Barreras arquitectónicas: las personas con discapacidad y el ambiente físico

General principles of physiotherapy

Physiotherapy begins in early infancy and continues throughout adolescence [A]. The primary purpose is to facilitate normal neuromotor development. With the help of correct positioning, appropriate stimulation and intensive exercise the therapist tries to gain head control, postural stability and good mobility in the child. This is possible only to the extent of the child’s neurological capacity. Even with vigorous physiotherapy many children remain functionally impaired in varying degrees.

There are different methods of therapy for children with neurological impairments. Even though they differ in the techniques they use, basic principles remain the same [B]. The problems of neuromotor development are difficulty flexing and extending the body against gravity, difficulty sitting and functional ambulation [C].

For functional ambulation a child needs motivation to move and explore the world around him [D]. He must have enough muscle strength and control. He must be able to shift his body weight and have an awareness of body position in space at rest and during movement. Visual and vestibular systems must be sufficient. There must not be any deformities interfering with joint function.

In physiotherapy sessions the therapist works with the child in supine [E,F] and prone [G,H] positions to improve head and trunk control. She supports the child in the sitting position [I,J] to develop weight shifting and unilateral balance, ability to rotate the body and the ability to respond to sudden changes in position. The rehabilitation team strives for long- term, functional mobility in a variety of environments so that the child will integrate into the community and social life in a healthy way.

Principles of therapy methods

Support the development of multiple systems such as cognitive, visual, sensory and musculoskeletal

Involve play activities to ensure compliance Enhance social integration

Involve the family Have fun

Basic problems in the neuromotor development of children with CP

Difficulty with flexing and extending the body against gravity Sitting

Functional ambulation

For functional ambulation a child needs Motivation to move

Enough muscle strength and control Able to shift his body weight (balance)

Awareness of body position and movement (deep sensation) Sufficient visual and vestibular system

No deformities interfering with joint function

Children who use the upper extremities for support when sitting can not develop hand function. Provide a seating support for better head and trunk control and give the child the opportunity to play. This way, he will have better vision, use his hands actively and have improved breathing capacity due to proper vertebral alignment and chest support. The child can also shift his body weight over the pelvis when supported in this position to exercise trunk rotation.

Therapy program

Infant Stimulating advanced postural, equilibrium and bal- ance reactions to provide head and trunk control Toddler &

preschooler

Stretching the spastic muscles, strengthening the weak ones, and promoting mobility

Adolescent Improving cardiovascular status

Flexion against gravity promotes visual and orienta- tion, self-touch/body awareness and active hip mobili- zation. It is preparation for rolling/fl oor mobility.

F

F

E

E

D

D

C

C

B

B

A

A

I

I

G

G

Support in prone facilitates visual orientation, head control, development of postural exten- sion and active control of weight shift.

Photos courtesy of S. Sterchi

H

H

J

J

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Rehabilitation & Physiotherapy

Conventional exercises are an integral part of physiotherapy. Stretching exercises are helpful for contractures whereas strengthening is neces- sary for weak muscles.

Therapy methods

Stretching, range of motion and strengthening exercises are essential in all children. In addition, neurofacilitation techniques stimulate the central nervous system to establish normal patterns of movement. These neurofacilitation techniques were developed over the years to minimise the neurological impairment and help the healing CNS to reorganize. This has not been possible and the focus of therapy shifted from trying to heal the neurological lesion to increasing motor function. There is no treatment method that can heal the lesion in the CNS. The intact neurons in the brain may substitute for lost function, new synapses may form and reorganisation of neurons take place so that the child gains function as he grows. This process is termed neuronal plasticity. The present neurofacilitation methods stimulate the CNS and accelerate neuromotor maturation through the process of neuronal plasticity. The Vojta method is common in Eastern Europe whereas the neurodevelopmental training technique established by B. Bobath and named after her is widely used in the Western world. Both because of difficulties in diagnosing CP in infancy, and the inherent potential of the CNS to heal, it is extremely difficult to judge the actual success of such procedures.

Plan the exercises according to the mobility needs of the child. It is not enough to have a therapy session only once during the day with the therapist. Children with CP need to exercise at home to gain maximum function. The success of the techniques used in physical therapy depends on repeated practice. The parents must repeat the exercises with their children every day and observe children for improvement or changes that may be needed.

Conventional exercises

Conventional exercises consist of active and passive range of motion exercises, stretching, strengthening and fitness to improve the cardiovascular condition [A].

Range of motion [B] and strengthening exercises [C] continue for a lifetime in CP, but are especially important in the recovery stage following orthopaedic surgery and in the growth spurt period when risk of contracture formation is maximal. Teach the stretching exercises to the caregiver to prevent contractures. Physiotherapists and parents should be careful with stretching exercises so as not to tear muscle fibers and cause pain, otherwise they will have the opposite effect. Night splints and stretching are not by themselves sufficient to prevent contractures. Strengthening exercises to the antagonist muscles are always necessary because spastic muscles are also weak. Sports activities are helpful in decreasing stiffness and contractures in adolescents using the wheelchair. Cardiovascular conditioning is crucial for the total body involved individual in the wheelchair.

Balance is a prerequisite for independent walking, balance training is one of the key reasons for physiotherapy [D,E].

Strengthening [F] does not affect muscle tone, it does not increase spasticity. On the contrary, the importance of strengthening the spastic muscles and their antagonists cannot be over emphasized for efficient motor function.

Do not prevent sitting in the W-position [G] for fear of hip subluxation. W-sitting does not increase femoral anteversion or cause hip subluxation. Children with femoral anteversion sit in a W-shaped position because it is comfortable. When forced to change position for fear of contracture, the child needs to use his hands for balance which interferes with hand function.

Equilibrium reactions and balance can take a very long time to develop and sometimes do not develop at all despite intensive training.

Conventional exercises Active and passive range of motion Stretching

Strengthening Fitness

Do not prevent W sitting if the child is comfortable and relaxed in this position. It is only a result of increased femoral anteversion and will not cause hip subluxation. Strengthening is essential for function. It

does not increase spasticity or cause de- formity.

F

F

E

E

D

D

C

C

B

B

A

A

G

G