Pediatric rehabilitation is the team approach to the picture of disability or disability caused by physical, mental, sensory-perception or cognitive disorders that may occur due to prenatal, birth or postnatal reasons.Cerebral palsy can be defined as a non-progressive and permanent disorder in the posture and movement system that causes limitations in functional activities; this can be accompanied by sensory, perception and communication problems, epilepsy and musculoskeletal system problems. Physiotherapy approaches in rehabilitation applications aim to normalize sensory and motor experiences, to provide proper posture and independent functional activity, to try to regulate muscle tone, to improve visual and auditory reactions, to support normal motor development and to provide motor control, to improve the quality of the existing movement, to improve walking, to try to prevent soft tissue, joint and posture disorders that may occur, to support orthopedic and surgical interventions and ultimately to prepare the child for adolescence and adulthood. Determining realistic goals and priorities, informing the family and ensuring active participation in the physiotherapy program will increase the success of physiotherapy.

In the rehabilitation of children with cerebral palsy (SP), various approaches and techniques are used, ranging from traditional techniques such as muscle strengthening, stretching and massage to more complex motor learning-based theories such as neurodevelopmental therapy.  Motor disorders in SP are often accompanied by sensory, cognitive, communication, perceptual, and/or behavioral disorders, so that therapeutic approaches are tailored to meet the child’s individual needs.

SP symptoms range from mild to severe from person to person. Some people with CP may have difficulty walking and sitting. Other people with CP may have difficulty grasping objects. Symptoms may become more severe or less severe over time. It can also vary depending on the affected part of the brain.

Some of the frequently encountered situations are as follows:

• delays in reaching motor skill milestones such as rolling, sitting alone or crawling
• changes in muscle tone, such as being too loose or too stiff
• Delays in speech development and speech difficulty
• spasticity or stiff muscles and exaggerated reflexes
• ataxia or lack of muscle coordination
• Tremors or slight involuntary movements
• excessive saliva and swallowing problems
• difficulty walking
• prefer one side of the body, such as reaching with one hand
• neurological problems such as seizures , mental disabilities and blindness

1- In children with cerebral palsy (spastic), shortening occurs over time in the muscles that are always in the same position due to contraction. As a result, joint range of motion cannot be completed. In the later stages of treatment, when active movement occurs due to development in the brain, the child cannot make the desired movement because of structural disorder.

2- To increase the functional capacity of the child. Children with cerebral palsy need to complete the functions in their developmental stages in order to gain independence in daily life. These functions are: Head control, standing on forearms, standing on hands, rotating, creeping, sitting, crawling, standing on knees, standing and walking.

Clinical Symptoms

One of the defining physical characteristics of cerebral palsy is that there is an abnormal hard,solid or tension in the muscles, which is spasticity. Spasticity reduces the child’s ability to control muscle movements, especially in the hips, knees, ankles, shoulders, elbows and wrists. Spasticity may also cause exaggerated reflexes, making movements appear erratic or tense.

Physiotherapists add simple stretching and strengthening exercises into rehabilitation to help relax tense muscles. Additional exercises to increase muscle tone can help a child with cerebral palsy better control their body movements. Physical therapy also aims to improve balance, strengthen posture, and reduce the risk of joint problems due to irregular gait.

Ergotherapists help children control the movement and coordination in their hands that can help with writing, eating, dressing, and other routine tasks. Therapists help children with more severe symptoms find creative ways to cope with daily challenges.

HOW CEREBRAL PALSY CLASSIFIED ?

Cerebral palsy is classified according to the Coarse Motor Function Classification System (GMFCS). The World Health Organization (WHO) and the Cerebral Palsy Surveillance in Europe have developed GMFCS as a universal standard for determining the physical abilities of people with CP. The system focuses on:

• seating capability
• mobility
• graphic independence
• use of adaptive technology

5 LEVELS of GMFCS LEVEL

1.level of cerebral palsy

Level 1 CP is characterized by the ability to walk without limitations.

2.level of cerebral palsy

A child with a level 2 CP can walk long distances without restrictions, but the child cannot run or jump.When first learning to walk, they may need auxiliary devices such as leg and arm supports. They may also need to use wheelchairs to get around outside their homes.

3.level of cerebral palsy

A child with a level 3 CP can sit with little support and stand without support.They need hand-held auxiliary devices, such as a walker or a cane, when walking indoors. They also need a wheelchair to get around outside the house.

4.level of cerebral palsy

A child with a level 4 CP can walk with the use of auxiliary devices.They can move independently in a wheelchair, and they need some support while sitting.

5.level of cerebral palsy

A child with level 5 CP needs support to maintain the head and neck position.

They need support to sit and stand, and they can control a motorized wheelchair.

 

WHAT TO DO DURING THE REHABILITATION PROCESS

Evaluation

1.Type of cerebral palsy: What typeof contraction the child has is examined.These types of contractions are called:

Spasticity: Resistance to passive movement. Spasticity increases when the child wants to move. Spastic CP is the most common type of CP that affects approximately. It causes muscle stiffness and exaggerated reflexes, making it difficult to walk. Many people with spastic SP have gait abnormalities such as bending their knees when walking or making scissor-like movements with their legs. Muscle weakness and paralysis may also be present in individuals. Symptoms can affect the whole body or only one side of the body.

Dystonia: It is called convulsions in the curved pipe or rotational style.

Atetoid: Involuntary snake-like movements.

Ataxia: Is a coordination and balance disorder. Auxic CP is the least common type of CP. Ataxic SP is often characterized by voluntary muscle movements that appear erratic, incompetent, or jerky.People with this form of SP often experience balance and coordination problems. They may have difficulty in walking and performing fine motor functions, such as grasping and writing objects.

Hypotonia: There is no contraction in the child, on the contrary, it is in the form of a child jelly. Hypotonic CP causes a decrease in muscle tone and excessively relaxed muscles. The arms and legs move very easily and look loose like a diaper baby. Babies with this type of SP have little control over their heads and may have difficulty breathing. As they get older, they may find it difficult to sit upright because of their weakened muscles. There may also be speech difficulties, poor reflexes, and gait abnormalities.

2. Functional evaluation: The functional status of the child is determined. Functions that can and cannot be performed are checked.

3. Structural evaluation: Contraction areas in the child, weak movements in the body, (example: weakness in the elbow flexion muscle), places with structural disorders in the body, places where there is a risk of structural deterioration in the body are examined.

4. Child’s perception capacity: Educators make the intelligence assessment, but it must be roughly evaluated by the rehabilitation team before starting the rehabilitation program.In
addition, the age of the child, the socio-cultural level of the family and the participation of the child and the family in the treatment should be evaluated.

The most important part of cerebral palsy rehabilitation is evaluation. There are very frequent changes in the child’s biomechanical structure when targeted active rehabilitation is performed. When rehabilitation is continued without taking these changes into consideration, rehabilitation after a while may cause harm instead of benefit.

What other conditions are associated with cerebral palsy?

People with SP may have other problems such as:

• Communication difficulties, including speech and language disorders
• Drooling
• Spinal deformity such as scoliosis (curvature), lordosis (saddleback) and kyphosis (hump)
• Osteoarthritis
• Contractures that occur when muscles are locked in painful positions
• Incontinence
• Weak bone density that can make osteopenia or bones easily breakable
• Dental problems

 TREATMENT

Cerebral palsy requires multidisciplinary study for rehabilitation. It should be followed by developmental neurology from the moment the symptoms of cerebral palsy are seen in the child. Rehabilitation should be started at the earliest period deemed appropriate by the developmental neurologist and it should be continued without interruption. It should be evaluated for spasticity surgery when the child stops progressing in rehabilitation due to spasticity and even begins to regress. If structural disorders have developed in the body, they should be evaluated by a pediatric orthopedist.

The most commonly applied physiotherapy method in our country is the old bobath method. In this method, contraction is first tried to be eliminated by stretching. Then, the new muscle tone (muscle consistency) is tried to be taught to the body and then this normal tone is ensured to be used in function. This principle is still valid, but stretching studies to eliminate contraction have been shown to be ineffective in the rehabilitation of cerebral palsy. The relaxation obtained by stretching disappears when the child wants to act actively. Very rapid contractions increase when no stretching is performed for a while. Therefore, those who applied the bobath treatment method gave up stretching exercises. In the bobath concept method, exercise is not performed. The child is tried to be taught the movements that the child cannot do with play activities in daily life. In this treatment method, treatment should be started very early. If the contraction is located in the body, it is very difficult to place normal muscle consistency with play activities. In therecently popular thera suite therapy method, a dress that makes the child’s posture close to normal is used. When this dress is worn for a long time, contractions decrease. The treatment here is performed in an iron cage. The number of well-trained physiotherapists who can apply the Thera suite therapy method is very few. With their recent imitations, children are being treated by our colleagues who do not know how to use this  method at all. This method is not used in children under three years of age.

REHABILITATION OF CEREBRAL PALSY WITH FACILITATED EXERCISES

This method is used in the rehabilitation before and after spasticity surgery. The main problem in a child with cerebral palsy (spastic) is brain damage. It is not possible to treat this damage with existing treatment systems. What is done in the treatment of these children is to take advantage of the shape-shifting feature of the brain and to ensure that the damaged areas assume the role of the healthy areas. This is due to the fact that the damaged areas learn the task of the intact areas. It should be from easy to difficult in learning. It has been accepted that rehabilitation in water is effective. Here, the lifting power of water helps the movements that the child cannot do and makes child movements easier. In this way, the child makes frequent movements and enables the brain to learn. When the child accelerates the movements, the water gives resistance and strengthens the  structure. Facilitated exercises and cerebral palsy rehabilitation also have features close to the benefit mechanism of water exercises.

In this method, body exercises are performed first. This is because the arms, legs and head, which are attached to the strong body, are more controlled and can move more easily. Secondly, it is the strengthening of the weak places in the arms and legs determined as a result of the evaluation. Thirdly, functional exercises are exercised.

Body exercises:

Body exercises can be studied on a bobath ball.

BECAUSE :

• Rhythmic movements reduce contraction. Rhythmic movements on the ball are very easy. Example: swinging back and forth on the ball, lying face down.
• While the body strengthening exercises are performed by sitting on the ball, it is also operated in balance.
•  In body exercises performed on the ground, only the abdominal and back muscles are strengthened. In the body exercises performed on the ball, it is strengthened in the abdominal  and back muscles as well as other muscles that provide stability.
• While doing body exercises on the ball, the child also has to use his arms and legs. This increases active movement in the arms and legs.
• The cost of the Bobath ball is very cheap. Every family can take home and do ball exercises at home.

 

Stages of body exercises on the ball:

If there is not active movement in the body, passive sitting exercise is performed. When the body weight is given to the body from the child’s armpit, the structure is kept in a way that it will not be disturbed. The ball is quickly moved back and forth while the child is sitting on the ball. In the first stage, body movements are assisted. After a certain period of time, the child starts to react actively to the displacement of the ball. After a certain amount of active movement occurs, the grip is brought to the hips so that the body is controlled by more children. In this way, it will be possible to actively operate the child body in the forward and rear swing. After the active movement in thebody occurs, the child is held by his/her knees. The body is strengthened by making the child move back and forth and right and left on the ball.

Operating the arms and legs: Exercise tires can be used when operating the weak places on the
arms and legs. When starting the movement, the exercise tires are attached to the child in a way that they are tensioned in both directions. The resistance of one of the attached exercise tires should be one degree higher than the other.

 

The advantages of working in this way:

 

•  Exercise tires teach the child the direction in which the child will move.
•  When we attach the exercise band with high resistance to help the weaker direction, the child makes this movement easier. As a result, the child participates in the movement more and learns the movement as the movement is performed frequently. After a certain strengthening in the movement, the exercise tires are moved. The structure is strengthened because the exercise rubber with high resistance will give resistance to the weak place.
•  In the study conducted with exercise tires, bending and pushing movements are performed together. This makes it easier for the child to use movement in functional exercises.
•  In the study conducted with exercise tires, the person who makes the movement never engages in compelling activities. It takes advantage of the ability of exercise tyres to help. This ensures that the person making the movement is not forced and the movement can be operated for a longer time.
• In the work done without exercise tires, it is not possible to provide the same level of help and resistance when moving. This makes learning difficult. In the work done with exercise tires, the same help and resistance is always given. This makes learning easier. Exercise tires cost less. It can be applied in any family home.

Functional exercises:

Functional exercises of cerebral palsy rehabilitation withfacilitated exercises are performed with CPP (functional exercises mechanism). In this mechanism, it is connected in a way that makes movement easy with the help of child exercise tires. The places where exercise tires are attached go up, down and back. This adjusts the help level of the exercise tyres. As the child learns the movement here, the help is reduced and the child is more involved in the movements, and as the child learns the functions in this arrangement, he /she starts to do them in daily life. Advantages of working with FFED:

• Exercise tires always have the same resistance from the first tension to a certain tension. When the exercise tires are attached to the child in this assembly in a way that helps the function, they always help the child in the same way from the moment the function starts until it is completed. This accelerates the child’s learning of the movement. At this stage, the focus is on the electronic system to be applied instead of exercise tires. It is thought that more effective results will be obtained when working in this system.
• In this  arrangement, the child can only move in the direction of the function we want while being connected with exercise rubbers.
• Exercising functional exercises is very difficult for the person who performs the movement. After working for a certain period of time, the person who performs the movement has difficulty and cannot perform functional exercises for a long time. In this setup, the person who makes the movements while the child is tied stands only at the beginning of the setup and functional exercises can be performed for a long time.
• Since the size of the assembly is not very large, it can be easily used in any home.

In this setup, all functional exercises other than rotation exercise can be performed.

The most important factor in the rehabilitation ofcerebral palsy is the early initiation of treatment. When active and targeted physiotherapy is performed and when working with other members of the rehabilitation team when necessary, the highest functional condition allowed by brain damage can be revealed.

Today, it offers a wide range of rehabilitation treatments for children with cerebral palsy, a neuromuscular disorder that prevents movement, muscle coordination and gait.

In the rehabilitation of children with cerebral palsy (SP), various approaches and techniques are used, ranging from traditional techniques such as muscle strengthening, stretching and massage to more complex motor learning-based theories such as neurodevelopmental therapy.  Motor disorders in SP are often accompanied by sensory, cognitive, communication, perceptual, and/or behavioral disorders, so that therapeutic approaches are tailored to meet the child’s individual needs. Approaches can be divided into two groups with and without equipment. Examples of unequipped rehabilitation approaches include neurodevelopmental therapy, motion therapy due to conductive education restriction, and task-oriented therapy; robotic therapy, virtual reality, and equestrian therapy are examples of equiped rehabilitation approaches. CP is a common, inhibitory condition. The application of evidence-based methods provides maximum gain in children. In addition, approaches that increase the motivation of the patient and aim at daily life activities and participation are the most effective approaches in the functional recovery of children with CP.Intensive rehabilitation treatments usually begin in early childhood and are designed to improve muscle control, manage spasticity, and help your child develop self-confidence.Some children may continue to work with physical and occupational therapists during adulthood.

Auxiliary Devices

These devices help to manage spasticity, keep the limbs in the correct position, and prevent unusual alignment of bones and joints from becoming permanent.
There are various splints and other devices thata doctor can provide.Physiotherapists work one-on-one with children to choose the most effective option and help them get used to it. While some devices are designed to be used when a child is awake and on the move, another type of device may be specially designed to gently stretch tendons while a child is sleeping.

Speech Therapy

Some children with cerebral palsy may have difficulty creating words and speaking clearly.This inability to communicate is often frustrating for a child. Speech pathologists increase the child’s verbal motor skills and communication intelligence by using exercises that train the brain to pronounce, understand, and interpret individual words, sounds, numbers, and movements.

Recreational Therapy

It offers recreational therapy to improve the physical, cognitive, emotional and social skills of children and young adults withcerebral palsy.This also helps children transform the skills they learn in physical and occupational therapy into their  daily activities.Recreational therapy allows children to combine practical skills with fun, social experiences that often take place outdoors.Our doctors can plan a trip that includes skiing or swimming or helps children prepare to participate in an organized team sport, such as wheelchair basketball.

In addition, techniques such as hypotherapy where children ride horses are also used.Coordinated movements of horses as they walk can help children feel more comfortable with their own balance and walking  senses.Recreational therapy promotes independence and can help children and their families feel more comfortable navigating social settings such as restaurants or movie theaters.

Dance therapy

Objective: To review the research literature on the use of dance and movement (rhythmic auditory stimulation [Ras]) with music in neurorehabilitation of children and adults with cerebral palsy.

Method: We conducted a systematic research and quality evaluation of the research literature on dance and Ras in SP. In addition, we linked the research results to the International Classification of Functionality, Disability and Health (ICF) Participation.

Conclusions: Studies have shown preliminary evidence of the benefits of dance and Ras for individuals with CP on body functions, particularly balance, gait, gait, and cardiorespiratory fitness. Research gaps are evident in all areas of the ICF, especially in the areas of participation and environment.

Comment: In order to facilitate the translation of quantitative research results into the clinical classification of ICF, a table has been created that links traditional areas of quantitative rehabilitation research with ICF categories that highlight research strengths and areas where increased rigor is desired. The potential of dance and Ras to have positive effects on body functions, emotional expression, social participation and attitude change are areas that should be considered in future research.

The potential for dance and movement to music helps balance, walk, and walk in children and adults with cerebral palsy. Research gaps are evident in the areas of International Functionality Classification, Disability and Health, especially in the areas of participation and environment.

HYPPOTHERAPY

Purpose:The aim of our study was to investigate the effects of hypotherapy on gross motor function and functional performance in children with spastic cerebral palsy.

Materials and  methods: We included 34 children (M: F=15:19, age: 3-12 years) with spastic SP who received 45 minutes of hypotherapy twice a week for 8 weeks. 21 children with spastic SP were included in the control group. The rough motor function classification system level and mean age distribution did not differ significantly between the two groups. Outcome measures, including Coarse Motor Function Measurement (GMFM) -66, GMFM-88, and Pediatric Evaluation of Disability Inventory: Functional Skills Scale (PEDI-FSS), were evaluated before treatment and after 8 weeks of intervention as outcome measures.

Results: There was no significant difference between the intervention and control groups in the mean baseline total scores of GMFM-66, GMFM-88, or PEDI-FSS. After 8 weeks of intervention, the mean GMFM-66 and GMFM-88 scores improved significantly in both groups. However, the hypotherapy group showed significantly more improvement in E dimension and GMFM-66 total score than the control group. The total PEDI-FSS score and the subscores of the 3 domains improved significantly in the hypotherapy group, but not in the control group.

Conclusion: The results of our study show the beneficial effects of hypotherapy on gross motor function and functional performance in children with CP compared to the control group. Significant improvement in PEDI-FSS scores suggests that hypotherapy may be useful to maximize the functional performance of children with cp.

 AQUATHERAPY

There are three main techniques used today. These are the Bad Ragaz Ring Method, which is based on the in-water application of PNF patterns, the Halliwick method, also known as swimming training, and the Watsu technique used to increase flexibility, endurance, and muscle strength in healthy people who are not used for treatment. In recent years, in-water exercises have come to the fore as an alternative to land-based exercises. In-water exercise applications provide a fun, motivation-enhancing and safe working environment for strengthening, stretching exercises, functional activity studies and balance training .