Dressing for the child with cerebral palsy

Dressing is a important activity in daily living. Young children learn to dress and undress themselves fairly early in life. They learn to take off their socks, shoes and underpants before they can take off the more complicated clothing like shirts and dresses. Teaching children with cerebral palsy to take off and put on clothes may take time. Owing to their physical or mental disability, it may be difficult for them to learn these skills on their own.  If the parents or caregiver follow some common rules, they may find it easier to help their child to learn how to dress and undress.A disabled child has the desire as well as the ability to learn different skills. With time, effort and constant encouragement, he will eventually achieve results to the best of his ability. www.samvednatrust.com30-4-14

Choose a good position. Decide the position in which your child is most steady, with or without support. This will make dressing and undressing easier for him. It will also help him to dress or undress himself if he has the physical ability to do so. The child should be in comfortable and safe place and position. The floor should not be slippery.

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Involve your child. Involve your child every time you dress or undress him. Give him clear instructions or show him how to straighten his arms and legs. This will help him to cooperate with you as he grows older.

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Start with simpler clothing. Always start with a simple item of clothing like a loose shirt with front buttons open. He will find it easier to take it off and put it on. This will make teaching and learning more successful.

Teach undressing first. First teach your child to take off his clothes as it is much easier than learning to put them on.

Start early. Normally parents help their children to dress and undress till they are four or five years old. But if your child is handicapped, start teaching him as early as possible since it will take him more time to learn the skill.

 

SUGGESTIONS FOR BUYING NEW CLOTHES

Buy or make clothes one size larger. Whenever you get your child new clothes always make sure that they are one size larger. Shoes must be of the correct size, otherwise the child will find it difficult to walk.

Have front openings on clothes. It will be easier to unfasten if the fasteners are at the front of the clothes.

Fasteners should be as simple as possible. Instead of buttons, use zips on pants and shirts. Use elastic instead of string on pyjamas and buy all clothes with front openings.

Loose T-shirts without any fasteners are easy to wear.

Dress your child in clothes that are suitable for his age.

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The therapist must instruct and teach following tasks step by step to the child, parents or caregiver :-

Teach your child to take off his lower garments.

Teach your child to put on his lower garments.

Teach your child to take off his upper garments.

Teach your child to put on his upper garments.

Teach your child to button and unbutton.

Teach your child to take off his shoes

Teach your child to put on his shoes.

Teach your child to take off his socks.

Teach your child to put on his socks.

Teach your child to comb his hair.

Teach your child to do fine activities like makeup, putting thread into needle.

Note:-

When you are teaching him to take off his lower garments, make sure that your child is wearing an  underwear. This will teach him that he should not undress in front of anyone and he will develop a sense of privacy. For an older person, it will be less embarrassing for him to take off his pants in front of others if he is wearing underwear. Once your child has learnt to take off other types of lower garments, he can practice taking off his undergarments in private. Practice is very necessary for your child to improve. So make sure that you give him the opportunity to practice . Choose a time when you are not in a hurry to dress him so that he can take his time.

In the beginning, he will need extra time to learn.

Balance
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Mobility Exercises in Cerebral Palsy children

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Mobility exercises are sequence of the activities typically progresses to the stability within a posture and the advances through controlled movement. It is important to note that the exact methods of performing the functional activity may vary from individual patient.
Rolling. Rolling is the bed mobility functional activity, preparation for the independent positional changes in the bed. It is also important to progression to lower limb dressing. Two main patterns to roll are supine to prone and prone to supine. For supine to prone rolling head and neck are in flexion with rotation will assist the movement to take position and for prone to supine rolling head and neck are in extension with rotation will assist the movement to acquire the rolling.
Prone-on-Elbows. Functional implication of this activity is to improve the bed mobility and progression to the quadruped position and sitting position. Weight bearing in prone-on-elbow position will improve the stability of the shoulder. Rhythmic stabilization may be used to increase stability of the head, neck and scapula. www.samvednatrust.com
Prone-on-Hands. The functional carryover of this position includes development of the initial hyperextension of the hip and low back for the patients who will require postural alignment during the ambulation and standing rising form floor. Hand placement in prone-on-hands is similar as the standard push-up position except the hands are more lateral and arms externally rotated. Lateral weight shifting between hands increase the joint approximation. Additional approximation force can be applied through manual contacts to facilitate tonic holding. Scapular depression and prone push-ups are used as strengthening exercises.
Supine-on-Elbow. The purpose of this activity is to assist the bed mobility to improve the patient to assume long sitting position. If control strength in the abdominal muscles is present then patient is able to do supine elbow push-ups. Lateral weight shifting can be practiced in this position. Side to side movement enhances patient’s ability to align trunk when lower extremity is on bed, preparation of the positional change. Precaution it can cause shoulder pain if done in excess. www.samvednatrust.com
Pull-ups. The pull-ups are to strengthen the biceps to hold the crutches and canes as the lower extremity is weak. The therapist should grasp’s supinated hand just above the wrist.
Sitting. Both long and short sitting are essential for many daily living activities such as dressing, ROM exercises, transfers and mobility. Good sitting balance and the ability to move within this posture are also critical prerequisite skills to standing.
Quadruped position. The implication of this all-four position is to lead up ambulation. Rhythmic stabilization can be used to facilitate co-ordination. Weight shifting can be practiced in forward, backward and sideward’s direction. Rocking through increments of the range will promote development of balance responses. Alternatively freeing one upper extremity from weight wearing position may be used in the quadruped position.
Kneeling position. This position is particularly important for establishing functional patterns of the trunk and pelvis control and for further promoting upright balance control. It is important that this activity s done with Ankle-Foot Orthoses. Initial activities will concentrate on maintaining using available postural control. Variety of exercises used in kneeling position as weight shifting anteriorly, posteriorly and laterally with emphasis lower extremity and pelvic control.
Mobility Exercises in Cerebral Palsy children
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Constraint-Induced Movement Therapy

Constraint Induced means induced with pressure or without permission.  It is a type rehabilitation that increases activity of the upper extremity. Typically CIMT used to restart the unaffected arm in the patient with cerebral palsy (spastic hemiplegic) for most of the time while involving affected limb in a range of everyday living activity.

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CIMT basically a technique applied when the child stops using his affected limb due to its unexpected activities. Child with spastic hemiplegic has less power on one side then other. He just doesn’t use his affected side due to its clumsy response and this neglecting behavior towards affected side make it more and more suppressed in activity. CIMT seeks to reverse this process.

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As the result of engaging patient in repetitive activity of the affected limb brain develops new neural pathways. This change referred as cortical reorganization. This CIMT is more important in cerebaral palsy with the child whose one limb is more affected then other.

CIMT may work on the damaged motor network. Although, due to the intensity of this treatment, patient who have suffered profound upper extremity paralysis from their condition are normally not eligible for constraint-induced upper extremity training.  www.trishlaortho.com

Effect of CIMT is too good. It improves movement not only this improvement remains stable for months. This also increased functional activity of daily living of the affected limb. CIMT includes transfer package in this physiotherapist applies many strategies to make learn the activities outside the clinical setups. This includes first monitoring, needs to documents patients activity towards target behavior second problem solving, in which patient needs to solve problem of obstacles third one is behavior contracting, involves getting identify the components and methods carrying out normal behavior.  www.trishlaortho.com

There are some limitations of the CIMT. If patient is not cooperative then it’s a great problem in CIMT, as patient is of severely affected. In case of balance problem CIMT process creates problem. In case of global aphasia and cognitive problem, communicating problem may be phased. CIMT technique is intensity based if patient can tolerate this intensity then its good otherwise it creates a problem. Lack of facility is also a great problem faced by patient and therapist. Combination of therapy and CIMT shows better result its unknown till.

Over all CIMT is very beneficial and result giving. So its use is more in hemiplegic childs.

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HYDROTHERAPY FOR CHILDREN WITH CEREBRAL PALSY

As a part of normal development, a child is continuallymoving his arms and legs, exercising as he learns toroll, crawl, move through sitting positions and walk.This spontaneous exercise is often limited in childrenwith cerebral palsy. They may only be capable of a fewmovements, relatively inactive compared with otherchildren, limiting their amount of spontaneous exercise.

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Exercise is very important for children with cerebralpalsy. Exercise is defined as an activity that involvesrepeated body movements, with the aim to improve ormaintain a level of physical fitness.In children with cerebral palsy, exercise is used tostrengthen muscles, increase flexibility, improverespiratory function, enhance a child’s gross motor function and to have fun.

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We can encourage the child to exercise and have fun

Swimming is a great way for you to encourage yourchild to exercise, have fun and learn confidence in thewater. Exercise in water is very appealing to allchildren.It gives the child with cerebral palsy a freedom ofmovement that they may not otherwise have on land. Ifa child has significant movement limitations,participation in land- based exercise may be limited.The buoyancy of water reduces the effects of gravity,poor balance and poor postural control. It providespostural support, allowing children with cerebral palsyto exercise with more freedom in water than they can onland. The buoyancy of water creates an environment thatreduces the level of impact on the child’s joints,providing a gentler environment for children withunstable joints to exercise and weight- bear.

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Swimming has numerous benefits for children withcerebral palsy.Being in the water encourages children to move theirlimbs and experience the effect of movement on theirbody. Warm water encourages stiff muscles to relax,and children move more easily in the water due tobuoyancy.

Water play is a great opportunity for children toexperience a variety of sensory feedback. Childrenexperience the feel of the warm water, the sounds andsights of splashing and the movement of their limbs.Perceptual and visuomotor skills improve because waterslows down movement and gives the child time to reactand appreciate how to use their body. Learning to swim will give your child the skillsto participate in sport, play with his friends and family,and provide him with a means of keeping fit. Treatmentand play are inseparable in the young child. The child will become more confident due toachievements made in the water. As he develops theability to move and enjoy the water, his self awarenessand self- esteem will improve as well.

 

Beginning of swimming lessons for children

It is important to encourage any form of exercise at anearly age, particularly if your child has limitedspontaneous movement.“Babyswim” classes are an excellent way to introduce the baby to the water. The child can begin to attendswimming lessons as early as 6 months of age.These classes will give your child an early opportunity tobegin exercising and strengthening their muscles(especially their hip muscles). Classes can also give youand your child an opportunity to socialise and formsupport networks with children of a similar age,enabling ‘play dates’.

Local pools generally have their own swim schools thatcater from babies to adults. Small classes of up to 4children are often available.

The Centre for Cerebral Palsy physiotherapistshave developed a manual to assist swimming teachersin providing optimal swimming opportunities forchildren with cerebral palsy.

Physiotherapist can help you choose themost appropriate environment for your child to learn to

Finding the ‘right’ pool foryour needs

It is important to choose the right pool for your child’sneeds. The facilities provided at community pools vary.It may be advisable to check with your local pool to ensure they can best meet your family’s needs.There are many factors to consider when selecting apool.Water temperatureHydrotherapy pools are generally 33- 34 degrees. Someindoor pools are 30 degrees. Warm water has a relaxingeffect and can help decrease muscle tone. Cold watercan increase muscle tone. Water kept at a constanttemperature of 35 degrees is most suitable for a childwith spasticity. A pool kept at about 33 degrees issuitable for a child with low muscle tone

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If your child has epilepsy, please discuss the mostappropriate pool environment with your pediatrician.

Access

  • How will you and your child enter the pool: – stairs /ramp / side of pool / hoist?
  • Change rooms
  • Facilities available
  • A large change table
  • Do you need to ask the centre to ensure one is availablefor your use?
  • Noise level / echo -This could make your child tense oranxious and result in an increase in their tone.

v  Hydrotherapy is a water- based physiotherapy program.

 

Hydrotherapy programs are used by physiotherapists to:-

• increase gross motor co- ordination

• maintain or increase range of movement andflexibility

• increase muscle strength

• improve balance and posture

• improve fitness and endurance

• promote breathing control

• promote water safety and awareness

• develop basic swimming skills

• reduce muscle spasm and encourage relaxation andenjoyment

• encourage normal movement patterns.

 

A variety of swim rings, arm ‘floaties’, pool noodles andtoys are incorporated into the hydrotherapy session topromote independence and freedom of movement in thewater.

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The children enjoy activities in the pool includingacceptance of the water and buoyancy, bubble blowingand protection of the airway, kicking, splashing,floating, singing and playing.

The children’s skills are progressed with the aim tocomplete competencies required for swimming lessons.

 

Halliwick

The Halliwick Method is a specific swimming programused by physiotherapists. It is based on the scientificprinciples of body mechanics and the properties ofwater, aiming to teach people with special needs tobecome as safe and independent as possible in thewater.The philosophy of the program is that the child is happyin the water and the emphasis is on the child’s ability,not disability.

Movement in water allows people with disabilitiesfreedom from the constraints that they endure on dryland.No matter how severe the physical disability they canlearn movement in the water.

The program consists of 10 specific progressive stagesthat are achieved without the use of floatation devices.Waterproof swimming pantsare required to wear either a waterproof nappy

orEenee Swimmers if they are incontinent. Eeneeswimmers have a stretchy waterproof inner sling forcontaining incontinence.

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Play for child

Play is an essential activity for all children. This is where real learning begins. Because some children with cerebral palsy are more limited in their physical ability, it may not be easy for them to engage in spontaneous play, so be ready to give child any assistance they may need to help them enjoy playing. This is an area where friends and family can be fully involved in the therapy www.trishlaortho.comof your child’s development. Image
Obviously, not all toys will be suitable for all children, as cerebral palsy varies so greatly, from a very mild disability to total immobility. Always be sure that the child’s toys are accessible to him or her and that he or she has some way of letting you know what she wants to play with. As they get older, and depending on the severity of their disability, they will be able to indicate which toy they’d like in a clear and certain way. You must ensure, however, that they don’t miss out on the early opportunity to make choices in the area of play. As early as possible you should devise a system through which child can communicate to you their preferences. This may be through speech or signs, or as they get older through picture boards or electronic devices.
No matter how old child is, playing is a most valuable area of their therapy. It not only helps to release stress, it can also aid their development, and in some cases speed it up. Play also induces laughter, which we all know is the best medicine. Playing also increases hand-eye coordination, can aid in developing fine motor skills, and as they get older, can aid in developing their gross motor skills, such as playing with balls, tee ball or other backyard athletics.

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Activities that seem like play to a child often have an ulterior motive. For instance, games involving “spotting the difference”, or pointing out which part of a picture or drawing does not belong, help the child’s neurological development. Obstacle courses, ball games, playing in the sand and even make believe not only help the child’s mental development, but also their motor skills, balance and coordination. As these areas of development are generally more difficult for children with cerebral palsy, frequent play is a fun and easy way for a child to practice trouble zones, and they won’t even know that they’re undergoing therapy at home!
One of the most important things you can do for your child’s development is just putting them on the floor. A child’s earliest independence comes from exploring the world, using whatever mobility he or she has, from a position where he or she is free to do so. Putting a child on the floor, even if they have limited mobility, at least provides the opportunity for exploration. Time spent lying on the floor with a few toys around will be a valuable opportunity to exercise early self-help in play and mobility.
Oftentimes, parents of children with special needs can easily get caught in a trap of thinking they must always control their child’s positioning and activities, but all children must have the chance to learn from experience. If you are offering a lot of stimulation to your child, there has to be an opportunity for them to show you what they have learned (input and output) by being allowed to roam free occasionally. Putting your child on the floor and letting them play and explore will give them a chance to not only learn more, but to show you what you what they have learned already.

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NDT (Neuro-Developmental Therapy) in cerebral palsy

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NDTis a technique to facilitate the movements which are not present in the Cerebral Palsy children.

Facilitation is a process in which therapist hand gives a direction to the child’s body how to move. In this technique therapist holds the complete control of child’s body weight and the movement. Therapist gives a direction to the body to shifts its COG (Center of Gravity). As the COG shifted to some direction the control over the balance in the child is lost. Therapist should teach the child how to gain control again, by shifting weight to another side. This whole procedure is the part of NDT.

Equipments used in the NDT are Ball, Bolster, or Table/Bench.

Equipments are to challenge the body weight, to help accommodation the structural deformities of the child. These facilitation techniques are used improve the postural control of the child by challenging the posture.

BOLSTER/ROOSTER is devices which is used to for prone, sitting and sit to stand facilitating techniques. It should be firm, provides a mobile surface that is easy to control because it rolls predictably front to back when child lies prone or sit on it.

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BALL is the most challenging device for the facilitation techniques. It is not firm because it can move in any direction and the base of support is very less.

There are two type of cerebral palsy according to the tone, Hypertonic and Hypotonic. Facilitation is given according to the tone of child. Hypertonic child is given facilitation techniques to decrease its tone and to improve its posture. Hypotonic is given different facilitation to increase the tone and posture.

First of all we should check the child’s stage and milestones before taking in the NDT.

Neck holding is the first step which should come in the child if it is absent then just facilitate neck extensors to extend the neck. On bolster put child in prone then ask him to hold the neck in extension by facilitating trapezius muscle or taking the shoulders in retraction. On ball put child in creep/crawl positions then the same facilitation done. Facilitation on the spine can also be done to make spine in extension and neck in hold position.

Quadruped position is the next position attends by the child. In this weight bearing on all four limbs is essential. So the power on all four limb must be good. This posture is attended on the ball. We can make it more challenging by rolling the ball so that the COG of the child’s body shifts and the opposite muscles work to prevent a fall.

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Pelvic control facilitation techniques can be done on the ball and bolster both. On the bolster we can make child sit and the roll the bolster to shift COG and facilitate muscles to prevent any fall. Like this we can make child sit on the ball and can move ball too to shift the base of support and facilitate muscles. On ball different positions can be attended like cross sitting, kneeling, sitting by legs open wide on ball, sitting and hands are extended and sitting with hand in overhead position. Rankly decrease base of support and increase pelvic control. In all these positions we can facilitate pelvic muscles by rolling ball, shifting base to either side, ask child to reach an object to either side, make base less supportive by tilting ball on opposite side. All these make the muscles work and repetition of this strengthen the muscles.

The main purpose of the NDT is to improve balance with less support. Facilitation technique is more effective then passive movements. Resistive exercises are difficult in cerebral palsy child because they are not so cooperative and not following commands. So the most effective technique is NDT in the cerebral palsy.

 

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Group Therapy and Socialization in Cerebral Palsy Children

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Group Therapy and socialization is essential in the cerebral palsy children. Group Therapy is meant by therapy done in group of same population. In this technique same cerebral palsy children were collected and given same kind of therapy. Socialization is a technique in which cerebral palsy children were exposed to entire world to get prepared for the world’s challenges.

Group Therapy increases the concentration and the competition between the children. This concentration and competition felling gives a sprit to do work. Like other children cerebral palsy children also like complements, competition. In group therapy we mostly give same task to all children and ask them to complete in ease and in less time. For example if we ask children to pick same color ball by their right hand and to put it in a bowl kept on the opposite side. Ask this to do faster and with ease this challenge and competition produce a sprit to complete the task. By Group Therapy any activity can be approached. There are many fine motor movements like griping any object by full hand, four finger and thumb, two fingers and thumb or three fingers and thumb.

Organize children according to their disability as mild moderate and severe. We have to also divide them into hypertonic and hypotonic group. Now decide the therapy which is given in which group. For example as hypertonic group we have to teach them the relaxation, so for this we lie down all of them in plinth and ask them to relax their muscles by producing a competitive environment. This can help children to get the things the things more easily. As in hypotonic children we stimulate them ask for the movement in a competitive way.

Group therapy is very effective because the environment in same group is more according to them then the real world. In the real world they feel themselves weak and differently abled. First prepare them in their own group then we can put them in social world.

Social world means the world in which we live. As human being is a social body not possible to live alone without society. Socialization is technique by which we make these children expose to the society. As because of their disabilities they were kept inside the home by their parents. This can be because of many reasons as such they pamper them a lot, they think that child may get depressed or parents thing them a curse and feel guilt of them. All this prepare a self centered world in mind of these children. They feel them alone and away from society.

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Socialization is must in these children. In this technique parents having the greatest role so counseling of parents is must. Teach parents how these children can be socialized. There are main two steps of socialization, first is home and second is school.

Tell them when child is too little parents usually keep the child with them all time only. Usually mothers not allow anybody to touch their child, teach them that to recognize all the family members is important. Allow the child to roam here and there. Let the other normal child to play with them. Talk with them frequently about every subject as talk to normal child, this increase the interest and knowledge of the child. If child can move let them out with or without parents. Introduce them with strangers. In school going age if child is able to speak, understand so admit them in a normal school. Here in normal school society makes them aware and prepare for the barriers and difficulty might come in their life ahead.

 

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