Pre and Post Surgical Protocol in Cerebral Palsy Children

There is no special investigation required for SEMLS by OSSCS concept. Simple blood test and x-ray required in some cases. Total duration of surgery is depending upon many factor but 3-4 hour in diplegic and 5-6 hours in quadriplegic. OSSCS Surgery in lower limb is being performed in epidural anesthesia and upper limb in brachial block.

We try that child is not completely unconscious but in small child medicines only given to take them in sleep. Till now no adverse effect is seen. After taken out from Operation Theater water should be given after two hours and food can be given in evening. After surgery no special precaution is to be taken. Child can turnover and sit on bed also. In this surgery all stiffness and Spasticity can be control by only one procedure and muscle balancing power becomes good.

Normally, physiotherapy started after two weeks of surgery. In starting, exercises done only to decrease pain, increase the range of joints and decrease the stiffness of muscles. Then after 1 month of surgery, strength training exercises and exercises for activities of daily living will start. These strengthening and daily living exercises run for almost six months to one year. After this protocol, exercises will be continued till the adolescent phase and child became independent as much as possible. Child should be under close observation. By close observation, child can be secured by the adverse effect of any further problem.

Child feels easy in walking and balancing. Result of surgery depends on many things like therapy, child’s ability to understand and the main parent’s hard work.  In last five years it is never seen that there is no effect of surgery, ever child who has undergone surgery has shown response depending upon their pre operative functional disability.

Operation in these child done after complete investigation and child is operated only who has need and capability too. In this only physical specially deformities and Plasticity is to be corrected and function recovery depends upon therapy and the child’s ability.

Electrical Stimulation for Cerebral Palsy

Electrical stimulation have given some positive results in the muscles of cerebral palsy children. Electrical stimulation is a type of therapy that provides the muscles with a low dosing of electric current. Electrical stimulation for cerebral palsy is used to decrease the effects of stiffness and plasticity in the muscles of the children. The effects of electrical stimulation are not long lasting and need to be given over a fairly long period of time.

The therapy is often used in combination with other types of treatments such as physical therapy. When the muscles are less stiff, physical therapy helps with movement and relieves associated symptoms. Electrical stimulation helps in reducing these symptoms. This combination therapy is effective in treating contractures in cerebral palsy patients.

Electrical stimulation alone may be effective in helping smaller body parts, such as the fingers and toes. Exercise and physical therapy are often combined with electrical stimulation to produce results in larger body parts, like the legs or hips. Some of the benefits of electrical stimulation for use in cerebral palsy are a marked reduction in muscle plasticity. Electrodes can be placed either over the muscle or near the offending body part. Skin electrodes send slight, almost unperceivable electronic impulses to the muscle tissue. Often other methods of reducing plasticity in cerebral palsy patients result in a weakened or damaged muscle, but electrical stimulation does not harm the muscle.

Electrical stimulation(ES) has also been successfully combined with positioning and voluntary effort, when possible, to correct contractures and maintain range of motion. It is critical to the success of ROM protocols to use a comfortable ES protocol one or more times each day. When the body segment to be moved is relatively small (fingers, wrist or ankle), the muscle pull created by ES alone may accomplish the goal. When the body segments are larger (knee or hip) ES may assist the patient in exercising to the end of their range. The therapist should combine ES with voluntary effort. It is important to remember that the maximum benefit of ES for spasticity may not be realized until ES has been used for 1-2 hours each day for 1-3 months.

If ES is discontinued, spasticity usually can be expected to return. For this reason, many patients elect to continue to use ES throughout their life. In addition to the modulation of interfering spasticity, ES can be incorporated into a variety of therapeutic strategies to enchance voluntary movement and function.

These activities can be carried into functional tasks such as using the hands, standing, shifting weight from one leg to the other, and walking. All electrical stimulation therapy should be done under the supervision or recommendation of a physiotherapist or any medical practitioner.

Diagnosis of Cerebral Palsy - Understanding Cerebral Palsy

Initial signs for parents to notice, that their infant is not developing normally. Infants with cerebral palsy perform movements slowly, take longer time to roll over, sit, crawl, or walk. When an infant develops comparatively slowly then it is called developmental delay.

Some of the skills that normal infants should have: Holding own head up when lying flat in a bed at 3 months, Sitting and rolling over by 6 months, Walking by 12-18 months, Speaking simple sentences by 24 months.

Earlier most children with cerebral palsy were diagnosed by the time they are two years old. But if a child’s Symptoms was mild; it would be hard for a doctor to make a true diagnosis before the child is four or five years old. With better understanding of patho-mechanism and presentation, now we can make suspicion as high risk baby at the time of birth and definite diagnosis at the age of three month so we can give much better response in these children by early intervention. 

Doctors diagnose cerebral palsy by obtaining a complete medical history of development and examining the child, paying special attention to the child’s movement pattern and associated medical problem like epilepsy, vision, hearing, speech problem& recurrent chest infection. In addition to checking for the most common symptoms

such as slow development, abnormal muscle tone, and unusual posture -- a doctor also has to make sure the child doesn’t have something else that could cause similar symptoms.

Some children have hypotonia, which means that their muscles are too relaxed. In this case, the Childs muscle may appear very flexible. Sometimes a child can have hypotonia that later become hypertonia two to 24 months after birth. Other children have hypertonia which makes their muscles seems stiff. Child can also have fluctuating pattern of tone known as dyskinetic pattern of movement disorder. Children may also have unusual posture or favouring one side of their body.

What’s most important to the doctor is making sure that the child's condition is not getting worse. Although cerebral palsy symptoms may change over time, children with cerebral palsy do not usually lose function at rapid pace. That means, if a child does seem to be losing motor skills, the problem is probably not cerebral palsy. It more likely a genetic or muscle disease, a metabolism disorder, or tumours in the nervous system. A complete medical history, special medical tests, and, in some cases, repeated check-ups can help confirm whether or not the child has cerebral palsy for certain. Usually the diagnosis of cerebral palsy has been made based on the basis of detail medical history and physical examination. Lab investigation is not required in most of the cases. But in few cases with doubtful cases and suspected brain lesion few investigation may required.

With recent advancements in technology and its reach, some time Doctors conduct brain scans (like MRI scans), that allow doctors to look into the brain, can find problems that may be able to be treated.  If it is cerebral palsy, an MRI scan can also show a doctor the location and type of injury to the brain. This test uses a computer, a magnetic field, and radio waves to create a picture of the brain's tissues and structures. Doctors prefer MRI imaging because it offers better detail and does not involve radiation. Other methods may include Cranial ultrasound. 

This test is used for high-risk premature infants because it is the least intrusive of the imaging techniques. However, it is not as effective as the two methods described below at seeing small changes in “white matter” – which is the type of brain tissue that is affected in cerebral palsy.

Computed tomography (CT) scan. This technique creates images that show brain injury. On rare occasions, metabolic disorders can be mistaken as cerebral palsy and some children will require additional tests to rule them out.

• Xray- xray of pelvis and spine are required to see hip and spinal problem

• Blood investigation are required to see metabolic causes and other associated medical problem.

• Genetic analysis is being advised in certain cases to see some genetic cause of neurological deficit.

To confirm a diagnosis of cerebral palsy, a doctor may send a child to other doctors who have specialized knowledge and training or to specialty clinics where these doctors work with a team of health professionals who specialize in working with children with cerebral palsy and other developmental delays. These doctors  Might be child neurologists, developmental paediatricians, ophthalmologists (eye doctors), or otologists (ENT doctors). Additional observations by these specialists can help the doctors make a more accurate diagnosis and begin to develop a specific plan for treatment.

Feeding Children with Spastic Cerebral Palsy

In cerebral palsy there are 3 biggest problems that the spastic children are – the body is in a poor position, the jaws are tight, the tongue pushes the food forward. Swallowing is difficult because of some reasons like head pushing back, jaw and lips are not closed, the bottom lips tend to bitten in by the top set of teeth or mouth is wide open, tip of tongue is down behind the teeth, the tongue cannot roll the food back to mouth or there can be chewing problem.

There are also some problems with breast feeding or feeding by bottle. The child would push back his head and body and their legs and arms would get stiff. They cannot suck and swallow easily. So it is very important that the head and body should be in correct position, all the muscles of neck and jaw must be relaxed, jaw must be back and not clenched, the lips must be together and the tongue must be able to move the food from side to side in the mouth.

To breast feed or by a bottle a child with cerebral palsy the head must be in forward direction so that he can swallow more easily. The baby must be in half sitting position with hips bent and the mother must keep the shoulders of baby in forward direction by pushing firmly on the chest. In feeding by bottle the teat of bottle should be bigger in size so that it would not choke.

The therapist should concentrate to control jaw movement in the child. If the therapist teaches a child how to control his mouth, particularly his jaw, then sucking and swallowing, spoon feeding from plate and drinking from a cup can be improved. To teach a child the therapist should sit in a chair facing the child’s face. The therapist can put the child on his lap or on standing frame (it simultaneously relax the muscles of whole body during feeding).

The position of child should be decided according to child’s age and ability. The therapist should stabilize the head then clasp the jaw and the index finger should be kept on the jaw of the child. The therapist should push the jaw backward (not downward) and push the bottom lip up, as this is necessary for swallowing. The third finger is put under tongue, to help the tongue move. The other fingers are lifted away from the child’s face. To reduce the Plasticity the therapist should use his right index finger and introducing inside the child’s mouth he should move the finger in semicircle on the top gum from middle to left then to right side. This is done firmly and not too fast. It is done 3 times and the child is encouraged to swallow by the 3rd finger of the left hand moving from forward to backward.

The therapist must also concentrate on hand activities (prehension and precision) to teach the child to hold plates and spoons to feed themselves. While teaching therapist must work on dominant as well as non-dominant hand. The non-dominant hand should be stabilized during activities of dominant hand and vice versa.

The swallowing activities also depend on quality of food. It must be started from liquid then semisolid and finally solid. Only metal teaspoon must be used to feed a child. Small amount of food must be put on the teaspoon. The spoon must be put right in the mouth and pressed down to the tongue. By doing this the tongue will be encouraged to stop pushing the food forward and the child will be able to use his lips better. To teach drinking water or milk the therapist must correct the shape of the plastic cup.

Cut a semicircle at the mouth of one side of plastic cup so that the child will not push his head back to get the liquid. Keep the cut part upward and put the cup on top of bottom lip and then tilt the cup slowly upward. The therapist must demonstrate all activities to child’s mother so that she will learn how to feed his child.

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Group Therapy and Socialization in Cerebral Palsy Children

Group Therapy and socialization is essential in the cerebral palsy children. Group Therapy is meant by therapy done in group of same population. In this technique same cerebral palsy children were collected and given same kind of therapy. Socialization is a technique in which cerebral palsy children were exposed to entire world to get prepared for the world’s challenges.

Group Therapy increases the concentration and the competition between the children. This concentration and competition felling gives a sprit to do work. Like other children cerebral palsy children also like complements, competition. In group therapy we mostly give same task to all children and ask them to complete in ease and in less time.

For example if we ask children to pick same color ball by their right hand and to put it in a bowl kept on the opposite side. Ask this to do faster and with ease this challenge and competition produce a spit to complete the task. By Group Therapy any activity can be approached. There are many fine motor movements like griping any object by full hand, four finger and thumb, two fingers and thumb or three fingers and thumb.

Organize children according to their disability as mild moderate and severe. We have to also divide them into hypertonic and hypotonic group. Now decide the therapy which is given in which group. For example as hypertonic group we have to teach them the relaxation, so for this we lie down all of them in plinth and ask them to relax their muscles by producing a competitive environment. This can help children to get the things the things more easily. As in hypotonic children we stimulate them ask for the movement in a competitive way.

Group therapy is very effective because the environment in same group is more according to them then the real world. In the real world they feel themselves weak and differently baled  First prepare them in their own group then we can put them in social world.

Social world means the world in which we live. As human being is a social body not possible to live alone without society. Socialization is technique by which we make these children expose to the society. As because of their disabilities they were kept inside the home by their parents. This can be because of many reasons as such they pamper them a lot, they think that child may get depressed or parents thing them a curse and feel guilt of them. All this prepare a self centered world in mind of these children. They feel them alone and away from society.

Socialization is must in these children. In this technique parents having the greatest role so counseling of parents is must. Teach parents how these children can be socialized. There are main two steps of socialization, first is home and second is school.

Tell them when child is too little parents usually keep the child with them all time only. Usually mothers not allow anybody to touch their child, teach them that to recognize all the family members is important. Allow the child to roam here and there. Let the other normal child to play with them. Talk with them frequently about every subject as talk to normal child, this increase the interest and knowledge of the child.

If child can move let them out with or without parents. Introduce them with strangers. In school going age if child is able to speak, understand so admit them in a normal school. Here in normal school society makes them aware and prepare for the barriers and difficulty might come in their life ahead.

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NeuroDevelopmental Therapy in Cerebral Palsy

NDT is a technique to facilitate the movements which are not present in the Cerebral Palsy children.

Facilitation is a process in which therapist hand gives a direction to the child’s body how to move. In this technique therapist holds the complete control of child’s body weight and the movement. Therapist gives a direction to the body to shifts its COG (Center of Gravity). As the COG shifted to some direction the control over the balance in the child is lost. Therapist should teach the child how to gain control again, by shifting weight to another side. This whole procedure is the part of NDT.

Equipments used in the NDT are Ball, Bolster, or Table/Bench.

Equipments are to challenge the body weight, to help accommodation the structural deformities of the child. These facilitation techniques are used improve the postural control of the child by challenging the posture.

BOLSTER/ROOSTER: is devices which is used to for prone, sitting and sit to stand facilitating techniques. It should be firm, provides a mobile surface that is easy to control because it rolls predictably front to back when child lies prone or sit on it.

BALL: is the most challenging device for the facilitation techniques. It is not firm because it can move in any direction and the base of support is very less.
There are two type of cerebral palsy according to the tone, Hypertonic and Hypotonic. Facilitation is given according to the tone of child. Hypertonic child is given facilitation techniques to decrease its tone and to improve its posture. Hypotonic is given different facilitation to increase the tone and posture.
 

First of all we should check the child’s stage and milestones before taking in the NDT.

Neck holding is the first step which should come in the child if it is absent then just facilitate neck extensors to extend the neck. On bolster put child in prone then ask him to hold the neck in extension by facilitating trapezius muscle or taking the shoulders in retraction. On ball put child in creep/crawl positions then the same facilitation done. Facilitation on the spine can also be done to make spine in extension and neck in hold position.

Quadruped position is the next position attends by the child. In this weight bearing on all four limbs is essential. So the power on all four limb must be good. This posture is attended on the ball. We can make it more challenging by rolling the ball so that the COG of the child’s body shifts and the opposite muscles work to prevent a fall.

Pelvic control facilitation techniques can be done on the ball and bolster both. On the bolster we can make child sit and the roll the bolster to shift COG and facilitate muscles to prevent any fall. Like this we can make child sit on the ball and can move ball too to shift the base of support and facilitate muscles. On ball different positions can be attended like cross sitting, kneeling, sitting by legs open wide on ball, sitting and hands are extended and sitting with hand in overhead position. Rankly decrease base of support and increase pelvic control. In all these positions we can facilitate pelvic muscles by rolling ball, shifting base to either side, ask child to reach an object to either side, make base less supportive by tilting ball on opposite side. All these make the muscles work and repetition of this strengthen the muscles.

The main purpose of the NDT is to improve balance with less support. Facilitation technique is more effective then passive movements. Resistive exercises are difficult in cerebral palsy child because they are not so cooperative and not following commands. So the most effective technique is NDT in the cerebral palsy.

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