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Effectiveness of Neurodevelopmental Technique and

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ISSN: 2165-7025
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Journal of Novel Physiotherapies Kalimuthu, J Nov Physiother 2018, 8:5
DOI: 10.4172/2165-7025.1000399

Research Article Open Access

Effectiveness of Neurodevelopmental Technique and Task Specific


Training with Strengthening Exercise on functional Performance of Lower
Extremities in Spastic Diplegia Children 4-12 Years
Shanthakumar Kalimuthu*
Department of Physiotherapy, Mahsa University, Selangor, Malaysia
*Corresponding author: Shantha kumar. K, MPT, DGC, PhD, Mahsa University, Department of Physiotherapy, Level 6, Main Building, Bandar, Saujana Putra, 42610
Jenjarom, Selangor, Malaysia, Tel: +601137103041; E-mail: shanthadhaniya@gmail.com
Received date: September 06, 2018; Accepted date: October 05, 2018; Published date: October 11, 2018
Copyright: © 2018 Kalimuthu S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Objective: To assess the effectiveness of Neurodevelopmental technique and Task specific training with
strengthening exercise on children with spastic diplegic cerebral palsy.

Method: A randomized controlled trial was carried out in twenty four children with Spastic diplegia. Children were
randomly assigned into two groups, conventional group I underwent Neurodevelopmental technique and
experimental group II underwent Task specific training with strengthening exercise for a period of four months. The
Outcome Measures used for the study are Gross motor function measure (walking); Modified timed up go test, Gait
right and left stride length measurements. The Statistical techniques used for analyzing the data are one way
repeated measures ANOVA, Newman kuel’s post hoc test and Analysis of Co-variance (ANCOVA).

Results: Statistical significance differences were found between groups in Gross motor function measure
(walking) were F ratio value is 11.195, Gait right and left stride length measurements were F value is 6.517 and
4.798 respectively. Significant difference were found within groups in one way repeated measures ANOVA and post
hoc test in Neurodevelopmental technique group ANOVA -F values were 63.067, 92.172, 38.315, 43.792 in Gross
motor function measure (walking), Modified timed up go test, Gait right and left stride length measurements
respectively and in Task specific training with strengthening exercise group ANOVA -F values were 102.065,
100.180,70.117, 102.508 for Gross motor function measure (walking), Modified timed up go test, Gait right and left
stride length measurements respectively.

Conclusion: Task specific training in addition with strengthening exercise can be applied in spastic diplegia
children to improve walking ability with increased stride lengths.

Keywords: Cerebral palsy; Spastic diplegia; Neurodevelopmental Neurodevelopmental technique


technique; Task specific training; Strengthening; Gait
Bobath concept is a problem-solving approach with assessment and
treatment of individuals with disturbances of function, movement and
Introduction postural control due to a lesion of the central nervous system [4].
Spastic diplegia is a form of cerebral palsy involving both upper and Treatment delivered according to the abilities and disabilities of the
lower extremities (lower limbs more affected than the upper limbs) [1]. client and severity and involvement. Muscles generate the most
Spastic diplegia children adapt abnormal posture because of the efficient active force at the mid-length so it is important to gain
tightness in spastic agonist muscles and weak antagonist muscles and alignment. This may involve muscle stretching to achieve length.
the antagonist muscle cannot function effectively to overcome the Stimulation of muscle activity through use of weight bearing,
strong pull of the spastic agonist muscles and thereby correction of resistance, sensory stimulation in appropriate postures and patterns to
abnormal posture becomes difficult [2]. Structural changes in spastic enable the person to have a sufficient basis for the training of
muscles are seen as a result of adaptation and abnormal movement functional tasks [5].
patterns. Spastic muscles are normal in structure but are not as Physiotherapist guides patient to perform motor function in
extensible causing difficulty of muscle elongation. appropriate way without causing increase in muscle tone. The concept
Physical therapy professionals around the world are trying to is primarily a way of observing, analyzing and interpreting task
establish an effective therapeutic method to improve the functional performance [6]. Few studies reported that neurodevelopmental
abilities in spastic diplegic children. The movement-disabled individual approach in children with cerebral palsy will lead to improvements in
must attempt to gain or regain effective motor performance in at least gross motor function [7], motor skills functionality.
essential everyday actions such as standing up, walking, reaching in
sitting and standing, and manipulation [3].

J Nov Physiother, an open access journal Volume 8 • Issue 5 • 1000399


ISSN:2165-7025
Citation: Kalimuthu S (2018) Effectiveness of Neurodevelopmental Technique and Task Specific Training with Strengthening Exercise on
functional Performance of Lower Extremities in Spastic Diplegia Children 4-12 Years. J Nov Physiother 8: 399. doi:
10.4172/2165-7025.1000399

Page 2 of 4

Task specific training with strengthening exercise spastic diplegia in experimental group II. Duration of follow up period
was four months.
Task specific training are therapeutic exercise program taught to
clients who suffer from neurological impairments and unable to The inclusion criteria were as follows, children clinically diagnosed
perform functional activities independently. After looking into as spastic diplegia cerebral palsy alone considered for the study,
research evidences of functional improvements due to Task specific cerebral palsy children aged between 4 to 12 years, both male and
exercise in stroke clients based on motor learning principles, female children participated in the study, children who scored 30 and
movement control and functional anatomy it is chosen as one of the above in Modified mini mental state examination are considered for
treatment method in this research [8]. The requirements for motor the study and Modified ashworth scale score of 1 and 1+ were included
activity learning are repetition of movements, encouragement, for the study.
functional goal, and expected results. Motor learning refers to the The exclusion criteria were as follows, children with cognitive
acquisition and modification of movement [9]. Skill acquisition is impairment, cardiac and pulmonary problems, undergone cardiac, hip,
dependent upon motor learning. Motor learning requires the intention knee, ankle and spinal surgeries and Gross motor functional
to perform a task, practice and feedback (both intrinsic and extrinsic) classification system (Level I, III and IV).
[10]. Certain types of practice are more beneficial for task acquisition
as well as task transference.
Intervention
Developing the ability to stand up is essential to independent
performance of other actions such as walking which require the ability Neurodevelopmental technique protocal
to get into standing. Strength and control of propulsion and support
over a fixed foot can be practiced by step up and down exercise. This a. Sit to stand: Patient in long sitting. Therapist sits back of the
approach uses various techniques of muscle stretching and patient. Hands placed on the lower anterior thighs. Therapist assists
strengthening exercises, and functional activities. the patient to come up to stand. Facilitation provided from back
encouraging sit to stand from standard bench.
The task specific exercise applied in adults who suffered stroke
showed improvements in functional tasks. Few studies are conducted b. Weight shift to stand from half kneeling: The Therapist’s assisting
in cerebral palsy children to evaluate the effectiveness of this kind of hands remains on the client’s lower rib cage and the guiding hand is
therapeutic application. Recent evidence suggests that weakness is a placed symmetrically over the client’s hip extensors. The therapist’s
problem for the neurologically impaired adult and child. Therapist can hands and body guide the client’s weight diagonally forward and up
work to increase strength by the use of activity, repetition and weigh over the forward leg. The therapist and the client both move through a
bearing, it has been shown that when used appropriately, step-stance position.
strengthening can improve function and does not increase spasticity
c. Standing (Symmetrical Stance): Weight shift to the lateral borders
[11]. Studies that support task related strengthening, spastic variety
of the feet therapist assisted with both arms stretched. Proximal control
cerebral palsy can be benefitted with functional related resistance
for lower extremity extension to activate gluteus maximus.
therapy [12], and resistance therapy is one beneficial technique to
recover walking ability of individuals with cerebral palsy. Pivot to step stance, the therapist’s guiding hand externally rotates
the client’s face-side (right) femur so that the client’s foot, lower
Need for the study extremities, and trunk pivot to the right with weight shift. At the end of
the pivot, the face-side leg is in front of the other leg. Both of the
Current treatments for cerebral palsy focus either client’s feet point in the direction of the rotation. Pivot to step stance,
neurodevelopmental approach principles or task specific training with mid-stance position, the therapist’s guiding hand stabilizes the client’s
functional strengthening methods. front leg and shifts the client’s weight forward onto the right foot. The
The gross motor function, gait stride length and gait speed assisting hand stabilizes the client’s back leg in hip and knee extension
improvements brought about in functional performance in spastic with neutral rotation. The back foot plantar flexes and the toes extend.
diplegia between neurodevelopmental technique and Task specific
training with strengthening exercise is not clearly studied and Pivot to step stance, terminal stance position, the therapist’s
reported. Hence, this study aims to quantify the functional assisting hand maintains the forefoot and toes of the client’s back foot
improvement when spastic diplegia children are given on the floor while the thumb presses up toward the hip and shifts the
Neurodevelopment technique and Task specific training with client’s weight forward and facilitates terminal stance. The calcaneous
strengthening exercise and to identify the better treatment. inverts.
Forward walking, facilitation from the rib cage and pelvis. Passive
Hypothesis stretching to Quadriceps, Hip flexors and adductors, Ilio-tibial band,
Hamstrings and Gastroneumius, Three treatment sessions per week for
The hypothesis of the study can be stated as there may be significant
four months.
difference between Neurodevelopmental technique and Task specific
training with strengthening exercise on functional performance of
lower extremities of spastic diplegic children of 4-12 years. Task specific training with strengthening exercises protocal
Sit to stand (Wooden bench 40 cm and 20 cm): Training is aimed
Material and Methods at giving the child practice in standing up and sitting down with
prescribed number of repetitions from 40 cm bench and 20 cm bench.
A randomized, controlled clinical trial that involves 12 children
with spastic diplegia in conventional group I and 12 children with

J Nov Physiother, an open access journal Volume 8 • Issue 5 • 1000399


ISSN:2165-7025
Citation: Kalimuthu S (2018) Effectiveness of Neurodevelopmental Technique and Task Specific Training with Strengthening Exercise on
functional Performance of Lower Extremities in Spastic Diplegia Children 4-12 Years. J Nov Physiother 8: 399. doi:
10.4172/2165-7025.1000399

Page 3 of 4

Step-up and step-down exercises validity of walking speed, cadence, stride length comparison of
measurement with stop watch and three dimension motion analyzer,
a. Forward step-ups: Left foot on a step (15 cm). Forward and for stride length contribution ratio was 85%, gradient around 0.80 and
upward translation of the body mass over the foot with upper body the intercept 8.9, high reliability and strong validity.
remaining erect. Therapist assist and places the foot on to the step.
b. Lateral step-ups: Left foot on a step. Step up with left limb with Results
body mass remaining erect. Speed up the step ups, tapping down
lightly and quickly every time. Lateral step up with 1 kg weight cuff in Twenty eight children with spastic diplegia cerebral palsy were
the other side forearm. screened and twenty four spastic diplegia children who full filled the
eligibility criteria were selected. Figure 1 displays the flowchart of the
3. Calf muscle exercise: Forefoot on step, heels free. Heels are study. Two Children who underwent Hamstring and gastroneumius
lowered as far as possible then rose to plantigrade. Hips and knees lengthening and two undergone ayurvedic management were
remain extended throughout the exercise. excluded. The statistical analysis used for the study were one way
4. Stair Walking: Children walk up and down with ½ kg weight repeated measures ANOVA, Newman Keuls’ post hoc test. The
cuff wrapped around left ankle. (10 steps, 2 times). comparison between groups was statistically analysed using Analysis of
Co-variance (ANCOVA). To find out whether the modified timed up
5. Simple active exercise isolated hip extension training. Passive and go test, Gross motor function measure (walking), right and left
stretching to Quadriceps, Hip flexors and adductors, Ilio-tibial band, stride length measurements Post-test values between
Hamstrings and Gastroneumius, Three treatment sessions per week for Neurodevelopmental technique group and Task specific training with
four months. strengthening group differ significantly after adjusting the effect of Pre-
test values.
Strengthening exercise
ANCOVA result shows (Appendix Tables 1-14) that the calculated
Free ankle weights of ½ kg and 1 kg used to give resisted exercise, F ratio values between groups is 3.667, 11.195, 6.517 and 4.798 for
three treatment sessions for 4 months, ten repetitions concentric slowly Modified timed up and go test, Gross motor function measure
with rest as needed, 10 repetition eccentric for each muscle. (walking), gait right and left stride length measurements respectively.
The Critical value is 4.325. Since the calculated value is greater than the
Evaluations table value, it is inferred that the post-test values differ significantly
between Neurodevelopmental technique and Task specific Training
All the subjects were assessed and Pre-test score is recorded before with strengthening exercise groups. Hence there is a significant
commencement of treatment. During treatment, evaluation is done at difference in the Gross motor function measure walking, gait right and
the end of second month (Mid test) and end of study (4 months- Post- left stride length measurements (Post-test) values between
test) for both groups. The following parameters were assessed during Neurodevelopmental Technique and Task specific training with
all evaluations, strengthening after adjusting with Pre-test values.
1. Gross motor function measure (walking), 24 items were tested Based on advanced statistical analysis made using ANCOVA there is
and score ranges from 0 if does not initiate to 3 if completes the no significant difference in the Modified timed up and go test- post-
activity. (Validity was high with an ICC of 0.99 (95% confidence test values between Neurodevelopmental Technique and Task specific
interval= 0.972-0.997, Reliability was high with ICCs of greater than training with strengthening exercise after adjusting with Pre-test values
0.98 (95% confidence interval=0.965-0.994). Brunton and Barlett [13] (Appendix Tables 14-23 and Figures 1-13). Considering the statistical
strongly support the instrument after determined the validity and analysis made using ANOVA and post hoc test, there is significant
reliability of two abbreviated versions of Gross motor function improvements in walking speed in Timed up go test in both
measure. Neurodevelopmental technique and Task specific training with
2. Modified timed up go test, the child sits in a chair, on instruction strengthening exercise groups (Appendix Table 4 & Figures 2,3,7,8).
‘Go’ from the evaluator should stand up, walk the line on the floor
reach 10 metres distance, turn around walk back to chair and sit down. Discussion
Time taken to cover 10 metres distance and come back to chair and sit
The purpose of this study is to determine and validate the effects
down is recorded in seconds. Reliability of assessment was high, with
of Neurodevelopmental technique and Task specific training with
ICC of 0.99 for within-session reliability and 0.99 for test –retest
strengthening exercise on functional performance of lower extremities
reliability [14]. Studies that support the instrument are [15] to review
in spastic diplegia children.
the benefits of using two different outcome measure Gross motor
function measure and to examine whether the assessment tests the The results of this study reveal that Task specific training with
improvements in physical activity in subjects with cerebral palsy who strengthening exercise group had significantly improved in GMFM
were provided with therapy. walking and gait strides than the Neurodevelopmental technique
group. The task specific training results in larger gains in gross motor
3. Gait right and left stride length measurements, lengthy white
skills and it is superior to neurodevelopmental approach (Appendix
sheet pasted on the ground, the children should put both the feet on
Tables 3-10). Sit to stand activity, lateral step ups, stair climbing with
the ink pad and should walk on the white sheet. The inch tape used to
weights, walking with weights wrapped around ankle and
measure the distance between the two heel strikes right to the next
strengthening exercise with weights delivered through therapy
right heel strike is measured as right stride length. The best distance
improved the walking ability. So the alternate hypothesis is accepted
between one left heel strike to the next left heel strike measured as left
that is “Task specific Training with strengthening exercise can bring
stride length. Study of Handa et al. [16] examined the reliability and
out significant improvement in functional performance of lower

J Nov Physiother, an open access journal Volume 8 • Issue 5 • 1000399


ISSN:2165-7025
Citation: Kalimuthu S (2018) Effectiveness of Neurodevelopmental Technique and Task Specific Training with Strengthening Exercise on
functional Performance of Lower Extremities in Spastic Diplegia Children 4-12 Years. J Nov Physiother 8: 399. doi:
10.4172/2165-7025.1000399

Page 4 of 4

extremities than the Neurodevelopmental technique among the spastic 2. Levitt (2004) Treatment of Cerebral palsy and motor delay. Blackwell
diplegia children of 4 to 12 years”. publishing, Hoboken, New Jersey, United States.
3. Blundell SW, Shepherd RB, Dean CM, Adams RD, Cahill BM (2003)
The results of this study reveal that “Task specific training with Functional strength training in cerebral palsy: a pilot study of a group
strengthening exercise did not show significant improvement than circuit training class for children aged 4-8 years. Clin Rehabil 17: 48-57.
Neurodevelopment technique on Modified timed up and go test”. 4. Bohman, Gjelsvik (2000) International Bobath Instructors Training
These results supports study done by Buchner et al. [17] in older adults Association.
and suggested that a curvilinear relationship exists between lower limb 5. Mayston MJ (2001) People with Cerebral palsy. Effects of perspectives for
function and strength. Below a certain threshold, strength has a direct Therapy. Neural Plast 8: 51-69.
linear relationship with functional ability. Above that threshold, 6. Mayston MJ (2000) Bobath concept today. Synapse-Association of
further increases in strength may not be associated with corresponding Chartered Physiotherapists Interested in Neurology pp: 32-35.
increase in function for example no relationship was found between 7. Shamsoddini A (2010) Comparison between effects of
strength and walking speed in able bodied younger adults. Neurodevelopmental treatment and Sensory integration therapy on gross
motor function in children with cerebral palsy. Iranian Journal of Child
In conclusion Task specific training with strengthening exercise Neurology 4: 1300.
showed better improvement than Neurodevelopmental technique on 8. Carr JH, Shephard RB (1998) Neurological Rehabilitation: Optimizing
performance of gross motor function measure (walking), gait stride motor performance. Butterworth Heinemann Oxford, London, United
measurements in children with spastic diplegia. Children showed Kingdom.
interest towards therapy and were able to learn task specific exercise 9. Shumway, Woollocott (2001) Motor control Theory and Practical
easily. Strengthening exercise provided with weight cuffs, walking with Applications.
weights wrapped around ankles, lateral step ups with weight in 10. Boyd, Winstein (2003) The role of feedback on cognitive motor learning
contralateral arm, stair climbing with weights and calf muscle exercise in children with cerebral palsy.
increased the gait stride length of lower extremities. 11. Damiano DL, Abel MF (1998) Functional outcomes of strength training
in spastic cerebral palsy. Arch Phys Med Rehabil 79: 119-125.
12. Godwin (2009) Effects of task-oriented training on functional mobility in
Clinical Message children with cerebral palsy. Division of Physical therapy pp: 307-313.
Task specific Training with strengthening exercise requires cost 13. Brunton LK, Bartlett DJ (2011) Validity and reliability of two abbreviated
version of Gross motor function measure. Phys Ther 91: 577-588.
effective equipments like lateral step up, wooden bench and weight
cuffs. Children show interest towards therapy and was able to learn 14. Dhote SN, Khatri PA, Ganvir SS (2012) Reliability of Modified timed up
and go test in children with cerebral palsy. J Pediatr Neurosci 7: 96-100.
task specific exercise easily.
15. Alotaibi M, Long T, Kennedy E, Bavishi S (2014) The efficacy of GMFM-
88 and GMFM-66 to detect changes in gross motor function in children
Conflict of Interest with cerebral palsy, a literature review. Disabil Rehabil 36: 617-627.

The authors declare no conflict of interest 16. Handa T, Sahara R, Yoshizaki K, Endou T, Utsunomiya M, et al. (2007)
Examination of reliability and validity of walking speed, cadence, stride
length –Comparison of measurement with stopwatch and three
Funding dimension motion analyser. J Phys Ther Sci 19: 213-222.
17. Buchner DM, Larson EB, Wagner EH, Koepsell TD, de Lateur BJ (1996)
This research received no specific grant from funding agency in Evidence for a Non-linear relationship between leg strength and gait
public or commercial. speed. Age Ageing 25: 386-391.

References
1. Eckersley, King (1993) Treatment systems. Elements of Paediatric
physiotherapy. edited by Eckersley. Churchill Livingstone, London, UK.

J Nov Physiother, an open access journal Volume 8 • Issue 5 • 1000399


ISSN:2165-7025

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