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EFFECTS OF PHYSICAL THERAPY TREATMENT IN CHILDREN WITH ATHETOID CEREBRAL PALSY.

Byline: Farjad Afzal and Sidra Manzoor

Keywords: Cerebral palsy, Functional training, Parents, Stationary cycling, Strengthening, Treadmill.

INTRODUCTION

Cerebral palsy is a condition characterized by problems in movement and posture due to a lesions in immature brain1. Children with cerebral palsy present with faulty postures and problems in motor movements along with oral motor, speech and hearing problems2. Cerebral palsy is a major cause of disability in children3. Prevalence of cerebral palsy is 2.11 in 1000 live births in total population4. This is a non prog-ressive lesion in brain; However symptoms of cerebral palsy may be progressive with time, for example developing wrong patterns of movements and synergies5. Cerebral palsy can be categorized into spastic, athetoid, ataxic, low tone and mixed4. Children with spastic cerebral palsy have increased tone in muscles and there is spasticity in one group of muscles. In spastic cerebral palsy there is deficiency of gamma amino butyric acid (GABA), that has inhibitory effects on lower motor neurons6.

Due to lesion in upper motor, there is deficiency of GABA that can lead to spasticity and increased tone in muscles7. In athetoid cerebral palsy, there are involuntary movements in hands and facial muscles and also there is fluctuating tone in muscles5. Immaturity and hypoxic brain injury is considered a leading cause in cerebral palsy, other causes may be traumatic brain injury, neonatal infections, pregnancy disorders and exposure to radiations8. Physical therapy interventions that we can use for the management of cerebral palsy are neuro developmental techniques, strength training, functional training, constrain induced movement therapy, body supported treadmill training and conductive education9. In cerebral palsy there is a lesion in immature brain. For the control of movements and patterns of the body, brain has motor areas. These motor areas control the movements of muscles.

By practice and repetition of activity, brain can be trained with specific patterns and skills that can help the children with cerebral palsy to control their body10. Children with cerebral palsy have persistent reflexes that are not integrated due to brain lesion11. Reflexes in early age of life play vital role in the development of tone, posture and skills. Newborns are under the influence of neonatal reflexes during six months of life. After 6 months most of the reflexes start to integrate and body starts to control movements. In cerebral palsy reflexes are not absent and persist that causes delay in milestone development and also body can learn wrong patterns due to reflex activity in abnormal brain. If physiotherapy treatments are given that stop the reflex activity then children can learn skills and movements, which can help their activity of daily life.

In this study we used a combination of physical therapy interventions to improve the motor activity of children with athetoid cerebral palsy. Objective of the study was to find the effectiveness of physical therapy treatment in the form of treadmill training, stationary cycling training, sit to stand exercises, knee walking and walking with minimum support. Interventions that were included in this physical therapy treatment were treadmill training, stationary cycling training, sit to stand exercises, knee walking and walking with minimum support. These interventions can be performed by parents. If these interventions were effective in improving the gross motor and functional skills, we trained the parents to continue these protocols at home. It reduce the cost of treatments and parents provided physical therapy exercise plan at home. It further increased adherence to exercise in these children.

Use of treadmill in this study was modified from body supported treadmill training. We modified our use of intervention in that sense, we provided manual support, and assistance was removed as children were able to walk without support. In a recent study it was concluded that body weight support treadmill training had significant effect in changes in spine of children with cerebral palsy that helped to improve gross motor function in children with cerebral palsy12. Second intervention in our study was use of stationary cycle in children with cerebral palsy. Previous studies concluded that stationary cycling activity increases the speed of gait, improves the cardiopulmonary endurance, increases the limb strength, increases quality of life and induces happiness in children with cerebral palsy13-19. A number of studies also support the effectiveness of strengthening exercises with manual resistance on motor function and mobility in children with cerebral palsy20-22.

A number of interventions can be selected that can be used by parents of children with cerebral palsy. Regular training of these interventions at home can improve motor function and mobility in children with cerebral palsy. In this study we selected some interventions and used them in combinations. In combination therapy a longer session was required to provide an exercise plan. In this study we use a session of two hours.

PATIENTS AND METHODS

A quasi experimental study was conducted on children with athetoid cerebral palsy, visiting for physical therapy treatment in special school, from November 2013 to November 2014. Seven children with inclusion and exclusion criteria were selected for therapy. A convenient sampling technique was used to select the sample. Study was conducted on children that were already taking the treatment sessions. Total number of children was 15. Out of 15, we selected 7 children who fulfilled the inclusion and exclusion criteria. Sample size was not calculated by any calculating procedure. Therapy was carried out two days in a week for 12 months; the duration of single session was 2 hours. Interventions were treadmill training, stationary cycling training, sit to stand exercises, knee walking and walking with minimum support. Outcome measurement tools were gross motor functional measure (GMFM-88), walking distance, 01 minute walk test and 6 minutes walk test.

Pre treatment measurements were taken on gross motor functional measure (GMFM-88), walking distance, 1 minute walk test and 6 minutes walk test and measurements were repeated after 1 year on same scales. Pre treatment and post treatment scores on GMFM-88 were measured in mean with standard deviation and compared with wilcoxon signed rank test with 0.05 significant level. Inclusion criteria were children with athetoid cerebral palsy, age between 10 and 12 years, already have sitting and kneeling control and standing with support. Exclusion criteria were children with contracture and deformity on joint, previous surgery of joint and muscle and mental retardation.

INTERVENTION:

Intervention###Methodology###Intensity###Volume###Frequency###Duration

###Intervention started with###Start with###Starting time was

###minimal support and with the###minimal###minimal that child###02

Treadmill###time support is removed for###resistance to###could tolerate and###sessions###12

###progress with###progression was###months

###independent walking in###maximum safe###made from 10 to 15###per week

###treadmill###resistance###minutes

Stationary###Intervention started with###Start with###Starting time was

cycling with###minimal support to run cycle###minimal###minimal that child###02

adjustable###and with the time support is###resistance to###could tolerate and###sessions###12

seat and###removed for independent###progress with###progression was###per week###months

resistance.###cycling.###maximum safe###made from 10 to###15

###resistance.###minutes

###Start with###15 repetitions on

Strengthening###Movements according to action###minimal###key joints,###02

exercises with###of group of muscles and###resistance to###shoulder, elbow,###sessions###12

manual###functional patterns###progress with###spine, hip, knee,###per week###months

resistance###maximum safe###ankle

###resistance

###Key transitions like sitting to###Start with

Functional###side sitting, side to cross sitting,###minimal support###10 minutes###02 session###12

training###sitting to kneeling, kneeling to###to progress###per week###months

###standing with minimal support###without support

Quadriceps###Sit to stand on stool with###Start with###02

build up###stabilizing distal joints of legs###minimal support###10 repetitions with###sessions###12

training###providing minimal assistance to###to progress###03 sets###per week###months

###independent standing###without support

###Child was given a challenge to

###stand for maximum time

###without losing balance and do###Start with###Minimum time to###02

Standing###not fall. With time child was###minimal support###12

activity###involved with activity like###to progress###time that child can###sessions###months

###throwing ball, holding and###without support###tolerate###per week

###releasing objects and building

###ring tower.

Walking###Start with###Minimum time to###02

training###Start with parallel bar to###minimal support###time that child can###sessions###12

activity###progress without support.###to progress###tolerate###per week###months

###without support

Table-I: Pre and post measurements on outcome measurements scale.

###Pre-Treatment###Post-Treatment

GMFM-88###49.36 +- 30.79###69.78 +- 25.55

Standing Time###10 +- 05 seconds###10 +- 04 minutes

Walking Distance###06 minutes Walk test###02 +- 01 steps###100 +- 12 steps

###01 minute walk test###02 +- 01 steps###20 +- 08 steps

Table-II: Related samples wilcoxon signed rank test statistics.

Total N###7

Test statistics###28.000

Standard error###5.292

Standardized test statistics###2.646

Asymptotic Sig.###0.008

RESULTS

Seven children, 71.42% male and 28.57% female with athetoid type cerebral palsy were selected. Mean age of children were 9 +- 3 years. Pretreatment score on gross motor functional measure was 49.36 +- 30.79 and after 12 months was 69.78 +- 25.55 (table-I, graph-1). Pre intervention standing mean time was 10 +- 5 sec with minimum support without losing balance and post intervention standing time was 10 +- 4 minutes without losing balance and without support. Pre-intervention walking distance was 2 +- 1 steps in 6 minutes walk test and also in one minute walk test, with minimum support without losing balance and post intervention walking distance was 100 +- 12 steps in 6 minutes walk test and 20 +- 8 steps in 1 minutes walk test without losing balance and without support. Post intervention standing and walking improved significantly.

Pre-intervention GMFM score was compared with wilcoxon signed rank test and show that (0.008) there was significant change between pre treatment and post treatment (table-II).

DISCUSSION

In this study treatment sessions were provided only two days in a week. Efficacy of treatments can be increased if numbers of sessions are increased in a week. In this study the duration of single session was two hours, if same interventions are used with intensive protocols (a session of longer duration) then there will be more effectiveness of treatment. Study supports the results of previous studies in which the interventions like treadmill, stationary cycling with adjustable seat and resistance, strengthening exercises with manual resistance, functional training, quadriceps build up training, standing activity and walking training activity were used(2,9,10,12,13,15-19,22). This study can be repeated with bigger sample size, more treatment sessions and with intensive physical therapy protocol. This protocol can be used in a specific cerebral palsy rehabilitation center.

By using treadmill, stationary cycle and other interventions we can also reduce the cost of treatment as these interventions need only one time investment and many children can benefit from this. Moreover these interventions can be used by parents to train their children at home and thus children will receive physical therapy services at their door step. This study also can be repeated in comparison, for example, with same treatments the efficacy of treatment with parents and physio-therapist can be compared. If there is no signi-ficant difference in two expertise (parents and therapist), then parents can take part in rehabi-litation efficiently. This protocol can also be repeated with spastic cerebral palsy or in com-bination of spastic and athetoid cerebral palsy.

Duration of single session was 2 hours, so children with cerebral palsy can be involved in therapy session for longer duration, it will train their brain more efficiently and with more adaptations and more neuropalstic brain.

CONCLUSION

Treadmill, Stationary cycling with adjustable seat and resistance, strengthening exercises with manual resistance, Functional training, quadri-ceps build up training, standing activity and walking training activity in combination have significant effects on gross motor function mea-sure, trunk stability, standing time and walking distance in children with athetoid cerebral palsy.

CONFLICT OF INTEREST

This study has no conflict of interest to be declared by any author.

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Publication:Pakistan Armed Forces Medical Journal
Date:Jun 30, 2019
Words:2818
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