뇌성마비 형태별 특징과 Bobath concept

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1 뇌성마비형태별특징과 Bobath concept

2 Bobath concept? CNS 손상, spinal cord. 뇌성마비및 CVA 치료시많이쓰임 과거계단식으로발달 현재는 interaction 발달, 종적인관계만은아니고횡적인관계이다 다양한변화를수용

3 Bobath concept? Facilitation Normal movement Normal postural reaction Equilibrium reaction Function skill preparation Inhibition Abnormal postural reflex Primitive reflex Uninhibited movement Undesired movement

4 Bobath concept? Normal Postural tone: 적당한 m. tone 유지 Reciprocal innervation: 주동근, 길항근의작용이정상적, 적절해야 Movement pattern: 관절움직임이각자필요로하게자유롭게, 섬세하게 total pattern <-> selective movement

5 Bobath concept? 평가자세긴장도자세패턴과움직임의패턴반사 Cf) Biomechanical FOR : CNS정상, motor unit, 질환, 병변 : 평가 : ROM, MMT, Endurance : RA,Burn,Amputation,Deformity

6 뇌성마비정의 Nonprogressive abnormalities in the developing brain that create a cascade of neurologic, motor, and postural deficit Persist disorder of movement and posture caused by nonprogressive defects or lesions of the immature brain Impairment of coordination to maintain normal posture, to perform normal movement 진행성병변혹은일과성장애는제외 유전, 전염, 진행되지않으며사망의직접적인원인이되지도안음 But chronic 장애가발생한시기제한 : 미성숙한뇌 만 3-5 세전, 후 : 현재는그개념을확대

7 뇌성마비의발생빈도 약출생아수 1000 명당 명 ( 미국 ) 남, 여의비율 = 1.4: 년도를기점으로발생빈도가점차감소하다가다시증가하는추세 : 조산아나저체중아의생존율증가 ( 중증복합장애가증가 ) 경직형이전체의 80% 이상

8 뇌성마비의원인 출생전모체감염 : 임신초 3개월동안일어난감염방사선노출약물중독 : 마약, 음주탯줄, 태반의이상임신중의무산소증임신중흡연혈액형부조화

9 뇌성마비의원인 출생시비정상적인분만분만중의허혈성뇌증 : 저산소증양수흡입호흡마비미숙아 : 2.5Kgdlgk / 저체중아 1.5kg / 초저체중아 :1.0kg 출생후뇌막염이나뇌염뇌종양두부외상 : 사고, 낙상뇌혈관질환

10 뇌성마비의원인 ( 조산 premature) 정의 : 37주이전 (26-32주) 에 1500g 신체상의특징 midline으로의자세경험부족 proximal part사용의경험부족자세안정성부족 원인원인미상 40% 자간전증 : 임산부고혈압, 부종, 경련, DM -> 태반산소공급장애분만전출혈, 자궁내감염, 자궁막자체파열다산임산부, 양수과다증, 자궁강이적은경우

11 뇌성마비의원인 ( 조산 premature) PVL(Periventricular Leukomalacia) 외측뇌실주변의혈액공급장애로인한뇌조직괴사 corticospinal tract. leg 해당부위손상 : diplegia optic tract 손상 : 눈움직임이상 associated area: perception 이상 IVH(intravenrticular hemorrhage) 뇌압상승시막의출혈 : 출혈, CSF침범, 뇌실비대

12 뇌성마비의원인 (asphyxia) (1) 혈압 & 혈류량증가로인한원인 1. Premature subependymal hemorrhage ( 뇌실막하출혈 ) - intraventricular hemorrhage 2. Term intraparenchymal hemmorrhage ( 뇌실질내출혈 ) (2) 혈압 & 혈류량저하로인한원인 1. Premature PVL 2. Term cortex, BG, pons, cerebellum

13 뇌성마비의원인 ( 핵황달 Kernicterus) Bilirubin 이가저핵 (basal ganglia) 에침착 무정위형뇌성마비발생

14 Classification 1) Spasticity severe, moderate 2) Athetosis athetosis with spasticity athetosis with tonic spasm athetosis with intermitten spasm dytonia pure choreathetosis 3) Ataxia 4) Flaccid child or hypotonicity

15 근긴장도 (muscle tone) 정상근긴장도란? 비정상근긴장도란? Hypertonus Fluctuation Hyponus

16 뇌성마비의 Distribution 에따른분류 (1) Quadriplegia - spasticity, athetosis (2) Diplegia - 하지손상이심함 - spasticity, ataxia (3) Hemiplegia - more affected side 있음 - spasticity, athetosis

17 뇌성마비의 Distribution 에따른분류 1) Quality of tone 2) Distribution of tone 3) Range of motion 4) Reflexes & reaction 5) Oral motor control

18 뇌성마비의의학적치료 Antispasticity oral medication:diazepan, balclofen, dantrolene, side effect Injectable agents: motor conduction control Neural block: disrupt reflex arch botulinum toxin: MN-junction block, 3-6m effects Orthopedic surgery: tendon release, tendon transfer Selective posterior rhizotomy(spr) 50% of dorsal roots at L2-S2, spastic diplegia, normal cognitive status, no fixed deformity

19 Guide to assessment General impression Abilities Disabilities Postural tone Postural pattern Associated problem Contracture & deformity

20 형태별특징및접근법

21 뇌성마비의임상증상 Severe spasticity 주동근과길항근모두과긴장 (hypertonus) 거의혹은전혀움직임보이지않음 장애부위의평형반응과정위반응결여 동반장애 : 호흡, 영양섭취, 배설, 순환, 정서적문제 임상증상 :Moderate spasticity - 생후 4 개월까지는경직분명하게나타나지않는경우많음 - 경직형패턴 : 비정상적인감각 - 운동경험이학습되어보상패턴사용으로강화됨 - 과긴간장도는상황에따라변하여예측가능함 - 구축발생위험높으며탈구용이 - 연합반응이강하게나타남 - 감각 - 운동경험부족으로인지장애및학습장애

22 Spastic: 경직성아동의신전패턴 Ataxia.gif

23 Quadriplegia 1) Severe Spasticity Micro-cephalus, hydrocephalus Visual(blindness), visual agnosia Hearing(deafness) Seizure ㆍFeeding problem ㆍKeep on crying Cyanosis-convulsion ㆍConstipation Irregular breathing ㆍsleeping disorder MR ㆍhypertonus ㆍco-contraction Great ganger of deformities Startle reaction-poor adaptation Right reaction ㆍno voluntary movement

24 Quadriplegia 2) Moderate Spasticity stability <-> mobility 상지를쓸수있도록개선하라 손을사용한다면안정성이있으므로 tone이감소 손을사용하지않는다면안정성이없으므로 tone이증가 Secondary spastic quadriplegia와구별 %%% SQ 와의차이점

25 Spasticity Diplegia 1) Inactive trunk Lack of sensori-motor experience If reinforces increasing tonus of the pelvis & leg and compensatory movement of hand and arm Poor arm & hand movement Poor concentration/ adaptation Insecurity 2) Hypertonus on pelvis & legs 3) Asymmetry due to different distribution of postural tone 4) Poor dissociation between pelvis & legs poor mobile with weight bearing 5) Contracture = poor biomechanical movement

26 Hemiplegia Spasticity Stability/mobility 에서모든 activity 는 proximal 에 coactivation 을시킴 Lack of experience(sensory & movement) Changing of direction Stability 를바꾸어줌 Cross over midline 반대쪽을 relax 하는데사용 좋은쪽을사용하는동안 affected side 를 associated reaction 줄이도록시키면서 relax(clam down) 상태에서사용하도록 AM 과 AR 을확인하면서치료

27 임상증상 뇌성마비의임상증상 Athetoid - 과긴장과저긴장이모두나타나며불안정하고비정상적인자세긴장도보임. 불수의운종나타남 - 안정성결여 - 단계적인근수축이나움직임조절결여 - 현저하게비대칭적인자세패턴 - 언어와호흡상이문제 - 청각문제 : 난청, 주파수결손 - 시각문제 : 시선고정, 독립적인안구운동어려움 - 감정조절불안정함 - 정위반응과평형반응결여 : 강직이강한경우

28 General feature Postural tone Athetoid fluctuating between hyper & hypotonus unsteady unsustained, poor cocontraction - Lack of fixation difficulty or instability of maintaining and posture skill, sustained(especially against gravity) no co-contraction lack of proximal stability - No or sufficient grading impaired reciprocal innervation - Breathing

29 General feature - Speech Athetoid 예측할수없음, 소리가폭발적 dysarthric: 호흡 & speech coordination 이나쁘기때문에 midline 이없어서사람과마주보며이야기할수없음 -> communication 에서좌절 - Oral motor 근육이짧아져있어서윗입술이내려올수없음 drooling - Hearing 들을수있으나집중이안됨 - Vision : fixation, nystagmus, dissociation; head & eye - Emotion: 폭발적, 움직임의형태 = speech = 성격 - Postural pattern: very asymmetry, poor alignment, total patterm, never learn midline orientation

30 Athetoid _Athetoid.jpg dwe00211g16.gif Ataxia.gif _Athetoid.jpg

31 Athetoid _Athetoid.jpg dwe00211g16.gif Ataxia.gif

32 뇌성마비의임상증상 Ataxia 자세긴장도낮은편이나중력에대한자세와운동조절가능 근위부의협력수축부족 운동의협조성저하 Tremor, truncal sway, dysmetria, nystagmus 부적절한평형반응

33 Ataxia 1. Postural tone-low 2. Postural stability poor coordination of movement 3. Distributed reciprocal innervation intension tremor, truncal sway, titubation of head Dysmetria, nystagmus, jerkiness of movement 4. Movement pattern appear to be normal Immature & total pattern Lack of selectivity Problem with grading

34 뇌성마비의임상증상 Ataxia low tone variety movement 성격 : 수동적 mass pattern grading excessive midline LOM x deformity & contraction x Dysmetria-direction speed timing head titubation intension tremor truncal sway

35 Ataxia Ataxia.gif

36 Ataxia Ataxia.gif

37 뇌성마비의임상증상 Flaccidity 자극의역치가비정상적인높음 두부의체간부조절결여 과도한관절가동범위 턱관절이나견괄절탈구주의 정서적으로온화하고조용하고수동적

38 Hypotonia 시간거의 sleep!! 2. 거의모든뇌성마비의 70~80% 는 hypotonia 로시작 3. Spinal, Muscular Dystropy 문제를가지고있는아이들 4. 가장민감한부위 : proximal, rib cage 가종이장같음 5. Stimulation:self-movement 가가장큰 stimulation(perceptual training)

39 뇌성마비의동반문제 1. Language & intellectual deficit %, elow average - speech disturbance 30% 2. Seizure disorder - 50% of CP, spastic type 3. Feeding problem - abnormal oral movement, tone, sensation - hypo, hyper touch to around mouth 4. Sensory deficits - impaired vision, hearing problem(35%), limit eye motor control, strabismus - visual perception poor(40-50%) 5. Behavioral problem

40 Type 별특징과치료원칙

41 치료의기본원리 - 정상적인긴장력 (Normal tone), 정상적인동작 (Normal movement), 정상적호흡 (Normal breathing), 정상적인언어 (Normal speech) 가형성되도록노력 - 뇌성마비어린이는한번도정상적인근긴장력에의한정상적인운동을경험해보지않았기때문에정상적인수준에이르기까지많은조정 (handling) 을받아가면서정상적인동작을습득 - 정상적인발달순서내에서운동숙련 (motor skill) 을촉진 (facilitation) - 환자가족이집에서도환자치료를계속할수있도록환자가족에대한교육 - 좀더정확한자세를획득하기위해서비정상적인자세반사를억제하고, 정상적인운동패턴을촉진하고, 자동정위반응과평형반응이발달될수있도록치료사가보조를줄여가면서보조나조절없이환자혼자서움직이게함 (Placing 과 Holding). - 과도한노력은비정상적인반사를유발하므로피해야함

42 Spastic quadriplegia Features: Great deal of exaggerated cocontraction Little or no movement Contractor tend to be more toward midposition Associated reaction are absent Associated problem breathing, feeding, speech Emotional very frightened, passive

43 Spastic guadriplegia Features: 1 Great deal of exaggerated co-contraction 2 Little or no movement 3 Contracture tend to be more toward mid-position 4 Associated reaction are absent 5 Associated problem breathing, feeding, speech 6 Emotional very frightened, passive Treatment principles: 1 강직의패턴을분석한다. 2 구축이나변형을최소 3 화서서히자극을주지만움직임을얻기위해서는많은자극이필요 4 두려움을줄이려고균형감각을준다. 5 자발적인움직임을촉진시킨다.

44 Spastic hemiplegia Feature: 1 처음엔양측성차이가많이안남 ( 생후 7~8개월부터나기시작 ) 2 한손만사용 3 감각자극을한쪽만받음 ( 실패, 좌절감 ) 4 한쪽을지나치게사용하면경기발병율높아진다. 5 건측으로마비쪽을보상작용 6 기형과구축 Treatment principles: 1 가장편안하고안정된자세에서치료를시작 2 Sensory input 3 Bilateral activity 4 마비쪽을지지해앉도록유도 5 양발에체중걸리어고루사용토록

45 Spastic diplegia Features: 첫 4개월에서 6개월동안에는정상처럼보인다. 앉기위하여머리와척추를앞으로숙여서고관절과슬관절의불충분한굴곡을보상해야만가능정위반응과균형반응이허리위에서만나타나기때문에과도하게사용하게될것이다. 하지의보상작용으로상체의움직임이많다. Treatment principles: 1 고관절운동의준비로양하지의긴장성을떨어뜨린다. 2 신체근위부에일을준다.

46 Athetoid Features: 1 불안정하게보이고자극에대한반응을예측할수없다. 2 감정변화가심하다 근육의긴장도가불규칙 Total pattern 감각예민 Treatment principles: 1 움직임을줄여라 2 과제를줄여라 3 Symmetry

47 Premature child Too adult Speech IQ Movement IQ GAP, 합리성 언어치료해야함 Compensatory by sppech: talkative

48 NICU(sensory infarction) 뱃속 incubator 따뜻 Noise: major stress 움직임이적음 Brightly light: 시각장애 부드러움 Body contact with hard surface 어두움 Frequency handling : 수천개의 sensory input Internal environment 안정성 (self-suffocation: 질식 ) Homeostasis Sleeping Rhythm Sleeping rhythm irregularly crying: main complains of the mother

49 Prematurity 로인한 delayed development child Features: 1 2 Incubator care-출생시부터인공적요소가많아사회성저해요소생김신체적무능과행동발달장애 3 시도능력떨어짐 4 정상적인긴장성을유지하기어려운문제점소유 5 엄마뱃속에서중심으로모으는경험을하지못함 Treatment principles: 1 하체움직여가운데로모으기 2 앉힐때도중간자세유지 3 복근강화 4 근긴장성높임

50 뇌성마비아동의 perception 문제 1. Presence of abnormal postural tone and patterns of movement -> disorded sensations and movements : sensory information limited- not clear disorganized abnormal lack of exploration-dullness -> limited experiences -> limited memory for comparision 2. Information processing disorder

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