The Effect of Upper Extremity Strengthening on Functionality, Muscle Strength and Trunk in Children With Cerebral Palsy
Condition: Cerebral Palsy; Upper Extremity Dysfunction; Upper Extremity Functions; Muscle Strength; Cerebral Palsy, Spastic; Cerebral Palsy Spastic Diplegia
MeSH terms: Muscle Spasticity; Paralysis; Cerebral Palsy
Study type: Interventional

Summary: 
      Cerebral Palsy (CP) is an activity limitation, movement and posture deficiencies in early
      stage of life. In 80% of these children, upper extremity (UE) dysfunctions are observed,
      which leads to loss of quality of life, resulting in limited participation in activities of
      daily living (ADL). When the hands are affected in UE, fine motor skills such as grasping,
      writing and object manipulation are usually limited. This results in inadequate use of the
      extremities in functional activities. Although all children with CP are known to be affected
      by UE, studies in terms of physiotherapy and rehabilitation methods mostly focused on
      children with hemiparetic CP. Similar problems are observed in children with bilateral
      involvement. However, a wide variation is observed in the bimanual performance of children
      with hemiparetic and bilateral involvement. Studies evaluating UE activities in children with
      CP; emphasized that the inability to manipulate objects manually is one of the most important
      reasons for the restriction of participation in ADLs. Physiotherapy and rehabilitation
      programs include many neurodevelopmental treatment approaches including stretching,
      strengthening, positioning, splinting, casting, orthosis selection and movement facilitation.
      However, it is known that studies investigating the current efficacy of these treatments on
      UE functions mostly focus on unilateral CP. Interventions that focus on improving UE
      functions in children with bilateral CP are limited. In UE rehabilitation in bilateral CP;
      states that target-focused therapy, bimanual intensive task specific training programs and
      trainings such as HABIT (intensive bimanual training of the upper extremity) involving the
      lower extremity have been used, but there is only evidence for HABIT-ILE (HABIT involving the
      lower extremity). In the literature, it is observed that strengthening training with the
      Proprioceptive Neuromuscular Facilitation (PNF) method, which makes a significant
      contribution to muscle strength balance, is mostly used in lower extremity rehabilitation in
      these children. In this study, in the UE rehabilitation of children with hemiparetic and
      diparetic CP; in order to stimulate motor responses and improve neuromuscular control and
      function, the superiority of the PNF approach applied with scapular and UE patterns over the
      traditional Neurodevelopmental Therapy (NGT-Bobath) method will be determined.
    

Detailed description: 
      European SP Surveillance (SCPE), CP subtypes according to the dominant type of tone and
      movement abnormality; divided into spastic, dyskinetic and ataxic CP. Spastic type SP;
      unilateral spastic (hemiparetic) and bilateral (quadriparetic and diparetic), dyskinetic SP;
      defined as dystonic and choreoathetotic. Spastic type constitutes 90% of this population and
      bilateral/unilateral involvement is observed in this group. In 80% of these children, upper
      extremity (UE) dysfunctions are observed, which leads to loss of quality of life, resulting
      in limited participation in activities of daily living (ADL).Children with CP as a result of
      damage to the motor cortex and corticospinal tracts; develop abnormal movement patterns by
      having difficulties in reaching, grasping and fine motor skills of UE. When the hands are
      affected in UE, fine motor skills such as grasping, writing and object manipulation are
      usually limited. This results in inadequate use of the extremities in functional activities.
      Although all children with CP are known to be affected by UE, studies in terms of
      physiotherapy and rehabilitation methods mostly focused on children with hemiparetic CP. The
      most common in children with hemiparetic CP; increase in muscle tone and decreased normal
      joint movement (ROM), decrease in UE muscle and grip strength, primitive grasping reflex,
      loss of speed and dexterity are observed. In addition to pure motor impairment, sensorimotor
      problems are also observed. Similar problems are observed in children with bilateral
      involvement. However, a wide variation is observed in the bimanual performance of children
      with hemiparetic and bilateral involvement. Studies evaluating UE activities in children with
      CP; emphasized that the inability to manipulate objects manually is one of the most important
      reasons for the restriction of participation in ADLs. In a study examining UE disorders, hand
      dexterity, grip strength and functionality in ADLs in children with diparetic CP; it was
      emphasized that these children also had deficiencies in dexterity, grip strength and
      functions in ADL. Therefore, it has been shown that these children are also negatively
      affected in terms of hand skills, coordination, UE muscle strength, grip strength, ADL and
      functional skills compared to their healthy peers. Observing that UE rehabilitation in CP
      remains in the background, studies on the pathophysiology and treatment of UE sequelae in the
      last 5 years have come to the fore. Physiotherapy and rehabilitation programs; it includes
      many neurodevelopmental treatment approaches including stretching, strengthening,
      positioning, splinting, casting, orthosis selection and movement facilitation. However, it is
      known that studies investigating the current efficacy of these treatments on UE functions
      mostly focus on unilateral CP. Interventions that focus on improving UE functions in children
      with bilateral CP are limited. In UE rehabilitation in bilateral CP; states that
      target-focused therapy, bimanual intensive task specific training programs and trainings such
      as HABIT (intensive bimanual training of the upper extremity) involving the lower extremity
      have been used, but there is only evidence for HABIT-ILE (HABIT involving the lower
      extremity). In the literature, it is observed that strengthening training with the
      Proprioceptive Neuromuscular Facilitation (PNF) method, which makes a significant
      contribution to muscle strength balance, is mostly used in lower extremity rehabilitation in
      CP. In this study, in the UE rehabilitation of children with hemiparetic and diparetic CP; in
      order to stimulate motor responses and improve neuromuscular control and function, the
      superiority of the PNF approach applied with scapular and UE patterns over the traditional
      Neurodevelopmental Therapy (NGT-Bobath) method will be determined. As a result of this study,
      it is thought that in addition to traditional NGT-Bobath treatment approaches, muscle
      strengthening with scapular pattern and upper extremity patterns of PNF can be an effective
      treatment alternative in the UE rehabilitation of children with CP, and it is thought that UE
      functional skills, muscle strength and trunk control of individuals will be positively
      affected. Included children will be randomized by simple randomisation and divided into 2
      groups. An exercise approach with PNF UE patterns will be applied to the first group for 30
      minutes, 3 days a week for 6 weeks. UE rehabilitation consisting of Neurodevelopmental
      Treatment (NGT-Bobath) approaches will be applied to the second group for 6 weeks, 3 days a
      week, 45 minutes a day. Treatments will be carried out by the same doctor physiotherapist
      investigator. Evaluations will be made twice, before and after the treatment. All assessments
      will be made by a blind doctor physiotherapist investigator who is unfamiliar with the
      treatment groups. Alongside the studies in the literature, this study will be the first to
      compare the effectiveness of the use of UE patterns of PNF in children with hemiparetic and
      diparetic CP.
    

Intervention name(s): traditional physiotherapy approach; muscle strengthening exercise/Proprioceptive Neuromuscular Facilitation (PNF)
Intervention type(s): Other; Other
Intervention description(s): Traditional upper extremity strengthening and tonus regulation (weight shifting, weight bearing, active reaching in sitting exercises) exercises consisting of Neurodevelopmental Therapy (NDT-Bobath) approaches will be applied to the second group for 45 minutes, 3 days a week for 6 weeks.; Muscle strengthening with scapular and upper extremity patterns of PNF exercise approach will be applied to the first group for 6 weeks, 3 days a week, 30 minutes a day.
Other intervention name(s): Neurodevelopmental Therapy (NDT-Bobath); Proprioceptive Neuromuscular Facilitation (PNF)
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The study will include 30 children with cerebral palsy (CP) diagnosed at the GMFCS I-II level with 15 controls and 15 treatment groups. Included individuals (n=30) will be randomized by simple random method and divided into 2 groups. 2 groups; different upper extremity strengthening training and 1 grup (n=15,control): Neurodevelopmental Treatment (NDT-Bobath) approaches will be applied to the second group for 6 weeks, 3 days a week, 45 minutes a day. Group 2: An exercise approach with Proprioceptive Neuromuscular Facilitation (PNF) (n=15, exercise group) UE patterns will be applied to the first group for 30 minutes, 3 days a week for 6 weeks.
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Cerebral Palsy; Upper Extremity Dysfunction; Upper Extremity Strengthening; muscle strength; trunk; functionality; Proprioceptive Neuromuscular Facilitation