INTERFENSI PADA

KASUS GANGGUAN
NEUROMUSCULAR
MENEJEMEN FT PEDIATRI
EARLY SIGN & SYMPTOMS
 Muscles are Hypertonic (stiff)

Muscles are Flaccid (soft)

 The child is slow to hold up
his head, to sit, or to move
around.
 He may not use his hands. Or he
only uses one hand and does not
begin to use both.
 Feeding problems
 Her body may stiffen when she is
carried, dressed, or washed, or
during play. Later she may not
learn to feed or dress herself, to
wash, use the toilet, or to play with
others. This may be due to sudden
stiffening of the body, or to being
so floppy she 'falls all over the
place'.
 The baby may cry a lot and seem very fussy or
'irritable'. Or she may be very quiet (passive) and
almost never cry or smile.
 Communication difficulties The baby
may not respond or react as other
babies do. This may partly be due to
floppiness, stiffness, or lack of arm
gestures, or control of face muscles.
Also, the child may be slow in beginning
to speak. Later some children develop
unclear speech or other speaking
difficulties.
 Intelligence Some children may seem dull
because they are so limp and slow
moving. Others move so much and
awkwardly they may appear stupid. Their
faces twist, or they may drool because of
weak face muscles or difficulty
swallowing. This can make an intelligent
child appear mentally slow.
About half of the children with cerebral
palsy are mentally retarded, but this
should not be decided too soon. The child With help and training, some children who
needs to be given help and training to have been considered retarded prove to be
show what she is really like. Parents can quite intelligent.
often tell that she understands more than
she can show.
 Hearing and sight are sometimes
affected. If this problem is not
recognized, the family may think that
the child lacks intelligence. Observe
the child carefully and test him to find
out how well he can hear and see.
TUJUAN
Relaxing muscles

Training in movement which encourages normal body postures

Facilitating development of delayed milestones

Training in activities of daily living. This involves working closely and effectively with the
child, mother and family (Occupational therapy + Physiotherapy)
Developing normal muscle tone and bulk (avoid disuse atrophy)

Good handling is the basis of ALL training suggestions. It makes it

easier to care for your patient.
 Lifting a Child with Abnormal
Muscle Tone
 Handling to Encourage: To
relax a spastic child: Twist the
childs body from side to side
as shown. Twisting can also
be done while the child is
lying. For a bigger child,
straighten his/her knees by
putting your legs over them.
 Positions that keep the hips and
knees bent and knees separate
help relax and give better control
to a child with cerebral palsy
whose body straightens stiffly and
whose knees press together
 child with cerebral palsy stiffens as you pull his arms, try pulling the
shoulder blades forward as you lift him up.
 Press down on the shoulders and tilt the head forward
 Bring both arms forward. Press on the chest to tilt the head
forward.
 Hold the shoulders and lift slowly. Turn child to one side as you lift.
This helps bring head forward.
 Lying face down is a good
position for a child to begin to
develop control of the head,
shoulders, arms and hands,
and also to stretch muscles in
the hips, knees, and
shoulders. However, some
children have difficulty in this
position.
 Twisting, or rotation of the upper body on the lower body,
must be learned before a child can learn to crawl and later
to walk.
If the child has spasticity, you may need to help position this
arm before she can roll over.
 If the child is very stiff, before
doing other exercises or activities,
first help to relax him by
swinging his legs back and forth,
or curl up the child in a 'ball' and
slowly roll his hips and legs from
side
 Activities to help develop gripping, reaching, and hand-eye
coordination
 CAUTION: In a child with spasticity, stroking the back of the
hand may cause her to grip or open the hand stiffly without
control. If so, do not do it, but look for ways that give her
more control.
 place an object in her hand, and bend her
fingers around it. Be sure the thumb is
opposite the fingers

Gradually let go of her hand and pull the

object up against her fingers or twist it
from side to side.

When you think she has a firm grip, let go.

Repeat several times in each of the child's
hands.
 At first a child can only grasp large objects
with her whole hand. As she grows she will
be able to pick up and hold smaller things
with thumb and. Help her do this by playing
with objects of different sizes. Fingers

To help strengthen grip, play 'tug-of-war' with

the child - making it a fun game.
 hand-eye coordination
 Activities for body control, balance, and sitting
 In order to sit well a child needs to be able to hold her body up, to
use her hands to catch and support herself, and finally to balance
with her body so that she can turn and reach.
 If the child simply falls over when you sit him up, help him develop a protective reaction with his
arms. Put him on a log, hold his hips, and slowly roll him sideways. Encourage him to 'catch'
himself with a hand.
Or do the same thing with the child on your belly.
 After the child learns to 'catch' herself when lying, sit her up, hold her above the
hips, and gently push her from side to side, and forward and backward so that she
learns to catch and support herself with her arms.
CAUTION: The child must be able to raise and turn her head before she can raise her
body.
 To help your child gain
balance sitting, first sit her on
your knees facing you.
Hold her loosely so her body
can adapt to leaning.
 Later, you can sit her facing out
so that she can see what is
going on around her.
Slowly lift one knee to lean her
gently to one side. Then the
other, so that she learns to bend
her body to stay seated.
 As he gets better balance, move your
hands down to his hips and then thighs, so
that he depends less on your support.
Give him something to hold so that he
learns to use his body and not his arms to
keep his balance.
 With an older child who has
difficulty with balance, you can
do the same thing on a 'tilt
board'.
At first let her catch herself with
her arms.
 Later, see how long she can do it
holding her hands together.
Make it a game.
 Note: You can also do these exercises by sitting
the child on a table and gently pushing him
backward, sideways, and forward. But it is
better to tip what he is sitting on.

Pushing him causes him to 'catch himself'

from falling with his arms.
Tilting him causes him to use his body to keep
his balance, which is a more advanced skill.
 Help the child learn to keep her
balance while using her hands and
twisting her body, sitting on the
ground, and sitting on a log or seat.
When the child can sit by herself,
help her learn to sit up,
from lying on her back, From lying on her back. As
the child starts to rise, push on the higher hip

and from lying on her belly. From lying on her belly.

First help her lift her shoulders.

Press down and back on hip. Press down and back on

hip. Help her roll to one side, rise onto one elbow,
and sit.
Activities for creeping and crawling

To move about, many babies first begin to

creep
and then to crawl
or to scoot on their butt

Note: Some babies never crawl but go directly from sitting to

standing and walking. Whether or not they crawl often
depends on cultural patterns and whether the family
encourages it.
 If the child can lift her head well when lying on her
stomach, encourage her to begin creeping in these
ways:
Put a toy or food the child likes just out of reach.

At first it may help to support his feet.

CAUTION: If the child has cerebral palsy,

supporting the feet may cause legs to straighten
stiffly. If this happens do not support her feet.
 To straighten the back, hold him/her around the hips. Press down. If
he/she is very floppy, support the chest with one hand. Press down on
the lower back with your other hand
 To support his/her sitting, hold
around his/her shoulders. Press
them down and in to bring the
arms forward. When his/her
sitting is steady it is easier for
him/her to look and listen.
If the child can lift his/her head
when lying on his/her stomach,
encourage him/her to begin
creeping in this way:
 Put a toy or food the child likes just out of reach. At first it may help to
support his feet.
 If the child cannot bring his/her leg forward to creep, help
him/her by lifting the hip
If the child has difficulty in beginning to creep or crawl
 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.
 Or put the child over a
bucket or log. To help
him/her bear weight with
his/her elbows straight,
firmly push down on
his/her shoulders and
release. Repeat several
times
 Move the child from side to
side so he/she shifts weight
from one arm and leg to the
other. Encourage the child to
first reach, and later crawl, for
something he/she wants.

If the baby has trouble

beginning to crawl, hold
him/her up with a towel as in.
As he/she gains strength,
gradually support him/her less.
 To encourage the child to crawl you can suggest these exercises.\

Moving Around: Pull to Stand: When pulling to stand, children need to lean
well forward. Often they push back and this will make standing difficult. To
move from sitting to standing correctly:
 Step One: Place his/her feet flat and underneath the knees. Press
down on the knees while the child leans forward.
 Step Two: As he/she stands,
support his/her chest and
knees.
DO NOT LET HIM/HER LEAN
BACK
 Step One: To move from
kneeling to standing, press
down on one knee. Keep the
other knee well back while
he/she leans well forward.
As he/she stands support
his/her chest.
 Step Two: 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.
Position when standing: Children with delayed standing can benefit from standing
supported in a good position. Many children will need equipment to be able to stand.
Local artisans can make the equipment shown in Figs. 20.55 to 58 if directed by a
therapist. Practise standing when washing, dressing, and playing.
Standing encourages the muscles that hold the body up to work. It prevents
contractions and strengthens leg bones. The child has his hands free for play, can
see and can communicate more easily with others.
Good Standing: Body in a straight line and feet flat with equal weight on both.
 If the child needs support to stand and his/her body is bent,
or he/she cannot keep his/her heels on the ground, use a
forward lean stander.
 If he/she needs less body
support, use an upright stander.
Make sure the upright poles are
pushed well into the ground or
fix them to a large square base
for use indoors.
 Various ways a child can practice getting balance on knees
 When a child begins to stand,
support the hips with your hands.
Spread his/her feet apart to form
a wide base. First do this from in
front, later from behind. Move
him/her gently from side to side,
so that he/she learns to shift
his/her weight from one leg to the
other.
 Or have the child hold a hose or rope. Because it is flexible,
he/she needs to balance more
 To encourage a child to pull up to standing, put a toy he/she
likes on the edge of a table
 Home made pushcarts or walkers can provide both support and independence for a
child who is learning to walk or who has balance problems.
After training in movement skills, the next important activity is self care because the
ultimate aim of rehabilitation is to help a child with cerebral palsy become
independent and as self reliant as possible.
 Your child may find it easier to use a
chair for support while dressing.
Dressing: If your child has learned to
dress him or herself, he/she may
need to hold onto things or lean
against a wall for support. He/she
should dress himself or herself while
lying, kneeling or sitting. He/she can
choose the position that is easiest.
 A corner potty can be built that
provides support for your child
Rods are used to keep the legs
apart. A pear-shaped seat hole is
better for boys.
 If squatting balance is poor, give him/her a stick to
hold and a wooden wedge or two bricks to sit on.
Opportunities to Play: Like other children, a child
with cerebral palsy should be given an opportunity
to play. See Fig.20.70. This can be done by:
Designing some of the rehabilitation activities in
the form of games or play
Using brightly coloured toys

Encouraging games with normal children.

After each treatment or rehabilitation session, the

therapist should always design a follow up home
programme for the mother or carer for continuity.
 Rehabilitation exercises can be
designed in the form of games
and play. Likewise, play with
other children benefits the CP
child socially and physically.
While in play, the CP child can
practice walking, improve his/her
balance, step up and down, and
integrate with other children.
 More examples of how a CP
child can combine
rehabilitation with play and
self-help exercises.
Activities for communication and speech

A normal child's ability to communicate develops

through these stages:
expresses needs through body movements, looks on
the face, and crying

makes 'happy sounds'-coos and gurgles

 babbles-listens to sounds and tries to
imitate

says a few words

 begins to put words (and ideas)
together
SPECIAL PROBLEMS IN SPEECH DEVELOPMENT
CAUTION: If the child's mouth hangs open and she drools, do not
keep telling her to close it! This will not help and will only
frustrate the child.

Stroke or tap the upper lip, or gently press the lower lip several
times
 Or, gently stretch the lip muscles. This may help the child to
close his mouth.

To strengthen the tongue and lips, put honey or a sweet,

sticky food on the upper and lower lips. Have the child lick it
off.

You can also put sticky food on the inside of the front teeth
and roof of the mouth. Licking this food helps prepare the
tongue for saying the letters T, D, N, G, H, J, and L.
 Also have the child lick sticky food from a spoon and lick or
suck 'suckers' and other foods or candies.
Play games in which you have the child:
 Encourage mouthing and chewing on clean toys (but
not thumb sucking).

Help the child discover how to make different sounds

by flapping her lips up and down with your finger,

You can help the child make different sounds by

pushing on and jiggling his chest.
 Have him repeat sounds that require jaw
movement.

When the child has difficulty pronouncing

words, do not correct her. Instead, repeat the
words correctly and clearly, showing that you
understand.
 Both boys in these
pictures are doing
the same learning
activity. For one, it is
play. For the other, it
is not. Can you say
why?
If the child is at the level where she sits, but finds it hard to keep
her balance or open her knees, look for play that helps her with
these.
If in preparation for standing and walking the child needs practice shifting
weight from one knee to the other, you might try imitation games. Here
are 2 ideas:
TOYS TO DEVELOP A CHILD'S MIND AND HAND-
EYE COORDINATION
Learning to fit things into things
Start simple-dropping objects into a jar, then taking
them out again.

As the child develops, make things more complex,

Note: Rings can be of different sizes, colors or

shapes so that the child can also learn to match
these.
 To help develop controlled movement of the
hands and arms, the child can move beads
or blocks along a rod or wire.

Using animals or funny figures makes the

exercise more fun. Other children will be
more likely to join in the game.
Matching games
The child can match objects of similar shape, size, and color.

Small pegs glued onto cut-out pieces help develop fine hand
control.
 Start with simpler games with
square or round figures.