a study to ANALYZE the effect of cryotherapy and stretching exercise on spastic hip adductors in the CHILDREN WITH CEREBRAL palsy
SUBMISSION OF SYNOPSIS FOR THE REGISTRATION OF THE DISSERTATION FOR MASTER OF PHYSIOTHERAPY
SUBMITTED TO
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARANTAKA
SUBMITTED BY
DESAI DHARMIL NALINBHAI
NAVODAYA COLLEGE OF PHYSIOTHERAPY
P.B. NO. 26, MANTRALAYAM ROAD, RAICHUR
KARANATAKA
APRIL- 2007
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARANATAKA
ANNEXURE – II
PROFORMA OF REGISTRATION OF SUBJECT FOR DISSERTATION
1. /Name and address of candidate:
/ 1. DESAI DHARMIL NALINBHAINAVODAYA COLLEGE OF PHYSIOTHERAPY
MANTRALAYAM ROAD, RAICHUR, KARNATAKA.
2. / NAME OF THE INSTITUTION / NAVODAYA COLLEGE OF PHYSIOTHERAPY
MANTRALAYAM ROAD, RAICHUR, KARNATAKA.
3. / COURSE OF STUDY AND SUBJECT: / MASTER OF PHYSIOTHERAPY (MPT)
PHYSIOTHERAPY IN NEUROLOGY AND PSYCOSOMATIC DISORDER
4. / DATE OF ADMISSION TO COURSE / APRIL 2007
5. / 2. TITLE OF THE TOPIC:
“a study to ANALYZE the effect of CRYOTHERAPY AND stretching EXERCISE on spastic hip adductors in the CHILDREN WITH CEREBRAL palsy”
6. RESEARCH QUESTION:
Is there any significant effect of cryotherapy and stretching exercise on the spasticity of hip adductors muscles in the children with spastic Cerebral Palsy.
6.1 BRIEF RESUME OF THE INTENEDED WORK:
Cerebral palsy (CP) is a non-progressive disorder of the brain, which will affect the locomotion of the child1.
CP covers a wide spectrum of non-progressive disability occurring in about 1-2 per 1000 live births in Britain and America and is usually the results of some complication of labour or delivery2.
There are mainly two classification of CP one is topographical classification. Topographical classification shows how many limbs are affected because of brain damage like monoplegia, diplegia, triplegia, hemiplegia, or quadriplegia. Another classification is based on types of clinical feature like spastic, athetoid, ataxic or mixed3.
There are many problem related with CP, like drooping of saliva, poor head control, muscle weakness, muscle contracture, lack of co-ordination, flaccidity, spasticity, scissoring gait, ataxic gait, poor intelligence, impaired vision, poor motor activity. Balance disturbance etc,. They all are depend upon which area in the brain is affected and which types of CP is present1.
Among all types of CP the spastic CP covers about 85 to 90 percent 4, 5.
Spasticity is defined as motor disorder characterized by velocity dependent Increase in tonic stretch reflex (muscle tone) with exaggerated tendon jerks resulting from hyper excitability of the stretch reflex as one component of the upper motor neuron syndrome6.
Spasticity arises as a result from upper motor neuron lesion. Loss of inhibitory control on lower motor neurons results in disordered spinal segmental reflexes, including increased alpha motor neuron excitability, increased spindle (I-a) and flexor reflex afferent excitability, altered synaptic activity, decreased presynaptic I-a inhibition and so forth. Spasticity is measured by Modified Ashworth Scale7.
Spasticity is an important "positive" diagnostic sign of the upper motor neuron syndrome, and when it restricts motion, disability may result. The "negative" signs–weakness and loss of dexterity–invariably alter patient function when they occur. In an upper motor neuron syndrome, the alpha motor neuron pool becomes hyper excitable at the segmental level. This hyper excitability is hypothesized to occur through a variety of mechanisms, not all of which have yet been demonstrated in humans8.
Spasticity caused by spinal cord lesions is often marked by a slow increase in excitation and over activity of both flexors and extensors with reactions possibly occurring many segments away from the stimulus. Cerebral lesions often cause rapid build-up of excitation with a bias toward involvement of antigravity muscles. Chronic spasticity can lead to changes in the physiological properties of the involved and neighboring muscles. Stiffness, contracture, atrophy, and fibrosis may interact with pathologic regulatory mechanisms to prevent normal control of limb position and movement8.
There are various muscles undergoes for spasticity among all, adductor spasticity is a most common among CP children and it causes scissoring gait. Reduction in spasticity in adductor group plays a vital role in a treatment of CP1.
Spasticity is treated by many methods like prolonged passive stretching, application of heat (hot water, short wave diathermy ultra sound), cryotherapy, electrical stimulation, massage etc9.
Cryotherapy involves cooling of definitive parts of the body10.
It is an old remedy for relieving pain, inflammation, and control of bleeding, reduce edema and reduction of muscle spasm11. There are so many methods are available to achieve the goal of reducing tissue temperature. They are cold or ice packs, ice cubes or ice massage, vapocoolant sprays, cold baths and controlled cold compressions units12.
When cold is applied, it lowers the temperature of the skin and underlying tissue by abstracting,or removing heat from the body. The principal modes of energy transfer used for therapeutic cooling include conduction and evaporation11.
When particular area cooled, the muscle spindles are less sensitive, thus the muscle relaxes and spasticity is relieved. The relief of exaggerated stretch reflex activity in spasticity by cold has been attributed directly or indirectly to changes induced in one or more of the various structures involved in the stretch reflex response including skin receptors, muscle mechanical receptors, spindle excitability, nerve and muscle transmission13.
Cold packs are suitable for home use. Cold packs remain at a sufficiently low temperature for 15 to 20 minutes. If longer treatment is desired, the pack should be replaced with another11.
Stretching is a general term used to describe any therapeutic maneuver designed to increase mobility of soft tissues and subsequently improve range of motion (ROM) by elongating structures that have adaptively shortened and have become hypo mobile over time22.
When a muscle has been in a shortened position or immobilized following injury, shortening occurs and the muscles become quite resistant to stretch23.
Static stretching is one of the safest and most commonly performed stretching methods used to increase muscle length. This type of stretch is applied slowly and gradually at a relatively constant force to avoid eliciting a stretch reflex. The resultant increase in muscle length is related to viscoelastic behavior that has been demonstrated in vitro and in vivo experiments. This behavior is proportional to the magnitude of the applied load 24.
Stretching is important because it is believed to provide many physical benefits, including improved flexibility, improve range of motion, improved muscle or athletic performance, reduce spasticity, injury prevention, promotion of healing and possibly decreased delayed onset muscle soreness25.
Hence the purpose of this study is to know the effect of cryotherapy and stretching in the reduction of hip adductors spasticity in CP child.
6.2 HYPOTHESIS:
NULL HYPOTHESIS (H0)
There will be no effect on spasticity of hip adductors in subjects with CP after the application of cryotherapy and stretching for a period of 6 weeks.
ALTERNATIVE HYPOTHESIS (H1)
There will be a significant effect on spasticity of hip adductors in subjects with CP after the application of cryotherapy and stretching for a period of 6 week.
6.3 REVIEW OF LITERATURE:
The studies related to effect of cryotherapy and stretching on spastic hip adductors have been quoted in literature.
1. Malgorzata Marz, Wieslaw Strek, Zdzislaw Zagrobelny, Regina Soroka, Macias Mraz, Dorota Wojtowicz ( 2005 )carried out a study to know the therapeutic benefits of cryorehabilitation in neurological patient. Twenty six people (children and teenagers) with infantile CP subjected to cryorehabilitation. On their study they noted reduction of spasticity and increased spontaneous motor activity. Cryorehabilitation has significant position in rehabilitation of people with central nervous system damage14.
2. Semenova KA, Bubnova VA, Vinogradova LI, Tikunova NP (1986) In their study of cryotherapy in the complex restorative treatment of children with infantile cerebral palsy, they took children with spastic diplegia, hemi paretic and hyperkinetic forms of infantile CP , all were treated with local cryotherapy onto the hands. Local cryotherapy induced a reduction in the muscle tone. Cryotherapy diminished the intensity of hyperkinese and increased the functional possibilities of the hand so that writing became possible15.
3. Stephen C. Allison and Lawrence D. Abraham (2001 )in their study of sensitivity of qualitative and quantitative spasticity measures to clinical treatment with cryotherapy, took 26 adult traumatic brain injured subjects , 22 males and 4 females , mean age of 28.15 years (range; 18-57 SD 10.78 ). Sensitivity of qualitative and quantitative spasticity measures to clinical treatment with cryotherapy, took 26 adult traumatic brain injured subjects, 22 males and 4 females, mean age of 28.15 years (range; 18-57 SD 10.78). They applied 20-minute cold pack to the calves. Cryotherapy resulted in lowered Modified Ashworth Scale score consistent with a reduction in spasticity. Doubly multivariate repeated measures ANOVA revealed a significant difference (F =24.16, P< 0.001) in test scores between the pre- and post- cryotherapy test. Significant pre- and post-cryotherapy differences (P<0.03) for all dependent measures contributed to the main effect for cryotherapy16.
4. Preisinger E and Quittan M (1994) in their study of thermo and hydrotherapy, muscle spasm can be reduced by heat as well as by therapeutic cold. However in upper motor neuron lesions, cold is more effective in reducing the spasticity. This effect lasts long enough to be of therapeutic value17.
5. Miglieta (1973) conducted a study over 40 spastic paralyzed patients to investigate a effects of cold on sustained ankle clonus in neurologically involved patients. After giving cold whirlpool bath at 18.30C for 15 mins, the clonus was either decreased or abolished and remained for 4-5 hours18.
6. S Akinbo, B A Tella, A B Onunla, E O Temiye (2007) on their study of comparison of effect of neuromuscular electrical stimulation and cryotherapy on spasticity and hand function in patient with spastic CP, they took 20 subjects with mild to moderate spastic CP patient. They divided 20 subjects in to two equal group A and B. Group A was treated with cryotherapy and group B was treated with neuromuscular electrical stimulation. They found 7 to 8 out of 10 in each group were reduced spasticity and improved in their hand function19.
7. Knuttsson (1970) on his study, topical cryotherapy in spasticity, took 15 patients with spasticity. He applied 15 minutes of cold packs to the upper extremity or 20 minutes to lower extremity. TEN out of 15 patients had a decreased in resistance to passive movement, two had no change, and three had increased. Clonus decreased in frequency, duration, and threshold in all patients who had displayed it initially20.
8. J.Harlaar, J J Ten Kate and et al (2001) conducted a study over 16 patients to investigate the muscle co-ordination in spasticity under the influence of cooling. The results showed reduction in spasticity and improved muscle co-ordination with just a slightly increased active range of motion (p=0.049) 21.
9. Glen M Depino et al (2000) conducted a study on 30 male subjects with limited hamstring flexibility of the right lower extremity were randomly assigned to control an experimental group. Stretching for four-30 seconds static stretch is separated by 15 seconds rest. The results suggest that four consecutive 30 seconds static stretch is enhanced hamstring flexibility26.
10. Chun Yu Yeh, Kuen horgTsai et all (2005) in their study of to compare the effectiveness of prolonged muscle stretching (PMS) in the inhibition of ankle hypertonia , result showed that PMS treatment reduced the viscous and elastic component of hypertonic muscles27.
6.4 OBJECTIVES OF THE STUDY
To find the effect of cryotherapy and stretching on spasticity of hip adductors in subjects with spastic CP.
7. MATERIAL
1. A plinth to position the subject,
2. Ice Packs,
3. A stopwatch,
4. Towels,
5. Petroleum jelly (Oil),
7.1 SOURSE OF DATA:
For the purpose of data 30 subjects of spastic CP with the age ranging between 2 years to 6 years having spasticity in the hip adductors attending physiotherapy OPD in Navodaya Medical College Hospital and Research center, Raichur will be chosen for this study. Both male and female children will be included in this study.
A. REASERCH DESIGN:
A pre-test post –test control group study design is chosen for this study, which is true experimental in nature.
B. SETTING OF THE STUDY:
NAVODAYA MEDICAL COLLEGE HOSPITAL AND RESEARCH CENTRE, RAICHUR, which is a 750, bedded multispecialty hospital with fully equipped physiotherapy department.
C. VARIABLES:
Independent variable: Cryotherapy and Stretching
Dependent variable: Spasticity
D. SAMPLES:
Total samples consist of 30 subjects with spasticity of hip adductors diagnosed as spastic CP in the age group of 2-6 years.
E. SAMPLING TECHNIQES:
Randomized sampling technique will be chosen for this study. 15 subjects with spastic hip adductors will be put in experimental group and the remaining 15 subjects will be put in a control group.
F. INCLUSION CRITERIA:
1. CP children with adductors spasticity.
2. Age group from 2-6 years.
3. Bilateral adductors spasticity.
4. Spasticity grade 2 and 3 measured by MAS.
G. EXCLUSION CRITERIA:
1. Severe mental retardation.
2. Orthopedic fixed deformity.
3. Pain.
4. Recent Surgery.
5. Other type of CP.
6. Sensitive skin.
7. Skin infection.
7.2 METHODS OF COLLECTION OF DATA:
The subjects will be taken for this study who are directly referred to physiotherapy department from the pediatric department of Navodaya Medical College Hospital & Research Centre.
Subjects will be included in the study based on the inclusion and Exclusion criteria.
Thirty Subjects are randomly selected and 15 subjects were included in each group.
Before and after treatment, spasticity will be measured through modified Ashworth scale.
A. STATISTICAL TEST:
The obtained data will be analyzed and compared with pre-test and post-test values of the same group by using Paird T-TEST for both experimental and control groups.
The comparative analysis between the groups will be done by using Unpaird T TEST.
7.3 PROCEDURE:
· A brief explanation of the procedure shall be given to parents after obtaining the informed consent.
· At the initial stage, the spasticity will be measured by using the Modified Ashworth Scale.