CHAPTER II

LITERATURE REVIEW

The review of literature of the present study was presented as

follows:

1.Cerebral palsy .

2.Hemiplegia in children.

3.fine motor skills.

4.scapular kinesio tape

1-Cerebral palsy:

1-1.Definition and Prevalence:

Cerebral palsy is an umbrella term to describe a group of permanent

disorders of the development of movement and posture, causing activity
limitation, that are attributed to non-progressive disturbances that
occurred in the developing fetal or infant brain.Cerebral palsy may
involve problems in the neuromuscular system such as spasticity,
contracture, muscle weakness, and loss of selective movement (Gormley,
2001).

Cerebral palsy (CP) is a diverse group of neurodevelopmental

Impairment occur in immature brain due to constant injury which

primarily results in persistant disorder of movement and posture
(MacLennan AH et al .,2015).
 Incidence of CP in the general population varies throughout the
world at a rate of 0.1%to 0.2% of live births in developed countries and is
slightly higher in developing countries, with the risk of CP increasing
with decreasing gestential age (Oskoui et al., 2013).

Associated disorders of Cerebral Palsy is often sensory, perceptual,

cognitive, communication and behavioral disorders, also epilepsy and
secondary musculoskeletal problems(Rosenbaum P et al .,2007).
The prevalence of Cerebral palsy is 1.5 to 2.5 per 1000 live
births(Johnson birth and hypoxia, but recently are thought to be
reflection of factors that impair development. infants with prenatal
inflammation are more likely to be born prematurely and develop cerebral
palsy(Van GE,2002).

1-2.Topographical classification in cerebral palsy:

Unilateral and Bilateral Cerebral Palsy(Cans C,2002).
 Monoplegia
 Hemiplegia.
 Diplegia
 Triplegia,
 Quadriplegia
Diplegia, triplegia and quadriplegia are classified as bilateral cerebral
palsy according to SCPE terminology.
 Fig (1)Topographical classification in cerebral palsy (Cans C,2002).

1-3.Clinical Presentation of CP:

Early signs of CP:
In a baby 3 to 6 months of age:
 Head lagging when picked up while lying on back
 Feels stiff
 Feels floppy
 Seems to overextend back and neck when cradled insomeone’s arms
 Legs get stiff and cross or scissor when picked up

In a baby older than 6 months of age:

 Doesn’t roll over in any direction
 Cannot use hands together
 Has difficulty getting hands to mouth
 Reaches out with only one hand while keeping the other fisted
In a baby older than 10 months of age:
 Crawls lopsidedly, using one hand and leg to push off while
dragging the opposite hand and leg.
  Scoots around on buttocks or jumps on knees instead of crawling
on all fours.
1-4.Motor Impairment of CP:
According to the “The International Classification of Functioning -
Disability and Health of WHO” the clinical manifestations of CP
children limits their ability to do daily tasks and limit their ability to play
an independent role in society. Spasticity, muscle contractures, bone
deformities, loss of selective motor control, and muscle weakness are all
possible causes that disrupt normal gait patterns in children with.
Recent studies have found that inadequate muscle strength, rather than
spasticity, causes the largest loss of motor function in children with CP,
leading to a focus on strength training rather than spasticity management
for these children.(Zhou et al., 2015).

Coordination is the ability to execute a sequence of movements smoothly

and accurately repeatedly. This may involve the senses, muscular
contractions and joint actions. Children with CP present complex motor
skill disorders which include abnormal muscle tone that affects posture
and movement, alteration of balance and motor coordination, decrease in
strength and loss of selective motor control, with secondary issues of
contracture and bone deformity. All of these particular disorders of CP
hinder performance of motor abilities and consequently prevent the
learning of daily skills (Massetti, 2014).

1-5.Assessment of CP:
Children with spastic cerebral palsy can be assessed with many and
different scales that can assess their function and their gross motor
abilities. Many scales were found to reliable and valid in children with
spastic cerebral palsy evaluation (Strączyńska et al., 2015).
Some of those scales will be discussed in the following lines.
a) Peabody Developmental Motor Scales:

Peabody Developmental Motor Scale (PDMS) (Folio and Fewell, 1983)

is one of the most commonly used tests used to asses’ motor development
in infants and preschool children (Brown et al., 2005), and it provide a
comprehensive and useful information for early intervention (Case-
Smith and Allen, 2005).

The original version of the PDMS was published 1983 by Folio and
Fewell. The PDMS was developed for a varied purposes including
determining the relative developmental skill of the child and planning an
instructional program to develop those skills .The PDMS is standardized ,
norm referenced test that asses both fine and gross motor functions of
children from birth till 83 month of age , but unfortunately the repertoire
of motor skills and the comprehensive age range incorporated in the
PDMS doesn’t provide a separate assessment of fine and gross motor
functions , and can only be used for children ranging age from 0 to 3.5
years only (Folio and Fewell, 1983).

Peabody developmental motor scale had extensive scientific grounding,

however, when it was developed, the test developers didn’t adhere to any
specific theoretical perspective as its conceptual Foundation.
Following the

practical application the developers saw the need to revise the PDMS and
they developed the PDMS- Second edition in 2000 (Chien, 2007). The
revised PDMS-2 adapted a general developmental framework and
incorporated the use of qualitative and quantitative approaches for
assessment. The revised PDMS-2 differ from the original version as its
divided into six new subtests which are Reflex, Stationary, Locomotion,
Object Manipulation, Grasping and Visual-Motor Integration , and at the
same time still incorporates the fine motor and gross motor attributes. A
combination of the results of the fine motor and gross motor forms a total
quotient which is an indicator for the overall motor ability of the child
(Folio and Fewell, 2000).

The PDMS-2 could assist either in early detection or in longitudinal

monitoring of motor delays across the age from birth till 72 months. In
addition, the scale has a practical value of being suitable to asses various
populations of children known for their physical disabilities (Folio and
Fewell, 2000).
b) Gross Motor Function Measure:

The Gross Motor Function Measure (GMFM) is a clinical tool designed

to evaluate changes in gross motor functions in children with cerebral
palsy. There are two versions of the GMFM - the original 88-item
measure (GMFM-88) and the more recent 66-item GMFM (GMFM-66).
Items on the GMFM-88 span the spectrum from activities in lying and
rolling up to walking, running and jumping skills. The GMFM-66 is
comprised of a subset of the 88 items identified as contributing to the
measure of gross motor function in children with cerebral palsy. The
GMFM-66 provides detailed information on the level of difficulty of each
item thereby providing much more information to assist with realistic
goal setting (Canchild, 2017).

The purpose GMFM is to monitor a child’s development, assist with goal

setting and planning therapy, evaluate the outcome of motor interventions
and therapies and assist with predicting motor outcomes at older ages
(Cerebral Palsy Alliance, 2017).

1-6. Spasticity :

The most known definition of spasticity is the physiological definition

proposed by Lance (1980) who states:”Spasticity is a motor disorder
characterized by a velocity-dependent increase in tonic stretch reflexes
(muscle tone) with exaggerated tendon jerks, resulting from hyper
excitability of the stretch reflex, as one component of the upper motor
neuron syndrome” (Takahashi, 2016).
 The European working group, EUSPASM, as part of a review of
spasticity measurement and evaluation, looked at lance’s definition of
spasticity in detail, and proposed new definition that describes spasticity
as disordered sensorimotor control, resulting from an upper motor neuron
lesion, presenting as intermittent or sustained involuntary The velocity
dependence that lead to increase in tonic stretch reflexes is showed
clearly clinically by the fact that at slow velocities of movement, no or
only a minimal increase in tone is detectable; however at faster rates, an
increase In spasticity, the stretch-evoked muscle contraction occurs at a
short latency – appeared with a monosynaptic response and the stretch
reflex lasts for a longer period of time (a tonic stretch reflex) (Thilmann
et al., 1991). activation of muscles in tone is appeared clearly.
(Pandyan et al., 2005).

Pathophysiology of Spasticity:
Spasticity is a complex motor disorder that arises from a central nervous
system dysfunction and causes changes at all locomotor systems, from

the cerebral cortex to muscles, joints and bone (Sheean, 2002). Spasticity
is associated with increased muscle tone and with hyperactivity of phasic
proprioceptive, cutaneous, and autonomic reflexes (Young, 2002).
The pathophysiology of spasticity has been evolved in the last three
decades, so now it’s not depend in its discussion on stretch reflex only ,
but also we consider changes in the biomechanical properties of muscle
fibers (Marque and Brassat, 2012).

Spasticity arises from lesions involving the corticoreticulospinal

system in the brain such as in cerebral palsy, brainstem or spinal cord.
Abnormal suprasegmental influences lead to increased spinal cord
excitability and to impairment of interneuronal systems leading to an
increase in muscle tone, and shows its effect as enhancement of stretch
reflexes, muscle overactivity and antagonist muscle co-contraction
(Priori et al., 2006).

2-Hemiplegia in children:
2-1.Definition and Prevelance:

Hemiplegia is caused by a brain damage to the area of the brain

that controls motor function.. Hemiplegia can occur suddenly or progress
over a period of days, weeks, or months.(Syed G et al., 2012) .Children
with hemiplegia represent about 25% of all cerebral palsied children (Patel
et al., 2020).Hemiplegic Children ignore their affected side(Fontes et al,
2017).

Spastic hemiplegia was found to be associated with mild to

moderate degrees of functional impairment, and a significantly lower
prevalence of hearing impairment, speech defects, mental retardation and
growth impairment (Adedokun and Lagunju, 2008).

Fig (2)Hemiplegia topography(Fontes et al, 2017).

2-2.Classification:
Spastic hemiplegic cerebral palsy can be classified as congenital and
acquired forms.Atrophy of the cerebral hemispheres is a pathological
kind of congenital deformity. Acquired forms are frequently the result of
vascular abnormalities such as blockage or bleeding (due to trauma or
inflammation) or co-existing perivascular inflammation (due to trauma or
inflammation). ( Lin RS, Gage JR ,1989).

2-3.Clinical Presentation:
Spasticity, sensory impairments, and muscle weakness affect lower
limb skills are common problems in children with hemiplegic cerebral
palsy. Spasticity impairs spontaneous and selective motor control,
resulting in increased energy expenditure and the development of
secondary musculoskeletal problems in children with CP.(Morrell DS et
al .,2002).
Children with hemiplegia may suffer from abnormal muscle tone,
improper movement control, incoordination within motor strategies,
impaired anticipatory postural control, decreased cutaneous sensation,
distorted lower limbs proprioception and impaired visual and abnormal
vestibular mechanism, all of which affect the ability to maintain balance
while standing and walking.(Jonsdottir J, Cattaneo D .,2007).
Children with spastic hemiplegic CP demonstrate motor control
problems, with abnormal movement patterns ,have a massive movement
pattern and difficulty performing certain tasks, due to lower limb
problems they experience limitation with activities of daily living, such
as walking, running, and jumping.(Verschuren O et al .,2007).
Children with unilateral CP tend to have impaired coordination of
movements, reduced coordination of the limbs, and low weight bearing
on the affected side, which in turn can directly affect the ability to
maintain erect weight-bearing position as well as gait(Domagalska-
Szopa and Szopa , 2014).
When walking, motor coordination is impaired in children with spastic
hemiplegic cerebral palsy resulting in a short stride, increased cadence to
maintain speed, increased swing, and poor stability due to center of
gravity fluctuations (Wang X and Wang Y, 2012).

Impaired arm and hand function are the main problems in about
half of affected children and are the main factors contributing to disability
in activities of daily living (ADL). It is well known that children with
hemiplegic CP have difficulty performing bimanual tasks. However, there
is mounting evidence that, despite having a unilateral cerebral lesion, the
function in both hands is impaired to some degree. Children with CP also
often demonstrate impaired somatosensory function. Compared with
typically developing children, children with CP have impaired texture,
perception and two-point discrimination (Gordon et al., 2013)

Hemiplegics when asked to perform activities of upper extremity,

the movements are not smooth and coordinated. The probable causes are
impaired shoulder joint stability and mobility, scapular mal-alignment,
spasticity/weakness of involved muscles of upper extremity, synergy
patterns and pain around shoulder joint. There is increased tone in upper
trapezius muscle and weakness in other scapular muscles like serratus
anterior, rhomboids, middle and lower trapezius. So, the movements of
the upper extremity and its functions to be carried out smoothly the bony
alignment, joint stability and mobility, the kinetic forces produced by
muscles, the tone of muscles and length-tension relationship all these are
required ( Long et al., 2006).
 In children with unilateral CP, tasks range from simple forward
reaching to grasping and object manipulation and more gross motor tasks
such as hand to mouth or hand to back pocket (Jaspers et al. , 2011)
Any child can perform reaching tasks, irrespective of their arm and hand
function. During gross motor tasks, such as bringing the hand to the
mouth, to the head, the back pocket, or across the midline to the other
shoulder, children with unilateral CP exhibit increased wrist flexion and
reduced elbow supination, which is accompanied by increased scapular
and trunk movements (Mackey et al. 2006; Jaspers et al. 2011).

There are many models of intervention targeting deficits in hand

and arm functions that aim to reduce activity limitations for children with
hemiplegia. The goal of therapy is to prevent contractures, preserve range
of motion, improve function, and strengthen limbs and back. In the case
of the affected hand, treatment should focus on improving hand grip and
muscle control. (Sakzewski et al., 2009).

3.fine motor skills.

Hemiplegia result in from cerebral palsy is known as a sensorimotor

problem affecting postural control (Saavedra SL et al., 2020). muscle
coordination, and movement (Stavsky M et al.,2017).

One of the most debilitating symptoms of hemiplegia, which may

occur in more than 80% of children suffering from cerebral palsy, is
dysfunction of the upper limbs, especially the arms and hands (Makki D
et al.,2014).They usually suffer from fine motor skill deficits, weak grip
st rength, and decreased hand dexterity (Arner M et al., 2008).
 Upper limb function in cerebral palsy plays a crucial role in
independence, quality of life (Tonmukayakul U et al., 2020). children’s
participation in their activities of daily living (ADLs) (Park H et al.,
2020).social interactions, and exchanging information with others
through non-verbal communication; in a way that proper function and
control can help express the concepts and convey emotions (Andersson
GB et al., 2011).

Hemiplegic cerebral palsy causes problems with contraction, sensation,

and muscular strength in the upper limbs, which its effective use of
muscles for reaching, grasping, releasing, and manipulating objects is
often compromised (Basu AP et al.,2014).

Children with hemiplegia will often find using their affected hand
for fine motor tasks very difficult. This is often due to altered muscle tone
in the affected hand in comparison to that of their unaffected hand. You
may notice that they have difficulty with isolating finger movement,
turning their hand over to face palms up and grasping and releasing
objects. They may also have a strong dominance of their unaffected hand
and avoid using their affected side during activities such as play.

Things to consider:

 Encourage your child to always involve their affected arm in every

activity. They are likely to neglect this side as it is easier to only use their
unaffected hand. Often using a specific verbal prompt to remind them to
use their other hand works well i.e. ‘use your big/pretty/special hand’.

 Find ways to make things easier for your child when playing with toys
i.e. securing them to a surface using with Velcro or non-slip mats.

 You may notice that when your child is tired or distressed their muscle
tone is likely to increase, this will make activities even more challenging.
 Think about where things are places around your child; try and puts
objects/toys on their affected side to encourage them to use this hand.

Activities to try:

PLAY ACTIVITIES FOR FINER MOVEMENTS OF AFFECTED

HAND -The child may need you to hold their unaffected hand whilst
completing these activities.

 Push button toys – encourage your child to activate the toy using a
pointed finger

 Pegging out clothes on clothes line .

 Peg board puzzles and jigsaws– start by using larger size puzzles and
then progressing to smaller ones

 Squeezing pipettes with water.

 Posting games – start with larger shape sorters and then progress onto
coins and letters.

 Picking up small objects such as pasta shapes or beads and holding as

many as possible in their palm at one time. Encourage to child to open
their hand very wide so they can count how many they are holding.

 Card games – playing snap or pairs and encouraging your child to turn
the cards over using their affected hand .
 Hand & finger painting – encourage your child to use individual
fingers of their affected hand to paint with.

 Bubbles – bursting bubbles using a pointy finger

 Bowl of Treasure – fill a bowl with rice, beans or pasta shapes and then
bury some small treasure. Encourage your child to try and find the objects
and identify them without looking.

Other ideas you could try

 Skittles – throwing the ball and replacing the skittles using affected
hand
 Balloon batting – batting a balloon up in the air with affected arm.
Encourage your child to try and keep it in the air without falling to the
floor.
 Simon Says – ‘clap your hands, wave your arms, reach up tall’.

 Ball Games – using large balls i.e. physio ball, beach ball or foam ball,
encourage your child to roll, push, throw and catch using both hands.

 Books - turning the pages, lifting flaps, pop ups .

 Baking – encourage your child to hold onto the mixing bowl with their
affected hand and stir with the other hand.

 Bath time – encourage your child to help wash themselves using their
affected hand. This is also a good opportunity to stretch out their hand
and arm as warm water will help their muscles relax.

 Dressing up – this will help develop dressing skills .

 Obstacle courses .

 Using equipment in the park – climbing frames, slides etc .

 Sit and ride toy/ trike – encourage your child to hold onto the handle
bars with both hands.

 Musical instruments .

4. Kinesio Tape

Kinesiology tape or as known as kinesio- tape is a thin elastic cotton

strip with an acrylic adhesive that have been introduced by the Japanese
chiropractor Kenzo Kase in the 70’s of the last century and have been
adapted by the Japan Olympics team in the 88 and then invade all the
world (Octavian, 2015). Kinesio- tape is thought to increase the muscle
function, increase lymphatic and blood flow, decrease pain, increase
proprioception and correct joint alignment (Callaghan et al., 2008; Kafa
et al., 2015).

Kinesiology taping is an increasingly popular technique used in both

child and adult rehabilitation. Kinesiology tape is a thin, elastic
therapeutic tape applied directly onto the skin and consists of an air
permeable, water-resistant cotton matrix that can stretch longitudinally
with a stretch capacity of 40% – 60% of its resting length, mimicking
human skin properties (Morris et al. 2013).

Kinesio taping is a widely used non-invasive treatment technique in

patients with musculoskeletal conditions (Zhang et al., 2019). Compared
to traditional rigid/inelastic tape, this tape may be stretched up to 140% of
its original length and kept in place for several days before removal.
Therefore, a constant shear force is subsequently provided to the skin
over which it is applied. Kinesio taping does not limit movement or
provide structural support (Yoshida et al., 2007).
Physiological Effect of Kinesio Tape:
It’s suggested that the cutaneous afferent stimulation and motor unit
firing in both central and peripheral nervous systems play a role in
kinesio tape effect as it was shown that peripheral nerve stimulation
promote excitability to the motor cortex (Ridding et al., 2000).

The functional performance of the muscle may be improved due to the

inducement of cutaneous stimulation which easily recruits the motor units
(Maratou and Theophilidis, 2000).
Muscular inhibition is thought to be achieved by Golgi tendon organ
stretching in the distal ends of the muscles. Kinesio-Tape has been proved
to be effective in pain control by muscle activity inhibition (Kalichman
et al., 2010).

It’s stated that the muscle taping can change the tone of the muscles ,
as muscle tone is refers to the tension in the muscle that is maintained by
central nervous system impulses as long with periphery afferents from
skin , muscles or even proprioceptors from joints through the peripheral
feedback system. Skin receptors are activated by kinesio tape application,
through enhancement of the afferent signals from the periphery. This
mechanism can be used to influence tonus regulation; also kinesio-taping
is thought to assist muscle control through exciting the mechanoreceptors
in muscles and proprioceptors that control postural motor function and
dynamic functions of joints (Kumbrink, 2016).

Kinesio Tape Application:

Tape Direction: The two basic kinesio tape applications depend on the
direction of application of the method on muscles the tape is applied from
insertion to origin) in order to inhibit muscle function, and when
facilitation of the muscle is the aim, the tape is applied from origin to
insertion. In insertion to origin (Inhibitory) application of Kinesio Tape
the tension applied is very light or light which is from 15-25% of the
available tape tension , take in mind that applying too much stretch in this
application decreases the desired result effects (Yasukawa el al., 2006).
Muscular inhibition is thought to be achieved by Golgi tendon organ
stretching in the distal ends of the muscles. Kinesio-Tape has been proved
to be effective in pain control by muscle activity inhibition (Kalichman
et al., 2010). Kinesio Taping is commonly used in pediatric rehabilitation
to reduce pain, facilitate or inhibit muscle activity, prevent injuries,
reposition joints, aid the lymphatic system, support postural alignment,
and improve proprioception (Yasukawa et al., 2006). Because of these
properties, investigators used it to stabilize joints, manage spasticity,
facilitate muscle function via increased stimulation of cutaneous
mechanoreceptors and decrease pain and inflammation by improving
lymphatic and blood circulation ( Gittler et al., 2018).
 It’s stated that the muscle taping can change the tone of the muscles,
as muscle tone is refers to the tension in the muscle that is maintained by
central nervous system impulses as long with periphery afferents from
skin, muscles or even proprioceptors from joints through the peripheral
feedback system. Skin receptors are activated by kinesio tape application,
through enhancement of the afferent signals from the periphery. This
mechanism can be used to influence tonus regulation; also kinesio-taping
is thought to assist muscle control through exciting the mechanoreceptors
in muscles and proprioceptors that control postural motor function and
dynamic functions of joints (Kumbrink, 2016)