Effect of a Combination of Myofascial Release Technique to Conventional Physiotherapy Program on Functional Outcomes in Pediatric Cerebral Palsy Post Achilles Tendon Surgery in the Gaza Strip
Phase: NA
Conditions: Cerebral Palsy Achilles Tendon Contracture Achilles Tendon Surgery
Sponsor: Ismail K. Al-Qudra

 
Effect of a Combination of Myofascial Release 
Technique to Conventional Physiotherapy Program 
on Functional Outcomes in Pediatric Cerebral Palsy 
Post Achilles Tendon Surgery in the Gaza Strip 
 
 
 
     NCT Number: Pending 
Document Date: JULAY 3, 2025 
Principal Investigator: 
Ismail Kamal Al Qedra, PT, MSc 
Affiliation: 
Al-Azhar University – Gaza 
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Al-Azhar University-Gaza 
Deanship of Postgraduate Studies 
Faculty of Applied Medical Sciences 
Department of Physical Therapy 
 
Effect of a Combination of Myofascial Release Technique and 
Conventional Physiotherapy Program on Functional Outcomes in 
Pediatric Cerebral Palsy Post Achilles Tendon Surgery in the Gaza 
Strip 
By: 
Ismail Kamal Al-Qedra 
Supervised By: 
Dr. Mosab M. Aldabbas (Assistant Professor) 
Dr. Ahmed A. Najim (Assistant Professor) 
 
Faculty of Applied Medical Sciences Department of Physical Therapy 
Al Azhar University, Palestine, Gaza 
 
 
A proposal submitted partially fulfils the requirement for the master's degree 
in orthopedic physical therapy 
1446-2025 
 

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Contents 
Chapter One: Introduction ........................................................................................... 5 
1.1 Introduction ............................................................................................................ 5 
1.2 Problem Statement.................................................................................................. 7 
1.3 Justification of the Study ........................................................................................ 8 
1.4 Objectives of the Study ........................................................................................... 9 
1.4.1 General Objective:........................................................................................... 9 
1.4.2 Specific Objectives: ......................................................................................... 9 
1.5 Research questions .................................................................................................. 9 
1.6 Context of the Study ............................................................................................. 10 
1.7 Operational Definition of Key Terms ................................................................... 10 
Chapter Two: Conceptual Framework and Literature Review ................................. 12 
2.1 Conceptual Framework ........................................................................................ 12 
2.1.1 Independent Variables .................................................................................. 12 
2.1.2 Dependent Variables ..................................................................................... 13 
2.2 Literature Review ................................................................................................. 15 
Chapter Three: Materials and Methods ..................................................................... 17 
3.1 Study design .......................................................................................................... 17 
Flow Diagram ............................................................................................................. 17 
3.2 Setting and Period of the Study ............................................................................ 17 
3.3 Study Population ................................................................................................... 18 
3.4 Eligibility Criteria ................................................................................................. 18 
3.5 Sample Size and Sampling Process ....................................................................... 19 
3.6 Data Collection Procedure .................................................................................... 19 
3.6.1 Assessment study Tools................................................................................ 19 
3.6.2 Timing of Data Collection .............................................................................. 20 
3.6.3 Data Collectors .............................................................................................. 20 
3.7 Intervention: ......................................................................................................... 20 
3.7.1 Control Group: Conventional Physiotherapy Program ................................... 20 
3.7.2 Intervention Group: Myofascial Release + Conventional Physiotherapy ........ 20 
3.8 Instruments of the Study ...................................................................................... 22 

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3.8.1 Gross Motor Function Measure-88 (GMFM-88) ............................................. 22 
3.8.3 Goniometric Measurement of Ankle Range of Motion (ROM) ........................ 23 
3.9 Pilot Study: ............................................................................................................ 23 
3.10 Validity and Reliability ....................................................................................... 24 
3.10.1 Gross Motor Function Measure (GMFM-88) ................................................ 24 
3.10.2 Pediatric Balance Scale (PBS) .................................................................... 24 
3.10.3 Goniometer for Range of Motion (ROM) ...................................................... 24 
3.11 Statistical Management and Procedures ............................................................ 25 
3.12 Ethical and Administrative Considerations ....................................................... 25 
3.13 Gantt Chart: (Timetable for research activity) .................................................. 25 
 
References ........................................................................................................ 26 
 
 
 
 

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List of Abbreviations 
CP 
Cerebral Palsy 
 
GMFM-66 
Gross Motor Function Measure-66 
 
ROM 
Range of Motion 
 
RCT 
Randomized Controlled Trial 
 
PT 
Physical Therapy                   
QoL 
Quality of Life 
SPSS 
Statistical Package for Social Science 
WHO 
 
World Health Organization 
 
MFR 
Myofascial Release 
 
MoH 
Ministry of Health 
UNRWA 
United Nations Relief and Works Agency 
 
 
 

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Chapter One: Introduction 
1.1 Introduction 
Cerebral palsy (CP) is a group of permanent movement and posture disorders caused by 
non-progressive disturbances in the developing fetal or infant brain (Odding et al., 2006) 
It is the most common motor disability in childhood, often associated with spasticity, 
muscle weakness, and impaired coordination. These neuromotor deficits contribute to a 
spectrum of functional limitations, varying in severity and presentation across individuals. 
Children with CP often experience abnormal muscle tone, joint contractures, and impaired 
motor control, making functional mobility a significant challenge (Odding et al., 2006). 
 
Functionally, CP affects a child’s ability to perform age-appropriate activities such as 
standing, walking, and maintaining balance. Within spastic CP, balance impairments are 
highly prevalent due to deficits in postural control, sensory integration, and muscle 
coordination. Such impairments increase the risk of falls and restrict participation in daily 
activities. Therefore, balance is a critical outcome to assess, in addition to gross motor 
function and joint range of motion.(Araújo et al., 2020) 
One of the most frequent musculoskeletal deformities in spastic CP is equines foot, 
commonly resulting from tightness or contracture of the gastrocnemius-soleus complex  
(Sarathy et al., 2019). This condition significantly affects gait and postural alignment. In 
more severe cases, surgical interventions like Achilles tendon lengthening are required to 
improve ankle dorsiflexion and facilitate better gait mechanics (Tateuchi, 2019). However, 
even after surgery, many children continue to face functional limitations due to persistent 
muscle tightness, fascia restrictions, and poor motor coordination. Surgical correction 
addresses structural deformity but often fails to resolve underlying neuromuscular 
dysfunction. Studies have shown that recurrence of equine deformity post-surgery is not 
uncommon, with rates reported up to 43% in some cohorts, particularly among those with 
severe preoperative contractures or younger age at surgery. Additionally, muscle-tendon 
lengthening procedures can lead to significant and prolonged muscle weakness, which may 
impede functional recovery and necessitate extended rehabilitation periods. These findings 

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underscore the importance of comprehensive postoperative rehabilitation strategies that 
address not only the structural corrections but also the persistent neuromuscular 
impairments to optimise functional outcomes.(Sala et al., 1997) 
 
Post-surgical rehabilitation is crucial in enhancing outcomes, and physiotherapy plays a 
central role in this process. Conventional physiotherapy aims to improve muscle strength, 
range of motion, balance, and gait through stretching, strengthening, and task-specific 
training(Jain et al., 2023). Despite its importance, standard physiotherapy may not fully 
address deep soft tissue restrictions and altered fascial dynamics. In some cases, progress 
may plateau due to residual stiffness and abnormal tone, which can limit functional 
recovery.(Kilbride & McDonnell, 2000) 
 
Myofascial Release (MFR) is a manual therapy technique designed to reduce fascial 
restrictions, improve tissue extensibility, and restore functional mobility. It involves gentle, 
sustained pressure into the fascial system to release adhesions and improve neuromuscular 
function (Ajimsha et al., 2015a). In recent years, growing evidence has supported its use 
in children with spastic CP. For example, studies have shown that MFR may help reduce 
spasticity, improve joint mobility, and enhance gross motor function when added to 
conventional physiotherapy (Chen et al., 2022). However, there remains a lack of focused 
research on the use of MFR in the postoperative context, especially following Achilles 
tendon lengthening procedures. 
 
To date, to our knowledge no studies have specifically explored the effect of integrating 
MFR into rehabilitation programs for children with CP, after Achilles tendon surgery. 
Given the complexity of CP-related impairments and the potential of MFR to enhance 
tissue mobility and motor outcomes, this study aims to address gap in this area. 
 

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1.2 Problem Statement 
Cerebral palsy (CP) is a prevalent neurological disorder in children, characterised by motor 
impairments, abnormal muscle tone, and movement dysfunction (Patel et al., 2020). 
Globally, CP affects approximately 2 to 2.5 per 1,000 live births, making it the most 
common motor disability in childhood (McIntyre et al., 2022). In certain areas within the 
Middle East and North Africa (MENA) region, such as Al-Quseir City in Egypt, the 
prevalence of cerebral palsy has been reported to reach 3.6 per 1,000 live births, potentially 
due to limited access to maternal and neonatal care (Shehata et al., 2014). 
In Palestine, particularly in the Gaza Strip, the true prevalence is unclear due to the lack of 
national registries; however, regional clinical data and observations suggest a notably high 
rate, especially in areas affected by limited healthcare access, poverty, and repeated 
conflict-related trauma. 
In cases of spastic CP, equinus deformity is common, resulting in altered gait patterns and 
reduced mobility (Horsch et al., 2021). Surgical options, such as Achilles tendon 
lengthening, aim to correct equinus and improve ambulation. However, many children 
continue to face limitations in range of motion, muscle stiffness, and balance even after 
surgery and physiotherapy, which hinders their ability to perform daily functional tasks 
(Horsch et al., 2021). 
Children with CP face long-term functional limitations that severely impact their daily 
activities and overall well-being, including decreased muscle strength, joint contractures, 
poor postural control, and impaired motor coordination (Mutlu et al., 2017). They often 
struggle with walking, climbing stairs, maintaining balance, and engaging in play or 
recreational activities, leading to dependence on caregivers and assistive devices (Sutapa 
et al., 2021). These impairments also restrict participation in educational and social 
contexts, contributing to social isolation, reduced self-esteem, and a lower quality of life 
(Maciver et al., 2019). Additionally, chronic movement difficulties and fatigue may reduce 
physical activity and exacerbate secondary health complications (Mahindru et al., 2023). 
Despite the importance of post-operative physiotherapy, current rehabilitation strategies 
for children with CP, following Achilles tendon lengthening are often limited to 

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conventional techniques such as stretching, strengthening, and balance training. However, 
few studies have investigated the integration of advanced manual therapy techniques, 
particularly Myofascial Release (MFR), into post-surgical rehabilitation (Page, 2012). 
Most research either focuses on pre-operative conditions or lacks specificity in addressing 
fascial restrictions and biomechanical deficits that persist after surgery. 
This gap in the literature limits our understanding of how combining MFR with standard 
physiotherapy may affect gross motor function, balance and range of motion (ROM), in 
pediatric CP patients. Without evidence-based protocols incorporating MFR, clinicians 
may miss critical opportunities to optimize recovery and improve long-term outcomes. 
Thus, this study seeks to evaluate the effectiveness of adding MFR to conventional 
physiotherapy on functional outcomes in children with CP, following Achilles tendon 
surgery in the Gaza Strip — a setting with unique challenges and an urgent need for 
enhanced rehabilitation solutions. 
 1.3 Justification of the Study 
 
This study provides critical evidence on the role of MFR as a complementary approach in 
rehabilitating children with CP after Achilles tendon lengthening surgery. While 
conventional physiotherapy is the standard in postoperative rehabilitation, many children 
still show persistent limitations in functional mobility, muscle tightness, and postural 
control. These outcomes suggest that traditional methods may not fully address the 
complex neuromuscular and fascial restrictions associated with CP. 
This research addresses a significant gap in pediatric rehabilitation by integrating manual 
resistance therapy (MRT) with conventional therapy. While evidence supports MFR's 
effectiveness in reducing spasticity and improving motor performance in children with CP, 
few studies have explored its role in postoperative recovery. Investigating this integration 
is crucial, as fascial restrictions may limit the benefits of surgical correction and hinder 
long-term functional gains. 
This study may refine rehabilitation protocols by showing if MFR improves gait quality, 
range of motion, and daily activity independence. It could also inform therapists and 

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healthcare planners about cost-effective strategies that enhance recovery and functional 
independence in children with CP. Ultimately, this research aims to improve the quality 
and efficiency of rehabilitation services for children with complex motor impairments. 
1.4 Objectives of the Study 
1.4.1 General Objective: 
To evaluate the effectiveness of adding Myofascial Release (MFR) to conventional 
physiotherapy on functional outcomes and balance in children with cerebral palsy 
following Achilles tendon lengthening surgery in the Gaza Strip. 
1.4.2 Specific Objectives: 
1. To evaluate the effectiveness of conventional physiotherapy on functional 
outcomes in children with cerebral palsy following Achilles tendon lengthening 
surgery in the Gaza Strip. 
2. To evaluate the effectiveness of conventional physiotherapy on balance in children 
with cerebral palsy following Achilles tendon lengthening surgery 
3. To evaluate the effectiveness of adding Myofascial Release (MFR) to conventional 
physiotherapy on functional outcomes and balance in children with cerebral palsy 
following Achilles tendon lengthening surgery. 
1.5 Research questions 
1. Does conventional physiotherapy alone improve gross motor function, balance, and 
ankle range of motion (ROM) in children with cerebral palsy following Achilles 
tendon lengthening surgery? 
2. Does the addition of Myofascial Release (MFR) to conventional physiotherapy 
result in greater improvement in gross motor function compared to conventional 
physiotherapy alone? 
3. Does the addition of Myofascial Release (MFR) to conventional physiotherapy 
result in greater improvement in balance compared to conventional physiotherapy 
alone? 
4. Does the addition of Myofascial Release (MFR) to conventional physiotherapy 
result in greater improvement in ankle range of motion (ROM) compared to 
conventional physiotherapy alone? 

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1.6 Context of the Study 
Sociodemographic Context: 
The Gaza Strip, a densely populated region with over 2.3 million inhabitants, faces 
numerous socioeconomic challenges due to prolonged political instability, blockade, and 
recurrent conflicts. More than 70% of the population are refugees, and a significant 
proportion lives below the poverty line. Children with disabilities, including those with CP, 
face multiple barriers in accessing education, healthcare, and social inclusion. Limited 
community awareness and stigmatization further contribute to their marginalization. The 
socioeconomic hardships often lead to reduced family resources, transportation difficulties, 
and limited parental engagement in rehabilitation services. 
Palestinian Healthcare System: 
The Palestinian healthcare system in Gaza is composed of three main providers: the 
Ministry of Health (MoH), the United Nations Relief and Works Agency for Palestine 
Refugees in the Near East (UNRWA), and non-governmental organizations (NGOs). 
While efforts are made to offer rehabilitation services for children with disabilities, the 
sector suffers from chronic underfunding, shortage of specialized staff, outdated 
equipment, and limited access to advanced physiotherapy modalities. The majority of 
rehabilitation services are provided by NGOs with external funding, and continuity of care 
is often interrupted by supply shortages or unstable security conditions. These challenges 
underscore the need for cost-effective, evidence-based interventions—such as combining 
Myofascial Release (MFR) with conventional physiotherapy—to optimize functional 
outcomes for children with CP post-surgery. 
 
1.7 Operational Definition of Key Terms 
Cerebral Palsy (CP): 
A group of permanent disorders affecting the development of movement and posture, 
causing activity limitations, that are attributed to non-progressive disturbances occurring 
in the developing fetal or infant brain. While the injury itself is non-progressive, the 
resulting neuromuscular and musculoskeletal impairments, such as tone abnormalities, 

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joint contractures, and motor coordination deficits, may evolve over time. (Blair & Cans, 
2025; Panda et al., 2024) 
Spastic CP: 
The most common type of cerebral palsy, characterized by increased muscle tone 
(hypertonia), stiffness, and restricted joint movement.(Novak et al., 2012) 
Equine's Deformity: 
A musculoskeletal condition commonly observed in children with spastic CP, involving 
excessive plantarflexion of the ankle, which impairs gait and balance.(İğrek et al., 2022) 
Achilles Tendon Lengthening Surgery: 
A surgical procedure performed to release or elongate the Achilles tendon to correct 
equinus deformity and improve ankle dorsiflexion. 
Conventional Physiotherapy: 
A structured rehabilitation program including stretching, strengthening, gait training, and 
balance exercises delivered by a licensed physiotherapist. 
Myofascial Release (MFR): 
A hands-on manual therapy technique aimed at relieving fascial restrictions to improve 
range of motion, reduce pain, and enhance movement efficiency.(Ajimsha et al., 2015b) 
 
 
 
 
 
 

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Chapter Two: Conceptual Framework and Literature Review 
2.1 Conceptual Framework 
 
Cerebral palsy (CP) is a group of permanent movement disorders caused by non-
progressive disturbances in the developing fetal or infant brain. These neurological 
impairments frequently result in spasticity, joint contractures, and musculoskeletal 
deformities—most notably equinus foot due to gastrocnemius-soleus spasticity. Surgical 
interventions such as Achilles tendon lengthening are often employed to correct these 
deformities and improve gait. However, postoperative outcomes depend heavily on the 
quality of rehabilitation. 
Conventional physiotherapy (CPT) is the cornerstone of post-surgical rehabilitation. It 
aims to improve muscle strength, range of motion (ROM), balance, and gross motor 
function through structured exercises and task-specific training. However, conventional 
techniques may not adequately address soft tissue and fascial restrictions that persist after 
surgery. 
Myofascial Release (MFR) is a manual therapy technique that applies gentle, sustained 
pressure to fascial structures to reduce adhesions and restore tissue extensibility. When 
integrated with CPT, MFR may enhance the effectiveness of rehabilitation by improving 
tissue flexibility and reducing muscle tone, thereby allowing better engagement with 
physiotherapy exercises. 
2.1.1 Independent Variables 
 
Conventional Physiotherapy 
This includes standard rehabilitation interventions provided to children with cerebral palsy 
post-Achilles tendon surgery. It typically consists of stretching, strengthening, balance 
training, and gait re-education to improve functional outcomes. 
 
 

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MFR 
A manual therapy technique applied to the fascia and soft tissues to reduce tightness, 
improve tissue mobility, and support better functional movement. When added to 
conventional physiotherapy, it is hypothesized to enhance motor recovery and joint 
mobility. 
2.1.2 Dependent Variables 
Gross Motor Function 
This refers to a child's ability to perform large muscle activities, such as sitting, standing, 
and walking. It will be measured using the Gross Motor Function Measure (GMFM), a 
validated scale for children with CP. 
Range of Motion (ROM) 
Specifically focused on ankle dorsiflexion and plantarflexion, ROM will be measured 
using a goniometer to assess joint mobility post-surgery and throughout rehabilitation. 
Improved ROM is essential for better gait and balance. 
 Balance: 
The ability to maintain upright posture and stability during static and dynamic tasks. It will 
be measured using the Pediatric Balance Scale (PBS), a validated tool for young children 
with CP. 
In this study, the independent variables—CPT and MFR—are expected to influence the 
dependent outcomes: gross motor function, balance, and ankle ROM. MFR is hypothesized 
to enhance the structural readiness of muscles and fascia, reducing tone and improving 
tissue mobility. This, in turn, may augment the efficacy of CPT by enabling more effective 
execution of strengthening, balance, and gait exercises. The synergistic combination is thus 
anticipated to yield greater improvements in functional outcomes compared to CPT alone. 
 
 
 

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Conceptual framework (Self developed) 
 
 
 
 
 
Independent Variables 
Group1: 
Conventional 
Physiotherapy 
Group2:  
MFR+ Conventional 
Physiotherapy 
Dependent Variables 
 Gross motor function 
 Balance 
 Ankle Range of 
Motion(ROM) 
Functional 
Independence
/Quality of 
Movement 

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2.2 Literature Review  
CP is one of the most prevalent motor disorders affecting children worldwide, characterised 
by spasticity, muscle stiffness, impaired motor control, and poor functional mobility. 
Numerous interventions have been proposed to enhance motor function and quality of life 
in children with CP, among which MFR has gained increasing attention as a 
complementary technique to conventional physiotherapy. This literature review explores 
existing evidence on the effectiveness of MFR and related interventions, particularly after 
Achilles tendon lengthening (ATL) surgery, and highlights current gaps in the research. 
(Khanna et al., 2023) Compared Neurodevelopmental Therapy (NDT) alone to NDT 
combined with MFR in children with spastic CP. The study found that the combined 
therapy group demonstrated significantly greater improvements in gross motor function, 
as measured by GMFM-88, suggesting that MFR may enhance the outcomes of 
conventional approaches. 
(Avilash Mohapatra et al., 2024) Investigated the comparative impact of MFR and Deep 
Oscillation Therapy (DOT) on hamstring flexibility and muscle tone. Their results showed 
that both techniques effectively reduced spasticity and improved ROM, with MFR being 
slightly more effective. 
(Paul et al., 2018) focused on MFR's effectiveness in reducing hamstring spasticity among 
diplegic CP children. The findings confirmed that MFR significantly decreased spasticity 
and enhanced knee ROM, thus supporting its inclusion in pediatric CP rehabilitation 
programs. 
(Curtis et al., 2018)evaluated the effects of trunk and head control training on functional 
changes in children with CP. The study highlighted improvements in gross motor function, 
emphasizing the importance of integrated therapeutic strategies. 
(Kwan et al., 2023) explored the biomechanical impact of tendon release surgery on gait 
and stiffness control in spastic diplegic CP children. Post-surgical improvements in inter-
limb leg stiffness were observed, indicating that ATL surgery positively influences gait 
mechanics but still requires adjunctive therapy for optimal results. 

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(Horsch et al., 2022) provided a meta-analysis on the recurrence of equinus deformity 
following ATL in CP patients. The recurrence rate was significant, underlining the 
necessity for effective postoperative rehabilitation methods such as MFR. 
(Usta Ozdemir et al., 2024) Presented a case report involving electromyographic 
biofeedback training post upper limb tendon transfer surgery in a CP patient. The 
intervention yielded functional improvements, illustrating the benefit of integrating novel 
physiotherapy techniques. 
 
Dietz et al. (2006) provided a medium-term follow-up of patients after ATL surgery. 
Despite improvements in ankle ROM, continued physiotherapy was deemed essential to 
sustain functional gains, reinforcing the role of adjunctive therapies. 
 
In summary, while existing literature demonstrates the potential benefits of MFR in 
improving gross motor function and ROM in children with CP, few studies have directly 
examined its effect post-Achilles tendon surgery. Most research has been limited by small 
sample sizes, short follow-up periods, or lack of standardized protocols. This gap 
underscores the need for further investigation into the combined use of MFR and 
conventional physiotherapy, particularly in the post-surgical context. The present study 
aims to address this gap by evaluating the effectiveness of adding MFR to conventional 
therapy on gross motor function and ROM in pediatric CP patients post-ATL in the Gaza 
Strip. 
 
 
 

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At 
Allocated Conventional Physiotherapy 
Group (n= 20 ) 
Allocated to MFR Combined 
with Conventional 
Physiotherapy Group: (n= 20 ) 
At 
Lost to follow-up (give reasons) (n= ) 
Discontinued intervention (give reasons) 
Lost to follow-up (give reasons) (n= ) 
Discontinued intervention (give reasons) 
Follow up 6 
Analysed (n= ) 
Excluded from analysis (give reasons) 
(n= ) 
Analysed (n= ) 
Excluded from analysis (give reasons) (n= 
) 
Randomized (n= 40 ) 
Excluded (n= ) 
Not meeting inclusion criteria (n= ) 
Declined to participate (n= ) 
Other reasons (n= ) 
Assessed for eligibility (n= 80-100) 
Chapter Three: Materials and Methods 
3.1 Study design 
A single-blind randomized controlled trial (RCT) will be conducted to evaluate the effect 
of adding Myofascial Release (MFR) to conventional physiotherapy on functional 
outcomes in children with cerebral palsy after Achilles tendon surgery. Participants will be 
randomly assigned to either an intervention group (MFR + physiotherapy) or a control 
group (physiotherapy only). Assessments will be conducted at baseline and after 8 weeks 
of intervention. 
Flow Diagram 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.2 Setting and Period of the Study 
The study will be conducted at The Jerusalem Princess Basma Centre located within Al-
Ahli Al-Arabi Hospital in Gaza, Palestine. This centre is a specialized and well-established 
Enrollment 

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rehabilitation facility that offers multidisciplinary services for children with neuromuscular 
disorders, including cerebral palsy. It is equipped with qualified rehabilitation 
professionals, physiotherapy units, and child-friendly environments tailored to the needs 
of pediatric patients. The center regularly manages post-operative cases of Achilles tendon 
lengthening, providing an appropriate setting for the implementation of structured 
physiotherapy programs, including advanced manual techniques such as Myofascial 
Release (MFR). 
The feasibility of conducting the study at this center is considered high due to the presence 
of skilled staff, consistent patient flow, and administrative support for research activities. 
The center's rehabilitation protocols and follow-up systems also support the monitoring 
and documentation required for clinical research. The study period will span from March 
to August 2025, covering participant recruitment, delivery of the intervention, and pre- and 
post-intervention data collection. 
3.3 Study Population 
The study population will comprise children aged 2 years and older who have been 
diagnosed with spastic CP and have undergone Achilles tendon surgery within the past 3 
months. Participants will be sourced from the patient registry at The Jerusalem Princess 
Basma Centre at Alahli Al-arabi hospital, a specialised rehabilitation centre in Gaza, 
ensuring they meet the eligibility criteria outlined in section 3.4. 
3.4 Eligibility Criteria 
Inclusion Criteria: 
1. Children aged 2 to 5 years. 
2. Diagnosed with spastic cerebral palsy (GMFCS levels I–IV). 
3. Have undergone Achilles tendon lengthening surgery within the past 3 months. 
4. Medically stable and cleared to begin physiotherapy. 
5. Parental/guardian consent to participate in the study. 
Exclusion Criteria: 
1. Diagnosis of other neuromuscular or developmental disorders. 
2. Received Myofascial Release therapy in the past 6 months. 

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3. Severe cognitive or behavioral impairments that interfere with following 
instructions. 
4. Participation in another rehabilitation study in the past 3 months. 
3.5 Sample Size and Sampling Process 
A sample size of 40 participants (20 per group) will be targeted, based on feasibility, 
resource availability, and statistical power considerations. A consecutive sampling method 
will be employed, selecting eligible participants who consent to participate during the 
recruitment period. 
3.6 Data Collection Procedure 
Data collection will be conducted using standardized, validated tools and structured clinical 
procedures to ensure reliability and accuracy in assessing the functional outcomes of 
children with cerebral palsy following Achilles tendon lengthening surgery. 
3.6.1 Assessment study Tools 
The following tools will be used to collect data on the primary outcome measures: 
Gross Motor Function Measure-88 (GMFM-88): 
This is a standardised observational instrument designed to measure changes in gross 
motor function in children with cerebral palsy. It consists of 88 items categorised into 
five dimensions: lying and rolling, sitting, crawling and kneeling, standing, walking, 
running, and jumping. GMFM-88 has been validated and widely used in pediatric 
rehabilitation settings (Choi, 2024). 
Pediatric Balance Scale (PBS): 
An adapted version of the Berg Balance Scale for children, used to assess functional 
balance in sitting and standing tasks. It consists of 14 items scored on a 5-point scale, and 
has demonstrated strong validity and inter-rater reliability in children with CP. 
Range of Motion (ROM): 
Passive ankle dorsiflexion will be measured using a standard universal goniometer. 
Measurements will be taken with the knee both flexed and extended to assess the length 
and flexibility of the gastrocnemius-soleus complex. This will provide an objective 
evaluation of the effect of the interventions on joint flexibility. 

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3.6.2 Timing of Data Collection 
Data will be collected at the following time points: 
Pre-Intervention (Baseline): 
Before to the start of any physiotherapy sessions, baseline data will be recorded to 
establish initial levels of function and range of motion. 
Post-Intervention (After 8 weeks): 
After the completion of the intervention period, a post-treatment assessment will be 
conducted to measure changes in gross motor function and ankle dorsiflexion ROM. 
3.6.3 Data Collectors 
Trained physiotherapists who are not involved in the intervention sessions will perform all 
assessments to avoid bias. They will undergo calibration and training sessions to 
standardise the assessment procedures and ensure inter-rater reliability. 
3.7 Intervention: 
This study will include two intervention arms: 
3.7.1 Control Group: Conventional Physiotherapy Program 
Duration: 8 weeks 
Frequency: 3 sessions per week 
Session Duration: 45 minutes 
Intervention Content: 
Passive and active stretching for gastrocnemius-soleus complex 
Strengthening exercises for lower limb muscles (especially tibialis anterior and 
quadriceps) 
Balance and postural control training 
Functional task training including sit-to-stand, step-ups, and gait training 
Use of assistive devices if needed 
Objective: To enhance muscle flexibility, improve gross motor performance, and 
facilitate independence in functional mobility after Achilles tendon lengthening surgery. 
3.7.2 Intervention Group: Myofascial Release + Conventional Physiotherapy 
Duration: 8 weeks 

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Frequency: 3 sessions per week 
Session Duration: 60 minutes  
Intervention Content: 
The intervention will be conducted over a period of 8 weeks, with three sessions per 
week, totaling 24 sessions. Each session will last approximately 60 minutes, divided as 
follows: 
45 minutes for Conventional Physiotherapy (CPT), described above 
15 minutes for Myofascial Release (MFR) 
Myofascial Release (MFR): 
MFR will be administered by a physiotherapist using 4 selected techniques based on 
individual patient needs and tissue restrictions. Each MFR session will focus on releasing 
soft tissue restrictions in key muscle and fascial structures involved in gait and postural 
control in children with spastic cerebral palsy, particularly post Achilles tendon 
lengthening surgery. 
 
The selected MFR techniques will be drawn from evidence-based protocols described in 
advanced myofascial release manuals and include: 
 
1. Cross-Hand Release 
2. Plantar Fascia Release 
3. Gastrocnemius–Soleus Complex Release 
4. Hamstring Fascial Lengthening 
Each technique will be applied for 2–3 minutes, with gentle, sustained pressure held until 
tissue "melting" or release is palpated. Sessions will be performed in a calm, supportive 
environment, ensuring that the child is relaxed and comfortable throughout the treatment. 
 
All sessions will be individualized based on functional level and tolerance, and monitored 
for consistency and safety. 
Rationale: MFR may help release fascial restrictions, improve tissue mobility, reduce 
muscle tone, and promote better joint ROM and gross motor function—especially after 
surgical correction. 

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3.8 Instruments of the Study 
To evaluate the functional outcomes of adding Myofascial Release (MFR) to 
conventional physiotherapy in children with cerebral palsy following Achilles tendon 
lengthening surgery, the study will utilize the following validated instruments: 
 
3.8.1 Gross Motor Function Measure-88 (GMFM-88) 
What it assesses: 
Gross Motor Function – the child’s ability to perform age-appropriate motor activities 
such as sitting, standing, crawling, walking, and jumping. 
 
How it will be assessed: 
The GMFM-88 includes 88 items divided across five domains: 
 
Lying and Rolling 
 
Sitting 
 
Crawling and Kneeling 
 
Standing 
 
Walking, Running, and Jumping 
 
Each item is scored on a 4-point ordinal scale from 0 (does not initiate) to 3 (completes 
the task fully). The total and domain-specific scores will be calculated. 
3.8.2 Pediatric Balance Scale (PBS) 
What it assesses: 

23 
 
Functional balance — the child’s ability to maintain equilibrium during various static and 
dynamic tasks in sitting and standing positions. 
How it will be assessed: 
The PBS consists of 14 tasks such as sitting to standing, turning, reaching, and standing 
with eyes closed. Each item is scored on a 5-point scale (0 to 4), with a total score out of 
56. This tool has demonstrated strong reliability and validity in children with cerebral palsy 
and will be administered pre- and post-intervention. 
3.8.3 Goniometric Measurement of Ankle Range of Motion (ROM) 
What it assesses: 
Passive dorsiflexion of the ankle joint – to determine changes in muscle length, joint 
flexibility, and soft tissue extensibility after intervention. 
How it will be assessed: 
A standard universal goniometer will be used to measure passive ankle dorsiflexion: 
With the knee flexed (isolating the soleus) 
With the knee extended (measuring the gastrocnemius-soleus complex) 
Measurements will be taken in degrees and documented pre- and post-intervention. 
 
3.9 Pilot Study: 
Prior to the commencement of the main trial, a pilot study will be conducted at the same 
setting (The Jerusalem Princess Basma Centre at Al-Ahli Al-Arabi Hospital). The aim of 
the pilot is to assess the feasibility and practicality of the intervention protocol, data 
collection tools, and logistical arrangements. A small number of participants (e.g., 5–8 
children) who meet the inclusion criteria will be involved. This pilot phase will help 
identify any challenges related to participant recruitment, administration of Myofascial 
Release (MFR), timing of assessments, or issues with outcome measurement tools such as 
GMFM-88 and goniometric ROM assessment. 
Findings from the pilot study will be used to refine the intervention schedule, improve data 
collection processes, and ensure clarity and reliability of the instruments. The data 

24 
 
collected during the pilot will not be included in the final statistical analysis of the main 
study. 
3.10 Validity and Reliability 
This study will utilize three validated assessment tools: the Gross Motor Function Measure 
(GMFM-88), Pediatric Balance Scale (PBS), and Goniometry for ankle Range of Motion 
(ROM). All instruments are well-established in pediatric rehabilitation and have 
demonstrated strong validity and reliability in children with cerebral palsy. 
3.10.1 Gross Motor Function Measure (GMFM-88) 
Validity: 
The GMFM-88 has demonstrated high content and construct validity for assessing gross 
motor function in children with cerebral palsy (2024). 
Reliability: 
The tool shows excellent test-retest and inter-rater reliability, with Intraclass Correlation 
Coefficients (ICCs) exceeding 0.95, confirming its consistency across different 
evaluators and over time.  
3.10.2 Pediatric Balance Scale (PBS) 
Validity: 
PBS is adapted from the Berg Balance Scale and has shown strong concurrent validity with 
other motor performance measures in pediatric populations. 
 
Reliability: 
The scale exhibits high inter-rater and intra-rater reliability in children with CP, with 
reported ICCs ranging from 0.92 to 0.98 (Franjoine et al., 2003). 
3.10.3 Goniometer for Range of Motion (ROM) 
Validity: 
Goniometry is a widely used method with established face and criterion validity when 
performed by trained professionals. 
Reliability: 

25 
 
Goniometric assessments of the ankle have shown high intra-rater and inter-rater 
reliability, with ICCs ranging from 0.86 to 0.98, making it a dependable tool for clinical 
and research use (Menadue et al., 2006). 
 
3.11 Statistical Management and Procedures 
Data will be analyzed using the Statistical Package for Social Sciences (SPSS) version 22. 
Descriptive statistics will summarize demographic and clinical characteristics. Inferential 
statistics, such as paired t-tests or Wilcoxon signed-rank tests, will compare pre- and post-
intervention scores within groups. Independent t-tests or Mann-Whitney U tests will 
compare changes between groups. A significance level of p < 0.05 will be set for all 
analyses. 
3.12 Ethical and Administrative Considerations 
 
1. The researcher will obtain all the necessary ethical documents to conduct the study. 
2. Approval from the Helsinki committee in Gaza will be obtained to conduct the 
study.  
3. An official letter of approval to conduct the research will be obtained from Al-
Azhar University, Gaza. 
4. The researcher will explain the purpose and objectives of the study to all 
participants, and written informed consent will be obtained from each participant 
before their participation. 
3.13 Gantt Chart: (Timetable for research activity) 
This study is expected to take six months, commencing in June 2025 and concluding in 
November 2025. This period will be divided into two main phases, illustrated in the table 
below: 

26 
 
 
 
 
 
 
 
 References  
 A report: The definition and classification of cerebral palsy April 2006. (2007). 
Developmental 
Medicine 
& 
Child 
Neurology, 
49, 
8–14. 
https://doi.org/10.1111/j.1469-8749.2007.tb12610.x 
 Ajimsha, M. S., Al-Mudahka, N. R., & Al-Madzhar, J. A. (2015a). Effectiveness 
of myofascial release: Systematic review of randomized controlled trials. Journal 
Activity 
Month (2025) 
Date 
June. 
Jul. 
Aug. 
Sep. 
Oct. 
Nov. 
Preparation of proposal and obtaining 
permissions 
Development of research tools 
Sample selection and implementation 
study program 
Data collection 
Data entry and data analysis 
Evaluation of results 
Review of literature 
Thesis report writing 
Submitting 

27 
 
of 
Bodywork 
and 
Movement 
Therapies, 
19(1), 
102–112. 
https://doi.org/10.1016/j.jbmt.2014.06.001 
 Ajimsha, M. S., Al-Mudahka, N. R., & Al-Madzhar, J. A. (2015b). Effectiveness 
of myofascial release: Systematic review of randomized controlled trials. Journal 
of 
Bodywork 
and 
Movement 
Therapies, 
19(1), 
102–112. 
https://doi.org/10.1016/j.jbmt.2014.06.001 
 Araújo, P. A. D., Starling, J. M. P., Oliveira, V. C., Gontijo, A. P. B., & Mancini, 
M. C. (2020). Combining balance-training interventions with other active 
interventions may enhance effects on postural control in children and adolescents 
with cerebral palsy: A systematic review and meta-analysis. Brazilian Journal of 
Physical Therapy, 24(4), 295–305. https://doi.org/10.1016/j.bjpt.2019.04.005 
 Avilash Mohapatra, Monalisha Pattnaik, & Patitapaban Mohanty. (2024). The 
Impact of Myofascial Release Therapy and Deep Oscillation Therapy on Hamstring 
Muscle Length and tone in Children with Spastic Cerebral Palsy: A Comparative 
Study. Indian Journal of Physiotherapy & Occupational Therapy - An 
International Journal, 18(1), 7–15. https://doi.org/10.37506/x165sq15 
 Chen, D., Wu, Y., Li, H., Pan, X., & Zhou, J. (2022). Treatment on patients with 
spastic cerebral palsy in the past 30 years: A systematic review and bibliometric 
analysis. 
Medicine, 
101(45), 
e30535. 
https://doi.org/10.1097/MD.0000000000030535 
 Choi, J. Y. (2024). Motor Function Measurement in Children: Gross Motor 
Function Measure (GMFM). Annals of Rehabilitation Medicine, 48(5), 301–304. 
https://doi.org/10.5535/arm.240078 

28 
 
 Curtis, D. J., Woollacott, M., Bencke, J., Lauridsen, H. B., Saavedra, S., Bandholm, 
T., & Sonne-Holm, S. (2018). The functional effect of segmental trunk and head 
control training in moderate-to-severe cerebral palsy: A randomized controlled 
trial. 
Developmental 
Neurorehabilitation, 
21(2), 
91–100. 
https://doi.org/10.1080/17518423.2016.1265603 
 Dietz, F. R., Albright, J. C., & Dolan, L. (2006). Medium-term follow-up of 
Achilles tendon lengthening in the treatment of ankle equinus in cerebral palsy. The 
Iowa Orthopaedic Journal, 26, 27–32. 
 Hanks, J., & Myers, B. (2023). Validity, Reliability, and Efficiency of a Standard 
Goniometer, Medical Inclinometer, and Builder’s Inclinometer. International 
Journal of Sports Physical Therapy, 18(4). https://doi.org/10.26603/001c.83944 
 Horsch, A., Klotz, M. C. M., Platzer, H., Seide, S. E., & Ghandour, M. (2022). 
Recurrence of Equinus Foot in Cerebral Palsy following Its Correction—A Meta-
Analysis. Children, 9(3), 339. https://doi.org/10.3390/children9030339 
 Horsch, A., Klotz, M. C. M., Platzer, H., Seide, S., Zeaiter, N., & Ghandour, M. 
(2021). Is the Prevalence of Equinus Foot in Cerebral Palsy Overestimated? Results 
from a Meta-Analysis of 4814 Feet. Journal of Clinical Medicine, 10(18), 4128. 
https://doi.org/10.3390/jcm10184128 
 İğrek, S., Akgülle, A. H., & Kesimer, M. D. (2022). Effect of rotational deformities 
after pediatric femoral fracture on clinical outcome. Journal of Pediatric 
Orthopaedics 
B, 
31(2), 
e130–e134. 
https://doi.org/10.1097/BPB.0000000000000842 

29 
 
 Jain, S. N., Lamture, Y., & Krishna, M. (2023). Enhanced Recovery After Surgery: 
Exploring 
the 
Advances 
and 
Strategies. 
Cureus. 
https://doi.org/10.7759/cureus.47237 
 Khanna, S., Arunmozhi, R., & Goyal, C. (2023). Neurodevelopmental Treatment 
in Children With Cerebral Palsy: A Review of the Literature. Cureus. 
https://doi.org/10.7759/cureus.50389 
 Kilbride, C., & McDonnell, A. (2000). Spasticity: The role of physiotherapy. 
British 
Journal 
of 
Therapy 
and 
Rehabilitation, 
7(2), 
61–64. 
https://doi.org/10.12968/bjtr.2000.7.2.13900 
 Kwan, K. Y. C., Ng, K. W. K., Rao, Y., Zhu, C., Qi, S., Tuan, R. S., Ker, D. F. E., 
& Wang, D. M. (2023). Effect of Aging on Tendon Biology, Biomechanics and 
Implications for Treatment Approaches. International Journal of Molecular 
Sciences, 24(20), 15183. https://doi.org/10.3390/ijms242015183 
 Maciver, D., Rutherford, M., Arakelyan, S., Kramer, J. M., Richmond, J., 
Todorova, L., Romero-Ayuso, D., Nakamura-Thomas, H., Ten Velden, M., 
Finlayson, I., O’Hare, A., & Forsyth, K. (2019). Participation of children with 
disabilities in school: A realist systematic review of psychosocial and 
environmental 
factors. 
PLOS 
ONE, 
14(1), 
e0210511. 
https://doi.org/10.1371/journal.pone.0210511 
 Mahindru, A., Patil, P., & Agrawal, V. (2023). Role of Physical Activity on Mental 
Health and Well-Being: A Review. Cureus. https://doi.org/10.7759/cureus.33475 
 McIntyre, S., Goldsmith, S., Webb, A., Ehlinger, V., Hollung, S. J., McConnell, 
K., Arnaud, C., Smithers‐Sheedy, H., Oskoui, M., Khandaker, G., Himmelmann, 

30 
 
K., & the Global CP Prevalence Group*. (2022). Global prevalence of cerebral 
palsy: A systematic analysis. Developmental Medicine & Child Neurology, 64(12), 
1494–1506. https://doi.org/10.1111/dmcn.15346 
 Menadue, C., Raymond, J., Kilbreath, S. L., Refshauge, K. M., & Adams, R. 
(2006). Reliability of two goniometric methods of measuring active inversion and 
eversion range of motion at the ankle. BMC Musculoskeletal Disorders, 7(1), 60. 
https://doi.org/10.1186/1471-2474-7-60 
 Moffitt, T. E., Caspi, A., Taylor, A., Kokaua, J., Milne, B. J., Polanczyk, G., & 
Poulton, R. (2010). How common are common mental disorders? Evidence that 
lifetime prevalence rates are doubled by prospective versus retrospective 
ascertainment. 
Psychological 
Medicine, 
40(6), 
899–909. 
https://doi.org/10.1017/S0033291709991036 
 Mutlu, A., Büğüsan, S., & Kara, Ö. K. (2017). Impairments, activity limitations, 
and participation restrictions of the international classification of functioning, 
disability, and health model in children with ambulatory cerebral palsy. Saudi 
Medical Journal, 38(2), 176–185. https://doi.org/10.15537/smj.2017.2.16079 
 Novak, I., Hines, M., Goldsmith, S., & Barclay, R. (2012). Clinical Prognostic 
Messages From a Systematic Review on Cerebral Palsy. Pediatrics, 130(5), e1285–
e1312. https://doi.org/10.1542/peds.2012-0924 
 Odding, E., Roebroeck, M. E., & Stam, H. J. (2006). The epidemiology of cerebral 
palsy: Incidence, impairments and risk factors. Disability and Rehabilitation, 28(4), 
183–191. https://doi.org/10.1080/09638280500158422 

31 
 
 Page, P. (2012). Current concepts in muscle stretching for exercise and 
rehabilitation. International Journal of Sports Physical Therapy, 7(1), 109–119. 
 Patel, D. R., Neelakantan, M., Pandher, K., & Merrick, J. (2020). Cerebral palsy in 
children: A clinical overview. Translational Pediatrics, 9(S1), S125–S135. 
https://doi.org/10.21037/tp.2020.01.01 
 Paul, J., C.V, S. N., Kumar, P., & K. R, R. (2018). Effectiveness of myofascial 
release in reduction of hamstrings spasticity among diplegic cerebral palsy 
children. International Journal Medical and Exercise Science, 04(01), 453–458. 
https://doi.org/10.36678/ijmaes.2018.v04i01.003 
 Sala, D. A., Grant, A. D., & Kummer, F. J. (1997). Equinus deformity in cerebral 
palsy: Recurrence after tendo Achillis lengthening. Developmental Medicine & 
Child 
Neurology, 
39(1), 
45–48. 
https://doi.org/10.1111/j.1469-
8749.1997.tb08203.x 
 Sarathy, K., Doshi, C., & Aroojis, A. (2019). Clinical Examination of Children with 
Cerebral 
Palsy. 
Indian 
Journal 
of 
Orthopaedics, 
53(1), 
35–44. 
https://doi.org/10.4103/ortho.IJOrtho_409_17 
 Shehata, G., El-Tallawy, H., Farghaly, W., Rageh, T., Badary, R., Sayed, M., Abd-
Elwarth, A., Kandil, M., Metwally, N., & Abd El Hamed, M. (2014). Cerebral palsy 
in Al-Quseir City, Egypt: Prevalence, subtypes, and risk factors. Neuropsychiatric 
Disease and Treatment, 1267. https://doi.org/10.2147/NDT.S59599 
 Sutapa, P., Pratama, K. W., Rosly, M. M., Ali, S. K. S., & Karakauki, M. (2021). 
Improving Motor Skills in Early Childhood through Goal-Oriented Play Activity. 
Children, 8(11), 994. https://doi.org/10.3390/children8110994 

32 
 
 Tateuchi, H. (2019). Gait- and postural-alignment-related prognostic factors for hip 
and knee osteoarthritis: Toward the prevention of osteoarthritis progression. 
Physical Therapy Research, 22(1), 31–37. https://doi.org/10.1298/ptr.R0003 
 Usta Ozdemir, H., Kitis, A., & Fahir Demirkan, A. (2024). Electromyographic 
biofeedback training in a cerebral palsy patient undergoing pronator teres rerouting 
and brachioradialis to extensor carpi radialis brevis tendon transfer surgery: A case 
report. 
Joint 
Diseases 
and 
Related 
Surgery, 
35(2), 
448–454. 
https://doi.org/10.52312/jdrs.2024.962 
 
 
   
 
 
 
 
 
 
Appendix 

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