Every child who comes for therapy will be assessed individually. Exercises for children are varied based on their diagnosis, and in neurological impairment. The rehabilitation program is set up according to their age group of development as well as the severity of the in impairment. The physiotherapist will implement the treatment plan only after detail assessment and discussion with the orthopaedic consultant together with the parents or child’s caregiver during the medical case review.

PHYSIOTHERAPY PROGRAM

STRETCHING:

Stretching of muscles is done by moving the arms or legs in a way that produces a slow, steady pull on the muscles to keep them loose with suitable fixation. The child is grasped by the therapist and moved in such a way that a sustained stretch can be applied to the contacted structures for a period of time within a functional pattern of movement. Steady and sustained stretching is used to overcome Spasticity pattern, Contracture, and Deformities of limbs. 

POSITIONING: 

The body is placed in a specific position to attain long stretches. Positioning can be done in a variety of ways, including: bracing, abduction pillows, knee immobilizers, wheelchair inserts, sitting recommendations, and handling techniques to minimize unwanted tone. 

BREATHING EXERCISE AND POSTURAL DRAINAGE: 

Breathing exercises are taught either to improve chest expansion or to obtain better relaxation of the thorax. Exercises such as diaphragmatic breathing, localized breathing, chest percussion, vibration and modified postural drainage technique

STRENGTHENING: 

Strengthening exercises work specific muscle groups to enable them to support the body better and increase function. Strengthening exercises can be carried out by applying resistance either manually or mechanically. The equipment or tools such as dumbell, theraband, sand bags, weight, pulley, static bicycle, treadmill, trampoline and so on are commonly used. Exercises will be prescribed by Physiotherapist according to the individual patient’s need.

MOBILITY AND GROSS MOTOR FUNCTION: 

This includes large muscle group, active, inactive, outdoor, indoor and daily living activities. Functional re-education which includes Creeping, Crawling, Sitting (learning to sit with arm support), Sitting to kneeling (learning to kneel from sitting using active muscle work), Kneeling to standing (learning to stand from kneeling position using the wall bar) and Standing (learning to stand by grasping on to the ladder/ parallel bar and rails).

BALANCE EXERCISE: 

Balance training can be implemented in any position based on the individual’s problem. Some of the children might not be able to maintain side lying, kneeling, four-point kneeling or even sitting position. The Physiotherapist will guide the various techniques that can be practiced and combined with the games to attract child maintain in desired position and thus improve their balance. Playing in standing position has many purposes, in addition to strengthen the legs’ muscles, it also help the child to gain active control of her trunk and hopefully the child will be able to maintain standing without support within the targeted time frame.

GAIT TRAINING AND AMBULATION: 

The Physiotherapist will give the child equivalent chance to exercise as adult but surely within their capability using walking aids such as rollators, crutches, tripods and sticks. Walking in the parallel bars with obstacles to enhance the balance dynamically & strengthen the muscles of lower limb. The walking ladder is beneficial for children with adductors spasticity to help them control the scissoring gait. Walking on the treadmill to increase the endurance of individual child as a preparation for outdoor ambulation. 

HYDROTHERAPY : 

The therapeutic effects of exercises in water relates to :

1. the relief of pain and muscle spasm
2. the maintenance or increase in rang of motion of joints
3. the strengthening of weak muscles and an increase in their tolerance to exercise
4. the re-education of paralyzed muscles
5. the improvement of the circulation
6. the encouragement of functional activities
7. the maintenance and improvement of balance, co-ordination and posture

In addition, water provides the potential for exercises in three dimensions which cannot be achieved on land. More information page 29

HYPPOTHERAPY : 

The important factor that hippotherapy (therapeutic horseback riding) offers is it teaches a skill while at the same time helps the rider to stretch, strengthen muscles and reduce spasticity. The rhythm of riding helps to relax the body and improve balance and co-ordination. A good riding program will have save, gentle horses, provide riding helmets, assist with getting off and on the horse/pony and provide a handler for leading and attendant walking on alongside the rider. These are special horses with a special attitude, many of these horses know that they have to ‘take care’ of the rider.

HOME MANAGEMENT PROGRAM: 

The success of the home management program would not be achievable without the parents’ compliance to practice the exercises at home. Continuous exercises at home are substantially advised to prevent the contracture in CP children, and help the child to master and competent in carrying out daily self-management of functional skills within the targeted time frame. Home exercise program is fostered to each parent or caregiver through advice and demonstration by Physiotherapist on how they should commit the exercises correctly at home following prescribed repetition or reasonable duration.

ROUTINE ACTIVITIES

• Morning exercise - Every morning except Friday, almost every child is encouraged to participate in this activity.
• Exercise therapy - ccording to the timetable, each student receives therapy once in a week.
• Mobility program - Every Wednesday the children will be divided into small groups based on their age, ability and severity. Average number of children will be 15 in each group.
• Hippotherapy - Every Monday at Pasir Pelangi Riding (Horseback riding) School. This activity is carried out class by class basis with maximum 6 children.
• Hydrotherapy - Every day according to the timetable. (Aquatic therapy) Maximum 10 children involved in therapy.
• Out-patient therapy - Everyday afternoon and Friday morning.
  

HYDROTHERAPY

ADVANTAGES & THERAPEUTIC AIMS OF HYDROTHERAPY 

1. To develop head control in all directions.
2. To reduce Spasticity, maintain normal tone and muscle power.
3. To improve and maintain the range of movements of the head, trunk and all four limbs.
4. To encourage balance, co-ordination and postural reactions.
5. To develop body image and awareness.
6. To develop awareness of skills of daily living.
7. To improve respiration and breathing control.
8. To improve gait.
9. To increase mental adaptability.
10. To develop rhythmical movement towards independence. 
    

CARE OF THE PATIENT

During Hydrotherapy sessions, ensure the following conditions are observed:

1. WARMTH

• The pool should be kept at a temperature between 94 degree F and 100 degree F. This will vary with local conditions and the type of case. For instance, a patient with a Spastic paralysis should be treated in warmer water than is necessary for a fracture case.
• The hall or room enclosing the pool should be well aired but draught free.
• Corridors and dressing-rooms should be at a temperature of 70 degree F. and cooling-room for sitting in after dressing should not be higher than 65 degree F.
• There should be a plentiful supply of hot sheets and towels in which to wrap the patients after treatment.
• Bathing-costumes, dressing-gowns and washable slippers should be provided.

2. DISINFECTION

• There should be adequate disinfection and filtration of the pool. The department floor and duckboards should be washed with disinfectant daily.
• Precautions against Tinea Pedis should be strictly observed. This fungoid disease is highly contagious. It first appears between the toes, where the skin splits and irritates. No one should go bare footed until they have walked through an antiseptic foot-bath.

3. SHOWERS

• Shower baths or rose-spray douches should be available for the patients before and after treatment.

DURATION OF TREATMENT 

• Pool treatment may last from 5 to 30 minutes. Five minutes is often enough for the first treatment, bearing in mind that the patient may be undergoing an entirely new experience. 
• The patient may enter the pool by means of a gantry, by being adopted, the immersion should be gradual, and the physiotherapist should watch for any embarrassment of the circulatory or respiratory systems. 
• A short first treatment to create confidence is a valuable prelude, but once the patient is accustomed to the water, the length of the treatment varies according to the pathological condition of the patient and the length of time he has been on treatment. 

CONTRA-INDICATIONS

Patients suffering from the following conditions should not be treated in the pool:

1. Any febrile condition.
2. Certain cardiac disabilities.
3. Some pathological conditions of the chest.
4. Some kidney conditions.
5. Advanced debility.
6. Markedly high or low blood pressure.
7. Infective skin conditions.
8. Open wounds. These may be effectively treated in a separate saline pool.
9. Incontinence.
10. During menstruation.