Cerebral Palsy Part II Treatment of Cerebral Palsy by P h y s i o t h e r a p i s t s of the Pretoria School for Cerebral Palsy A. SPASTIC i S p a s tic Q u a d rip le g ia ' T^ e treatment, which is described in detail, is for the spastic quadriplegic. It is adapted for the other , Spastic types, athetoids, ataxias and- , hypotonic spastics. I U S E O F T H E N O R M A L D EV E L O PM E N T PA T T E R N ' I t is e s s e n t i a l to try and follow this pattern in the treat­ m e n t o r o s r a m m e . It is o f no use to teach a child standing, when the head control is still extremely weak. T he direction o f m otor development is cephalo-caudal. m H e a d control: It is first taught in lying, then prone lying, sitting (with or without support) and prone kneeling. rii'i Rolling' At first the child rolls the body as a whole, i e if the head is turned, the shoulders and hips follow simultaneously. Later the child learns to rotate on its own axis, i.e. if the head is turned, the shoulders follow and then the hips follow till the rolling is c o m p le te d . Teach the child to roll into prone as well as into supine lying. (iii) Prone lying forearm support, progressed to straight arm support. Fig. 1. Page 6 P H Y S I O T H E R A P Y SEPTEMBER, 1971 riv} Moving into sitting position from lying or prone lying, at first assisted, later unassisted. As a progression they are taught to sit astride on a small roller and then sitting on a small stool with or w ithout back and/or side supports. (v) Prone kneeling, crawling, kneeling: PR O N E k n e e lin g : At first the child may be supported by a towel held under the abdom en, or at the hips. Later he has to keep the position on his own. Best done in front o f a mirror. Fig. 3. c r a w l i n g : Is taught from the stable prone kneeling position as above and the child may at first be similarly supported. When teaching crawling to a child with a strong symmetrical tonic neck reflex, it has been found useful to start off by keeping the child in prone lying. The child lifts the head, moves the arms himself (arms in forearm support position). The therapist grasps just above the child’s ankles, the hip is flexed and thigh abducted. The child then pushes himself away from the therapist’s hand. Fig. 4. k n e e l i n g : Is first taught with support o f the hips by the physiotherapist, later it is progressed to kneeling alone and half-kneeling as well as side-sitting, changing to left and right hips, with or without support on the hands. It is good to do kneeling training in front of a mirror. Fig. 5. (vi) Moving to standing from sitting or from kneeling positions: At first the child is supported, either by the physiotherapist or by holding on to a walking aid or wallbars. Later he does this unassisted and with no support. (vii) Starting walking, with support (holding on to a table, the wall, the physiotherapist’s hands or a walking aid) and later progressed to little or no support if possible. (viii) Throughout this programme balance and equilibrium reactions are facilitated. B a l a n c e R e a c t i o n s : These are the protective reactions to prevent the body from falling. It may consist o f body righting reactions only if the body, is pushed, e.g. sitting or standing on a balance board that is moved. It may also consist of movement of the arms or legs (e.g. a step taken forward, backward or sideways to prevent falling when the body is pushed while standing). Fig. 6. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) SEPTEMBER, 1971 P H Y S I O T H E R A P Y C o m b in e d with teaching b a la n c e reactions, the Sprung- bereitschart reflex is also facilitated and developed It is important that these children are taught to fa ll correctly to reduce their fear o f falling as well as prevent or reduce head injuries which occur with incorrect falling. Start to teach falling on a soft mat, from sitting and kneeling positions and later standing positions. Progress to falls on the lawn or the floor. (a) Forward, bend the knees and stretch out the arms. Fig. (b) Backward: bend the knees, hips, trunk and keep the head well forward. Fig. 7(ii). (c) Sideways: turn while falling to fall slightly backward or slightly forward. Fig. 7. Page 7 & (0 E q u il ib r iu m R e a c t io n s Automatic compensatory movements to maintain equi­ librium in all positions. It is stimulated in lying, kneeling sitting, half-kneeling, standing, half-standing, etc. A balance board may be used in stimulating equilibrium reactions, if the spasticity and associated movements are not too severe. Otherwise the child’s centre o f gravity is changed on a static surface. Further aids are: fibreglass tub for little ones, roller, ball catching and throwing in different positions, etc. Fig. 8. (i) Sitting on a table. - I t (“ 0 (iv) (i) Sit on table, change centre o f gravity (Notice that the eyes stay in a horizontal line. (ii) Kneeling, change centre o f gravity — eye level stavs horizontal. J (iii) Pushed backward in standing (also sitting or kneeling) — eye level stays horizontal. (iv) Pushed sideways in standing (or sitting or kneeling) — notice eye level stays horizontal. D is s o c ia t io n : Dissociation of movements necessary for normal develop­ ment js facilitated, e.g. prone-kneeling, extend opposite arm and leg, riding a tricycle to therapy or a static bicycle. G r a s p : It is important to try. and obtain a pincer grip and this must be taught step by step from the primitive pattern of grasping with the whole hand (seen in the small baby), to the fine pmcer grip between thumb and forefinger. This is accompanied by stimulating normal sensation of the palm of the hand, e.g. brushing the open hand over different types of surfaces, e.g. smooth, cold, hairy, etc. (Note: This is necessary for the sole o f the foot too, but it is developed in the normal weightbearing of the feet.) The spastic hand is often held in a fist with the thumb held m the palm. This prevents the child having the oppor­ tunity to experience sensation which contributes to the development o f stereognosis. R e f l e x e s : (a) It is essential to inhibit in every possible way those reflexes which should have disappeared early in baby­ hood (many of these between the second and fifth months), e.g. the assymetric tonic neck reflex or the symmetric tonic neck reflex. Fig. 9 (i) + (ii). Fig. 9. (ii) (a) Head lifted backward: Anns extend, Legs flex. (b) Head bent downward: Arms flex, Legs extend. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 8 P H Y S I O T H E R A P Y SEPTEMBER, 1971 (b) Simultaneously the normal reflexes which should appear later, like the Sprungbereitschaft reflex (protective exten­ sion of the arms) and postural reflexes, are facilitated. Note: Constantly aim at promoting fu ll independence in all facets o f life. II. INHIBITORY TREATM ENT This aims at inhibiting spasticity. (a) Ice: It is used for longer periods, e.g. up to 20 minutes. Ice towels or ice packs can be used. (b) Bobath: Reflex inhibitory positions, like sitting astride or dia­ mond sitting, are used (Fig. 10) with the aim o f preventing a mass pattern, e.g. a full flexion pattern o f the leg consists o f flexion, adduction and internal rotation of the hips, flexion o f the knees, dorsiflexion with adduction, inversion or abduction, eversion o f the feet and flexion of the toes. Diamond sitting places the hips in flexion, abduction and external rotation and the feet into plantarflexion. Fig. 10. D (i) Diamond sitting. (ii) Sitting astride. Longsitting with the legs in extension and abduction can also be used, as well as prone-kneeling. Fig. 10(iii) + (iv). (iii) Long sitting. (iv) Prone kneeling. It is important that these positions are used as starting positions for other exercises (e.g. arm exercises or balance exercises or to initiate standing). Always encourage movement out o f abnormal patterns into normal patterns. D o not ever use these positions only, doing nothing further! Of course voluntary co-operation is essential. (c) Rood splint: F or the hand. A forearm plaster splint with a cone fitting into the hand, the base at the radial side of the hand so that the fingers and thumb grasp over the cone. Pressure on the flexor tendons reduces flexor spasticity. Note: Inhibitory plasters were found to be o f temporary value only and are no longer used. m. FACILITATORY TREATM ENT This forms an important facet of the treatment pro­ gramme. (a) Balance and equilibrium reactions are facilitated as dis­ cussed above. (b) Rood technique with the brush, vibrator or ice. (i) t h e b r u s h is used to stimulate the nervefibres in a dermatome to facilitate the muscle with the corres­ ponding nerve segment. It must be applied three to five minutes. (ii) t h e v ib r a t o r is used to cause a repetitive stretch reflex that facilitates the muscle and is also applied about five minutes. (iii) i c e can also be used in short stimulating strokes. (c) Modified Proprioceptive Neuromuscular Facilitation Patterns (P.N.F.) is used to break the typical pattern o f spasticity (e.g. flexion, adduction, internal rotation). Resistance must be used with care when strong associa­ tion reactions are present. Often an orthopaedic opera­ tion is required before the antagonists can overcome the mechanical disadvantages caused by overaction o f the spastic muscles, e.g. extension o f the hand is only mechanically possible after a flexor release (e.g. a flexor slide of the short finger flexors, or a flexor carpi ulnaris transplant to the dorsum o f the hand). Experimental electromyography has already shown normal reaction in the wrist extensors where no move­ ment was possible due to strong flexor spasticity. (d) Facilitatory tapping on the musclegroup with the fingers. This must be light and reasonably short raps on the musclegroup. Approximation or joint pressure which facilitates the antagonists, e.g. in side sitting, pressing o r leaning on the extended arm. See that the hand is kept open. Here we find approximation o f the shoulder and elbow joints (Fig. 11). Fig. 11. (e) Side sitting — support on hemi-arm. (f) Repetition lowers the threshold for nerve impulses. IV. IT IS ESSENTIAL TO PREVENT CONTRACTURES AND DEFORM ITIES This is an important reason why treatment should start as early as possible, i.e. as soon as the abnormality has been noticed, even at three or four months of age. These abnormal movement patterns can then be discouraged before they become a fixed pattern. Early treatment prevents atrophy and passive stretching is aimed at preventing shortening from leading to contracture. Parents are advised how to handle the child (e.g. to carry the child, who has strong adductor spasticity, so that the legs are kept abducted — astride over their hips or piggy-back style —“ abba”). A child with severe hipflexor spasticity could be treated in prone lying. V. ORTHOPAEDIC APPLIANCES (1) Adaptations to shoes or boots, e.g. Thomas Heels, weighted heels — with lead — for athetoids, medial or lateral wedges to the heel and sole, raised heels for hyperextension o f the knees, calipers (full length or below knee, single or double irons and many more may be made. (2) Crutches and walking aids o f various kinds may be used. (3) Nightsplints may be made of leather (like Dennis Brown Nightsplints or abduction nightsplints) or o f plaster of Paris. They are used for conservative treatment or post operatively. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) The orthopaedic surgeon, physiotherapist and often the occupational therapist must decide together what type of orthopaedic appliances each child needs. VI. PRE- AND POST OPERATIVE TREATMENT AND OPERATIVE TREATMENT T o g e th e r with the usual strengthening exercises and pre­ paration of pre- and postoperative treatment, is the very important task of making films and photos to record exactly what the patient’s condition was before the operation and how he reacted to the operation. Follow-up films must be made regularly. Operative treatment of Cerebral Palsy is still a very new field and every success, but also every failure should be recorded. (a) Lower limbs: Operations on the lower limbs have been done for quite a while now, but have been modified according to results of operations. A n adductor tenotomy does not necessarily involve only a tenotomy o f Adductor Longus and Brevis, but sometimes of Gracilis too, as well as a neurectomy of the anterior branch of the Obturator Nerve. It is advisable to do Tendon Achilles lengthen­ ings rather than a Gastrocnemius recessions, as the latter usually have bad results for spastic muscles. Other leg operations include a modified Egger’s operation, muscle transplants, Soutter slide, Grice’s operation, osteotomy and seldom a triple arthrodesis, or an operation in which the patellar tendon is fixated lower down on the tibia so that the patella is once more over the knee-joint and not above it. (This condition develops because of the gait with the knees in flexion.) With the Tendon Achilles lengthening, it is necessary to put the plaster of paris on with the foot in 90 % dorsiflexion with extension of the toes and knee (not the knee in flexion as in the case of polio patients). The plaster must reach well over the toes, but not include them completely. After two weeks a below-knee walking plaster is put on for three to four weeks. (b) Arm operations Arm operations are in the experimental stage, yet very good results have been obtained by the school’s honorary orthopaedic surgeons. In the case of severe flexor spasticity and associated reactions (of the elbow — especially seen in hemiplegias) 'a partial tenotomy of Brachialis with Biceps tendon lengenthening and sever­ ing of the flexor fascia has been proved successful cos­ metically and functionally. For the hand a flexor slide of the Flexor Sublimus or a Flexor Carpi Ulnaris trans­ plant to the dorsum of the hand (into Extensor Radialis Longus or Extensor Pollicis Longus has been proved successful. 2. Diplegia This is treated very much the same as for quadriplegia, concentrating on the legs and trunk. Dissociation, balance and equilibrium reactions require special attention. They often learn to walk with elbow crutches, and may discard these later. 3. Double hemiplegia These cases are treated on the same principles as for quadriplegia, but concentrating on the arms and inten­ sive strengthening o f the weak trunk muscles. 4. Hemiplegia Hemiplegics are treated on the same principles as an adult hemiplegia and quadriplegias. A strange fact that was noticed at the Pretoria School for Cerebral Palsy, is that most of the congenital hemiplegias (lesions before or during birth) are right-sided hemiplegias while more of the acquired hemiplegias (post natal lesions) are left­ sided. (Comment from other schools would be welcome!) It is essential to inhibit the association flexion pattern SEPTEMBER, 1971 of the arm on the affected side while standing, jumping, running or while doing activities with the other hand (e.g. writing, building with blocks, etc.). In the class­ room the teacher should be shown how the child must sit, and how he must use his hemi-hand as an assisting hand, e.g. the forearm with open hand resting on his desk, to hold the book while he is writing. Dissociation of arm from leg movements in the affected side, as well as the two hands and arms during exercise of either, is essential. Even in normal people strong action in one hand (e.g. clenching a fist against strong resistance) might cause a slight co-contraction in the other hand. This is exaggerated in the hemiplegic during activities such as writing or building with blocks. The Rood splint has been proved very successful in releasing the flexion spasticity of the wrist and finger flexors. It also allows the wrist and finger extensors to be strengthened as the mechanical disadvantage caused by the spastic flexors has been overcome to some degree. A valuable aspect o f the Rood technique of brushing and vibrating, is the correction of a squint by brushing and vibrating the Stemo-cleido Mastoid Muscle on the affected side. This causes stimulation of the Medial Rectus muscle of the eye and thus draws the eye to a position from where it can focus normally. It is best done- before bed time. Later on the child can maintain the-results even during activities. This is a process which may take six months before it shows lasting results, but it has been proved effective. B. ATHETOID Athetoids are treated similarly to quadriplegia, but attention is concentrated on teaching the child static posi­ tions, i.e. to control various basic postures. Simultaneously intensive balance and equilibrium reaction exercises are given, as well as dissociation and co-ordination exercises, especially for the bigger rather than finer movements. Boots are weighted down with lead heels to facilitate walking. C. ATAXIA Balance and equilibrium reaction exercises, as well as fine co-ordination exercises are especially important for the ataxies. If they show any pyramidal signs, they are treated as spastics too. D. H Y POTONIC SPASITCS These are also treated as quadriplegias. In addition to intensive strengthening of the antagonists of the spastic muscles, as well as all the the postural muscles, they need a lot o f stimulation — mental stimulation as well! They seldom “want” to do anything and would prefer to lie in any position and listen to a favourite story or record — and have everything done for them. E. HYPERKINETIC These children often have very little physical disability and seldom need physiotherapy. Treatment for balance and equilibrium reactions and co-ordination is occasionally necessary. Try to improve their concentration span — and test your own patience I It is a good idea to arrange classes for hemiplegias, ataxies and for breathing exercises. (Breathing in the spastic quadriplegias and athetoids especially is often very shallow and inefficient. Brushing and icing — short quick stimulating strokes over the diaphragm — facilitate breathing. The children must learn to cough properly. They often suffer from chronic bronchitis and even pneumonia.) A short note on the work of the rest of the team The occupational therapist: The occupational therapist tests the child for any per­ ceptual problems (e.g. body concept, colour concept, figure background, etc.) and then follows up with perception training. She teaches the child balance and equilibrium reactions, as well as fine co-ordination, using different kinds Page 9P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) of motivation (e.g. games or working an electric train while rocking a small balance bench — if the child stops rocking, the train also stops, etc.). She teaches the child all activities o f daily living (e.g. dressing and undressing, putting on and fastening shoes, getting in and out of bath, etc.) as well a:s personal care (e.g. make-up, care o f the hair, etc.). Work orientation is most important as the capability of the child is tested, and he can be taught useful activities, preparing him for life after leaving school. Among these activities are typing, welding, batik, matmaking, making plastic articles, office work, e.g. working a telephone switchboard, etc. The speech therapist: She deals with any communication problem the child may have. Hearing tests are done and they arrange the fitting of hearing apparatus when necessary and do hearing training. Any speech problem, e.g. stuttering, is also treated, as well as the mandibular thrust (reflex opening o f mouth with any intention o f movement) o r tongue thrust (the tongue thrusts forward and out at any attempt to speak or to eat). They teach the child to move the tongue, close the lips, to swallow and to suck. They treat children suffering from expressive o r receptive aphasia o r dysarthria due to brain lesions. They help children with reading or spelling problems which often develop due to hearing loss o r in­ capability to vocalise certain sounds. The teaching staff: Very intensive, specialized teaching to children in small classes (8-10 preferably) allows individual attention. These teachers must have a knowledge of the physiology and anatomy as well as the basic pathology of the brain and nervous system. They must have some knowledge of epileptic fits and be able to help a child who has an epileptic fit. Page 10 P H Y S I O Specialized teaching methods are used, e.g. the Glendo- m an method for reading, Montessori’s method, etc. Each child progresses as fast as he can and in one class one may find a child doing Grade II reading and Standard I arithmetic. The teachers must have great patience and can be admired for it. The psychologist: The psychologist is invaluable in helping to determine the approximate intelligence of the child (by various verbal and non-verbal tests). They help children suffering from learning, behaviour o r other problems. The social worker: Valuable information about the home, social and family background may be obtained by the social worker. Further­ more information about the financial problems o f the parents and the parent-child relations may be collected by the social worker. The medical staff: The neurologist, orthopaedic surgeon, paediatrician, urologist, internist, ear-nose-and-throat specialist and the dentist give invaluable services to these children for which we are all very grateful. Teamwork: It is essential that the parents, teaching staff, all therapists, the psychologist and all medical staff should co-operate and endeavour to understand each other in all aspects o f treat­ ment for the child. Every member of the team also benefits from co-operation with the other members o f the team. Teamwork is the only way that positive and lasting results can be achieved for the cerebral palsied child. H E R A P Y SEPTEMBER, 1971 O B IT U A R Y MISS M ARJORIE DOUGLAS, m .c .s .p ., ̂ . Member o f the South African Society of Physiotherapy Miss Marjorie Douglas died in Johannesburg, on 8th August, 1971, after an illness lasting several months. Marjorie Douglas trained a t Guy’s Hospital, London, and was in private practice in Johannesburg for many years. During this time she was closely associated with the Hope Convalescent Home in a part-time capacity. During these comparatively early days o f the South African Society o f Physiotherapy Miss Douglas served on various committees, both in the Central administration and in the Southern Transvaal Branch. It was at this time, too, that she assisted with the examination and teaching o f the first Physiotherapy training in South Africa. When war broke out in 1939 Marjorie, in company with a woman friend, drove by car to Kenya to join the British Women’s Transport Services, with whom she served in Kenya and Somaliland, before transferring to the South African Medical and Nursing Services as a Physiotherapist again. She eventually returned Up North and took charge o f physiotherapy in the South African Hospital in Florence. After the war she returned to Johannesburg and private practice and later took over the newly-form ed Physio­ therapy Department at the Hope Convalescent Home in a full-time capacity, building it up into an efficient rehabilita­ tion unit including an Occupational Therapy Department and indoor Therapy Pool. In 1964 Marjorie left Johannesburg to live in Durban until early 1971 when illhealth sent her back to her family in Johannesburg. During this latter period o f semi-retire- ment Marjorie retained her life-long interest in Physio­ therapy by helping the Cheshire Homes in N atal in all manner o f ways, and doing occasional locums at local hospitals in Durban, and became a member of the Natal Coastal Branch o f the S.A.S.P. In 1964 she was made an Honorary Member o f the S.A.S.P. in recognition o f her services to Physiotherapy in South Africa. Early in her adult life, nearly 40 years ago, Marjorie made a name for herself by being one o f the first two women in South Africa to gain pilot’s wings. She will be sadly missed and ever remembered by her large family and friends and all the countless people of various races and creeds whom she helped during her long and fully active life. E.M.B. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )