Parent's Opinion About OSSCS and Physiotherapy Treatment

I am father of Ankit from Varanasi. My son is suffering with cerebral palsy since birth. Previously he was not able to walk properly. We had gone through so many treatments from various places and also consulted so many doctors and therapists. Somehow, he started walking with the help of walker. But I was not satisfied with his walking pattern because he was walking with bending his both knees and his both hand also had some problem.

He was having great urge to go school but we were not able to send school due to his physical problem. One day someone ask me to consult Dr. J.K. Jain an orthopedic surgeon in Allahabad. I had consulted him and he suggested me that Ankit needs SEMLS by OSSCS concept, which will help him to relieve his disability and will able to walk nicely. My son had gone through this surgery on 23rd January 2012. After few days physiotherapy has also started.

We stay at Allahabad for 6 month for therapy after surgery. After 3 months of surgery, my son has shown excellent response in walking pattern his hand function also became better. He started walking with two sticks. During this treatment period, we got a nice accommodation at CP Home in Allahabad. Each and every person here is very much familiar. I am very much grateful to Dr. Jain and his team. I am highly satisfied with the whole team of Samvedna.

I am from Raipur, Chattisgarh. I am farmer by profession. My daughter Jyotsna had problem in walking, sitting, standing etc. She was not able to do her own work. I had shown her to so many doctors at different places but there were no positive outcome. I was hopeless. She was making every effort for walking but due to deformity in all four limbs, she was not able to walk.

Then one day I read about camp of Samvedna at Raipur in a newspaper and met Dr. J. K. Jain at a camp in Raipur. Then he said that through an OSSCS surgery and physiotherapy, my daughter’s disability will be restored. I was having lots of financial problem. Dr J K Jain has given assurance for financial support for our daughter surgery. Jain Samvedna trust from Raipur as well as Samvedna , Allahabad is given us assurance for support. Then with lot of hope I took my daughter to Allahabad. Dr. J.K. Jain performed surgery on her. She was undergone surgery in all four limbs by SEMLS. After few days’ of surgery, physiotherapy was started. She started showing positive response within month of surgery.

She was able to put proper pressure upon her entire feet. Now she is able to walk with the help of the sticks. Her hand function became much better. I hope that she will be able to walk without any support and for that we also have to support her a lot.

We got a very good accommodation at Cerebral Palsy Home in Allahabad. I cannot explain response and support given by whole team of Dr J K Jain without much expenditure. Here everybody is very helpful by nature. I am very much grateful to Dr. Jain. The physiotherapy team has also done a really hard work. I am highly satisfied with the whole team of Samvedna and thankful to all of them who have taught my daughter to stand her on her own feet.

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.

Beginning of Swimming Lessons for Children

It is important to encourage any form of exercise at an early age, particularly if your child has limited spontaneous movement. “Babyswim” classes are an excellent way to introduce the baby to the water. The child can begin to attend swimming lessons as early as 6 months of age. These classes will give your child an early opportunity to begin exercising and strengthening their muscles (especially their hip muscles). Classes can also give you and your child an opportunity to socialist and form support networks with children of a similar age, enabling ‘play dates’.

Local pools generally have their own swim schools that cater from babies to adults. Small classes of up to 4 children are often available. The Center for Cerebral Palsy physiotherapists have developed a manual to assist swimming teachers in providing optimal swimming opportunities for children with cerebral palsy.

Physiotherapist can help you choose the most appropriate environment for your child to learn to swim.

Finding the ‘right’ pool for your needs

It is important to choose the right pool for your child’s needs. The facilities provided at community pools vary. It may be advisable to check with your local pool to ensure they can best meet your family’s needs. There are many factors to consider when selecting a pool. Water temperature Hydrotherapy pools are generally 33- 34 degrees. Some indoor pools are 30 degrees. Warm water has a relaxing effect and can help decrease muscle tone. Cold water can increase muscle tone. Water kept at a constant temperature of 35 degrees is most suitable for a child with plasticity. A pool kept at about 33 degrees is suitable for a child with low muscle tone

If your child has epilepsy, please discuss the most appropriate pool environment with your paediatrician.

Access

• How will you and your child enter the pool: - stairs /ramp / side of pool / hoist?

• Change rooms

• Facilities available

• A large change table

• Do you need to ask the centre to ensure one is available for your use?

• Noise level / echo -This could make your child tense or anxious and result in an increase in their tone.

Hydrotherapy is a water- based physiotherapy program.

Hydrotherapy programs are used by physiotherapists to:-

*   increase gross motor co- ordination
*   maintain or increase range of movement and flexibility
*   increase muscle strength
*   improve balance and posture
*   improve fitness and endurance
*   promote breathing control
*   promote water safety and awareness
*   develop basic swimming skills
*   reduce muscle spasm and encourage relaxation and enjoyment
*   encourage normal movement patterns.

A variety of swim rings, arm ‘floaties’, pool noodles and toys are incorporated into the hydrotherapy session to promote independence and freedom of movement in the water.

The children enjoy activities in the pool including acceptance of the water and buoyancy, bubble blowing and protection of the airway, kicking, splashing, floating, singing and playing.

The children’s skills are progressed with the aim to complete competencies required for swimming lessons.

Halliwick

The Halliwick Method is a specific swimming program used by physiotherapists. It is based on the scientific principles of body mechanics and the properties of water, aiming to teach people with special needs to become as safe and independent as possible in the water. The philosophy of the program is that the child is happy in the water and the emphasis is on the child’s ability, not disability.

Movement in water allows people with disabilities freedom from the constraints that they endure on dry land. No matter how severe the physical disability they can learn movement in the water.

The program consists of 10 specific progressive stages that are achieved without the use of floatation devices. Waterproof swimming pants are required to wear either awaterproof nappy or Eenee Swimmers if they are incontinent. Eenee swimmers have a stretchy waterproof inner sling for containing incontinence.

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.

Author Bio:

Kanhaiya Jha is working as Sr. Associate - Internet Marketing. Get in touch with him on Facebook here.

Communication Problems and Dysarthria

Dysarthria refers to speech problems. The child has difficulty producing sound and articulating words. Dysarthria occurs in 40% of patients. The causes are respiratory difficulties due to respiratory muscle involvement, phonation difficulties due to laryngeal involvement, and articulation difficulty due to oromotor dysfunction. Spasticity or athetosis of the muscles of the tongue, mouth and larynx cause dysarthria. It is important that every child is provided with an alternative means of communication as early as possible to avoid further disability.

Oromotor dysfunction

The child has difficulty sucking, swallowing, and chewing. Drooling , dysarthria and inability to eat result in failure to thrive, delayed growth and nutrition, poor hygiene and impaired socialization.

Teeth problems

Dentin : Primary or hyperbilirubinemia

Malocclusion : Spasticity

Tooth : Decay Feeding swallowing problems

Gingival : Hyperplasia Antiepileptic drug use

Gastrointestinal problems and nutrition

There is a general deficiency of growth and development. Children with dyskinesia and spastic quadriplegia fail to thrive. This is related to inadequate intake of food, recurrent vomiting with aspiration secondary to gastroesophageal reflux and pseudobulbar palsy. Difficulties in swallowing (dysphagia), hyperactive gag reflex, spasticity or loss of fine motor control impair feeding. Gastroesophageal reflux and impaired swallowing cause aspiration pneumonia. Many children with CP have high basal metabolic rates. Increase in basal metabolic rate coupled with feeding difficulties cause malnutrition. Malnutrition may be severe enough to affect brain growth and myelination in the first 3 years of life. There is immune system suppression and increased risk of infection.

Respiratory problems

Aspiration in small quantities leads to pneumonia in children who have difficulty swallowing. Premature babies have bronchopulmonary dysplasia. This leads to frequent upper respiratory tract infections. Respiratory muscle spasticity contributes to the pulmonary problems. These problems can be reduced by various chest physiotherapy.

Bladder and bowel Dysfunction

Loss of coordination of bowel and bladder sphincters results in constipation and/or incontinence. Enuresis, frequency, urgency, urinary tract infections and incontinence are common problems. The causes are poor cognition, decreased mobility, poor communication and neurogenic dysfunction. Urodynamic assessment has demonstrated bladder hyper-reflexia, detrusor sphincter dyssynergia, hypertonic bladders with incomplete leakage and periodic relaxation of the distal sphincter during filling.

Constipation is a common but overlooked phenomenon. It causes distress in the child, increases spasticity and results in poor appetite. It is a result of many factors, including poor diet and decreased mobility. Establishing a routine for bowel training and encouraging upright posture help reduce constipation.

Urinary problems may include enuresis, frequency, urgency, urinary tract infections, incontinence. Causes of urinary problems can be poor cognition, decreased mobility, decreased communication skills, Neurogenic dysfunction.

Psychosocial problems

A diagnosis of CP is extremely stressful for the family and the child when he grows up. This causes various reactions ranging from denial to anger, guilt and depression. Coping with the emotional burden of disability is easier if the family has strong relationships, financial security, and supportive members of the community. The child and the family need to find ways to connect to each other. A healthy relationship between the mother and the child forms the basis of future happiness. Prevention or appropriate treatment of associated problems improves the quality of life of the child and the family.

Author Bio:

Gajendra Jain is Sr. Software Engineer with Daffodil Software Ltd. Connect with Gajendra on Facebook here.