Conductive education in cerebral palsy

DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

By

KHATRI ESHA RAJEEV

UNDER THE GUIDANCE OF

Prof. NATARAJAN

VIKAS COLLEGE OF PHYSIOTHERAPY

MARYHILL, KONCHADY, MANGALORE-575006

2010-12

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

1.

Name of the Candidate

and Address

KHATRI ESHA RAJEEV

VIKAS COLLEGE OF PHYSIOTHERAPY

AIRPORT ROAD

MARYHILL, KONCHADY

MANGALORE – 575008

2.

Name of the Institution

VIKAS COLLEGE OF PHYSIOTHERAPY

Mangalore.

3.

Course of study and subject

Master of Physiotherapy (MPT)

Paediatric Physiotherapy

4.

Date of admission to Course

14-09-2010

5.

Title of the Topic

EFFECTIVENESS OF CONDUCTIVE EDUCATION INTERVENTION FOR CHILDREN WITH CEREBRAL PALSY IN IMPROVING SHORT TERM FUNCTIONAL SKILLS

6

BRIEF RESUME OF THE INTENDED WORK

6.1) Need for the study

Optimising participation is seen as the main goal of interventions for children with cerebral palsy (CP). Due to damage of the immature brain, children with CP have disorders of movement and posture development, often accompanied by disturbances of sensation, perception, cognition, communication, behaviour, and by epilepsy and secondary musculoskeletal problems1. According to the children and youth version of the WHO's classification (ICF-CY)2, function can be classified, measured and influenced in several dimensions; like body structure and function, and in activity and participation. In addition, environmental factors as well as the child's health and personal factors may influence the functioning. The relationships between all dimensions are not fully understood3-7, and which aspects that should be addressed in physiotherapy to promote participation, is an issue of debate.

At present, CP occurs in about 2.2 per 1000 liveborn children8-10. A commonly cited definition of CP is “an umbrella term covering a group of non-progressive, but often changing, motor impairment syndromes secondary to lesions and anomalies of the brain arising in the early stages of development”11. CP is subdivided by type (spastic, ataxic or dyskinetic) and topography (hemiplegia, diplegia or tetraplegia) representing different motor dysfunction manifestations11. CP is frequently accompanied by additional neuroimpairments, such as learning disabilities, epilepsy, visual impairments, speech and language disorders and perceptual problems12. Improved grouping due to severity of impairment in gross motor function has been achieved13,14 and increasing degrees of physical disability are accompanied by increasing degrees of additional neuroimpairments12,15 and functional limitations16. The heterogeneity of CP comprises a wide range of functional problems and gives rise to a large variety of needs in the children and their families.

In physiotherapy approaches like neurodevelopmental therapy (NDT), quality of movement has traditionally been considered important17,18. As a reaction to the earlier major focus on quality of movement, a functional task-oriented treatment approach has evolved and is now the preferred therapy19,20. However, these approaches are typically done twice or thrice a week and even just once a week due to factors like accessibility, cost and available of man power.

Whether an intensified training program would accelerate motor development and improve the children's function more than one hour of twice or thrice weekly physiotherapy training as often afforded is questioned by parents and professionals.21 One reason was a lively debate criticizing child and youth rehabilitation for being too pessimistic about the development of the child, making the children passive by compensating too much with assistive devices and environmental adaptations and failing to support active functional and more intensive training.21 There was also a debate among professionals whether treatment of the capacities of the child was sidelined in favour of actions taken to support social aspects and participation of the child in their environment. Another suggestion as to why treatment was sidelined was the uncertainty about treatment effects and utility from the aspect of health22.

Improvement in gross motor function has been indicated after periods of intensive physiotherapy for non-ambulatory children23, and in children who have practiced functional tasks intensively in their everyday environments24. No difference in change of gross motor function has been demonstrated, neither between different intensive approaches24 nor between training offered in intensive periods versus spread over time21,25. Intensive physical training for children has been defined in several ways in recent studies e.g. five sessions a week over six months25, five sessions a week over four weeks26, or several daily sessions over five months23. There is no consensus regarding the optimal dose of training, and there are only a few studies examining the outcome of intensive physiotherapy training in a group setting21,27,28.

Conductive education (CE) is an educational approach for children with cerebral palsy. A basic tenet that influences the philosophy of CE is that CP is considered a learning problem and needs are met with educational principles29, 30–31. The primary aim is to stimulate the developmental process29 and the general goal of CE is defined in the concept of “orthofunction”, which implies “the ability to function as a member of society, to participate in normal social settings appropriate to their age without assistive devices and environmental adaptations” (Cottam and Sutton (1986), quoted in 29. The use of adaptive equipment and assistive devices is not encouraged by CE, but there are “modified forms” which allow for a limited use31. Today, CE is applied to different diagnoses in CP as well as to different levels of severity. Originally children with a higher level of functioning and walking capacity were addressed 32.

Although numerous techniques and approaches have been used in the management of cerebral palsy, the results are mixed and the most successful treatment strategy still remains elusive. Though the CE has been practiced in Europe and America since 40 years, it is hardly practiced in Indian conditions and patients. Hence this study attempts to find out the short term gains in functional skills in cerebral palsy children.

6.2 Review of Literature

Dr. Andreas Petö conceived the concept known as conductive education (CE) in Hungary in the 1940’s to assist children with motor dysfunction to attain ‘orthofunction’, enabling them to attend school with maximum independence. A basic tenet that influences the philosophy of CE is that CP is considered a learning problem and needs are met with educational principles33,34-36. The primary aim is to stimulate the developmental process34 and the general goal of CE is defined in the concept of “orthofunction”, which implies “the ability to function as a member of society, to participate in normal social settings appropriate to their age without assistive devices and environmental adaptations”33 . The use of adaptive equipment and assistive devices is not encouraged by CE, but there are “modified forms” which allow for a limited use35. Today, CE is applied to different diagnoses in CP as well as to different levels of severity. Originally children with a higher level of functioning and walking capacity were addressed36.

CE is provided in a group. The children work collectively to monitor and to encourage each other. Conductors lead the group and provide a motivating and supportive environment. Educational goals are determined by the general ability level of the group and by the performance of each individual5. Group activities are highly structured and are broken down by task series into a series of steps. Each step represents an intentional activity rather than an isolated exercise. Task series are built on the premise that the tasks start within the child’s ability level and then progress in difficulty culminating in a functional independent goal. Rhyme and song are used in a technique labeled ‘rhythmical intention’. Through rhyme and song a background rhythm is provided for the motor action and facilitates learning, motivation, control, and initiation of functional movements. Rhythmical intentions are verbal instructions incorporated into the task series. The children use wooden slatted beds and ladder-back chairs to assist with their movements. Other adaptive equipment such as splints, walkers and wheelchairs are not encouraged, although some programs now allow assistive devices and adaptive equipment.32

Liberty conducted a study was to evaluate the developmental gains of 26 young children with cerebral palsy and three children with other disorders attending early intervention based on the principles of conductive education or community-based (CB). Skill gains by children with spastic quadriplegia, cerebral palsy and severe developmental delay who were not able to sit independently who participated in CE were significantly greater than skill gains by children with similar disabilities who participated in CB. Children with quadriplegic cerebral palsy, severe developmental delay, epilepsy and sensory disabilities also achieved significant gains in functional skills in CE. She concluded that Conductive education may benefit young children with motor dysfunction as well as concomitant disorders and severe developmental delay. Gains were not related to intensity, age, or a product of maturation.37

O¨dman P and O¨berg B in a study compared the short-term effectiveness of intensive training period in child and youth rehabilitation with a modified Move &Walk conductive education versus the learning motor skills (Lemo) in 52 patients with cerebral palsy. Gross Motor Function Measure (GMFM) and Pediatric Evaluation of Disability Inventory–Functional Skills (PEDI-FS) were measured. Results showed no difference in proportion of change on the clinical measures between the training programmes, except for a higher proportion of improvement on the GMFM total score in Lemo. At the group level, small improvements were shown on GMFM and PEDI FS in the short-term and on PEDI FS only at 1 year. A higher proportion of children who participated in repeated intensive training periods showed improved social functioning. They concluded that no major differences were shown between the 2 training programmes.21

Stiller et al in a study compared the effects of intensive therapy, conductive education, and special education on function in 19 children with cerebral palsy in a five-week program. Pediatric Evaluation of Disability Inventory (PEDI), the Gross Motor Function Measure (GMFM), and the Fine Motor Scale of the Peabody Developmental Motor Scales before and after intervention were administered. Results showed no statistically significant differences between groups before or after treatment. However, statistically significant within group changes were found only for the intensive therapy group. They concluded that greatest improvements were noted in the group receiving intensive therapy, with children in all groups showing some improvement in function.38

Blank et al conducted an individual cohort study to determine the effects of conductive education, a combined educational and therapeutic task-oriented approach for children with cerebral palsy (CP), on their hand motor functions and activities of daily living (ADLs) in sixty-four children with CP. A 4.5-month period of special education, including 2 hours of individual physiotherapy or occupational therapy per week (special education) followed by a 9-month period, conductive education was administered in 3 blocks of 4 weeks. Hand functions, standardized parent questionnaire to measure ADL were measured. Results showed that conductive education and ADL competence improved coordinative hand functions from baseline, compared with no improvement during special education. They concluded that Conductive education improved coordinative hand functions and ADLs in children with CP.39

Wright et al conducted an 8 month pre and post test study to determine which measures from a core set were most responsive to physical, functional and psychosocial changes associated with a school-based CE programme. Results showed that the Gross Motor Function Measure, QUEST, PEDI and IFS were most responsive to change. GAS was useful in documenting and quantifying goals. Problems were encountered in evaluating self-esteem and school participation. They concluded that several strong measures of outcome were identified and further work is needed to find valid and sensitive psychosocial and school participation measures for these young children.40

Pediatric Evaluation of Disability Inventory (PEDI) is an instrument for evaluating function in children with disabilities aged 6 months to 7.5 years. The PEDI measures both functional performance and capability in three domains: (1) self-care, (2) mobility, and (3) social function. The inter-rater and intra-rater part of the study showed excellent agreement of the observations, indicated both by small differences and high Intraclass Correlation Coefficients. Results of this study indicate that improved reliability is secured when the same interviewer interviews the same respondent, as well as when two trained interviewers interview the same respondent.41

Sorsdahl et al investigated the impact on motor function, quality of movements and everyday activities of three hours of goal-directed activity-focused physiotherapy in a group setting, five days a week for a period of three weeks. Results showed significant improvement in Gross Motor Function Measure-66 (GMFM-66), GMFCS-levels, PEDI scales. They concluded that basic motor abilities and self-care improved in young children with CP after goal-directed activity-focused physiotherapy with involvement of their local environment, and their need for caregiver assistance in self-care and mobility decreased. The individualized training within a group context during a limited period of time was feasible and well-tolerated. The coherence between acquisition of basic motor abilities and quality of movement should be further examined.42

Vos-Vromans conducted a study to describe the responsiveness of the Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI) in a group of 55 children with cerebral palsy aged 2 to 7 years. Two frames of references for determining responsiveness were used: change over time and external criterion. Responsiveness was calculated with help of the Effect Size (ES), Standardised Response Mean (SRM) and Spearman rank order correlations of change on both the PEDI and GMFM, with change in motor functioning according to the parents as external criterion. Results showed that both the GMFM and the PEDI are responsive for change in motor ability over time in children with CP, the most in children younger than 4 years of age.43

.

7.

Materials and methods

7.1 Source of data

Data will be collected from patients, who are referred to the outpatients Physiotherapy department of Vikas College of Physiotherapy, Mangalore, with diagnosis of cerebral palsy after obtaining informed consent.

7.2 Method of collection of data

Hypothesis:

There is significant improvement in short term functional skills of cerebral palsy patients after conductive education intervention

Null Hypothesis:

There is no significant improvement in short term functional skills of cerebral palsy patients after conductive education intervention

Research Design:

Randomized controlled experimental design will be used in this study.

Sampling method

Random sampling method

Methodology

Patients who are diagnosed to have cerebral palsy and fulfilling the following inclusion and exclusion criteria will be selected for the study after obtaining informed written consent.

Inclusion Criteria:

1. Clinically diagnosed cerebral palsy

2. Normal cognitive level

3. Children using adaptive equipment and assistive devices

3. Age group 4 - 7 years

4. Both males and females

Exclusion Criteria:

1. Recent intensive therapy within three months

2. Children on anti spastic or other medications

3. Children with a IQ level below 70

4. Fixed deformities

5. Inability of child’s parent or care giver participation

6. Previous surgeries for correction of deformities

7. Associated systemic problems and epilepsy

Study Design

The selected subjects will be randomly assigned into one of two groups. Each group will consist of 15 patients of both genders within the age group of 4-7 years.

Group I: This will consist of 15 patients and they will undergo conductive education intervention.

Group II: This will consist of 15 patients and they will undergo conventional physical therapy.

Interventions

Group I

All children will undergo an average daily session of 3 hours, 5 days a week for 3 months. The type of interventions are as follows as described by Sorsdahl et al42:

A group session depending on the children’s goals, ages, functional levels, interests and current state will be organized. There will be some variations between the childrens and day-to-day variations regarding content, duration of the activities and applied learning/teaching strategies. The amount of training is approximate estimates, and includes small breaks. Transitions between and preparation for activities including undressing/ dressing, and one major break with self initiated activities, will supplement the described activities. Each child should be accompanied with one escort (parent, assistant). The escorts will actively participate in the training e.g. in clapping games, singing, shaking the parachute, ball games. They gave physical and verbal guidance, and will take responsibility for security e.g. when children were climbing.

The children’s goals will be related to transitions (e.g. from chair to toilet, from the floor to standing without help, climbing into the sofa at home), maintenance of positions (e.g. sitting, standing, standing on one foot), and different skills (e.g. hopping on one foot, ball-bouncing and ability to climb to the top of the wall bars). In addition some children will have goals related to dressing and to hand activities (e.g. more use of affected hand).

Two PTs will conduct the group training; one will instruct, while the other will supervise the children/escorts. The training will be conducted in a large room furnished for paediatric activities. Equipment used will be exercise mats, stools, wall bars, climbing wall, balance beam, parallel bars, parachute, large boat-swing, prone crawling board, balls, foams of different sizes and shapes, balance cushions, cardstock with song cards, cones, sticks, small toys.

Activity

Task/movement

Reps/Time

Motor Learning and teaching strategies identified during the part (always, often, sometimes, occasionally)

PART 1: GROUP ACTIVITIES ORGANIZED IN A RING

Welcome songs

Squat-position: Performing arm movements along with the songs

5 min

During part 1:

- Visual demonstration (always before and during activities)

- Verbal instruction - action (always before and often during activities) e.g. “Now we are going to be elevators. Wepush 19th floor and stop, then 38th floor, stop, 101th floor,stop. Ready?” or “Now we are going to stand up. How do we do?”

- Verbal instructions - movements (occasionally during activities) e.g. “Can you sit with the feet a bit more together?”

- Physical assistance/tactile guidance to children who lacks ability to perform the action (often three children, amount of guidance vary between and within children;

occasionally three children)

- Children active in creating the activities e.g. choosing

songs, deciding which floor the elevator stops, singing, counting, deciding which animal they want, suggesting

variations (often)

- Using songs, rhymes, short stories and counting for

motivation (often)

- Using toys and equipment for motivation (sometimes)

- Motivating feedback e.g. “Well done” (occasionally after activities)

“Elevator”

Rising from squat to stand. Stop and hold the position

three times during the movement trajectory

A total of 15 reps, 2-3 in a set with

breaks sitting on a

stool in between

Clapping and finger

games

Sitting on a stool: Finger games like “Itsy Bitzy Spider”. Clapping to rhymes involving bending and

rotating the trunk e.g. clapping on opposite shoulder

10 min

Clapping games and

oral motor activities

Prone lying: Clapping games, waving, pressing a toy that makes bubbles, blowing bubbles

12 min

Safari

High kneeling and half kneeling. Using arms as binoculars, looking for animals. Reaching for and

holding large animal toys, balancing animals on

different parts of body. Dorsal flexion in ankles when crocodile eats on toes

10 min

Parachute

Sitting, lying and high kneeling: Parachute games like hiding, shaking, para-ball, make balloon fly

15 min

Hot-dog

Children are wrapped in a mat, “unwrap” themselves

by rolling

10 min

PART 2: INDIVIDUAL ACTIVITIES ORGANIZED AS STATIONS OR OBSTACLE COURSES

Individual programs of

activities

Ball bouncing, throwing and catching

Balance on one foot, different surfaces and heights

Crawling over foams of different sizes and shapes

Climbing steps or stairs sometimes while carrying a toy

Sitting to standing

Floor to standing

Picking up toys from floor

Walk on balance beam, between or over obstacles

Climb wall-bars or a climbing wall

Crawling over a balance beam fasten to a wall bar

Standing with/without support, different surfaces

Walking in parallel bars

Prone crawling board

3 individual

sessions during the

training, each

lasting 10-15

minutes

During part 2:

- Verbal instruction from escort (often before and during

activities). Action or movement instructions dependent of

the escort

- Physical assistance/tactile guidance (occasionally or never

depending on the activity)

- Using toys and equipment for motivation (always)

- Motivating feedback e.g. “Well done” “Come on!”(often

during activities)

- Feedback on result “You are standing!” (occasionally

after activities)

- Visual demonstration (occasionally before activities)

PART 3: CLOSING ACTIVITIES

Stretching

Muscles in legs and arms

8 min

During part 3:

- Verbal instruction - movement (always before stretching)

- Visual demonstration (always before stretching)

- Verbal instruction - action (always –swing)

- Songs, music CD and counting for motivation (always)

- Physical assistance (always during stretching, two

children when climbing into the swing

- Children active in creating the activities e.g. choosing songs, singing, counting, deciding when enough stretch (sometimes during activities)

- Motivating feedback e.g. “Well done” (occasionally after

activities)

Large boat swing

Climbing into. Sitting or standing in the swing

10 min

Reflections/comments

Each child comments on the training

5 min

Group II

The children in this group will receive traditional physiotherapy for one hour, three times a week

Evaluation: Before the beginning and after the 8 months of intervention period, all patients will be evaluated in the following outcome measure.

1. Functional skills domain of Pediatric Evaluation of Disability Inventory (PEDI)

PEDI provides a comprehensive tool to assess the development and capability of functional skills in children ages, 6 months to 7.5 years, who have a variety of disabilities that result in functional problems as defined by three categories: self-care, mobility, and social function.41,44,45 The PEDI provides resources to assess a child on three different measurement scales.41 The first, Functional Skills, establishes the ability of the child to complete discrete functional skills. Caregiver Assessment determines the amount of assistance that the child is provided with during complex functional skills.41 And finally, Modification Skills assess what types of modifications the child requires to complete and support his/her function. The scales can be used concurrently or independently of one another depending on the domain of interest for each individual child.41

Part I of the inventory assesses discrete functional skills through 197 items. Skills are rated as 0 (unable, or limited in capability, to perform the skill) or 1 (able to perform the skill, or beyond the level).41 Part II, Caregiver Assistance, assess 20 complex functional activities and is rated on a scale between 0 (total assistance) and 5 (independent).41 The third portion, Modifications, assess the child on 20 complex functional activities and is rated as N (no modification), C (child-oriented modifications), R (rehabilitation equipment), or E (extensive modifications).41 Scores from each section are then summarized and a composite score is formulated.

Statistical tests:

The following statistical tests will be used to analyze the collected data:

The disability data collected using PEDI will be analyzed using parametric tests as the data are interval in nature. The intra group pre and post-test data will be analyzed using Unpaired t-test, while the post-test inter group data will be analyzed with Paired t-test.

7.3 Nature of Investigations and Interventions:

The study requires non-invasive investigations and interventions to be conducted on patients. They include physical examination like inspection, palpation, and measurement of range of motion, etc. Treatment interventions include application of exercises and education.

7.4 Ethical clearance:

Ethical clearance has been obtained from the ethical committee of our institutions to carry out the investigations and interventions on patients necessary for this study.

8

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9.

Signature of the candidate :

10.

Remarks of the Guide

11.

Name and Designation of

11.1 Guide : S NATARAJAN

Professor

11.2 Signature :

11.3 Co-Guide : -

11.4 Signature : -

11.5 Head of the Department : Prof. S. NATARAJAN M.P.T.

11.6 Signature :

12.

12.1 Remarks of the Chairman and Principal

12.2 Signature :