Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DESSERTATION
1. / Name of the Candidate and Address / SUNNA AMINSHREE DEVI COLLEGE OF PHYSIOTHERAPY, MAINA TOWERS, BALLALBAGH, MANGALORE-3.
2. / Name of the Institution / SHREE DEVI COLLEGE OF PHYSIOTHERAPY, MAINA TOWERS, BALLALBAGH, MANGALORE- 3.
3. / Course of study and subject / MASTER OF PHYSIOTHERAPY (MPT) 2 YEARS DEGREE COURSE
PHYSIOTHERAPY IN PAEDIATRICS
4. / Date of Admission to Course / 12th May 2007
5.
6. / Title of the Topic “A COMPARATIVE STUDY TO EVALUATE
THE EFFECTIVENESS OF
CRYOSTRETCHING VERSUS MASSAGE
THERAPY ON SPASTICITY OF
PLANTARFLEXORS IN SPASTIC
CEREBRAL PALSY CHILDREN”.
Brief resume of the intended work:
6.1 Need for the study
Cerebral palsy is a dynamic disorder of posture and mobility being the motor manifestation of non progressive brain damage sustained during period of brain growth in fetal life, infancy or childhood. The cause can be hypoxic ischemic encephalopathy, trauma, infection, hemorrhage etc.1
Cerebral palsy can be acquired or congenital type. Acquired cerebral palsy can be due to trauma, infections, stroke etc. In congenital cerebral palsy damage may arise from genetic defects, migrational defects, nutritional deficiency, hypoxic ischemic encephalopathy etc.
It is classified by the type of movement problem such as spastic or athetoid cerebral palsy or by the parts affected for e.g. hemiplegia, diplegia and quadriplegia. Cerebral palsy babies may initially be “ floppy” and may later become spastic.2
Spasticity is velocity dependent hypertonicity of the muscle in resistance to movement. It refers to the inability of the muscle to relax which is commonly seen in lower limbs. It is disabilitating and leads to musculoskeletal complications like equinus deformity of ankle and wrist flexion, these two are the common deformities in cerebral palsy.1,3
The equinovarus position of foot, a common posture in lower extremity is major limitation to function. Due to spasticity in plantarflexors mainly gastrocnemius, dorsiflexion of ankle is limited.
There are various therapeutic interventions for spasticity as sustained stretching, massage, vibration, heat modalities, cryotherapy, electrical stimulations, hippo therapy and hydrotherapy.4
Local hypothermia is used in motor disorders in cerebral palsy. It causes reduction in muscle tone by gradual switching off the activity of individual muscle. Stretching is used in spastic cerebral palsy to reduce spasticity and prevents the muscle from contractures and shortening. Massage therapy is also known to reduce the physical symptoms like spasticity in cerebral palsy children. In addition to this, it enhances development and is considered as early intervention in cerebral palsy .6,8,9
The aim of the study is to evaluate the effect of cryostretching and massage therapy on spasticity of plantarflexors in spastic cerebral palsy children
Research question:
· Whether the application of cryostretching on spasticity in ankle plantarflexors is effective?
· Whether the application of massage therapy on spasticity in ankle plantarflexors is effective?
Null hypothesis:
There will be no significant difference in the effectiveness of cryostretching versus massage therapy on spasticity of plantarflexors in spastic cerebral palsy children.
Alternate hypothesis:
There will be a significant difference in the effectiveness of cryostretching versus massage therapy on spasticity of plantarflexors in spastic cerebral palsy children
6.2 Review of literature
The prevalence data vary from 1.5 – 2.5/1000 live births for moderate to severe cerebral palsy. It is major developmental disability affecting function in children. All children with cerebral palsy have suffered some form of brain damage and this has involved motor pathway. The other manifestations of cerebral are epilepsy, specific learning problems, organic behavior disturbances, speech problems or mental handicap.1
The four major classifications of cerebral palsy are spastic, athetoid / dyskinetic, ataxic, mixed. In 30 percent of all cases, the spastic form is found along with one of the other types.2
Spastic diplegia, hemiparetic and hemikinetic forms of infantile cerebral palsy when treated with local cryoapplication on the hands. It caused reduction in the muscle tone by gradual switching off the activity of individual motor units. It was proposed that a decrease in the level of affrentiation alters the functional activity of some links of the motor analyzers. Local hypothermia is also used to manage motor disorders in infantile cerebral palsy. Ice applied to the affected muscle causes not only the reduction in muscle spasticity but also leads to the functional reconstruction in the spinal motor neuron pool.5,6
A study was conducted to see the effect of ice on the spastic masseter muscle , in cerebral palsy children and it was seen that there was decrease in the spasticity of masseter muscle and increase in inter incisal distance after the treatment7.
Also in a review on effectiveness of passive stretching in children with cerebral palsy it appeared that sustained stretching of longer duration was preferable to improve range of movements and to reduce spasticity of muscles around the targeted joints.8
The benefits of massage to cerebral palsy patients are undeniable. It has been seen that children receiving massage therapy showed fever symptoms such as spasticity, less rigid muscle tone over all and in the arms, and improved fine and gross motor functioning. It has been suggested that massage therapy reduces physical symptoms associated with cerebral palsy.9 It was also seen that massage therapy had effect on the condition of cerebral palsy children.10
A study was conducted on the parents of cerebral palsy children who received massage for themselves were very likely to give massage to their cerebral palsy children and were pleased with the out come.11
Studies were conducted to test the validity of Tardieu scale and it was seen that the Tardieu scale is more valid measurement of spasticity.12
A study was conducted to compare the Tardieu scale as a clinical measure of spasticity with Ashworth scale and it was concluded that Tardieu scale differentiates spasticity fro contractures where as Ashworth scale is confounded by it.13
6.3 Objectives of the study
1) To evaluate the effect of cryostretching on spasticity of plantarflexors in spastic cerebral palsy children
2) To evaluate the effect of massage on spasticity of plantarflexors in spastic cerebral palsy children.
3) To compare the effect of cryostretching and massage on spasticity of plantarflexors in spastic cerebral palsy children.
7.
8. / Materials and methods:
7.1 Source of data.
Children with spastic cerebral palsy are referred to ,
1) Govt. Wenlock District Hospital, Manglore.
2) Shree Devi College of Physiotherapy, Manglore
3) Yenepoya Medical College and Hospital, Manglore.
7.2 Method of collection of data
A sample size of 30 is taken and divided into two groups as Group A and Group B. Each group will consist of 15 cerebral palsy children who will be treated for the total duration of 2 weeks. Treatment will be given for 5 day in a week and one session a day. Pre-assessment and post-assessment will be taken on the first day before the treatment and at the end of 2nd week after the treatment using Tardieu Scale.
Inclusion criteria
· Patients with age group between 5-15years
· Patients with spastic diplegia
· Patients with spastic quadriplegia
· Patients with spasticity grade I and II of Tardieu scale.
Exclusion criteria
· Children with developed deformities of lower limb.
· Skin infection
· Fractures
· Un- cooperative children
· Dislocation of lower limb
Methodology
GROUP A
15 Cerebral palsy children will be treated with cryotherapy using ice pack technique of application on plantarflexors. Patient will be in prone position. Vegetable oil will be applied on the plantarflexors muscle to prevent ice burns and ice pack will be kept on the length of the plantarflexor for 10-15 minutes.
Ice pack application will be followed by stretching of plantarflexors. The patients will be in supine position on the couch. The stretch is maintained for 1 minute for 5- 10 repetitions.
GROUP B
15 Cerebral palsy children will be taken and treated with massage for 25-30 minutes. The patient’s position will be prone position and therapist position will be according to the convenience. Sequence of the massage techniques to be used is effleurage, slow stroking, palmar kneeding, wringing, rolling. Effleurage will be given before and after each technique of massage.
Sampling
Convenience sampling / Experimental design.
Statistical Analysis
· Mann Whitney U test .
· Wilcoxon signed rank test.
Tools used
· Ice packs
· Towels
· Talcum powder
· Vegetable oil
· Couch
· Pillows
Outcome measures
· Tardieu scale .
7.3 Does this study require any investigations or any interventions to be conducted on patients or other humans or animals? If so, please describe briefly?
Yes. The study requires physiotherapy treatment such as cryostretching and massage therapy to be given to cerebral palsy children for a period of 2 weeks.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes.
List of References
1. Neil Mchntosh , Peter J Helms et al, Forfar and Arneil’s text book of pediatrics , Churchill Livingstone : Elseviers, 5TH Edition ,1998, pp 738 – 756.
2. Cerebral palsy from Wikipedia, the free encyclopedia, en . Wikipedia.org/wiki/cerebral_palsy.
3. Flett PJ ,Rehablitation of spasticity and related problems in childhood cerebral palsy, J Paediatr Child Health ..2003 Jan-Feb; 39 (1):6-14.
4. Elizebeth A Moberg-Wolff. Spasticity: 2005, June 2.
5. Semenova KA ,Bubnova VA ,et al , Cryotherapy in the complex restorative treatment of children with infantile cerebral palsy , Zh Nevropatol Psikhiatr Im SS Karsakova . 1986 ; 86 (10 ):1459-63.
6. Stepanchenko OV , Semenova KA , Vinogradova LI , Artificial local hypothermia in the treatment of children with cerebral palsy , Zh Nevropatol Psikhiatr Im SS Korsakova .1998 ; 88 (8) : 39 – 42.
7. dos Santos MT, de Oliveira LM, Use of cryotherapy to enhance mouth opening in patients with cerebral palsy, Spec Care Dentist. 2004 July- Aug; 24 (4):232 -4.
8. Pin T , Dyke P, Chan M , The effectiveness of passive stretching in children with cerebral palsy , Dev Med Child Neurol . 2006 Oct ; 48 (10 ) :855-62.
9. Maria Hernandez – Reif, Tiffany Field et al, Cerebral palsy symptoms decreased following massage therapy, Early Child Development and Care. 2005 july;175 ( 5 ) :445 -456.
10. Samdup DZ , Smith RG , Il Song S , The use of complimentary and alternative medicine in children with chronic medical conditions , Am J Phys Med Rehabil . 2006 Oct; 85 (10 ) : 842-6.
11. Hurvitz EA, Leonard C et al, Complimentary and alternative medicine use in families of children with cerebral palsy , Dev Med Child Neurol . 2003 Jun ; 45 (6) : 364-70.
12. LA da , E Patrick,The Tardieu scale is more valid clinical measure of spasticity than the Ashworth scale , Disabil Rehabil . 2006 Aug 15 ; 28 ( 15 ) : 899-907.
13. Patrick E, Ada L, The Tardieu scale can differentiate contractures from spasticity where as the Ashworth scale is confounded by it, Clinical Rehab . 2006 Feb ; 20 (2 ): 173 – 82.
14. Forster and Palastanga, Clayton’s Electrotherapy, Delhi : A.I.T.B.S, 9TH Edition,2002 ; pp 199-208.
15. Margaret Hollis, Massage For Therapists, Blackwell Science, London: 2ND Edition, 1998.
16. Elizabeth Holey and Eileen Cook, Therapeutic Massage, W.B Saunders, Harcourt Brace Asia, London.:1ST Edition ,1998.
9. / Signature of the Candidate
10. / Remark of the Guide
11. / Name and Designation of
(In Block Letters)
11.1 Guide / DR. S. PADMAKUMAR
PRINCIPAL,
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MANGALORE – 3.
11.2 Signature
11.3 Co-guide
11.4 Signature
11.5 Head of department
11.6 Signature / DR. S. PADMAKUMAR
PRINCIPAL,
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MANGALORE
12. / 12.1 Remark of the Chairman and Principal
12.2 Signature
9