing exercises should be mastered by the child.
①Learn the correct standing posture. When training the child to stand, the first thing to emphasize is the correct standing posture at rest, rather than just pursuing the child to be able to “stand”. Because the main purpose of standing training is to lay the foundation for the child to walk independently in the future, children with cerebral palsy often show many abnormal movements and postures, such as head bowing, leg bending, waist bending, and excessive leg separation, in order to maintain the stability and balance of the body during standing training due to different degrees of motor function impairment. This will not only affect the practice of standing function but also seriously affect the training of walking and other motor functions in the future. The correct standing posture should include the child’s feet flat on the ground, both knees and hips as straight as possible so that the legs and trunk are straight, the head is centered, the child’s shoulders and hips should be at the same level when viewed from the side, and both lower limbs can be slightly separated but not too wide so as not to affect future walking training.
② Correct and prevent abnormal standing posture in a timely manner. In the process of standing training, the child often appears some abnormal movements and postures. This is mainly due to two reasons, one is due to the child’s fear of falling or excessive pursuit of physical stability and balance, and take some protective actions and postures, generally through the active teaching and help of trainers or family members is not difficult to overcome; and the other reason is mainly due to the child’s own motor function disorders, the most common reason, is due to the child’s lower limb motor function disorders caused by Various abnormal postures. For example, due to the spasm or increased tension of the lower limb muscles, the knee or hip joint flexion causes difficulties in extending the leg and waist; the child’s foot inversion or foot drop due to increased tension or muscle spasm of the calf muscle group, so that it can land on the ground with the soles of both feet when standing; the child’s thigh muscle group tension or muscle spasm, resulting in double lower limb stiffness and double foot inversion, etc. For these situations, the trainer or family members should train the child to stand at the same time, but also with the help of some other auxiliary training methods, such as massage, pulling, physical therapy and plaster or splint fixation, so that the child in the standing training in a variety of abnormal posture is constantly corrected.
③The degree and method of standing training. Similar to the procedure and method of sitting training for children with cerebral palsy, the training procedure for standing should be to practice supporting standing first and then standing alone. In the initial practice, the trainer or the family can hold the child’s hands or hold the child’s armpits to let him/her practice standing; in addition, the child can be allowed to stand in a standing bucket or surrounded by a protective guardrail in the center to practice. This not only overcomes the child’s fear, but also allows the child’s whole body coordination to be trained. After the rehabilitation training, when the lower limbs and waist reach a certain level of support and the ability to maintain the stability of the body, the child can gradually reduce the support or let the child gradually away from the guardrail and other auxiliary facilities, and let the child gradually extend the duration of standing, in order to exercise its ability to stand alone and maintain the stability and balance of the body at rest. At the same time, the trainer or family members should observe the child from time to time and correct the abnormal posture when they find it.
After the child learns to stand alone smoothly for a certain period of time, the following training methods can be used in order to train the child’s ability to maintain body stability and balance at rest. This is also called leg-splitting exercise to avoid shifting the body weight to the healthy side; place blocks of different heights under the child’s two feet and practice standing, then train the child’s ability to support the weight on one leg by continuously exchanging legs and changing the thickness of the blocks. For children with hemiplegia, the lower limb of the healthy side can be consciously placed on the block to enhance the exercise of the support ability of the affected limb.
In the training of dynamic standing balance, according to the degree of paralysis, age and intelligence of the child, various actions can be taken to make the child’s body center of gravity change and train the child’s ability to maintain body balance during activities. For example, for younger children, the upper limbs can be used to move the body’s center of gravity by teasing them to play with toys or games; for older children, they can be trained by using a buckboard; for children who can cooperate well with the training, they can practice their balance when standing with their bodies swaying back and forth, left and right, and so on.
In conclusion, in the rehabilitation training of somatic motor function for pediatric cerebral palsy patients, especially for those with obvious spastic paralysis, the training of static and dynamic balance in standing position is relatively difficult. The training method and training progress should not only vary from person to person, but also require a certain degree of patience and persistence.
(5) Walking training.
①Standing position training is an important basis for walking training. The child’s standing position training performance is good or bad, is one of the key factors to practice walking function and the progress of fast or slow. Because in the walking action, the child is not only required to be able to coordinate the hip, knee and ankle joint flexion and extension at the same time, and to complete the leg lifting and striding action. More importantly, the child is required to be able to support the weight of the body in the standing position with one or both lower limbs during walking, and to move the weight of the body forward and the lower limb of the striding side with the striding movement, so as to maintain the balance of the body in the dynamic standing position. Therefore, if the child is already standing alone and is able to maintain balance in both static and dynamic stance, then walking training will be relatively easy. If the child is only able to stand with support, the child’s ability to maintain balance in both static and dynamic positions needs to be continuously reinforced while practicing walking.
The walking training procedure for children with cerebral palsy is basically similar to that for normal children learning to walk. In terms of training procedures, walking training for children with cerebral palsy is basically similar to the way normal children start to learn to walk, such as first practicing walking with the support of people around or supporting things like railings, and then gradually disengaging from the support and leaving the railings to practice walking independently, and then gradually disengaging from the support and leaving the railings to practice walking independently; first practicing on level ground, and then practicing in places with uneven heights or steps; the speed of walking The speed and distance of walking is also from small to large, etc. For example, when training a child with cerebral palsy to cross an obstacle, the child should first cross the leg of the paralyzed side when going down a step and the leg of the healthy side when going up a step, so as to consciously give the lower limbs of the paralyzed side of the child more opportunities to exercise. In addition, a very important additional training element in the walking exercises of children with cerebral palsy is gait training.
Gait training is the key to walking training for children with cerebral palsy. Gait is also the posture that we show when we walk. Children with cerebral palsy will show various abnormal postures when practicing walking due to muscle spasm, abnormal muscle tone and ataxia, etc. These abnormal postures must be corrected continuously during walking training in order to facilitate smooth walking training. For example, in children with spastic cerebral palsy, excessive flexion or extension of the hip, knee and ankle joints may occur due to muscle spasm or abnormal muscle tone, and cause the child’s body to lean too far forward or backward, lower limb stiffness or excessive flexion, foot valgus dorsiflexion or internal rotation and droop, and so on. The child may have difficulty lifting the leg, striding and landing on the heel during walking exercises. The child’s ability to control various movements of the lower extremities and the appearance of various abnormal gait patterns during walking affect the child’s ability to maintain the stability of body balance.
For the correction of these abnormal movements and postures, the trainer or the family needs to analyze the causes of the abnormalities and develop corresponding training measures to correct the causes of the abnormal muscle tone in different muscle groups. For example, let the child lie on his back first, then carry out pulling, massage therapy, etc.; or let the child carry out hip, knee and ankle extension exercises with the help of the trainer and family members; or let the child practice coordinated stirrups with the lower limbs hanging and not touching the bed. Or let the child sit on a chair first and practice alternating forward and backward sliding of the legs; or practice flat-footed stepping on the ground, etc. If necessary, you can also use Chinese medicine massage, massage and physiotherapy methods. In short, to gradually correct different parts and different nature of the local movement disorder training, and finally achieve the overall coordination and balance of motor function. In addition, for some children with tardive dyskinesia and ataxia, it is necessary to focus on the training of the limbs and the control of the whole body. For example, let the child practice walking in a straight line or, according to the specific situation of the child, let them practice according to the line of footprints on the ground; also let the child practice stepping or swinging the upper limbs in place, etc.