DESCRIBE IN DETAIL THE REHABILITATION GOAL SETTING AND MANAGEMENT OF A 14 YR OLD FEMALE PATIENT HAVING WRIST AND HAND DEFORMITIES DUE TO CEREBRAL PALSY ( HEMIPLEGIA ) ?
A 16 INTRODUCTION
1 Cerebral palsy (CP) is the commonest cause of neurological disability in children.
2 The upper limbs are often affected, with significant wrist and hand involvement from an early age
3 Persisting from infancy, affected children may have abnormal hand postures such as thumb adduction and/or flexion with limited wrist extension, as well as more proximal abnormalities of upper limb tone, posture, and function, which also impact on hand use.
4 Hemiplegic cerebral palsy affects around 1 in 1300 live births and has a range of etiologies including neuronal migration abnormalities, periventricular leukomalacia, intracranial hemorrhage, and infarction.
5 The common feature is disturbed cerebral control of motor function.
A ) A large component relates to corticospinal tract damage, as the corticospinal tract is the major descending tract controlling skilled, fractionated, voluntary hand movements .
B ) In addition, there is often extrapyramidal involvement
C ) some patients have marked dystonia. As well as disruption of motor pathways, there are often sensory impairments including astereognosis , which impact detrimentally on hand function.
D ) These sensory impairments may reflect additional damage to ascending thalamocortical pathways and/or somatosensory cortical areas , as well as failure of sensorimotor integration .
6 Disturbances of visual function, including but not limited to hemianopia, further contribute to difficulties with hand use ( vv imp )
7 Deficits in motor planning and motor imagery as well as broader deficits in executive function are also seen
8 Finally, a minority of patients have significant learning disability, which can also impact adversely on the development of hand function
1 It aims at optimizing the available resources rather than normalization
2 Is based on activity - focused approach ( task oriented approach )
3 It also focused on family in the form of counselling to encourage the child and to motivate him ( COLLABORATIVE GOAL SETTING )
4 It also included postural management and special sitting - using modified chair according to the grade of spasticity or a modified wheelchair ( ONE ARM DRIVE )
5 Establishing SMART goals ( specific , measurable , achievable , realistic and time framing ) vv imp
6 The ultimate goal being to minimise disability and maximize independence
MECHANISM OF ACTION
1 STEP BY STEP **
2 GOAL DIRECTED MOVEMENT THROUGH MOTOR RELEARNING PROGRAM ( v imp )
A )GRAB - GRAB - HIT - PICKING - HOLDING ( VISUAL CUEING )
B ) EXAMPLE -
A ) for a 14 yr old
1 the subject was asked to grab colored cubes and spheres and to stack them up according to a specific sequence reported on a side of the screen.
2 the subject had to move a colored ball following a reference curved trajectory, painted on the screen.
3 the subject had to move a colored ball following reference straight trajectories in both vertical and horizontal directions, painted on the screen.
4 the subject was asked to hit a frog appearing in random places on the top and around a virtual castle placed in the center of the screen.
5 the subjects had to grab a quickly moving fish in a sort of underwater environment.
6 the exercise was developed to mimic a common everyday activity: to tide up a sort of virtual bedroom by picking up all the toys scattered on the carpet and putting them in a basket.
3 repititive task oriented approach -
Screwing and unscrewing bolts
6 HOURS / DAY FOR 10 DAYS
2 Activities of daily living
5 Psychosocial issues
1 VIRTUAL REALITY BASED TREATMENT -
I - ARTIFICIAL ENVIRONMENT
A ) is a computer based artificial environment, presented to the user through appropriate sensory stimulations vv imp
B ) Subjects interact with the virtual environment through a number of sensing devices (i.e., keyboards, mice, motion sensors, cameras, etc.), receiving a continuous feedback, which is usually visual and auditory, but might also be kinesthetic.
C ) is done through measurement from a wireless tracker system
D ) The sensor on the hand was used to move a simple object (a sphere) within the virtual environment, while the sensor on the trunk was meant to provide a visual feedback to participants, helping them to maintain the upright position, without excessive bending. Cabling from sensors to hub was firmly taped on the forearm and on the subjects’ clothes
E ) Exercises administered by means of VRRS had the aim of improving reaching and tracking movements of the paretic arm.
2 COMBINATION ( VIRTUAL REALITY + TRADITIONAL PHYSIOTHERAPY EXERCISES - passive ROM exercises and CIMT - constraint induced movement therapy , NDT / VOJTA )
II - GAMING CONSOLES
A ) require head mounted displays (HMDs), suitable 3D goggles, or several screens surrounding the subject.
B ) involves shaping activities - grabbing a dish and putting in a box
III - ROBOT ASSISTED TREADMILL THERAPY ( LOKOMAT ) - for lower limbs in general
IV - HABIT ( hand arm intensive bimanual training )
V - BONT ( botulinum toxin ) + physical therapies
Hemiplegics and diplegics have better prognosis and quality of life as compared to quadriplegics