REHABILITASI MEDIK ANAK

REHABILITASI MEDIK
IS A PHYISICAL MEDICINE AND REHABILITATION SCIENCE ILMU KEDOKTERAN FISIK DAN REHABILITASI ( IKF&R)

SEJARAH REHABILITASI MEDIK DIMULAI SAAT PENGGUNAAN BAHAN FISIK UNTUK PENGOBATAN PADA MASA LALU. HYDROTHERAPY TELAH DIKEMBANGKAN SEJAK KAKISRAN ROMAWI PADA ABAD IX DAN X MASA PENGGUNAAN GALVANIC AND PARADIC 1890 : PENGGUNAAN GELOMBANG ELEKTROMAGNETIK FREKUENSI TINGGI ( DIATHERMIA ) OLEH d ARSONVAL DI FRANCIS UNTUK TUJUAN PENGOBATAN

REHABILITASI ANAK Secara khusus dalam penilaian dan penanganan bayi, anak dan dewasa muda dengan berbagai jenis developmental disabilities The disabilities may include cerebral palsy, muscular dystrophy, or spina bifida.

Disability / disabilitas ??? interaksi yang komplek antara individu terhadap lingkungannya word health organisation (WHO )

Impairment
disfungsi fisiologis Disabilitas perawatan diri dan mobilitas fungsional dalam suatu lingkungan Handikap Pilihan peran sosial, bekerja, sekolah, berkeluarga,gaya hidup, rekreasi

Impairment
disfungsi fisiologis Aktivitas perawatan diri dan mobilitas fungsional dalam suatu lingkungan Partisipasi Pilihan peran sosial, bekerja, sekolah, berkeluarga,gaya hidup, rekreasi

Definisi WHO
Impairmen suatu kondisi abnormal dari struktur atau fungsi disfungsi fisiologis

Aktivitas adalah melaksanakan tugas atau aksi oleh seorang individu cerminan dari sudut pandang individu tsb. Contoh kemampuan untuk melakukan pemenuhan perawatan diri keterbatasan beraktivitas = disabilitas

Partisipasi tergantung pada keterlibatan sorang individu dalam situasi kehidupan dan cerminan dari sudut pandang sosialnya Keterbatasan partisipasi = handikap atau ketidak mampuan untuk dalam menggunakan peran sosial normal

KEDOKTERAN FISIK DAN REHABILITASI MEDIK

KEDOKTERAN FISIK : CARA INTERVENSI UNTUK MEMPERBAIKI FISIOLOGI MENTAL DAN FUNGSIONAL

REHABILITASI MEDIK : MEMUNGKINKAN MASYARAKAT UNTUK BERPARTISIPASI AKTIF DALAM LINGKUNGAN SOSIAL

 Khusus terhadap anak anak di titik beratkan pada

1.

2.

3. 4.

Mengerti terhadap proses komplek perkembangan bayi, anak, adolesen, dewasa muda dan keluarganya dalam pengertian komunitas . Mengerti peran biologis, psikologis dan sosial dalam perkembangan emosi, sosial, motoris, bahasa dan kognitif Mekanisme dari pencegahan primer dan sekunder terhadap kelainan dalam prilaku dan perkembangan Mengindentifikasi dan menangani terhadap gangguan dari lingkungan dan perkembangan sepanjang anakanak dan dewasa
Source: Accreditation Council for Graduate Medical Education
(ACGME)

Understanding the complex developmental processes

In the first few months of life some children need help learning to roll, sit, crawl and walk. The earlier a developmental delay is detected, the better the outcome will be with therapy .

Some major milestones:

Rolling:

4-6 months Sitting: 6-8 months Crawling: 7-10 months Walking: 12-15 months Running: 24-28 months Jumping: 26-30 months

REFLEX
CATEGORY
NEONATAL

DEVELOPMENT 0 - 5 YEARS
REFLEX
MORO GALANT CROSSED EXTENSOR FLEXOR WITHDRAWAL EXTENSOR THRUST REFLEX WALKING PALMAR GRASP PLANTAR GRASP TONIC LABYRINTHINE ATNR STNR POSITIVE SUPPORTING NECK LABYRINTHINE OPTICAL BODY ON BODY BODY ON HEAD PROTECTIVE EXTENSION - FORWARD - SIDEWAYS -BACKWARD LANDAU EQUILIBRIUM - PRONE - SUPINE AND SITTING - ALL FOUR - STANDING

APPEARS
BIRTH BIRTH BIRTH BIRTH BIRTH BIRTH BIRTH BIRTH BIRTH 2 MONTTH 4 6 MONTH BIRTH BIRTH 2 MONTH 7 12 MONTH 6 9 MONTH 8 MONTH 10 MONTH 3 6 MONTH 6 MONTH 7 8 MONTH 9 12 MONTH 12 21 MONTH

INTEGRATED BY
6 MONTH 2 MONTH 1 2 MONTH 1 2 MONTH 1 2 MONTH 6 MONTH 6 MONTH 9 MONTH 6 MONTH 4 MONTH 10 MONTH 2 MONTH 4 6 MONT LIFE LONG LIFE LONG LIFE LONG 5 YEARS LIFE LONG LIFE LONG LIFE LONG 1 2 YEARS LIFE LONG LIFE LONG LIFE LONG LIFE LONG

POSTURAL

RIGHTING AND PROTECTIVE

DEVELOPMENT
AGE SKILL

0 - 12 MONTH

2 MONTH 4 MONTH

LIFTS HEAD IN PRONE LIFTS HEAD IN PRONE , WEIGHT ON FOREARMS BRINGS HANDS TO MIDLINE HEAD KEPT IN LINE WITH TRUNK WHEN PULLED TO DITTING

5 MONTH

LIFT HEAD IN SUPINE LIFT BOTTOM IN SUPINE BRIGES ROLL TO SIDE TAKE BOTH FEET TO MOUTH HELPS PULL SELF TO SITTING SITS WITH HANDS IN FRONT FOR SUPPORT ROLLS SUPINE TO PRONE TAKES BOTH FEET TO MOUTH HELPS PULL SELF TO SITTING PIVOTS AND PUSHES SELF BACKWARDS IN PRONE

6 MONTH

7 MONTH

AGE 8 MONTH

SKILL CREEPS FORWARDS ON FOREARMS SITS UNSUPPORTED WITH STRAIGHT BACK CAN REACH IN SITTING CAN GET INTO LYING CRAWLS ON ALL FOURS PULLS TO STANDING

8 10 MONTH

10 12 MONTH

GETS DOWN FROM S TANDING WALKS WITH BOTH OR ONE HAND HELD

12 MONTH

SOME CHILDREN WALK INDEPENDENTLY

SUMBER

: PHYSICAL THERAPY FOR CHILDREN ( PAMELA ARGARET )

Specific Examples: Development

Developmental Delay Cognitive Disabilities Motor Disabilities

Examples: cerebral palsy, spina bifida Examples: Down Syndrome, Fragile X

Chromosomal/Genetic Disorders

Autism Spectrum Disorders Neonatal Intensive Care Unit follow-up

Physical Development

COGNITIVE DEVELOPMENT

Person

Social emotional Development

Cultural influence

PEDIATRIC REHABILITATION

HABILITATION Congenital Cerebral palsy Chilhood aphasia Developmental delay

REHABILITATION Acquired Disorder Brain injury Spinalcord injury

THE

APROACHMENT

Comprenhensive evaluation Identification of specific area of deficit development of threatment plan based on development level, age of child and outcome expectation Implementation of a threatment plan as appropriate discharge planing

Assesment The functional balance

Score : + : can without helped + : can with helped - : cannot

The examination point:

From lying to sit down From sit down to stand up Standing with support Standing Standing with right foot Standing with left foot squat

The Examination Musculosceletal condition

MMT ROM Antopometri Scoliosis Test Club Foot Test Trandelenburg Test Gait test

Double support

Double support

(10%)
Loading response

Stance (60%)
Midstance Terminal stance

(10%) Preswing Initial swing

Swing (40%
Midswing Terminal swing

10%

30%

50%

Toe off

70%

85%

One complete gait cycle

GAIT COMPONENT

Initial contact Loading response Midstance Terminal stance Preswing Initial swing mid swing Terminal swing

FUNCTIONAL EXAMINIATION / GROWTH & DEVELOPMENT

DENVER DEVELOPMENTAL TEST ( DDST ) - SOCIAL PERSONAL - FINE MOTOR ADAPTIVE - LANGUAGE - GROSS MOTOR

INTELLIGENCE EXAMINATION

The good IQ grade is ease

the EXERCISE

MEDICAL REHABILITATION DIAGNOSTIC ( IMPAIRMENT, DISABILITY HANDICAPS ) functional disorder

APROACH PROBLEM ORIENTED R1. MOBILISATION R2. ADL R3.COMUNICATION R4.PSYCHOLOGY R5.SOCIAL R6.VOCATIONAL R7.ETC

ICF ( WHO 2002)

( International Clasification of Function )

Structure of body fanction Physiological dysfunction ( Erbs Palsy : parese Flexus brachialis ) Activity ( Graps disorder ) Particifation ( cant plays )

MEDICAL REHABILITATION PROGRAM REALISTIC GOAL A. PHYSIOTHERAPY / Physical Therapy - With Modality - Exercise B. Ocupational therapy C. Orthotic - Prostetic D. SPEECH THERAPY

Therapy Physical Therapy (PT) specializes in the assessment and management of infants, children and adults with a variety of developmental disabilities. The disabilities may include cerebral palsy, muscular dystrophy, or spina bifida. What Is Occupational Therapy?... Technically, it is defined by the American Occupational Therapy Association executive board (1976) as: "The therapeutic use of work, self-care, and play activities to increase development and prevent disability. It may include adaptation of task or environment to achieve maximum independence and to enhance the quality of life."

Physical

Goal Of Occupational Therapy (OT ) Occupational Therapy has the same goal in mind (increasing function and independence) in regards to physical disabilities and limitations, and we may use repetitive exercises, but most often we use them in the context of a "functional activity". This refers to performing meaningful activities while simultaneously working on increasing function and mobility. For example, suppose we have a patient with limitations in upper extremity strength and range of motion. A Physical Therapist may have a patient doing an arm exercise bike or repetitively lifting weights over their head (using heavier weights as the patient tolerates). This HAS it's place and definite purpose in rehab!

The

PHYSIOTHERAPY
THERAPY EXERCISE TRADITIONAL MODE - Strengthening - ROM ( Range Of Movement ) - Endurance - Compensation - Game

THE PRINCPLE Doing activity that funny but the purposes is to doing therapy For Example With game activity direct the fine motor movement ( skil hand movement , Coordination hand movement , Coordination eye movement , centrum attention ) Many kind of puzzle dll

Activities that promote the development of gross motor skill

Playground equipment Endurance activities Swimming Ball Toss Kick Ball Jump Rope, Skipping, galloping, hopping Playing outside Imitating animals Wheelbarrow walking "Simon Says" Log Rolling Riding bicycles General exercises Walking a line, curb, railroad ties

SPEECH PATOLOGY ( SPEECH THERAPY )

COMUNICATION PROBLEM Language disorder Voice production disorder because neurogenic disorder and organ disorder had role in Voice production Sensory disorder ( Auditory )

Orthotic The porpuse is to support , function , adaptation Prosthetic - ( protese )

Orthotic Prosthetic

8.

PROGNOSIS - MEDICAL ( ACCORDING WITH MEDICAL DIAGNOSTIC ) - FUNCTIONAL ( MOBILITATION, PERSONAL ADL, INSTRUMENT ADL, EDUCATION ) FOLLOW UP / EVALUATION / DISEASE RECOVERY, NEUROLOGICAL RECOVERY , FUNCTIONAL RECOVERY

9.

DISEASE IMPAIRMENT DISABILITY - HANDICAP

CNS PROBLEM / CEREBRAL PALSY BRACHIAL PALSY MUSCULAR DISTROPY SCOLIOSIS TORTICOLIS CTEV FLAT FEET DEFISIENSI EXTREMITY AUTISM SPECTRUM SPINAL MUSCULAR ATROPI FRAKTUR EKSTREMITAS DOWN SYNDROME

JUVENIL

RA POLIOMYELITIS, SINDROMA GUILLAINBARE, MIELITIS TRANSVERSA SPINALCORD INJURY NEURITIS TRAUMATIC PARALISIS PERIODIK
POT

DISEASE

DEVELOPMENTAL

DELAYED SPEECH DELAYED

MOTOR DELAYED

CEREBRAL

PALSY

REHABILITATION OF C.P
Principles of proper rehabilitation :
1. Proper evaluation ( individual treatment ) - to plan a therapy program.to assess progress. - to add observation to the diagnostic picture. 2. Early treatment( increasing functional deficits w/ age as secondary effects of spasticity &other primary problems 3. Team work ( global dysfunction )

EVALUATION OF CP CHILD
(A) Clinical evaluation

1. Functional : Postural control

Primitive reflexes 2. Swallowing & dysphagia 3. Communication: Speech/ language Auditory 4. Chest 5. Urinary bladder

Mobility
Motor exam

Visual Mentality

6. Bowel 8. psychosocial

7. Self -care activities (ADL)

SCOPE OF CP REHAB.
1. Neurodevelopmental training. 2. Motor facilitation approach. 3. Treatment of spasticity. 4. Rehab. of swallowing problems. 5. Rehab. of speech problems. 6. Rehab. of auditory problems. 7. Rehab. of visual problems. 8. Rehab. of chest problems. 9. Rehab. of urinary bladder & bowel problems. 10.Rehab. Of ADL & 11.Psychosocial rehab.

ASSESSMENT OF MILESTONES & POSTURAL CONTROL

Understanding normal development allows to adaptive equipment to assist child in gaining increase the interaction with the environment. Sitting balance at age 2 yrs. is an indicator of future walking. Observe how much parental support given to child. child own ability in postural stabilization. collapse on one side of his body, twist to one side, tilt & turn to one side.

EVALUATION OF PRIMITIVE REFLEXES

Can be used as indicator of ambulation Abnormal response for two of the following seven reflexes by age 12 month has a poor prognosis for walking this are Should be absent Should be present ATNR parachute reaction STNR foot placement Moro response Neck righting reflex Extensory thrust Presence of Moro or ATNR, seizures, ability to sit at 12 month indicate ambulation by age of 6 yrs.

MOTOR EXAMINATION
GAIT

DEFORMITIES

Hemiplegia Toe walk Diplegia Bilateral equinovaras, Knee flexed & in valgus

Hemiplegia

: adducted arm, flexed elbow, wrist & fingers equinus foot. Diplegia: adducted hip, flexed knee in valgus, bilateral EV knee height discrepancy indicates hip dislocation. Quadriplegia: combination scoliosis & hyperlordosis in spastic CP

kyphoscoliosis in hypotonic CP

Scissoring Cerebellar Ataxic

MOTOR EXAMINATION

R.O.M. Degree by goniometry: Limited (= fixed deformity = ms. Contracture) Not limited (+ deformity = threatening deformity = muscles imbalance) ABNORMAL MOVEMENT Dystonia, ( cervical = spasmodic torticollis ) Chorea & Athetosis Tremors

MUSCLE

TONE Spasticity ( = clasp knife ): - generalized or focal - grade 0 (non) - 4 (severe) [Ashworth scale] Rigidity ( = lead pipe ) Hypotonia ( cerebellar ) Combination : the predominant symptoms will contribute to diagnostic type referred for treatment

MOTOR EXAMINATION
MUSCLE STRENGTH Grade 0 = No contraction detected 1 = Flicker of contraction w/ no movement. 2 = Joint movement possible only with gravity eliminated. 3 = Muscle contraction possible against gravity without resistance. 4= Muscle contraction against gravity & less than normal amount of resistance. 5 = Normal power against gravity and resistance.
MUSCLE

STRENGTH Values of muscles grading: - To determine ambulation with or without brace ( grade 3 antigravity muscles can ambulate without brace - Topographic classification for treatment plan ( strengthening exercise for weak muscles ) - Ex. must be low grade and non-fatiguing in ms.<3/5 -N.B (I) grade drops form muscle power following tendon lengthening.

SWALLOWING STUDY
Values: - To facilitate appropriate position for safe, effective feeding - To increase ability to self feed. Methods: 1. Video fluoroscopic swallowing study - Requires speech - pathologist & radiologist - Patient is given liquid & various consistency of solid food impregnated w/ baruim & folowed by X-ray until be sure safe effective swallowing 2.Fiberoptic evaluation of swallowing ( FEES ) Transnasal endoscopy of hypopharynx to observe foodway & airway before & after( but not during ) the moment of swallowing. 3. EMG, manometry, scintigraphy & U.S: less commonly use.

Assessment of speech
Speech problems : Dysarthria (oral motor control problems ) : Spastic Hypokinetic (ataxic ) Hyperkinetic (dystonia,chorea) Aphasia Language delay (brain pathology, MR, hearing impairment )

VISUAL ASSESSMENT

Problems: Strabismus ( imbalance in eye ms. ) Hemianopsia(in dense hemiplegi w/ MCA occlusion) Blindness ( anoxic cortical vision loss ) Effects: 1. More motor delay 2. Language delay 3. Abnormal movements ( blindism ) 4. More delayed postural mechanism especially hypotonic CP

AUDIOLOGICAL EVALUATION

Must be early so that important speech development period not lost. In infant (1-2 d. of birth): Brain stem auditory evoked response (BAER): Electrodes placed on the child & presenting a stimulus picked up from a computerized system. A specific wave form response is recorded from the brain stem if stimulus is heard. Otoacoustic emission testing (OAE): Echo from hair cell of normally functioning cochlea picked by a microphone placed in the middle ear & connected to micro computer.(middle ear pathology is ruled out)

NEURODEVELOPMENTAL TRAINING
EQUIPMENT TRAINING Criteria for selection:
1. to carry out tasks otherwise impossible with his ability. 2. appropriate support to participate in social & educational activities . 3. good alignment & correction of abnormal postures 4. adjust for child growth, removal of support with increasing ability. 5. modification for different children in schools & clinics 6. provide additional motor experience in different posture 7. Comfort and protect joints & skin.
Equipments

varieties: 1. Wedges: Abductor W : prevent adduction deformities 2. Trumble form wedges & trumbles. 3. Large inflatable ball set 4.Crawlers: -platforms on wheels or wedges on wheels -A canavas sling under child abdomen & supports on casters, straps to hold thighs in flexion. 5. Sitters

NEURODEVELOPMENTAL TRAINING
6. Apparatus for supporting standing
a) Prone or supine standers to encourage weight bearing & standing b) Standing frames adjusting correct alignment: -checked for height so that child does not grasp them w/ abnormal shoulder hunching , excessive elbow flexion & radial deviation of wrist. -supplied w/ strapping to correct flexed hip & knees -feet held at right angles by a board &/or foot place. c) Parallel bars d) Mirrors e) Stairs with bannisters: very in height. f) Rumps, uneven ground, various floor services for gait training.
7.Walking

aids

Walkers Crutches Braces & Calipers: Knee gaiters (polyethylene knee moulds) to keep knee straight abduction parts to keep legs apart. Elbow gaiters which keep elbow straight for correct arm push & grasp of walkers.

MOTOR FACILITATION APPROACH

1. Bobath Method: inhibition of abnormal tone & posture of released
postural reflex while facilitating specific automatic motor response (by special technique of handling) resulting in performance of skilled voluntary movements.

2. Rood Method: Use of peripheral input of cutaneous sensory stimuli

(brushing, tapping, icing, heating, pressure, ms. stretch, muscle contraction, joint approximation. or retraction) Various nerves & sensory receptors are described & classified into types ,location, effect, response, indication.

MOTOR FACILITATION APPROACH

3. Propioceptive Neuromuscular facilitation (Kabat & Knott) Use of such mechanisms as maximum resistance , quick stretch & spiral diagonal (mass) movements, sensory afferent stimuli (touch, pressure, traction,compression & visual) to facilitate normal mov . [special techniques: irradiation. stim. of reflexes,reversal(successive induction), relaxation.]. 4. Brunstrom Method ( hemiplegia): Produces motion by provoking primitive movement pattern or synergitic pattern as follows : -Reflex response used initially & later voluntary control -Control of head & trunk by stim. of TNR, tonic labrinythine R -Associated reaction : hyperextension of the thumb produces relaxation of finger flexors.

MOTOR FACILITATION APPROACH

5. Motor relearning program of Carr & Shepherd:
functional training, practice, repitition, in the performance of tasks & carry over those motor skills into functional activities.

6. Forced use paradigm (= constraint - induced movements therapy CIMT):

Non hemiplegic limb is restrained in a sling during 90% of waking hrs. to force the patient to use the hemiplegic limb. The minimum amount of motion in the paretic limb before being enrolled into CIMT protocol is 20 of wrist extension and 10 of extension of 2 fingers at MCP or IPJ.

TREATMENT OF SPASTICITY
Positioning

Avoid prolong sitting (less hip & hamstring flexion ) Prone lying at night (less hip flexion ) Abduction wedge at night & in wheelchair (less hip adduction) AFO splint Standing frame Molded thoracolumbar orthosis for early scoliosis or kyphosis Total contact support incorporated into a contoured seating system

TREATMENT OF SPASTICITY
Drugs
Indication : generalised spacticity to aid in mobility Types :
1. Dantrolene Sodium (Dantrium): Inhibits Ca release in excitation-contraction coupling Used in cerebral form of spacticity Dose: 25- 200mg 2. Baclofen (Lioresal ) [ presynaptic inhibition ] Used in spinal form of spasticity Dose :5-40mg 3. Diazepam (Valium) [postsynaptic inhibition] Used in spinal form of spasticity Dose :2-30mg

TREATMENT OF SPASTICITY
PHYSIOTHERAPY
PHYSICAL AGENTS Aim: a. Analgesia b. Ms. Relaxation c. Collagen extensibility Modalities: 1) Ice 20mins.
2) Heat: Superficial : Dry: I.R. Moist: hot packs Deep : S.W. U.S ELECTRIC CURRENTS Aim: Ms. strengthening (galvanic & faradic) . Analgesia ( TENS, IF) EXERCISES For spasticity : Passive ROM Stretch (short ms.) Strengthening (weak ms., antagonist), resistive > 3/5 For hypotonia : Strengthening ( weak ms) Balance For athetosis : Training to control simple joint motion

TREATMENT OF SPASTICITY
Nerve/ Motor Point Block
Indications Localized spasticity poorly responsive to drugs or PT, interfering w/ mobility, bracing, hygiene & causing pain Contraindication: - Absolute: Allergy Infection Pregnancy - Relative: Coagulopathy Problems: -Loss of motor function of injected ms. -Return of spasticity ( axon sprouting )

TREATMENT OF SPASTICITY
SERIAL CASTING Indications: focal contracture (especially elbows, knees, ankles ). Method: Limb is stretched then casted in a lengthened position ( can be combined with blocks ) Changed every few days or weeks to gradually stretch contracted structures.

TREATMENT OF SPASTICITY
BRACES ( = CALIPERS = ORTHOSIS )
Aim:
To correct deformity To control athetosis To obtain upright position AFO: For ankle instability w adequate Q > 3/5 Types: solid ( in ankle clonus ) Klenzak ankle joint w/spring(A,P) w/ stop (A,P) Accessories: varus strap valgus strap KAFO: For correction of knee deform. & instab. HKAFO: For ambulation w/ hip instability Shoe modification

Types:

REHAB OF SWALLOWING PROBLEMS

Team: speech language specialist, OT, Dietary specialist. Items: Changes in posture & head position during feeding. Oral motor exercise for the tongue & lips to increase strength, ROM, velocity, percision. Use of thickened fluid & soft food in small boluse Use of alternative feeding routes e.g. nasogastric tube, gastrotomy or jejunostomy tubes with severe aspiration or caloric need.

REHAB OF SPEECH PROBLEMS

Team : speech -language pathologist & nurse Items : 1- oral option : electrolarynx 2 - non oral options : - simple hand writing - gestures - augmentative communication device (simple alphabet & picture board to sophosticated computer systems 3- treatment of hearing & visual problems

REHAB OF ADL

Team : occupational therapist Items : - provision of self help devices - training in activities of ADL - provision of creative interest - training in suitable work

PSYCHOSOCIAL REHAB

Team : psychiatrist + social specialist Items : - provision of recreational activities e.g.- special olympics, athletic competition - horse back riding programs (recreational & therapeutic ) - computers ( for schools & recreation

Muscular Dystrophy

Definition Refers to a group of hereditary progressive diseases. Muscular Dystrophy affects muscular strength and action, some of which first become obvious in infancy, and others which develop in adolescence or young adulthood. The syndromes are marked by either generalized or localized muscle weakness, difficulties with walking or maintaining posture, muscle spasms, and in some instances, neurological, behavioral, cardiac, or other functional limitations.

Nursing Diagnosis
Impaired mobility, activity intolerance, risk for injury, risk for aspiration, risk for impaired skin integrity, self-care deficit, knowledge deficit, caregiver role strain, low self-esteem, social isolation, disturbed body image, and hopeless to name a few.

Nursing Implications and interventions:

Multidisciplinary. Care for these patients involves arranging for consultations with physical therapy, occupational therapy, respiratory therapy, speech therapy, psychosocial therapy, and dieticians. Reinforce techniques learned in all of the above therapies. Educate client and family members thoroughly about expected outcomes and possible problems. Encourage exercise while teaching s/s of exercise overload: feeling weaker rather than stronger after exercise, excessive muscle soreness, severe muscle cramping, heaviness of extremities, and prolonged shortness of breath. Ensure braces are a good fit to prevent pressure ulcers and promote stability. Have equipment (braces, wheelchairs) evaluated by PT, OT to ensure proper fit. Be sensitive to psychosocial needs and make appropriate referrals. Refer to support groups and clinics.

(*) Gowers' sign

Devices. Rehabilitation

Polypropylene orthosis

Devices. Rehabilitation

Orthopedic shoes

Devices. Rehabilitation

An overhead arm suspension attaches to the back of the wheelchair. The device eliminates gravity and may make it possible for some patients to have functional use of a weak upper extremity.

 Effects of treatment Walking: Prolonged by 2 to 5 years Strength: Increased Falling: Reduced While patient still ambulatory ? When started at early age (3 to 5 years) ? May prolong walking long enough to reduce likelihood of serious scoliosis
Death Most common between 15 - 25 years Due to respiratory or cardiac failure Life prolonged by ~ 6 years to 25 years with respiratory support Life shortened by 2 years with cardiomyopathy

Traumatic obstetric brahial plexopathy usually result from traction on the brachial plexus 80 % ( ERBS DUCHENE PALSY ( C5 C6 ) other ( KLUMKES PALSY ) C8 TH 1 or totaly

Exercise Therapy
Goals = Improve ROM Especially in direction of convexity Reduce contractural change of soft tissues on concave side Done through: Improve strength, endurance, & postural control of muscles on convex side Identify & correct vestibular and/or proprioceptive imbalance/deficiency Improve balance & coordination Normalize weight bearing in lower extremities & spine

Exercise Therapy
Specific Exercises: Stretch concave side = balance ball, hanging from bar, leaning against wall Strengthen convex side = active exercise Strengthen trunk muscles Rotary torso exercises to left (right thoracic curve) Proprioceptive training Heel lift (up to 5 mm) goal is to balance weight bearing for CNS re-education, re-evaluate every 6 weeks

Exercise Therapy - continued

Exercises to restore cervical lordosis Work with Exercise Ball proprioceptive control Sleep posture lying on side with pillow under ribs To correct pelvic unleveling (ex. elevated Rt. Ilium) Strengthen: Lt. QL, Lt. hip adductors, Rt. G Med Stretch: Rt. QL, Rt. hip adductors, Lt. G Med Breathing exercises maximize & normalize chest expansion

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