Measurements and Management of Motor Development in Children with Cerebral Palsy

Introduction

According to the scenario, Sherley is a 4-year-old girl with spastic diplegic type of cerebral palsy with atypical motor development. Cerebral palsy (CP) refers to damage to developmental disorder correspond with lifelong motor impairment and disability which a permanent disorder of the development of movement and posture that cause activity limitations (Mindy,2011).

Normal motor development milestones is a structural frame for observing and monitoring a child’s development progression, it can be either normal or abnormal throughout the development (R.Jason,2010). The developmental milestones act as a set of behaviour, skills, or abilities that appear at specified ages during early childhood and it affects the gross motor, fine motor, cognitive, expressive and receptive language, personal and social-emotional of a child (Jennifer,2013). In normal developmental milestones, a child should achieve head control in prone position by 1month, able to rolls over by 3month, sit with support by 5month and progress to sit without support by 7months, able to start crawling by 9month, by 12month able to stand well and slowly walk independently by 13month (Rebecca.J,2016 and Martin,2013).

Base on the scenario, Sherley unable to achieve crawling and walking because of lower extremities stiffness occurs and lead to abnormal crouched gait pattern happen at the lower extremity. However, she needs moderate to maximum assistance for bed mobility and transfers, and also difficulty in maintaining a seated position due to hypertonicity. In normal developmental process, head and trunk control works together in postural control and balance ability that cause the erector muscle to become more stronger to have the ability to manage to achieve stability (Ji-Won,2017). Postural control is a mechanism provides an erect posture to stabilize head and trunk against the gravity to allow the actual base to perform activities such as sit, reach, stand, and walk (Sivatejaa, 2017).

Primitive reflex (PR) are automatic movement patterns that begin during pregnancy and it fully presented at birth which helps the child to move against gravity during the 1st month of life (Ewa.Z,2016). PR is important in developmental of tone and posture while posture is basic achieve in the development of skills (Farjad,2016). Based on the scenario, Sherley presented with a positive plantar response which indicates pyramidal tract dysfunction (Sandra,2014). Pyramidal tract dysfunction allows the response to revert the primitive withdrawal movement by release the ‘flexion reflex synergy’ of the contraction of the extensor hallucis longus muscle forms an integral part (Geeta,2005).

Main Body I

The 1st problem that will prioritize towards management is spasticity of the upper limb, lower limb and trunk. Muscle tone helps to maintain the normal posture to facilitate movement and balance (Lynn,2015). When spasticity occurs will result in a functional problem with activity daily living such as gait, dressing and toileting and adaptive shortening might lead to contracture (Alireza,2014). The spasticity in upper limb muscle that affected in children with CP commonly are shoulder external rotators, elbow, wrist and finger flexors and elbow pronators, while spasticity happens in lower limb muscle mainly are gastro-soleus, rectus femoris, hamstrings, adductors and psoas (Lynn,2015). Spasticity of the upper limb will influence the range of movement, speed and excessive efforts in performing functional tasks (Mehdi,2011). Impairment of the upper limb function restricts gross motor development and effect on actions such as rolling over, creeping, and crawling (Mehdi,2011).

Trunk plays an important role in maintaining postural control and balances reactions throughout the developmental process whereas, spasticity of the trunk impaired trunk control and balance in CP child will influence the activity daily living such as reaching, sitting, standing, and walking (Sivatejaa 2017). Spasticity of the lower limb usually influences the speed of walking and difficulty in performing activities such as walking up and down steps or running (Deivendran,2012). There are several physiotherapy managements in reducing spasticity include Bobath technique, sensory integration therapy, proprioceptive neuromuscular facilitation, myofascial release, hydrotherapy, ice and heat therapy, positioning, stretching exercise, standing, and ortho devices (Alireza,2014, Ammar,2012). Ice can inhibit spastic muscle, but the effects just short-lived and heat used for relaxation of spastic muscle (Alireza,2014).

Proper positioning of trunks and limb during a stand, sit, and lying can prevent furthermore spasticity and develop contractures (Ammar,2012). Aquatic exercise very beneficial when the body is immersed in warm water that can reduce spasticity (Sevda,2016). Bobath technique helps to normalize the muscle tone, inhibit the primitive and abnormal reflexes and facilitating normal movements (Antigone.S,2009). Orthoses or splints can prevent or correct deformities, maintain body alignment in a certain position and help to overcome activities limitation such as difficultly in stand and walk. (Antigone.S,2009).

The 2nd problem will prioritize towards management is delay motor development. CP child commonly influences in global developmental delay (GDD) (Sarah,2011). A child with GDD present with delay in accomplish of developmental milestones at the expected age and implies deficits in learning and adjustment (John B., 2014). Based on the scenario, Sherley did not achieve crawling, walking and unable to sit upright due to hypertonicity. The trunk helps in maintaining postural control and balance reactions throughout the developmental process and spasticity of the trunk in CP child will influence the activity daily living such as reaching, sitting, standing and walking (Sivatejaa 2017). Postural reactions allow the body to adjust to the environment and maintain an upright equilibrium on the voluntary movements (Meenakshi,2010). Postural control includes balancing in standing, walking and step-change which deficit postural control will lead to unsafe situations such as poor postural control will increased risk of fall and injuries occurs (J.Walter,2018).

Treatment that suitable for delay motor development are Neurodevelopmental Therapy (NDT), Sensory Integration (SI), Conductive education, Hippotherapy and Vojta Therapy (C.Stark,2010). The SI help in visual perception, tactile perception, visual-motor coordination, and body awareness (Rajalaxmi,2016, A.R.Shamsoddini,2009). NDT helps to enhance movement, postural reactions to improve gross motor function (C.B.Senthikumar,2009). Conductive education is a program of group activities by using music and rhythm to enhance learning capability and rhythmic speech which effective in improving motor skills (Negin,2017). Vojta Therapy showed effectiveness in gross motor function measurement also effective in coordination. (Hyung,2012). Whereas, hippotherapy more focusing on trunk stability, posture and pelvic mobility to improve gait and balance (Jeong-Yi,2011).

The 3rd problem will prioritize towards management is difficulty in walking and crouched gait pattern. Spastic diplegia child usually walks slow and difficult to perform activities such as walking up and down steps or running (Deivendran,2012). CP child with gait abnormalities will present with increased hip and knee flexion, decreased ankle dorsiflexion, increased knee extensor and increased extensor movement during stance phase (Ting-Ming,2015). Spastic diplegia child attempt to walk in crouch gait with hip, knee and ankles flexion during stance phase (Waness,2016). Rapid onset of weight and height growth may cause knee flexion contractures, hamstrings contracture, and gastro-soleus weakness which present in crouch gait (Justin,2017).

The type of physiotherapy management for the difficulty in walking and crouched gait patter are NDT, strengthening exercise and Task-oriented training. NDT help to improve in gait parameters of children with spastic diplegia (Mandar,2017). Strengthening exercise for lower limb shows improvement in gross motor function in standing, walking, running and jumping (Vidhi,2018). Task-oriented training was effective to improve in gait which comprised of walking on treadmill beginning with comfortable speed then slowly progress to more difficulty intensity and result increase in functional ability and improving in walking and balance performance (Hyun-Kyung.H,2016).

Main Body II

Spasticity of the upper limb, lower limb and trunk influence various functional activity daily living such gross and fine motor movement (Alireza,2014). Hydrotherapy is widely used in clinical settings and it is effective in CP child because of the antigravity position and buoyancy help in reducing muscular spasticity, while it also helps in decrease the compressive forces on joints (Masoud,2016). Studies show hydrotherapy is extremely beneficial when the body is immersed in warm water that can reduce spasticity and facilitated muscle relaxation and the advantages of hydrotherapy for child with CP is to learn new thing, gain experience, and enjoy new movement skills which will lead in increase functional skills and mobility, and build up self-confidence (Sevda,2016).

Thermal effects showed increase soft-tissue elasticity, reduce in pain, and reduce spasticity in CP child Aquatic therapy help in protecting joint integrity, and it has manifest useful for CP child in reducing spasticity, improve gross motor function, increase cardiorespiratory endurance, vital capacity and also improving in gait (Chih-Jou,2014). Furthermore, a study also concludes that hydrotherapy exercise programme for spastic CP child has a significant effect in improving gross motor functioning to reducing spasticity and also increase cardiorespiratory endurance (Lidija,2014). A study of the effects of the aquatic program on gross motor function is shown positive effects in improving gross motor function, increase range of motion and reduce spasticity among CP spastic child (Nikolaos,2009). There is a study also concludes that 10 weeks of hydrotherapy with water temperature around 28 to 32 degrees by performing passive stretching and functional training exercise show significant improvement in gross motor function among spastic CP child (Bolarinwa,2019).

CP affects numerous motor disorder such as gross and fine motor, cognitive, communication, sensory, perception and behaviour impairment (Iona,2014). Neurodevelopmental Therapy (NDT) is one of the most common therapy that use in CP child to improve gross motor function and postural stability that includes lying, rolling, crawling, kneeling, sitting and standing (Sina,2015). NDT help to correct abnormal postural tone and facilitated in normal development movement pattern for performing better performance skills (Hamid,2009). Besides, a study concludes that NDT was significant to improve in motor function, independent level on daily living and also balance ability (Erdogan,2018). Another study concludes 3 months of NDT gross motor training such as rolling, sitting, crawling, kneeling, standing and walking shown effective and reducing spasticity, reflexes and movement pattern (Vaceed,2018).

A 6 weeks study concludes that the NDT program is more effective compare to gross motor activities for CP child and parents also report that NDT improves positioning and daily function of CP child (K.Kalaichandran,2019). NDT also shows effectiveness in reducing disease symptoms and improve the general functional well being among CP child (Senthikumar,2009). Lastly, a study comparing the effectiveness of intensive versus standard physical therapy for motor progress with CP child and conclude that 8 weeks of intensive physiotherapy regimens are more beneficial than standard therapy especially in CP child with low functional level (Mohammad,2015).

Children with CP diplegic often contribute gait abnormalities which is crouched gait pattern such as excessive knee and hip flexion, weakness of the hip extensor, knee extensor, and ankle plantar flexor (Deivendran,2012). Strengthening exercise of the lower limb is a common method to improve muscle strength and gait function Jung-Hwan,2009). A study found that 6 weeks of the functional strength training program by using TheraBand shows improvement in gross motor function, especially in standing, walking. Running and jumping among CP diplegic child (Vidhi,2018). Besides, maximal hip extensor strength and the number of squats to stand for 6 weeks have significantly shown improvement in increasing gait speed and stride length among CP child (Jung-Hwan,2009). Furthermore, a 5-week of lower limb strengthening exercise with 3 times per week for 1 hour includes warm-up, lateral step-up, stairs walk up and down, the isotonic and isokinetic exercise of lower limb shows improvement in gait function of CP child (Lee-J.H,2008). Lastly, strengthening exercise by using static cycling were found to be effective in improving functional abilities such as step length, cadence and speed among CP diplegic children (Manal,2008).

Main Body III

The outcome that use to measure spasticity is the Tardieu Scale. According to research, the Tardieu Scale is more effective than Ashworth scale in measuring spasticity, contracture and severity of contracture (Adel,2010). Tardieu Scale shows an excellent intrarater and interrater reliability when assessed especially over the elbow and ankle joints of CP child (Gracies,2010).

The outcome that use to measure developmental delay and gross motor function such as crawling and walking is Gross Motor Function Measure-88 (GMFM-88). GMFM-88 is widely used in clinical settings and it is valid and reliable for CP child (Katja,2012). GMFM-88 helps to determine changes in motor function in CP child and it consists of 88 items which divide into 5 dimensions which is A: lying and rolling, B: sitting, C: crawling and kneeling, D: standing, and E: walking and, running, and jumping and it was assessed by interclass correlation coefficient (ICC) from 0.975-0.997 (Ki-Jeon,2018).

Conclusion

Cerebral palsy (CP) refers to damage to developmental disorder correspond with lifelong motor impairment and disability which a permanent disorder of the development of movement and posture that cause activity limitations. Normal motor development milestones is a structural frame for observing and monitoring a child’s development progression, it can be either normal or abnormal throughout the development.

The best treatment in the reduction of spasticity id hydrotherapy which can be measured by Tardieu Scale. Furthermore, the best treatment to improve gross motor functions is Neurodevelopmental Therapy and the best treatment to improve crouched gait pattern and walking ability is strengthening the exercise of the lower limb and it can be measured by GMFM-88 because it is valid and reliable.