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ORIGINAL ARTICLE
Efficacy of cold therapy on spasticity and hand function
in children with cerebral palsy
Gehan M. Abd El-Maksoud
a,
*
, Moussa A. Sharaf
b
, Soheir S. Rezk-Allah
c
a
Department of Physical Therapy for Growth and Developmental Disorders in Children and its Surgery,
Faculty of Physical Therapy, Cairo University, Giza, Egypt
b
Department of Physical Therapy for Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Cairo University,
Giza, Egypt
c
Department of Basic Science, Faculty of Physical Therapy, Cairo University, Giza, Egypt
Received 1 September 2010; revised 9 October 2010; accepted 15 February 2011
Available online 26 March 2011
KEYWORDS
Cold therapy;
Spasticity;
Hand function;
Cerebral palsy;
Occupational therapy
Abstract Spasticity remains a major cause of disability among children with cerebral palsy (CP).
Effective management depends on careful assessment and an interdisciplinary treatment approach.
The purpose of this study was to investigate the effect of cold therapy when used in combination
with conventional physical and occupational therapy to control upper limbs’ spasticity and to
improve hand function in children with spastic CP. Thirty children of both sexes (12 girls and 18
boys) with spastic CP with ages ranged from 4 to 6 years (mean age 62.2 ± 7.5 months) participated
in this study. They had mild to moderate spasticity in elbow and wrist flexors. Children were ran-
domly divided into two groups of equal number: group I and group II. Children in group I received
cold therapy on elbow and wrist flexors immediately before the application of conventional physical
and occupational therapy. Those in group II received the same conventional occupational and
physical therapy only. In both groups treatment was conducted three times per week for a succes-
sive 3 months. Spasticity, range of motion (ROM) and hand function were evaluated before and
after the treatment by using the Modified Ashworth Scale, the electronic goniometer and the Pea-
body Developmental Motor Scale, respectively. Both groups showed a statistically significant
reduction in spasticity, increase in ROM and improvement of hand function but group I showed
*
Corresponding author. Tel.: +20 127502122; fax: +20 23 7617692.
E-mail address: gehanmosad@msn.com (G.M. Abd El-Maksoud).
2090-1232 ª 2011 Cairo University. Production and hosting by
Elsevier B.V. All rights reserved.
Peer review under responsibility of Cairo University.
doi:10.1016/j.jare.2011.02.003
Production and hosting by Elsevier
Journal of Advanced Research (2011) 2, 319–325
Cairo University
Journal of Advanced Research
a more significant improvement. It can be concluded that cold therapy in conjunction with conven-
tional physical and occupational therapy significantly reduced spasticity, increased ROM and
improved hand function in children with spastic CP.
ª 2011 Cairo University. Production and hosting by Elsevier B.V. All rights reserved.
Introduction
Spasticity is a widespread problem in cerebral palsy (CP) as it
affects function and can lead to musculoskeletal complications
[1]. It occurs as a result of pathologically increased muscle tone
and hyperactive reflexes mediated by a loss of upper motor
neuron inhibitory control [2].
Children with CP demonstrate poor hand function due to
spasticity in the wrist and finger flexors [3]. Thus spasticity in
the flexor muscles of the upper limbs poses a great deal of
functional limitation in the hands. One common problem
associated with poor hand function as a result of spasticity
is the inability of the child to grasp objects and difficulty with
fine motor tasks such as writing or cutting with hands [2,3].
The management of upper limbs’ problems in CP is often
complex and challenging. Effective treatment requires a multi-
disciplinary approach involving paediatricians, occupational
therapists, physiotherapists, orthotists and upper extremity
surgeons. Interventions are generally aimed at improving func-
tion and cosmoses by spasticity management, preventing con-
tractures and correcting established deformities. Treatment
objectives vary according to each child and range from static
correction of deformities to ease nursing care, to improvement
in dynamic muscle balance to augment hand function [4].
Previous studies have reported various treatment ap-
proaches and modalities to manage spasticity associated with
spastic CP and other upper motor neuron lesion disorders.
These include the use of oral neuropharmacological agents,
injectable materials such as botulinum – a toxin or surgical
treatment. The other treatment approaches are contracture
reduction, orthosis, topical anesthesia application using vari-
ous massage techniques, strengthening the antagonist muscula-
ture with electrical stimulation and the application of
cryotherapy or ice therapy [5,6].
Ice or cold therapy is a widely used treatment technique in
the management of acute and chronic conditions of various
types. There are many tissue-based effects which are promoted
by the application of cold therapy and these include post-in-
jury reduction of swelling and oedema, an increase in the local
circulation, lowering of the acute inflammation that follows
tissue damage, muscle spasm reduction, and pain inhibition.
Muscle contraction can be facilitated by using cold therapy
and this can be used to improve muscle contraction to increase
joint ranges of motion after injury. Another effect of cold is a
time-related reduction in spasticity once the cold has been ap-
plied for some time. Cold can be applied to the body in three
different ways: immersing in cold water, rubbing with ice cubes
or ice packs or using evaporative sprays such as ethyl chloride
[7].
The ability of muscles to function after spasticity reduction
varies. Treating spasticity does not always facilitate the acqui-
sition of undeveloped skills. The importance of physical and
occupational therapy intervention for achieving functional
goals cannot be overemphasized [8].
This study was therefore designed to investigate the effect
of cold therapy when used in combination with conventional
physical and occupational therapy to reduce upper limbs’ spas-
ticity and improve hand function in children with spastic CP.
Subjects and methods
Subjects
Thirty children with spastic CP (18 diplegia and 12 quadriple-
gia), with ages ranged from 4 to 6 years (mean age 62.
2 ± 7.5 months), participated in this study after their parents
signed consent forms for their children’s participation. They
were selected from the outpatient clinic of the Faculty of Phys-
ical Therapy, Cairo University.
Children were enrolled in this study if they met the following
criteria: a mild to moderate degree of spasticity in the elbow
and wrist flexors; ranged from grade 1+ to grade 3 according
to the Modified Ashworth Scale (MAS) [9]; ability to sit alone
or even with support; sufficient cognition to allow them to fol-
low simple verbal commands and instructions during tests and
training; and normal skin sensation of the upper limbs.
Children were excluded from the study if they had fixed
contractures or deformities in the upper limb, concurrent ther-
apy with oral antispastic drugs, previous treatment with botu-
linum toxin injection, alcohol or phenol into upper limbs,
previous surgical intervention in the upper limbs, vasospasm
or cold urticaria, visual or auditory defects or autistic features.
The study was approved by the ethical committee of the Fac-
ulty of Physical Therapy, Cairo University.
The participants were randomly divided into two groups
(group I and group II) of equal numbers. Group I consisted
of 15 children with spastic CP (five girls and ten boys), nine
with diplegia and six with quadriplegia. Their mean age was
63.2 ± 7.4 months. They received cold application on the area
of upper arm and flexor compartment of the forearm (elbow
and wrist flexor muscles) immediately before the application
of the conventional physical and occupational therapy pro-
gramme. Group II consisted of 15 children with spastic CP (se-
ven girls and eight boys), nine with diplegia and six with
quadriplegia. Their mean age was 61.2 ± 7.7 months. They re-
ceived the same physical and occupational therapy programme
only.
Procedures
Evaluative procedure
Each child was evaluated for degree of spasticity, ROM and
fine motor skills. Spasticity was assessed by using MAS to
quantify the degree of spasticity in the elbow and wrist flexors
for all children in both groups. The degree of spasticity ranged
from grade 1+ to grade 3 according to MAS. To accommo-
date the ‘‘1+’’ modification for numeric analysis, grade
320 G.M. Abd El-Maksoud et al.
‘‘1+’’ was recorded as 1.5 [10]. ROM of elbow and wrist
extension was measured by the electronic goniometer. The
Peabody Developmental Motor Scale (PDMS-2) was used to
evaluate fine motor skills including grasping and visual motor
integration. This scale provides a comprehensive sequence of
gross and fine motor skills by which the therapist can deter-
mine the relative developmental skill level of a child, identify
the skills that are not completely developed and plan an
instructional programme that can develop those skills [11].
Assessment of these parameters was carried out before the
commencement of training (pre-treatment) and at the end of
3 months of treatment (post-treatment) for all children by
the same examiner who was blinded regarding the group to
which each child was assigned.
Treatment procedure
Group I. The children in this group were placed in a sitting po-
sition. The upper arm and entire forearm were carefully and
decently exposed and skin sensation was assessed for all chil-
dren to ensure that none of them had defective skin sensation.
Two test tubes were used for this assessment, one filled with
hot water and the other with cold water. The test tubes were
randomly placed in contact with the skin area to be tested.
The child was asked to indicate when a stimulus was felt and
to report ‘‘hot’’, ‘‘cold’’, or ‘‘unable to tell’’ [12]. The area
was then cleaned with cotton wool and methylated spirit.
The upper limb of the child was positioned on a pillow with
the shoulder maintained in mild abduction by a tumble form.
The forearm was also positioned in mid flexion and supina-
tion. Cold pack (Compress-Reusable cold gel back) was ap-
plied over a wet towel to the skin of the treated area to
avoid excessive local cooling (ice burn); this pack was held in
place by dry towelling. The skin under the cold pack was
checked for a minute after applying it to look for abnormal
reactions or unusual changes in skin colour. This was repeated
after 5 min if no abnormal reactions were obvious in the initial
inspection [13]. The cold pack was applied for 20 min, then re-
moved and the skin dried [14,15]. Immediately after cold appli-
cation all children received the following physical and
occupational programme for 2 h [16–18]. The cold therapy fol-
lowed by the physical and occupational programme was ap-
plied three times per week for a successive 3 months.
Physical and occupational therapy programme
All children participating in this study received the same phys-
ical and occupational therapy programme lasting for 2 h/ses-
sion, three sessions per week over a successive 3 months.
This programme included manual passive stretching for elbow
and wrist flexors, which was based on the passive range of mo-
tion (PROM) therapeutic exercises described by Kisner and
Colby [19]. The PROM consisted of moving the elbow, wrist,
fingers and thumb passively into extension and holding this
position for 60 s. This procedure was repeated five times giving
a total duration of 5 min. Hand weight bearing (HWB) exer-
cises for both upper limbs, as ROM exercises and as proprio-
ceptive training, were also applied from positions of sitting or
side sitting on a mat and/or sitting on a roll. Additionally, pro-
tective extensor thrust (PET) was provided from sitting on a
roll and prone on a ball to stimulate the extensor pattern of
the upper limbs. Furthermore, strengthening exercises for the
antispastic muscles (elbow and wrist extensors) using different
toys and motivation to encourage the child to perform the de-
sired exercises, were also part of our programme.
Exercises facilitating hand skill patterns included basic
reach, grasp, carry and release and the more complex skills
of in-hand manipulation and bilateral hand use. The child
sat on a chair-table and the therapist sat at the side to guide
and assist the child to perform the exercises correctly. The
exercises included the following:
– Reach with both hands and then by each hand for an object
presented at midline.
– Reach with 45 and 90 of shoulder flexion, neutral rotation
of humerus, elbow extension and forearm supination to mid
position.
– Reach across midline while keeping an erect trunk.
– Use a sustained palmer and pincer grasp with wrist
extension.
– Release objects into container at arm length from the child’s
body to encourage elbow and wrist extension.
– Use both hands together to push, carry or lift large object to
encourage elbow and wrist extension.
– Throw ball unilaterally or bilaterally to encourage the
extensor pattern of upper limbs.
Group II. Children in this group received only the same phys-
ical and occupational therapy programme given to group I
without the prior cold therapy.
Data analysis
Descriptive statistics of mean and standard deviation pre-
sented the children’s ages, MAS scores, ROM and fine motor
quotient (FMQ). Non-parametric tests (the Wilcoxon signed-
rank test and the Mann–Whitney test) were used to analyze
the pre- and post-treatment values of MAS and FMQ within
and between the groups. The paired and unpaired t-test was
used to compare the pre- and post-treatment values of ROM
of elbow extension and wrist extension within and between
the groups. A P-value of less than 0.05 was taken as
significant.
Results
Thirty children with spastic CP (18 with diplegia and 12 with
quadriplegia) were enrolled in this study. Twelve (40%) of
them were girls and 18 (60%) were boys. Their ages ranged
from 4 to 6 years. Both upper limbs were treated, but only
the dominant arm was included for analysis.
Spasticity
Comparison of the pre- and post-treatment MAS scores for
group I revealed a significant reduction in spasticity
(P = 0.0002) in 13 children while in the remaining two subjects
the scores remained constant. Comparison of the pre- and
post-treatment MAS score for group II showed a significant
reduction in spasticity (P = 0.002) in 10 of the children while
in the remaining five the scores remain unchanged. The analy-
sis between the groups, using the Mann–Whitney test, showed
no significant difference in the spasticity scores pre-treatment
Cold therapy in cerebral palsy 321
(P = 0.7992), while there was a significant difference in the
spasticity scores post-treatment in favour of group I
(P = 0.0143) (Table 1).
Range of motion
Range of motion was assessed using the electronic goniometer
according to the Norkin and White procedure [20]. Three rep-
etitions were performed at both the elbow and the wrist. We
concentrated on joint extension as extension is commonly
more problematic in spasticity than is flexion.
Comparisons of the pre- and post-treatment values of
ROM of elbow and wrist extension were made using the paired
t-test. The results showed a significant improvement in both
groups in elbow extension and wrist extension (P < 0.0001).
The analysis between the groups using the unpaired t-test
showed no significant difference in ROM of elbow and wrist
extension pre-treatment (P = 0.3793 and 0.6247, respectively),
while there was a significant difference in post-treatment values
of ROM of elbow and wrist extension between the groups in
favour of group I (P = 0.0003 and 0.0020, respectively)
(Tables 2 and 3).
Hand function
The Peabody Development Motor Scale was used to evaluate
the hand function for children in this study. Fine Motor Quo-
tient (FMQ), which is the most reliable score yielded by this
scale, was used to measure the changes in-hand function
(grasping and visual motor integration) after our intervention.
Comparison of the pre- and post-treatment values of FMQ,
using the Wilcoxon test, revealed a significant improvement
in both groups (P < 0.0001). The analysis of FMQ values
pre- and post-treatment between the groups, using the
Mann–Whitney test, revealed no significant difference in pre-
treatment results (P = 0.7061), while there was a significant
difference in the post-treatment results in favour of group I
(P = 0.0387) (Table 4).
Discussion
The results of this study showed a significant improvement in
both groups in all measuring variables (MAS for spasticity,
ROM of elbow and wrist extension, FMQ for hand function)
after 3 months of treatment. However, higher improvement
was achieved in group I in all measuring parameters. In agree-
ment with many reports [14,21–26], the results of this study
indicate that cold therapy is an acceptable method for the tem-
porary relief of spasticity. In addition the present study proved
that cold therapy is effective when combined with physical and
occupational therapy in reducing spasticity and improving
hand function in children with spastic CP.
In this study, it was intended to apply the cold therapy for
20 min on elbow and wrist flexors, aiming to gain significant
and long duration reduction in spasticity, as an adequate per-
iod of time was needed for subsequent ROM exercises and
training of fine motor skills without interference of spasticity.
In most of the children (n = 13), the spasticity reduced for 60–
90 min after cold application. This is supported by the findings
of Miglietta [24] who studied the effect of cooling on clonus in
40 spastic patients. He found that clonus had reappeared in
100% of patients 90 min after cold treatment stopped.
The results of this study showed a significant reduction in
spasticity in both groups, which may be due to stretching of el-
bow and wrist flexor muscles through manual passive stretch-
ing and hand weight bearing. Both provided continuous
stretching of those muscles, which led to fatigability of stretch
receptors and decreased its response to any stimulus; this also
led to breakdown of the contracture, which allowed more
lengthening of muscle fibres, which counteracts the effect of
spasticity. Moreover, approximation of the upper limb via
hand weight bearing inversed the proprioceptive reflex in the
Table 1 Statistical analysis of MAS (spasticity) scores within
each group and between groups.
Item Pre X ± SD Post X ±SD Z (Sum of ranks) P-Value
Group I 2.2 ± 0.53 1.33 ± 0.56 91 0.0002
Group II 2.13 ± 0.48 1.8 ± 0.65 55 0.0020
U 106 53
P 0.799 0.014
X: Mean; SD: standard deviation; U: Mann–Whitney U statistic.
Table 2 Statistical analysis of elbow extension within each
group and between groups.
Item Pre X ± SD Post X ±SD t-Value P-Value
Group I 78.9 ± 4.03 95.13 ± 5.94 19.536 0.0001
Group II 77.67 ± 3.74 87 ± 4.89 12.594 0.0001
t-Value 0.8933 4.097
P-Value 0.379 0.0003
X: mean; SD: standard deviation; t: Student t-test.
Table 3 Statistical analysis of wrist extension within each
group and between groups.
Item Pre X ± SD Post X ±SD t-Value P-Value
Group I 21.27 ± 5.93 6.8 ± 7.45 28.69 0.0001
Group II 22.3 ± 5.88 3.33 ± 8.81 15.39 0.0001
t-Value 0.494 3.401
P-Value 0.624 0.002
X: mean; SD: standard deviation; t: Student t-test.
Table 4 Statistical analysis of FMQ (hand function) within
each group and between groups.
Item Pre X ± SD Post X ±SD Z (Sum of ranks) P-Value
Group I 49.2 ± 2.651 55 ± 3.928 120 0.0001
Group II 48.8 ± 2.651 52 ± 2.535 120 0.0001
U 103 62.5
P 0.7061 0.0387
X: mean; SD: standard deviation; U: Mann–Whitney U statistic.
322 G.M. Abd El-Maksoud et al.
upper limb and added more inhibition to the spasticity in the
elbow and wrist flexors.
The post-treatment results of MAS revealed a significant
difference between the groups in favour of group I. This differ-
ence may be attributed to the effect of cold therapy on reduc-
ing spasticity. There are many possible underlying mechanisms
that explain how cold therapy reduces spasticity. The first
mechanism was explained by Eldred et al. [27], Ottosn [25],
and Knutsson and Mattsson [26] who reported that ice appli-
cation reduces muscle tone through a reduction of spindle sen-
sitivity. They found that the rate of spontaneous spindle
discharge decreases with decreasing temperature. Also, the rate
of discharge from the Golgi tendon organs was found to be
temperature-dependent. The change in discharge of the muscle
spindle may result from the effect of cold on extrafused muscle,
the intrafusal fibres or the sensory endings. Similarly,
Michlovitz et al. [28] stated that inhibition occurring due to
the use of cryotherapy may be due to the local cooling effect
on every component of the segmental sensorimotor complex,
including large afferent fibres of muscle spindles (both alpha
and gamma motoneurons), all skin receptors, extrafusal mus-
cle fibres and the myoneural junction. The second possible
mechanism is explained by Lippold et al. [29] who suggested
that the effect of cold application is related to the role of
change in membrane polarization. They found that hyperpo-
larization or low potassium concentration reduced or abol-
ished spindle discharge. Also, their findings are in agreement
with those of Eldred et al. [27] and associates who concluded
that the site of thermal effect is the sensory terminal itself
and is likely to be the result of change in membrane stability
similar to those included in axons by lowering the temperature.
Finally, Miglietta [24] reported that clonus and spasticity are
not abolished unless the muscle temperature drops signifi-
cantly. He mentioned the possibility that sympathetic fibres
stimulation by cold application not only produces vasocon-
striction but also decreases spindle sensitivity.
The results of this study revealed that most of the children
(13) treated with cold therapy had a significant reduction in
spasticity, while the remaining two children’s MAS scores re-
mained constant. It may be argued that these children had lit-
tle spasticity (grade 1+ on MAS) to remedy by cold therapy or
that the deep muscle cooling was not achieved and insufficient
cooling occurred. This agrees with Urbscheit et al. [30] who
investigated the changes in H-response and the Achilles tendon
jerk in hemiplegic patients after cold application. They found
that the hemiplegic patients responded differently. The author
suggested that local cooling might decrease, increase, or exert
no effect on the spasticity.
The results of this study support the findings of Warren
et al. [31] who concluded that deep prolonged and penetrat-
ing cold could be used in therapy to induce relaxation.
They attributed their findings to be due to lowering of
the background level of stretch afferent input. They re-
ported that deep cold (penetrating the muscle mass) pro-
duces cold block of the receptors or the afferent fibres
themselves.
The previous work of Price et al. [21] on the effect of cryo-
therapy on spasticity at the human ankle supports our results.
They established that cryotherapy has an effect on reducing
the path length, a parameter indicating the frequency depen-
dent viscoelastic response at the ankle. High values of path
length have been shown to be associated with the presence of
spasticity. They recommended the use of cryotherapy for 1 h
on the calf muscles aiming for spasticity reduction.
The results of this study confirm the findings of Lehman
and de Lateur [14] who reported that cold application has been
found useful to be used to reduce spasticity in upper motor
neuron lesion and in muscle re-education to facilitate muscle
contraction.
Regarding the ROM of elbow and wrist extension, there
was a significant improvement in both groups. Increases of
the extension of elbow and wrist joints may be due to reduc-
tion of flexors’ spasticity and strengthening of antagonistic
muscles. Reduction of spasticity in elbow and wrist flexors pro-
vided less resistance to lengthening those muscles during the
movement in the opposite direction, thus allowing more
ROM. This explanation is supported by Exner [32] who re-
ported that tightness of soft tissue found in spastic children
could restrict movement and reduce the child’s ability to exhi-
bit a normal ROM.
In addition, increases of the extension of elbow and wrist
may be attributable to protective extensor thrust that facili-
tated the whole extensor pattern of upper limb including elbow
and wrist extension. Moreover, hand weight bearing may also
have a role in improving elbow and wrist extension. This
agrees with Barnes [33] who found improvement of wrist
extension in children with CP after upper limb weight bearing.
Higher improvement of ROM of elbow and wrist exten-
sions in group I may be attributable to the effect of cold ther-
apy. Cold therapy reduced spasticity of elbow and wrist
flexors, which allowed the antagonistic muscles to work in
an opposite direction without restriction from spastic agonist.
Moreover, cold therapy reduced pain which encouraged the
child to achieve maximum ROM as much as possible during
strengthening exercises.
The results of this study agree with Knutsson [34] who
found that passive resistance to stretching the chilled muscle
was reduced and clonus was abolished. Also, he found that
the strength of chilled muscles did not increase, but that the
power of the antagonist was enhanced. The antagonist could
function better because it was unopposed by the spastic mus-
cles. Similarly, Lin [35] found that cold can facilitate increasing
the range of motion in a joint. Also, Lehmann et al. [36] re-
ported that in the management of spasticity, cold application
can decrease tendon reflex excitability and clonus, increase
ROM of the joints and improve the power of the antagonistic
muscle group.
Concerning hand function, there was a significant improve-
ment of FMQ in both groups. Improvement of hand function
in both groups may be due to the combined effect of the phys-
ical and occupational therapy programmes. Reduction of flex-
or spasticity and increase of ROM of elbow and wrist
extension, allowed the children to grasp and manipulate object
in a more skillful manner. This is confirmed by the opinions of
Brown et al. [37] and Francis et al. [38] who reported that
reducing arm spasticity is associated with significant improve-
ment in arm function.
Moreover, repetition of our occupational therapy pro-
gramme over a successive 3 months helped the children in this
study to improve their selective motor control and fine motor
skills. During this period, the children started to construct sen-
sory and motor memory about these skills that enabled them
to become more skillful. This explanation agrees with
Mclaughlin [39] who stated that repetitive activities guided
Cold therapy in cerebral palsy 323
by a therapist improve activities of daily living. This improve-
ment may be due to the lying down of new engrams through
repetitive activities.
Post-treatment results of FMQ (hand function) revealed a
significant difference between the groups in favour of group
I. This higher improvement may be attributable to the effect
of cold therapy that led to a temporary reduction of spasticity
for about 60–90 min. This enabled the therapist to promote
normal patterns of hand function and attempt to ‘‘break’’ the
learned abnormal motor patterns through continuous training
of fine motor skills. Moreover, improvement of fine skills was
attributable to higher improvement in wrist and elbow exten-
sion. This explanation is in agreement with O’Driscoll et al.
[40] who said that achieving the majority of manipulative skills
and good grip strength needs wrist extension.
Also, this study supports the work of Semenova et al. [41]
who studied interference and needle EMGs of the forearm
muscles after local cryotherapy application onto hands. They
found that the cryotherapy produced a reduction of spasticity
and increased the functional possibilities of the hand so that
the writing became possible.
Conclusion
The results of this study provide evidence that the combination
of cold therapy and conventional physical and occupational
therapy experienced by children with spastic cerebral palsy
can reduce spasticity and can translate into practical functional
gains in the hand function. Cooling was used to reduce spastic-
ity, enabling physical and occupational therapy training to be
initiated for appropriate motor skills learning without the
interfering spasticity. Finally, cold therapy is essential in pre-
paring children with spastic cerebral palsy for subsequent
physical and occupational therapy, which should be given
immediately following cold therapy application. Further stud-
ies are needed to evaluate the effect of cold therapy in combi-
nation with splints, and also with neuromuscular electrical
stimulation on hand function in children with spastic cerebral
palsy. Also, studying the effect of cold therapy on speed of
movement and hand function in children with dyskinesia is
needed.
Acknowledgements
The authors would like to express their appreciation to all the
children and their parents for their co-operation and participa-
tion in this study.
References
[1] Flett PJ. Rehabilitation of spasticity and related problems in
childhood cerebral palsy. J Paediatr Child Health
2003;39(1):6–14.
[2] Scheker LR, Chesher SP, Ramirez S. Neuromuscular electrical
stimulation and dynamic bracing as a treatment for upper-
extremity spasticity in children with cerebral palsy. J Hand Surg
[Br] 1999;24(2):226–32.
[3] Mehl-Madrona L. Cerebral palsy: an introduction
and overview; 2001. <http://www.healing-arts.org/children/cp/
cpoverview.htm>.
[4] Chin TY, Graham HK. Botulinum toxin A in the management
of upper limb spasticity in cerebral palsy. Hand Clin
2003;19(4):591–600.
[5] Young RR, Weigner AW. Spasticity. Clin Orthop Relat Res
1987;219:50–62.
[6] Glenn MB, Whyte J. The practical management of spasticity in
children and adults. Philadelphia: Lea & Febiger; 1990.
[7] Smith JB. Cryotherapy or cold therapy; 2009. <http://www.
articlesbase.com/health-articles/cryotherapy-or-coldtherapy-
910946.html>.
[8] Moberg-Wolff EA. Spasticity; 2003. <http://www.emedicine.
medscape.com/article/318994-overview>.
[9] Bohannon RW, Smith MB. Interrater reliability of a modified
Ashworth scale of muscle spasticity. Phys Ther 1987;67(2):
206–7.
[10] Friedman A, Diamond M, Johnston MV, Daffner C. Effects of
botulinum toxin A on upper limb spasticity in children with
cerebral palsy. Am J Phys Med Rehabil 2000;79(1):53–9, quiz
75–6.
[11] Folio MR, Fewell RR. Peabody development motor scale. 2nd
ed. Austin, TX: PRO-ED Inc.; 2000.
[12] Schmitz TJ. Sensory assessment. In: O’Sullivan SB, Schmitz TJ,
editors. Physical rehabilitation: assessment and
treatment. Philadelphia: F.A. Davis Company; 1994. p. 91.
[13] Robertson V, Ward A, Low J, Reed A. Electrotherapy
explained: principles and practice. 4th ed. Butterworth–
Heinemann; 2006.
[14] Lehman JF, de Lateur BJ. Therapeutic heat. In: Lehman JF,
editor. Therapeutic heat and cold. Baltimore, MD: Williams &
Wilkins; 1990. p. 563–602.
[15] Akinbo SR, Tella BA, Onunla AB, Temiye EO. Comparison of
the effect of neuromuscular electrical stimulation and
cryotherapy on spasticity and hand function in patients with
spastic cerebral palsy. Nig Med Pract 2007;51(6):128–32.
[16] Fox T, Lawson M, Jacobs M. The role of rehabilitation services
in the management of cognitive impaired resident. Paper
presented at: AMDA’s 30th annual symposium, Hollywood,
FL, March 29–April 1, 2007. <http://www.prolibraries.com/
amda/?select=session&sessionID=61>.
[17] Occupational therapy; 2010. <http://www.anthem.com/
medicalpolicies/guidelines/gl_pw_a051173.htm>.
[18] Lagalla G, Danni M, Reiter F, Ceravolo MG, Provinciali L.
Poststroke spasticity management with repeated botulinum
toxin injections in the upper limb. Am J Phys Med Rehabil
2000;79(4):377–84, quiz 391–4.
[19] Kisner C, Colby LA. Therapeutic exercise: foundations and
techniques. 4th ed. F.A. Davis Company; 2002.
[20] Norkin CC, White DJ. Measurement of joint motion: a guide to
goniometry. 2nd ed. Philadelphia: F.A. Davis; 1995.
[21] Price R, Lehmann JF, Boswell Bessette S, Burleigh A, de Lateur
BJ. Influence of cryotherapy on spasticity at the human ankle.
Arch Phys Med Rehabil 1993;74(3):300–4.
[22] Bell KR, Lehmann JF. Effect of cooling on H- and T-reflexes in
normal subjects. Arch Phys Med Rehabil 1987;68(8):
490–3.
[23] Lightfoot E, Verrier M, Ashby P. Neurophysiological effects of
prolonged cooling of the calf in patients with complete spinal
transection. Phys Ther 1975;55(3):251–8.
[24] Miglietta O. Action of cold on spasticity. Am J Phys Med
1973;52(4):198–205.
[25] Ottoson D. The effects of temperature on the isolated muscle
spindle. J Physiol 1965;180(3):636–48.
[26] Knutsson E, Mattsson E. Effects of local cooling on
monosynaptic reflexes in man. Scand J Rehabil Med
1969;1(3):126–32.
[27] Eldred E, Lindsley DF, Buchwald JS. The effect of cooling on
mammalian muscle spindles. Exp Neurol 1960;2(2):144–57.
324 G.M. Abd El-Maksoud et al.
[28] Michlovitz S, Smith W, Watkins M. Ice and high voltage pulsed
stimulation in treatment of acute lateral ankle sprains. J Orthop
Sports Phys Ther 1988;9(9):301–4.
[29] Lippold OC, Nicholls JG, Redfearn JW. A study of the afferent
discharge produced by cooling a mammalian muscle spindle. J
Physiol 1960;153:218–31.
[30] Urbscheit N, Johnston R, Bishop B. Effects of cooling on the
ankle jerk and H-response in hemiplegic patients. Phys Ther
1971;51(9):983–90.
[31] Warren CG, Lehman JF, Koblanski JN. Elongation of rat tail
tendon: effect of load and temperature. Arch Phys Med Rehabil
1971;52(10):465–74.
[32] Exner CE. Development of hand skills. In: Case Smith J, Allen
AS, Pratt PN, editors. Occupational therapy for children. St.
Louis, MO: Mosby; 1996. p. 268–306.
[33] Barnes KJ. Relationship of upper extremity weight bearing to
hand skills of boys with cerebral palsy. Occup Ther J Res
1989;9(3):143–54.
[34] Knutsson E. Topical cryotherapy in spasticity. Scand J Rehabil
Med 1970;2(4):159–63.
[35] Lin YH. Effects of thermal therapy in improving the passive
range of knee motion: comparison of cold and superficial heat
applications. Clin Rehabil 2003;17(6):618–23.
[36] Lehmann JF, Price R, de Lateur BJ, Hinderer S, Traynor C.
Spasticity: quantitative measurements as a basis for assessing
effectiveness of therapeutic intervention. Arch Phys Med
Rehabil 1989;70(1):6–15.
[37] Brown JK, van Rensburg F, Walsh G, Lakie M, Wright GW. A
neurological study of hand function of hemiplegic children. Dev
Med Child Neurol 1987;29(3):287–304.
[38] Francis HP, Wade DT, Turner Stokes L, Kingswell RS, Dott
CS, Coxon EA. Does reducing spasticity translate into
functional benefit? An exploratory meta-analysis. J Neurol
Neurosurg Psychiatry 2004;75(11):1547–51.
[39] Mclaughlin JF. Efficacy of selective dorsal rhizotomy in cerebral
palsy: changes in spasticity and neurological signs after 12
months. Dev Med Child Neurol 1996;38(Suppl. 74):33.
[40] O’Driscoll SW, Horii E, Ness R, Cahalan TD, Richards RR, An
KN. The relationship between wrist position, grasp size and grip
strength. J Hand Surg [Am] 1992;17(1):169–77.
[41] Semenova KA, Bubnova VA, Vinogradova LI, Tikunova NP.
Krioterapiia v komplekse vosstanovitel’nogo lecheniia detei s
detskimi tserebral’nymi paralichami [Cryotherapy in the
complex restorative treatment of children with infantile
cerebral palsy]. Zh Nevropatol Psikhiatr Im S S Korsakova
1986;86(10):1459–63.
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