6.. Brief Resume of the Intended Work:

6.1 Need of the Study

Cerebral palsy has high rates of secondary condition that evolve over the lifespan and affect

function and quality of life. It is usually identified as the most common physically disabling

condition seen and managed by Childs health professionals with a prevalence of 2.0 - 2.5. In India,

prevalence of cerebral palsy is high, during delivery one out of 50 children is affected by it. A

recent study shows that an average prevalence of cerebral palsy estimate was notably different

from that of the previous surveillance as 10.3 per 10000, or 1 in 100 childrens.1

Cerebral palsy is a general term describing a group of chronic non-progressive neurological

symptoms which cause impaired control of movement and which are evident in the first few years

of life, usually before age 3. The disorders are induced by damage or faulty development of the

motor areas in the brain, disrupting the patient's ability to control movement and posture.2 The

motor disorders of cerebral palsy are often accompanied by disturbance of sensation and

perceptions, cognition communication and behaviour by epilepsy and secondary manipulated

problem.2

Symptoms of cerebral palsy include difficulty with fine motor tasks such as writing, poor balance,

walking and involuntary movements. The exact combination of symptoms differs from patient to

patient and may vary over time. 2

Cerebral palsy is a permanent disorder that is non progressive but has caused damage in the

developing foetal or infant brain. Insults affecting the brain during prenatal, perinatal and postnatal

time frames are associated with the cause of Cerebral Palsy. These insults can be hypoxic,

ischemic, infectious, congenital, or traumatic events within any of the three time frames listed

above. Other related factors could be atypical uterine growth, premature birth, genetic factors, and

multiple births. The brain lesion in CP is non progressive but secondary impairments of the

musculoskeletal system can be progressive and are seen in most children. Muscle or tendon

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contracture, hip displacement, bony torsion, and spinal deformity can all occur with CP and lead to

functional limitations.2

There are many causes of cerebral palsy:

Prenatal (75% of cases) e.g.-. Developmental brain anomalies, congenital intrauterine infections,

Perinatal 8 To 10% e.g. Birth asphyxia, hypoglycaemia, and untreated jaundice.

Postnatal 10% e.g.-. Accidental injury, severe brain infection.

Type of motor disorder seen in CP are spasticity, Athetosis, ataxia or mixed and the distribution

seen are hemiplegic, diplegic and quadriplegic. Children who are born prematurely or preterm (less

than 37 completed weeks or 259 days of gestation) have higher rates of cerebral palsy, sensory

deficits, learning disabilities, visual impairment, speech disorder and respiratory illness, compared

with children born at preterm.5

A child with cerebral palsy has difficulty maintaining normal postures because there is lack of

muscle co activation which brings about abnormal movement pattern in Childs Day to day

functional activity. From the perspective of international classification model (ICF) of impairment,

disability and health, patient presents with impairment of body functions such as spasticity and low

muscle strength and motor control. These impairments may limit the performance of activities and

participation of daily life. Improving and optimizing activities and participation are important

treatment goal for therapeutic intervention. 6

Most important are the spastic cerebral palsy accounting for 60 to 70% of children. Spasticity leads

to muscle imbalance which if left unattended will cause contracture and other complications on

child’s ability to perform daily activities. Many approaches in cerebral palsy such as stretching

exercise, splinting, Neurodevelopment technique, Bobath approach, Rood’s approach and

Biofeedback are used.6

The majority of people with cerebral palsy have spastic syndrome of which the diplegic group is

the smallest. Dependent on the subgroup of cerebral palsy, 25-80% has additional impairments,

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commonest being cognitive impairment resulting from increased rate of epilepsy. Epilepsy is

present in 20 to 40% of cerebral palsy, most common among the hemiplegic.7

Hemiplegic is the word derived from hemi means half side of the body is affected, one arm and

one leg on the same side of the body. Infantile hemiplegic is a condition that may be noted at birth or develop in

the first six months of life - there is often an abrupt onset. It probably is caused by a

cerebrovascular accident in utero or in the Perinatal period. It occurs more often in boys than girls,

and affects the right side of the body twice as often as the left.

Functional strengthening programme is a resistance exercise which involves functional movement

pattern (multi joint, closed kinematic chain) 15 Resistance is simply putting a load on a muscle,

making it move against a force. That force might be external, such as a weight, or it might be

internal, like another muscle in our body.8

Children with spastic cerebral palsy usually have problems of muscle tightness which causes

movement dysfunction. The muscle strength of lower limb and upper limb correlates with

motor activity functions in children with cerebral palsy. An effective intervention for such

children is important to preserve or improve their motor ability at school age. Balance and trunk

control is the integral part of everyday activities for children.

Studies have been done in Muscle-strengthening programs with single joint, open-kinetic-

chained, and non-weight-bearing resistive exercises have chained, and non-weight-bearing

resistive exercises have been used for the treatment of children with cerebral palsy and have shown

evidence of improvement in the muscle strength of the target muscle. The reasons for in conclusive

effectiveness on motor activities may be due to the fact that single-joint and non-weight-bearing

exercises are not task oriented approaches and have limited transferability to actions and that are

weight bearing and that involve different and more complex patterns of muscle activation. This is

the importance of strengthening programme.

Studies that have been examined the effects of the functional strength training for children with

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cerebral palsy has shown the improvement in physical performance and psychological benefits

Developing intervention to improve sit to stand activity in cp children is a priority, so there is a

need arises to conduct a study on sit to stand resistance exercise in children with mild spastic

infantile hemiplegic cerebral palsy so they can improve their basic motor abilities, functional

strength, balance, trunk control and walking efficiency .

Further studies is needed to clarify the STS resistance exercise for different ages and severities of

cerebral palsy Limited studies have been done in effectiveness of sit to stand resistance exercise in

spastic infantile hemiplegic cerebral palsy. Hence, this study is undertaken to evaluate the

effectiveness of sit to stand resistance exercise in mild spastic infantile cerebral palsy for

improving balance and functional strength in children.

Hypothesis:

There will be no significant effect on sit to stand resistance exercise in infantile hemiplegic

cerebral palsy.

6.2 Review Of Literature

Literature on Incidence And Prevalence Of Cerebral Palsy

Gladstone At, al 2010: Conducted a study With 80% of children with disabilities living in

resource-poor settings, it is likely that there is a high prevalence of cerebral palsy and neurological

impairment in these settings. The prevalence and incidence rates of disability, in particular of

children with Cerebral palsy in resource-poor settings, are difficult to access and clarify the aim of

this study is To review the recent literature relating to the prevalence, incidence, type and

aetiology of cerebral palsy in low-income setting

Vanessa A Schulte’s ATt, al 2008: conducted a study on lower limb strength training in children

with cerebral palsy- a randomized controlled trial protocol for functional strength training based on 4

progressive resistance exercise principles. Fifty-one children aged of 6 to 13 years, Author

Concluded that Randomized clinical trials are considered to present the highest level of evidence.

Nevertheless, it is of utmost importance to report on the design, the applied evaluation methods,

and all elements of the intervention, to ensure adequate interpretation of the results and to facilitate

implementation of the intervention in clinical practice if the results are positive.

Literature on Definition Of Cerebral Palsy:

Rosenbaum P, Panetta, Levittown A Goldstein M, Bax M Damiano D Dan, Jacobsson, At al,

2006: Author has given the definition and classification of cerebral palsy For a variety of reasons,

the definition and the classification of cerebral palsy need to be reconsidered. On conclusion

Rates of CP and neurological impairment are difficult to obtain in resource-poor settings. Methods

of identifying children with Cerebral palsy and causal factors and the effects of disability need to

be better classified in order to improve management and help shape preventive measures.

Literature on Outcome Measures Tool:

Russell DJ, Avery LM, Rosenbuam PL, Riana PS, Walter SD, Pallisano At, al 2000: The

purpose of this study is to examined the reliability, validity, and responsiveness to change of

measurements obtained with a 66-item version of the Gross Motor Function Measure (GMFM-66)

developed using Rash analysis the result of overall changes in GMFM-66 scores over 12 months

and a time severity age interaction supported our hypotheses. Test-retest reliability was high

(interclass correlation coefficient. On conclusion This study demonstrated that the GMFM-66 has

good psychometric properties. By providing a hierarchical structure and interval scaling, the

GMFM-66 can provide a better understanding of motor development for children with CP than the

88 item GMFM and can improve the scoring and interpretation of data obtained with the GMFM.

Literature on Resistance Exercise

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Morton, j Brownlee, M, & McFadden At, al 2005: Conducted a study on the effects of

progressive resistance training for children with cerebral palsy in order to Was performed in order

to examine the effects progressive resistance training on muscle tone and strength of the

hamstrings and quadriceps muscles as well as the effects on functional outcomes in children with

bilateral hypertonic cerebral palsy.

Literature on Reliability And Validity Of Outcome Measures:

Hwang AW, liao HF, Hsu AT, Gann, SM, and Lee At, al 2000: Conducted studies on Cerebral

palsy muscle are weaker than normal children, but apply to such less children dynamometer

reliability. The purpose of this study is to explore the Nicolas hand dynamometer (Nicholas

Manual Muscle Tester (NMMT) and then retest reliability in normal children with cerebral palsy

children muscle testing. On Conclusion The NMMT is reliable in testing muscle strength of non-

disabled children IN children with Cerebral palsy.

Karen J. Dodd, PhD, Nicholas F. Taylor, PhD, Diane L. Domino PhD, At, al 2002: conducted

a study on effectiveness on strength training programme for people with cerebral palsy to

determine whether strength training is beneficial for people with cerebral palsy The trials suggest

that training can increase strength and may improve motor activity in people with CP without

adverse effects.

Tze-Hsuan Wang Hua- fang Liao, Yinchuan At, al 2002: Conducted a study of reliability and

validity of five repition of sit to stand To investigate the psychometric properties of the five-

repetition sit-to-stand test, a functional strength test, in children with spastic diplegic cerebral palsy

on conclusion The five-repetition sit-to-stand test was a reliable and valid test to measure

functional muscle strength in children with spastic diplegic in clinic.

Blundell SW, Shepherd RB, Dean CM, Adams RD, Cahill BM At,al 2003: Conducted a study

For the Functional strength training in cerebral palsy: a pilot study of a group circuit training class 6

for children aged 4-8 years To determine the effects of intensive task strength training on lower

limb Strength and functional performance in children with cerebral palsy Four weeks after school

exercise class for one hour twice weekly and group circuit training, children moved between

stations practising functionally based exercise including treadmill walking, step ups sit to stand and

leg presses on conclusion a short programme of task strengthening exercise And training for

children with cerebral palsy, run as a group circuit class, resulted in improved strength and

functional strength and functional performance over time

Diane L. Damiano PhD, PTMark F.abel At,al 1998: Conducted a study on functional outcomes

on strength training in spastic cerebral palsy to determine the clinical effectiveness in strength

training in spastic cerebral palsy this study reinforced the relationship of strength to motor function

in cerebral palsy and further demonstrated the effectiveness of strengthening in this population

Liao HF, Jeng SF, Lai JS, Cheng CK, Hu MH At,al 1997: Conducted a study on the

relationship between standing balance and walking performance, eight children with spastic

diplegic cerebral palsy and 16 non-disabled, age- and sex-matched children were studied on In the

children with cerebral palsy, dynamic balance significantly correlated with walking function. It is

suggested that rhythmic weight-shift training should be encouraged to improve the walking

performance of children with cerebral palsy.

Luke E Kelly, Diane L Damiano Christopher L Vaughn At, al 1995: as one component in the

Rehabilitation of children with cerebral palsy, Conducted a study to know the effects of

Quadriceps Femoris Muscle Strengthening on Crouch Gait in Children With Spastic Diplegic The

children exercised three times per week for 6 week using ankle weights at loads of approximately

65% of each child's maximum isotonic force production. Their findings suggest that resistance

exercise is an effective treatment strategy and as such should be considered.

Kramer and Mikhail At, a1 1994: conducted a study on the relationships among measures of

walking efficiency, gross motor ability and Isokinetic strength in 17 adolescents with cerebral

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palsy. on conclusion They reported that "adolescents with mild cerebral palsy could safely and re

Malleably be tested for knee extensor and flexor strength during standardized kinetic tests of

concentric and eccentric muscle actions." They also reported that isokinetic equipment can be

safely used with this population.

6.3 Objectives of the Study

To investigate effectiveness of a functional strengthening program, the loaded sit-to-stand (STS)

resistance exercise, for Infantile hemiplegic children.

7. Materials and Methods:

7.1 Source of Data:

Primary schools around Bangalore.

Parijma Neuro rehabilitation centre (shantinagar.)

ESI hospital (Rajajinagar).

Padmashree clinic (Nagarbhavi) .

Method of Collection of Data:

Population: Mild spastic hemiplegic children.

Sampling- Convenience sampling.

Sample size : 30.

Study design: Pre& post experimental design.

Duration of study: 5 weeks

Inclusion Criteria-

The inclusion criteria of this study were as follows-

Subjects with age group between 2-5 years old.

The gmfcs between level 1 and 2.

Able to stand for more than 2 minutes.

Able to follow verbal commands without obvious limitations in the passive range of motion

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of lower extremities.

Exclusion Criteria-

Orthopaedic problems or medical conditions that prevented children from participating in

the exercise.

Have orthopaedic intervention, or botulinum toxin injections to the lower extremities and

upper limb.

Outcome Measure:

GMFM66 (GMFM)18

Gait speed (GS)15

.Methodology:

Informed consent will be taken from the subject followed by screening for inclusion and exclusion

criteria. Subjects who meet the inclusion criteria will be assigned based on experimental and

control group, Participants will be explained about the procedure and will be assessed using the

following scales. To measure lower limb, upper limb and isometric strength of the knee the two

outcome measure are used.

Gross motor function measure (GMFM 66): Gross motor function measure is used in children to

assess the children with cerebral palsy. It is scored on 4.point scale with specific descriptors It has

five dimensions kneeling, crawling, jumping hopping and in by hand upper limb like playing

activities

Gait speed- Gait speed is the temporal distance parameter that has been traditionally measured in

the laboratory setting one aspect of normal and pathological gait, this outcome measure is used to

measure the isometric strength of the knee in the sit to stand resistance exercise in spastic infantile

hemiplegic cerebral palsy. Because in sit to stand there is isotonic contraction of the knee. In these

gait speed in meters per minute was calculated using the time it took the child to walk the 10-m

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distance converted to meters per minute.

30 patients will be recruited from hospital and will be randomly assigned to either a control group

(n=15) or one of the two experimental groups(n-15) both groups will be receiving physiotherapy

Treatment.

GROUP A( Experimental group)-

Children of the experimental group were will be asked to perform the loaded STS exercise 3 days

a week, and 3 sets per day under STS exercise 3 days a week, and 3 sets per day under the

supervision of caregivers at home The loaded STS exercise program will be started with 5 to 10

minute warm-up activities for each session In addition to active movements of lower exercise

program started with 5 to 10 minute warm-up activities For each session In addition to active

movements of lower extremities, the warm-up included stretching of hip adductors, ankle plantar

flexors, hamstring muscles, and lumbar extensors After warming up, the child will be

performingSTS 10 times with a body vest at 20% of 1-RM STS load. After that child rested for

another 2 to 3 minutes, then, child performed STS for 10 times with 10% of 1-RM STS weight,

then cooling down exercise will be performed at the end of sit to stand resistance exercise. In these

group caregivers will be asked to encourage the children’s for the sit to stand resistance exercise.

GROUP(B)(Control group)--:

In regular PT programs in control groups included slow gentle stretching passive range of motion

exercises, positioning, functional balance, gait training and Neurodevelopment training will be

given in 5 weeks of study.

Materials used:

Manual muscle tester.

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Mat

Toys

Weight cuffs

Lead pieces of ½ kg

Sand bags

Stool for exercise

Stastical analysis:

Data analysis will be performed by SPSS (version 17) for windows. Alpha value will be set as

0.05.

Mean, standard deviation, range will be used to assess the tool.

To compare between two groups pre and post, Wilcoxin test will be used.

To compare the pre and post control and experimental group Mann Whitney test will be

used.

7.3 Does the study require any investigation to be conducted on patient or other humans or

animals if so please describe briefly?

Yes, the study will be carried out on human subjects of both genders with the age group of 2 to 5

years of the age in Effectiveness of sit to stand resistance exercise in infantile hemiplegic cerebral

palsy.

7.4 Has ethical clearance has seen applying from one institution in case of 7.3? / Yes

As this study involves human subjects the ethical clearance will be obtained from the ethical

committee of Padmashree institute of Physiotherapy Nagarbhavi Bangalore, As per ethical

guidelines research from biomedical research on human subjects, 2000, ICMR, New Delhi.

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8. List of References:

1. Dickinson J. The incidence and prevalence of cerebral palsy. American journal of

Obstetrics and Gynecology.1992; 2:417-423.

2. Rosen MG, Dickinson JC. The incidence of cerebral palsy. Am J Obstetric Gynecol. 1992;

167(2):417-23.

3. Gladstone and other A Study in 2010 http://www.disabled- world.com/health,

neurology/cerebral palsy/ / who definition of cp.

4. Longo M, Hankins GD Minerva. Cerebral palsy, pathogenesis, path physiology and new

intervention. Gynecol. 2009; 61:421- 429.

5. Bax M. Terminology and classification of cerebral palsy in childhood. Dev Med Child

Neurology.1964;6: 295-297.

6. World Health Organizations. International Classification of Functioning, Disability and

Health. Geneva, WHO: 2007.

7. Else Odding, Marij E. Roebroeck and Hendrik J. Stam. The epidemiology of cerebral palsy:

incidence, impairments and risk factors. 2006; 28(4):183-191. Med Child Neurol

2002;44:309-16.

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8. Beckung E, Hag berg G. Neuroimpairments, activity limitations, and participation

restrictions in children with cerebral palsy. Dev Med Child Neuro 2002;44:309-169.

9. Mikhail HE, Kramer JF. Effect of isokinetic strength-training on functional ability and

walking efficiency in adolescents with cerebral palsy. J dev medical child neurology.1995;

37:763-767.

10. Liu CC, Liao HF, Lin KH. The relations between the sit-to-stand functional muscle

strength and walking capacity in children with mild spastic diplegic. Form’s J Phys

Therapy 2004; 29:176-85.

11. Ross SA, Enosburg JR, Relationships between spasticity, strength, gait and the GMFM-88

in persons with spastic diplegic cerebral palsy. Journal of Arch Phys Med Rehabilitation.

2007; 88:1114-20.

12. Guy JA, Michele LJ. Strength training for children and adolescents’. Am Aced Orton Surf.

2001; 29- 36

13. Damiano DL, Kelly LE, Vaughn CL. Effects of quadriceps Femoris muscle strengthening

on crouch gait in children with spastic diplegic. Phys Therapy 1995;75:658-71

14. Liao HF, Jeng SF, Lai JS, Cheng CK, Hu MH. The relation between standing balance and

walking function in children with spastic diplegic cerebral palsy. Dev Med Child Neuro

1997: 399

15. Finch E, Brooks D, Stratford PW, Mayo NE. Physical rehabilitation outcome measures. A

guide to enhanced clinical decision making 2nd edition Hamilton: Canadian physiotherapy

association 2002.

16. Blackmore PhD, and Scott Phillips, PhD, and Scott Phillips(physiotherapy) Effects of

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Circuit Training for Adolescents and Young Adults with Spastic Diplegic , 2005.

17. Kathleen Northridge and James Dryden definition of resistance exercise, Journal of

physiology, 2010; http://www.livestrong.com/article

18. Definition of infantile hemiplegic cerebral palsy ,General practice notebook, medical

reference http://www.gpnotebook.co.uk/simplepage.cfm

19. Morton JF, Brownlee M, McFadden AK. The effects of progressive resistance training for

children with cerebral palsy Clin Rehabil 2005;19:283-9

20. Pallisano RJ, Rosenbaum PL, Walter SD, Russell DJ, Wood EP, Galuppi BE. Development

and reliability of a system to classify gross motor function in children with cerebral palsy.

Dev Med Child Neuro 1997;39:214-23

21. Dodd KJ, Taylor NF, Graham HK. A randomized clinical trial of strength training in young

people with cerebral palsy. Dev Med Child Neuro 2003:4- 652.

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