Developing Mid-Range Control and Function in Children with Fluctuating Muscle Tone

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4OT1 9.23.33.35.48(第七組)
 Basic Problems of the Child with Athetosis 手足徐動症兒童的基本問題 P4~6
1. Early signs: 第一點：早期症狀
The child often begins life with a hypotonic base and may resemble the premature infant in
tonal qualities.
兒童患者常常以低張力基底開始生活，其張力特質可能類似於早產兒。
This low tone base may be evident for the first two to three years of life.
這種低張力基底可能會在生命的頭兩到三年內明顯表現出來。
As the child grows older and attempts more movement, the fluctuation in tone ; surfaces as
sudden stiffening of muscles and intermittent spasms.
隨著孩子年齡增長並嘗試更多的運動，張力波動會出現，表現為肌肉突然僵硬和間歇性痙攣。
The child may begin to use marked extension of head, spine, and hips in supine and
supported sitting.
孩子可能開始顯著地伸展頭部、脊柱和髖部，無論是仰臥還是支持坐位。
Head control will be difficult in all positions and the child may not tolerate the prone
position.
頭部控制會很困難，並且孩子可能無法忍受俯臥姿勢。
As the fluctuating tone continues to emerge, asymmetrical posturing of the head, neck, jaw,
and shoulders may become a major long-term problem.
隨著波動性張力的持續出現頭部、頸部、下顎和肩部的不對稱姿勢可能成為長期問題。
The degree of involvement and the type of tonal dysfunction will vary greatly among
children.
不同孩子的受累程度和張力功能障礙的類型差異很大。
When central nervous system damage is extensive, the child begins life with significant
feeding and respiratory difficulties.
當中樞神經系統損傷範圍廣泛時，孩子在出生時會有明顯的喂養和呼吸困難。

2. Quality of tone: 第二點：張力質量

Fluctuations in the child's postural tone are sudden and cause movement in extreme ranges.
孩子姿勢張力的波動是突然的，並且會在極端範圍內引起運動。
The child is unable to generate and time the appropriate amount of stiffness where it is
needed in the body to achieve function.
孩子無法在需要的部位生成並適時調節適當的僵硬度以實現功能。
The Bobaths describe this as an inability to grade antagonistic activity during movement.
Bobath 形容這種情況為運動過程中無法調節拮抗性活動。
Instead, contraction of one group of muscles leads to complete relaxation of the
opposing group.
相反，某一組肌肉的收縮導致對側肌群完全放鬆。
For example, as the child activates spinal extension, the trunk flexors do not slowly elongate
and therefore do not grade the intended movement.
例如，當孩子激活脊柱伸展時，軀幹屈肌不會慢慢延長，因此不能調節預期的運動。
Consequently, as the child extends the spine to move the body into an upright position, the
unopposed extensors forcefully pull the child backward.
結果，當孩子伸展脊柱以將身體移至直立姿勢時，未對抗的伸肌強力地將孩子後拽。
It appears as if the child is throwing the body backward.
這似乎使孩子的身體向後扔。
When the child attempts to bring the body forward, the trunk flexors activate unopposed by
the extensors and the child produces a total flexion pattern.
當孩子試圖將身體向前拉時，軀幹屈肌在沒有對抗的伸肌啟動下，孩子會表現出完全的屈曲模式。

3. Quality of movement: 第三點：運動質量

In general a variety of involuntary movements can occur as the child attempts to coordinate a
purposeful movement.
一般來說，當孩子試圖協調有目的的運動時，可能會出現各種不自主運動。
In an attempt to control these involuntary movements, the child uses strong asymmetry as a
point of stability and consequently moves with poor alignment of head, trunk, and limbs.
為了控制這些不自主運動，孩子常使用強烈的不對稱作為穩定點，因此頭部、軀幹和四肢的對準通常較差。
One side of the body is usually more involved than the other, and arms are usually less
functional than legs.
身體的一側通常比另一側參與更多，而手臂通常比腿的功能差。
Manual skills are very difficult because there is little grading of the flexors and extensors in
the lower arm and hand.
由於前臂屈肌和伸肌的調節較少，手部操弄技巧非常困難。
The child may posture strongly in wrist flexion with extended and weak fingers.
孩子可能會強烈地表現出手腕屈曲、手指伸展無力的姿勢
Righting, equilibrium, and protective responses are poorly developed and may continue to be
limited throughout life.
翻正、平衡和保護反應發育不良，可能會在一生中持續受限。
The child is unable to work off the base of support because the hips are not dynamically
mobile in sitting and the feet are poorly aligned in standing.
由於髖部在坐姿中不能動態地支撐，且站立時雙腳對齊不良，孩子無法利用支撐基底來活動。
Standing and walking will depend on the degree of involvement in the legs as well as the
level of head control.
站立和行走取決於腿部的參與程度以及頭部控制的水平。
The lack of isolated movement in the legs may lead to "bunny hopping," rather than a
mature use of quadruped
腿部缺乏單獨的運動可能會導致“兔跳”現象，而不是成熟的四足運動。
Consequently, when attempting to walk, the child will collapse into flexion as each step is
initiated.
因此，在嘗試行走時，孩子在每步開始時會陷入屈曲狀態。
Due to inadequate control of the head, visual control is poorly developed.
由於頭部控制不足，視覺控制發育不良。
The child has difficulty separating eye movements from head movements.
孩子難以將眼睛運動與頭部運動分離。
Because the child experiences involuntary movements of the head and neck, difficulty
maintaining visual contact with objects will be experienced.
由於孩子頭部和頸部的不自主運動，維持物體的視覺接觸會有困難。
Visual scanning will be poorly controlled as well.
視覺掃描也會受到控制不良的影響。
Visual convergence relies on development of head flexion on neck.
視覺會聚依賴於頭部對頸部的屈曲發展。
Conseguently, the child may depend on monocular rather than binocular visual control.
因此，孩子可能依賴單眼而不是雙眼視覺控制。

4. Respiration: 第四點：呼吸
Fluctuations in muscle tone impact on respiration as well as whole-body movement.
肌肉張力的改變會影響呼吸以及全身運動。
Breathing is irregular, creating difficulty in coordinating phonation with respiration.
呼吸不規律，導致很難將發聲與呼吸協調一致。
Phonation fluctuates in volume and pitch.
發聲的音量和音調也會改變。
The ability to initiate sounds is unpredictable.
發聲的起始能力無法預測。
The child may attempt to stabilize the respiratory mechanism by holding strongly with the
pectorals, rectus abdominis, and hip flexors.
孩子可能會嘗試通過強烈使用胸大肌、腹直肌和髖屈肌來穩定呼吸機制。
Over time, this holding pattern can create joint immobility in the pelvis ,spine and rib cage.
隨著時間的推移，這種用力模式可能會導致骨盆、脊柱和肋骨的關節僵硬。
The inability to communicate is a major area of frustration for the child and others.
由於無法交流，這成為孩子和他人的主要挫折來源。
Since many levels of movement are experienced, the child's system is consistently very alert.
由於經歷了多種程度的運動，孩子的系統始終處於高度警覺狀態。
Consequently, the central nervous system is gathering a great deal of information from all the
sensory channels.
因此，中樞神經系統從所有感官通道收集了大量信息
The child tends to respond to input quickly and there is little time to categorize and integrate
the information.
孩子對輸入的反應迅速，幾乎沒有時間對信息進行分類和整合。
Without a means to communicate with others, the child has no way to verify perceptions of
the world. There is no opportunity to ask
沒有與他人交流的手段，孩子無法驗證對世界的認知。
"What is that?" or "Why?" Without communication, the child's needs cannot be expressed.
沒有機會詢問“那是什麼？”或“為什麼？”沒有交流，孩子的需求無法表達。
5. Oral motor: 第五點：口腔動作
Fluctuating muscle tone is reflected in the oral motor mechanism.
肌肉張力的改變會反應在口腔機制中。
Lip, cheek, and tongue retraction are associated with head and neck hyperextension.
嘴唇、臉頰和舌頭的後縮與頭部和脖子的的過度伸直有關。
The child will attempt to cope with lack of oral control by using an exaggerated jaw closure,
lip pursing, and tongue thrusting.
孩子會試圖使用下頜閉合、嘴唇收縮和舌頭前伸來應對口腔控制的不足。
The child may also gain stability by holding the tip of the tongue against the hard palate.
孩子還可能將舌頭壓在上腭取得穩定。
Oral hypersensitivity may be expressed as involuntary tonic biting with a generalized
increase in whole body extension.
口腔過度敏感可能為不自主的咬合，增加全身伸直。
Eating is often the most difficult activity to manage, both for the child and the adult offering
the food.
進食通常是最難管理的活動，無論是對孩子還是提供食物的大人。
The child's whole body must be properly positioned during feeding.
進食時孩子的整個身體必須擺位正確。
Presentation of food must be carefully graded as the child tends to overreact to the activity. 食
物必須小心分級，因為孩子對這種活動會反應過度。
The child must be given adequate time to coordinate swallowing with breathing, particularly
when liquids are offered.
孩子必須有足夠的時間去協調吞嚥和呼吸，特別是在喂流體食物時。
Because the child's body is in a high state of motion, caloric input needs to be balanced with
output.
由於孩子的身體處於高度運動狀態，所以熱量攝取需要與消耗平衡。
Nutritional counseling may be needed to provide suggestions for high-calorie foods to meet
these needs.
可能需要營養諮詢提供高熱量食物以滿足這些需求。
Facial expressions are often misinterpreted because the fluctuating tone creates a grimacing
effect.
臉部表情經常被誤解，因為變動的肌肉張力會產生一種扭曲的效果。
The child may appear to be expressing"yes" when trying to express "no."
孩子可能在試圖表達「不」時，看起來像在說「是」。
Augmentative communication systems should be introduced as early as possible.
增強性溝通系統應盡早介入。
6. Possible deformities: 第六點：可能的變形
Since the child's basic tone is often hypotonic, joints are hypermobile.
由於兒童的基礎張力通常較低，關節超出正常活動範圍。
This puts the child at risk for subluxation of the hips, shoulders, fingers, and mandible.
這使得髖關節、肩膀、手指和下頜骨半脫位的風險增加。
Scoliosis and flexor deformities of the elbows, wrists, hips, and knees are possible in those
children who have a combination of fluctuating tone and spasticity.
有肌張力波動和痙攣的孩子，可能會出現脊椎側彎以及手肘、手腕、髖關節和膝關節的屈曲變形。
This should be monitored carefully by the clinician.
臨床醫生應仔細監控這些情況。
Shortened heel cords are also a common problem and may be managed with orthoses.
跟腱縮短也是常見問題，可以用裝具來處理。
7. Personality characteristics: 第七點：性格特徵
Unpredictable postural tone is associated with unpredictable emotional responses.
不可預測的姿勢張力與不可預測的情緒反應有關。
The child tends to shift quickly from one emotional state to another.
孩子往往會迅速地從一種情緒狀態轉變為另一種情緒狀態。
A sudden outburst of anger may be quickly followed by uncontrollable laughter.
憤怒的突然爆發可能會很快伴隨著無法控制的笑聲。
The child tends to overreact to social situations as well.孩子也常對社交場合反應過度。