ACTA ORTHOPAEDICA et TRAUMATOLOGICA Acta Orthop Traumatol Turc 2009;43(2):173-180 TURCICA doi:10.3944/AOTT.2009.173 Rehabilitation of children with cerebral palsy from a physiotherapist’s perspective Fizyoterapist bakış açısıyla beyin felçli çocukların rehabilitasyonu Mintaze KEREM GÜNEL Department of Physical Therapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara Pediatric rehabilitation requires a multidisciplinary team Çocuk rehabilitasyonu, doğum öncesi, doğumda ya da doğum approach to disabilities or handicaps caused by physical, sonrası nedenlerle oluşabilen fiziksel, zihinsel, duyu-algı ya mental, sensory-perceptional, or cognitive disorders due to da bilişsel bozuklukların yarattığı özür ya da engel tablosu- prenatal, natal, or postnatal causes. Cerebral palsy (CP) is na ekip yaklaşımını gerektirir. Beyin felci (BF), fonksiyonel defined as persistent but not progressive disorder of pos- aktivitelerde kısıtlılıklara neden olan, postür ve hareket siste- ture and movement system, associated with functional ac- mindeki ilerleyici olmayan, kalıcı bozukluk olarak tanımla- tivity limitations and sensorial, cognitive, communication nabilir; bu tabloya duyu, algı ve iletişim sorunları, epilepsi ve problems, epilepsy, and musculoskeletal system problems. kas-iskelet sistemi sorunları da eşlik edebilmektedir. Reha- Physiotherapy approaches in rehabilitation applications bilitasyon uygulamaları içinde fizyoterapi yaklaşımları, du- aim to normalize sensorial and motor functions, provide yusal ve motor deneyimleri normalleştirmek, düzgün postür normal posture and independent functional activity, regu- ve bağımsız fonksiyonel aktiviteyi sağlamak, kas tonusunu late muscle tone, improve visual and auditory reactions, düzenlemeye çalışmak, görsel ve işitsel reaksiyonları geliştir- support normal motor development and motor control, mek, normal motor gelişimi desteklemek ve motor kontrolü improve ambulation and endurance, increase the quality sağlamak, var olan hareketin kalitesini artırmak, yürümeyi of the existing movements, prevent soft tissue, joint and geliştirmek, oluşabilecek yumuşak doku, eklem ve postür postural disorders, support orthopedic and surgical pro- bozukluklarını önlemeye çalışmak, ortopedik ve cerrahi gi- cedures, and finally to prepare the child for the adolescent rişimleri desteklemek ve sonuçta çocuğu gençlik ve yetişkin and adult periods. Setting realistic goals, determination of dönemlerine hazırlamak gibi genel amaçları taşır. Gerçekçi the priorities, informing the family and enhancing family hedefler ve önceliklerin belirlenmesi, ailenin bilgilendiril- participation in physiotherapy programs will increase the mesi ve fizyoterapi programına aktif katılımının sağlanma- success of physiotherapy. This article reviews current re- sı fizyoterapinin başarısını artıracaktır. Bu derlemede BF’li habilitation approaches and physiotherapy applications for çocuklarda güncel rehabiltasyon yaklaşımları ve fizyoterapi children with CP. uygulamaları incelenmeye çalışılmıştır. Key words: Cerebral palsy/rehabilitation; child; disability evalu- Anahtar sözcükler: Beyin felci/rehabilitasyon; çocuk; özürlü- ation; exercise therapy; muscle, skeletal; physical therapy mo- lük değerlendirmesi; egzersiz tedavisi; kas, iskelet; fizik tedavi dalities; range of motion, articular. uygulamaları; hareket açıklığı, eklem. Pediatric rehabilitation is defined to improve the habilitation process requires several disciplines to independence level of a disabled child functionally come together. In this process, inter- and intradis- and psychologically, in the physiological, anatomic, ciplinary communication is a necessity and every and environmental restrictions and to increase the discipline should act according to the needs of the quality of life of children and their families.[1] Re- child and family.[2-4] Correspondence / Yazışma adresi: Dr. Mintaze Kerem Günel. Hacettepe Üniversitesi Sağlık Bilimleri Fakültesi, Fizik Tedavi ve Rehabilitasyon Bölümü, 06100 Sıhhıye, Ankara, Turkey. Tel: +90 312 - 305 15 77 / 154 e-mail: [email protected] Submitted / Başvuru tarihi: 15.01.2009 Accepted / Kabul tarihi: 19.03.2009 © 2009 Turkish Association of Orthopaedics and Traumatology / © 2009 Türk Ortopedi ve Travmatoloji Derneği 174 Acta Orthop Traumatol Turc The World Health Organization (WHO) estimated causing activity limitations, that are attributed to non- the disability ratio in developing countries as 12%. It progressive disturbances that occurred in the develop- has been reported that 6 million disabled people live ing fetal or infant brain.[8] The motor disorders of CP in Turkey. In our country, there are 25 million children are often accompanied by disturbances of sensation, in the 0-18 age group, of which 3 million are disabled perception, cognition, communication, and behavior, children between 0-16 years of age.[5] In terms of quali- with epilepsy, and with secondary musculoskeletal ty of life and deficiency, rehabilitation targets should be problems.[12] The estimated prevalence in the general determined exactly, problems identified, the outcomes population is 2/1000.[13] The limitations in activity re- interpreted, and regular follow-ups questioned.[6] quire individual rehabilitation throughout life.[14] Im- In our opinion, rehabilitation terms about chil- paired control and coordination of voluntary muscles dren have quite various definitions in Turkey, which is accompanied by mental retardation or learning dis- should be clearly defined in order to establish proper abilities in 50 to 75% of children and by speech disor- approaches. The use of terms in accordance with the ders (25%), auditory impairments (25%), seizure disor- [14] accepted situation of children is quite as much im- ders (25-35%), or abnormalities of vision (40-50%). portant as established medical definitions. The defini- In Turkey, the prevalence of CP is higher than most tions that are used or ought to be used in our country developed countries. Various reasons to explain this should be generated through interdisciplinary collab- include poor perinatal care, high rates of postnatal oration and taking the opinions of the handicapped maternal diseases and infections, malnutrition, and a children and their families. high rate (25%) of consanguineous marriages.[15] This If we define impairment, disability, and handicap latter factor is increasing and causes, predictably, as to the problems of disabled children; impairment higher numbers of children born with recessive con- [16] defines the primary lesion and pathology, such as the ditions, many of which have associated disabilities. problem with the brain that causes spasticity, and in- In our previous study on rare disorders, we found cludes the direct effects of spasticity, such as a dislo- that 90 (40%) of 226 had first-degree, and 27 (12%) [17] cated hip caused by the spastic muscles;[7] disability had second-degree consanguineous marriage. The [18] is used to express loss of function that an individual prevalence of CP in Turkey is 4.4/1,000 live births. experiences because of impairment; therefore, the in- Damage to the central nervous system cause dis- ability to walk or sit well is a disability arising from orders in neuromuscular, musculoskeletal, and senso- the impairment.[8] Handicap is the result of limita- rial systems.[19] These disorders result in posture and tions imposed by the environment and society, which movement deficiencies. Functional independence lev- limits an individual having a specific disability.[9] els of these children are affected negatively due to Another significant classification that has been put secondary disorders such as various musculoskeletal forward in recent years is the International Classifica- deformations and tertiary disorders due to different tion of Functioning, Disability and Health (ICF).[10] compensation mechanisms that develop over time. Al- For rehabilitation professionals, the complex relation- though the damage is not progressive, manifestations [6,14,20] ship between disability, participation, and environ- of deficiency and disability may be progressive. ment represents an area of specific importance for Finally, CP occurs as a developmental disor- children. The revised version of the ICF incorporates der.[8,21] The main problem in all types of CP is mo- biological and social perspectives on disablement, so tor disorders accompanied by sensorial and cogni- as to represent fully the impact of health on a person’s tive problems.[1,7,22] The causes of motor disorders are life, including participation in the community. Physi- developmental retardation, abnormal muscle tone, cal, social, and environmental factors, service systems muscle weakness, postural control deficiencies, sen- and policies may influence a person’s attitude to his/ sorial problems, behavioral problems, orthopedic her impairment or activity limitations.[11] problems, abnormal movement patterns and reflex activity, asymmetry and deformities.[3,6,13,23] The func- Cerebral palsy tions that a child with CP should gain following mo- Cerebral palsy (CP) refers to a group of permanent dis- tor developmental milestones are delayed related to orders of the development of movement and posture, the severity of the lesion. The persistence of primitive Kerem-Günel. Rehabilitation of children with cerebral palsy from a physiotherapist’s perspective 175 reflexes which should have been inhibited in the nor- processing skills needed for basic activities of daily mal developmental