sleep disorders case report Batelić Dragić R. New concepts in rehabilitation of children with cerebral palsy. pp. 278 – 284 NEW CONCEPTS IN REHABILITATION OF CHILDREN WITH CEREBRAL PALSY Rašeljka Batelić Dragić, dipl. physioth. E-mail: [email protected] 0000-0002-0623-6706 ABSTRACT Cerebral palsy is a major burden for the affected person, their family, health insurance, educational institutions and society in general. In the past few years, new rehabilitation concepts which could offer better results on the activity/participation level and better functional skills of everyday life are being discussed. The Therasuit® therapy is a new concept in rehabilitation, based on the theory of motor learning and motor control, individualized progressive strength training, primitive reflex integration, used in combination with other well-known neu- rophysiotherapy techniques. A case study outcome using Therasuit® therapy on a 7.5-year-old child with spastic cerebral palsy, one month after multiple Ulzibat fibrotomy, will be presented in this article. Keywords: cerebral palsy, strength training, primitive reflex integration, Therasuit® INTRODUCTION Cerebral palsy (CP) is a common name used The main goals and problems of rehabilita- However, new evidence has been found that for different disorders of the postural system tion dealing with the described population isolated strength training with increased caused by a non-progressive damage to the are multiple and the number of different replication of motoric tasks and activities brain in its early stages of developement.1 types of intervention used around the world does not increase spasticity13,14 nor co-con- Around the world, a large number of children is very large, starting with drugs, orthopedic tractions of antagonistic muscles,15 but in- are diagnosed with CP, about 1.5 to 4 on 1000 procedures, orthotics, occupational therapy, stead normalizes the muscle tone and pos- live births. In the USA, 10.000 children are speech therapy, cognitive-behavioral thera- itively affects walking, functional activities diagnosed with CP every year.2 The preva- py, neurofeedback, nutritionism, different and participation.14-18 lence in Europe is the same as in the rest of alternative treatments and physiotherapy, When speaking of reactions commonly the world and the epidemiological data for which includes hydrotherapy, hippotherapy known as primitive reflexes, traditional Croatia are poor and incomplete, but can be and neurodevelopmental concepts such as theories define them as primitive reactions compared with the rest of the world.3,4 Re- Bobath,7 Vojta,8 Doman-Delacato,9 Jane Ay- which must be cortically inhibited through search shows that 77.4% of children with CP res’ Sensory integration10 and many others. normal development.8,10,19 New theories such have spasticity or hypertonic musculature, Research in rehabilitation of children with as the Masgutova’s theory,20 which is based 35–50% have epileptic seizures and some CP has been focused on physiotherapy in- on the physiological research conducted level of mental retardation, difficulties with terventions, strength training methods and by Pavlov, Sechenov, Vygotsky, Bernstein, learning, sight, hearing and speech. 6.9% of treatments since the ‘60s of the past century. Sherrington, Luria and Anokhin, give evi- affected children show symptoms within the In the past two decades, researchers’ in- dence that primitive reflexes, besides their autistic spectrum and 40–45% display poor terest has been piqued by new controver- protective role, also play a very important coordination and motor control, which lim- sial methods based on new theories about role in supporting neurogenesis, synapto- its them in participation and activities such strength training and the integration of genesis, and myelination, as neurophys- as crawling, independent walking, running primitive reflexes. iological foundation for higher levels of and playing.5 A study reported that 31% of Karol and Berta Bobath and many other ther- motoric, emotional and cognitive devel- children with CP use special equipment like apists who followed their theories, stated opment. Masgutova stated that primitive walkers, crutches or wheelchairs.6 that isolated strengthening of spastic mus- reflexes are always present as genetic codes CP represents a major burden for the affected cles could lead to increased co-contractions, or natural afferent-efferent motor patterns child, the family, health insurance, educa- spasticity and associated reactions with which are not inhibited by cortical develop- tional institutions, and society in general.4 consequences of poorer motor control.7,11,12 ment, but integrated as a link between lower gyrus | vol. 4 | no. 3–4 | july – december 2017 278 sleep disorders case report Batelić Dragić R. New concepts in rehabilitation of children with cerebral palsy. pp. 278 – 284 and higher centers of our central nervous connected to facilitate or inhibit muscle Indications: system during its development.20,21 Associ- activity. The suit with rubber cables gives a 1. CP ated reactions, according to the primitive strong proprioceptive input and loading at 2. Developmental delays reflex integration theory, can be defined as the same time. The theory behind the suit 3. Balance and coordination delays and reflexive genetically conditioned answers therapy is that it induces a strong afferent, disorders that emerge when the nervous circuits have proprioceptive input which stimulates the 4. Traumatic brain injury been disrupted. This disruption inhibits the formation of cerebral systems whose post- 5. Stroke next level of sensory-motor development natal development has been delayed. The 6. Hypertonicity and cognitive function. Masgutova’s theory elastic cables provide the body and articu- 7. Hypotonicity practitioners commonly call the primitive lations with a vertical loading of about 15 to 8. Dyskinesia: ataxia, athetosis and dystonia reflexes the missing link in the facilitation 45 kg (33 to 88 pounds), which is significant 9. Non-progressive neurological disorders of development.21 to patients that have no appropriate stimu- and syndromes: spina bifida, spinal cord New theories about isolated strength train- lation from their own soft tissue because of injury, Down syndrome ing and the integration of primitive reflexes abnormal muscle tone. The Therasuit® with complement and enrich the neurophysiolog- its individualized placing of rubber cables Contraindications: ical concepts, such as Vojta, Bobath, propri- becomes a dynamic orthosis which can give 1. Progressive and genetic metabolic oceptive neuromuscular facilitation (PNF), support and stabilize correct posture in a syndromes P. and G. Dennison and Ayres.21,22 natural way. At the same time, it facilitates 2. Severe degeneration of bones and and strengthens correct functional patterns articulations The Therasuit® concept of movement by providing dosed resistance. 3. Severe osteopenia/osteoporosis Along with new evidence of the effective- The concept of the described intervention fol- 4. Loss of integrity on the level of body struc- ness of strengthening exercises for children lows neurophysiological principles, training ture (severe subluxations, scoliosis and with CP, new concepts have begun to devel- theories and antioxidant diet principles to structural fixed contractures) op. The Therasuit® concept was developed support the functioning of the neural tissue in 2002 by husband and wife Izabela and and the musculoskeletal system. It is also Precautions: Richard Koscielny, parents of a child with characterized by a constant increase of the 1. Hypertension, hemodynamic disorders CP, who are both physiotherapists from Po- number of exercise repetitions, increase of 2. Uncontrolled epileptic seizures land. The Therasuit® concept was based on resistance and change of contraction types.23 3. Subluxations the idea of Russian researchers in 1971 and According to the Koscielny physiotherapists23 4. Metabolic disorders their modified version of a cosmonaut suit the positive effects, indications, contraindi- 5. Hydrocephalus (VP shunt) called “Penguin”, developed to prevent the cations, precautions and goals of the Thera- 6. Kidney damage detrimental effects of hypokinesis in the suit® treatment are the following: 7. Poor bone mineralization weightless conditions in space. 8. Status post botox or alcohol injections Therasuit® is a rehabilitation concept that integrates different manual, myofascial Positive effects: Goals: and neurodevelopmental techniques in the 1. Provides deep proprioceptive and tac- 1. Support for weak structures (trunk) Universal Exercise Unit (UEU) (Figure 1) that tile input 2. To provide resistance (for deeper proprio- accentuates progressive strength training 2. Stimulates the reorganization of the cen- ceptive input and strengthening) and repetitive functional activities while tral nervous system 3. Reeducation of pathologic synergies and wearing a specially designed suit. The pro- 3. Enables ontogenic development and cen- patterns of movement gram is highly intensive because it is carried tral activation 4. Facilitation of new functional and eco- out for five days a week, 3–4 hours a day and 4. Enables external activation of muscles nomic patterns for at least 3–4 weeks. needed in stabilization 5. Reflex integration According to the Therasuit® concept, the pa- 5. Normalizes muscle tone providing the tient is first prepared with manual, myofas- sense of center of gravity, inhibiting hy- cial techniques, massage,