CP MAGAZINE MARCH 2004

Cerebral Palsy Magazine March 2004 1

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FROM EDITOR Editor Welcome As always, thank you for all the feedback CONTRIBUTING WRITERS and your kind words. Also, we would like to SINCE 2003 greet all of our new writers; welcome aboard! It is a true pleasure to read your articles. Anat Baniel ................... Bethany Elliot We are very excited to deliver to your hands Carrie Southgate another issue of CP Magazine packed with information. In this issue we Charlotte Versagi have focused on the concept of intensive therapies. Although the word Cindy Baranowski intensive may have a different meaning for different people, we would like David Bauer to stress the importance of it. Debbie Hirsch Through your lifelong search for the treatment method or technique most Derek MacFadden suitable for you, your patients, or your loved one, you have already learned Diane Mason a lot. One thing that might have caught your attention was the length and Edward Hurvitz intensities of certain programs. The time and dedication to those programs Janessa Rick is enormous. Results may greatly vary depending on the specifics of the Kaya Kosicielny injury sustained. Very often we put our hopes and dreams in a particular Kevin Hickling program. Expectations are high. Before you get that far, we would like to Kimberly Loving encourage you to do your homework. Please, find as much information as Kinga Czegeni Balogh possible. Ask questions. Lara Ameen To help you understand the concept of the intensive approach, my husband Laura Znajda Richard has written an article on page 40. Before you invest both money Leonid Blyum and time, make sure that the program you are researching meets the Michael I. Opipari necessary criteria. Also, follow with the article on strength on page 12. Naomi Ora Liebowitz Equipped with the basic knowledge, you will be a better judge of what is Oleh Kachmar appropriate and necessary in your particular case. Patricia Al-Attas Patricia Gonzalez Waiting for longer and warmer days, I would like to wish you a peaceful and Paul Stuart Wichansky joyous Spring. Peggy Cahill Renata Sumar Izabela Renee Uitto Izabela Koscielny Scott Silverman Sharon Gaiter Sherry Hudson Simona DeMarchi Sue Rusco Alexander Svadovskiy Volodymyr Kozijavkin [email protected] 4 Cerebral Palsy Magazine March 2004

























TREATMENTS movement. Rib cage and spinal manipulations and and space in the joints depending on how they are mobilizations are stressed to prioritize movement modified. Children with both low and high muscle from the center out to the extremities and reduce tone will benefit from increasing core musculature “fixing” patterns common in CP. with a focus on the abdominals, shoulder girdle muscles, and improved weight bearing on the legs/ Pediatric Developmental Pilates feet. The use of both Basic and Advanced exercise gives the therapists and the children many options, Pediatric Developmental Pilates (PDP), combines so that either progression, (to make an exercise the principles of the Pilates method including core more difficult) or support (to make it easier) will stability with yoga positions, breath work, and help in obtaining successful goals. developmental approach to promote increased strength of debilitated muscle groups necessary To find out more about trainings for these holistic for enhanced functioning. In the PDP training, approaches, contact Janessa Rick, PT at Hampton therapists are taught a series of exercises that can CARES [email protected], toll free at 877- be utilized with the children, regardless of age and 439-9700 or on the web at www.hamptoncares.com degree of delay. The exercises increase muscle strength, (especially eccentric strength), proprioceptive awareness, the length of soft tissue, Cerebral Palsy Magazine March 2004 17

TREATMENT METHOD Intensive Neurophysiological Rehabilitation System The Kozijavkin Method by: Prof. Volodymyr Kozijavkin, MD, PhD and Dr Oleh Kachmer, MD It is well understood that Cerebral Palsy is caused by many different More than 40 families from the United States have also traveled to the Ukraine to experience this treatment. noxious factors applied to the developing brain. Nowadays, more Already in 1993, the rehabilitation system has been officially than 400 different causes are known, which determine very different recognized by the Ukrainian government. Due to the high level of clinical signs in each child affected. Each patient is a peculiar success with the Kozijavkin Method, it has received international individual, and therefore one universal way of treatment cannot be approval and has been included in the encyclopedic edition of child applied to all patients. orthopedics by the well-known German professor, Frits Niethard Unfortunately, the use of only traditional methods of physical therapy and (1998), as one of the four most effective approaches to the rehabilitation fail to bring the desired results in many cases. The therapy rehabilitation of Cerebral Palsy. should not have a single focus. Only an individualized combination of Statistical analysis of the medical records of a group of 12,256 patients different treatment modalities can achieve the desired results. treated by the Kozijavkin Method confirmed the high efficiency of One such multimodal approach to the rehabilitation of patients with this rehabilitation system. CP is the Intensive Neurophysiological Rehabilitation System (INRS), Muscle tone normalization was noted in 94% of patients, also known by the name of its author – the Kozijavkin Method. improvement of head control in supine position was noted in 75% of Stimulating compensatory possibilities and brain plasticity, this patients, 62% of the patients who were unable to sit before the method creates a new functional state which opens the possibility treatment have learned to sit, 19% of patients began to walk without for faster motor and mental development of the child. assistance, and 87% of patients after the treatment were able to Different rehabilitation modalities of this system complement and open their spastically fisted hand∗. intensify each other, and are aimed at the main task of rehabilitation: improvement in the quality of the patient’s life. It is important to stress that the Kozijavkin Method is not an alternative to existing rehabilitation approaches. It complements and significantly increases the efficiency of many other existing rehabilitation systems. The new functional state, created by the INRS, along with muscle tone normalization, joint mobility restoration, improvements of tissue trophicity and blood circulation, opens new wide possibilities for the development of the child and enhances the results of other rehabilitation treatments. The Kozijavkin Method was created 15 years ago in the Ukraine and thus far, more than 15, 000 patients have been treated by this method, including about 7,000 from Germany, Austria, Switzerland, and France. Fig 2. Results of the rehabilitation by the Kozijavkin Method Over the past few years, the interest in our rehabilitation system has grown in the USA. Beginning in 1999, our doctors have made presentations of the Kozijavkin Method in the USA and this information was accepted with great interest at the University of Illinois in Chicago (1999), the Cleveland Clinic (2000), the conferences of the American Academy of Physical Medicine and Rehabilitation (2000), and at the American Congress of Rehabilitation Medicine (2001). Several special conferences and workshops have been conducted in New York, Ohio, Florida, California and Washington. This article about the basics of our rehabilitation system will provide Fig 1. Geography of our patients a clear explanation of the Intensive Neurophysiological Rehabilitation 5. 6.System for health professionals, patients and parents. 18 Cerebral Palsy Magazine March 2004

TREATMENT METHOD History of the Kozijavkin Method In the process of its rise and development, the Kozijavkin Method, Fig 3. Institute for Medical Rehabilitation Intensive Neurophysiological Rehabilitation System went through was established in 1996 several evolutionary stages, constantly improving and adjusting. The basis of the rehabilitation system – the method of the Good results and the high efficacy of the new rehabilitation technology biomechanical correction of the spine was worked out already in assisted in its recognition not only in the Ukraine, but also far abroad. the late 1980’s. The author of the method, Prof Kozijavkin, while Well-known German professor Frits Niethard in his encyclopedic treating patients with diseases of the nervous system and spine, edition of child orthopedics (1998) includes the Kozijavkin Method in had utilized the methods of manual therapy. With long-term the four most effective approaches to rehabilitation of Cerebral Palsy. experience, he discovered that the use of certain spine mobilization techniques resulted in normalization of muscle tone. Fig 4. The encyclopedic edition in child orthopedics included This practical experience encouraged the successful use of the the Kozijavkin Method in a list of the four most effective spine mobilization techniques for the reduction of muscle spasticity rehabilitation systems for patients with CP in children with Cerebral Palsy. For major achievements in rehabilitation research, a group of However, the anatomical and physiological peculiarities of the physicians headed by Prof Kozijavkin received the State Prize of child’s spine required an adaptation of the classical methods of Ukraine in the Field of Science and Technology in 1999. the manual therapy. Therefore, V Kozijavkin developed the original To spread the advanced experience in the field of rehabilitation, our technique of the polysegmental biomechanical correction of the Institute in close cooperation with the department of physical therapy spine specific to the child. and rehabilitation of Kiev Medical Academy of Postgraduate For the first time a report about the new method of rehabilitation Education has established educational postgraduate courses. was delivered at the All-Union Research Conference on child Since 1999, over 750 physicians of different specialties have become neurology and psychiatry in Vilnius in 1989. acquainted with the basics of the Intensive Neurophysiological The new rehabilitation system awakened interest among doctors Rehabilitation System during the advanced training courses. and researchers of the Soviet Union. In the same year, a In order to provide high-level accommodations for an increasing commission of experts headed by the leading Soviet neurologist, number of patients, and permit continued improvements and expansion Prof K. Semenova, confirmed the effectiveness of the new in the rehabilitation system, a new contemporary International Clinic rehabilitation system. of Rehabilitation was put into service in the summer of 2003 in the In 1990 to enable wider implementation of the new rehabilitation ecologically clean area, in the health resort Truskavets. system in Lviv (Ukraine), a new contemporary Rehabilitation Center was founded. This center began treating patients from the Ukraine and Russia. However, as information about the new rehabilitation system spread to Europe, the first group of patients from Germany arrived in the Ukraine for treatment in 1991. Positive treatment results have since led to an increase in the number of patients. Since 1993, a group of patients arrive for the treatment in the Ukraine routinely, twice a month, by a special flight from Frankfurt (Germany). In 1993 by the resolution of the Ukrainian government, this method has been officially recognized and recommended for the wide application in the medical practice. In order to broaden the range of the research work and further refine the rehabilitation approach, a new Institute for Medical Rehabilitation was established. The main direction of its work was the further research in the medical rehabilitation of patients with diseases of the nervous system and spine.Employees of the Institute collaborate with Lviv Medical University, Ukrainian Research Institute of Neurology and Psychiatry, Kiev Medical Academy of Postgraduate Education, German Academy for Rehabilitation and Development, Munich Child Center, and many other scientific and practical institutions. Cerebral Palsy Magazine March 2004 19

TREATMENT METHOD Pathophysiological basis of the rehabilitation system The damage of the central nervous system in Cerebral Palsy is Fig 5. Releasing of functional spinal blockages opens the flow of accompanied by the secondary changes of the muscloskeletal the proprioceptive information to the central nervous system and system and other systems of the body. High muscle tone, pathological reflexes, improper body position, creates a new functional state in the individual. and pathological movement patterns cause changes of the joints, shortening of the spastic muscles, tendons and ligaments, and The results of this technique are not limited to the changes in joint abnormalities of blood circulation and metabolism. mobility, but are accompanied by complex changes in the body – the Those pathological changes are accompanied by restriction of joint so-called new functional state is created. The muscle tone is normalized, movement and development of functional blockages. and tissue trophicity, blood circulation, and metabolism are improved. As is evident in literature, functional blockages by themselves The new functional state significantly enhances the possibility for augment disturbances in trophicity, circulation, and autonomic faster motor and mental development. functions resulting in further slowing and distortion of motor However, isolated use of the biomechanical correction of the spine is development in the child. A pathological vicious circle is formed. not sufficient. It only creates the basis for the possible future In Cerebral Palsy, functional blockages develop in the majority of development of the child. the joints. In the study of this phenomenon, most authors have This rehabilitation approach assumes that the human body is a complex addressed joints in the extremities, but there is little discussion of self-organizing system, made up of many subsystems which can exist the more than 100 joints of the human spine in which functional and develop normally only if their interconnections are ordered and blockages are also developing. harmonious. Our studies, which began in the mid eighties, showed the important The damage or malfunction of one subsystem disturbs the function of role of the spine in the pathogenesis of Cerebral Palsy. The the entire organism as is the case in CP. When self- regulation is not functional blockages are not limited to a single joint of the spine, sufficient, the dysfunction of the whole body occurs. but rather the blockages occur in several adjacent vertebrae resulting Influencing the different chains of the pathological process with in polysegmental spinal blockages. different modalities, our task is to break the pathological vicious cycle, These spinal blockages influence all the organs of the human body create a new functional state in the body, and open up the possibilities which are innervated by the corresponding segments of the spinal for faster motor development. cord. Hence, the Intensive Neurophysiological Rehabilitation System was The segmental interactions are disturbed (both with respect to created. It combines different treatment modalities that complement innervation of the organs and systems innervated by the same and reinforce each other. The method of biomechanical correction of segment of the spinal cord), as well as those innervated by vertical the spine, combined with other treatment methods, is used to prepare connections of the segment with the higher centers of the nervous the child for the correction, sustain the achieved results, create correct system (connections with brain stem, basal ganglia and cortex). movement patterns, and accelerate motor and mental development. Proprioception may also be affected in CP. In the joints, tendons The pathophysiological mechanism presented above is only one of and muscles there are receptors that relay information about body several hypotheses regarding the effects of this treatment method. position, equilibrium and movements. There are muscle spindles in Other hypotheses of the therapeutic influence of the Kozijavkin the muscles, Golgi tendon organs in the tendons, and joint Method are now in the process of development. kinesthetic receptors in the joints. Information from those receptors is essential, not only for the performance of all movements, but also for motor training and learning new movements. Recent studies have shown that functional spinal blockages are blocking and distorting the flow of proprioceptive information from the musculoskeletal system through the central nervous system, which further complicates the motor development of the CP patient. In an attempt to correct the above-mentioned pathological signs, the method of biomechanical correction of the spine and large joints has been developed. This method became the basis of the Intensive Neurophysiological Rehabilitation System. The technique of the biomechanical correction releases functional blockages of the spine, restores joint mobility and opens the “gate” for the flow of the proprioceptive information to the central nervous system. 20 Cerebral Palsy Magazine March 2004

TREATMENT METHOD Principle of the Star in Rehabilitation The next step is meant to influence the proximal structures. The large joints of the shoulder and pelvic girdle are influenced utilizing the Some rules of the medical rehabilitation by the Kozijavkin Method mobilization techniques of physical therapy and massage (circle B). could be illustrated using the principle of a pentagon star. Gradually the methods aimed at activation of the medium sized joints A man could be represented as a star and the points of which (circle C) are added, and finally the small distal structures are treated correspond to the hands, legs and head. All the points are joined (circle D). around the center and the axis of the body – around the spine and Creation of the higher and more “distal” fine motor functions of the spinal cord. Each point includes main structures – muscles, bones, hand, development of balance, and improvement of speech is possible joints, vessels, and nerves. The proximal large joints, big muscle groups, only after the development of the previous, more “proximal” functions. large vessels and nerves are situated near the center of the star. Distal The correction begins with the “central” structures, which affect small joints and muscles, tiny vessels and nerves are on the ends of phylogenetically older and more simple functions. Then the influence the star points. Phylogenetically older structures of the brain stem on the “proximal” and “middle” structures is added, and ultimately, occupy the most proximal areas of the point representing the head, the treatment of the “distal” structures, which fulfill a new and higher followed by younger structures (basal ganglia), and distally the function merged. youngest structures, which determine higher functions – the brain cortex. Short Description of the Kozijavkin Method Tight interconnections of all the structures are necessary for the normal development of the body achieved by the efferent (from center to The Kozijavkin Method or INRS consists of two subsystems – The periphery) and afferent (from periphery to center) informational flow. Intensive Correction Subsystem and The Stabilization and Effects Functional blockages of the spine in cases of CP patients disturb Potentiation Subsystem. The Intensive Correction is performed in this interconnection, and block the flow of proprioceptive information. the Rehabilitation Center and lasts for two weeks. In the period of This could be presented as a disturbed interrelation of the star points. Stabilization and Effect Potentiation, treatment is continued at home Restitution of normal interconnection among the points to achieve according to the recommendations given to the patient at the center. harmony of the star in the Kozijavkin Method is achieved using the This period usually lasts from 6 to 8 months, at which point the principle from the “center to the periphery”. patient is admitted to the center again for the next course of Intensive Correction. Fig 6. Principle of the Star in the Rehabilitation. Fig 7. The Kozijavkin Method is a multimodal rehabilitation The therapeutic influence starts on the central structures system (circle A), then gradually added the influence on the proximal INRS is a multimodal rehabilitation system in which the influence of -B, middle–C, and distal–D structures of the body one component is complemented and intensified by the others. The In the early sessions the therapy is applied primarily on the central structure, the spine (circle A on the picture). main treatment programs include biomechanical correction of the The purpose of this method is to release the functional spinal blockages, normalize muscle tone, tissue trophicity and blood spine, extremity joint mobilization, reflexotherapy, mobilizing physical circulation, and create a new functional state in the organism. In the central nervous system this new functional state is manifested exercises, special massage system, rhythmical group exercises, by the mental arousal of the patients, a psychological “awakening”, opening possibilities for the motor and mental development of the mechanotherapy and apitherapy which are described in the next child and enhanced effectiveness of other treatment modalities. section. ... Continued on page 22 Cerebral Palsy Magazine March 2004 21

TREATMENT METHOD Biomechanical Correction of the Spine Mobilizing Physical Exercises The basis of the rehabilitation system is the polysegmental Physical therapy is an essential part of the rehabilitation system. In biomechanical correction of the spine created by Prof. V. Kozijavkin our program we use mobilizing physical exercises that are aimed at the MD. It is aimed at releasing the functional blockages of the spinal improvement of mobility of the joints of both the spine and extremities, segments and resumption of normal mobility of the joints of the spine. creation of new motor patterns, and acquisition of the necessary mobility for daily life skills. The exercises are performed following the rule “from center to periphery”, so that the main influence is on trunk movement and proximal joints with gradual involvement of movement in distal small joints. New motor acts are taught first through passive movement, then through passive- active movement, and finally through active movement. Simple movements are undertaken first, followed by more complex movements. Daily sessions include breathing exercises, exercises for joint mobilization, as well as strengthening exercises. Fig. 8. Biomechanical correction of the spine is an important part of the treatment Biomechanical correction of the spine is carried out consecutively Fig 9. Physical therapy is an essential part of the in lumbar, thoracic and cervical regions. Lumbar spine correction includes simultaneous mobilization of all blocked movement rehabilitation system segments using our method of “backward rotation”. Correction of the thoracic blockages is performed starting from the upper regions Special Massage System to lower using special impulse techniques. Corrections of the cervical spine are performed using movement with complex In our rehabilitation program the special massage system is used to trajectory to simultaneously influence all blocked segments. prepare for the biomechanical correction of the spine, muscle relaxation and reflexotherapy. It includes techniques of classical, segmental, and Extremity Joint Mobilization periosteal massage in combination with post- isometric and post- isotonic relaxation. In order for the biomechanical correction of the Extremity joint mobilization is used for the improvement in mobility spine to be effective, the appropriate preparation of the musculoskeletal of the joints, stretching and improving muscle elasticity, stimulating system is essential. Such preparation is provided by means of relaxation blood circulation, and for prevention of joint contractures. massage techniques. Elements of joint mobilization and acupressure Mobilization starts with the treatment of the large joints (hip, knee, are also included in the massage system. Techniques of stimulating shoulder) and then gradual involvement of the small joints. In our massage are used for activation of hypotonic, weak muscles. work we use classical principles and also newly created techniques. The joints in our rehabilitation system are brought out of the passive Rhythmical Group Exercises range of motion using a certain limited force. Gentle tactile traction methods are used in combination with vibrating movements, as Rhythmical group exercises are used to encourage emotional well as an impulse technique of tapping along the joint cleft. During development and social integration of the child. Group exercises are the treatment course the intensity of the mobilization increases performed with the elements of play therapy using music and dance. gradually. Mobilization of the mandibular joints with the facial The patients are grouped by age and the level of motor ability and massage is used for improvement of articulation and chewing parents are also involved in these sessions. A positive emotional movements. attitude assists in the stimulation of the patient’s motivation for recovery and strengthens their belief in their own power and potential. Reflexotherapy Apitherapy The method of reflexotherapy serves to intensify the achieved spasticity reduction, eliminate trigger points in the muscles and The method of apitherapy (treatment with bee’s products) in our correct autonomic disturbances. The biologically active points are rehabilitation system includes beeswax wraps and the application of influenced by means of a portable electric low voltage stimulator, bee venom. Apitherapy is used for the improvement of local blood which is applied to the points of classical meridians, as well as circulation, metabolism and tissue trophicity. Allergy testing is specific points. Influence on the trigger points is performed performed prior to this treatment. In the technique of beeswax wraps, simultaneously with the post-isometric and post-isotonic muscle relaxation. Reflexotherapy is performed through intact skin and is painless. 22 Cerebral Palsy Magazine March 2004

TREATMENT METHOD the warm packages of beeswax mixed with paraffin, honey and propolis Treatment results are applied to selected joints or muscle groups. Along with the thermal influence, the diffusion of biologically active substances through The primary goal of the outcome studies of the Intensive the skin is important for muscle growth. Neurophysiological Rehabilitation System is the assessment of those functions which influence the quality of life, the main aim of Mechanotherapy our rehabilitation treatment. Therefore, the studies evaluate gross motor function, fine motor function of the hand, and mental Several methods of mechanotherapy are used to strengthen muscles, development. improve coordination and correct movement patterns. Lower extremity A four-level diagnostic algorithm has been worked out for the training is done using lever devices. The optimal training regime is complex patient evaluation. It includes the preliminary selection set by adjusting levers, weights and the number of repetitions. of patients for treatment, obtaining data necessary for the Treadmill and cycling devices are used for the correction of lower development of individual rehabilitation programs, observation extremity movement patterns. For the upper extremities we use of the changes in the patient’s conditions during the treatment primarily block devices. Devices such as the “Vibroextensor”, which and preparation of the home program for the patient. combines heat, vibration and mechanical massage of the para-vertebral In 2002, the extended analysis of the medical data of 12,256 patients regions are also used. treated with Intensive Neurophysiological Rehabilitation System was reported.1 Fig 10. Methods of mechanotherapy are used to strengthen In this group, 89% of the patients were children with different muscles, improve coordination and correct movement patterns forms of Cerebral Palsy, 6% - with disorders of the spine, 3% with residual conditions after damage of the central nervous system Indications and Contraindications (stroke, brain trauma), and 2% with other conditions. Main Indications Among the CP patients, 73% had spastic quadriplegia, 16% spastic • Cerebral Palsy (all forms) diplegia, 7% hemiplegia, 2% had hypotonic form and 2% - • Gross and fine motor delay hyperkinetic. • Post traumatic brain injury, stroke and neuroinfections The largest age group consisted of patients from 7 to 14 years – 36% (Fig 11). Unfortunately, only 3% of the patients began at least 6 months after the event treatment below 4 years of age. • Vertebral pathology with low back pain Fig 11. Distribution of Patients by Age and Gender • Impairments of the autonomic nervous system, e.g. Before treatment in our clinic, patients have tried other functional cardiac and respiratory complaints rehabilitation methods: 73 % neurodevelopmental therapy • Headaches and Migraine Contraindications (Bobath), 59% rehabilitation by Vojta, 18% Conductive • Congenital anomalies of the vertebral column and of the Education by Petö, and 22% tried other treatment methods .. central nervous system (Fig 12)......... ............... . . . .................................... • Expressed spine instability – spondylolisthesis, and Continued on page 24 osteoporosis • Acute inflammatory and infectious diseases of the central nervous system • Acute period after brain trauma and stroke • Severe brain damage • Decompensated Hydrocephalus • Severe epilepsy and convulsions with frequent seizures • Tumors of the spine, spinal cord and brain • Inflammatory diseases of the spine • Prior spine surgery • Fragile medical condition • Pronounced psychiatric disorders In doubtful cases, the decision is made individually after extended examination and review of medical records. Cerebral Palsy Magazine March 2004 23

TREATMENT METHOD had learned to control their head. 62% of patients who were unable to sit, had learned to sit, 28% of patients had learned to crawl, 41% of patients who earlier were unable to stand, had learned to stand, and 19% of patients began to walk without assistance. Fig 12. Rehabilitation Methods Used Before our Treatment Fig 14. Development of New Motor Functions 37% of patients were treated in the Clinic for the first time. 26% The ability of the hand to grasp an object and release it are both came for the second treatment, 14% of patients for the third visit, important functions for independent life and both components 9% for the fourth visit, and 14% for five or more times. are often disturbed in CP. The Sollerman Hand Test (1995) was One of the important clinical signs of the CP patient is the alteration used to evaluate the grasp function. Improvement of fine motor of muscle tone. skills was noted in 87% of the patients that had problems with The Ashworth Scale was used for the assessment of muscle tone. grasp before the treatment. Hand function was unchanged in 13% Among the group of 10,793 patients with spastic forms of Cerebral and there was no deterioration in any case. Palsy , 93% of patients experienced a reduction in muscle tone. (Fig 13). In 7% of the cases, the muscle tone remained unchanged. Fig 13. Changes in Muscle Tone Fig 15. Function of the Hands Range of passive and active joint movements is one of the important Once the child with CP returned home, further improvement of rehabilitation goals. Our results presents the changes of active and motor function was noted in 45% of cases if therapy was continued passive range of motion in large joints in a group of 10.793 patients at home. In 47%, the achieved results remained at the same level with a movement limitation before the treatment. and the results were deteriorated in only 8%, mostly after infection, After the treatment, the range of passive movement increased in diseases, or surgery. 91% of the cases. The volume of active movements increased in 84%. Passive and active movements remain unchanged in 8 and 15 % of cases respectively, and there was some reduction of the movements’ volume in only 1%. We have developed a scale of gross motor function, which was used to evaluate a group of 12,256 patients following treatment. 75% of patients without prior head control in the supine position 24 Cerebral Palsy Magazine March 2004

TREATMENT METHOD correction of movements and posture of the patient, and assists in acquiring new movement patterns. While strengthening relatively weak muscle groups, especially the extremity extensors, this program promotes vertical positioning of the child. Fig 16. Results of Treatment between Intensive Courses It was noted that the Kozijavkin Method of rehabilitation resulted in Fig 18. Biodynamical Correction Suit “Spiral” with elastic improvement not only of movement and posture, but also in the development of the psychological and mental function of the CP straps to provide the necessary corrective force patient. 300 patients with CP were evaluated together with the Ukrainian Research Institute of Neurology and Psychiatry2.Using The suit consists of a system of elastic straps which are wrapped the British Picture Vocabulary Scale, a significant increase of the in a spiral across the body and extremities. Imitating the positions intelligent quotient after the treatment was noted. In the case of the of main muscle groups, they provide the necessary corrective patients with spastic quadriplegia, the scores increased from 76 to 89 force. points. The straps can be attached to the supportive elements on the trunk and extremities (vest, shorts, knee, elbow, foot and wrist pieces). Velcro attachments on the straps allow for various adjustments to be made optimizing the corrective action desired. The development of a new movement pattern and the correction of the posture of the patient is attained through the sum of forces applied by the appropriate placement of the elastic straps. Attention is paid to the peculiarities of a patient’s musculoskeletal system and the goals of treatment. Fig 17. Changes of Intelligent Quotient (IQ) Novelties in the Kozijavkin Method Through activation of both internal compensatory potential and Fig 19. Training in Biodynamical Correction . . plasticity of the nervous system, the effect of Intensive “Spiral” Suit enhances physical therapy Neurorehabilitation is the new functional state of the child’s body. The next important step after the normalization of muscle tone and Continued on page 26 increase in range of passive and active movements during a rehabilitation course is to eliminate previous pathological movement patterns and to develop new, correct movements. To solve the above problem, we created a new component and it was added to the program, which is based on the principles of dynamic proprioceptive correction. All exercises of this program are carried out with the use of a biodynamical correction “Spiral” suit, which applies additional exertion to certain joints. This creates forces for the dynamic Cerebral Palsy Magazine March 2004 25

TREATMENT METHOD The biodynamical correction suit is used to enhance remedial gymnastic exercises, mechanotherapy, treadmill training, training with play therapy devices, and plain movement activity of the child. For the relaxation of muscles and joint mobilization a “Dolphin- Imitator” is used. This device causes wavy movements of the ankles, which are propagated along the body. Those movements are much like the movements of a dolphin in the water. Fig 21. Hand training device improves hand function in the game Another device is a training chair in which a game is played with trunk movements. The training chair provides a method for developing body movement coordination and improvement of postural control. The chair is equipped with a special system of sensors, which determine position and movement of the body in three dimensions. The information is transmitted to a computer that operates a computer game. While taking part in the game, the patient directs a virtual object by bending forward and back, tilting to the side and rotating the trunk. To enhance emotional involvement of the patients, in some cases, virtual reality may be used. Fig 20. Wavy movements of the ankles spreading along the body Fig 22. Training chair. By assists in spinal joints mobilization, relax spastic and overstrained bending forward and back, muscle groups tilting to the side and rotating his trunk , a child plays a computer An individual selection of frequency and amplitude provides game. movement waves, which pass along the whole spine and body assisting in spinal joint mobilization, relaxation of spastic and overstrained muscle groups, and improvement in blood supply and trophicity of the musculoskeletal system. This effect can be enhanced by comfortably positioning the patient, and by adding acoustic or visual stimulation during the treatment. American psychologist, O’Gorman (1975) has mentioned that: “Motivation of the patient is the most important, yet the most difficult part of the work of the therapeutic professions”. Keeping this in mind, we have developed a series of special game- training devices aimed at the improvement of different movements and the activation of the patient’s motivation for training sessions. One of these is a hand-training device, which requires the patient to perform a specific exercise in order to successfully play a computer game. This stimulates the development of movement speed, increases movement amplitude, shortens reaction time and improves eye-hand coordination. Specially developed existing computer games turn physical training into an effective, and most important, an interesting treatment procedure. Simultaneously, game software measures movement parameters – volume, speed, frequency, and all the data of each training session is stored, and can be used to analyze the patient’s progress. 26 Cerebral Palsy Magazine March 2004

TREATMENT METHOD International Clinic of Rehabilitation of the functional condition of the child, his adaptation and compensatory possibilities. Increasing number of patients, constant development and expansion Contemporary diagnostic equipment makes a wide range of of our rehabilitation system, and the need of the patients for Neurophysiological examinations possible including tests of comfortable accommodations forced the creation of a new respiratory and cardiovascular systems, extensive study of gross rehabilitation facility. motor functions, gait analysis, and hand functions. In the summer of 2003 in the ecologically clean area near the mountains, in the health resort Truskavets, a new 14 thousand sq. m International Clinic of Rehabilitation was opened. The new building, situated near a lake, is created in the Secession architectural style, distinguished by the escape and release from the old traditions and dogmas. Fig 25. Diagnostic equipment makes possible a wide ............ range of examinations Fig 23. International Clinic of Rehabilitation Spacious rooms in the rehabilitation department with comfortable furniture and modern rehabilitation equipment ensure that training All the lobbies of the clinic are ornamented with flower decorative sessions may be carried out effectively and provide for the comfort patterns made with stained glass with internal lighting. Stylized of the patients and the medical personnel snowdrops and violets symbolize spring and revival of nature. Special rooms for mechanotherapy and physical therapy are equipped Decorative patterns and ornaments are part of the art- therapy aimed with the gear for strength training, improvement of movement at stimulating the patient’s motivation for recovery and freedom from coordination, gait training, and gradual body adaptation to its new disease. Internal decorations, parquet and furniture were made with functional state. birch, a tree, known for its healing influence. Fig 26. Rooms for mechanotherapy are equipped with all the necessary gear Fig 24. Lobbies of the clinic are ornamented with flower Several rooms are specially equipped for training in the biodynamical decorative patterns made with stained glass with internal lighting movement correction program and for sessions of computer game training. The medical departments of the clinic are situated on the first and Computer network and specially developed software automate ground floor of the clinic and in the tower. Diagnostic departments storing and analysis of all the medical data. were planned bearing in mind the main task of the diagnostics in the The Clinic also includes 100 living quarters, which provide all the Intensive Neurophysiological Rehabilitation System – assessment necessary comfort for the patients and accompanying persons during the entire rehabilitation course. Modern interior design, nice furniture, and comfortable beds make the stay in the clinic suitable and cozy. Continued on page 28 Cerebral Palsy Magazine March 2004 27

TREATMENT METHOD Spacious one, two or three-room suites with the living space of Professor , MD, PhD, Specialist in Neurology and Manual therapy. over 24 sq. m, are equipped with phone, refrigerator, TV, and Internet Director of the International Clinic for Rehabilitation, Institute connection. Roomy bathrooms with the space of 6 sq. m are accommodated to the special needs of the residents. for Medical Rehabilitation and Rehabilitation Center “Elita” Volodymyr Kozijavkin is a well- known specialist in neurology and medical rehabilitation and the author of a fundamentally new rehabilitation technology–Intensive Neurophysio- logical Rehabilitation System, known also under the name of its author – the Kozijavkin Method. Fig 27. The Clinic includes 100 living quarters Volodymyr Kozijavkin was born on June 9, 1947 in Ukraine. In 1971, he accommodated to the special needs of the residents graduated from the medical department of Grodno Medical Institute. Standard services – laundry, ironing, clothes repair, etc are available In 1990, he established the Rehabilitation Center “Elita” in Lviv. In 1996 for guest use. Room security is provided by electronic locks and a he founded the Institute for Medical Rehabilitation, and in 2003 the reliable access control system. Most technological processes of the International Clinic of Rehabilitation in Truskavets. clinic are automated according to the technology of “Clever House”. V. Kozijavkin makes an important contribution not only as a practical A comfortable restaurant, which seats up to 180 people is situated medical doctor. He is also a well-known scientist, the author of more than on the second floor of the clinic. Self-serving tables adapted for 100 research publications and 2 scientific monographs. people with disabilities feature a large assortment of meat, fish and In 1992, he completed his postgraduate work: “Manual Therapy for the vegetable dishes, different juices, fruits, and confectionaries. Rehabilitation of Patients with Cerebral Palsy”. His practical, research, and public work were highly regarded by the Fig 28. A comfortable restaurant is situated on Ukrainian government and in 1994 he was awarded the title of “Honored the second floor Scientist and Technician of Ukraine.” Patients, parents and accompanying persons may spend free time In 1996 he completed his doctoral thesis: “Structural and Functional in a bar located on the first floor of the clinic. Different drinks, Pathology of the Spinal and Cerebral Structures in Patients with Cerebral snacks, and confectionaries are served here in a cozy setting. Palsy and Rehabilitation System for such Patients”. In 1996, he headed the newly established Institute for Medical ∗ More data is presented in the chapter treatment results Rehabilitation. 1 Kozijavkin V., Kachmar O. Outcome Evaluation of the Medical In 1997 he was awarded the Presidential Distinction and Honorable Order “For Great Services”. Rehabilitation in the Intensive Neurophysiological Rehabilitation System/ In 1999, V. Kozijavkin became a professor in the department of medical Ukrainskij medychnyi chasopys, 2003; 3(35):61-66. rehabilitation and resort science of Kyiv Medical Academy of Postgraduate 2 Kozijavkin V, Shestopalova T, Podkorytov V. Infantile Cerebral Palsy. Education, and the Institute for Medical Rehabilitation became the research Medical psychological problems. Lviv. Ukrainski Technologij, 1999 branch of this department. In the same year, he became a winner of the State Prize of Ukraine in the Field of Science and Technology for the scientific proceeding, “Organic lesions of the nervous system in children, development and application of new methods of diagnostics, treatment, prophylactic, medical rehabilitation and social adaptation” In June 2001, V. Kozijavkin was awarded the Bavarian (Germany) Medal “For efforts in helping children with special needs”. In July 2003, the International Clinic of Rehabilitation was established in Truskavets and headed by Prof. Kozijavkin. Our address: International Clinic of Rehabilitation 37, Pomiretska str., Truskavets, 82200, Ukraine Tel +38 03247 65200 Fax +38 03247 65220 E-mail: [email protected] http://www.reha.lviv.ua 28 Cerebral Palsy Magazine March 2004

TREATMENT METHOD The Kozijavkin Method - A Parent’s Perspective By Regina Spinazzola-Kinney, MD By Mrs. Linda Mograbi, Lawrence, New York As a parent, I naturally have high hopes for my daughter, Laura, a For the past three summers, my 12-year-old son, Sammy and I have bright 8-year-old with cerebral palsy, and have searched out many traveled from New York to the Ukraine so that he can participate in the INRS treatment program at the International Clinic of forms of treatment ranging from Rehabilitation in Truskavets. Sammy has cerebral palsy in the form conventional physical therapy to of spastic quadriplegia, athetosis and a stubborn ATNR Conductive Education. As a physician, (asymmetrical tonic neck reflex) that prevents him from bringing his I have evaluated many treatments that hands to midline for functional movements. He can use a manual might benefit my patients as well. Some wheelchair and a walker with minimal assistance. of my friends and former patients had visited the Institute for Medical After each session Sammy has shown a notable, overall reduction Rehabilitation with impressive results, in muscle tone, a greater range of motion in his joints, improvement so in the summer of 2002, my then 6 in articulation and cognitive function and a reduction in his ATNR. year old daughter and I made our first He continued to show functional improvements for several months trip to the Ukraine for treatment at the following the trip. Each year, I schedule a visit to our neurologist center. shortly after our return and these changes have been documented. I did not know what changes to expect, Sammy has been able to maintain most of his gains and improve but was open to learn, observe, and upon some by following the home therapy/activity recommendations help Laura get the most out of our visit. After the very first session made by Dr. Kozijavkin. Because of Sammy’s extraordinary results, of biomechanical correction of the spine with Prof. Kozijavkin, I was we plan to continue a yearly visit to the Clinic as part of his able to feel a marked decrease in her spastic muscle tone. The rehabilitation and to share our experiences with parents and treatments began slowly, but new therapies such as massage, bees professionals. wax applications, mechanotherapy and vigorous physical therapy were added to the schedule every few days so that by the end of the The accommodations are excellent, the staff is skilled, kind and 2 week session, Laura was quite busy. Once her muscle tone improved, professional, the food is healthful, the trip is long but manageable, she was able to perform many of the therapy activities more easily. the cost is reasonable and the results are remarkable. An itemized She could learn new patterns of movement that had not been open to daily treatment plan/receipt is issued with American insurance her before. In the evenings, there was time for relaxation and games codes. Since the majority of patients are European, it is advisable to of “floor hockey” and ice cream snacks with new-found friends from plan your trip when other Americans will be attending to provide around the world. All of the staff at the Institute were extremely optimal socialization opportunities for parent and child. dedicated and worked hard to ensure that she put forth her best effort and made the most progress possible. We can be reached at [email protected]. By the end of her 2 week session, Laura had better head and trunk control, was able to stand with less support and able to open her hands more easily. She and all the other children participated in “Olympic games” at the close of the treatment period. For the children, this was not only a fun-filled activity, but a culmination of all their hard work. Many proudly demonstrated newly acquired skills while their parents looked on with tears in their eyes. When we returned home, family and friends were amazed at how much she had improved in such a short time. We have since made another trip to the newly opened, beautifully decorated treatment center, and again with very positive results. The combination of Prof. Kozijavkin’s technique with many different modalities all under one roof is a truly impressive regimen, and we are planning to take advantage of this program often in the future. We can be reached at [email protected] Cerebral Palsy Magazine March 2004 29

TEENAGERS and CP What CP Means to Me By: Bethany Elliot Cerebral Palsy means a lack of oxygen to the brain. Cerebral phone, play on the computer, listen to music, go shopping, go to Palsy can also mean brain trauma. Most people are born with the movies and work in my garden. I also like to train dogs, ride it, but I was not. I nearly drowned. At the age of two I fell in my horses, volunteer, and travel. I like doing those things because swimming pool and was hospitalized for six weeks. hopefully other people can see I’m a normal seventeen-year-old girl with CP, who wants people to treat her just like any other Because I have CP, I live a great life. I get therapy and I love it. seventeen-year-old. I get Physical Therapy, Occupational Therapy, and Speech Therapy. In Physical Therapy, I’m working on balancing and My parents taught me to try and do things that normal people do. building up my strength. I’m also I trained my own Service Dog, Cinnamon. working on walking with my crutches. She is a Golden Lab. When Cinnamon In Occupational Therapy, I’m working first came to me, she was just a puppy. I on improving my handwriting and on found a dog trainer and started training gaining control over my left hand. In with her. I’m still teaching her things. She Speech Therapy, I’m working on has also taught me some things too. She interview skills and some reading skills taught me to be more kind to other dogs, like spelling. I have made a lot of more willing to be around other dogs, and progress in the past fifteen years. to keep trying to do things with her. Having CP is not a punishment; it is a One of the reasons that I love gift from God. It is a gift because it shows therapy is that it helps me to be more you who your true friends are. Although independent and responsible. Another I have many friends, maybe only five might reason is that I have a special be called “true friends”. True friends are relationship with my therapists. I like people who look past your disability to to spend time with them. who you really are. Now comes the big question, “What does CP mean to me”? My best friend happens to be a true friend. One reason I Well, I guess I love it. It is a part of who I am. I get to learn how to do things different ways that other people don’t get to learn. It love her is because she doesn’t see me as a person with CP. She doesn’t bother me that I do things differently because we are all sees me as a normal person. She has always been there for me different if you really look at it. I often find myself wondering, through the good times and bad times. She is there when I need to where would I be in life if I hadn’t fallen in my swimming pool? I talk, or need a shoulder to cry on. mean who would I be if I didn’t have CP? How different would I be? I also have a good role model. Her name is Joni Eareckson I love having CP, but I do admit it is hard sometimes, once Tada. She broke her neck at the age of 17 in a diving accident. you realize that there is no cure only improvement with therapy. Since then, she has written many books, has put out many CDs and tapes, paints, has many movies out including her movie that tells Also, there are days when I feel like dying because I can’t about her accident. She has her own business called Joni and do anything right. Maybe I will spill a can of soda or I might break Friends, as well as her own radio program. In one of Joni’s books something by accident. The one thing that has helped me through she said, “all people have a disability in one way or another, whether those days is the love and support from my family and friends. it is an invisible or visible handicap”. The only thing I hate about having CP is that no one My whole reason for doing this is to get people who have understands how you feel on the inside, and how hard it is. It is CP, and their families, to enjoy life just like I do. Life is a real joy hard because I take more time to do things. There are times when even though I have CP. Remember you only live once, so enjoy it I wish I could do one thing fast, but then I think, “what is the while you can. Even if someone is handicapped, it doesn’t mean point”? I’ve always told myself that “You should just be happy that they are incapable of following their dreams. All people have that you can do it”. dreams and even though some people have a disability; it doesn’t mean their dreams can’t be met. Although I have CP, I’m still very active. I’m a Girl Scout and a baby-sitter. I like to swim, spend time with my friends, talk on the 30 Cerebral Palsy Magazine March 2004

TEENAGERS and CP It’s My Life by Lara Ameen Being a teenager in itself isn’t easy, but being a therapy, including Conductive Education in Ontario, Canada; the Russian Suit program in Poland; and currently the ABR (Advanced teenager with cerebral palsy makes everything even Biomechanical Rehabilitation) program in Montreal, Canada for more challenging. When I was born, I was a 27-week my severe scoliosis. All of the therapies have benefited me in preemie and very soon after that I had a Grade 3 to 4 some way, having taught me about patience and maintaining a brain bleed as well as hydrocephalus. After a stressful positive attitude. and complicated two years, I was diagnosed with cerebral palsy. Despite all of the challenges I have faced, ( some being everyday challenges like getting dressed, taking a shower or even combing It has always been difficult for me, although I always my hair) I still am a normal 17-year old. I attend Tesoro High try to have a positive outlook on life. When I was School, a public high school, located in Las Flores, California. growing up, I always sensed I was “different” from Currently, I am a junior in high school where I take a heavy other children. At the age of about five or six, I sensed academic load consisting of two Advance Placement (college-level) this and I asked my father what was “wrong” with me. courses. Sometimes it’s frustrating because it takes me twice as He explained to me that I was disabled and couldn’t do long to complete tests and homework assignments compared to certain activities like normal children. my peers. Although I am not active in student government, I am part of an advanced high school choral ensemble, Drama Club, Still hopeful and inquisitive about finding an answer National Honor Society, and the California Scholarship Federation. to my question, I sought out a “higher being”; the rabbi. Some of my accomplishments include having a Bat Mitzvah at age I thought that because he was a rabbi and he abided by 13, receiving my Girl Scout Silver Award at age 14, and being and taught God’s laws that he could somehow “heal” named Miss Junior America Young Teen Queen for Mission Viejo me and make the disability go away. He gently told me at age 15. I am currently working on earning my Gold Award for that he couldn’t do that, but he encouraged me to have Girl Scouts. faith in God and reach my ultimate goal of walking independently by working hard. My future aspirations include attending a UC or Ivy League college where I plan to major in Creative Writing, and then furthering Since that time, I have continued to strive and push my education by obtaining a Master’s Degree in it. With that, I myself along closer to my goal. Although I have come hope to fulfill another lifelong dream of mine: becoming a writer. across many challenges, which block my path to success, (It has been my dream since 3rd grade). I have conquered them all with my strong determination and perseverance. Even though I have to deal with school and therapy, I still manage to have a social life. In my free time I enjoy reading, writing in my Every experience I have had, whether good or bad, journal ,as well as writing short stores, songs and poems, community has taught me valuable lessons, which I will carry with theatre, watching TV, and sleepovers with friends or going to the me for the rest of my life. One particular experience mall. I also enjoy going to Laguna Beach with my family. stands out in my mind right now. When I was in 6th grade, I went through a brutally painful hip surgery. I I would not be where I am today without the loving support of also had to have a blood transfusion, which was my family (especially my mom), friends and teachers. They all especially horrifying for an 11-year-old girl. The doctors have helped me in some way to guide me along the path of told me I would never be able to walk with my walker success. again. But I proved them all wrong. Within two months of getting out of my body cast, I was walking using my My message to all kids, teens and adults everywhere is to always walker again. I was extremely motivated and that’s what believe in yourself and no matter what your challenges are know kept me going. that success comes with hard work and dedication. I have tried many different types of “alternative” Although being a teenager with a disability isn’t easy, I’m always therapy and have traveled around the world to seek ready to conquer any new challenge I face because it’s my life. Cerebral Palsy Magazine March 2004 31

TREATMENT METHOD Hyperbaric Oxygen Treatment in Improved blood flow to the cerebral hemispheres is well Cerebral Palsy documented. However, there is still no extensive research to prove the second hypothesis of the HBOT. According to this Part 2 theory, increased oxygen supply to the brain tissue supports the “dormant” brain cells. Those are the brain cells that are by Izabela Koscielny there, but do not perform any function. They are in the “sleeping” state. Once the oxygen level increases, those cells “awaken” and can take over the function that was previously performed by the ischemic cells. These conclusions are based mainly on clinical observations. There have been many different research studies performed SPECT before and after to prove the effectiveness of HBOT. Still, there is a big question: how does it help to treat CP? (SPECT- Single Positron Emission Computed Tomography) Dr. P. Harch is the very first in the United States to use HBOT for Cerebral Palsy and brain injured individuals. Dr. Harch Is the age of an individual with CP relevant in the HBOT? first used SPECT scan to document the changes in the brain According to the data collected and studied by Dr. Harch and caused by HBOT. There is no doubt that oxygen delivered in Dr. Neubauer, as well as other specialists, SPECT scan increased pressure speeds up the healing of wounds. Based performed before, during and after the HBOT revealed that on the same hypothesis, Dr. Harch introduced HBOT to the younger patients had higher blood flows, but not more indivuduals with CP in 1992. improvement than the older patients. The theory behind it is quite simple. The damage to the brain that occurred before, during, or after birth results in various ischemic changes of the brain tissue. One of them is scar tissue build up. The scar tissue and the immediate area of brain tissue are very poorly vascularized. The blood flow to that part of the brain is non existing or severely impaired. One of the well known phenomenon of HBOT is that it promotes angiogenesis. This is the process in which new capillaries are formed, and thus the blood flow improves. The blood delivers precious nutrients and most important oxygen to the previously damaged tissue. This again improves the metabolism of that part of the brain. Dr. Neubauer performs the SPECT Scan before and after the HBO treatments. Before the HBOT is administered, the SPECT Scan usually reveals hypoperfusion, and as a consequence, decreased oxygen supply to certain parts of the brain. After the HBOT is accomplished, another SPECT Scan reveals significant improvement in the flow of the blood to the cerebral hemispheres. 32 Cerebral Palsy Magazine March 2004

TREATMENT METHOD What can I expect from HBOT? On top of the spasticity reduction, Dr. Machado noticed The results of HBOT will vary among all individuals. improved motor planning, balance and cognition. Some will show decreases in spasticity, while others demonstrate gains in speech, improvements in cognitive skills, This is where we all can clearly see the tremendous need functional movement or better balance. Improvements in vision for more in depth studies. While one scientist’s observations are noted quite frequently as well. show positive changes, but not lasting, the other one has a Overall, there is no predictability of the outcomes with HBOT. dramatically different conclusion. The human brain is very complex and unique just like all the Dr. Barrett, Professor of Hyperbaric Medicine (University of individuals diagnosed with CP. Texas) reports a modest decrease in spasticity measured by the Ashworth scale, improvements in motor skills as What are the side effects of HBOT? demonstrated by the use of the Gross Motor Functional The most common side effect is the barotrauma to the middle Measure Scale. A very controversial Canadian study (McGill ear (Cornell Study, presented in November, 2000).Usually study), revealed no major results between the two groups. The treatment is discontinued until the pain and inflammation frequently asked question while interpreting this study is its subsides or the tubes equalizing the pressure need to be inserted. accuracy. Two groups of children were tested. One received Middle ear barotrauma is not the only side effect. true HBOT,100% oxygen delivered at 1.75ATA, while the Studying different research protocols you can find information others received air at 1.3 ATA. about children withdrawn from the study because they developed seizures (Cornell). Acording to Dr. Paul Harch, the If you had a chance to read the first part of this article in highest expression of oxygen toxicity manifests in a form of the previous issue of Cerebral Palsy Magazine, you can seizure activity. There is also a documented case of developing clearly see that even pressurized air has high therapeutic a cerebral infarction due to an oxygen embolism during the effects. Therefore, a comparison of better and best is not quite decompression phase of treatment (Nuthall et al, Pediatrics, appropriate. The improvements were noticed in both groups 2000;106:E80). Some lung problems have also been and according to Dr. Marois, the only way to find out the truth documented. would be to start a new study. Contraindications to HBOT Hyperbaric Oxygenation Therapy is not intended to cure According to The Newsletter of The Children’s Hospital Cerebral Palsy. It is merely an attempt to bring the individuals Physical Medicine and Rehabilitation, Denver, Colorado, suffering form Cerebral Palsy and other conditions alleviation Winter 2002, Volume 5, Issue 1, the following are the in symptoms. A thorough medical examination prior to HBOT contraindications to HBOT: is highly recommended. - Upper Respiratory Infections - Chronic Sinusitis References: - Poorly controlled seizure disorder 1. The Newsletter of The Children’s Hospital Physical Medicine Do the effects last? and Rehabilitation, Denver, Colorado, Winter 2002, Volume 5, Dr. Packard presenting the Cornell study reports improvements Issue 1 in motor skills, attention, language and play. In the follow up 2. The Cornell Study, presented by Dr. Maurine Packard at the check-up (6 months), it was found that the previous gains in University of Graz, November 2000 attention, language and play remained. The level of spasticity, 3. Nuthall et al, Pediatrics, 2000; 106:E80 previously decreased, returned. The other case study 4. Kevin Barrett, MD., A pilot study performed by Dr. Machado from Brazil reveals that the 5. McGill study, Hyperbaric Oxygen Study In Canada, October 2000 reduction of spasticity was very significant and was observed 6. Hyperbaric Oxygenation for Cerebral Palsy and the Brain Injured in 94.78% ( out of 218 cases).The spascticity was reduced by Children, James T. Joiner 50%. According to Dr. Machado, in the follow up (that took 7. Cerebral Palsy Magazine, December 2003,Voume 1, Issue 3 place 6 months or more after the original base line was 8. Machado, J.J., Clinically Observed Reduction of Spasticity in established), the spascticity reduction persisted in 75.6 % of Patients with Neurological Diseases and in Children with the patients. Cerebral Palsy from HBO To find the position of the American Academy for Cerebral Palsy and Developmental Medicine on HBOT, please visit: www.aacpdm.org/library/HBOT_Statement_AACPDM.htm Cerebral Palsy Magazine March 2004 33

TREATMENT METHOD METHOD OF NEUROSURGICAL TREATMENT OF CEREBRAL PALSY Svadovskiy Alexander, MD, neurosurgeon and neurologist Neuroaesculap Clinic, Moscow, Russia During many years thousands of specialists, including The patients with such a temperature anomaly were neurosurgeons, have researched and treated a disease laminectomized in the region of the cervical part of the vertebral called infantile Cerebral Palsy (CP). At the same time column. That revealed the presence, in this or that degree, despite all achievements in neurosciences signs of chronic epidurites (the missing of epidural fat and/or (neurosurgery is one of them), no significant result in its iatrical degeneration), small multiple breaks of dura mater CP understanding and its treatment has been achieved. encephali, and the fluid flowing through these small breaks. Using this method, we operated on 12 patients from the age In my clinic I deal with neurosurgical and neurological of 3 to 15 years old who had changes in the cervical segment pathology and constantly get in touch with patients, children shown during the thermo visiual examination. The majority of and adults, suffering from CP, who ask for an examination and possible those patients during the preoperative treatment. The overwhelming majority period were not able to move, or of such patients had a spastic form of were moving about only with outside the disease (Tetra/hemi Syndrome). A help. thorough examination of those CP patients, with the application of CT, During the post operative period MRI, ultrasound methods, EEG, and it was observed that all patients had lumbar puncture with liquorodynamic significant improvement (progress) of tests did not reveal any sign of their motor functions with the regress compression of any parts of the brain of Tetra/hemi Syndrome and brain and spinal cord. In other words, there stem signs, improvement with were no classic (evident) indications psychical functions including speech, for neurosurgical intervention. and a decreasing of the gap in their intellectual development. Other However, when examining a group positive symptomatic improvements of CP patients by means of a modern included pelvic organ functions. As digital thermovizor (a posterior surface a rule, patients stay at the clinic for of the vertebral column was examined), two weeks. a distinctive abnormal fall of the temperature was registered in the We consider the epidural space region of the cervical segment of the an important anatomical and vertebral column and paravertebrally, functional formation, which as well as in the extremities affected. participates in the formation of blood flow in the spinal cord and it’s roots, We regarded those facts as a probable latent and non- mainly of its venous constituent. The evident lesion of the cervical segment of the vertebral injury of the epidural space (in that case in the form of chronic column and its roots, caused by something unknown before. epidurites) causes ischemia of the spinal cord and roots, as Later that was proved to be completely correct. well as their dysfunction. Besides taking into account the anatomic and functional links of the cervical sector of the 34 Cerebral Palsy Magazine March 2004

TREATMENT METHOD spinal cord with the brain stem and further up with the major In comparison with a well-known neurosurgical hemispheres, and down – to the thoracolumbar segment, we intervention – selective dorsal rhizotomy (SDR), our method can explain the improvement of neurological functions, not of treatment does not imply direct manipulation on the spinal only due to the cervical sector of the spinal cord, but due to cord roots and their curtailing............ ................................ the total improvement of the central nervous system (CNS) Laminectomy, as the way of posterior access to the vertebral functions (brain and spinal cord). canal and its contents, is well-known. At the same time we can not consider laminectomy a routine neurosurgical In our opinion, chronic epidurites can be caused by various factors, treatment, as CP including intrauterine patients are in a state of and/or birth injury. lingering ischemia of the Thus, laminectomy is the spinal cord and it’s main type of treatment roots, as a result of the for this form of CP and chronic epidurites. In it results in significant our clinic we take improvement of the some medicament psychomotor functions. precautions during the If a neurosurgeon perioperation period. apprehends the danger During the neurosurgical of instability in the intervention through the cervical sector of the multiple breaks of the vertebral column during dura mater encephali, the postoperative we observed in the period, a special dorsal surface of the stabilizing construction spinal cord the dynamics made of metal or other ofthecolorchanging–fromwhite(beginningofthe laminectomy) compatible materials can be fixed after the laminectomy is to bright red after its termination. We suppose those spinal cord finished. We have never used such construction, as there were dorsal surface color changes are connected with the no indications for it. development of so called post ischemic hyperperfusion, which is developing in the spinal cordandrootspreviously ischemized. We are concerned that only a maximally complete and So, the most probable expected complication of clinical complex medical examination of CP patients will let us get to significance is a syndrome of the postischemic hyperperfusion, that very segment of the CNS, which is really affected and though it is not clear yet how many surgical patients will have causes the motor, psychical and other kind of deficiencies. postischemic hyperperfusion, and what way it will manifest Our method of neurosurgical treatment of CP has never itself. resulted in negative outcomes in the neurological aspect, A contraindication to our method of CP treatment is the meaning motor functions and other systems. There have been lack of convincing results of the patient’s cervical segment of no lethal terminations. the spinal column examination with the thermovizor, as well as general clinical reasons, meaning obvious pathology of the For the first time, this way of neurosurgical treatment of internal organs. CP was successfully applied in 1998, then in 2002, we took Our clinic does not practice post-operative rehabilitation out the patent for this method of treatment. In 2003 it was therapy. Our aim is to examine thoroughly our CP patients patented in the United States. Continued on page 36 Currently for the surgery we take children of 3-5 years old. We plan to treat CP adults as well. In the latter case, the recovery period is likely to be longer than that of children. It goes without saying, that our method can be applied only after a thorough examination of the CP patient. Cerebral Palsy Magazine March 2004 35

TREATMENT METHOD and determine the indications for the surgical treatment, Address: according to our method. Sherbakovskaya 50/52 str. Moscow,105187 The cost of the treatment is individual and depends on the Russia complication of every case, the risk rate during the neurosurgical intervention, and can not be less than $100.000. Tel. +7 095 3695550 / 3695560 Agreement between patient or one of the parents is needed for admission. The author of the method and the holder of the patent for the intellectual property is Svadovskiy Alexander, Doctor of Medicine, neurosurgeon and neurologist. Svadovskiy Alexandere, MD, has 20 years of experience, more than 40 scientific works published, as well as 8 patents, and is head of his own private clinic. For more information, please contact: Dr. Svadovskiy Alexander, MD Our web-site:www.neuroaesculap.ru (Eng. version under constr.) E-mail: [email protected] 36 Cerebral Palsy Magazine March 2004

TREATMENT METHOD Cerebral Palsy Magazine March 2004 37

TREATMENT METHOD The Institutes for the Achievement of Human Potential Doman - Delacato method F=HJ What I learned about brain development in crawling, a child’s injured brain might not know how to direct one week and how it helped me raise and teach the complex movement so essential for brain development, but my brain-injured child that doesn’t mean that if given the right opportunity, intensity and frequency, their brain is not capable of learning. By Krisztina Kincses Vida During that wonderful week in Philadelphia, I really began to understand that the key to helping our kids is to CREATE When people ask me about the week-long training program maximum opportunity and to ESTABLISH the right I attended years ago at the Philadelphia Institutes for the environment for their brain to grow and develop. Achievement of Human Potential, I always tell them that it was the best week of my life. No, I didn’t discover a magic Like any other parent looking for effective therapies, I have cure to teach my son Daniel, now 8, to speak or to walk (YET!), researched many alternative methods. My experience has but I did learn perhaps the single most important lesson in my proven time and again that what Glenn Doman taught me— unending quest to figure out what to do with my brain-injured and has taught thousands of others—is true. As a result of child. The lesson was (and I still carry it with me) that the incorporating Doman’s approach into his daily routine, Daniel, brain, even the severely injured brain, CAN BE TRAINED!!! who has very low muscle tone, and in the first year of his life couldn’t even hold his head up, now crawls independently and The founder and leader of the Institutes, Glenn Doman, has is learning to walk. He uses a gait trainer, rides an adaptive spent decades working with children and adults with disabilities, bike and can stand by holding on to a bar. and has devised a very strict program to rewire their brain and to speed up the process of brain development. Instead of describing the program in detail, I want to share with you what I learned and what still helps me deal with the challenges of raising and teaching Daniel to do all the things that he has the potential to learn. Glenn Doman’s method is based on his philosophy that brain growth is a dynamic process. He and his staff believe that the brain has infinite potential and, in some cases, needs to be taught to grow and develop through many, varied experiences for proper development. He says that repetitive—endlessly repetitive—visual, auditory and tactile stimulation is the way to train this miraculous muscle that in children with any kind of brain injury requires much, much, much more exercise than parents are told or would like to accept. For instance, in normal development, the young brain controls the motion of crawling, but Doman’s principles of brain development recognize the two-way cause and effect relationship—that the repeated movement of crawling actually teaches the brain to learn and eventually control the crawling. In the case of our kids, the body needs to do more teaching of the brain than in others. Staying with the example of 38 Cerebral Palsy Magazine March 2004