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international journal of science and healthcare research vol 6 issue 1 jan march 2021 website ijshr com case study issn 2455 7587 pnf training for improving lower limb coordination in ...

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                                                                         International Journal of Science and Healthcare Research 
                                                                                                Vol.6; Issue: 1; Jan.-March 2021 
                                                                                                            Website: ijshr.com  
                 Case Study                                                                                  ISSN: 2455-7587 
                            PNF Training for Improving Lower Limb 
                   Coordination in Cerebral Palsy: A Case Study in a 
                                          Child with Spastic Diplegia
                                                          Preksha Sharma 
                                                            Assistant Professor, 
                                Department of Physiotherapy, Sanskriti University, Mathura, U.P., 281401, India
                 ABSTRACT                                               childhood[1].  Cerebral  palsy  is  considered 
                 The  research  focused  on  assessing  the             as severe mental, physical dysfunction along 
                 effectiveness  of  PNF  training  on  lower  limb      with disturbances in growth, gait, cognition 
                 coordination  on  a  Male  child  with  spastic        and  sensation[2].  Commonest  childhood 
                 diplegia  Cerebral  Palsy.  Mental  and  physical      disability  hampering  physical  growth  the 
                 dysfunctioning along with the growth, sensation        most, worldwide affecting  2 to 2.5 children 
                 and  gait  disturbances  is  termed  as  Cerebral      per  1,000    live  born  [3].  Spastic  Diplegia 
                 Palsy.   This  is  unconditional  neurological         (both legs are affected) is predominant type 
                 problem that has severe effect on the control and      of  CP  preterm  infants  specially  born  with 
                 coordination of muscles. This generally occurs         birth weights below 1000gm [4]. 
                 at early childhood age or infancy. This research               Velocity  dependant  increased  in 
                 is a case study in which subject was a child with      resistance  to  passive  muscle  stretch  is 
                 dysfunctioning  arms  and  legs.  The  branch  of      considered as Spasticity [5]  .The onset of 
                 Cerebral Palsy that deals with dysfunctioning of       spasticity in the legs is during the first year. 
                 arms and legs is termed as Spastic Diplegia. The       During first 4 months of life most of spastic 
                 patient  underwent  PNF  on  both  lower  limbs        diplegic  children  have  normal  tone,  or 
                 (hip, knee, foot), followed by hot fermentation.       hypotonia. In first year onset of spasticity is 
                 After the intervention, significant improvement        insidious and slowly progressive [6].  
                 is  seen  in  all  the  outcome  measures  (gait               Lesion  in  sensorimotor  cortex  and 
                 parameter,  BBS  score,  GFMC  score)  .As  the        extra pyramidal system (corticospinal tract) 
                 result affected lower limb improved in terms of        results in lower limb dysfunction. The lower 
                 coordination, execution and accurateness of the 
                 movement,  number  of  jerks,  and  duration  of       limb is usually more severely involved than 
                 clonus.  Improvement  was  seen  in  preciseness       upper    limb.     This    restricts   walking, 
                 and  accurateness  of  coordinated  movement  at       ascending       and      descending       stairs, 
                 the different ranges of motion for lower limbs.        exploration, play and other  ADL activities 
                 PNF seems to be a promising intervention for           [7].  
                 improving  lower  limb  movement  coordination                 Common  management  effective  in 
                 in    Cerebral     palsy     children.    Further      spastic  diplegia  includes  pharmacological 
                 investigations are certainly needed to assess.         (botulinum  toxin,  intrathecal  pump  and 
                 Keywords: Cerebral palsy, Proprioceptive               surgical management (orthopaedic surgery), 
                 Neuromuscular Facilitation, Gait Training,             constraint   induced     movement  therapy, 
                 Balance, Incoordination.                               occupational therapy, Neuro-Developmental 
                                                                        Therapy,  Sensorimotor  training  program, 
                 1. INTRODUCTION                                        balance         training,        Proprioceptive 
                         Cerebral  Palsy  is  considered  to  be        Neuromuscular       Facilitation    and    other  
                 the mundane disability that is chronic. This           traditional  physiotherapy  techniques    to 
                 is  the  disability  most  common  in  today’s 
                                  International Journal of Science and Healthcare Research (www.ijshr.com)             35 
                                                    Vol.6; Issue: 1; January-March 2021 
                       Preksha Sharma. PNF training for improving lower limb coordination in Cerebral Palsy: a case study in a child 
                       with spastic diplegia 
                       improve gait, balance and  coordination of                                          The important clinical findings were 
                       lower limb function [1],[8].                                             showed in Table no 1. Limited dorsiflexion 
                                  PNF is considered as very effective                           was  seen  in  bilateral  feet.  In  postural 
                       therapeutic  exercise  for  the    betterment  of                        examination bilateral flat foot, exaggerated 
                       gait and dynamic balance [9]. PNF is used                                lumbar lordosis, bilateral adductor tightness, 
                       widely in clinics to treat post stroke physical                          valgum  deformity  is  seen  at  knee.  It  was 
                       dysfunctions[10].  Studies  done  states  that                           seen in the assessment that patient was able 
                       PNF  techniques  mainly  focus  on  muscle                               to perform with bilateral upper limb without 
                       activity.  Evidences  also  suggest  change  in                          much difficulty. 
                       stiffness and increased tone due to spasticity                            
                       after stroke [12].                                                         Table 1: Patients parameters diagnosed during assessment 
                                                                                                                                              Left    Right 
                                  Most  of  the  literature  work  done                                MUSCLE TONE  Hip Adductors              1+      1+ 
                       earlier  focussed  on  using  of  PNF  for  the                                                      Hamstrings         2+      1+ 
                       management  of  Stroke  patient  to  reduce                                                          Calf Muscles       1+      1+ 
                                                                                                       REFLEXES             Knee Reflex       +++      ++ 
                       spasticity and improve tone. This case study                                                         Ankle Reflex      +++      +++ 
                       aim to use PNF as an potential approach to                                
                       show  improvement  in  gait  parameter,                                  5. Therapeutic Intervention 
                       walking  status,  balance  and  functional                                          In starting of the treatment session to 
                       independence.                                                            normalize           increased           tone        inhibitory 
                                                                                                techniques were given. It took 3 months to 
                       2. Patient Information                                                   normalize  tone.  Session  was  started  with 
                                  Patient  was  7  year  old  Spastic                           rhythmic  stabilization  exercises  of  entire 
                       diplegic        male  child  who  was  under                             lower  limb  focusing  on  proximal  joint 
                       physiotherapy treatment since past 2 years                               primarily  to  gain  stability  of  lower  limb. 
                       which includes PROM of all the joints, Mat                               After  that  sets  of  hold  relax  and  dynamic 
                       and  gym  ball  exercises.  Child  was  having                           reversals  in  both  the  diagonal  pattern 
                       good communication skills, but not going to                              performed, initially with assistance later on 
                       school. Able to perform his ADLs activities                              without          assistance.           Exercises           were 
                       with  difficulty,  highest  functional  ability                          performed  in  both  supine  and  standing 
                       was independent sitting, donning on & off                                positions. Treatment was given 40 minutes a 
                       clothes with assistance. His primary concern                             day, for 6 days a week for 16 weeks. Follow 
                       was his difficulty of independent standing,                              up was taken after each 15 days to see the 
                       walking  and  inability  to  go  up  and  down                           long term effect of treatment.   
                       stairs.  He  was  taking  muscle  relaxants                               
                       earlier  on  regular  basis,  but  currently  not                               Table 2: Pre and post scores of outcome measures 
                                                                                                                                   Pre Scores    Post Scores 
                       taking any medication and no psychological                                    Berg Balance Scale Score          18             30 
                       illness found. Patient was already diagnosed                                  Stride length (in cm )            60             75 
                       by paediatrician as Spastic cerebral palsy.                                   Step length (in cm )              35             48 
                                                                                                     Cadence (in cm )                  38             48 
                                                                                                     GMFCS score                    Level V        Level IV 
                       3. Diagnostic Assessment                                                             
                                  Balance  was  assessed  by  Berg                                         Outcome  measures  were  recorded 
                       balance  scale;  different  parameters  like                             before and after completing treatment that is 
                       (Stride  length  (cm),  Cadence  (steps/min)                             1 day of the treatment and after 16 weeks. 
                       and  Gait  velocity  (m/  min))  were  used  to                          Treatment  protocol  was  not  changed  and 
                       evaluate  gait  characteristics.  Gross  Motor                           only dosage was progressed.  Treatment was 
                       Function          Scale        is     used        to      check          not  even  missed  for  a  single  day.  After  4 
                       independence  level  of  the  child.  Pre  and                           months during follow up it was found that 
                       post scores of all the variables are shown in                            treatment  was  effective.  Activity  specific 
                       Table no 2.                                                              lower limb training, Sit to Stand, Single leg 
                                                                                                standing  like  activities  ,  muscle  stretching 
                       4. Clinical Findings                                                     exercises  was  given  to  the  patient  to 
                                                   International Journal of Science and Healthcare Research (www.ijshr.com)                                     36 
                                                                      Vol.6; Issue: 1; January-March 2021 
                  Preksha Sharma. PNF training for improving lower limb coordination in Cerebral Palsy: a case study in a child 
                  with spastic diplegia 
                  perform  at  home  as  the  part  of  Home                this child motivated us to follow the similar 
                  Exercise Program.                                         protocol in other children too. 
                                                                             
                  6. DISCUSSION                                             ACKNOWLEDGEMENT 
                           Present study aimed to evaluate the                       We would like to thank patient and 
                  efficiency  of  PNF  training  in  improving              his     attendants      for     their    enormous 
                  lower  limb  coordination  in  a  child  with             cooperation during this duration of 1 year. I 
                  Spastic  diplegic  Cerebral  palsy.  Evidences            would  also  like  to  thank  Management  of 
                  are  present  in  previously  done  studies  of           School  of  Medical  and  Allied  Sciences, 
                  PNF in stroke populations were proved to                  Department of Physiotherapy for providing 
                  be  highly  beneficial.  Sang  Wang  et  al  in           required  infrastructure.  Ethical  clearance 
                  their  study  applied  PNF  to  chronic  stroke           was  obtained  from  Institutional  ethical 
                  patients  and  concluded  that  it  decreases             committee and   Informed consent was filled 
                  muscle  stiffness  and  abnormally  increased             by patient after explaining all the procedure. 
                  muscle tone. FCR muscle of affected side                   
                  with MAS grade 2 in stroke patients with                  7. REFERENCES 
                  Brunnstrom  stage  III  showed  significantly             1.  A.N. Berker, M.S. Yalçin, Cerebral Palsy: 
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                  PNF intervention [11].                                         Pediatr.  Clin.  North  Am.  55  (2008)  1209-
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                                              International Journal of Science and Healthcare Research (www.ijshr.com)         37 
                                                        Vol.6; Issue: 1; January-March 2021 
                  Preksha Sharma. PNF training for improving lower limb coordination in Cerebral Palsy: a case study in a child 
                  with spastic diplegia 
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                      https://doi.org/10.1589/jpts.27.1629. 
                                                                    ****** 
                                              International Journal of Science and Healthcare Research (www.ijshr.com)       38 
                                                       Vol.6; Issue: 1; January-March 2021 
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...International journal of science and healthcare research vol issue jan march website ijshr com case study issn pnf training for improving lower limb coordination in cerebral palsy a child with spastic diplegia preksha sharma assistant professor department physiotherapy sanskriti university mathura u p india abstract childhood is considered the focused on assessing as severe mental physical dysfunction along effectiveness disturbances growth gait cognition male sensation commonest disability hampering dysfunctioning most worldwide affecting to children termed per live born this unconditional neurological both legs are affected predominant type problem that has effect control cp preterm infants specially muscles generally occurs birth weights below gm at early age or infancy velocity dependant increased which subject was resistance passive muscle stretch arms branch spasticity onset deals during first year months life patient underwent limbs diplegic have normal tone hip knee foot follow...

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