July- 1954. P H Y S I O T H E R A P Y Page Seventeen 2. M ental: A t a clinic held in 1952 the child was assessed as being mentally retarded. Since treatm ent began in O ctober 1953 he has improved greatly in writing and general school work. H e has an excellent ability to concentrate and follow instructions, and despite adequate testing, on his school work it is felt his l.Q . is average. 3. Speech: M arked lim itation in basic functions. Articulatas are poorly utilized. Treatment : By constant repetition o f specific movements e.g. grasping, it is hoped to train new • brain pathways. Occu­ pational Therapy and th e general school program m e give the child everyday experiences and opportunities for norm al development. There are various methods o f achieving relaxation, a very satisfactory m ethod is one o f a calm, friendly relaxed approach on the p art o f the therapist, this is transferred to the patient. 1. Weaving: (a) on a fram e which involves grasp— [the shuttle is m ade a suitable size to involve use o f all the fingers in flexion. (b) co-ordination—the shuttle is darned in and out of the warp threads thus involving slow controlled movements. (c) elbow flexion and extension—as th e shuttle is drawn out o f the warp. • This teaches the same arm movement required in feeding. (d) abduction o f the 'fingers ,and extension o f the wrist in beating down the weft threads. This child has some tension and requires movem ent at the wrist joint. 2. Constructional toys such as “ Teachem” toys are given for co-ordination and grasp. 3. Skills: The patient is to button up and unbutton large buttons on a frame. 4. Feeding: The child practises feeding in front of a m irror. Being unable to supinate the child is taught to flex his elbow with the wrist in pronation, to bring the spoon to his m outh. The m irror assists him to reach his m outh directly. 5. Drooling is checked by constantly rem inding him - to keep his m outh closed. H e is given gum and sweets to check the flow o f saliva. This carried out in conjunction with the speech therapist. H e is a. co-operative and keen patient. -Unfortunately, due to lack o f time both on the part o f the therapist and th e child, who has a full program m e o f therapy and school, he is unable to participate in group activities, which would be particularly beneficial for— 1. A rt and finger painting—which gives opportunity for self-expression and finger dexterity. 2. Games—this prom otes a healthy spirit o f competi­ tion and an outlet for excess energy not forgetting the norm al desire o f children to play. , N o child is treated in isolation. Each therapist and teacher w ork as a closely knit team to equip these children to take their place in society, despite their handicap. Observation : As it can be seen from the treatm ent o f the aforesaid case histories it is impossible to draw a well defined barrier between th e function o f the various medical auxiliaries— for upon th e closer co-operation only, between the medical staff, physiotherapist, speech therapists, social w orker, teachers and the occupational therapist, depends th e success o f the R ehabilitation o f th e patient. Thanks: We w ould like to th an k the O ccupational Therapy D epartm ents a t the G eneral H ospital, Johannesburg, B aragw anath N on-E uropean H ospital, Edenvale H ospital and th e Forest Town School for C erebral Palsy Children fo r their co-operation in providing the case histories. THE HABILITATION OF THE CEREBRAL PALSIED CHILD B y F. M. TR A G O T T -V O R W E R G (Principal). SOPHIE LEVITT (Head Physiotherapist) Forest Town School for Cerebral Palsy. IT cannot be denied th at Cerebral Palsy and its treat­ment presents a growing problem all over the world today, not least in South Africa. F rom about the mid-nineteenth century, when D r. William Little gave some attention to “Spastics,” Cerebral Palsy cases were all labelled Little’s Disease, and those dealing with it, accepted an .associated m ental deficiency with a hopeless prognosis. Only in- recent years has it been realised th a t th e Cerebral Palsied had potentially greater abilities than hitherto suspected. Much o f the pioneering work in this field began in the U.S.A., under the direction o f such as C rothers, Phelps, Fay, Perlstein and others. _ I t was emphasized th a t a damaged brain did no t necessarily indicate m ental deficiency, and th at the condition is m anifest in several forms, of which Spasticity is only one. Definition. C erebral Palsy is comm only defined as a condition characterised by paralysis, weakness, inco-ordination, or any other aberrations o f m otor functions, due to -m a l­ function o f the m otor centres o f th e brain. . T he types o f Cerebral Palsy are described according to clinical findings rather than to aetiology, and the fol­ lowing classifications are generally accepted : Spasticity. The cases in this group may be quadriplegias, p ara­ plegias, hemiplegias and the rarer m onoplegias and tri- plegias. T he m ain features reveal postural deformities, e.g. internally rotated, abducted position o f the legs; increased tendon reflexes and the presence o f the hyperactive stretch reflex. Thus, when a muscle group contracts, the stretched antagonist contracts simultaneously instead o f relaxing to allow a sm ooth norm al movement, as referred to in Sherrington’s “ Law o f Reciprocal Innervation.” Athetosis. . These cases are comm only “ quadriplegias” and also hem iathetoids have been described. Athetoids exhibit in­ voluntary unpatterned movements, disturbances in balance, co-ordination and often tone. 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 Eighteen P H Y S I O T H E R A P Y July, 1954. Ataxia. H ere defects o f balance and kinaesthesia are the most prom inent features. There may also be lack o f tone and diminished reflexes. Tremor and Rigid Types are tw o rarer forms mentioned. These types are similar but differentiated from the athetoid and spastic types respectively. M ixed Types have also been observed. Sub-classifications o f all types have been m ade by some workers e.g. Phelps has noted twelve types o f athetosis. M any Cerebral Palsy workers classify strictly, particularly those' who practise a technique o f treatm ent based on specific diagnostic classifications. However, it is contro­ versial as to w hether the classification should be so rigid. W ork carried o u t at the Forest Town School for Cerebral Palsy leaves us with the impression th a t a wider definition o f Cerebral Palsy is m ore acceptable than the one \ye have quoted a t the beginning o f this article. - In addition to varying types an d degrees o f m otor handicap, one finds all o r some o f the following disabilities : hearing loss, visual disorders, speech difficulties, aberrations o f perception (visuo-auditory and others), differences in tem peram ent and personal stability, convulsions. We ask therefore, w hether C erebral Palsy m ay not be: (1) A syn­ drom e o f several individual defects based on localised areas damaged in the brain; o r (2) w hether brain damage does not show effect in a general dysfunction. This may not indicate mental deficiency but creates disturbances o f the “ whole” child as outlined, and makes h a b it a ti o n a complex problem. T he needs o f the Cerebral Palsied Child include all those o f a child, plus additional assistance to help him supply his own particular needs. The problem has many facets, educational, medical’ psychological and social, to mention the m ost im portant. These factors are inter­ related, and the Child requires attention to all. There is no other group o f th e handicapped for whom habilitation in the widest sense o f the term, makes so much difference, and is so im portant. The range o f improvement is a wide one. There is no relationship between the degree o f handi­ cap and the possible results o f treatm ent. ^ Statistics show th a t at least 70 % o f cases are o f mild or m oderate involvement. M ost o f these have norm al intel­ ligence and should profit materially from treatm ent.. Many show im provement o u t o f all proportion to the habilitation given. Left without help, they could become hopeless cripples, uneducated and a continual burden to the State. “ H olism” in approach to Cerebral Palsy is essential. M ultiple disabilities need a team o f workers to overcome them. Each o f these trained workers must not only evaluate th e child and plan treatm ent in their sphere, but be aware o f his limitations and potential abilities in all other aspects. A t the same time, th e accent m ust be on the child, and not on his defects. In a rehabilitation team the word “I ” m ust be replaced by the word “ W e.” Individual ideas and techniques must be acceptable to all and there m ust be constant re-assess- m ent o f cases, and program m es of treatm ent. W hat team work is required for Cerebral Palsy Cases? (1) A consultant panel o f medical experts to assist in accurate -diagnosis—and .direction o f habilitation. The Paediatrician, O rthopaedist, N eurologist, Psycho­ logist, E ar, N ose and T hroat Specialist are am ong the m ore im portant o f these Specialists. (2) .A team o f trained experts to carry out treatm ent and education. The following personnel are usually necessary: Physiotherapist, Speech Therapist, Occu­ pational Therapist, and Teacher. T he H abilitation Team should be localised in a centre functioning as a unit with an environm ent modified to the needs o f the children. Treatm ent assumes the following aspects: Physiotherapy. The Physiotherapist concerns herself mainly with the prevention o f contractures and the guidance o f m otor development towards independence. C o-ordination, bal­ ance, strengthening and posturally corrective movements are incorporated in the therapeutic exercises in association with the neuro-m otor development. Play therapy is in­ valuable in the learning o f m otor skills particularly as this is being simultaneously integrated with the other im portant aspects o f the child. Occupational Therapy. Activities in > this departm ent are mainly concerned with the skills o f daily Jiving. Cerebral Palsied Children have to be taught to do m any things which, in norm al children, are taken for granted. Feeding, dressing, washing, and toilet training m ust be successfully perform ed if these cases are to be socially acceptable. i / W riting or typing is vital for School W ork. F rom ' the functional aspect, the use o f the hands and arm s is more im portant than th a t of the lower limbs, and one must continually bear in m ind the pre-vocational aspect o f O ccupational Therapy. W ith some children, crafts are used for this reason, and in addition, provide corrective movements and creative expression. Speech Therapy. 1 In any C erebral Palsied Children, chewing, sucking and swallowing are im properly developed. As . develop­ m ent o f speech is based upon these reflexes, one can expect to find defects which range from no speech a t all, to a mild disability. F aulty articulation and poor breathing patterns m ake a child’s speech unintelligible- to many. Speech correction is an essential p art o f the program m e devised for each child. It gives the child means o f com ­ m unication, and helps him fit into his social environment. Play Therapy. This is an im portant aspect to the basic approach to the child. N o t only does it satisfy the need for play in the children, b u t builds up an awareness of the im portance o f achievement, develops com petition, encourages the child to develop critical attitudes to his own efforts and teaches him to become a social m em ber o f his group. In play therapy there is freedom self-confidence. Education. The m ultiple handicaps associated with Cerebral Palsy have direct bearings on learning processes. T he therapists usually treat a child individually, but a teacher is expected to take' ten o r so problem atical children and teach them all at once. A fter evaluation by the Medical Panel, the Teacher has to plan a curriculum suited to the individual child. The Teacher faces m any problems. Visual, auditory' sensory and speech defects complicate reading and writing. C om bination o f these with lack o f m o to r co-ordination means th a t a child m ust be taught slowly an d carefully to read from left to right—to know the position on the page o f given extracts, to apply correct pressure when writing, to distinguish the horizontal line from the vertical and to recognise differences in letter and num ber fo rm s/ Form al subjects o f reading, writing and arithm etic must be carefully presented by th e teacher. Initial learning is usually slow, and' a long period o f assimilation often required before progress o f note can be measured. which prom otes drive an d n 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. ) July, 1954. P H Y S I O T H E R A P Y Page Nineteen M any Cerebral Palsied Children show typical b eh av io u r, patterns o f the brain-injured child—Hyperactivity dis- inhibition and other signs o f exaggerated response to environment and stimulus are difficulties in the class-room, and must be dealt with by counteracting methods. I t i s . obvious th a t m any Cerebral Palsied Children cannot successfully fit into a norm al school environment and specialised education is an essential p a rt o f the corre­ lated program m e necessary for habilitation. Finally the parents m ust n o t be forgotten as im portant members o f the habilitation team. They need much guid­ ance and assistance in the handling o f their children in the home, in close co-operation with the unit. In this article, we are referring mostly to cases under the special environm ent o f a planned unit, in particular we have in m ind, the w ork being carried o u t at th e Forest Town School for Spastics, Johannesburg. However, the problem o f Cerebral Palsy is a N ational one, and many necessitous cases cannot be adm itted to Xhis School, which is a D ay School only. They are resident pb isolated areas o f the U nion, and at best, one can only suggest suitable home treatm ent for the parents to carry out. Then too, most progress is noted if treatm ent is begun a t the earliest possible age. It is obvious th at small babies with Cerebral Palsy cannot attend a D ay School. To provide the necessary hom e treatm ent and advise parents as to how this may best be carried out, the Forest Town School now runs a Clinic for O utpatients. A ttending this Clinic, we find the following groups o f children: (1) Cerebral Palsy cases transferred to norm al schools who are still under observation. (2) Infant C erebral Palsy cases. T he parents o f these children are advised on how to care for them in the home. They m ay return periodically for follow-ups on progress and further discussions. (3) Cases n o t able to attend School for reasons such as, too great a distance for transport, o r not educable according to the conditions laid down by the Transvaal Education D epartm ent. In view of the- fact th a t most cases of Cerebral Palsy are first seen by the Fam ily D octor, it is w orth while noting what general points are suggestive o f a Cerebral Palsy condition. . The Case History. The aetiology o f Cerebral Palsy is often difficult to'5 assess. C auses' may be pre-natal, natal and post-natal. Thus the history o f any abnorm alities during the pregnancy, difficulties at birth and the immediate post-natal period, particularly where there is asphyxia with cyanosis o r jaundice, and the subsequent post-natal events are im portant. 2. The Development H istory o f the Child. The usual development (especially- o f m otor abilities) is delayed and seldom appears at norm al age levels. Thus, one needs to know , fo r example, at which age th e child held up its head, rolled, obtained reach and grasp, sat alone, used both hands in play, crawled, stood alone and walked. Early difficulties in feeding and inability to take solids successfully or to suck an d swallow properly would indicate possible speech retardation and attendant defects should be noted. Inco-ordination in older children is apparent in inability to perform daily skills, e.g. buttoning coats, using spoon or fork, pouring water into a glass, climbing up and down steps, draw ing and writing. 3. Abnormal Persistence, of Normal Levels in Development. T he norm al infantile reflexes m ay persist, e.g. the tonic neck reflex, th e-M o ro reflex and the grasp reflex or th e norm al ataxia of a child commencing to walk. 4. Appearance of Abnormalities o f the different Types and th e associated handicaps as discussed above. Conclusion. 1: C erebral Palsy is a complex national problem. M ost cases require th e attention o f trained staff, working as a team in a special habilitation unit. / f 2. T here is a wide field open to research an d investi­ gation. 3. M ost cases can benefit by training and education, and the expense and time involved is justified. S O U T H A FRICA N RAILWAYS AND HARBOU RS SICK FU ND Appointment of Physiotherapist : Pieterm aritzburg : Salary £708 p.a. A pplications are invited from registered Physiotherapists for, appointm ent to the above position. Full particulars o f the appointm ent m ay be obtained from the D istrict Secretary, N atal D istrict Sick F und B oard, Belgrave M ansions, Smith Street, D urban. Closing date for applications : 31st July, 1954. P. J. K LE M , Johannesburg, G eneral Secretary. July, 1954. SITUATIONS V A C A N T C R IP PL E S’ C A R E A SSO C IA TIO N O F T H E TRA N SV A A L H O PE T R A IN IN G H O M E A pplications are invited for the post of Part-tim e Physiotherapist at th e above H om e fo r crippled children. H ours : 8 a.m .— 12 noon (M ondays to Saturdays). Salary : £30 0 0 per m onth inclusive. D uties to commence, as soon as possible. Applications accom panied by copies o f testimonials to be subm itted to : T H E SEC R E T A R Y , BO X 566, JO H A N N E SB U R G . * * * * PH Y SIO T H E R A PIST (Female) F o r M ine N ative H ospital, to assume duty as soon as possible after 1st A p ril,-1954. Commencing salary £35 per m onth, plus cost o f living allowance (approximately £10 per m onth), free b o ard and lodging. A nnual and long leave privileges. Please apply to C hief Medical Officer, P.O. Box 1056, Johannesburg. ERR A TU M It is regretted th a t in th e article “ The Development o f Electrical D iagnosis and T reatm ent o f R eaction of D egeneration” by Miss H inz in the A pril 1954 issue, the figures in the text did no t correspond with D iagram X. On Page 5, colum n two, paragraph one, fo r “ the quotient is ° is 2 5 /5 = 5 ” , read “ 4 0 /1 0 = 4 .” 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. )