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Vojta and Bobath combined treatment for high risk infants with brain damage at early period
NEURAL REGENERATION RESEARCH Volume 2, Issue 2, February 2007 Online English edition of the Chinese language journal
Cite this article as: Neural Regen Res,2007,2(2),121-5
Academic Discussion
Vojta and Bobath combined treatment for high risk infants with brain damage at early period Chunyan Wu1, Xiaohui Peng2, Xuesong Li3, Qingling Niu1, Hong Guo1, Huitao Huang1 1Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang Province, Daqing 163001, Heilongjiang Province, China 2Department of General Surgery, Daqing Oil Field General Hospital of Heilongjiang Province, Daqing 163001, Heilongjiang Province, China 3Department of Neurology, Daqing Oil Field General Hospital of Heilongjiang Province, Daqing 163001, Heilongjiang Province, China
Abstract BACKGROUND: In the process of early screening and interventions to high risk infants with brain damage, the occasion and choosing methods of interventions and the combined application of different interventions are still at the exploratory phase. OBJECTIVE: To observe the efficacy of early intervention using Vojta and Bobath combined treatment in high risk infants with brain damage, and investigate the effect of early rehabilitation on the prognosis. DESIGN: A randomized controlled comparative observation. SETTING: Daqing Oil Field General Hospital of Heilongjiang Province. PARTICIPANTS: Eighty-four high risk infants younger than 1 year were selected from the Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang Province from October 2005 to October 2006, including 52 boys (62%) and 32 girls (38%). The treatment started at the age of 03 months in 11 cases (13%), 46 months in 28 cases (33%), 79 months in 35 cases (42%), and 1012 months in 10 cases (12%). Infants with at least two of the followings were enrolled, including 7 Vojta abnormal postural reflexes, slow or disorder of motor development, increase of muscular tension, postural abnormality, primary reflection residual and CT/MRI abnormalities. Informed consents were obtained from their guardians. The 84 infants were randomly divided into treatment group (n =42) and control group (n =42). METHODS: All the children were intravenously injected with cerebroprotein hydrolysate injection or cattle encephalon glycoside and ignotin injection, 10 times as a course for 25 courses; Besides, the infants in the treatment group also received early rehabilitative training of Vojta and Bobath combined treatment, once a day, 40 minutes per time, 5 times a week followed by a 2-day rest, 1 month as a course, and totally 25 courses. The Vojta method was to facilitate the automatic regulation by reflexlocomotion. Bobath method was to inhibit abnormal posture but facilitate the normal one, thus it is also called neurodevelopmental therapy realized by reflex inhibition and facilitation. The rehabilitation was evaluated clinically using Gesell Development Schedules (GDS) after the courses when the infants were 1 year old. GDS included five aspects of adaptive behavior, gross motor, refine motor, speech, individual-social behavior. The developmental quotient (DQ) could be calculated according to their development. DQ=developmental age/actual age 100, < 85 points was taken as abnormal; The higher the DQ value, the better the development. Evaluation of efficacy: Cured: Developmental order reached normal or generally normal, abnormal posture disappeared, muscular tension ameliorated, symmetric limbs' motor function, free movement, normal intelligence, powerful reaction, and clear speech. Significant effect: Developmental order tended to normal, abnormal posture disappeared incompletely, muscular tension ameliorated incompletely, transient pause in the flexion and extension of limbs, good reaction, and improved intelligence. Effective: Developmental order improved to a certain degree, muscular tension ameliorated, limbs' motor function and posture improved as compared with before treatment, but still under control, intelligence improved a little. Invalid: No obvious changes before and after treatment. Total significant effective rate=(cured cases+cases of significant effect)/total cases 100%. The enumeration data and measurement data were compared with chi-square test and t test respectively. MAIN OUTCOME MEASURES: Clinical efficacy and GDS results at 1 year old in both groups. Efficacy: The total significant RESUTLS: All the 84 infants were involved in the analysis of results. 2 =4.2, P < 0.05). effective rate in the treatment group was higher than that in the control group (93%, 74%, Results of GDS evaluation: The DQ values of individual intercourse and social adaptation in the treatment group (93.57 11.23, 95.13 9.32) were higher than those in the control group (88.27 10.18, 90.10 10.67, t =2.267, 2.301, P < 0.05); The DQ values of gross motor, fine motor and speech in the treatment group (90.78 10.20, 98.63 9.23, 93.69 11.31) were higher than those in the control group
Chunyan Wu , Master, Associate chief physician, Department of Pediatrics, Daqing Oil Field General of Heilongjiang Hospital 163001, Province, Daqing Heilongjiang Province, China Wu CY,Peng XH,Li XS,Niu QL,Guo H, Huang HT.Vojta Bobath combined and treatment for high risk infants with brain damage at early period.Neural Regen Res 2007;2(2):121-5 www.sjzsyj.com/Journal/ 0702/07-02-121.html
Received:2006-10-20; Accepted:2006-12-10 (06-S-12-1197/SHM) Corresponding author:Chunyan Wu, Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang 163001, Heilongjiang Province, China E-mail: [email protected] Province, Daqing
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(84.32 11.33, 87.80 8.61, 85.52 10.61, t =2.746, 5.560, 2.746, P < 0.01). The interventional effects on each functional area were significant, especially the gross motor, fine motor and speech. CONCLUSION: The Vojta and Bobath combined treatment on the basis of drug therapy can improve the general developments of abilities in motor, intelligence, social intercourse, social adaptation and speech of high risk infants with brain damage, also can improve the curative efficacy. Key Words: brain injuries; cerebral palsy; rehabilitation
INTRODUCTION In recent years, the neonatal mortality is descending year by year with the development of perinatology and neonatal severe case technique. The infants of premature, low birth body mass, multiple fetuses and severe asphyxia can survive after emergency treatment, but they will suffer from brain damage induced neurological dysfunction, which can result in cerebral palsy, mental retardation, epilepsy, abnormalities of sensory perception and behavior, and it is the main cause for the disability in childhood. The early intervention to high risk children has become the urgent problem to be solved, and it has attacked the attentions of scholars of relevant subjects at home and abroad[1]. A great amount of foreign and national scientific studies have proved that early interventions has definite effect on children with brain damage[2]. Therefore, it is the important topic for perinatology and pediatrics to prevent and treat disability and improve the quality of life in high risk children by early evaluation of behavioral development, establishing proper intentional program and early interventions. However, the occasion and choosing methods of interventions and the combined application of different interventions are still at the exploratory phase. In this study, high risk infants were screened and given Vojta and Bobath combined treatment at early period, the follow-up data were also analyzed.
SUBJECTS AND METHODS Subjects Eighty-four high risk infants younger than 1 year were selected from the Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang Province from October 2005 to October 2006, including 52 boys (62%) and 32 girls (38%). The treatment started at the age of 03 months in 11 cases (13%), 46 months in 28 cases (33%), 79 months in 35 cases (42%), and 1012 months in 10 cases (12%). Inclusive criteria: Infants with at least two of primary reflection residual and CT/MRI abnormalities. Infants with progressive diseases were excluded, such as genetic metabolic disease. The main cause was premature in 21 cases, low birth body mass in 16 cases, hyperbilirubinemia in 9 cases, hypoxic-ischemic encephalopathy in 8 cases, asphyxia at birth in 6 cases, distress in uterus in 4 cases, pregnancy-induced hypertension syndrome in 2 cases, difficult labour in 2 cases, bigeminal in 2
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cases, and others in 14 cases. The 84 infants were randomly divided into treatment group (n =42) and control group (n = 42). There were no significant differences in the month age of infants, parental educational level, profession, family income, inhabited environment and constitution of disease between the treatment group and control group (P > 0.05), and they were comparable. Methods The infants were examined with cranial CT or MRI after admission, and the results showed that 53 cases were normal and 31 cases had imaging abnormalities, manifested by ventriculomegaly and broadening of sulcus fissure, hydrencephalus, softening of alba, intracranial hemorrhage, brain edema, etc. The muscular tension, abnormal movements and posture were evaluated, Vojta reflection, gross motor function assessment and CT assistant examination were also performed. All the children were intraveneously injected with cerebroprotein hydrolysate injection or cattle encephalon glycoside and ignotin injection, 10 times as a course, followed by a 20-day rest, totally 25 courses; Besides, the infants in the treatment group also received early rehabilitative training, which was mainly the Vojta and Bobath combined treatment, once a day, 40 minutes per time, 5 times a week followed by a 2-day rest, 1 month as a course, and totally 25 courses. The rehabilitation was evaluated clinically using Gesell Development Schedules (GDS) after the courses when the infants were 1 year old. GDS was used to assess the maturity of neurological development and mental development in children by five aspects, including adaptive behavior, gross motor, refine motor, speech, individual-social behavior, and it was suitable for children of 0 6 years old, and the developmental quotient (DQ) could be calculated according to their development. DQ=developmental age/actual age 100, < 85 points was taken as abnormal; The higher the DQ value, the better the development. Vojta method, also named as Vojta induction therapy, was summarized and established by Dr. Vojta (Germany). The Vojta method was to facilitate the automatic regulation or control of the body's position, to facilitate the active maintenance of the support function of the extremities, and to stimulate coordinated muscle activity by reflexlocomotion. Bobath therapy was the method to inhibit abnormal posture but facilitate the normal one, thus it is also called neurodevelopmental therapy realized by reflex inhibition and facilitation, including: Reflex inhibition: Inhibiting
Wu CY, et al. / Neural Regeneration Research,2007,2(2):121-5
extension and flexion postures. The former was suitable for infants with head dorsiflexion, ATNR shape of whole body and opisthotonus, whereas the latter for those with head anteflexion, spinal curvature, and flexion at bending hip and knees; Adjusting the key point: It could be adjusted at the specific site on the body of infants to alleviate spasm, as well as the maneuvers that could facilitate normal posture and movement; Facilitating postural reflex to induce the maximal potential of the infants without their overexertion, form the movement posture of functional activity, and learn and comprehend the experience, so as to reach the aim of treatment; Percussion was a facilitating maneuver to improve the muscular tension at certain sites of the infants, induce muscular tension by regular or random percussion at limbs and body, and maintain the normal posture of infants. Evaluating the efficacy The infants were self-evaluated according to the traditional 4-grade standard in combination with the improved degree of motor developmental order, amelioration of abnormal posture and muscular tension, and the intellectual improvement. Cured: Developmental order reached normal or generally normal, abnormal posture disappeared, muscular tension ameliorated, symmetric limbs' motor function, free movement, normal intelligence, powerful reaction, and clear speech. Significant effect: Developmental order tended to normal, abnormal posture disappeared incompletely, muscular tension ameliorated incompletely, transient pause in the flexion and extension of limbs, good reaction, and improved intelligence. Effective: Developmental order improved to a certain degree, muscular tension ameliorated, limbs' motor function and posture improved as compared with before treatment, but still under control, intelligence improved a little. Invalid: No obvious changes before and after treatment. Total significant effective rate=(cured cases+cases of significant effect)/total cases 100%. Statistical analysis The data were analyzed by the first author using SPSS 10.0 software, the enumeration data were compared with chi-square test, whereas the measurement data were compared with the t test. P < 0.05 was considered as significant difference, and P < 0.01 as very significant difference.
RESULTS Quantitative analysis of the participants Totally 84 infants with brain damage were enrolled, and all were involved in the analysis of results. Clinical effects (Table 1) Results of GDS evaluation(Table 2) Table 2 showed that the DQ values of the five functional areas in the treatment group were all higher than those in the control group, the interventional effects on each functional
area were significant, especially that there were very obvious differences in gross motor, fine motor and speech. Table 1
Group
Comparison of clinical effects between the two groups (n /%) Significant Effective effect
Cure
n
Treatment 42 31/74 42 12/29 Control a
2
2/5 5/12
8/19 19/45
Invalid
Total significant effective rate(%)
1/2 6/14
93a 74
=4.2, P < 0.05, vs. the control group
Table 2 Comparison of Gesell Development Schedules (GDS) scores between the infants at 1 year old (x s) Group
n
Gross motor
Fine motor
Treatment Control
42 42
90.78 84.32
98.63 87.80
t P
10.20 11.33
2.746 < 0.01
Group
n
Treatment Control
42 42
t P
5.560 < 0.01
Individual-social intercourse 93.57 88.27
9.23 8.61
11.23 10.18
2.267 < 0.05
Speech 93.69 85.52
11.31 10.61
2.746 < 0.01
Social adaptation
95.13 90.10
9.32 10.67
2.301 < 0.05
DISCUSSION High risk infants of perinatal brain damage refer to the neonates with various causes induced brain damage at perinatal stage, they might have high mortality and disable rate, and suffer from sequela of nervous system of different severity, and it is the main cause of disability in childhood. Especially that it has complex causes and various clinical manifestations, besides the nervous system of infants develops rapidly, and various abnormal and normal postural reflexes can occur alternately, which bring about certain difficulties for detection and intervention at early and ultra-early periods[3]. As the epidemiological study goes deeper, it has been proved that various brain damages are not only associated with perinatal factors, also have correlations with genetic susceptibility, amnionitis caused by congenital intrauterine infection at early pregnancy and the level of placentitis inflammatory factors[4]; size of uterus[5]; eNOS, F7, LTA, PAI21 and ADRB22 gene[6]; viral infection during pregnancy, especially the neurotropic herpesvirus[7,8], etc. Domestic and foreign data have shown that the incidence rate of cerebral palsy becomes higher as the pregnant week of the infants is fewer, the lower the body mass at birth, the higher the
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incidence rate, and it is higher in small for gestational age infants than in appropriate for gestational age infants[9-11]. Central nervous system has an important property of plasticity, which enables certain functional recovery after brain damage. It has been confirmed that[12] as compared with cats raised in standard surrounding, the body mass, brain mass, width and length of cerebral hemisphere, as well as cerebral angiogenesis, were all increased in those raised in rich surrounding. The nerve cells in human brain proliferate from 3 months of cyesis to 1 year after birth, after which they will not duplicate or regenerate any more, whereas the supporting cells that maintain the nutrition and conduction of nerve cells proliferate from late cyesis to 2 years after birth. Once the brain is damaged, the function can be recombined by early rich environmental stimulation and functional training[13-15]. The "nervous plasticity theory" in modern neurorehabilitation believes that the recovery of nerve function has two conditions[16]: The damaged nerve are not dead, and the After the death of the function can recover directly; damaged nerve, the axonal regeneration of central nerve cells, dendritic germination and synaptic threshold changing mechanism again form a network system of functional cell group in central nervous system, which realize the functional recombination, manifested by regional functional reconstruction in cortex, or the function is performed by distal cortex with similar function. The functional recovery of nerve cells is associated with brain plasticity, and the regeneration following brain damage depends on exercise training and activities[17]. Therefore, it is believed that the nervous plasticity theory is the theoretical basis for guiding the rehabilitative interventions of high risk infants. Many studies have confirmed that early rehabilitative treatment is effective for infants with abnormal development of physical ability[18]. Early screening and intervention are significant for high risk infants of brain damage. However, the occasion and methods of interventions and the combined application of different interventions are still at the exploratory stage. Parkes et al[19,20] treated infants with hypoxic ischemic brain damage by using comprehensive methods of drug, hyperbaric oxygen, limbs massaging, passive gymnastics, visual, auditory and tactile stimulations, etc., and found that the developmental quotient and intellectual index of the infants were obviously higher than those in the control group. Liao et al [21] observed that neurodevelomental therapy combined with hyperbaric oxygen was one of the effective methods for the early intervention of cerebral palsy. Satisfactory outcomes were also obtained from the comprehensive interventions of exercise developmental therapy and conductive education in addition to drug and hyperbaric oxygen[22,23]. Besides, the music and art therapies can be used in the training[24]. In this study, Vojta and Bobath combined treatment was applied on the basis of nutritional
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nerve cells for the early interventions. Vojta method induces reflex movement by compressing and stimulating the initiation zone of the infants, the repeated and regular appearance of the movements (time and spatial overlapping) promote the normal reflex pathway and movement, whereas inhibit the abnormal ones for treatment. At present, it is the main rehabilitative method for children with central coordination disorders used in most rehabilitation institutions in China[25]. Bobath therapy is also called neurodevelopment therapy. Bobath suggested two viewpoints: The damaged brain tissue during development leads to the developmental lag or retention of motor function that should develop normally. After brain damage, the inhibitory and adjusting functions of central nervous system are weakened, abnormal postures and movement occur. Once brain is damaged during the development, abnormal sensory-motor conduction appears between the brain tissue and surrounding, the infants can not experience the sense of normal movement because of the abnormal one, but experience the abnormal sensory-motor conduction continuously, and the abnormal posture and movement will stabilize after a long time, which will aggravate the conditions of the infants. The vicious cycle of the sensory-motor conduction is not interrupted, and the symptoms still progress. Therefore, according to the neurodevelopmental order of the infants, the techniques of inhibition, facilitation and percussion are adopted to inhibit abnormal posture and movement, and facilitate normal motor sense and mode. Reflex inhibitory posture is used in this inhibition, and key points are adjusted to promote normal posture, and it is one of the main therapies for cerebral palsy. Li et al[26] combined the Vojta and Bobath therapy with Shangtian method in the rehabilitative training of children with spastic cerebral palsy of different ages, and obtained satisfactory results. Our results also showed that there were satisfactory outcomes after interventions of Vojta and Bobath combined treatment for 25 courses. In the treatment group, the effective rate reached 98%, and the normalized rate reached 92.86%, which were significantly different from those in the control group (P < 0.05). GDS results at 1 year showed that the developments of the five functional areas in the treatment group were better than those in the control group, there were significant differences in individual-social intercourse and social adaptation, and very significant differences in gross motor, fine motor and speech. It was indicated that early interventions could promote motor development, also promote the comprehensive developments of intelligence, social intercourse, social adaptation and speech, also ameliorate the prognosis, which had laid good physical and mental bases for the infants to enter the society in the future. The signs of brain damage occur a little later, whereas the
Wu CY, et al. / Neural Regeneration Research,2007,2(2):121-5
parents can not find the abnormalities in time, thus it is very significant to follow up regularly, perform nervous system examination and GDS evaluation for finding infants with brain damage earlier and guiding the parents to give intervention pertinently, preventing and treating cerebral palsy and reducing disability rate. It is realized during the early intervention that it is the key point to enhance the management of high risk infants for the early detection of abnormalities, all the high risk infants should be enrolled in the follow up, especially that the infants with highly sensitive indexes[27-29] should be traced more closely. Besides, it is also concluded that the interventional effects can be affected by the followings: The degrees of the parents' realization and attention to the early interventions; Efforts should be made to enable the parents to cooperate and participate positively, and it is the crucial to persevere for the success. Time to start the early intervention; The earlier, the better. Duration and intensive of training. parental educational level, family environmental and economical conditions. In conclusion, early intervention to perinatal high risk infants can promote and ameliorate the recovery and development of their damaged nervous system, and the earlier the intervention begins, the better the results are[30]. It has been proved to be an economical and effective method to reduce and alleviate the incidence rate of cerebral palsy by the pertinent recovery of limbs' motor function based on the overall promotion of intellectual development in infants.
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Ogi S, Arisawa K, Takahashi T, et al. Mental effects of intervention program for very low birthweight infants. No To Hattatsu 2001;33(1):31-6 2. Jin HZ, Huang DM, Guan XJ. Practical Neonatology. Beijing: People's Medical Publishing House 2002;3:192-3 3. Mirmiran M, Barnes PD, Keller K, et al. Neonatal brain magnetic resonance imaging before discharge is better than serial cranial ultrasound in predicting cerebral palsy in very low birth weight preterm infants. Pediatrics 2004;114(4):992-8 4. Sundrum R, Logan S, Wallace A, et al. Cerebral palsy and socioeconomic status: a retrospective cohort study. Arch Dis Child 2005;90(1):15-8 5. Jarvis S, Glinianaia SV, Arnaud C, et al. Case gender and severity in cerebral palsy varies with intrauterine growth. Arch Dis Child 2005,90(5):474-9 6. Nelson KB, Dambrosia JM, Iovannisci DM. Genetic polymorphisms and cerebral palsy in very preterm infants. Pediatr Res 2005;57(4):494-9 7. Tang JL, Wang ML, Qiu JJ, et al. Building a mouse model hall marking the congenital human cytomegalovirus infection in central nervous system. Arch Virol 2002;147(6):1189-95 8. Gibson CS, MacLennan AH, Goldwater PN, et al. Neurotropic viruses and cerebral palsy: Population basedcase-control study. BMJ 2006;332(7533):76-80 9. Marlow N, Wolke D, Bracewell MA, et al. Neurologic and developmental disability at six years of age after extremely preterm birth. N Engl J Med 2005;352(1):9-19
10. Li S, Hong SX, Wang TM, et al. Premature, low birth weight, small for gestational age and childhood cerebral palsy. Zhonghua Erke Zazhi 2003;41(5):344-7 11. Stoll BJ, Hansen NI, Adams-chapman I, et al. Neural developmental and growth impairment among low birth-weight infants with neonatal infection. JAMA 2004;292:2357-65 12. Schrijver NC, Pallier PN, Brown VJ, et al. Double dissociation of social and environmental stimulation on spatial learning and reversal learning in rats. Behav Brain Res 2004;152(2):307-14 13. Bao XL. Early intervention in high risk infants and decreased incidence of cerebral palsy. Zhongguo Kangfu Yixue Zazhi 2005;20 6 :403-4 14. Ke QP, Wu YQ, Guo CF, et al. Effect of brain cell metabolic activator combined with rehabilitation training on the development quotient and the motor function in children.Zhongguo Linchuang Kangfu 2004;8(27):5924-5 15. Lin QJ, Chen WX, Chen JY, et al. Analysis of risk factors, evoked potential and brain CT in children with mental retardation and/or cerebral palsy: A retrospective study. Zhongguo Linchuang Kangfu 2004;8(12):2296-7 16. Vicari S, Albertoni A, Chilosi AM, et al. Plasticity and reorganization during language development in children with early brain injury. Cortex 2000;36(1):31-46 17. Wang BG, Wang SB, Guo YL, et al. The effect of early rehabilitation and its molecular mechanism on the functional outcome after focal cerebral ischemia penumbra in rats. Zhongguo Kangfu Yixue Zazhi 2004;19(3):196-9 18. Huang Z, Xi YC, Zhou CL, et al. Early intervention for high-risk infants of perinatal cerebral injury. Zhongguo Kangfu Yixue Zazhi 2005;20(6):426-8 19. Parkes J, Hill N, Dolk H, et al. What influences physiotherapy use by children with cerebral palsy? Child Care Health Deu 2004;30(2):151-60 20. Tan WJ, Li JJ, Ou LM. The effect observation of hyperbaric oxygen combined with rehabilitation training on the cerebral palsy children by. Zhonguo Linchuang Kangfu 2002;6(7):955 21. Liao W, Zhao CM, Zhang YP, et al. Neurodevelopmental therapy combined with hyperbaric oxygen therapy in evaluating the effect of early intervention on infants with cerebral palsy. Zhongguo Linchuang Kangfu 2002;9(6):1310 22. Zhao CM, Zhang YP, Liao W, et al. Conductive education and therapeutics of neurophysiology combined to improve and evaluate the motor function in children with cerebral palsy. Zhongguo Linchuang Kangfu 2002;6(7):954-7 23. Petrofsky J, Petrofsky D. A simple device to assess and train motor coordination. J Med Eng Technol 2004;28(2):67-73 24. Lammi BM, Law M. The effects of family-centred functional therapy on occupational performance of children with cerebral palsy. Con J Occup Ther 2003;70(5):285-97 25. Yuan HB, Zhang GX, Tao Y, et al. Investigate of early intervention on ZKS. Zhongguo Wuzhenxue Zazhi 2006;6(14):2658-60 26. Li BH, Ren YP, Cai FC. Effect of cinesiatrics on motor function development in children with spastic cerebral palsy. Zhongguo Linchuang Kangfu 2004;8(18):3582-3 27. Huang Z, Xi YC, Zhou CL, et al. Retrospective analysis of muscle tone for high-risk infants of cerebral palsy. Zhongguo Kangfu Yixue Zazhi 2003;18(4):200-3 28. Hadders Algra M. General movements: A window for early identification of children at high risk for developmental disorders. J Pediatr 2004;145(2 Suppl):S12-8 29. Zhou CL, Jiang Y, Tang ZZ, et al. Influence of cerebral parenchymal injury on neurological development in neonates with periventricular/intraventricular hemorrhage. Linchuang Erke Zazhi 2004;22(1):8-10 30. Wang HY, An T, Wang J, et al. Clinical evaluation of early intervention in high-risk infants for abnormal nervous system development. Zhongguo Ertong Baojian Zazhi 2006;14(1):6-8
(Edited by Chen L/Yin YL/Wang L)
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Cite this article as: Neural Regen Res,2007,2(2),121-5
Academic Discussion
Vojta and Bobath combined treatment for high risk infants with brain damage at early period Chunyan Wu1, Xiaohui Peng2, Xuesong Li3, Qingling Niu1, Hong Guo1, Huitao Huang1 1Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang Province, Daqing 163001, Heilongjiang Province, China 2Department of General Surgery, Daqing Oil Field General Hospital of Heilongjiang Province, Daqing 163001, Heilongjiang Province, China 3Department of Neurology, Daqing Oil Field General Hospital of Heilongjiang Province, Daqing 163001, Heilongjiang Province, China
Abstract BACKGROUND: In the process of early screening and interventions to high risk infants with brain damage, the occasion and choosing methods of interventions and the combined application of different interventions are still at the exploratory phase. OBJECTIVE: To observe the efficacy of early intervention using Vojta and Bobath combined treatment in high risk infants with brain damage, and investigate the effect of early rehabilitation on the prognosis. DESIGN: A randomized controlled comparative observation. SETTING: Daqing Oil Field General Hospital of Heilongjiang Province. PARTICIPANTS: Eighty-four high risk infants younger than 1 year were selected from the Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang Province from October 2005 to October 2006, including 52 boys (62%) and 32 girls (38%). The treatment started at the age of 03 months in 11 cases (13%), 46 months in 28 cases (33%), 79 months in 35 cases (42%), and 1012 months in 10 cases (12%). Infants with at least two of the followings were enrolled, including 7 Vojta abnormal postural reflexes, slow or disorder of motor development, increase of muscular tension, postural abnormality, primary reflection residual and CT/MRI abnormalities. Informed consents were obtained from their guardians. The 84 infants were randomly divided into treatment group (n =42) and control group (n =42). METHODS: All the children were intravenously injected with cerebroprotein hydrolysate injection or cattle encephalon glycoside and ignotin injection, 10 times as a course for 25 courses; Besides, the infants in the treatment group also received early rehabilitative training of Vojta and Bobath combined treatment, once a day, 40 minutes per time, 5 times a week followed by a 2-day rest, 1 month as a course, and totally 25 courses. The Vojta method was to facilitate the automatic regulation by reflexlocomotion. Bobath method was to inhibit abnormal posture but facilitate the normal one, thus it is also called neurodevelopmental therapy realized by reflex inhibition and facilitation. The rehabilitation was evaluated clinically using Gesell Development Schedules (GDS) after the courses when the infants were 1 year old. GDS included five aspects of adaptive behavior, gross motor, refine motor, speech, individual-social behavior. The developmental quotient (DQ) could be calculated according to their development. DQ=developmental age/actual age 100, < 85 points was taken as abnormal; The higher the DQ value, the better the development. Evaluation of efficacy: Cured: Developmental order reached normal or generally normal, abnormal posture disappeared, muscular tension ameliorated, symmetric limbs' motor function, free movement, normal intelligence, powerful reaction, and clear speech. Significant effect: Developmental order tended to normal, abnormal posture disappeared incompletely, muscular tension ameliorated incompletely, transient pause in the flexion and extension of limbs, good reaction, and improved intelligence. Effective: Developmental order improved to a certain degree, muscular tension ameliorated, limbs' motor function and posture improved as compared with before treatment, but still under control, intelligence improved a little. Invalid: No obvious changes before and after treatment. Total significant effective rate=(cured cases+cases of significant effect)/total cases 100%. The enumeration data and measurement data were compared with chi-square test and t test respectively. MAIN OUTCOME MEASURES: Clinical efficacy and GDS results at 1 year old in both groups. Efficacy: The total significant RESUTLS: All the 84 infants were involved in the analysis of results. 2 =4.2, P < 0.05). effective rate in the treatment group was higher than that in the control group (93%, 74%, Results of GDS evaluation: The DQ values of individual intercourse and social adaptation in the treatment group (93.57 11.23, 95.13 9.32) were higher than those in the control group (88.27 10.18, 90.10 10.67, t =2.267, 2.301, P < 0.05); The DQ values of gross motor, fine motor and speech in the treatment group (90.78 10.20, 98.63 9.23, 93.69 11.31) were higher than those in the control group
Chunyan Wu , Master, Associate chief physician, Department of Pediatrics, Daqing Oil Field General of Heilongjiang Hospital 163001, Province, Daqing Heilongjiang Province, China Wu CY,Peng XH,Li XS,Niu QL,Guo H, Huang HT.Vojta Bobath combined and treatment for high risk infants with brain damage at early period.Neural Regen Res 2007;2(2):121-5 www.sjzsyj.com/Journal/ 0702/07-02-121.html
Received:2006-10-20; Accepted:2006-12-10 (06-S-12-1197/SHM) Corresponding author:Chunyan Wu, Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang 163001, Heilongjiang Province, China E-mail: [email protected] Province, Daqing
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Wu CY, et al. / Neural Regeneration Research,2007,2(2):121-5
(84.32 11.33, 87.80 8.61, 85.52 10.61, t =2.746, 5.560, 2.746, P < 0.01). The interventional effects on each functional area were significant, especially the gross motor, fine motor and speech. CONCLUSION: The Vojta and Bobath combined treatment on the basis of drug therapy can improve the general developments of abilities in motor, intelligence, social intercourse, social adaptation and speech of high risk infants with brain damage, also can improve the curative efficacy. Key Words: brain injuries; cerebral palsy; rehabilitation
INTRODUCTION In recent years, the neonatal mortality is descending year by year with the development of perinatology and neonatal severe case technique. The infants of premature, low birth body mass, multiple fetuses and severe asphyxia can survive after emergency treatment, but they will suffer from brain damage induced neurological dysfunction, which can result in cerebral palsy, mental retardation, epilepsy, abnormalities of sensory perception and behavior, and it is the main cause for the disability in childhood. The early intervention to high risk children has become the urgent problem to be solved, and it has attacked the attentions of scholars of relevant subjects at home and abroad[1]. A great amount of foreign and national scientific studies have proved that early interventions has definite effect on children with brain damage[2]. Therefore, it is the important topic for perinatology and pediatrics to prevent and treat disability and improve the quality of life in high risk children by early evaluation of behavioral development, establishing proper intentional program and early interventions. However, the occasion and choosing methods of interventions and the combined application of different interventions are still at the exploratory phase. In this study, high risk infants were screened and given Vojta and Bobath combined treatment at early period, the follow-up data were also analyzed.
SUBJECTS AND METHODS Subjects Eighty-four high risk infants younger than 1 year were selected from the Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang Province from October 2005 to October 2006, including 52 boys (62%) and 32 girls (38%). The treatment started at the age of 03 months in 11 cases (13%), 46 months in 28 cases (33%), 79 months in 35 cases (42%), and 1012 months in 10 cases (12%). Inclusive criteria: Infants with at least two of primary reflection residual and CT/MRI abnormalities. Infants with progressive diseases were excluded, such as genetic metabolic disease. The main cause was premature in 21 cases, low birth body mass in 16 cases, hyperbilirubinemia in 9 cases, hypoxic-ischemic encephalopathy in 8 cases, asphyxia at birth in 6 cases, distress in uterus in 4 cases, pregnancy-induced hypertension syndrome in 2 cases, difficult labour in 2 cases, bigeminal in 2
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cases, and others in 14 cases. The 84 infants were randomly divided into treatment group (n =42) and control group (n = 42). There were no significant differences in the month age of infants, parental educational level, profession, family income, inhabited environment and constitution of disease between the treatment group and control group (P > 0.05), and they were comparable. Methods The infants were examined with cranial CT or MRI after admission, and the results showed that 53 cases were normal and 31 cases had imaging abnormalities, manifested by ventriculomegaly and broadening of sulcus fissure, hydrencephalus, softening of alba, intracranial hemorrhage, brain edema, etc. The muscular tension, abnormal movements and posture were evaluated, Vojta reflection, gross motor function assessment and CT assistant examination were also performed. All the children were intraveneously injected with cerebroprotein hydrolysate injection or cattle encephalon glycoside and ignotin injection, 10 times as a course, followed by a 20-day rest, totally 25 courses; Besides, the infants in the treatment group also received early rehabilitative training, which was mainly the Vojta and Bobath combined treatment, once a day, 40 minutes per time, 5 times a week followed by a 2-day rest, 1 month as a course, and totally 25 courses. The rehabilitation was evaluated clinically using Gesell Development Schedules (GDS) after the courses when the infants were 1 year old. GDS was used to assess the maturity of neurological development and mental development in children by five aspects, including adaptive behavior, gross motor, refine motor, speech, individual-social behavior, and it was suitable for children of 0 6 years old, and the developmental quotient (DQ) could be calculated according to their development. DQ=developmental age/actual age 100, < 85 points was taken as abnormal; The higher the DQ value, the better the development. Vojta method, also named as Vojta induction therapy, was summarized and established by Dr. Vojta (Germany). The Vojta method was to facilitate the automatic regulation or control of the body's position, to facilitate the active maintenance of the support function of the extremities, and to stimulate coordinated muscle activity by reflexlocomotion. Bobath therapy was the method to inhibit abnormal posture but facilitate the normal one, thus it is also called neurodevelopmental therapy realized by reflex inhibition and facilitation, including: Reflex inhibition: Inhibiting
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extension and flexion postures. The former was suitable for infants with head dorsiflexion, ATNR shape of whole body and opisthotonus, whereas the latter for those with head anteflexion, spinal curvature, and flexion at bending hip and knees; Adjusting the key point: It could be adjusted at the specific site on the body of infants to alleviate spasm, as well as the maneuvers that could facilitate normal posture and movement; Facilitating postural reflex to induce the maximal potential of the infants without their overexertion, form the movement posture of functional activity, and learn and comprehend the experience, so as to reach the aim of treatment; Percussion was a facilitating maneuver to improve the muscular tension at certain sites of the infants, induce muscular tension by regular or random percussion at limbs and body, and maintain the normal posture of infants. Evaluating the efficacy The infants were self-evaluated according to the traditional 4-grade standard in combination with the improved degree of motor developmental order, amelioration of abnormal posture and muscular tension, and the intellectual improvement. Cured: Developmental order reached normal or generally normal, abnormal posture disappeared, muscular tension ameliorated, symmetric limbs' motor function, free movement, normal intelligence, powerful reaction, and clear speech. Significant effect: Developmental order tended to normal, abnormal posture disappeared incompletely, muscular tension ameliorated incompletely, transient pause in the flexion and extension of limbs, good reaction, and improved intelligence. Effective: Developmental order improved to a certain degree, muscular tension ameliorated, limbs' motor function and posture improved as compared with before treatment, but still under control, intelligence improved a little. Invalid: No obvious changes before and after treatment. Total significant effective rate=(cured cases+cases of significant effect)/total cases 100%. Statistical analysis The data were analyzed by the first author using SPSS 10.0 software, the enumeration data were compared with chi-square test, whereas the measurement data were compared with the t test. P < 0.05 was considered as significant difference, and P < 0.01 as very significant difference.
RESULTS Quantitative analysis of the participants Totally 84 infants with brain damage were enrolled, and all were involved in the analysis of results. Clinical effects (Table 1) Results of GDS evaluation(Table 2) Table 2 showed that the DQ values of the five functional areas in the treatment group were all higher than those in the control group, the interventional effects on each functional
area were significant, especially that there were very obvious differences in gross motor, fine motor and speech. Table 1
Group
Comparison of clinical effects between the two groups (n /%) Significant Effective effect
Cure
n
Treatment 42 31/74 42 12/29 Control a
2
2/5 5/12
8/19 19/45
Invalid
Total significant effective rate(%)
1/2 6/14
93a 74
=4.2, P < 0.05, vs. the control group
Table 2 Comparison of Gesell Development Schedules (GDS) scores between the infants at 1 year old (x s) Group
n
Gross motor
Fine motor
Treatment Control
42 42
90.78 84.32
98.63 87.80
t P
10.20 11.33
2.746 < 0.01
Group
n
Treatment Control
42 42
t P
5.560 < 0.01
Individual-social intercourse 93.57 88.27
9.23 8.61
11.23 10.18
2.267 < 0.05
Speech 93.69 85.52
11.31 10.61
2.746 < 0.01
Social adaptation
95.13 90.10
9.32 10.67
2.301 < 0.05
DISCUSSION High risk infants of perinatal brain damage refer to the neonates with various causes induced brain damage at perinatal stage, they might have high mortality and disable rate, and suffer from sequela of nervous system of different severity, and it is the main cause of disability in childhood. Especially that it has complex causes and various clinical manifestations, besides the nervous system of infants develops rapidly, and various abnormal and normal postural reflexes can occur alternately, which bring about certain difficulties for detection and intervention at early and ultra-early periods[3]. As the epidemiological study goes deeper, it has been proved that various brain damages are not only associated with perinatal factors, also have correlations with genetic susceptibility, amnionitis caused by congenital intrauterine infection at early pregnancy and the level of placentitis inflammatory factors[4]; size of uterus[5]; eNOS, F7, LTA, PAI21 and ADRB22 gene[6]; viral infection during pregnancy, especially the neurotropic herpesvirus[7,8], etc. Domestic and foreign data have shown that the incidence rate of cerebral palsy becomes higher as the pregnant week of the infants is fewer, the lower the body mass at birth, the higher the
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incidence rate, and it is higher in small for gestational age infants than in appropriate for gestational age infants[9-11]. Central nervous system has an important property of plasticity, which enables certain functional recovery after brain damage. It has been confirmed that[12] as compared with cats raised in standard surrounding, the body mass, brain mass, width and length of cerebral hemisphere, as well as cerebral angiogenesis, were all increased in those raised in rich surrounding. The nerve cells in human brain proliferate from 3 months of cyesis to 1 year after birth, after which they will not duplicate or regenerate any more, whereas the supporting cells that maintain the nutrition and conduction of nerve cells proliferate from late cyesis to 2 years after birth. Once the brain is damaged, the function can be recombined by early rich environmental stimulation and functional training[13-15]. The "nervous plasticity theory" in modern neurorehabilitation believes that the recovery of nerve function has two conditions[16]: The damaged nerve are not dead, and the After the death of the function can recover directly; damaged nerve, the axonal regeneration of central nerve cells, dendritic germination and synaptic threshold changing mechanism again form a network system of functional cell group in central nervous system, which realize the functional recombination, manifested by regional functional reconstruction in cortex, or the function is performed by distal cortex with similar function. The functional recovery of nerve cells is associated with brain plasticity, and the regeneration following brain damage depends on exercise training and activities[17]. Therefore, it is believed that the nervous plasticity theory is the theoretical basis for guiding the rehabilitative interventions of high risk infants. Many studies have confirmed that early rehabilitative treatment is effective for infants with abnormal development of physical ability[18]. Early screening and intervention are significant for high risk infants of brain damage. However, the occasion and methods of interventions and the combined application of different interventions are still at the exploratory stage. Parkes et al[19,20] treated infants with hypoxic ischemic brain damage by using comprehensive methods of drug, hyperbaric oxygen, limbs massaging, passive gymnastics, visual, auditory and tactile stimulations, etc., and found that the developmental quotient and intellectual index of the infants were obviously higher than those in the control group. Liao et al [21] observed that neurodevelomental therapy combined with hyperbaric oxygen was one of the effective methods for the early intervention of cerebral palsy. Satisfactory outcomes were also obtained from the comprehensive interventions of exercise developmental therapy and conductive education in addition to drug and hyperbaric oxygen[22,23]. Besides, the music and art therapies can be used in the training[24]. In this study, Vojta and Bobath combined treatment was applied on the basis of nutritional
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nerve cells for the early interventions. Vojta method induces reflex movement by compressing and stimulating the initiation zone of the infants, the repeated and regular appearance of the movements (time and spatial overlapping) promote the normal reflex pathway and movement, whereas inhibit the abnormal ones for treatment. At present, it is the main rehabilitative method for children with central coordination disorders used in most rehabilitation institutions in China[25]. Bobath therapy is also called neurodevelopment therapy. Bobath suggested two viewpoints: The damaged brain tissue during development leads to the developmental lag or retention of motor function that should develop normally. After brain damage, the inhibitory and adjusting functions of central nervous system are weakened, abnormal postures and movement occur. Once brain is damaged during the development, abnormal sensory-motor conduction appears between the brain tissue and surrounding, the infants can not experience the sense of normal movement because of the abnormal one, but experience the abnormal sensory-motor conduction continuously, and the abnormal posture and movement will stabilize after a long time, which will aggravate the conditions of the infants. The vicious cycle of the sensory-motor conduction is not interrupted, and the symptoms still progress. Therefore, according to the neurodevelopmental order of the infants, the techniques of inhibition, facilitation and percussion are adopted to inhibit abnormal posture and movement, and facilitate normal motor sense and mode. Reflex inhibitory posture is used in this inhibition, and key points are adjusted to promote normal posture, and it is one of the main therapies for cerebral palsy. Li et al[26] combined the Vojta and Bobath therapy with Shangtian method in the rehabilitative training of children with spastic cerebral palsy of different ages, and obtained satisfactory results. Our results also showed that there were satisfactory outcomes after interventions of Vojta and Bobath combined treatment for 25 courses. In the treatment group, the effective rate reached 98%, and the normalized rate reached 92.86%, which were significantly different from those in the control group (P < 0.05). GDS results at 1 year showed that the developments of the five functional areas in the treatment group were better than those in the control group, there were significant differences in individual-social intercourse and social adaptation, and very significant differences in gross motor, fine motor and speech. It was indicated that early interventions could promote motor development, also promote the comprehensive developments of intelligence, social intercourse, social adaptation and speech, also ameliorate the prognosis, which had laid good physical and mental bases for the infants to enter the society in the future. The signs of brain damage occur a little later, whereas the
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parents can not find the abnormalities in time, thus it is very significant to follow up regularly, perform nervous system examination and GDS evaluation for finding infants with brain damage earlier and guiding the parents to give intervention pertinently, preventing and treating cerebral palsy and reducing disability rate. It is realized during the early intervention that it is the key point to enhance the management of high risk infants for the early detection of abnormalities, all the high risk infants should be enrolled in the follow up, especially that the infants with highly sensitive indexes[27-29] should be traced more closely. Besides, it is also concluded that the interventional effects can be affected by the followings: The degrees of the parents' realization and attention to the early interventions; Efforts should be made to enable the parents to cooperate and participate positively, and it is the crucial to persevere for the success. Time to start the early intervention; The earlier, the better. Duration and intensive of training. parental educational level, family environmental and economical conditions. In conclusion, early intervention to perinatal high risk infants can promote and ameliorate the recovery and development of their damaged nervous system, and the earlier the intervention begins, the better the results are[30]. It has been proved to be an economical and effective method to reduce and alleviate the incidence rate of cerebral palsy by the pertinent recovery of limbs' motor function based on the overall promotion of intellectual development in infants.
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(Edited by Chen L/Yin YL/Wang L)
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