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Efficacy of cold therapy on spasticity and hand function in children with cerebral palsy

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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 6years (mean age 62.2±7.5months) participated in this study. They had mild to moderate spasticity in elbow and wrist flexors. Children were randomly 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 successive 3months. 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 Peabody 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 a more significant improvement. It can be concluded that cold therapy in conjunction with conventional physical and occupational therapy significantly reduced spasticity, increased ROM and improved hand function in children with spastic CP.
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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.
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Cold therapy in cerebral palsy 325
... Of the 30 participants involved in this present study, there was a preponderance of females compared with males (ratio 2.3:1). This finding is not in line with those found in previous similar studies 6,27,28 where males were found to predominate. No obvious explanation could be given for the predominance of females compared with males in this study. ...
... They reported that majority (63.4%) of their participants were aged 2 years and below. Other similar previous studies 14, 16,27,29,30 have also presented contrasting reports of age distribution, which are attributable to difference in inclusion criteria of participants. The findings that most participants in this study were older than 2 years may partly be due to the fact that Abbreviations: GMFCS, Gross Motor Function Classification System; X ± SD , mean ± standard deviation. ...
Article
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Introduction. Cerebral palsy (CP) is caused by an injury to the developing brain, and abnormal gross motor function is a hallmark of CP. Properly structured exercises on land have been reported to be effective in improving functional performance in children with CP while only few have been documented on aquatic therapy. Objective. To investigate the effect of a 10-week aquatic exercise training program on gross motor function in children with spastic CP. Methods. Thirty participants aged 1 to 12 years were randomized into the experimental and control groups. Both groups received manual passive stretching and functional training exercises, depending on their level of motor impairment, either in water (temperature 28°C to 32°C) or on land. Each exercise training session lasted for about 1 hour 40 minutes, twice per week for 10 weeks in both groups. Measurement of gross motor function was done using Gross Motor Function Measure (GMFM-88) at baseline and after 4 weeks, 8 weeks, and 10 weeks of intervention. Both groups were compared for differences in change in gross motor function using Mann-Whitney U test. The level of significance was set at P < .05. Results. Only the experimental group showed significant improvement ( P < .05) in all dimensions of gross motor function except for walking, running, and jumping ( P = .112). Statistically significant difference ( P < .05) was found between both groups for all dimensions of gross motor function after 10 weeks of intervention. Conclusion. Aquatic exercise training program is effective in the functional rehabilitation of children with spastic CP.
... There are several potential causal mechanisms to understand how cold therapy decreases spasticity. The first step has been described by Eldred et al. [19] , Ottosn [11], Knutsson and Mattsson [20] . Those researchers reported that the application of ice reduces the muscle tone by reducing the sensitivity of the spindle. ...
Article
Full-text available
Ice application has thought to reduce spasticity presented in upper motor neuron lesions in children and adults. Objectives was investigate the effect of prolonged ice application on the spastic muscle versus brief ice application on the antispastic muscles on the degree of muscle spasticity and kinematic gait parameters in children with spastic hemiplegic cerebral palsy (CP). Thirty children with spastic hemiplegic CP participated in this study. They were randomly assigned into two equal groups. Group A involved 15 children who received cryotherapy (ice pack) to the spastic muscles (calf muscles and wrist flexors) for 20 successive minutes. Group B involved 15 children who received cryotherapy (ice pack) to the antagonist muscles for the antispastic muscles (dorsiflexors and wrist extensors) for 10 seconds/20 seconds for 10 minutes. The study continued for two successive months for each child. The Modified Ashworth Scale was used for assessing the muscle tone before and after the treatment period. Kinematic gait analysis (3D motion analysis) was carried out before and after the interventions to assess the kinematic gait parameters. Mixed design Multivariate Analysis of Variance (MANOVA) revealed that stride length, speed, and ankle joint angle at initial contact increased significantly (p<0.05) while the cadence, wrist flexors and ankle plantar flexors spasticity decreased significantly after treatment compared with the pre-treatment condition for patients within group A, while patients within group B showed non-significant improvements. By comparing the post-treatment values of all the measured variables between both groups, the tests revealed significant effects in all the measured variables for the favor of group A. In conclusion, Prolonged cryotherapy application to the spastic muscles is more effective than brief cryotherapy application to the antagonist muscles in reducing muscle spasticityand improving gait pattern in children with spastic hemiplegic cerebral palsy.
... Furthermore, the pain score in the cryotherapy group decreased, which can be concluded that both cryotherapy and heat therapy was effective in reducing back pain in patients, which is in line with the findings of the present study (17). Abd El-Maksoud et al. performed a study entitled "The Effect of Cryotherapy on Spasticity and Hand Function in Children with Cerebral Palsy" and concluded that using the spasticity ice bag increased the range of motion and improved motor function (18). ...
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Full-text available
Background: Restless legs syndrome is a neurological disorder in hemodialysis patients that causes disturbance and disability in rest, discomfort, sleep disturbance, fatigue, and stress. Objectives: This study was done to evaluate the effect of cold water bags on the severity of restless leg syndrome and sleep quality in hemodialysis patients. Methods: This is a quasi-experimental study (before and after) performed on patients referring to three hospitals in Yazd province. In this study, 40 patients with restless legs syndrome were selected from all patients who were referred to the hemodialysis ward by simple random sampling. The samples completed the Restless Legs Syndrome Symptoms Severity Questionnaire before and after using the cold water bag. Data were analyzed by SPSS 20 software and descriptive statistics and paired t-test at the significance level of < 0.05. Results: This study showed a significant difference between the mean score of restless leg syndrome and sleep quality before and after the interventions (P = 0.000). Furthermore, the mean scores of restless leg syndrome and sleep quality were different between the two intervention groups and statistically significant (P = 0.000). Conclusions: Based on the results, using a water bag reduces the symptoms of restless leg syndrome. Therefore, it is suggested that cold water bags should be used as an effective, safe, low-cost method.
... then, it should be removed, and the skin should be dried. If a child's skin is sensitive to cold, cold therapy should never be used (16). A heating pad increases muscle elasticity and causes the muscle to relax. ...
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Full-text available
With the outbreak of the novel pandemic coronavirus disease 2019 worldwide, numerous pediatric rehabilitation clinics have closed to support social and physical distancing, and therapists similar to other individuals are staying at their homes. There is a common concern of parents and caregivers that how and with what quality children's rehabilitation exercises should proceed. Most children with neurological diseases have problems, such as muscle spasticity, range of motion (ROM) limitation, muscle shortening, balance loss, and mobility and movement impairments. The normalization of muscle tone, preservation of ROM, muscle stretch, and improvement of fine and gross motor skills and balance are essential activities that need to be considered. Therefore, this study aimed to summarize the necessities of a home-based rehabilitation exercise program during the quarantine period.
... CP is a set of non-progressive postural and motor dysfunction syndromes [10] .Occurrence varies between 2-3 per 1000 live births [11] ,It is believed to be leading aetiology of major bodily impairment in children [12] . ...
Article
The greatest substantial consequence of juvenile impairment is cerebral palsy (CP). Spasticity of numerous muscle groupings is common after Central Nervous System damage. Spasticity causes functioning issues. For individuals suffering from CP ankle anomalies seem strongly tied to workable limits. Spastic CP is highest frequent type of CP, which limits child's responsive status and prohibits them from participating in communal activities. Soft tissue mobilisation procedures would be used in variety ways. Cryotherapy is interventional method for stiffness in neurological patients that has narrow advantage. MFR can potentially utilised against spasticity. The focus of this investigation is to evaluate Cryotherapy and MFR influence over calf muscle stiffness in participants who have Spastic Diplegic CP. The survey's goal is to determine efficacy of Cryotherapy and MFR in calf muscle spasticity in Spastic diplegic CP subjects. Thirty individuals suffering spastic diplegic CP were chosen using randomized sampling procedure. The subjects was categorised onto 3 subgroups, each of ten individuals. Cryotherapy was applied to Group A, MFR was applied to B and C Group was applied with combination of cryotherapy and MFR. Both before and after therapy, MAS and goniometry are used to assess calf muscle spasticity and ankle PROM. Overall validity of MAS and PROM comparing before and after in subgroup was determined using Tukey Test. Spasticity was reduced and range of motion was improved (p<0.05) in intra group comparison. Cumulative influence of cryotherapy and MFR is beneficial in reducing calf muscle stiffness in spastic diplegic CP children, as per this investigation.
... There are several potential causal mechanisms to understand how cold therapy decreases spasticity. The first step has been described by Eldred et al. [19] , Ottosn [11], Knutsson and Mattsson [20] . Those researchers reported that the application of ice reduces the muscle tone by reducing the sensitivity of the spindle. ...
Article
Full-text available
Ice application has thought to reduce spasticity presented in upper motor neuron lesions in children and adults. Objectives was investigate the effect of prolonged ice application on the spastic muscle versus brief ice application on the antispastic muscles on the degree of muscle spasticity and kinematic gait parameters in children with spastic hemiplegic cerebral palsy (CP). Thirty children with spastic hemiplegic CP participated in this study. They were randomly assigned into two equal groups. Group A involved 15 children who received cryotherapy (ice pack) to the spastic muscles (calf muscles and wrist flexors) for 20 successive minutes. Group B involved 15 children who received cryotherapy (ice pack) to the antagonist muscles for the antispastic muscles (dorsiflexors and wrist extensors) for 10 seconds/20 seconds for 10 minutes. The study continued for two successive months for each child. The Modified Ashworth Scale was used for assessing the muscle tone before and after the treatment period. Kinematic gait analysis (3D motion analysis) was carried out before and after the interventions to assess the kinematic gait parameters. Mixed design Multivariate Analysis of Variance (MANOVA) revealed that stride length, speed, and ankle joint angle at initial contact increased significantly (p<0.05) while the cadence, wrist flexors and ankle plantar flexors spasticity decreased significantly after treatment compared with the pre-treatment condition for patients within group A, while patients within group B showed non-significant improvements. By comparing the post-treatment values of all the measured variables between both groups, the tests revealed significant effects in all the measured variables for the favor of group A. In conclusion, Prolonged cryotherapy application to the spastic muscles is more effective than brief cryotherapy application to the antagonist muscles in reducing muscle spasticityand improving gait pattern in children with spastic hemiplegic cerebral palsy.
... O efeito do frio permanece, após sua aplicação, por cerca de 30 minutos a 2 horas, servindo como um meio facilitador da cinesioterapia. Sua aplicação pode ser administrada de três formas diferentes: a imersão em água fria, bolsas de gelo ou deslizamento de cubos de gelo sobre a pele e Sprays de evaporação, como o cloreto de etila 7,48 . ...
Article
Introdução: A espasticidade é uma alteração do tônus muscular, bastante comum na prática clínica, e que, associada à outros sintomas, resulta em limitações importantes para os pacientes. Existe uma grande variedade de métodos para tratamento deste sintoma, contudo, ainda há uma escassez de estudos voltados para identificação de quais as melhores e mais efetivas modalidades de tratamento. Objetivo: Levantar e discutir as diversas modalidades de tratamento disponíveis na atualidade, apontando os melhores resultados com a aplicação destes recursos terapêuticos na prática clínica. Métodos: Realizou-se uma busca nas bases de dados PubMed, MEDLINE, Periódicos CAPES e Google Acadêmico no período compreendido entre 2005 e 2016, através dos descritores espasticidade (spasticity) e tratamento (treatment). Resultados: Foram encontradas as seguintes modalidades de tratamento: farmacológico (baclofeno, benzodiazepínicos, dantrolene sódico, gabapentina, tizanidina, toxina botulínica tipo A e fenol); fisioterapêutico (eletroestimulação, cinesioterapia, crioterapia, termoterapia, fisioterapia aquática, terapia vibratória e equoterapia); cirúrgico (rizotomia, tenotomia e transposição tendinosa); e órteses. Conclusões: Da ampla variedade de tratamentos destaca-se o uso da toxina botulínica tipo A, apresentando bons resultados e poucos efeitos colaterais, porém, o alto custo e a curta duração dos efeitos são limitações importantes. Merece destaque ainda, a cinesioterapia através das técnicas de alongamento como uma importante opção de tratamento da espasticidade, com efeitos imediatos da aplicação e por tratar-se de um procedimento simples e fácil. Muito embora, ainda não estejam claras as recomendações quanto ao número de repetições, amplitude de movimento realizado, tipo de alongamento e tempo do efeito terapêutico da técnica.
... Their parents were informed of the study objectives and protocol and provided written consent. The children who met the following criteria were enrolled in this study: diagnosis of hemiplegic CP; age 6-12 years; mild to moderate degree of spasticity in the elbows and wrist flexors; grade 1þ to grade 3 on the Modified Ashworth Scale; Manual Ability Classification System (MACS) level of 1-3; able to sit alone or with support; and sufficient cognition to allow them to follow simple verbal commands and instructions during the assessment and treatment process (Abd El- Maksoud et al. 2011). The children were excluded from the study if they had: health problems not associated with CP; sensory deficits (fine touch and/or proprioception) leading to neglect of the affected limb; severe cognitive, visual, or auditory problems (reviewed from medical records)that would interfere with the intervention or testing; severe increased muscle tone (Modified Ashworth Scale score >3); orthopaedic surgery on the involved upper extremity; dorsal rhizotomy; botulinum toxin therapy in the upper extremity musculature during the past 6 months or desire to receive it within the study period; alcohol or phenol injection into the upper limbs; and intrathecal baclofen. ...
Article
Abstract Purpose: Transcutaneous electrical nerve stimulation (TENS) is a nonpharmacological method used to reduce spasticity. It was also assumed that TENS reduces pain and therefore improves limb function. Most of the previous studies about the effect of TENS were done in the lower limb and in stroke patients. There is a lack of enough literature about the direct and indirect effects of TENS in the upper limb. Hence, our study aimed to determine whether TENS combined with therapeutic exercises helps to improves hand function by reducing spasticity in children with hemiplegic cerebral palsy (CP). Materials and methods: Twenty-nine children with hemiplegic CP were randomly assigned to the TENS group (n = 15) or the control group (n = 14). The TENS group received traditional physical therapy with the adjunct application of conventional TENS for 30 minutes (pulse duration, 250 µs; pulse rate, 100 Hz) on the wrist extensors, once daily, 3 days a week, for 8 weeks, while the control group received traditional physical therapy. Results: The results showed a significant intergroup difference in handgrip strength over the 8-week period. The time to accomplish the Jebsen Taylor Hand Function Test (JTHFT) task decreased by 48% and the ABILHAND-Kids questionnaire scores improved by 23% in the TENS group. Conclusions: The use of TENS in combination with therapeutic exercise may improve strength and hand function. Keywords: Hemiplegic cerebral palsy, transcutaneous electrical nerve stimulation, hand function, grip strength
Article
Full-text available
Background: Play therapy is now considered an important part of physical therapy programs in children with cerebral palsy. Objective: The purpose of this study was to investigate the effectiveness of play therapy along with conventional physical therapy on gross manual dexterity in children with spastic hemiparetic cerebral palsy. Participants and Methods: 30 children with spastic hemiparetic cerebral palsy were divided into two equal groups; a control group received conventional physical therapy and a study group received play therapy in addition to the conventional physical therapy. The treatment was given 3 days per week for 6 successive weeks for both groups. Box and Block Test was used to measure gross manual dexterity of the affected upper extremity before as well as after intervention. Results: There is a non-significant difference between the control and study groups before as well as after intervention. However, there is a significant difference in each group when comparing between pre and post measures. The percentage of improvement in the gross manual dexterity is about 16.7% in the control group and about 46.4% in the study group. Conclusion: Play therapy combined with the conventional physical therapy may have a significant effect in improving gross manual dexterity in children with spastic hemiparetic cerebral palsy.
Article
Background: Physical therapy modalities are often applied in treatment of neurological conditions in children and adolescents. Objective: Evaluation of the methodological quality of research focusing on application of physical therapy modalities in children and adolescents with neurological conditions. Methods: Papers published between 2007 and 2018 were included in the review. 149 papers were analyzed and finally 26 studies investigating the use of physical therapy modalities in children and adolescents with neurological conditions were included in the review. Jadad scale (0-5) was used to assess the methodological value of the studies. Results: The mean Jadad score was 1.46 (researcher 1) and 1.38 (researcher 2). A score of 0 was awarded to nine (r1) and eight papers (r2). The score of five points was awarded to three (r1) and two papers (r2). Conclusion: 1. The evidence showing the effectiveness of the use of physical therapy modalities is mainly of low quality. 2. The Jadad scale is a valuable tool to assess the quality of research, although it does not always reflect the real value in the case children participate in studies. 3. The analyzed studies show that physical therapy modalities are effective in the treatment of children and adolescents with neurological disorders.
Article
The purpose of this study was to obtain data concerning the relationship between a commonly used treatment technique-weight bearing on extended arms-and the reach, grasp, and release skills of 3 boys with spastic cerebral palsy. A multiple-baseline, across-subjects research design was used. With the possible exception of the results for one arm of 1 subject, the results indicated that the technique had a positive relationship with the prehension skills of the 3 boys. Direct and systematic replication is warranted to determine the generalizability of this technique. Although the results of studies of isolated techniques, such as weight bearing on upper extremities, cannot be generalized to total treatment procedures, they do provide tentative support for the use of commonly used techniques and direction for studies of total treatment approaches.
Article
Children with cerebral palsy (CP) often demonstrate poor hand function due to spasticity. Thus spasticity in the wrist and finger flexors poses a great deal of functional limitations. This study was therefore designed to compare the effectiveness of Cryotherapy and Neuromuscular Electrical Stimulation (NMES) on spasticity and hand function in patients with spastic CP. Thirty eight subjects aged 4 to 15 years with diagnosis of mild to moderate spastic CP participated in the study. Twenty of the subjects met the inclusion criteria of the study and were randomly assigned to two groups (A & B) with equal subjects number in each group. Group A were treated with cryotherapy and passive stretching and Group B, treated with NMES and passive stretching. The subjects were treated 3 times a week for 6 weeks. Spasticity and hand function were assessed pre-treatment and post-treatment using the Modified Ashworth Scale (MAS) and the Zancolli classification respectively. The results showed that 7 and 3 subjects in group A respectively and B had a significant reduction in spasticity respectively; while 7 and 8 subjects in group A and B respectively had a significant improvement in hand function. Cryotherapy and NMES were found to be effective and generally well tolerated by the patients. The study revealed that cryotherapy was not superior to NEMS and vice versa in the treatment of patients with spastic CP.
Article
The effect of gradual cooling on discharge from sensory receptors in the gastrocnemius muscle of the cat has been studied. Either the entire muscle as it lay in an oil pool or the vicinity only of individual sensory organs was cooled 10 to 15° C below normal body temperature as monitored by a thermocouple inserted into the muscle. Slowing, in general, occurred in the discharge of deefferented annulospiral, flower-spray and tendon organ afferents, identified by conduction rates of individual units and characteristic patterns of response. The firing from spindles decreased at all tensions above that needed to sustain a steady discharge, with greater absolute decreases at higher tensions. Relative to control rates, annulospiral endings were probably affected more than flower-spray ones. The discharge from spindles having intact efferent innervation was also slowed.Alterations in central excitability may result from changes in afferent discharge produced by cooling of calf muscles. In decerebrate cats paralyzed with gallamine, monosynaptic reflexes elicited by submaximal stimulation of the severed lateral gastrocnemius nerve were reduced when the medial gastrocnemius muscle of the otherwise denervated leg was cooled. Decerebrate rigidity in the triceps surae muscle also decreased with cooling.