Filetype PDF | Posted on 14 Sep 2022 | 3 years ago
Authentication
digital resources
164x Filetype PDF File size 0.17 MB Source: ijshr.com
International Journal of Science and Healthcare Research
Vol.6; Issue: 1; Jan.-March 2021
Website: ijshr.com
Case Study ISSN: 2455-7587
PNF Training for Improving Lower Limb
Coordination in Cerebral Palsy: A Case Study in a
Child with Spastic Diplegia
Preksha Sharma
Assistant Professor,
Department of Physiotherapy, Sanskriti University, Mathura, U.P., 281401, India
ABSTRACT childhood[1]. Cerebral palsy is considered
The research focused on assessing the as severe mental, physical dysfunction along
effectiveness of PNF training on lower limb with disturbances in growth, gait, cognition
coordination on a Male child with spastic and sensation[2]. Commonest childhood
diplegia Cerebral Palsy. Mental and physical disability hampering physical growth the
dysfunctioning along with the growth, sensation most, worldwide affecting 2 to 2.5 children
and gait disturbances is termed as Cerebral per 1,000 live born [3]. Spastic Diplegia
Palsy. This is unconditional neurological (both legs are affected) is predominant type
problem that has severe effect on the control and of CP preterm infants specially born with
coordination of muscles. This generally occurs birth weights below 1000gm [4].
at early childhood age or infancy. This research Velocity dependant increased in
is a case study in which subject was a child with resistance to passive muscle stretch is
dysfunctioning arms and legs. The branch of considered as Spasticity [5] .The onset of
Cerebral Palsy that deals with dysfunctioning of spasticity in the legs is during the first year.
arms and legs is termed as Spastic Diplegia. The During first 4 months of life most of spastic
patient underwent PNF on both lower limbs diplegic children have normal tone, or
(hip, knee, foot), followed by hot fermentation. hypotonia. In first year onset of spasticity is
After the intervention, significant improvement insidious and slowly progressive [6].
is seen in all the outcome measures (gait Lesion in sensorimotor cortex and
parameter, BBS score, GFMC score) .As the extra pyramidal system (corticospinal tract)
result affected lower limb improved in terms of results in lower limb dysfunction. The lower
coordination, execution and accurateness of the
movement, number of jerks, and duration of limb is usually more severely involved than
clonus. Improvement was seen in preciseness upper limb. This restricts walking,
and accurateness of coordinated movement at ascending and descending stairs,
the different ranges of motion for lower limbs. exploration, play and other ADL activities
PNF seems to be a promising intervention for [7].
improving lower limb movement coordination Common management effective in
in Cerebral palsy children. Further spastic diplegia includes pharmacological
investigations are certainly needed to assess. (botulinum toxin, intrathecal pump and
Keywords: Cerebral palsy, Proprioceptive surgical management (orthopaedic surgery),
Neuromuscular Facilitation, Gait Training, constraint induced movement therapy,
Balance, Incoordination. occupational therapy, Neuro-Developmental
Therapy, Sensorimotor training program,
1. INTRODUCTION balance training, Proprioceptive
Cerebral Palsy is considered to be Neuromuscular Facilitation and other
the mundane disability that is chronic. This traditional physiotherapy techniques to
is the disability most common in today’s
International Journal of Science and Healthcare Research (www.ijshr.com) 35
Vol.6; Issue: 1; January-March 2021
Preksha Sharma. PNF training for improving lower limb coordination in Cerebral Palsy: a case study in a child
with spastic diplegia
improve gait, balance and coordination of The important clinical findings were
lower limb function [1],[8]. showed in Table no 1. Limited dorsiflexion
PNF is considered as very effective was seen in bilateral feet. In postural
therapeutic exercise for the betterment of examination bilateral flat foot, exaggerated
gait and dynamic balance [9]. PNF is used lumbar lordosis, bilateral adductor tightness,
widely in clinics to treat post stroke physical valgum deformity is seen at knee. It was
dysfunctions[10]. Studies done states that seen in the assessment that patient was able
PNF techniques mainly focus on muscle to perform with bilateral upper limb without
activity. Evidences also suggest change in much difficulty.
stiffness and increased tone due to spasticity
after stroke [12]. Table 1: Patients parameters diagnosed during assessment
Left Right
Most of the literature work done MUSCLE TONE Hip Adductors 1+ 1+
earlier focussed on using of PNF for the Hamstrings 2+ 1+
management of Stroke patient to reduce Calf Muscles 1+ 1+
REFLEXES Knee Reflex +++ ++
spasticity and improve tone. This case study Ankle Reflex +++ +++
aim to use PNF as an potential approach to
show improvement in gait parameter, 5. Therapeutic Intervention
walking status, balance and functional In starting of the treatment session to
independence. normalize increased tone inhibitory
techniques were given. It took 3 months to
2. Patient Information normalize tone. Session was started with
Patient was 7 year old Spastic rhythmic stabilization exercises of entire
diplegic male child who was under lower limb focusing on proximal joint
physiotherapy treatment since past 2 years primarily to gain stability of lower limb.
which includes PROM of all the joints, Mat After that sets of hold relax and dynamic
and gym ball exercises. Child was having reversals in both the diagonal pattern
good communication skills, but not going to performed, initially with assistance later on
school. Able to perform his ADLs activities without assistance. Exercises were
with difficulty, highest functional ability performed in both supine and standing
was independent sitting, donning on & off positions. Treatment was given 40 minutes a
clothes with assistance. His primary concern day, for 6 days a week for 16 weeks. Follow
was his difficulty of independent standing, up was taken after each 15 days to see the
walking and inability to go up and down long term effect of treatment.
stairs. He was taking muscle relaxants
earlier on regular basis, but currently not Table 2: Pre and post scores of outcome measures
Pre Scores Post Scores
taking any medication and no psychological Berg Balance Scale Score 18 30
illness found. Patient was already diagnosed Stride length (in cm ) 60 75
by paediatrician as Spastic cerebral palsy. Step length (in cm ) 35 48
Cadence (in cm ) 38 48
GMFCS score Level V Level IV
3. Diagnostic Assessment
Balance was assessed by Berg Outcome measures were recorded
balance scale; different parameters like before and after completing treatment that is
(Stride length (cm), Cadence (steps/min) 1 day of the treatment and after 16 weeks.
and Gait velocity (m/ min)) were used to Treatment protocol was not changed and
evaluate gait characteristics. Gross Motor only dosage was progressed. Treatment was
Function Scale is used to check not even missed for a single day. After 4
independence level of the child. Pre and months during follow up it was found that
post scores of all the variables are shown in treatment was effective. Activity specific
Table no 2. lower limb training, Sit to Stand, Single leg
standing like activities , muscle stretching
4. Clinical Findings exercises was given to the patient to
International Journal of Science and Healthcare Research (www.ijshr.com) 36
Vol.6; Issue: 1; January-March 2021
Preksha Sharma. PNF training for improving lower limb coordination in Cerebral Palsy: a case study in a child
with spastic diplegia
perform at home as the part of Home this child motivated us to follow the similar
Exercise Program. protocol in other children too.
6. DISCUSSION ACKNOWLEDGEMENT
Present study aimed to evaluate the We would like to thank patient and
efficiency of PNF training in improving his attendants for their enormous
lower limb coordination in a child with cooperation during this duration of 1 year. I
Spastic diplegic Cerebral palsy. Evidences would also like to thank Management of
are present in previously done studies of School of Medical and Allied Sciences,
PNF in stroke populations were proved to Department of Physiotherapy for providing
be highly beneficial. Sang Wang et al in required infrastructure. Ethical clearance
their study applied PNF to chronic stroke was obtained from Institutional ethical
patients and concluded that it decreases committee and Informed consent was filled
muscle stiffness and abnormally increased by patient after explaining all the procedure.
muscle tone. FCR muscle of affected side
with MAS grade 2 in stroke patients with 7. REFERENCES
Brunnstrom stage III showed significantly 1. A.N. Berker, M.S. Yalçin, Cerebral Palsy:
lower muscle tension and stiffness after Orthopedic Aspects and Rehabilitation,
PNF intervention [11]. Pediatr. Clin. North Am. 55 (2008) 1209-
Furthermore, another study suggests 1225.
that combined PNF patterns are effective in https://doi.org/10.1016/j.pcl.2008.07.011.
treating increasing the muscle activity of the 2. P. Morgan, J.L. McGinley, Cerebral palsy,
rectus femoris, vastus medialis, tibialis 1st ed., Elsevier B.V., 2018.
anterior, lateral hamstring, and lateral https://doi.org/10.1016/B978-0-444-63916-
gastrocnemius after stroke. It was reported 5.00020-3.
3. K.A. Donald, P. Samia, A. Kakooza-
in a study that stroke patients at Brunnstrom Mwesige, D. Bearden, Pediatric cerebral
stages II or III showed decreased muscle palsy in Africa: A systematic review,
tone on the affected side after the PNF Semin. Pediatr. Neurol. 21 (2014) 30-35.
intervention. https://doi.org/10.1016/j.spen.2014.01.001.
Another study done Kumar et al in 4. W. Kulak, W. Sobaniec, Comparisons of
2016 which states both PNF and task right and left hemiparetic cerebral palsy,
oriented therapy on lower extremity Pediatr. Neurol. 31 (2004) 101-108.
function shown better results in CP children. https://doi.org/10.1016/j.pediatrneurol.2004.
The study focuses on PNF interventions for 01.009.
improving coordination. Also another 5. A.H. Tilton, Management of Spasticity in
objective of study was to make ADL Children With Cerebral Palsy, 11 (2004)
58–65.
activities possible with ease in children. https://doi.org/10.1016/j.spen.2004.01.008.
Significant improvement is seen in Berg 6. C.Y. Chung, C.L. Chen, A.M.K. Wong,
balance score when compared pre and post Pharmacotherapy of spasticity in children
treatment, all this is because the amount of with cerebral palsy, J. Formos. Med. Assoc.
motor learning and control happens in 110 (2011) 215-222. https://doi.org/10.1016
children is very fast in initial age. / S0929-6646(11)60033-8.
Significant improved was seen in gait 7. E. Jaspers, K. Desloovere, H. Bruyninckx,
parameters as child started walking with G. Molenaers, K. Klingels, H. Feys, Review
support, 2 steps of stair (up and down) in of quantitative measurements of upper limb
one go. It was concluded that the treatment movements in hemiplegic cerebral palsy,
is effective and helping him to progress day Gait Posture. 30 (2009) 395-404.
https://doi.org/10.1016/j.gaitpost.2009.07.11
by day. Though till now we have not 0.
achieved independent walking completely, 8. H. Anttila, I. Autti-Rämö, J. Suoranta, M.
although the achievements we have got in Mäkelä, A. Malmivaara, Effectiveness of
International Journal of Science and Healthcare Research (www.ijshr.com) 37
Vol.6; Issue: 1; January-March 2021
Preksha Sharma. PNF training for improving lower limb coordination in Cerebral Palsy: a case study in a child
with spastic diplegia
physical therapy interventions for children 11. L.L. Chuang, C.Y. Wu, K.C. Lin,
with cerebral palsy: A systematic review, Reliability, validity, and responsiveness of
BMC Pediatr. 8 (2008) 1-10. myotonometric measurement of muscle
https://doi.org/10.1186/1471-2431-8-14. tone, elasticity, and stiffness in patients with
9. K.C. Seo, S.H. Park, K. Park, The effects of stroke, Arch. Phys. Med. Rehabil. 93 (2012)
stair gait training using proprioceptive 532-540.
neuromuscular facilitation on stroke https://doi.org/10.1016/j.apmr.2011.09.014.
patients’ dynamic balance ability, J. Phys.
Ther. Sci. 27 (2015) 1459-1462. How to cite this article: Sharma P. PNF training
https://doi.org/10.1589/jpts.27.1459. for improving lower limb coordination in
10. S.E. Park, J.S. Wang, Effect of joint cerebral palsy: a case study in a child with
mobilization using KEOMT and PNF on a spastic diplegia. International Journal of
patient with CLBP and a lumbar transitional Science & Healthcare Research. 2021; 6(1): 35-
vertebra: A case study, J. Phys. Ther. Sci. 38.
27 (2015) 1629-1632.
https://doi.org/10.1589/jpts.27.1629.
******
International Journal of Science and Healthcare Research (www.ijshr.com) 38
Vol.6; Issue: 1; January-March 2021
no reviews yet
Please Login to review.
