Altered Back Geometry and Mobility Function After Backward Walking Training in Children With Cerebral Palsy
Condition: Cerebral Palsy, Spastic
MeSH terms: Cerebral Palsy
Study type: Interventional

Summary: 
      PURPOSE: To assess the effect of backward walking training on back geometry and mobility
      function in children with hemiparetic cerebral palsy through a comparative analysis with
      forward walking training.

      BACKGROUND:

      Spinal deformities are important orthopaedic problems among children with cerebral palsy. A
      detailed evaluation of all these areas when the child first arrives for treatment is
      essential. The majority of research in children with CP is focused on assessment and
      treatment of upper and lower extremities. In contrast, literature on trunk control in
      children with CP is scarce. Although proximal trunk control is a prerequisite for improving
      balance and weight symmetry, there is a lack of studies that reported the role of forward and
      backward walking training in treating the trunk for children with CP. Therefore, the purpose
      of this study will investigate the role of backward walking training in addition to
      conventional physiotherapy program on back geometry and mobility function in children with
      spastic hemiparetic cerebral palsy.

      HYPOTHESES: The null hypothesis of this study could be stated as: There will be no
      statistically significant difference in back geometry and mobility function after adding
      backward walking training to conventional physical therapy program in spastic hemiparetic
      cerebral palsy children compared with forward walking training.

      RESEARCH QUESTION: Do adding backward walking training to conventional physical therapy
      program improves back geometry and functional mobility in children with hemiparetic cerebral
      palsy?
    

Detailed description: 
      Introduction:

      Cerebral palsy (CP) describes a group of permanent disorders of the development of movement
      and posture, causing activity limitation. It is the most common cause of physical disability
      during childhood that affects the child on several health dimensions including neuromuscular
      deficits, such as spasticity, muscle weakness, and decreased selective motor control, and
      secondary musculoskeletal problems such as bony malformations and contractures.

      Trunk impairment is very common but an underscored feature of spastic CP that affects the
      upper and lower extremity motor functions as well. Impairments associated with the trunk seen
      in children with CP include but are not limited with decreased stability of the head and
      trunk, shoulder protraction, spinal curve deviations, and trunk muscle weakness. Inadequate
      control of trunk muscles leads to compensation of other muscles to maintain the upright
      posture. Inability of proximal stabilization and increased activation of extremity muscles
      during postural adjustments reduces their functionality during extremity movements.

      Trunk control is the initial frame of reference for postural control; it involves
      stabilization through selective movements of the trunk. Although trunk control strategies
      vary depending on the task and the environment, all functional tasks require adequate trunk
      control. Without the trunk as a stable center, selective movements of the extremities and of
      the head are profoundly impaired. In children, trunk control ensures the acquisition of basic
      gross motor skills in order to develop the goal-directed activities that are essential for
      independent life at home and in the community.

      Evaluation of the CP child's passive and active movement of the trunk is an essential part of
      the evaluation because mobility of the spine in all planes is necessary for correct
      alignment, smooth and asymmetric movements of the spine and for full range of motion of the
      extremities. The therapist must document any deviation from normal, note scoliosis, excessive
      kyphosis and lordosis and whether the curves are structural or functional.

      The majority of research in children with CP is focused on assessment and treatment of upper
      and lower extremities. In contrast, literature on trunk control in children with CP is
      scarce. Although proximal trunk control is a prerequisite for improving balance and weight
      symmetry, there is a lack of studies that reported the role of forward and backward walking
      training in treating the trunk for children with CP.

      Material and methods

      Subjects:

      A thirty-eight spastic hemiparetic cerebral palsied children of both sexes will participate
      in this study. The participants will be selected from the out-patient clinic of faculty of
      physical therapy, Cairo university. All participants will be selected according to the
      following inclusive criteria: Their age ranged from 5 to 7 years, with average height around
      one meter or more as it is the suitable height for Formetric measures (because the horizontal
      line which appears on the computer screen when the camera is ready for recording should be
      below the scapula to avoid the un-detection of the axillary points which will interfere with
      recording of the spinal image). They were able to stand alone independently and have the
      ability to walk both forward and backward over ground without an assistive device. They were
      able to understand and follow verbal command. They will be classified as I or II by gross
      motor function classification system (GMFCS). The degree of spasticity in the involved lower
      extremity according to Modified Ashworth Scale ranged between grades 1, 1+ and 2. Exclusion
      criteria for all participants will be neurological or orthopedic surgery in the last 12
      months, uncontrolled seizure disorder, visual, auditory or perceptual problems and who had
      any experience of backward training before the trial. This study protocol was approved by the
      research ethical committee of the Faculty of Physical Therapy, Cairo University
      (P.T.REC/012/002802) and parents will sign a consent form authorizing the child's
      participation.

      The participants will be randomly allocated into 2 groups (group A and B). The participants
      of group (A) will receive physical therapy program based on neurodevelopmental treatment
      (NDT) approach, in addition a specially designed forward walking training program. The
      participants of group (B) will receive the same physical therapy program, in addition a
      specially designed backward walking training program.

      For evaluation:

      The assessment will be conducted for each child of both groups individually before and after
      three successive months of treatment by the same examiner who will be blinded to treatment
      allocation. The outcome measures will be;

        1. Formetric instrument system

        2. Dynamic Gait Index (DGI)
    

Intervention name(s): Exercise training
Intervention type(s): Procedure
Intervention description(s): both groups received conventional physiotherapy training program, for one hour, three sessions per week, for three successive months, based on neurodevelopmental treatment, composed of approximation of the upper and lower limbs in a regular and rhythmic manner, facilitation of righting, equilibrium and protective reactions, training of postural stability and equal weight shift especially on the affected side, stretching, strengthening exercises for upper and lower limbs and back muscles
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Treatment