Pediatric

Rehabilitation

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Asmaun Nadjamuddin, md
Physical and rehabilitation medicine, fkuh-rsws

Pediatric
Rehabilitation
Pediatric Rehabilitation
Introduction PR
Motor development during early childhood
Development of Postural Control

Postural Adjustments are Anticipatory

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Pediatric
Rehabilitation
Postural Adjustments are Task and
CEREBRAL PALSY
Etiology

Pathology
Classification

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Pediatric
Rehabilitation
Different to Spastic,Rigidity,Athetoid
HYPOTONIC CP

SPASTIC CP
ATHETOID CP
ATAXIC CP

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Pediatric
Rehabilitation
Medical Treatment

Rehabilitation Management
Surgical
Complications..

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PEDIATRIC REHABILITATION

Introduction
Some of the more frequently encountered disabling
conditions of childhood are :
Cerebral palsy
Muscural dystrophy
Spina bifida
Developmental delays
Hypotonia
Keep in mind the following aspect of rehabilitation
that are unique to treating children.
Pediatric Rehabilitation

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Introduction PR
Do not treat children as trough they are little adults ;
It is the job of parents in society to help children, including
those with handicaps, grow into mature adults capable of
independents living.
This responsibility should be shared by the health
professional concerned with their care.
Because children are largely products environment ;
Educate parents about would constitute therapeutic
environment for their children.
Rehabilitation of children, in contrast to that of adults ;
Often does not mean relearning low skills, but rather,
learning appropriate motor and social skills for their age or
Developmental level under adverse conditions.

Introduction PR

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Introduction PR
Knowledge of normal motor learning, growth, and development
is essential for the
therapeutic intervention in the growing child
Understanding the emotional needs of the child at various
ages is equally important.
Treatment must take into consideration decelerated bone
growth in weakened
extremities, compared to the strong stimulus for bone growth
in extremities with normal
muscle activity.

Introduction pr

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Development of postural control :
Bobath ( 1964 ) response aspects of postural adjustment
used for evaluating child
Reflexes are part of assessment but role in MD not
known
Woollacott (1986) Role of postural control ignored
Perin (1989) Emphasis on treatment as being moved by
the therapist

Motor development during early chilhood

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Development of Postural Control

BALANCE

Needed:
Set segmental alignment before limb is moved voluntary
Respond to movement of surface in which we are
Withstand displacement by some outside force
Both internal and external forces
new findings
Postural adjustments are anticipatory and preparatory
Postural adjustments are task and context specific
Vision has a propioceptive role in postural control

Development of postural control

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Development of Postural Control

Development of postural control :
Gahery and Massion (1981) areas of the brain that
control voluntary movement also activate postural
adjustement
Treatment = self initiated movements made by the infant
and not postural adjustaments in response to
movements imposed on the infant by therapist
Postural adjustments vary ( task, enviroment, individual )

Development of postural control

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Postural Adjustments are

Anticipatory and Preparatory
Shepherd ( 1994 ) Lower limb postural
muscles activated before prime mover arm
Bouisset and Zattara (1981) activation
associated with joint rotation and changes
in centre of pressure

Postural Adjustments are anticipatory and

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Postural Adjustments are

Task and Context Specific
Cordo and Nasher (1982) muscles can vary
their main function, from stabilizing to
active movement
Nashner and Woollacott (1979) distal to
proximal activation

Postural adjustments are task and context

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CEREBRAL PALSY
Non-progresive group of brain disorders resulting from a
lesion on development in fetal life or early infancy
Pathological CNS mechanisms not progressive but clinical
features do appear to change as infant grows older, due to
infant experiences
Abnormal movements due to
Motor control deficits
Cognitive abilities
Enviroment where movement takes place

Experiences direct maturational changes in nervous system,

so position and movements practiced are important
CP child need multidisciplinary team: neuroly, psycology,
social work, PT, speech therapy, education, OT, orthotics...

Cerebral palsy

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Etiology
Have changed through time
More frequent disease in undeveloped countries,
but prevalence hasnt cut down due to
improvements in obstetric management and
perinatal cares (low prematures survivance)
Classification according to periods
PRENATAL

Etiology

Mother infections in the first gestational trimester

Circulatory ( anoxia, anemia, hypertension)
Metabolism (diabetes mellitus, fenilketonuria)
Rh incompatibility
X-Rays exposure
Premature periventricular leukomalacia related to spastic
diplegia (Kitchen 1987)

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Etiology
NATAL AND PERINATAL
Incidence in this period is dropping
Intrapartum asphyxia
POSTNATAL PERIOD
Infections (mengitis, sepsia)
Intoxications
traumatism

etiology

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Pathology
Haemorrhagic lesions
More common in premature infants, less 32 weeks
Origen at thalamic groove
Hypoxic ischaemic lesions
Select neuronal necrosis
Focal or multifocal ischaemic lesions
Intracranial haemorrhage
Hyperbilirubinaemia

pathology

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Classification
Bobath, 1976

classification

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Classification
SPASTIC showing characteristics of UMN involvement
ATHETOID showing signs of extrapyramidal
involvement, with involuntary movements, dystonia,
ataxia and sometimes rigidity
HYPOTONIC severe depresion of motor function and
weakness
ATAXIC cerebelar involvement, ataxia
MIXED

Classification

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Different to specific,, rigidity,, athetoid

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HYPOTONIC CP
Often transient to spasticity or athetosis(dystonics
attacks)
Evidencied:
Floppiness when picked up
Inability to generate muscle force to move body against gravity

Differencial diagnosis: Tay-Sachs, Werdnigg-Hoffmann,

premature infants and Down syndrome
Examiner can produce some activity, but child has little
spontaneuous movement ( even respiratory)
Possition decubit: arms and legs ABD, ER and F

Hypotonic cp

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HYPOTONIC CP
Pull to sit: head lag

Prone protective side turning of head

absent
Sitting/standing will colapsed
No kicking nor effective cough
Dificulty eating and drinking due to
muscle weakness
Hypotonic cp

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SPASTIC CP
Resistance to passive movement and abnormal patterns
not evident in young infants
Tone increases as infant develops ( Bobath 1975)
2 groups
Initial hypotonus
Spasticity due to effects adaptive neural and mechanical events that
reflects organization of CNS and MSS
Hypertonus result of
Structural changes on muscle and soft tissues
Neural recovery process at spinal level

Dystonia for severe extensive brain dysfunction afecting cortex

and spinal cord

Little ability to move in any position (changing influated

by tonic reflexes), resistance to passive movement
Spastic cp

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SPASTIC CP
Spasticity =
Hyperreflexia
Changes in muscle structure
and function
Abnormal muscle activity by
change of position
Major barrier to development is
negative features
Abnormal patterns of movement:
flexion upper limb at elbow,
wrist and fingers, shoulder IR
& ADD
Extended lower limb: IR&ADD
hip, plantiflex and inversion
ankle
Trunk for intersegmental
attachment of limbs muscles:
latissimus dorsi
Spastic cp

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SPASTIC CP
Associated movements in response to
stimuli
Behavioural adaptations
Contractures
skeletal deformity
Main problem= inhability to activate
muscles and control muscle force to
produce intentional movement
Spastic cp

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ATHETOID CP

Choreiform movements, dystonic posture

Involuntary movement both rest and volitional move
Infants typically trunk and head extension
Strategies for dealing w motor dyscontrol
Control of head position slow to develop=
vision=reaching
Grimacing face= breathing and swallowing
Joints hypermobile
Hip and jaw dyslocation
Scoliosis due to muscle imbalance

Athetoid cp

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Uncommon in CP, associated with hydrocephalus, head
injury, encephalitis or cerebral tumor
Dificulty with movement: rate, range, direction and force
Amplitude and velocity no functional actions (reaching)
Uncoodinated wide base locomotion ( no balance) so
use hands
Lack of braking joint dislplacements = overshoot

Ataxic cp

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Movement dysfuncion
Impaired motor control
Minimal brain dysfunction: clumsiness

Reaching and manipulation

Floor-sitting
Diplegia

Sitting on a chair
IR and flexed hips

Ataxic cp

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Sit to stand

Ataxic cp

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Medical Treatment
Baclofen
Antispastic agent
Reduces hyperactive of
Mono- and polynaptic stretch reflex
Arachnoyd space
Lessens involuntary spasm and spasticity ( Cambell 1995)

Botulinic Toxine
Inhibit presinaptic release of Ach in neuromuscular space
1-4 months
In muscles
Prone to contractures
Spasticity interfers in its function

Triceps, hamstrings, hip flexors and ADD

Co-adjunment to PT
Medical treatment

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Rehabilitation
Management
Birth to Three Years of Age
For the nurmal child, this is the age period when
intense motor learning and basic language
development occur.
Accordingly, this is the time that intervention by
physical therapy, and / or speech therapy can be most
beneficial in promoting the development of normal
motor patterns (gross, fine, and oral), and perhaps
inhibiting abnormal patterns.
With a good program of early intervention, surgeryis
rarely necessary in this age group.

Rehabilitation management

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Rehabilitation
Management

Three to Seven Years of Age

Brancing rarely is required before 3 years of age,

unless the child is standing or ambulating with severe
leg, ankle, or foot deformity.
Bracing is used to augment weak muscles and
oppose strong muscles, thus preventing deforming
forces on bones and joints.
For severe adductor spasticity causing scissoring
during ambulation, long leg braces with a pelvic band.
It functional ambulation without or with minimal
bracing has not been achieved by 5 to 7 years ago,
refer the child to orthopedic for surgical release.
Rehabilitation management

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Rehabilitation
Management

Eight Years of Age to Adulthood

Physical therapy should be limited to a

maintenance program for preventing
contractures and deformity and promotion
independence at the wheelchair level.
Occupational therapy may still be necessary to
enable the child to rich an optimal level of
independence in activities of daily living in
accordance with abilities and limitations.
If speech has not developed by age 8, further
speech therapy is probably not indicated
Rehabilitation management

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Surgical
Selective Posterior Rhizotomy :
This is a surgical procedure that reduces
excessive muscle tone in spastic cerebral
palsy.

Surgical

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Complications

The obvious Motor dysfunction

Mental retardation
Speech and language problem
Visual problem
Diminished hearing
Dental problems

Medical treatment

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