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Gross motor development in children is commonly described as the acquisition of motor milestones such as unsupported sitting, crawling, and walking. A child with cerebral palsy will be recognized by delayed gross motor development and the presence of abnormal movement and postural patterns. (Woollacott MH et al., 1996). A population-based study reported that about half of the children have mainly motor function affected, whereas the remainder also had accompanying major impairments adding to the disability, which affected the several areas of activity and participation (Himmelmann et al. 2005, WHO 2001).
An important physical therapy treatment approach for children with cerebral palsy is Neurodevelopmental treatment (NDT), a neurophysiological approach that aims at maximizing the child's potential to improve motor competence and to prevent musculoskeletal complications (Ottenbacher et al. 1986, Mayston 1992, Barry 1996). NDT is based on conceptual model devised by the Bobath's in 1940 (Bobath 1980, Bobath and Bobath 1972, 1984) and has achieved popular acceptance through its empirical appropriateness. This approach focuses on encouraging and building upon normal movement patterns and normal postural reactions, while trying to reduce abnormal movement (Scherrer AL 1982, Bobath B, Bobath K.1975).
Myofascial restrictions can occur through prolonged poor postures and movement patterns in children with cerebral palsy (Satalino, Lisa PT 2009). It can take 3-6 months following postural stress for a myofascial restriction to develop. When fascia is inflammed or under stress, it shrinks and the normally wet gelatinous ground substance that gives fascia its glide becomes hardened and binds down the tissue. This reduces the ability to absorb compressive forces. The restricted fascia get hardens and there is a entrapment of soft tissues under the fascia. The abnormal strain pattern pulls the osseous structures in to improper alignment and thus creates asymmetry of the skeleton (Barnes JF 1990).
In Myofascial release, a slow and sustained gentle pressure is applied which allows the viscous medium to flow. This phenomenon is called viscous flow phenomenon, which is having an impact in the body collagen. Thereby barriers in the collagen are slowly released and there is a change in the tissue length (Satalino, Lisa PT 2009).
Myofascial tissue is continuous from head to feet of the body and so the application of Myofascial release technique is having a generalized effect on the whole body (Regi Boehme, OT). Using both Myofascial release and neurodevelopmental therapy approaches is essential; neither one is a replacement for the other. There will be a change in the fascial mobility after the Myofascial release technique which cannot be obtained with the other techniques like neurodevelopmental therapy. With the change in the fascial mobility, the underlying structures like muscles, tendons are also getting affected which facilitates the patient's potential for active movement (Diane Weis, PT).
There are several scales to assess Gross Motor Function in children with Cerebral Palsy. The criterion-referenced observational measure, GMFM - 88 was developed to evaluate the gross motor function in children with cerebral palsy (CP). The GMFM-88 is having 5 dimensions: first-lying and rolling; second-sitting; third- kneeling and crawling; fourth-standing; and fifth-walking, running, and jumping. It is a gold standard measure for gross motor function assessment in children with all types of CP ( Annika Lundkvist Josenby et al., 2009).
1.1 NEED FOR THE STUDY
Myofascial release is safe and effective technique, to be used along with other treatments like mobilization, exercise, flexibility program, Neurodevelopmental therapy (NDT), sensory integration (SI)
and movement therapy. The goal of Myofascial release in children with spastic cerebral palsy is improved skeletal alignment with active postural control and independent function.
Some of the studies have shown that the NDT approach is effective in improving measures of motor performance in children with cerebral palsy. Since there is scarce literature on the combined effects of NDT and Myofascial release on gross motor function in children with cerebral palsy, there is a need for incorporating it in my study.
To examine the effectiveness of Neurodevelopmental therapy with Myofascial release on gross motor function in children with spastic cerebral palsy
To examine the effectiveness of Neurodevelopmental therapy on gross motor function in children with spastic cerebral palsy
To compare the effectiveness of Neurodevelopmental therapy with Myofascial release and Neurodevelopmental therapy on gross motor function in children with spastic cerebral palsy
There is a significant improvement in gross motor function with Neurodevelopmental therapy and Myofascial release in children with spastic cerebral palsy.
There is a significant improvement in gross motor function with Neurodevelopmental therapy in children with spastic cerebral palsy.
There is a significant difference in gross motor function between the groups of spastic cerebral palsy children who undergo Neurodevelopmental therapy with Myofascial release and Neurodevelopmental therapy.
1.4 OPERATIONAL DEFINITIONS:
NEURODEVELOPMENTAL THERAPY: Neurodevelopmental therapy is a holistic approach dealing with the quality of patterns of coordination and not only with the problems of individual muscle function but also with the problems of development, perceptual-cognitive impairment, emotional, social and functional problems of the daily life as well (Bobath, 1990).
MYOFASCIAL RELEASE: Myofascial Release is an effective hands-on technique in which a gentle sustained pressure is applied to the restrictions in myofascial tissue to restore motion (John F Barnes 1990).
GROSS MOTOR FUNCTION: It is the ability to do the activities like walking, running, jumping, throwing, and maintaining balance by using large muscle groups. (Mosby's Medical Dictionary, 8th edition).
1.5 PROJECTED OUTCOME
Based on the literature review it is expected that there will be a significant difference on gross motor function within and between the group of children with spastic cerebral palsy who undergo Neurodevelopmental therapy with Myofascial release and Neurodevelopmental therapy.
CHAPTER - II
A Randomized Controlled Trail analyzed the effectiveness of osteopathy in the cranial field, Myofascial release, or both versus acupuncture in children between the ages of 20 months to twelve years with moderate to severe spastic cerebral palsy. There were three groups in the study: OMT, acupuncture, and control. Fifty-five patients were included in the study. Treatment outcomes were assessed using Gross Motor Function Measure (GMFM) and Wee FIM. In which GMFM and the mobility domain of Wee FIM showed a significant improvement. In acupuncture group, there was no improvement. And the study concluded that treatments using osteopathy in the cranial field, Myofascial release, or both improved motor function in children with moderate to severe spastic cerebral palsy (Burris Duncan et al.,2008).
In a case series, 10 children with mild, moderate or severe cerebral palsy underwent Rolfing Treatment, and the results were evaluated. Mildly impaired children made gains in velocity, stride length and cadence; the moderately impaired group made only minor gains in velocity; and the severely impaired did not improve by any of the criteria used in this study. The study concluded that rolfing technique was improved the performance in mildly affected cerebral palsy children (Jacquelin perry et al., 2008).
A study was done to evaluate the effects of Myofascial release on children with cerebral palsy. Modified Ashworth scale of spasticity was used to assess the spasticity in the upper and lower extremities of six children with cerebral palsy following an intervention utilizing Myofascial trigger point release techniques over a period of 6 months. Paired t test and 2-way Analysis of Variance was used. Benefits were observed in the children including decreased spasticity, improved body symmetry, improved tone, and improved range of motion, ambulation, alertness and cooperation. The study concludes that Myofascial trigger point release reduce the spasticity and improve the quality of life in children with cerebral palsy(Sandra L. Whisleret al., 2004).
In a case series, four children with cerebral palsy ranging from 2 to 12 years old were undergone Rolfing treatment. Each of the children experienced changes during and following the Rolfing series. A two and half year old began to walk after the fourth Rolfing session. A four year old that used a walker to move about was pulling up to things, walking along things, and making attempts to walk, a three year old with severe CP become more flexible in her spine. Her abdomen and rib cage evened out with the abdomen softening, the condition of hands and feet being extremely cold, lessened considerably. A twelve year old who had no gait control, begun to walk keeping her balance and moving forward (Cindy Potter et al., 1986).
A study investigated the effect of two different treatment interventions, Neurodevelopmental treatment (NDT) and practice, on postural control of children with cerebral palsy during a reaching task. Children with cerebral palsy with age ranges from 10 to 15 years are included in this study. The treatment protocol was five days of NDT and five days of practice. Postural assessment scale was used to evaluate the postural alignment. And the study concluded that NDT is more effective in improving the postural alignment during a reaching task (Campbell S et al., 1997).
In a repeated measures randomized block design, infants aged 4 to 12 months with posture and movement dysfunction where evaluated to find out the efficacy of a Neurodevelopmental treatment (NDT)-based sequenced trunk activation protocol for change in gross motor function used. The experimental group received a dynamic co-activation trunk protocol and the controlled group received a parent-infant interaction and play protocol. The Gross Motor Function Measure was used as an outcome measure. The NDT-based protocol group made significantly more progress than the control group from pretest to posttest (Sherry W. Andrt et al., 2008).
In a randomized, controlled clinical trial, a treatment group received the Neuro-Developmental Treatment-based intervention protocol, whereas the preterm control group received an identical amount of nonspecific handling. Outcome was assessed by the Neonatal Behavioral Assessment Scale and a Supplemental Motor Test designed to assess quality of postural control. The term control group performed significantly better on the motor performance cluster of the Neonatal Behavioral Assessment Scale. The preterm treatment group showed a significant performance in spontaneous behavior items. The study concluded that postural control in premature infants were improved by the NDT and there is no significant improvement in tone, behavioral state and automatic reflexes (Gay L Girolami et al., 1994).
A study investigated the effectiveness of neurodevelopmental treatment when used both in isolation and in combination with other developmental therapies. The data was analyzed using the literature review method. The analysis showed that the group who received NDT performed slightly better than the group who did not received the intervention (Kenneth J Ottenbecher et al., 1986).
In a randomized controlled trail, the effect of Neurodevelopmental treatment (NDT) and differences in its intensity on gross motor function of children with cerebral palsy was examined. Participants were 34 children with mild to moderate spasticity and hemiplegia, diplegia, and tetraplegia. The paired sample, which was obtained by ratio stratification where matching by sex, age, and distribution of impairment from a total of 114 children with CP. The children were assigned randomly in to two groups: group A underwent NDT twice a week and group B five times a week for 16 weeks. Gross Motor Function Measure was used as the outcome measure. The results revealed that Children in group B performed better and showed significantly greater improvement than those in group A (T Sorlakis N et al., 2005).
In a meta-analysis, they compared the efficacy of intensive versus nonintensive Neurodevelopmental treatment in children with cerebral palsy. In search methods, only the manuscripts in English were considered. They used Medline and Embase to identify all the Randomized Control Trail's published between January 1996 and July 2007 using extended terms of CP, NDT, rehabilitative, physical therapy approach, in infants, adolescents and GMFM. Four articles were fulfilled these inclusion criteria and entered in this study. They excluded the studies that included therapies not generally used in 'so-called' conventional therapy (i.e. constraint, taping). The results concluded that intensive neurodevelopmental treatment may improve the functional motor outcome in children with cerebral palsy (Carla Arpino et al., 2010).
CHAPTER - III
MATERIALS AND METHODOLOGY
Play items of various sizes and textures.
3.2 STUDY DESIGN
Pre test and post test design with two comparison treatments - A Quasi Experimental study design.
The study was conducted in the following settings.
1. Pediatric Physiotherapy Centre,
2. Ramakrishna mission vidyalaya,
International Human Resource Development,
3.4 POPULATION & SAMPLING
Children with Spastic Cerebral Palsy from PSG Hospitals and Ramakrishna mission vidyalaya, Coimbatore were chosen as population for the study. A total of 20 Spastic Cerebral Palsy Children were randomly assigned into 2 groups.
Group A - 10 participants. (NDT with Myofascial release)
Group B - 10 participants. (NDT only)
3.5 CRITERIA FOR SAMPLE SELECTION
1. Children with spastic cerebral palsy.
2. Age group 2 to 12 years.
3. Gross motor function classification system- level I, II and III.
5. Children who are able to follow simple commands.
3.5.2 EXCLUSION CRITERIA
1. Usage of anti-spasticity drugs.
2. Injection of Botulinum toxin during the study period.
3. Any orthopedic or neurological procedure during the study.
4. Uncontrolled epilepsy.
3.6. INSTRUMENT & TOOL FOR DATA COLLECTION
The Gross Motor Function Measure - 88 (GMFM-88) was used to measure the Gross Motor Function in children with Spastic Cerebral Palsy. It is a standardized observational instrument. It comprises of 88 items with five dimensions and scored as 0-does not initiate, 1-initiates, 2-partially initiates, 3-completes for each item.
3.7. TECHNIQUES OF DATA COLLECTION
During pre test, each child of both groups was evaluated by the Gross Motor Function Measure - 88 (GMFM-88), after obtaining the informed consent from their parent/caregiver. Group A underwent combined NDT and Myofascial release and Group B underwent NDT only as per the needs of the child. The post test was performed 4 weeks after the treatment with GMFM and the results were compared.
3.8. TECHNIQUES OF DATA ANALYSIS & INTERPRETATION
Data collected from both group of children were analyzed using Paired 't' test to measure the changes between the pretest & posttest values of the Gross Motor Function Measure - 88 (GMFM-88) within the group. Independent't' test was used to measure the changes between the groups.
= Calculated Mean Difference of pretest & posttest values
SD = Standard Deviation
n = Number of samples
d = Difference b/w pretest & posttest values
X1 = Mean difference in Group A
X2 = Mean difference in Group B
SD = Standard Deviation
CHAPTER - IV
DATA ANALAYSIS AND INTERPRETATION
Data analysis is the systemic organization and synthesis of research data and testing of research hypothesis using these data. Interpretation is the process of making sense of the results of a study and examining the implication (Polit & Belt, 2004).
Thirty four children were assessed for eligibility in the present study, and twenty two were initially enrolled. Before random assignment, however, two families withdrew from the study. The remaining twenty children were randomly assigned to intervention program with Ten going to the Group - A and another ten going to Group - B. figure - 1 shows the enrollment of cases.
The pretest and posttest values for both Group A & Group B were obtained before and after combined Neurodevelopmental therapy with Myofascial release and Neurodevelopmental therapy only. The improvement in gross motor function was assessed using Gross Motor Function Measure-88(GMFM-88). The mean, standard deviation and Paired "t" test values were used to find out whether there was any significant difference between pretest and posttest values within the groups.
The Independent "t" test values were used to find out the significant difference between the groups after Combined Neurodevelopmental therapy with Myofascial release and Neurodevelopmental therapy only.
PRE TEST AND POST TEST VALUES FOR GMFM-88 IN
GROUP - A (n = 10)
PRE TEST AND POST TEST VALUES FOR GMFM-88 IN GROUP - A (n = 10)
PRE TEST AND POST TEST VALUES FOR GMFM-88 IN
GROUP - B (n = 10)
PRE TEST AND POST TEST VALUES FOR GMFM-88 IN GROUP - B (n = 10)
Paired 't' test values, the Mean, Mean difference and Standard deviation of Gross Motor Function Measure - 88 in Group A & Group B
COMPARISION OF MEAN DIFFERENCE BETWEEN
GROUP- A AND GROUP- B
Based on Table 3 and Graph 3 the mean difference of group A was found to be 18.89, Standard deviation was 8.75, the 't' value was 6.833 which was greater than the table value at p<0.001. In Group B the mean difference was 7.23, Standard deviation was 2.13,'t' value was 10.716 which was greater than the table value of at p<0.001.
Independent't' test values, Mean Difference and Standard deviation of Gross Motor Function Measure - 88 between Group A & Group B
Gross Motor Function Measure - 88
The independent't' test was performed between Group A and Group B to analyze the significance of Neurodevelopmental therapy with myofascial release and Neurodevelopmental therapy alone in spastic cerebral palsy children.
Based on the Gross Motor Function Measure - 88, the calculated 't' value was 4.1, which was greater than the table value at P<0.001. This shows that Myofascial release along with Neurodevelopmental therapy improved the gross motor function in Spastic Cerebral Palsy children.
RESULTS AND DISCUSSION
The aim of this study is to compare the effectiveness of Neurodevelopmental therapy with Myofascial release and Neurodevelopmental therapy on gross motor function in children with spastic cerebral palsy.
Thirty four children were assessed for eligibility in the present study, and twenty two were initially enrolled. Before random assignment, however, two families withdrew from the study. The remaining twenty children were randomly assigned to intervention program with Ten going to the Group - A and another ten going to Group - B. An algorithm representing the flow of cases in the study protocol is shown in figure - 1.
Table 5 displays the baseline demographics and gross motor function classification levels for the twenty children included in the analysis. There were no statistically significant differences for these baseline variables between Group - A and Group - B. Of the 20 children in the analyzed cases, 12 were boys and 8 were girls. All the children were between the ages 2 to 8 years. The severity of the motor disturbances ranged from GMFCS level I to III. Among the cases in the analyses, the number of children who were classified in GMFCS level I, level II and level III were 10, 5 and 5 respectively
Group - A (n=10)
Group -B (n=10)
2 - 4
>4 - 6
>6 - 8
>8 - 10
>10 - 12
All participants in Group A showed significant improvement in the Gross Motor Function Measure - 88, with a mean difference of 18.89, standard deviation of 8.75. Since the calculated 't' value using the paired 't' test for Group A was 6.833, which was greater than the table value at p<0.001, the study proves the hypothesis 1, as "there is a significant improvement in gross motor function with Neurodevelopmental therapy and Myofascial release in children with spastic cerebral palsy".
All participants in Group B showed significant improvement in the Gross Motor Function Measure - 88, with a mean difference of 7.23, standard deviation of 2.13. Since the calculated 't' value using the paired 't' test for Group A was 10.716, which was greater than the table value at p<0.001, the study proves the hypothesis 2, as "there is a significant improvement in gross motor function with Neurodevelopmental therapy in children with spastic cerebral palsy".
While comparing between the groups using the independent 't' test, the mean difference were 11.67 and standard deviation were 8.75 and 2.13. Since the calculated 't' value is 4.1, which was greater than the table value at p<0.001, the study proves the hypothesis 3, as "There is a significant difference on gross motor function between the groups of spastic cerebral palsy children who undergo Neurodevelopmental therapy with Myofascial release and Neurodevelopmental therapy".
Since the Myofascial restrictions in the children with cerebral palsy got reduced in the group who received Myofascial release with neurodevelopmental therapy, Myofascial release techniques can be used as an complementary therapy along with other therapies like sensory integration, functional training and other mobility exercises.
SUMMARY AND CONCLUSION
This study incorporated combined neurodevelopmental therapy and Myofascial release treatment and their influence in gross motor function of children with spastic cerebral palsy was studied. It was found that the neurodevelopmental therapy with Myofascial release improved the gross motor function in children with spastic cerebral palsy.
Therefore from the literature available and the statistical analysis of the data obtained, the study concluded that,
"There was a statistically significant difference between the groups which underwent Neurodevelopmental therapy with Myofascial release and Neurodevelopmental therapy"
SUGGESTIONS FOR FUTURE RESEARCH
A large sample size should be incorporated.
A long term follow up should be done in order to determine the carry over effects of the treatment.
Spastic cerebral palsy children with the GMFCS level of IV and V can also be included.
Children with mixed type of cerebral palsy, with features of spasticity and athetosis, provided that spasticity component is predominating can also be included.
Various dosing regimens should be incorporated and its effectiveness should be studied.
The effectiveness of Myofascial release on spasticity and range of motion can also be studied in the future.