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.

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.

CIMT TestAs 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 cerebral 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.

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.

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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Cerebral Palsy And Its Treatment During Pregnancy

Research have shown that, there has been diverse cause of cerebral palsy but still many cases are out there that can’t be defined under one cause. Thanks to advancement in medical science and technology like MRI and CT scans that has improved diagnostic capabilities and made the cases much lower.

Related to Cerebral Palsy

Clearing Myths Related to Cerebral Palsy

Cerebral Palsy is an umbrella term given to various disorders affecting the entire body movement, balance, and posture. It also means brain paralysis. The impairments first appear very early in life (infancy) and later after ages too. One can easily detect the disease as the growth rate in child is very slow. The victim may not sit, crawl or walk comfortably.The disease is related to movement, so, moving becomes a tougher task. Being a concerned society members and with a commitment to help, let’s take oath to assist children suffering from CP. We should never abuse them as this may hamper there brain too.

How to Prevent Cerebral Palsy

Cerebral palsy explains group of brain and nervous system conditions. In India every 3 in 1000 children are suffering from the disease. It is important that pregnant mothers should know on ways to prevent it. There awareness is sure to reduce the cases of Cerebral palsy. The symptoms include non-progressive and non motor conditions that cause physical disability in the child. In the severe case the damage reaches the brain.cerebral palsy treatments

Treatment of Cerebral Palsy

Cerebral palsy treatment starts with taking care. The expected mother needs to take utmost care during the period of pregnancy. A healthy pregnancy ensures that the infant is not affected with the severe disease. Let’s us know some of the preventive measures that need to be taken care during the pregnancy and after…

Quit Smoking: If you are prone to smoking, don’t let it over power your future. During the pregnancy it is important that you quit smoking. There has been many research that shows that children born to healthy and non smoker mothers are healthy as compare to the children born to smokers. In-fact if you are alcoholic or addicted to drugs quit that too.

Take Folic Acid: Doctors often recommend pregnant lady to take folic acid during pregnancy. You should take folio acid before a year of family planning. Folic acids are of great help; it not only lowers the risk of premature delivery but also restrict any birth defects to develop.

* Get yourself vaccinated against rubella because rubella virus can cause birth defects. The immunization should at least take place two month before the delivery

* If any of the parents are having Rh negative means that you need to take extra care during pregnancy.

* Regular treatment and doctor observation is must during these periods

* Make sure you are on very healthy diets. Take supplementary vitamins to ensure the complete diet. Any compensation regarding imbalance diets should be immediately made after doctor’s consultation. Prevention measure is far better than getting affected by the disease. Have a happy living.

The work is not completed after the healthy delivery, as a concerned parent make sure you’re your Cerebral Palsy children is protected from accidents. Head injury may lead to so while traveling keep the head protected.

Center of excellence for treatment of cerebral palsy & childhood orthopedic problem

Samvedna trust & Trishla foundation are working for upliftment of children with all kind of physical disability since 12 year—-

Trishla foundation is being recognized worldwide for center of excellence in holistic management of children and adult affected with cerebral palsy. Children are coming to Trishla foundation based at Allahabad from all over India as well from abroad like UK, USA, African and neighboring country. initially for 10 year we provide all services through samvedna trust. We provide multimodal approach of treatment to CP affected individual. Our approach includes advance therapy by team of developmental physiotherapist fully trained in cerebral palsy, speech therapy by speech therapist, special education by special educator. We also provide intervention modality like botulinum toxin in early age spastic child (2-6 years) & surgical intervention at the age when they stop responding to conservative treatment, develop fix deformity and start deteriorating. Ideal age for surgical intervention is 8-10 year year but can be perform even in older children and adult. Most of the children with cerebral palsy can be managed by intensive therapy program along with brace. only few children need surgery. nowadays surgery on muscle are being performed in lesser number.  we try to correct all bony torsion and deformity by bony surgical correction . He has managed thousands of children with this holistic approach, now more than 80% children are getting excellent outcome.  Surgical intervention is needed in only children affected with spastic and mixed cerebral palsy. More info is available at our website www.trishlafoundation.com  & you tube: trishla foundation  & jjain999.

Trishla foundation & its associated trishla orthopedic clinic provide all kind of consultation, rehabilitation and surgical management to every type of pediatric orthopedics problem with advance modality. This center is well known referral center in northern India for pediatric orthopedic problem like cerebral palsy, congenital bony deficiency, deformity, post infective sequel, pediatric trauma. This center provides facility of deformity correction & limb lengthening by latest concept like Paley approach, illizarrow, Ortho SUV and growth modulation. More info is available on website: www.trishlaortho.com, facebook: jitendra.jain.35513800 & you tube:  jjain999

Management protocol in Dyskinetic (Athetoid) Cerebral Palsy

It is very difficult to treat children & adult affected with dyskinetic cerebral palsy. Our aim of treatment in these children is to control abnormal movement & posture. It can only be possible with proper therapeutic technique and brace. Wrong and excessive exercise can do lots of harm to these children. We should avoid use of any muscle stretching & joint mobilization. Any type of surgery & botulinum toxin is not useful in these children. We have only few medicine that helps upto some extent but is not so effective in every case. It is also remember that these children should not be blame for any abnormal activity and avoid any loud sound and fall of any object on the ground in front of him. Anxiety & pain should be managed. Beside this general guideline, therapy in the form of TRP, MRP, Yoga, meditation helps upto great extent in these children. Muscle relaxation Posture (MRP) is a technique for learning to monitor and control the state of muscular tension. It was developed by american physician Edmund Jacobson in the early 1920s. It Control environmental and sensory influences by Inhibition of primitive reflexes, Facilitation of movement through space, Maintenance of body alignment and muscle length.  Purpose of this technique is to maintain body alignment, prevention of abnormal posture & deformities, to maintain stabilization of body parts & provide weight-bearing experiences, To promote active participation in meaningful activity, To allow mobility, Normalize  posture, Break-up involuntary patterns. In this technique we use key points of control & mid line orientation programme. We start this postural technique by powder massage & relaxation of child.  We should maintain trunk in correct posture, knee in flexed position & keeping load close to body. We should use all activity like painting, drawing and use of key board which improve mind to limb coordination. If child is not able sit from supine position then we should also promote w sitting.  Padmasana (Lotus position) is excellent means to control abnormal tone in lower limb & spine. Other yoga position also helps a lot but we should be cautious in using other yoga position for children affected with athetoid cerebral palsy. trishla foundation  provide good therapeutic facility to children affected  with cerebral palsy.

Dr Jitendra Kumar Jain

Secretary  & pediatric orthopedic surgeon

Samvedna, Allahabad, UP, India

http://www.trishlafoundation.com & http://www.samvednatrust.com

youtube: jjain999

Fb:samvednatrust.cerebralpalsy

Problem faced by adult with cerebral palsy & their solution

As with any other normal individual function of CP individual also declines significantly as result of aging but proportion of problems can be more. They can have job, married, have a children and retire like their other peers.  Adults with CP may have a shorter lifespan due to existing co-morbidities not because of cerebral palsy. Recent statistics show that nearly 50 percent of people aged 65 or older have some type of physical, psychiatric, or cognitive disability.

Problem faced by adult & older population with CP are Musculoskeletal, Cardiovascular, Psychological Status , Gastrointestinal, Social issues and Reproductive health etc.

Effect on Musculo-skeletal system:  With age muscles become tighter and there is decrease in flexibility, limited muscle strength, endurance & restricted movement. Energy expenditure is 3-5 time more, since it is difficult to perform tasks of daily routine & take longer time as a result fatigue is frequent. The problem get worse by development of muscle Sore anti epileptic drugs, sun exposure, poor intake lead to Vit D deficiency (osteomalacia). Less Wt. bearing & poor muscle lead to osteoporosis and abnormal muscle tone lead to deformity and other complications.

End result is loss of stamina, loss of physical functioning, obesity more need of support during standing & walking, fracture with trivial trauma and some other complications.

Effect on general health: As with all other they also may suffer from old age diseases like diabetes, obesity or under nutrition, hypertension & coronary artery disease, problem in bladder control like Urinary retention, incontinence, recurrent chest infection & restrictive lung disease, pressure sores

Effect on GI system:  there is earlier onset of disturbance in gastrointestinal functions, combination of mouth breathing, poor hygiene, tooth grinding, mal-occlusion & abnormalities in tooth enamel, cavities & periodontal disease, problem in chewing, swallowing, feeding & nutritional issues, heartburn, hemorrhoids, Gastro-esophageal reflux, frequent vomiting, poor general nutrition, retarded physical growth & aspiration, constipation

Effect on psychological state: because of prolonged illness and suffering by time old age so many psychological problems like early memory loss, sleep deprivation, fluctuating emotional state, depression, loss of self-esteem, self neglect

Reproductive health: as they are growing it becomes difficult to counsel of women with cerebral palsy, pregnancy related, problem of menstrual cycle, menopausal problems. Also there is also natural biological need of sex, STD, birth control, problem of body image.

 Social issues : many social issues also become prominent if they are not dealt with in time like lower level of education, higher level of poverty, higher level of unemployment, less disposable income, self care, lesser social activities and communication problem due to ambulatory & speech problem, social abuse, drug and alcohol abuse  etc.

Management: – Management includes continuation of therapy programme in adulthood, yoga & swimming, standing and walking with any support is much better than wheel chair, more use of assistive devices, sufficient intake of vit D and calcium, treatment of osteoporosis, good nutrition intake with sufficient protein, fiber intake, sufficient intake of water, vitamin and minerals, medical treatment for pain & Spasticity, maintains of Oral hygiene, control of body weight with social support system & health checkup at regular interval.

It includes……….

  • Continuation of therapy programme in adulthood
  • Yoga & swimming
  • Standing and walking with any support is much better than wheal chair
  • More use of assistive devices
  • Sufficient intake of vit D and calcium
  • Treatment of osteoporosis
  • Good nutrition intake with sufficient protein and minerals
  • Medical treatment for pain & Spasticity
  • Maintains of Oral hygiene
  • Control of body weight
  • Early intervention in any cardiovascular &  pulmonary problem
  • Good nursing care in severely disable patient
  • Barrier free environment at home and public places
  • Social and independence skills
  • Schooling along
  • Education of Reproductive health
  • Proper care of sanitation & hygiene
  • Social support
  • Implementation of life planning including health insurance & guardian ship declaration .
  • Group discussion
  • Detail counseling & meeting with other cerebral palsy affected adults who have more confidence & balanced mind like parent’s forum.
  • Academic and extracurricular activity like sport, drawing, music and literary work to maintain stamina & moral

It is not only important to live long but it is the quality of life which matters, so by good knowledge and well planned strategy we can prevent impending problems and miseries of life. It is the parents / guardian /affected person himself who can change the whole life and the can make their life beautiful by knowing & preventing future problem ahead.

DR JITENDRA KUMAR JAIN

CONSULTANT PEDIATRIC ORTHOPEDIC SURGEON,

TRISHLA ORTHOPAEDIC CLINIC & REHAB CENTER &

SECRETARY, SAMVEDNA TRUST, & chairman trishla foundation, ALLAHABAD, UP, INDIA-211002

www.samvednatrust.com, www.trishlafoundation.com www.trishlaortho.com

Email- jjain999@gmail.com, ,

Fb: samvednatrust.cerebralpalsy,

Youtube:jjain999 & trishlafoundation

Management protocol in severely disable young children (6-9 year age) with cerebral palsy

Whenever cerebral palsy affected child does not start standing or walking at the 5 year of age &  develops sever disability and then the affected child require intensive therapy as early as possible so that their potential for walking can be saved and they can be prevented from ending into permanent disability. If child is not able to stand & walk in spite of all physical exercises, then he surely have some problem that interfering in his walking ability. Reason can be spasticity & contracture, weakness in muscle, co contraction of muscle, bony deformity, misalignment of extremity & lots more.

 

for more info on disability in cerebral palsy link to

All these children require good evaluation in making the etiology of his problem, therapy protocol & brace. If child don’t have contracture or malalignment of body then child should be managed by vigorous therapy. But if the cause of disability is persistent contracture & deformity then child will surely need some surgical intervention to correct that. Routine orthopedic surgery does not help much in these children. We are very cautious in doing surgery on muscles . We always prefer to do repeated examination of child along with gait analysis before embarking on surgery and even we reconfirm our surgical planning under anesthesia. now days we more focus on correction of deformity by bony surgery in place of muscle surgery so that weakness do not come.  they need good post surgical therapeutic planning. Each child requires different set of therapy. In early phase (2-4 week) child need joint mobilization, relaxation exercises. Proper therapy will start after 4 week of surgery. Most of the children require good therapeutic exercise minimum for 6 month.

link to you tube : few example of excellent outcome in early age child (6-9 year age )

more info on www.trishlafoundation.com 

youtube: jjain999 & trishlafoundation

Vit D deficiency in children & adult with cerebral palsy

osteomalacia (flaring of distal femoral metaphysis)     Fracture B/L Subtrochanteric femur in diplegic spastic cerebral palsy

Vit D deficiency is very common in children & adolescent affected with cerebral palsy. in childhood Vit D Deficiency known as Ricket and in adolescent & adult it is known as osteomalacia. They have got many risk factors developing this deficiency. Risk factor includes lack of exposure to sunlight, nonambulatory status, immobility, lesser amount of Vit D supplement in food product, consumption of antiepileptic treatment.   Children with cerebral palsy in GMFC scale 4 & 5 have highest chance of Vit D deficiency. Vit D deficiency can be checked by Serum alkaline phosphatase level, Vit D level, loose zone in pelvic bone, widening & flaring of growth plate on xray & decrease BMD level . if child have less weight bearing & protein  malnutrition then they also develop osteoporosis. it causes  causes proximal muscle weakness, bony pain, decrease growth pattern of child, increases chance of fracture with little strain, failure to thrive. Bone in this patient fracture even with little trauma & exercise.  Our aim of treatment of osteomalacia is supplement of Vit D & calcium. Vit D should be continued for long duration. Along with this measure we have to promote ambulation & exposure to sun. Child & adult should be advised to maintained their physical activity and don’t confined to indoor only. Vit D supplementation of 1000 unit per day is required in children with deficient Vit D. Normal supplement dose is 400 unit per day. Vit D deficiency can also be managed in better way by giving loading dose of Vit D 6 lac unite as intramuscular injection and there after they can supplement with calcium & vit D at normal required dose. They should also be protected from trauma.    for more info on cerebral palsy log in to  samvednatrust.com 

Revision Surgery In cerebral palsy affected children & adolescent

1 (8)    Routine orthopedic surgery in children with cerebral palsy do not give guarantee that child will be better after surgery & will not require any further surgical intervention in future & some time child may deteriorate. It is a true fact that Recurrence of deformity can occur as age advance because muscle length in not able to pace with the increase in height. So right age for surgical intervention is very important it should not be early (<6 year) and not too late (>10year) that deformity can not be corrected by any measure and child develop permanent deformity and weakness. On other hand outcome after every surgical technique is not similar. Traditional surgical technique in cerebral palsy is not going to benefit these children and some time child can deteriorates. In these condition some time we became helpless because nothing left for revision surgery & even not able to reverse the impact of previous surgery. Planning and execution both are difficult in revision surgery. Few children may lucky that not much damage was done by previous surgery and it may be because of recurrence of deformity only. Revision surgery is being planned after repeated & detail evaluation. We utilized the concept of SEMLOSSS with some modification in these children.

http://www.samvednatrust.com/cerebral-palsy/recent-advancements/

Properly executed surgical intervention & good therapeutic intervention in previously operated cases of cerebral palsy give rise to excellent outcome. But it is important fact that before embarking on revision surgery we have to clear in making right judgment that another surgical intervention is going to benefit the child or not if not so then we have to put these children on good rehab measure by utilizing combination of different therapeutic technique and reassess after few months.  Our ultimate aim is getting good functional outcome after any measure suite to them .

LInk to you tube video showing outcome in few children & adolescent after revision surgery 

 

Management protocol in adolescent & adult with cerebral palsy & minor physical disability

Most of the times we think that my child with cerebral palsy is able to move around independently in home and community then why my child should go for surgery? Common myth is that surgery may harm the child. But the fact is that even minor improvement can make a lot of difference in personality & performance of child in all their routine & academic activity. Well performed surgery in right candidate never creates any problem if it is meticulously planned according to the need of patient.

Minor physical disabilities can create huge impact on the psyche of the adolescent, who are under pressure to not only compare their body image with their peer but also because of inability to perform highly coordinated tasks like playing outdoors & participating in recreational activity.  Despite of having good IQ, they may not be able to give best performance in their college because of negative feeling. Most of the time these children have only mild contracture in few group of muscles & tendon that hamper their activity. This entire problem can be managed very successfully in younger age (< 6 year) by the proper therapy, brace & botulinum toxin but in children of more than 6 years of age, adolescents & adults, surgical intervention is needed to correct all persisting problems.

Usually routine orthopedic surgeries don’t help much in these children but all the disability can be managed very much successfully by the new concept of SEMLOSSS. In this concept, every possible deformity is being managed in single setting surgery by the concept of OSSCS. Child need detail evaluation by physical examination & gait analysis. If it is managed properly along with correct therapeutic protocol then child can have excellent recovery.

Most of the times we think that my child with cerebral palsy is able to move around independently in home and community then why my child should go for surgery? Common myth is that surgery may harm the child. But the fact is that even minor improvement can make a lot of difference in personality & performance of child in all their routine & academic activity. Well performed surgery in right candidate never creates any problem if it is meticulously planned according to the need of patient.

Minor physical disabilities can create huge impact on the psyche of the adolescent, who are under pressure to not only compare their body image with their peer but also because of inability to perform highly coordinated tasks like playing outdoors & participating in recreational activity.  Despite of having good IQ, they may not be able to give best performance in their college because of negative feeling. Most of the time these children have only mild contracture in few group of muscles & tendon that hamper their activity. This entire problem can be managed very successfully in younger age (< 6 year) by the proper therapy, brace & botulinum toxin but in children of more than 6 years of age, adolescents & adults, surgical intervention is needed to correct all persisting problems. http://www.samvednatrust.com/cerebral-palsy/recent-advancements/

Usually routine orthopedic surgeries don’t help much in these children but all the disability can be managed very much successfully by the new concept of SEMLOSSS. In this concept, every possible deformity is being managed in single setting surgery by the concept of OSSCS. Child need detail evaluation by physical examination & gait analysis. If it is managed properly along with correct therapeutic protocol then child can have excellent recovery. link to you tube showing recovery in adolescence & adult with cerebral palsy

 

https://www.youtube.com/watch?v=SX-MRUmi1BA

Dr J K Jain

Pediatric orthopedic surgeon & secretary, samvedna