CP-Care - Module 1 - Prevention of secondary problems

IO2 Module 1
Prevention of Secondary
Problems
CP-CARE - 2016-1-TR01-KA202-035094
(01.12.2016 – 30.11.2019)

Unit 1 – Principles of Prevention

 Principles
◦ Facilitation of the normal motor development
 Knowledge of typical development is essential to
compare the atypical development of children
with CP at all stages of their development, but
even more so during the early stages where
impairments are often not so evident.

 Principles
 Spotting developmental delays in 5 domains
◦ Gross motor skills, such as crawling and walking
◦ Fine motor skills, such as stacking blocks or colouring
◦ Language skills, including speech and comprehension
◦ Thinking skills
◦ Social interaction

Milestones
•Smiles at the sound of your voice and follows you with their eyes as you move around
a room2 Months
•Raises head and chest when lying on stomach; Grasps objects; Smiles at other people3 Months
•Babbles, laughs, and tries to imitate sounds; holds head steady4 Months
•Rolls from back to stomach and stomach to back
Moves objects from hand to hand6 Months
•Responds to own name
Finds partially hidden objects7 Months
•Sits without support, crawls, babbles "mama" and "dada"9 Months
•Walks with or without support; Says at least one word; Enjoys imitating people12 Months
•Walks independently, drinks from a cup, says at least 15 words, points to body parts18 Months
•Runs and jumps
Speaks in two-word sentences; Follows simple instructions; Begins make-believe play2 Years
•Climbs well; Speaks in multiword sentences; Sorts objects by shape and colour3 Years
•Gets along with people outside the family; Draws circles and squares; Rides a tricycle4 Years
•Tells name and address; Jumps, hops, and skips; Gets dressed; Counts 10 or more
objects5 Years

 Principles
◦ Regulation of the muscle tone
•Muscle tone regulation helps to maintain
normal posture and to facilitate movement.Muscle tone
•When a muscle stretches, the neuromuscular
system may respond by automatically altering
muscle tone.
•This modulation of the stretch reflex is
important in the control of motion and
balance maintenance.
Stretching
muscle
•Proper muscle tone when bending an arm
requires the bicep to contract and the triceps
to relax.
•When muscle tone is impaired, muscles do
not work together and can even work in
opposition to one another.
Proper muscle
tone

 Principles
◦ Carrying and lifting principles
 Great care must be taken when picking up
and carrying the cerebral palsied client.
 Extra care should be taken when lifting the
client who has little or no head control,
remembering that good handling of the
shoulder girdle and arms makes it easier to
control his head.

 Correct ways to carry a CP affected client

 Wrong ways to lift a CP affected client

 Correct ways to lift a CP affected client

 Principles
◦ Feeding and Nutrition
 Individuals with CP frequently have feeding and
swallowing problems that may lead to poor
nutritional status, growth failure, chronic
aspiration, esophagitis, and respiratory
infections.

 Principles
 A number of feeding and oral-motor intervention
strategies have been developed to address
difficulties with sucking, chewing, swallowing
and to improve oral-motor skills, including oral
sensorimotor management, positioning, oral
appliances, food thickeners, specialized
formulas, and neuromuscular stimulation.

 Principles
 These interventions address different aspects of
feeding difficulties, reflecting the range in specific
problems associated with feeding and nutrition in
patients with CP.

 Different strategies
•Seek to strengthen oral-motor control and
counteract abnormal tone and reflexes to improve
oral feedings and typically require months of daily
application.
Sensorimotor
techniques
•Address poor postural alignment and control that
exacerbates swallowing difficulties and include
stabilizing the neck and trunk.
•Positioning interventions are individualized and often
guided by videofluoroscopy to optimize swallowing.
Positioning
techniques
•Have been used to stabilize the jaw and improve
sucking, tongue coordination, lip control, and
chewing.
Oral appliances

◦ Multiple approaches may be used in children with
growth failure, including sensorimotor stimulation,
positioning, food thickeners, and caloric
supplementation.
◦ For children with moderate to severe aspiration or
malnutrition related to oropharyngeal dysphagia and
gastroesophageal reflux (GER), surgical interventions
with gastrostomy (tube feeding directly into the
stomach) or jejunostomy, tubes and antireflux
procedures may be necessary to improve nutritional
status and reduce risk of chronic aspiration.
◦ Harms associated with feeding interventions have
not been thoroughly reviewed, and significant
concerns have been raised about potential serious
harms related to surgical interventions, including
new or worsening GER, risk of aspiration, and
mortality.

Analytic framework for feeding and nutrition interventions in CP, adopted and
modified from https://effectivehealthcare.ahrq.gov/topics/cerebral-palsy-
feeding/research-protocol/.

 Principles
◦ Communication, attachment and behavioural
attitudes
 Communication
◦ children and adults with severe speech or language
problems may need to find other ways to communicate.
There are many types of AAC (Augmentative and
alternative communication), which can be found at
http://www.eastin.eu/en/searches/products/list?freetex
t=aac (see module 3, Unit 2 for more information)
 Attachment
◦ The emotional bond between mothers and children is
affected by the severity of CP.
◦ A client with CP may not be able to signal the need for
physical proximity or closeness in a conventional way
due to motor, sensory or cognitive deficits.

 Behavioural attitudes
◦ Behavioural therapy empowers the individual in:
 Responding to challenging situations in a more effective and
acceptable manner.
 Completing task
 Delaying gratification
 Developing friendships
 Excelling academically
 Finding acceptance
 Gaining perspective
 Managing emotions
 Maintaining focus
 Obtaining coping skills
 Overcoming emotional trauma
 Reducing anxiety
 Resisting temptation
 Resolving relationship conflicts
 Treating depression

◦ Anger
◦ Aggression
◦ Anti-social
behaviours
◦ Anxiety
◦ Appetite loss
◦ Change in sleep
patterns
◦ Depression
◦ Difficulty in
performing tasks
◦ Distress
◦ Feelings of
helplessness
◦ Frustration
◦ Irritability
◦ Isolation
◦ Loss of interest
◦ Low academic
performance
◦ Moodiness
◦ Peer rejection
◦ Social-emotional
deficiencies
◦ Whining
Signs to look for in the client

 Principles of home based training
◦ A sample for daily care and training plan
 Care and training plan goals
◦ Manage primary conditions
◦ Prevent and manage complications, associative
conditions and co-mitigating factors
◦ Control pain
◦ Optimize mobility
◦ Maximize communication
◦ Maximize learning potential and special education
opportunities
◦ Encourage social and peer interactions
◦ Foster self-care and promote life skills
◦ Maximize independence and Self-Sufficiency
◦ Enhance quality of life and well-being

 A plan of daily care and training is a roadmap that
will improve a client’s physical, developmental and
psychological development
◦ Use a spreadsheet program
◦ In vertical cells, layout the tasks/needs related to the daily
care and training
 The daily care and training plan should not be rigid
◦ In horizontal cells, put the days of the week
◦ Then assign them per day (and per hour if needed)
◦ It must be flexible to insure the safety and well being of
your loved one. If it’s not working, you must be willing to
modify the plan. Flexibility, creativity, and adaptation, are
all key to success.
◦ Review and update the care plan regularly
◦ Per activity, an average time should be assigned

Activities of daily
living
Who will perform them
with client?
Time Monday Tuesday ...
Getting out of bed Mum 07:00 x x
Refresh pamper Mum 07:10 x x
Getting dressed Mum 07:20 x x
Feeding Dad 07:30 x x
Physiotherapy Dad 08:00 x x
... ... ... ... ...
Visit to physiotherapist Mum & dad 15:00 x

References
1. WebMD, https://www.webmd.com/parenting/baby/features/is-
your-baby-on-track#1
2. Bar-On L, Molenaers G, Aertbeliën E, Van Campenhout A, Feys
H, Nuttin B, et al. Spasticity and its contribution to hypertonia
in cerebral palsy. Biomed Res Int (2015) 2015:1–
10.10.1155/2015/317047,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306250/
3. http://www.eastin.eu/en/searches/products/list?freetext=aac

Unit 2 – Prevention of musculoskeletal
disorders for the personal assistants /
caregivers / physiotherapists

 Identifying problems and implementing
solutions for lifting and repositioning
◦ Basic biomechanical principles for prevention of
overuse
 Prevention of back and neck (biomechanical)
problems

Basic biomechanics rules should be adopted. Try to
carry the weight near your body as much as you
can.

 Relaxing
1
•All handling must start with the client in a relaxed position. All movement
must be done slowly.
2
•To rotate the trunk, gently push the client's shoulder forward with the
palm (not fingertips) of your hand. Do both shoulders to bring hands to
the midline. This technique can also be used to open a clenched fist.
3
•To open a clenched fist, you can gently push down on the top of the
client's clenched hand with the open palm of your hand.
4
•To flex a client's head, gently push forward from the crown of the head,
never the neck.

1. Be close to the client in all transfers
2. Use all your body parts, instead of using just the
hands to move the client
3. If the client is too heavy, ask help from others

 Lifting
1
• Bend your knees and keep your back straight or even slightly
hollow.
2
• It is sometimes easier to pick the client up with one foot
slightly in front of the other one.
3
• Hold the client as closely to your body as possible before
lifting.
4
• Lift by using the strong muscles of your legs, and not your
back
5
• If your client becomes much bigger and heavier, preferably do
not lift her alone, but ask someone to help you.
6
• If lifting with another person, count before lifting so that both
people lift at the same time.

 Positioning
1
• Whether in a wheelchair or at a desk, the client should be
positioned symmetrically.
2
• Pillows or bolsters made from rolled up towels or diapers are
used to support the trunk and to centre the client in the
chair.
3
• Feet must be supported, never left dangling.
4
• children should be secured in wheelchairs with a standard
seat belt.

 Positioning
1
• Tying children into chairs restricts mobility of the upper torso, constricts breathing,
and poses a safety hazard in the event the client must be removed from the chair
quickly (e.g., fire).
2
• The position must
• (a) be comfortable for work and learning,
• (b) minimize balance difficulties,
• (c) enable use of the hands to the best advantage,
• (d) be the easiest for eye-hand coordination. (see images next slide)
3
• A lap board not only helps keep the client in position, but provides a working
surface on which to place instruments and books.

 Repositioning
1
• Helpful start to move/reposition client
• If she is stiff you need to loosen her first.
• You can’t force her into a position, and expect her to stay there.
2
•Try to get your client into the best position that you can
•Aim for ‘ideal positions’.
•She may not be comfortable in a new position at first.
3
•Change her position often, about every 30 minutes
4
•Encourage her or help her to change her position herself.
•Remember, if you leave a client in one position for many hours, she may
develop pressure sores and her body may gradually stiffen into that
position which will increase her disability.
•She needs to be placed in a variety of helpful positions throughout the day.

 Carrying and holding
Small children without braces can be
carried most easily in a way that
allows arms and legs to be controlled
from flinging.
Pick up the client from behind,
positioning your arm under the hips
so that the client's knees can bend
over it.
Hold the client close to your body so
that you can wrap your other arm
around the client's shoulders to
control arms that are likely to fling
outward when the head is turned.

 Lap sitting
• You can face the client away from you,
supporting the back with the trunk of your
body.
• You can seat the client facing you with legs
on either side of your hips.
2 ways to hold a small
client in your lap for
rocking, swaying, and
so forth.
• Lay client on his/her back on your
outstretched legs.
• Slowly bend your knees,
• Gradually bring the client to a sitting
position, again with legs on either side of
your hips.
• The client's back and head are supported by
your thighs.
• Control arms from the shoulders if needed.
If sitting on the floor,
you can get the client
into this position...

 Motor skill assistance
◦ When a client who is hemiplegic uses a good hand to
reach out and grasp (e.g., an instrument or beater), the
arm on the affected side of the body is likely to react by
flinging up or clenching the fist.
 To relax, turn the arm out and up at the shoulder,
keeping the elbow straight and the palm up and open. If
the client uses the open palm for support, it will help to
maintain this position.
 Practice movement patterns that will be required before
giving the client an object or instrument for
manipulation. This helps the client to control muscle
function and reduces the tension brought on by the
excitement of the activity.

◦ Some children, such as those with
athetosis, (i.e., athetoid) have
involuntary movements that
interfere with motor responses.
 Chances for success are enhanced by
providing stability, such as holding the
client's legs together as she or he
plays an instrument (e.g., resonator
bells). This makes it easier for the
client to hold head and arms steady
and will improve the ability to grasp
and manipulate an instrument.
 In handling an instrument or other
object to a right-handed client,
approach directly in front but just to
the left of midline (just to the right,
for a left-handed client). It will then
be unnecessary for the client to turn
his or her head, which can cause
extension and involuntary
movements.

 Prevention of associated
movements
◦ What is an associated
movement
 Involuntary and unnecessary
contractions of muscles that
are not related, during a
movement.
 E.g. writing with sound side
while spastic movement with
other side
◦ How to prevent
 Physical therapy is used to
improve posture and
prevent contractures via
braces and casting.
 BUT: in some cases,
immobilization of limbs can
induce peripherally induced
dystonia.

◦ Usage of technological support for lifting and
repositioning
◦ Paediatric repositioning devices
◦ focuses on supportive equipment to help children to get
into proper position to accomplish activities such as
eating, sleeping, writing, reading, drawing, and toileting
◦ a "side layer“ is shaped like a couch, and angled in such
a way that when the client lays on it, the base cradles
the client
◦ additional positioning kits to allow for side-lying, prone
(facing downward), supine (face up), long leg sitting,
log roll sitting
Go to: Module 3

 Stand assist aids
◦ standing equipment
 Slings
◦ sling seat
 Mobility
◦ wheelchairs
◦ adaptive tricycle (for
therapeutic cycling)
◦ stool scooters (including
for gait training)
◦ car seats
◦ stair glides/elevators
◦ mechanical lifts

◦ Problems for lifting and repositioning
 Lifting
◦ Causes mothers back pain of various location and
intensity, with intensity determined by:
 the client's locomotor skills and independence level
 the necessity of lifting the client several times a day
 the number of additional tasks performed by the mother
 the age and body weight of the client
◦ Importance of correct lifting procedure
 Repositioning
◦ Lack of repositioning can cause pressure areas,
contractures, deformities

 How to lift, carry, hold, and position a client and
learn to control any muscle stiffness or
uncontrolled muscle movements
◦ the best way to handle a baby or young client depends
on age, type of CP and how the body is affected
◦ try not to move the client suddenly or jerkily, the
muscles may need time to respond to changes in
position.
◦ some children’s muscles tense (spasm), let muscles
tense and relax in their own time – don’t force
movements.
◦ fear can make muscle spasms worse, so give the client
as much support as is needed when you are handling
the client, being careful not to give more support than
the client needs.

◦ whatever the size or level of
impairment, make sure that the
client spends time in different
positions.
◦ try to position the client so he can
see what is going on around him.
◦ many physically disabled children
are greatly advantaged by properly
fitting and supportive seating.
◦ feet should be flat on the floor,
knees bending at right angles, with
hips firmly against the back of the
seat. (some children benefit from
chairs with arms).
◦ some children are particularly
sensitive to losing their centre of
gravity during rapid growth spurts
and they can become clumsier and
may be more disorganised.

References
1. Palmer FB, Hoon AH (2011). Cerebral palsy. In M Augustyn et al., eds., The
Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for
Primary Care, 3rd ed., pp. 164-171. Philadelphia: Lippincott Williams and
Wilkins.
2. Kıymet Muammer, Rasmi Muammer, Rasmi Muammer (2009). Pulmonary
Rehabilitation and Encountered Difficulties In Disabled children. Yeditepe
Medical Journal 2009;(11):220-226
3. WebMD, https://www.webmd.com/parenting/baby/features/is-your-baby-
on-track#1
4. https://www.cerebralpalsy.org.au/what-is-cerebral-palsy/how-cerebral-
palsy-affects-people/
5. Bar-On L, Molenaers G, Aertbeliën E, Van Campenhout A, Feys H, Nuttin B,
et al. Spasticity and its contribution to hypertonia in cerebral palsy. Biomed
Res Int (2015) 2015:1–10.10.1155/2015/317047,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306250/
6. Krzysztof, Czupryna & Nowotny-Czupryna, Olga & Nowotny, Janusz. (2014).
Back Pain in Mothers of Cerebral Palsied children. Ortopedia, traumatologia,
rehabilitacja. 16. 497-505. 10.5604/15093492.1128840,
https://www.ncbi.nlm.nih.gov/pubmed/25406923

CP-Care project partners
 Gazi University (Turkey)
 PhoenixKM BVBA (Belgium)
 Bilge Special Education And Rehabilitation
Clinic (Turkey)
 Spastic children Foundation Of Turkey
(Turkey)
 Serçev- Association For children With
Cerebral Palsy (Turkey)
 Asociacion Espanola De Fisioterapeutas
(Spain)
 National Association Of Professionals Working
With People With Disabilities (Bulgaria)

CP-CARE curriculum, learning material,
handbook by www.cpcare.eu is licensed
under a Creative Commons Attribution-
NonCommercial 3.0 Unported License.
Based on a work at www.cpcare.eu
Permissions beyond the scope of this
license may be available at www. cpcare.eu
This project (CP-CARE - 2016-1-TR01-
KA202-035094) has been funded with
support from the European Commission.
This communication reflects the views only
of the author, and the Commission cannot
be held responsible for any use which may
be made of the information contained
therein.

CP-Care - Module 1 - Prevention of secondary problems

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