PEDRIATRIC REHABILITATION

Assignment submitted to Dr. Zeest Hashmi

Submitted by Maira Pervez

Write down the home plan you recommend

to mother/care taker of a C.P hemiplegic
child?
Introduction: -
The most common type of cerebral palsy is
spasticity. This classification is given when muscles
are overactive and display a “stiff” or “tight”
quality, which impedes normal or smooth,
controlled movement. When only the leg and arm
on one side of the body are affected by spasticity,
this is referred to as ‘spastic hemiplegia. . Spastic
hemiplegic cerebral palsy is the mildest form of the disorder as independent walking, speech and
normal intellectual capacity is present
The main goals of therapy for children with cerebral palsy are to improve function
and ultimately participation in society. Motor learning and development takes place by
repeating a task several times and in various environments
For this reason therapists have been prescribing home programs to caregivers to
practice tasks done in therapy at home. 
Home programs, are therefore, a treatment strategy whereby therapists and the family
work together to design a specific set of activities that work on pre-established goals for the
child. The activities are performed by the family in the home setting

The use of a home program has many benefits for both the family and the
child

 A home program may improve functional outcomes in the child as it encourages

opportunities for repeated practice
 In many setting, especially in 3rd world countries, resources are limited, there are too
few therapists, clinics are inaccessible to families and there may be long waiting lists
for children to receive therapy
 By introducing a home program some of these constraints may be lessened as the
parent becomes an active participant in the child’s therapy.
 Parents become active participants in their child’s therapy. This in turn helps to
improve the knowledge of their child’s condition and interactions within the family
may also be improved upon
 Caregiver strain may be decreased.

 Physical gains, such as improved muscle strength

 Activity gains, like learning to get dressed independently
 Participation gains, such as meaningful inclusion in a local community sporting team
  Environmental adaptations, such as positive change in parenting style to manage a child’s
behaviour
 Personal gains, such as practising a goal that will enhance pleasure in life.

Are Home programs effective?

  Two studies have recently showed significant improvements in function with home
programs. A pre-test posttest designed pilot study by Novak, Cussick and Lowe, 2007 found
significant improvements in PEDI scores, GAS goals and in upper limb function after
administering a home program in 20 children with cerebral palsy.

Features of a good home program

Home programs should “be sensitive to family direction, daily routine,

resources as well as the attributes of the child and the potential capacity of the family to
enhance competency for caring. They need to be well designed, appropriately implemented,
and effectively evaluated”
Home programs should be incorporated into the daily routine of the family and the
child. The program needs to be easy for the caregiver to carry out.  It is important that
therapist allow mothers to observe them handling the child and in turn the therapist should
also observe the mother performing some of the activities. The therapist should encourage
the mother and provide positive feedback
A model for designing and implementing a home program

Novak has suggested a model for use for designing a home program for a child with
cerebral palsy
Phase 1: Establish a collaborative role with the caregiver.

Phase 2: Establishing mutually agreed upon goals.

Phase 3 Selection of therapeutic activities

Phase 4 Implementation of the home program

Phase 5 evaluating the program

Recommendations for a home program:

Home programs are usually completed over six to 12 weeks. The amount of time will
depend on the recommended intensity of the intervention. It can range from as little as one hour
per week to 15 hours per week. Some experts recommend home programs are carried out, on
average, four times per week for 15 minutes per session, making a total dose of one hour per
week. However, families planning to implement intense, contemporary intervention approaches
designed to encourage movement and neuroplasticity gains (for example, constraint-induced
movement therapy) will need to consider committing more time. The recommended time for this
type of intervention will be more like seven to 14 hours of weekly practice over a six to eight-
week period.
CHILDREN WITH SPASTIC HEMIPLEGIA

Impairments and activity limitations:-

 Tight and stiff arm and leg on one side of the body
 Unable to use arms in playing activities
 Walks with a limp
 Holding one hand in a fist

 Balance and walking difficulties

 Issues with fine motor skills and daily living tasks
 Developmental milestone delays
 Favoring one hand over the over
 Muscle stiffness on one side of the body
 Weakness on one side of the body
 Problems with limbs positioning properly while walking
 Jerky, shaking muscles
 Poor seating positions
 Contractures

Goals

 Educate child’s mother about positioning and give home plan

 The tightness must first be reduced in his arm and hand
 Then we can try to get him to move his tight arm and hand in a limited no of activities
 Home plan:-

Reducing tightness

1. Positioning to reduce tightness

 Lying on abdomen

 Children who have difficulty walking or who spend any

amount of time in a wheelchair are more likely to get
tight hips, knees and tummy muscles.
 They are also more likely to develop a rounded back (kyphosis and/or scoliosis) and often
their shoulders are forward and rounded.
 Being in a tummy-down position provides a stretch to the front of the hips, gravity helps
to straighten the knees and the back gets a lovely stretch away from being in a seated
position.
 Lying with arms up to the sides gives the shoulders a good stretch and keeping the face
turned to one side helps to give the neck a stretch.
 If your child is able to prop up on his or her elbows, their back will get even more of a
stretch but please don’t worry if they can’t manage it.

Important Tip: try to make sure your child is as straight as possible and not twisting one
way. Use cushions for support if needed.

 Lying on his back

 Put a pillow under babies head. Pull his hips down and curl up. Swings his legs side to side
keeping his hips and knee together. This is to get the muscles of his neck and back to relax.

 Lying on his sides.

1. Lengthen the sides:

Although one side is obviously so much tighter than the other side this must
be done to both sides. To lengthen the side and tight muscles on his side press
down through the shoulders and hips and gradually move your hands away
from each other. Stretch out the bottom leg and gently pull it, release and pull
again.

2. Rotate the sides :

Hold the hip and shoulder and move them alternatively and backwards and forwards.
This must be done slowly and the emphasis should be on moving both the shoulder
and pelvic forwards and not backwards.

3. Moving the shoulder :

Holding the scapula with one hand and supporting the arm with your
other arm, gently circulate the scapula moving it upwards and
forwards and then returning it to the midline. As the shoulder gets less
tight, the arm can be moved forward and up.

4. Weight bearing through the arm.

Bend the elbow so that the hand with open fingers can be laid flat on
the bed.The scapula must be held forwards and weight can be brought through hand and
arm by rocking his body forwards and backwards.

 Side sitting (weight bearing through the arm and hand)

1. Weight bearing through the tight side

This can only be done after he tightness in the hand and arm are
reduced, otherwise they will cause him a lot of pain. Weight bearing
through the arm and hand will further help to reduce the tightness in it.

2. Moving over the weight bearing arm

 Get the baby to reach for a toy with his other hand, on the side of the tight arm, so that he
turns and moves over his arm.

 Sitting

1. Sitting in a chair – clasping hands

To increase awareness of the limb and prevent soreness that may
occur due to floppy arm

2. Sitting at a table
Arms should be put on top of the table with the hand flat

3. Drinking
Child can use his/her tight hand to in a small way, to help him hold a cup
and drink

4. Walking
When getting the child to walk, hold onto his tight hand and pull it up , so
that is above his head with the hand facing inwards this will help prevent
limping

 Playing

Catching and throwing a ball, encourage him to use both hands

Playing with blocks encourage him to use both hands

2) Time on the tummy helps to develop head control and sitting balance

When your child lifts their head up to look around when they are
lying on their tummy, the muscles in the neck, shoulders, back, bottom and legs are all
being activated to get stronger.

These are the muscles that help to keep us up against gravity and are used during head
turning, rolling, sitting, crawling, standing and walking and when moving or transitioning
between positions.
 Being on the tummy helps children to learn to shift weight from one side of the body to
the other, right side to left side, forwards and back which is an essential part of developing
balance skills.

3) Tummy-down time helps with sensory development in so many ways: Touch and body
awareness

Being on their tummy provides your child with a different sensory experience.

The pressure of the floor on the front of the body helps to develop body awareness while
the different textures of the floor and blankets on the hands, face and other body parts
provides important touch (tactile) input.

Vision
When your child is on their tummy, they have to shift between looking directly down in
front to something across the room.

This helps to develop near and far vision and strengthens the eye muscles which makes it
easier to scan, focus and use both eyes together.

Speech and language

When your child lifts their head and looks around, they are stretching and developing
muscles in the neck, jaw and mouth which are important for speech and language and
other oral skills.

How to make tummy-down time work for your child:

 Make it part of the daily routine

 If you know that there is a possibility that your child may have any physical difficulties,
start incorporating the tummy-down position for play as early as possible. This way, it
becomes the ‘norm’ and a comfortable place for your child to be.
 Have a tummy time ‘tool box’.
 It can be uncomfortable for children to lie down on a flat surface right away. Make use of
wedges, cushions or rolled up towels to prop your child up under the chest so they are at
a bit of an angle. This makes it easier to lift up the head to look around and engage with
something in front of them.
 Use toys that are appropriate for your child and have them easily available to offer
distraction e.g. cause & effect, light toys, noisy toys, toys that feel great, books, puzzles,
building blocks etc.
  iPads (and other tablets), phones and other technologies are awesome for keeping older
kids in the tummy down position. Make it a rule that they can only play with them if they
do 20 minutes on their tummies first!
 The best tool to use is yourself

DEFORMITY PREVENTION

If the child has an urge to go backwards, position the child as shown below:

GOOD CARRYING POSITIONS

Carry the child like this, when his face is downward.

Position the child’s hips and knees bent and the knees separate while
carrying.
 Carrying baby like this frees his/her head and arms to move and look
around.

FACILITATE DEVELOPMENT OF MILESTONES

PRONE ON ELBOW

To encourage the child to raise his/her head when lying down, attract her attention with brightly
coloured objects that make strange or pretty sounds.

If the baby has trouble raising his/her head because of a weak

back or shoulders, try placing a blanket under his/her chest and
shoulders. Get down in front of him/her and talk to him/her. Or
put a toy within reach to stimulate interest and movement.

BRIDGING

Let your child lie down on his/her back, fold their knees, then
encourage your child to lift up his/her buttock.

ROLLING
Attract the child's attention by holding a toy in front of him/her, encourage the child to reach
sideways for the toy, then move the toy to one side, so the child turns his/her head and shoulders
to follow it. Then move the toy upward, so that he/she twists onto his/her side and back.

If he/she does not roll over after various tries, help the child by lifting
his/her leg.

SUPINE TO SIT

Do not pull the child up if his/her head hangs back.

If a child with cerebral palsy stiffens as you pull his/her arms, hold the shoulders and lift slowly.

QUADRUPED

Let him/her “ride” your knee. Play “horsy” and slowly move your
knee up and down and sideways so that he/she shifts his/her weight

from side to side .

KNEELING

After the child gets his/her balance on hands and knees, you can help
him/her begin to stand – and walk – on her knees.

SIT TO STAND
 Place the child in sitting position on a stool.
Hold the arms straight at the elbows with thumbs rotated
upward.
Slowly bring the body weight forward.
Bring the body weight up as you encourage the child to
stand.

STANDING PRACTICE

When standing, support him/her with your leg. Hold his/her hips straight and
forward over his/her feet. Sift his/her weight from side to side.

WALKING

Pushcarts or walkers can provide both support and independence for the child who is learning to

walk or who has balance problems .