Spastic Diplegic Cerebral Palsy Health And Social Care Essay

Spastic Diplegic Cerebral Palsy Health And Social Care EssayCerebral 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 1999It is defined as a permanent, non modern defect or lesion present at birth or shortly thereafter.Cerebral refers to mental capacity and palsy refers to lack of motor control. The childs co ordination of causa is affected, making it difficult or impossible to class period and perfect skills of daily life. Tradition tout ensembley prenatal etiology, prematurity, total growth retardation, perinatal asphyxia and other perinatal causes like trauma have all been implicated as risk factors for intellectual 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 involunt ary transaction., eg., Spasti , athetoid , ataxic Roberta B.Shepherd 19951.2 SPASTIC DIPLEGIC CEREBRAL PALSYSpasticity affects approximately 75% of all patients with cerebral palsy and when characterized by body part. Diplegia is the intimately commonest type. These disorders are due to faulty development damold age or to motor area in the brain which disrupt the brains ability to adequately control front line and posture.Tends to affect the legs of a patient more(prenominal) than the arms.Spastic Diplegia cerebral palsy patients have more extremity than the amphetamine extremity.This allows most people with convulsive diplegia cerebral palsy to eventually walk. The step of a person with spastic Diplegia cerebral palsy is typically characterized by a crouched gait. Toe walking and fixed genus are common attributes.Spasticity is a motor disorder characterized by a velocity dependent increase in impudent stretch reflexes (muscle tone) with exaggerated tendon jerks , resulting from hyper excitability of the stretch reflex Lance 1980. Contracture is a loss of peaceable 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 apply for the intercession of children with forcible disabilities are advanced physiotherapy treatment called Neuro developmental therapy (NDT) and muscle energy technique (MET). The aim of Neuro development therapy is through and 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 STUDYSince spasticity in the muscles affects the functi onal gait pattern and decreases the childs ambulatory independency, therefore the need for the study is to try 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 proBLEMEffectiveness 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 OBJECTIVETreatment of children using neuro developmental therapyTreatment of children using muscle energy technique.Compare and contrast Neuro Developmental Therapy in recounting 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 HYPOTHESISThe nugatory hypothesis upon which the study is designed can be stated as there is no significant improve ment in functional ability in children with spastic diplegic cerebral palsy by the application of NDT MET.2. REVIEW OF LITERATURERosenbaum palsy2003-Defines cerebral palsy as an umbrella term covering a convention 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 get out not self correct, which affects children while very strong and that disrupt the childs 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 a re 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 go out 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 pronounced 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 coif on reaching of children with spastic cerebral palsy. It was found that NDT was more effectiveIddav Embrey Et Al 1990 Conducted a study on effects of neuro -developmental treatment and inhibitive ankle natural elevation orthroses on gait with spastic diplegic children with cerebral palsy . The results shows that both methods of treatment can be used to decrease prodigal knee fold 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 documentation 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 slaying 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 improv ement in both primitive 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 change magnitude 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 analyze the effectiveness of Muscle Energy Technique MET on hamstring flexibility in normal INDIAN collegiate males. The result indicates that MET is significantly ameliorate the hamstring flexibility range of motion in collegia te 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 tenacious effects between passive stretc h 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 broadside 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 remainders 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 arrogant enough to encourage further trials of the Modified Ashworth Scale for grading spasticity.3. MATERIALS AND METHODOLOGYThe cerebral palsy children were selected on an initial baseline assessment and confirmation of their diagnosis.3.1 SUBJECTS manly 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 baby doctor and were referred to physical therapy.3.2 ASSESSMENT TOOL USEDModified Ashworth ScaleWeefim Scale3.3 MATERIALS USEDFloor Smooth non slippery Surface.A large firm set mat (minimum 4 or 6) with a maximum thickness of 1 for proprioception and tactile feedback. So the child has better arresting information regarding movement. itsy-bitsy arouse 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 sh ort sitting , table top activities , stepping , climbing and so on.A rail or collimate 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. reconciling equipment to offer postural support or may aid functional skills and mobility.Soft soothing music to motivate the child.Stop watch.3.4 METHODOLOGY3.4.1. STUDY spiritThis will be an experienced study with two groups having pretest and post test groups.3.4.2. STUDY SETTINGThis 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 DURATION6 Months.3.4.4. TREATMENT TIME45 Minutes duration per day for three weeks.3.5. SELECTION CRITERIA3.5.1. inclusion CRITERIAChildren with mi ld to moderate spastic diplegic type of cerebral palsy.Ability to to a lower placestand 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 CRITERIAGross Motor Function Classification level IV and V.Mental retardation. loose 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 translate command.3.6. have20 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 TOOLThe data still w as analyzed using freelance 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 n2S ( n1 + n2 )S = ( x1 x1 ) 2 + ( x2 x2 ) 2n1 + n2 2where,S = Combined standard leavingx1 = Difference between Pre test and post test in Group x2 = Difference between Pre test and post test in Group x1 = stringent Difference of Group x2 = Mean Difference of Group n1 = Number of subjects in Group n2 = Number of subjects in Group 4. TREATMENT TECHNIQUES4.1 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.PRINCIPLESPatterns of movementUse of handlingPrerequisites for movementNDT Treatment constructs a purposeful affinity between sensory input and motor output.Therapeutic handling is a primary interven tion strategy that NDT therapists use to assist the client in achieving independent function.ABNORMAL TONEABNORMAL POSTUREABNORMAL MOVEMENTSREGISTRATION OFABNORMALMOVEMENTSREPETITIONMEMORYEXECUTION OF ABNORMAL MOVEMENTSThe primary difference that separates NDT clinical coiffure from all other approaches is the inclusion of precise therapeutic handling, which includes both prohibition as key interventions to achieve independent function.HANDLINGHandling is facilitation or inhibition of posture and movementNormal postural controlMovement in ground and spaceExperiences of various postures commitural alignment to weight shiftsVariety of movement patterns count on, regulate and organize tactile, proprioceptive and vestibular input.Direct the clients initiation of movement more efficiently and with more effective muscle synergies.Decrease the amount of overstretch the client uses to stabilize the body segments.Guide to redirect the direction, speed, force and timing of the muscle activ ation 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 clients attention to pie-eyedingful aspects of the motor task.HAND PLACEMENTPlace the hands purposefully and just on the clients body to particularisedally influence the area under the hands to indirectly influence the body parts.FACILITATIONFacilitation 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 gloom and BOS.INHIBITIONInhibition refers to restricting the clients atypical postures and movements which interferes with the development of more selective movement patterns.BOBATH APPROACHIt 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 intend 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 operating(prenominal) par ticipation and support of the clients effort.Knowledge of development of posture and movement components are used in designing treatment strategies.NDT therapy sessions provide motivation purpose to soak up the client fully in developing and reinforcing movement responses.NDT intervention methods include modifying the task or the environment to take into account the clients 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 clients motor behavior.Families receive information regarding clients problems and management of those problems as they are able to understand and assimilate the information.4.2 MUSCLE ENERGY TECHNIQUEMuscle Energy Technique is a procedure that involves voluntary abri dgment 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 material dysfunction, especially decreased range of motion, muscular hyper tonicity and pain.MECHANISM OF ACTION FOR MUSCLE ENERGY TECHNIQUESMuscle Energy Technique is a direct,active technique requiring patients co-operation for maximal effect. The changes occurring when patient performs isometric conttaction areDirect inhibition of agonist muscles results due to Golgi Tendon Organ activation.At antagonist muscles there occurs reflexive reciprocal inhibition.When forbearing is relaxing agonist and antagonist remain inhibited. This allows the joint to be moved into the restricted range of motion.TECHNIQUESMuscle Energy Techniques could be applied to most areas of the body. severally of the technique requires following 8 stepsObtaining an accurate structural diagnosis.The restrictive barrie r is engaged in many planes.The unyielding counterforce matches patients force with therapists 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 recent restrictive barrier.Repeat 3-6 steps approximately 3-5 times.8. Repeat structural diagnosis to find whether dysfunction has resolved.DATA analysis AND INTERPRETATIONCerebral palsy children were set 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 overly consisted of 10 samples.DEMOGRAPHIC DATA sort out A (CONTROL GROUP)AGENUMBER OF PATIENTSMALEFEMALE4-5 years005-6 years006-7 years207-8 years208-10 years1010-12 years2112-14 years11GROUP B (EXPERIMENTAL GROUP)AGENUMBER OF PATIENTSMAL EFEMALE4-5 Years005-6 Years006-7 Years107-8 Years108-10 Years1110-12 Years1212-14 Years21DATA PRESENTATION AND ANALYSISWEEFIMLocomotion (Maximum score s14)Group A (Control Group)S.NoPrePostDifference1.3632.51053.71034.3745.5946.71037.5838.3639.79210.572MEAN5.08.23.2WEEFIMLocomotion (Maximum score 14)Group -B (Experimental Group)S.NoPrePostDifference1.3632.71143.31074.594531286.51277.4738.81249.37410.363MEAN4.49.24.7WEEFIMGROUPMEAN VALUECALCULATED T VALUETABLE T VALUEPRE TESTPRO TESTSDA5.08.20.9182.250.05B4.49.21.888MASGroup -A NDT (Control Group)S.NoPrePostDifference1.43-12.43-1341-34.42-25.43-16.31-2732-18.42-29.41-310.43-1MEAN3.82.1-1.7MASGroup -B NDT + METS.NoPrePostDifference1.41-32.41-33.41-3442-25.41-36.31-27.31-28.42-29.42-210.31-2MEAN3.71.3-2.4MASGROUPMEAN VALUECALCULATED T VALUETABLE T VALUEPRE TESTPRO TESTSDA3.82.10.8222.280.05B3.71.30.516DISCUSSIONThe aim of the study was to investigate the effects of NDT and MET in diminution of spasticity in children with spastic di plegic 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 add up 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=2.28For 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 Gr oup A and Group B, there is a significance of t=2.25From this we infer that NDT on 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.CONCLUSIONWith 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.LIMITA TIONSThe study was a time bound study lacking large sample size. extract of only one muscle cant fulfill the desire functional goal setup by therapist.Irregularities in attendance.Health problems.No regular experience of home advices.Difficulties of the communication.RECOMMENDATIONSThe 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 explore 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 de veloped.BOOKSLeon Chaitow Positional Release Techniques, 2002.Judith Delancy Clinical application of Neuro muscular techniques, 2005.Leon chaitow Muscle energy techniques.Janet.M,Howle NDT approach theoretical foundations, 2002.Lisa A Kurtz How to help a clumsy child, 2003. freeman Miller,Erin Brown cerebral palsy, 2005Sophie Levit Treatment of cerebral palsy and motor delay, 2010.Marcia Stame,MT Posture and movement of the child with cerebral palsy.Jan Stephan Tecklin Paediatric physical therapy 3rd edition, 1990.Gilroy J grassroots Neurology 2nd edition, 1992.Susan K Campbell material Therapy for children, 1996.Roberta B Sheperd Physiotherapy in Paediatrics 3rd edition, 1990.Rebecea Dutton Clinical Reasoning in physical disabilities, 1995.Gupta SP Text harbour of statistical methods 28th edition, 2000.Kothari CR Text book of research methodology-methods and techniques, 2009.Carolyn M. 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