pediatrik rehab 7th week kopyası 2 (1).pptx

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1. Pediatric Diseases and Rehabilitation Physiotherapy and Rehabilitation in Cerebral Palsy Course Lecturer : MSc . Pt . A. Asena YEKDANEH

2. Cerebral Palsy / Physiotherapy and Rehabilitation The most important success is early diagnosis and early intervention !! ( Without stereotypic movements ) Specific goals should be set for children and families . (** Family education ) When setting the goal , the expectations and needs of the child and the family should be taken into account . Goal setting is an interactive process . When the results are re- evaluated , there may be changes in treatment goals . Support normal motor development Maintaining and increasing muscle strength Maintaining and increasing functional mobility Improve postural control Improving the quality of motion Prevent musculoskeletal disorders Independence in GYA Ensuring accessibility with environmental regulations Identify assistive device needs

3. It is known that traditionally the most frequently used approaches are neurodevelopmental treatment (NGT). NGT is based on the principle of inhibiting or modifying disorders caused by spasticity and abnormal reflex patterns while facilitating normal movement patterns . In this way , contracture and deformity are prevented , functional movement is facilitated , and the child is ensured to be independent at the highest level of independence he has. NGT has remained up-to-date by integrating new approaches in rehabilitation such as motor control and motor learning throughout the process .

4. GOALS DURING INFABILITY; EARLY PHYSIOTHERAPY It should be known that tactil , proprioceptive , vestibular , auditory and visual sensory stimuli and training , especially in the early period , are effective methods in revealing a good motor skill . Good motor movement is provided by good sensory input . Family education should focus on problems that are certain and can be seen as potential . Early intervention in children with CP helps infants achieve their abilities in more normal ways , in relation to the plastic potential of the central nervous system

5. Infancy is an important period that involves their ongoing relationships with the family and their collaborative goals . Positioning , carrying , feeding , dressing techniques for families ; It should be taught to prevent abnormal posture and movements and to support postural stability , functional motor activities and symmetry . The basic principles in these methods are : 1- Using different sensory inputs and changing types of movement to provide sensory diversity 2- Using the appropriate positions to ensure the normal length of the spastic muscles 3- To provide optimum conditions to allow the extremities to perform functional , voluntary movements with minimal assistance  
4- To provide sensory , perceptual , motor integrity 5- Improving the sense of the midline 6- To gain motor control skills from early rotation

6. The movements are facilitated by the physiotherapist , but as soon as the child is able to initiate the movement spontaneously , the aid is reduced and / or withdrawn . Families should be given support , encouragement and warned to be careful in specific techniques and activities . The physiotherapist should ease the burden on the family while performing therapeutic exercises and routine activities of daily living . Written , illustrated and up-to-date home programs should be created . The use of computerized programs and video to obtain personal and effective information about activities , positions and exercises increases the active participation of the family in the program.

7. The use of equipment to support the treatment often provides development while facilitating posture and movement . For example ; The sitting position improves visual participation , promotes upper extremity use and social interaction . Children with CP may not be able to sit independently , and may even develop a static posture due to the lack of balance and correction reactions . Chairs or etiquette mechanisms created for these children regulate the baby's sitting and allow them to develop the necessary functions in order to ensure progress in different developmental areas .

8. Especially for infants with GMCSS levels IV and V, early postural management programs should be started for sleeping , sitting , standing with postural support in the early period . This program should be 6 months for sitting and 12 months for standing . It is very important to ensure that children with CP, who have not reached the level of standing at 13 months , stand with an adaptive mechanism , in preventing secondary musculoskeletal problems that may arise and supporting hip development . However , babies with limited upper extremity movements cannot bring their hands and toys to their mouths , as a result , normal oral motor sensory input cannot occur . In such cases , oral motor training should be included in the therapy and sensory development should be primarily emphasized .

9. Beyond the sitting position , it should be allowed to lengthen all muscle groups in various postures . The physiotherapist is not only working out activities of daily living in one position ; The child should be helped to position themselves in such a way that they can see their upper extremities and hands , to find the midline , to see their feet and hands , to suck their fingers , and to provide sensorimotor integrity .

10. Active movements that require the use of both hands should be combined with activities of daily living that encourage the development of flexor control and symmetry . These activities are ; It facilitates the use of neck and trunk muscles , supports anterior and posterior control

11. GOALS IN PRESCHOOL PERIOD The main purpose of physiotherapy is to prevent secondary problems , to optimize gross motor skills , to provide postural smoothness and musculoskeletal development leading to movements , physical fitness and control of functions . Specific mobilization targets are determined according to GMCSS levels . They should be directed to age-appropriate activity groups in the early period for providing play , communication , self- care activities , social skills , and problem- solving skills . Instead of progressing with normal development in children with GMFCS levels 4-5, special equipment and adaptive toys should be used .

12. INHIBITION OF SPASTICITY Passive stretching reduces spasticity for a short time, but the change is very small .  Continuous low-load passive stretching is effective in increasing range of motion and reducing spasticity .  Another method frequently used in the treatment of spasticity is Botulinum Toxin A ( Botox ) injection .  It prevents the release of acetylcholine at the neuromuscular junction . An injection into an area close to the neuromuscular junctions makes the muscle inactive for 4 months , the maximum effect is known to be reached 2 weeks after the injection .  Intrathecal baclofen reduces spasticity in the lower extremities .

13. INHIBITION OF SPASTICITY There are many types of orthoses used for the ankle that can be used according to the individual , functional and biomechanical needs of the child . The physical therapist evaluates the child and collaborates with other team members to determine the most appropriate device based on the basis of treatment goals . Lower extremity orthoses are used to reduce primary problems , prevent secondary problems , and facilitate walking and other functional activities . It is aimed to ensure smoothness in joint movements and alignment , to prevent contractures , to prevent hyperextensibility and deformities , to increase postural control and balance .

14. SCHOOL AGE AND ADOLESCENCE Some children and adolescents develop their motor skills significantly , while others focus on age-appropriate levels of participation . School- age children and adolescents , if they are cognitively competent , should be actively involved in determining the goals and program of treatment .  Maintaining muscle flexibility , strength , joint integrity and fitness is important for the prevention of secondary problems such as contractures that may occur with insufficient endurance , pain and aging .

15. Progressive resistance training is a common intervention method for children and adolescents with CP. Programs should be organized in short sets for 4 to 12 weeks , 3 days a week , between 80% and 90% of the maximum load , allowing the muscles to rest and regenerate . Endurance training , on the other hand , should include approaches with more repetitions at a low workload . Elastic bands , low weights , isokinetic equipment and functional movements are used for strengthening . Programs are implemented at home , in the clinic or in public spaces . In order to maintain muscle functions throughout life, strengthening exercises should be added to regular exercises and physical activities .

16. INHIBITION OF SPASTICITY Passive stretching reduces spasticity for a short time, but the change is very small .  Continuous low-load passive stretching is effective in increasing range of motion and reducing spasticity .  Another method frequently used in the treatment of spasticity is Botulinum Toxin A ( Botox ) injection .  It prevents the release of acetylcholine at the neuromuscular junction . An injection into an area close to the neuromuscular junctions makes the muscle inactive for 4 months , the maximum effect is known to be reached 2 weeks after the injection .  Intrathecal baclofen reduces spasticity in the lower extremities .

17. INHIBITION OF SPASTICITY There are many types of orthoses used for the ankle that can be used according to the individual , functional and biomechanical needs of the child . The physical therapist evaluates the child and collaborates with other team members to determine the most appropriate device based on the basis of treatment goals . Lower extremity orthoses are used to reduce primary problems , prevent secondary problems , and facilitate walking and other functional activities . It is aimed to ensure smoothness in joint movements and alignment , to prevent contractures , to prevent hyperextensibility and deformities , to increase postural control and balance .

18. Treatment Concepts and Methods

19. Neurodevelopmental Treatment Approach Neurodevelopmental therapy (NDT) was developed by Berta Bobath , a physical therapist , and her husband , neurologist / psychiatrist Dr. Karel Bobath , for use in the treatment of teenagers and adults with movement disorders . For the purpose , it is aimed to increase neuromotor and postural control and to minimize disorders and improve functions .

20. Neurodevelopmental Treatment Approach From the 1990s to the present ;
Active dynamic therapy Training with activities Coordination of movement and improvement of balance Running different nested activities in a movement flow Inhibition of the tonus Regulation of the tonus Use of large body parts for facilitation of movement Activate movement within the function and maintain applications in daily life

21. Neurodevelopmental Treatment Approach The quality of the movement ; It depends on the appropriate and correct execution of the target , speed , harmony and fluency .
Normal motion = task performed effectively in a variety of environments In NDT applications , an activity is run in different and adaptive ways . Purpose ; In line with the principles of motor learning , it is the acquisition of normal movement , normal function and necessary activity experience .

22. Neurodevelopmental Treatment Approach The motor behavior and functions of the individual depend on the interaction of many systems , the characteristics of movement and environmental factors . In motor performance , the person's desire , motivation , the nature of the activity to be done and the environment are also important . Movements are organized purposefully . In the NDT approach , functional problems are tried to be eliminated by focusing on the skills and abilities of the individual . Effective motor function is the combination of combinations of movements , contraction of muscles against gravity , and the ability to cope with environmental challenges .

23. Neurodevelopmental Treatment Approach Smooth movement In practice , the active participation of the person and the guidance of the physiotherapist are important . Motion analysis The purpose of NDT is to improve functionality . NDT uses the ICF model to classify health and disability status . With ICF, motor function and impairment , system integrity or insufficiency , function and activity limitations , and ability to fulfill personal roles are defined .

24. General Principles of the Bobath Approach Positioning Ensuring posture smoothness Regulating muscle tone Facilitating movements Increasing sensory input and sensory -motor experiences Minimizing respiratory and feeding problems Facilitating observation and intervention Assisting with weight transfers Improving the active use of other parts of the body by providing stabilization Increasing the feeling of midline and symmetry Preventing musculoskeletal deformities that may occur

25. General Principles of the Bobath Approach Materials that can be used for positioning Adaptive seating systems Chairs and stools of different sizes Exercise balls of different sizes Sensory stimulation balls Pillows of different sizes and shapes Rolls Sheets and piqués that can be used in a variety of ways Hammock All materials that the physiotherapist can use with his purposeful imagination and creativity

26. General Principles of the Bobath Approach In order to achieve functional movement , it is important to prepare the child in terms of muscle tone , joint smoothness , posture , balance and sensory system . Before all activities , the child should accept the activity or position to be done emotionally , feel comfortable , trust the environment and the physiotherapist . Using one part of the body to reveal movement in the other part is one of the ways that the physical therapist will use to facilitate proper movement .

27. General Principles of the Bobath Approach Stimulation is used for many purposes , such as revealing movement , directing movement , increasing the perception of body positions , regulating tone , stabilizing , and improving communication between the physio and the child . Teaching movement , regulating tone and stabilization have a very important place in improving the child's movement control . It is important to use all means of communication with the child and the family during the applications .

28. General Principles of the Bobath Approach Environmental regulation In order for a purposeful , coordinated movement to occur , the center of gravity must remain within the support surface biomechanically . The position of the head , its relationship with the body, the normal smoothness of the trunk and extremities depend on the adjustment of the support surface during movements and the transfer of weight to the appropriate support points .

29. Bobath Concept Active dynamic therapy Training with functional activities Tonus regulation Ensuring coordination of movement Striking a balance Stimuli to increase movement - positioning - sensory -motor activity

30. Main Principles in the Bobath Concept Facilitation (facilitation, support)
Stimulation (warning)
Communication (communication)

31. 1-What are the main disorders seen in Cerebral Palsy ? 2- What are the goals of physiotherapy rehabilitation in Cerebral Palsy ? 3- What are the common aspects in rehabilitation approaches applied in different periods ? 4- What should be the basic principles to consider when planning a physiotherapy program for a child with CP?

32. E-Mail: [email protected]