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By T. Rocko. Vanderbilt University.

Dependence upon equipment is contin- ually reduced until the individual achieves as much independence as possible buy generic confido 60caps line. The development of gait trainers with a high degree of modularity has been driven in part by the philosophy of the MOVE program to have children up weight bearing and moving in the device purchase 60 caps confido with visa, which gives the amount of support the child needs effective confido 60 caps. The goal is then to gradually reduce the amount of support as the child develops strength and motor skills. An important aspect of the MOVE program is the ability to get individuals into weightbearing positions, which is difficult for adult-sized adolescents. The development of mechanical lift walkers makes this process much easier for the caregivers. Rehabilitation Techniques 831 MOVE is designed to embed mobility skill practice into functional every- day routines. As a result, MOVE can occur at school, in a facility, at home, or in the community, thus providing opportunities for multiple repetitions. MOVE is successfully implemented by therapists, educators, paraprofes- sionals, parents, and anyone who interacts with the individual. The structured teaching approach used in the MOVE curriculum is val- idated in the article, Mobility Opportunities Via Education (MOVE): Theo- retical Foundations, by Barnes and Whinnery,36 which describes its use of natural environments, functional activities, scaffolding, partial participation, and use of contemporary motor theories related to teaching functional mo- bility skills. Leach School, the nation’s first MOVE model site, completed a pilot study in 1998 to evaluate the effectiveness of the MOVE curriculum. Eleven students (ages 4 to 18 years) with a variety of severe disabilities par- ticipated in the six steps of the MOVE program. After a 5-month period of instruction, improvements in sitting, standing, and walking were achieved. Improvements were also noted in the areas of communication, alertness, and overall health. Because of the success of the pilot program the MOVE cur- riculum was adopted for schoolwide use. For example, a 5-year-old boy with a diagnosis of Cornelia–DeLang syn- drome began the MOVE program at Leach School because he was nonweight bearing and intolerant of positions other than supine, as well as unable to communicate or play with his peers and siblings. Following daily practice in a mobile stander, he increased his tolerance for weight bearing. As support from the equipment was reduced, the student was able to practice standing as part of his classroom routines such as diaper changes and getting in and out of his classroom chair. Over a 3-year period he progressed from walking with full support in a gait trainer to walking with one hand held or pushing a forward rolling walker. This gain has led to increased social interaction and independent exploration of his environment.

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Trace the path of a light ray from the outside of the veals that the tympanic membrane is red and bulging out- eye to the retina order 60caps confido fast delivery. Define convergence and accommodation and de- does Maria have? Why is the incidence of this disorder scribe several disorders associated with them cheap 60 caps confido with mastercard. List in order the structures that sound waves pass tions are available to Maria? You and a friend have just finished riding the roller hearing order 60caps confido with visa. Compare and contrast conductive hearing loss and the ride, your friend stumbles and comments that the ride sensorineural hearing loss. It is divided into right and left cerebral (SER-e- bral) hemispheres by a deep groove called the longitu- and Spinal Cord dinal fissure (Fig. Each hemisphere is further The meninges (men-IN-jez) are three layers of connective subdivided into lobes. The outermost of tween the cerebral hemispheres and the brain stem. It these membranes, the dura mater (DU-rah MA-ter), is the includes the thalamus and the hypothalamus. The superior portion of tion of the meninges; dura means “hard. Inferior to the midbrain brain, the dura mater is in two layers, and the outer layer is the pons (ponz), followed by the medulla oblongata is fused to the bones of the cranium. The pons connects these two layers separate to provide venous channels, the midbrain with the medulla, whereas the medulla called dural sinuses, for the drainage of blood coming connects the brain with the spinal cord through a large from the brain tissue. The middle layer of the meninges is the arachnoid (ah- ◗ The cerebellum (ser-eh-BEL-um) is located immedi- RAK-noyd). This membrane is loosely attached to the deep- ately below the posterior part of the cerebral hemi- est of the meninges by weblike fibers, allowing a space for spheres and is connected with the cerebrum, brain stem, the movement of cerebrospinal fluid (CSF) between the two ANTERIOR POSTERIOR CEREBRUMCEREBRUMCEREBRUM Corpus callosum DIENCEPHALON: Thalamus Sagittal plane Hypothalamus Pituitary gland BRAIN STEM: Midbrain Pons Medulla oblongata Spinal cord CEREBELLUM Figure 10-1 Brain, sagittal section. THE NERVOUS SYSTEM: THE BRAIN AND CRANIAL NERVES 203 Table 10•1 Organization of the Brain DIVISION DESCRIPTION FUNCTIONS Cerebrum Largest and uppermost portion of the brain Cortex (outer layer) is site for conscious Divided into two hemispheres, each subdi- thought, memory, reasoning, and abstract vided into lobes mental functions, all localized within specific lobes Diencephalon Between the cerebrum and the brain stem Thalamus sorts and redirects sensory input; Contains the thalamus and hypothalamus hypothalamus maintains homeostasis, controls autonomic nervous system and pituitary gland Brain stem Anterior region below the cerebrum Connects cerebrum and diencephalon with spinal cord Midbrain Below the center of the cerebrum Has reflex centers concerned with vision and hearing; connects cerebrum with lower 10 portions of the brain Pons Anterior to the cerebellum Connects cerebellum with other portions of the brain; helps to regulate respiration Medulla oblongata Between the pons and the spinal cord Links the brain with the spinal cord; has centers for control of vital functions, such as respiration and the heartbeat Cerebellum Below the posterior portion of the cerebellum Coordinates voluntary muscles; maintains Divided into two hemispheres balance and muscle tone membranes. The innermost layer around the brain, the pia mater (PI-ah MA-ter), is attached to the nervous tissue of the brain and spinal cord and follows all the contours of these Checkpoint 10-2 The meninges are protective membranes around the brain and spinal cord. What are the names of the three structures (see Fig.

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None of these systems has gained wide acceptance for clinical use cheap 60caps confido with amex. Another very old technique is to measure the H-response generic 60caps confido visa, which is a nerve potential recorded in the motor neuron that occurs when a sen- sory nerve in close proximity is stimulated generic 60caps confido free shipping. The amplitude of this H-wave is thought to reflect the excitability of the alpha motor neuron (Figure 4. This measurement has been correlated to hyperreflexia, but does not correlate well with the Ashworth scale7, 10; therefore, we still are using the modified Ashworth scale for clinical evaluation of spasticity. Spasticity Spasticity is the most common presentation of all neurologic alterations in children with CP. Increased muscle tone expressed as spasticity must be a very strong chaotic attractor to the organization of residual activity in a child with a central neurologic injury. It is very difficult to understand what the components of the system are that make this spasticity such a strong attrac- tor. Because it has persisted in humans but is seldom seen in animals, this 106 Cerebral Palsy Management Figure 4. The effect of spasticity on the growth and development of skeletal muscle re- sults in a muscle that has fewer muscle fibers, shorter fiber length, and a longer tendon. This aberration results in a muscle that is weaker because of decreased cross-sectional area and has less excursion, resulting in de- creased joint range of motion because of the shorter fiber lengths. Even though spastic- ity is a strong chaotic attractor, any judgment about its benefit or harm to an individual cannot be made. From modern robotic research, it is known that adding stiffness to joints helps improve fine motor control; and also everyone has experienced a tendency to stiffen when wanting to do very fine delicate movements with their hands. It seems most conceivable that, on the whole, when the neurologic system loses some function but its organization still has the ability, muscle tone will increase to allow function with a lower degree of neurologic control. Therefore, when treating children with spas- ticity, the basic supposition is that muscle tone is good and the amount of muscle tone should be modulated for their maximum benefit. Effects of Spasticity on Nerves Because the lesion in CP is central, all other more distal changes are pre- sumed to be secondary. The best recognized change in spasticity is hyper- reflexia, which occurs because of a decreased inhibition from the cortical spinal tracts. As a normal child grows, the rate of muscle contraction and the ability to increase power by cerebral cortex modulation continues to in- crease until the child is approximately 10 years old.

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