Spastic Diplegic Cerebral Palsy Health And Social Care Essay

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‘Cerebral Palsy’ is a common neuro developmental disorder of childhood with prevalence is about 2 per 1000 births in industrial nations [Pameth et al, 1981] and 3 per 100 live births WHO – 1999]

It is defined as “a permanent, non – progressive defect or lesion present at birth or shortly thereafter”.

Cerebral refers to brain and ‘palsy’ refers to lack of motor control. The child’s co – ordination of movement is affected, making it difficult or impossible to practice and perfect skills of daily life. Traditionally prenatal etiology, prematurity, total growth retardation, perinatal asphyxia and other perinatal causes like trauma have all been implicated as risk factors for cerebral palsy. (National collaborative perinatal project NCPP data).

Cerebral Palsy (CP) is classified clinically in terms of the part of the body involved,eg., hemiplegia, diplegia, quadraplegia and by the clinical perceptions of tone and involuntary movement., eg., Spasti , athetoid , ataxic [ Roberta B.Shepherd 1995]

1.2 SPASTIC DIPLEGIC CEREBRAL PALSY

Spasticity affects approximately 75% of all patients with cerebral palsy and when characterized by body part. Diplegia is the most commonest type. These disorders are due to faulty development damage or to motor area in the brain which disrupt the brain’s ability to adequately control movement and posture.

Tends to affect the legs of a patient more than the arms.Spastic Diplegia cerebral palsy patients have more extremity than the upper extremity.This allows most people with spastic diplegia cerebral palsy to eventually walk. The gait of a person with spastic Diplegia cerebral palsy is typically characterized by a crouched gait. Toe walking and fixed knees are common attributes.

Spasticity is a motor disorder characterized by a velocity – dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks , resulting from hyper excitability of the stretch reflex [ Lance 1980]. Contracture is a loss of passive range of motion assessed by measuring maximum passive joint excursion [Horsley et al 2007, Harvey et al 2006]. Spasticity can lead to contracture [Farmer and James 2001, Tardien et al 1982] and both spastcicty and contracture can limit activity [Boyd and Ada 2008, Hoffler et al 1987].

Two approaches used for the treatment of children with physical disabilities are advanced physiotherapy treatment called Neuro developmental therapy (NDT) and muscle energy technique (MET). The aim of Neuro development therapy is through specialized techniques of handling, to give children with cerebral palsy the experience of a greater variety of co – ordinated movement patterns where as muscle energy technique functions by relaxing acute muscle spasm mobilizing the restricted soft tissue and toning the weakened musculatures.

1.3 NEED OF THE STUDY:

Since spasticity in the muscles affects the functional gait pattern and decreases the child’s ambulatory independency, therefore the need for the study is to evaluate the effectiveness of neuro developmental therapy with muscle energy technique for lower extremity to improve functional ability in children with spastic diplegic cerebral palsy.

1.4 STATEMENT OF THE PROBLEM:

Effectiveness of Neuro Developmental Therapy with muscle energy technique for lower extremity to improve the functional ability in children with spastic diplegic cerebral palsy.

1.5 OBJECTIVE:

Treatment of children using neuro developmental therapy

Treatment of children using muscle energy technique.

Compare and contrast Neuro Developmental Therapy in relation to muscle energy Technique.

To determine the effects of Neuro Developmental Therapy and muscle energy technique that improves the functional ability in children with spastic diplegic cerebral palsy.

1.6 HYPOTHESIS:

The null hypothesis upon which the study is designed can be stated as “there is no significant improvement in functional ability in children with spastic diplegic cerebral palsy by the application of NDT & MET.

2. REVIEW OF LITERATURE

Rosenbaum palsy[2003]-Defines cerebral palsy as an umbrella term covering a group of non – progressive, but after changing motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early stages of development. He is saying that cerebral palsy refers to a group of disabilities that will not self – correct, which affects children while very strong and that disrupt the child’s movement ability in connection with brain function.

Baxm,Goldstein,et al.,(2005) defined cerebral palsy as a group of disorders that affect the development of movement and posture, causing activity limitation, and are attributed to non progressive disturbances that occurred in the developing fetal or infant born.

Becker Jg-stated that spastic paresis is characterized by a posture-and movement – dependent tone regulation disorder. The clinical symptoms are the loss or absence of tone in lying, and increases in tone in sitting, standing, walking, or running, depending on the degree of involvement, spastic paresis is the most common motor disorder (83%).

Janstephan Tecklin (2008)-stated that the child with classic spastic diplegia will typically demonstrate hypotonia through the neck and trunk while having increased stiffness in both legs.

Bernard Dan (2001)-stated that spastic diplegia characterized by limb hypertonia, which is more marked distally, predominates the lower limbs and increases active mobilization, hyperactive jerks, extensor plantar responses and varying degree of trunk hypotonia.

Felters-1(Phy Therapy 1996)-Did a study on the effects of Neuro Developmental Therapy versus practice on reaching of children with spastic cerebral palsy. It was found that NDT was more effective

Iddav & Embrey Et Al [1990] – Conducted a study on effects of neuro -developmental treatment and inhibitive ankle – height orthroses on gait with spastic diplegic children with cerebral palsy . The results shows that both methods of treatment can be used to decrease excessive knee flexion during gait in a children with spastic diplegic cerebral palsy.

Lilly La Powell NJ -Conducted a study regarding measuring the effects of neuro developmental treatment on the daily living skills of two children with cerebral palsy. They examined the short – term effects of Neuro Developmental Treatment (NDT) was found that improvements were made in the motor performance of daily living skills in two girls with cerebral palsy.

Bobath Therapy is a physical technique, principally used with cerebral palsy to inhibit abnormal movement or postures and promote effective normalized movement and muscle tone [Early physiotherapy or Bobath technique in infants with suspected neuro motor disturbance 1981].

Ketelarr m, et al., Did a study on the effects of functional therapy programe on motor abilities of children with cerebral palsy. They found improvement in both gross motor abilities and functional skills in children who received functional physical therapy programe.(physical therapy 2001).

Nikos Tsorlakis Et al [2004] -Conducted a study on effect of Neuro Developmental Treatment on gross motor function of children with cerebral palsy. They found that improvement were made in the gross motor abilities in children who received Neuro Developmental Therapy.

Kostidis, Michaei [2009] -The purpose of this study was to compare the effect of Muscle Energy Technique (MET), to a static stretch of 30 seconds duration for increasing the extensibility of the hamstring muscles. The result showed that MET was more effective, compared to static stretching.

Mohd.Waseem et al [2009]-The purpose of this study was to investigate the effectiveness of Muscle Energy Technique [MET] on hamstring flexibility in normal INDIAN collegiate males. The result indicates that MET is significantly improving the hamstring flexibility [range of motion] in collegiate males.

Kmberly Bucham [2007] -In that study to investigate the effectiveness of MET in increasing passive knee extension. Results showed that a significant increase in range of motion was observed at the knee flexion a application of MET.

Wilson E, Donegam – Shoafl, et al., [2003]-Conducted a study on effects of MET in patients with acute low back pain. The results showed that MET was effective in decreasing disability and improving function in patients with acute low back pain.

Ballantyne, Fryer G, et al., [2003]-The study was conducted to investigate the effectiveness of Muscle Energy Technique in increasing passive knee extension and to explore the mechanism behind any observed change. Muscle Energy Technique produced an immediate increase in passive knee extension. This observed change in range of motion is passive due to an increased tolerance to stretch.

Ching Shag Anita,et al., [2004]-The study was conducted to compare the immediate effects and lasting effects between passive stretch and Muscle Energy Technique on Hamstring Muscle Extensibility. The result suggested that Muscle Energy Technique appeared to be more effective than passive stretching for increasing Hamstring Extensibility immediately post treatment and still at one hour.

Msalle me et al-WEE FIM is a valid measure for tracking disability in preschool age and middle childhood and this allows the paediatrician to prioritize interventions for enhancing comprehensive functional outcomes and supporting families.

Yung a, wong v et al., WEE FIM could be used to assist neuro rehabilitation clinicians in the selection of short term realistic goals and long term rehabilitation strategies for children with various Neuro Developmental disabilities.

Dr.Fayetteville,ms.smith et al.,- to determine the inter rater reliability of manual tests of elbow flexor muscle spasticity graded on a Modified Ashworth Scale was significant and the reliability was good and believe them to be positive enough to encourage further trials of the Modified Ashworth Scale for grading spasticity.

3. MATERIALS AND METHODOLOGY

The cerebral palsy children were selected on an initial baseline assessment and confirmation of their diagnosis.

3.1 SUBJECTS:

Male and female cerebral palsy children between age group of four to fourteen years were taken. The children were primarily diagnosed and evaluated by a neurologist and a pediatrician and were referred to physical therapy.

3.2 ASSESSMENT TOOL USED:

Modified Ashworth Scale

Weefim Scale

3.3 MATERIALS USED:

Floor Smooth non – slippery Surface.

A large firm exercise mat (minimum 4″ or 6″) with a maximum thickness of 1″ for proprioception and tactile feedback. So the child has better sensory information regarding movement.

Small interesting toys that can be touched with one or both hands for head control, reaching, eye fixation.

Pillows.

Therapy ball and Bolsters provides mobile surface and facilitate automatic reactions.

Small wooden chair, Bench and couch of various heights for short sitting , table top activities , stepping , climbing and so on.

A rail or parallel bars.

Tilt boards and equilibrium boards for the child may lie, sit, kneel, stand or maintain a quadruped position, while being rocked in mediolateral or anteroposterior directions and to elicit rightening reactions.

Adaptive equipment to offer postural support or may aid functional skills and mobility.

Soft soothing music to motivate the child.

Stop watch.

3.4 METHODOLOGY

3.4.1. STUDY DESIGN:

This will be an experienced study with two groups having pretest and post test groups.

3.4.2. STUDY SETTING:

This study was done in “Families for children podanur”, Amrit orthopedics & rehablitation centre, Coimbatore and in patients who were referred for physical therapy from department of pediatrics and neurology, SRI RAMAKRISHNA HOSPITAL, COIMBATORE.

3.4.3. TOTAL STUDY DURATION:

6 Months.

3.4.4. TREATMENT TIME:

45 Minutes duration per day for three weeks.

3.5. SELECTION CRITERIA

3.5.1. INCLUSION CRITERIA:

Children with mild to moderate spastic diplegic type of cerebral palsy.

Ability to understand and respond to verbal instructions.

Gross Motor Function Classification level and II and III.

Cognitively Sound.

Children within the age group of 4-14 years.

Both male and female.

3.5.2. EXCLUSION CRITERIA:

Gross Motor Function Classification level IV and V.

Mental retardation.

Uncontrolled Epilepsy.

Children with Athetoid and Mixed type of cerebral palsy.

Visual and hearing impairment.

Respiratory distress.

Congenital heart problems.

Children with fixed skeletal or hip deformities.

Difficulty to understand command.

3.6. SAMPLING:

20 Children were selected based on inclusion criteria. They were further divided into control and experimental group containing 10 children in each group based on convenient sampling.

Control group ( Group A ) : Children receiving Neuro developmental therapy.

Experimental group (Group B): Children receiving Neuro development therapy with Muscle Energy Technique.

3.7. STATISTICAL TOOL:

The data collected was analyzed using independent t- test. The test was carried out between 2 groups.

The pretest and post test values for 2 groups are to be calculated and will be assessed for variation and improvements their significance will be assessed.

t = x1 – x2 n1 n2

S ( n1 + n2 )

S = ∑ ( x1 – x1 ) 2 + ( x2 – x2 ) 2

n1 + n2 – 2

where,

S = Combined standard deviation

x1 = Difference between Pre test and post test in Group ‰

x2 = Difference between Pre test and post test in Group ‰‰

x1 = Mean Difference of Group ‰

x2 = Mean Difference of Group ‰‰

n1 = Number of subjects in Group ‰

n2 = Number of subjects in Group ‰‰

4. TREATMENT TECHNIQUES

4.1 NEURO DEVELOPMENTAL THERAPY

(BOBATH THERAPY)

Bobath concept is the most familiar and widely used approach for children with neurologic disorders. It is originated in 1940 and early 1950.

PRINCIPLES:

Patterns of movement

Use of handling

Prerequisites for movement

NDT Treatment constructs a purposeful relationship between sensory input and motor output.

Therapeutic handling is a primary intervention strategy that NDT therapists use to assist the client in achieving independent function.

ABNORMAL TONE

ABNORMAL POSTURE

ABNORMAL MOVEMENTS

REGISTRATION OF

ABNORMAL

MOVEMENTS

REPETITION

MEMORY

EXECUTION OF ABNORMAL MOVEMENTS

The primary difference that separates NDT clinical practice from all other approaches is the inclusion of precise therapeutic handling, which includes both inhibition as key interventions to achieve independent function.

HANDLING

Handling is facilitation or inhibition of posture and movement:

Normal postural control

Movement in ground and space

Experiences of various postures

Postural alignment to weight shifts

Variety of movement patterns

Direct, regulate and organize tactile, proprioceptive and vestibular input.

Direct the client’s initiation of movement more efficiently and with more effective muscle synergies.

Decrease the amount of force the client uses to stabilize the body segments.

Guide to redirect the direction, speed, force and timing of the muscle activation for successful task completion.

Sense the response of the client to the sensory input and movement outcome and provide non verbal feedback for reference of correction.

When the client can become independent of the therapist and take control of posture and movement.

Direct the client’s attention to meaningful aspects of the motor task.

HAND PLACEMENT

Place the hands purposefully and precisely on the client’s body to specifically influence the area under the hands to indirectly influence the body parts.

FACILITATION

Facilitation makes a posture or movement easier or more likely to occur. Facilitation modifies postural control by increasing the degrees of freedom, supporting a body segment during an activity.

Activating the postural system to produce a change in the alignment of the body relative to the gravity and BOS.

INHIBITION

Inhibition refers to restricting the client’s atypical postures and movements which interferes with the development of more selective movement patterns.

BOBATH APPROACH

It referred to reducing tone and reflex activity resulting from CNS dysfunction.

Inhibiting excessive co activation-dynamic stability for more effective postural control.

Balance antagonistic muscle groups.

Reduce spasticity or excessive muscle stiffness that interferes with moving specific segments of the body.(Facilitation and Inhibition techniques are used in combination)

Treatment strategies often include preparation and stimulation of critical foundation elements (task components) as well as practice of the whole task.

NDT intervention is designed to obtain active responses from the patient on goal activities.

Whenever possible during treatment movement is indicated and actively performed by the client.

NDT intervention includes planning and solving motor problems.

NDT intervention allows the patient to learn from errors that occur during movement.

Repetition is an important component during motor learning.

Create an environment that is conductive to co operative participation and support of the client’s effort.

Knowledge of development of posture and movement components are used in designing treatment strategies.

NDT therapy sessions provide motivation purpose to engage the client fully in developing and reinforcing movement responses.

NDT intervention methods include modifying the task or the environment to take into account the client’s current level of performance and capacity for function.

As client is able to perform the movement independently, the therapist provides time during the sessions for the client to move freely.

Individual treatment sessions are designed to evaluate the effectiveness of treatment within the session.

Recognize and respect the communicative effects of the client’s motor behavior.

Families receive information regarding client’s problems and management of those problems as they are able to understand and assimilate the information.

4.2 MUSCLE ENERGY TECHNIQUE

Muscle Energy Technique is a procedure that involves voluntary contraction of the patients muscle in a precisely controlled manner at varying level of intensity, against a executed counterforce applied by the therapist.

Muscle Energy Technique are used to treat somatic dysfunction, especially decreased range of motion, muscular hyper tonicity and pain.

MECHANISM OF ACTION FOR MUSCLE ENERGY TECHNIQUES:

Muscle Energy Technique is a direct,active technique requiring patient’s co-operation for maximal effect. The changes occurring when patient performs isometric conttaction are:

Direct inhibition of agonist muscles results due to Golgi Tendon Organ activation.

At antagonist muscles there occurs reflexive reciprocal inhibition.

When Patient is relaxing agonist and antagonist remain inhibited. This allows the joint to be moved into the restricted range of motion.

TECHNIQUES:

Muscle Energy Techniques could be applied to most areas of the body. Each of the technique requires following 8 steps:

Obtaining an accurate structural diagnosis.

The restrictive barrier is engaged in many planes.

The unyielding counterforce matches patient’s force with therapist’s force.

The isometric contraction of patient has correct amount of force, direction of effort and duration (3-5 seconds).

After muscle effort there is complete relaxation.

The patient is repositioned in possible planes into new restrictive barrier.

Repeat 3-6 steps approximately 3-5 times.

8. Repeat structural diagnosis to find whether dysfunction has resolved.

DATA ANALYSIS AND INTERPRETATION

Cerebral palsy children were treated with Neuro Developmental Therapy and Muscle Energy Technique. Neuro Developmental Therapy was given for control group (Group A ) which consisted 10 samples and Neuro Developmental Therapy with Muscle Energy Technique (Group B ) which also consisted of 10 samples.

DEMOGRAPHIC DATA:

GROUP A (CONTROL GROUP)

AGE

NUMBER OF PATIENTS

MALE

FEMALE

4-5 years

0

0

5-6 years

0

0

6-7 years

2

0

7-8 years

2

0

8-10 years

1

0

10-12 years

2

1

12-14 years

1

1

GROUP B (EXPERIMENTAL GROUP)

AGE

NUMBER OF PATIENTS

MALE

FEMALE

4-5 Years

0

0

5-6 Years

0

0

6-7 Years

1

0

7-8 Years

1

0

8-10 Years

1

1

10-12 Years

1

2

12-14 Years

2

1

DATA PRESENTATION AND ANALYSIS

WEEFIM

Locomotion (Maximum score: s14)

Group – A (Control Group)

S.No

Pre

Post

Difference

1.

3

6

3

2.

5

10

5

3.

7

10

3

4.

3

7

4

5.

5

9

4

6.

7

10

3

7.

5

8

3

8.

3

6

3

9.

7

9

2

10.

5

7

2

MEAN

5.0

8.2

3.2

WEEFIM

Locomotion (Maximum score: 14)

Group -B (Experimental Group)

S.No

Pre

Post

Difference

1.

3

6

3

2.

7

11

4

3.

3

10

7

4.

5

9

4

5

3

12

8

6.

5

12

7

7.

4

7

3

8.

8

12

4

9.

3

7

4

10.

3

6

3

MEAN

4.4

9.2

4.7

WEEFIM

GROUP

MEAN VALUE

CALCULATED “T” VALUE

TABLE “T” VALUE

PRE TEST

PRO TEST

SD

A

5.0

8.2

0.918

2.25

0.05

B

4.4

9.2

1.888

MAS

Group -A – NDT (Control Group)

S.No

Pre

Post

Difference

1.

4

3

-1

2.

4

3

-1

3

4

1

-3

4.

4

2

-2

5.

4

3

-1

6.

3

1

-2

7

3

2

-1

8.

4

2

-2

9.

4

1

-3

10.

4

3

-1

MEAN

3.8

2.1

-1.7

MAS

Group -B – NDT + MET

S.No

Pre

Post

Difference

1.

4

1

-3

2.

4

1

-3

3.

4

1

-3

4

4

2

-2

5.

4

1

-3

6.

3

1

-2

7.

3

1

-2

8.

4

2

-2

9.

4

2

-2

10.

3

1

-2

MEAN

3.7

1.3

-2.4

MAS

GROUP

MEAN VALUE

CALCULATED “T” VALUE

TABLE “T” VALUE

PRE TEST

PRO TEST

SD

A

3.8

2.1

0.822

2.28

0.05

B

3.7

1.3

0.516

DISCUSSION

The aim of the study was to investigate the effects of NDT and MET in reduction of spasticity in children with spastic diplegic type of cerebral palsy.30 children of age group between 4-14 years were selected for the experimental study.

The study was carried out for a total duration of six months for a period of 45 minutes of treatment per day. The pre and post test scores of MAS and Wee FIM shows that significant improvements were found in reducing spasticity and ADL activities such as standing, walking, and stair climbing with less caregiver assistance.

For MAS score, the average pre test and post test values of Group A and Group B showed significant difference. But the mean of Group A (1.7) shows more marked increase than that of Group B (2.4).

On Statistical analysis using Independent t-test, for Group A and Group B, there is a significance of t=2.28

For Wee FIM score, the average pre test and post test valves in Group A and Group B showed significant difference. But the mean of Group A (3.2) shows more marked increase than that of Group B (4.7).

On statistical analysis using Independent t-test, for Group A and Group B, there is a significance of t=2.25

From this we infer that NDT along with MET can be used as an efficient treatment protocol to reduce spasticity and to improve ADL activities in children with spastic diplegic cerebral palsy, thus rejecting the null hypothesis.

CONCLUSION

With reference to the statistical analysis done from the data collected for MAS and Wee FIM, it is noted that the combination of NDT with MET causes significant reduction in tone which produces improvement in ADL activities.

However it is necessary to state that mere NDT also produces improvement in MAS and Wee FIM but the data reveals that mean improvement is greater for the group to which MET is given. These findings suggest that MET attenuates physical symptoms associated with cerebral palsy and enhances development.

Hence forth it could be concluded with enough and proven confidence that “NDT along with MET forms an integral part in the treatment of children with spastic diplegic cerebral palsy”.

LIMITATIONS:

The study was a time bound study lacking large sample size.

Selection of only one muscle can’t fulfill the desire functional goal setup by therapist.

Irregularities in attendance.

Health problems.

No regular follow-up of home advices.

Difficulties of the communication.

RECOMMENDATIONS:

The technique of the study is not strict to one particular muscle or one specific condition, so it is applicable to various muscles in various conditions.

Post Isometric Relaxation and Post Facilitation Stretching, which is a safetyorm of stretching is advice to use maximum in place of passive stretching of muscle.

It is suggested for further research to conduct a combined therapy of NDT, MET with other Developmental Techniques for various muscle at a ”same time”, so this will enhance to achieve goal which is setting for a particular child.

This study may be useful to incorporate into further studies examining various muscles along with any development in multidisciplinary endorsed classification that are developed.

BOOKS

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ABSTRACTS

Fryer et al: The effect of muscle energy technique on hamstring extensibility; Journal of osteopathic medicine, 2005.

Shadmehr A: Hamstring flexibility in young women following passive stretch and muscle energy technique; J Back Musculoskeletal Rehabilitation, 2009.

Milivoj Velickovic Perat; Basic principles of the Neuro developmental Treatment, 2004.

Christina Evaggelina et al: Effect of intensive Neuro Developmental Treatment in gross motor function of children with cerebral palsy, Dev. Med. Child Neurology, 2004.

Smith M, Fryer G:

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