ISSUE 25/ 2010 ROMANIAN JOURNAL OF PHYSICAL THERAPY

28
CONTRIBUTION OF NEURO-MOTOR REHABILITATION PROGRAMS IN
THE EVOLUTION OF CHILDREN WITH CP/HEMIPARESIS (STUDY N3)

CONTRIBUTIA PROGRAMELOR DE RECUPERARE NEUROMOTORIE,
IN EVOLUTIA COPIILOR CU PC/ HEMIPAREZ (STUDIUL III)

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1
assistant professor, PhD., University of Oradea, The Department of Theoretic, Medical and Physical Therapy Sciences
1
2
Main physical therapist, postgradate!
"
assistant, PhD. #andidate, University of Oradea, The Department of Theoretic, Medical and Physical Therapy Sciences

$
Main physical therapist, master, licensed therapist in %o&ta and 'o(ath concept, #linic )ospital of Medical *ecovery +
',ile -eli. Oradea. *OM/012

425 67,-%8 9:(!-,2$ 7(": CP
%",;2, <*'!("5 = !(=2, %"'"(9-;($2"(9
=*$9"($, :2+(>',2%(%

A1%",'9"3 4mphasi5ing the importance of
neromotric recovery programs in motric
ac6iring for regaining the ma&or hman fnction
7 the gait, and the fnctional independence of first
and second level 8according to Gross Motor
Function Classification System Expanded and
Revised GMFCS98:9
;e preferred to present the data in three separate
stdies 8in e.tenso9 (ecase of the large nm(er of
parameters stdied and (ecase <e <anted to offer
a generic pictre over the etiologic, clinical+
fnctional, developmental and recovery aspects.
;e evalated the motric and fnctional
ac6isitions of the children <ith #P hemiparesis,
sing the =ross Motor -nction #lassification
System 7 4.panded and *evised =M-#S 7 4 > *
88,?,1@,119 taAing into consideration varios ages.
;e o(tained an optimm fnctional tons of
attitde, (alance <ithin the agonist+antagonist
msclar chains and <e increased the msclar
force almost ade6ate to the particlar age 7
necessary in (asic daily activities 8'2DB9, and <e
also o(tained the instrmental ones 812DB9 <ith
fnctional amplitdes in &oints.
The applied methodology <as efficient in all
circmstances and for every e.perimental grops
of the "
rd
stdy, so that the e.perimental
C*?($"2 9:2(28 9>(! 9* >','!(&(2
92,21,'!@, 9'!("'"2' ?(2A((, =*$9A('
%"'"/;($2"(9@, :2+(>',2&@

R2&*+'"8 Pnerea Cn evidenD, a
programelor de recperare neromotorie, Cn
achi5iDionarea motric,, pentr recEFtigarea
fncDiei ma&ore mane, mersl (iped Fi a
independenDei fncDionale la nivele de 1 si 11
dp, (Gross Motor Function Classification
System Expanded and Revised GMFCS)(5)
Data fiind mltitdinea parametrilor stdiaDi Fi
pentr a ptea oferi o imagine de ansam(l aspra
aspectelor etiologice, clinico+fncDionale, evoltive
Fi de recperare, am preferat pre5entarea datelor
noastre Cn trei stdii distincte c rm,toarele
aparitii si pre5ent,ri 8 lcrare in e.tenso9.
Gn cadrl stdili am evalat achi5iDiile motorii Fi
fncDionale a copilli diagnosticat c P#1
hemipare5,, prin Sisteml de #lasificare a -ncDiei
Motorii =rosiere 4.tins, Fi *evi5it, 8=ross Motor
-nction #lassification System 7 4.panded and
*evised =M-#S 7 4 > *988,?,1@,119Cn fnctie de
diferite vErste din evidenDele Cnregistrate Fi
prelcrate.
S+a o(Dint n tons fncDional optim de atitdine,
echili(r Cn cadrl lanDrilor msclare agonist+
antagonist Fi am reFit s, de5volt,m o forD,
msclar, 6va5iadecvat, vErstei, necesare vieDii Cn
activit,Dila 5ilnice de (a5, 8'2DB9 Fi cele
instrmentale 812DB9 o(DinEnd Fi amplitdini
fncDionale Cn articlaDii.
VOLUMUL 25/ 2010 REVISTA ROMN DE KINETOTERAPIE
2?








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Purp!" # r"!"$r%&
The prpose is to emphasi5e the nero+motor reha(ilitation programs, in motor ac6isition,
in order to regain the ma&or hman fnction, t<o legged gait, and fnctional independence at levels 1
and 11 after 8=ross Motor -nction #lassification System 7 4.panded and *evised =M-#S98:9
Theoretical fndament, throgh metastdies regarding ischemic hemiparesis in children and motor
(ehavior matring.
#ongenital hemiplegia is one of the (est Ano<n forms of cere(ral palsy in infants (orn at
time and it taAes the first place among the cases of cere(ral attacAs 8stroAes93
The ischemic neonatal attacA incldes the ischemic arterial perinatal attacA! the assmed pre+
or perinatal attacA and sinovenos cere(ral throm(osis are important factors <hich determine
cere(ral palsy. The attacA indced (y tramatism is focsed and Aeeping the normal areas of the
(rain provides ni6e opportnities of plastic ad&stment. The implications of this essential
difference can also (e emphasi5ed from the discssion regarding the <ay in <hich epidemiology,
pathophysiology, diagnosis and the therapetic nero+motor programs after the perinatal attacA
connect <ith cere(ral palsy.
The days (efore and after (irth represent a period of special risA, for mother and child,
pro(a(ly connected to the activation of coaglation mechanisms form this critical period. The
ischemic arterial attacA arond (irth occrs in one ot of $@@@ children (orn in time, presenting
nerological and systemic signs in ne<+(orn children. 8H9 The neonatal crises are most often
encontered in clinical analyses. 1n other children, the attacA is recogni5ed only retrospectively,
after the onset of hemiparesis or of crises after the first months of life.
The risA factors for perinatal attacA inclde hereditary or gained throm(ophilia and
environment factors. The perinatal attacA is at the (asis of congenital hemiplegia, cere(ral palsy,
spastic tetraparesis and epileptic disorders. There is mch to learn a(ot the history of perinatal
attacA, as crrently there are no prevention or treatment strategies (ased on concrete evidence. 8The
fetal attacA occrs in the 1$th <eeA of gestation and at the onset of la(or. This article presents a fe<
cases of fetal attacAs diagnosed in+tero and the revie< of $I cases of fetal attacAs from the
specialty literatre, March, 2@@$. #alifornia @8H.I9
#hemical tramatism, the ne<+(ornJ (rain can (e deprived of o.ygen throgh t<o
mechanisms3 )ypo.emia 8decrease of o.ygen 6antity in the cere(ral (lood flo<9! 1schemia
8decrease of (lood entering the #.0.S.9! )ypo.ia generates the sffering of nervos cell <hich,
nder these prolonged circmstances, dies and (ecomes necrotic. #onse6ently, acidosis occrs,
determined (y the increase of #O2 concentration, fact <hich, in its trn, increases the venos stasis,
dilatation of the capillary, rptre possi(ility and, implicitly, the into.ication of the nervos cell.
O.ygen does not reach anymore in the in&red area <here the ischemic condition sets in.
Throm(osis of capillary vessels occrs, p to infarct, affecting a smaller or <ider area, sally <ith
diffse character <ith conflent tendinitis. Dring prolonged la(or, hypo.emia can occr nder t<o
aspects3 total acte asphy.ia, sdden and total interrption of O2 and #O2 e.changes (et<een
mother and fets. ;hen the dration of total asphy.ia is redced, most of the ne<+(orn children
investigation had significant reslts for the stdied
parameters.
The implemented and sed methodology <as
accepted (y the physical therapist and children.
The most significant reslts are in children of $ +
12 years, (ecase the progress and motric
ac6isitions after this age are slo< and scarce.

Metodologia aplicat, Fi+a dovedit eficacitatea Cn
toate sitaDiile Fi la toate eFantioanele stdili 111
astfel CncEt demersl e.perimental s+a soldat c
re5ltate semnificative la parametrii stdiati.
Metodologia de lcr implementat,, parcrs, Fi
e.ectat,, a fost acceptat, de copii Fi
Ainetoterapet.
ISSUE 25/ 2010 ROMANIAN JOURNAL OF PHYSICAL THERAPY
"@
srvive, (t they <ill later present permanent cere(ral lesions. Occrring rarely and only if the
mother sffers a sdden heart arrest, partial asphy.ia determines, first of all, lesions at the level of
the cere(ral trnA 8reversed as in the case of total asphy.ia9. The cere(ral lesion determining spastic
paralysis is often the reslt of an o(stetrical tramatism or of a nero+vasclar syndrome prodced
dring or after the head goes throgh the cervi. teri, therefore intrapartm. =iven the fact that
ano.ia and its effects appear after e.plsion, other athors consider these lesions as (eing postnatal.
)o<ever, most often it is demonstrated the idea that cere(ral lesion is not an effect mainly of
o(stetrical tramatism, (t an anatomo+pathologic fact (ased on certain pree.istent pathological
phenomena.
The postnatal 8postpartm9 phenomenon represents 1:K of the #.P. cases, either
immediately after (irth, or later in infant and child, (efore the 0.S. reaches matrity. 8H, I, 8, ?9.
Dring the ac6isition of nero+motor fnctions and (ehaviors, the evoltion occrs to<ards
progressive corticali5ation, <hich implies &oining the old strctres <ith the ne< ones, in a ne<
nit. #oncomitantly the fnctional hierarchy occrs in a s(ordination relation of the inferior
strctres compared to the ne< ones, (t also the dependency of the ne< strctres on the old ones.
Ths the child <ill not <alA (efore it manages to hold its head p or assme the sitting
position and it <ill not ac6ire these (ehaviors ntil the pyramidal fascicle has (een sfficiently
myelinated. Matring happens only nder the inflence of stimli from the e.ternal environment.
This stimlation mst happen dring a period <ell determined for each strctre, named the Lcritical
periodM. The mere presence of stimli from environment is yet not enogh, a response is also
necessary. 2ction is needed in order to ac6ire a motor (ehavior. There is an in(orn matring
potential <hich is not validated nless in the presence of stimli and actions 8", $, + Pas5tai N. 2@@$,
2@@?9. The motor (ehavior (ecomes matre slo<ly and se6entially. 2ction generates the feed+(acA
mechanism <hich leads to the ac6isition of fnctional atonomy. The first phase of psycho+genesis
is achieved dring the period of @+2 years old (eing constitted (y the Lsensorial+motor
intelligenceM. The ac6isitions dring one phase do not disappear, (t they are integrated into the
ne< fnctional model ac6ired, serving as (asis for interaction <ith environment. =enerally, <e se
five systems to determine the place <here or (ody is in relation <ith the environment and the
relationship (et<een all (ody components.
11. Material and methods
11.1. Theoretical methods3 theoretical research of sorces, concepts and conceptions, theoretical and
practical approaches of e.isting reslts. =athering and processing of epidemiological, demographic
data, evalation of risA factors, of ma.imm nero+motor fnction, all these have (een
accomplished transversally for each case.
11.2. Specific o(&ectives3 =iven the mltitde of stdied parameters and in order to (e a(le to
provide a general image of etiologic, clinical+fnctional, evoltional and reha(ilitation aspects, <e
preferred the presentation of or data in three distinct stdies <ith the follo<ing appearances and
presentations3
Stdy nO 1 7 title3 L#haracteristics and stadiality of nero+psycho+motor evoltion of children
aged @+1 according to the specialty literatre in *omaniaM, ta(le " 819.
The stdy 7 theoretical research of sorces, concepts and conceptions, of theoretical clinical+
fnctional and etiological approaches, descriptive and of transversal type, <as carried on in the
#linical )ospital of Medical *eha(ilitation+-eli. Spa, childrenJs <ard+1st of May Spa, dring the
period Octo(er 2@@8 7 March 2@@? and it initially inclded a grop of nP?21 cases, ot of <hich it
<as later selected a representative lot of nPHI$ children diagnosed <ith #P1Q4S1 and other
locomotor disorders, aged (et<een 1 and 18.
Stdy nO 2 7 contains the evalation and statistic processing of e.isting data a(ot the
children <ho (enefited of nero+motor reha(ilitation. 1t <as carried on in the #linical )ospital of
Medical *eha(ilitation+-eli. Spa, childrenJs <ard+1st of May Spa, dring the period Ranary 2@@? 7
VOLUMUL 25/ 2010 REVISTA ROMN DE KINETOTERAPIE
"1
-e(rary 2@1@! it is a stdy of longitdinal o(servational type, prospective, non+e.perimental
8descriptive9 and it inclded nP$@? children aged (et<een 1 and 12, diagnosed <ith 4S1Q#P1,
spastic form, selected from the anterior lot of nP?21 children 81+18 years old9, for <hich the
follo<ing parametric data from the data (ase <ere processed and it <as presented at the "rd 'alAan
Physical Therapy #ongress 829
Stdy nO " 7 contains the period -e(rary 1st+2pril "@th 2@1@, a nm(er of ":? patients
8-e(rary 2@1@ 72pril 2@1@9 and it is the ne.t step of a ne< selection and maAing p of H lots of
children according to the ageQdiagnosis criterion3 @+2, 2+$, $+H, H+8, 8+1@ and 1@+12 in implementing
stdy nO ". Ot of ":? s(&ects admitted in hospital, a nm(er of 2@" children aged (et<een @+12 are
selected for the stdy.
)ypothesis ;hich is the contri(tion of the nero+motor reha(ilitation program to motor
ac6isition according to =M-#S classification, in children <ith #P hemiparesis diagnosisS
4valation 7 ;ithin the stdy, <e have evalated the motor and fnctional ac6isitions of the child
diagnosed <ith #P1 hemiparesis throgh the =ross Motor -nction #lassification System 7
4.panded and *evised =M-#S 7 4 > * 88, ?, 1@, 119 according to the different ages from the
recorded and processed data.
1mplementation of the nero+motor reha(ilitation program
The fnctional nero+motor reha(ilitation and treatment tooA place dring the school
semesters in the physical therapy and gym halls and at the childrenJs homes dring holidays <hen
hydrotherapy <as mainly applied. Some e.ercises <ere made nder the form of a game! the
principle applied <as team+<orA <ith the physical therapists and "rd year stdents and master
stdents in physical therapy, 1st and 2nd year, from the University of Oradea.


R"!u'(! $)* *+!%u!!+)


I$"2,>,2"'"($ = %"*-5 $ 3 ,2%*!"%
T'1!2 $ )/ S"*-(2- %*1B29"% =,+ ":2 C!($(9'! H%>("'! = R2:'1(!("'"($-F2!(C S>',
9:(!-,2$D% 7',--)
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= M'5 S>'




Hemiparesis 67 patients 33,6%
Paraparesis 63 patients 31,2%
Tetraparesis 39 patients 18,7%
Ataxic-cerebellar sy 20 patients 9,8%
t!er "is#r"ers 1$ patients 6,7%
TTA%& 203 patients
'esearc! peri#" 01()ebr*ary - 30April 2010 +r#m a n*mber #+ 3,9 patients








ISSUE 25/ 2010 ROMANIAN JOURNAL OF PHYSICAL THERAPY
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VOLUMUL 25/ 2010 REVISTA ROMN DE KINETOTERAPIE
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Motor acquisitions between the ages of 8-10 year
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F+)$' %)%'u!+)!
1. The approach of this ">(9 <as imposed (y the necessity to (ring in discssion a reality
presented only vagely (y the specialty literatre!
2. 1n order to achieve the prpose and to confirm or hypothesis, that is to o(tain gro<th,
normal development and normali5ation of static+Ainetic fnction, it <as necessary for s to
emphasi5e the perseverant <orA in the field of edcation for movement, sing physical
therapy!
". Ths <e have contri(ted to the increase of these individalsJ 6ality of life. The physical
therapist sed the means <hich are most specific to this age, easily accepted and sed (y the
s(&ects in any location 8in classroom, at home, in the (atht( 7 hydro+stretching9.
$. Optimm fnctional tons of attitde has (een o(tained, (alance <ithin the agonist+
antagonist mscle chain and <e have managed to develop mscle strength 6asi+ade6ate to
the age, necessary in (asic daily activities 8'2DB9 and in instrmental daily activities
812DB9, also o(taining fnctional amplitdes in &oints.
:. The applied +2":-!05 proved its 2==(9(2$95 in all sitations and at all stdy samples, so
the e.perimental <orA had significant reslts in the parameters from stdies 1, 2 and ".
H. The implemented <orA methodology, follo<ed and applied, <as accepted (y children and
physical therapists!
I. 2melioration and decrease of symptoms regarding the tension, hyper tonicity+spasticity
condition!
ISSUE 25/ 2010 ROMANIAN JOURNAL OF PHYSICAL THERAPY
"$
8. O(taining 2==(9(2$" +*%9*!', 9$",! $ ":2 -5%=*$9"($'! +*%9!2% and even the
disappearance of dysfnctional condition in several children from the lot <ith hemiparesis!
?. 1ncrease of nero+motor performances regarding motor and msclar control of a(ility and
finesse in the lot <ith hemiparesis!
1@. the increase rhythm of all parameters is slo<er in the s(&ects aged 8, 1@, 12, (ecase of the
already onset pathologic msclar hyper tonicity and of more redced mo(ility in space, less
motor ac6isitions!
11. S"'1(!("5 = ",*$;->2!?(%-!72, !(+1% is o(tained (y all those <ho manage orthostatism and
alternative 6adrpedal <alAing variants!
12. I$-2>2$-2$" 7'!;($0, 6ite coordinated, is o(tained (y a nm(er of 2@ s(&ects ot of HI.
;e sggest indction as a sccessfl therapetic means for the ftre T the techniue of
muscle stretch stretchin! and techniues on the "i! #o"ath "all in the prophyla.is and
treatment of static+Ainetic dysfnction, from the age of $+12, as a ftre method <hich <ill
allo< the elimination or fast recovery of dysfnction, that is the normali5ation of the static+
Ainetic fnction at the age of H+12!
There are still ncertain ":2 (%%*2% = =("$2%% for these children for ":2 ($9,2'%2 = <*'!("5
= !(=2 ($ ":2 =*"*,2/ Therefore, these isses mst (e stdied, researched, re6iring a
separate e.perimental stdy.
Throgh '$ '-'>"2- >:5%(9'! '9"(?("5 >,0,'+ 82P29 this can also (e achieved in <ell
ad&sted and e.pensive locations.

R"#"r")%"!
1. PUs5tai N., PUs5tai 4lisa(eta, #hiriac M., 'ogdan *., Ver(esc #armen 82@@?9, +Studiu priviind
evaluarea neuro$psihomotorie a su!arului %ntre &$' an$, %ol. 1W, 1SSU4 2, 2@@?. (ournal #) *+
code, reco!ni,ed "y C-CS.S #ucharest, Romania. .SS- '**/$015+. 23.4.5S 5-.3ERS.67 8RESS.
Constanta9 <<<.analefefs.roQanale+fefsQ2@@?Q#O%4*K2@isseK2@2K2@2@@?.pdf
2. PUs5tai NoltUn, -,rc,Fan Monica, 2das Dmitr, #hiriac Mircea, 'ogdan *ad, PUs5tai 4lisa(eta,
#ristea 2ndrei, RaAa( 1stvUn82@1@9 XContri"u:ii la studiul ;.dentificarea momentului locomo:iei< %n
recuperarea neuromotorie func:ional=<-ormatori Cn Yinetoterapie stdii Fi cercet,ri al 111+lea
#ongres 'alcanic de Yinetoterapie, editra X%asile =oldiF University PressM2rad 1S'0 ?I8+?I"+
HH$+"?$+1, pg 1@$+11@ ,2@1@!
". PUs5tai, N., 82@@?9, +Rolul stretchin!ului %n normali,area func:iei stato$>inetioce$9 Editura Corson?
.a@i? p!A?**0)*1*9
$. PUs5tai, N., 82@@$9, +Binetoterapia %n neuropediatrie+, 4ditra 2rionda, =alaDi, pg. 11@, 12", 12I,
1"H!
:. *o(ert Palisano, Peter *osen(am, Stephen ;alter, 4llen ;ood,'ar(ara =alppi 82@@I9 +Gross
Motor Function Classification System Dev. Med. #hild 0erol.1@@I3"@321$+22", -.!
H. Yirton, 2., de%e(er, =.8 2@@H, 1nie9,8are,a cere"ral= secundar= atacului perinatal ischemic?
#anada!
I. 0elson, Y.'., Bynch, R.Y., 8Martie,2@@$9 Ctacul cere"ral infantil/,Maryland US2!
8. ZZ81??"9+8romotin! 4evelopment of 7oun! Children Dith Cere"ral 8alsy$, =eneva, ;orld )ealth
Organi5ation!
+A ZZZ 2merican Medical 2ssociation3 81??:9 Ghuids the Evaluation of permanent .mpairment? CMC9