Comparative study of different treatment Methods of rehabilitation in cerebral palsy Reda Mohmed Maged, Prof. Ghada Farag El-Dorry,and Prof. Ahmed Mohamed El-Kahky, Faculty of Postgraduate Childhood Studies.

Cerebral palsy, hyperbaric oxygen therapy, ozone, acupuncture

Comparative study of different treatment Methods of rehabilitation in cerebral palsy

Reda Mohmed Maged, Prof. Ghada Farag El-Dorry,and Prof. Ahmed Mohamed El-Kahky,

Faculty of Postgraduate Childhood Studies.

ABSTRACT

Background: Cerebral palsy is a major health problem caused by brain damage during pregnancy, delivery, or the immediate postnatal period. Cerebral palsy (CP) is generally considered as a nonprogressive condition. The goal of any treatment program for cerebral palsy is to maximize function and minimize the development of secondary problems.

Objective: The aim of this study is to compare different protocols management in cerebral palsy.

Subjects and Methods: The study included120 patients with CP of both genders, between 4 and 8 years of age, attending the Special Needs Care Center of the Faculty of Postgraduate Childhood Studies, Ain Shams University. The available patient's records used to select the sample, as well as written informed consents were obtained from parents. The children were classified into 4 groups. Group A: Included 30 children with cerebral palsy who received physiotherapy (PT) and occupational therapy (OT) as control group. Group B: Included 30 children with cerebral palsy who received physiotherapy (PT) and occupational therapy (OT) and hyperbaric oxygen therapy (HBOT). Group C: Included 30 children with cerebral palsy who received physiotherapy (PT) and occupational therapy (OT) and acupuncture. Group D: Included 30 children with cerebral palsy who received physiotherapy (PT) and occupational therapy (OT) and ozone. According to the protocol of each type of management.

All The children in all groups received the same specific designed physiotherapy (PT) and occupational therapy (OT) program.

Results: Physiotherapy (PT) and occupational therapy (OT) are very important methods in management of children with cerebral palsy, hyperbaric oxygen therapy HBOT have the best effect in management children with cerebral palsy CP more than other management protocols such as ozone and acupuncture.

Conclusion: Hyperbaric oxygen therapy HBOT have the best results in this study followed by ozone followed by acupuncture.

Keywords: Cerebral palsy, hyperbaric oxygen therapy, ozone, acupuncture

دراسة مقارنة للطرق المختلفة لعلاج الشلل الدماغى

الخلفیه: الشلل الدماغی هو اضطراب تطور النظام العصبی و یمکن أن یسبب الإعاقة الجسدیة فی الإنسان وهو مشکلة صحیة کبیرة بسبب تلف فی الدماغ أثناء الحمل والولادة، أو فترة ما بعد الولادة مباشرة. تعتبر الولادة المبکرة و نقص الوزن عند الولادة أهم الأسباب التى تؤدى إلى حدوث الشلل الدماغى. والهدف من أی برنامج لعلاج الشلل الدماغی هو تحسین الوظیفة والحد من تطویر المشاکل الثانویة، وبالتالی تأخیر أو تفادی الحاجة للتدخل الجراحی. و برنامج العلاج الفعال یقلل لیس فقط الحاجة لإجراء عملیة جراحیة، ولکن یعزز قدرة المریض لتوازن أفضل ، والمشارکة فی الأنشطة مع الأقران . استخدام العلاج بالأکسجین تحت الضغط فی الشلل الدماغی یقدم نهجا علاجیا جدیدا لعلاج الشلل الدماغی ویؤدى إلى حدوث تحسن فی وظیفة الحرکة و کذلک الوخز بالإبر والعلاج بالاوزون یعدا من الأمور المبشرة.

الهدف: الهدف من هذه الدراسة هو دراسة مقارنة للطرق المختلفة لعلاج الشلل الدماغى .

الأهمیة: إن الشلل الدماغی کان دائما معضلة للوالدین جنبا إلى جنب مع المتخصصین فى العلاج فى محاولة للوصول لأفضل طرق العلاج .علاقة الدراسة باهداف القسم :الوصول لأفضل اداء ممکن للأطفال المصابین بالشلل الدماغى هو من أهم أهداف القسم . حیث تهدف هذة الدراسة إلى التحقق من نتائج بعض الأسالیب الحدیثة فى علاج الشلل الدماغى .

نوع الدرسة :دراسة مقارنة .

الفرضیة :یعتبر استخدام العلاج بالأکسجین تحت الضغط العالى أفضل من الوخز بالإبر والعلاج بالاوزون فی علاج الشلل الدماغی .

المرضى: شملت الدراسة على 120 طفلا مصابا بالشلل الدماغی التقلصى من الذکور والإناث المتابعین فی العیادة الخارجیة بمرکز رعایة الأطفال ذوى الأحتیاجات الخاصة بکلیة الدراسات العلیا للطفولة، جامعة عین شمس . قد استمرت فترة العلاج لمدة 6 شهور تبعا للبروتوکول الخاص بکل نوع من انواع العلاج.

النتائج :استخدام الأوکسجین بالضغط العالی حقق أفضل النتائج یلیه استخدام الاوزون ثم الوخز بالابر، وان العلاج الطبیعی والعلاج الوظیفى مهم جدا فى علاج الأطفال المصابین بالشلل الدماغى.

Introduction

Cerebral palsy (CP) describes a group of permanent disorders of development, movement and posture, resulting in activity limitation. Cerebral palsy (CP) is a nonprogressive disease that presents as a disorder of motion and posture following brain injury during a period of development (Asl  et al., 2015).

Also, CP is generally considered as a nonprogressive condition resulting from neurological injury in the antenatal or perinatal period. Perinatal hypoxic-ischemic insult leads to cellular necrosis, neuronal inactivation and cerebral white matter injury are the most common causes of severe neurological handicaps in children with CP (Efrati and Ben-Jacob, 2014).

Cerebral palsy (CP) is a very common neural system development disorder that can cause physical disability in human (Zheng et al., 2012).

Cerebral palsy is a major health problem caused by brain damage during pregnancy, delivery, or the immediate postnatal period. Perinatal stroke, intraventricular hemorrhage, and asphyxia are the most common causes of neonatal brain damage. Periventricular white matter damage (periventricular leukomalacia) is the predominant form in premature infants and the most common antecedent of cerebral palsy (Titomanlio et al., 2011).

Hyperbaric oxygenation therapy (HBOT) has shown promise in clinical trials and is sought by many parents of children with cerebral palsy (CP). Evidence from around the globe is now accumulating providing strong support for the use of hyperbaric oxygen therapy (HBOT) as an approach to the actual underlying problem in children with cerebral palsy – a technique which actually targets the abnormalities of brain function. The use of hyperbaric oxygen therapy in cerebral palsy offers an exciting new therapeutic approach for the treatment of cerebral palsy (Lin et al., 2012).

Hyperbaric oxygen therapy (HBOT) is an interesting therapeutic modality defined as the use of oxygen at greater than atmospheric pressure as a drug to treat basic pathophysiologic processes and the associated diseases (Lacey et al., 2012).

Acupuncture with or without conventional therapy may have benefit in children with CP (Dabbous et al., 2016).

Scalp Acupuncture, also known as Neuroacupuncture, is a treatment based on knowledge of traditional acupuncture and neurology. It is done by inserting acupuncture needles into the loose areolar tissue layer of the scalp to stimulate the brain neurons of the underlying area. It’s a very safe treatment, since underlying area. It’s a very safe treatment, since the skull protects the brain and there are no organs in the scalp to injure it. Scalp Acupuncture works by stimulating the brain cells that are related to the impaired functions. The mechanism is three-fold: to ‘wake-up’ the brain cells that are not dead but lacking in proper functioning, to encourage recruitment of healthy brain cells to perform the lost function and to promote a healthy reintegration of the brain system . (Neoh Choo et al., 2017).

Aim of the work:

The aim of this study is to compare different protocols management in cerebral palsy rehabilitation.

Subjects and Methods:

Type of the study: comparative study to compare different protocols management in cerebral palsy.

Subjects:

The study included120 patients with CP of both genders, between 4 and 8 years of age, attending the Special Needs Care Center of the Faculty of Postgraduate Childhood Studies, Ain Shams University. The available patient's records used to select the sample, as well as written informed consents were obtained from parents.

All The children in all groups received the same specific designed physiotherapy (PT) and occupational therapy (OT) program.

The children were classified into 4 groups:

Group A: Included 30 children with cerebral palsy who received physiotherapy (PT) and occupational therapy (OT) as control group. Group B: Included 30 children with cerebral palsy who received physiotherapy (PT) and occupational therapy (OT) and hyperbaric oxygen therapy (HBOT). Group C: Included 30 children with cerebral palsy who received physiotherapy (PT) and occupational therapy (OT) and acupuncture. Group D: Included 30 children with cerebral palsy who received physiotherapy (PT) and occupational therapy (OT) and ozone. According to the protocol of each type of management.

Control Group: who received a designed physiotherapy (PT) and occupational therapy (OT) program directed towards improving gait pattern and walking balance three times/week for three hours/day for eight successive weeks. The children in control group received a specific designed physiotherapy (PT) and occupational therapy (OT) program only. Study Groups: who received the same designed physiotherapy (PT) and occupational therapy (OT) program given to the control group in addition to the protocol of each type of management.

Inclusion criteria:

Spastic cerebral palsy.

Ages between 4-8 years.

Patients who signed the consent form.

The degree of spasticity ranged from grade 1+ to 2 according to Modified Ashworth Scale. (Bohannon, and Smith1987).

They were able to follow simple verbal commands or instructions in both evaluation and treatment procedures.

Exclusion criteria:

Patients with any other co-morbid chronic illness.

Children with chronic illness affecting growth e.g. cardiac or renal disease.

Severe mental retardation

Cerebral palsy with loss of vision or hearing loss.

History of epilepsy.

Previously received any antispastic drugs and battox.

Ethical issues: Written informed consents were obtained from parents after explanation of the aim of the study and its benefits for their children.

Data Analysis

The data obtained was statistically analyzed. The mean and standard deviation were calculated for each variable, for all groups A, B, C and D before and after the application of management programs.

Results:

Table (1) Comparison between the studied groups A & B according to Gait Parameters and Modified Ashworth Scale after applying protocols.

NS: Non significant; S: Significant; HS: Highly significant

*: Chi-square test; •: Independent t-test

Table (2) Comparison between the studied groups A & C according to Gait Parameters and Modified Ashworth Scale after applying protocols.

NS: Non significant; S: Significant; HS: Highly significant

*: Chi-square test; •: Independent t-test

Table (3) Comparison between the studied groups A &D according to Gait Parameters and Modified Ashworth Scale after applying protocols.

NS: Non significant; S: Significant; HS: Highly significant

*: Chi-square test; •: Independent t-test

Table (4) Comparison of the studied cases in group A pre and post applying protocols.

NS: Non significant; S: Significant; HS: Highly significant

*: Chi-square test; •: Paired t-test

Table (5) Comparison of the studied cases in group B pre and post applying protocols.

NS: Non significant; S: Significant; HS: Highly significant

*: Chi-square test; •: Paired t-test

Table (6) Comparison of the studied cases in group C pre and post applying protocols.

NS: Non significant; S: Significant; HS: Highly significant

*: Chi-square test; •: Paired t-test

Table (7) Comparison of the studied cases in group D pre and post applying protocols.

NS: Non significant; S: Significant; HS: Highly significant

*: Chi-square test; •: Paired t-test

Discussion:

CP is generally considered as a nonprogressive condition resulting from neurological injury in the antenatal or perinatal period. Perinatal hypoxic-ischemic insult leads to cellular necrosis, neuronal inactivation and cerebral white matter injury are the most common causes of severe neurological handicaps in children with CP (Efrati and Ben-Jacob, 2014).

Children with cerebral palsy typically receive physiotherapy therapy to facilitate motor development and to enhance their independence in motor skills, Self-care ,play, and leisure activities. Over the years, many systems of treatment have been developed that differ in their specific treatment strategies, but aim to lead children with cerebral palsy toward the greatest degree of independence possible.

In our study, as regards the age, there was no statistical significant difference between the mean value of the 4 studied groups A,B, C & D, Which was 5.90 ± 1.16, 5.90 ± 1.20, 5.90 ± 1.20,and 5.90 ± 1.20 years respectively.

In our study, as regards the gender, there was no statistical significant difference between the percentages of the 4 studied groups. Group A was 12 (40%) female and 18 (60%) male, Group B 4 (40%) female and 6 (60%) male, Group C 5 (50%) female and 5 (50%) male and Group D 6 (60%) female and 4 (40%) male.

In our study, there was no statistical significant difference pre treatment between the 4 studied groups A,B, C & D regarding Gait Parameters (Step length, Stride length, Step width, and Foot progression angle) and Modified Ashworth Scale.

In group A (Control) there was statistical significant improvement in gait parameters and Modified Ashworth scale. There was high statistical significant difference between pre and post treatment regarding Step length, Stride length, Step width, Foot progression angle and Modified Ashworth scale.

In group B there was statistical significant improvement in gait parameters. There was high statistical significant difference between pre and post treatment regarding Step length, Stride length, Step width and Modified Ashworth scale.

In group C there was statistical significant improvement in gait parameters. There was high statistical significant difference between pre and post treatment regarding Stride length, Step width, Foot progression angle.

In group D there was statistical significant improvement in gait parameters. There was high statistical significant difference between pre and post treatment regarding Step length, Stride length, Step width, and Foot progression angle.

In our study, In Comparison between the post treatment of studied groups A, B, C, and D according to Step length there was more improvement in groups Band C.

In our study, In Comparison between the post treatment of studied groups A, B, C, and D according to Stride length there was more improvement in group B.

In our study, In Comparison between the post treatment of studied groups A, B, C, and D according to Step width there was more improvement in group B.

In our study, In Comparison between the post treatment of studied groups A, B, C, and D according to Foot progression angle there was more improvement in group B.

In our study, there was no statistical significant difference post treatment between the 4 studied groups A, B, C & D regarding Modified Ashworth Scale. There was more improvement in groups A and B.

In agreement of our study, hyperbaric oxygen therapy (HBOT) is an interesting therapeutic modality defined as the use of oxygen at greater than atmospheric pressure as a drug to treat basic pathophysiologic processes and the associated diseases (Lacey et al., 2012).

As HBOT can initiate vascular repair and improve cerebral vascular flow, induce regeneration of axonal white matter, stimulate axonal growth, promote blood-brain barrier integrity and reduce inflammatory reactions as well as brain edema (Huang and Obenaus, 2011).

At the cellular level, HBOT can improve cellular metabolism, reduce apoptosis, relieve oxidative stress and increase levels of neurotrophins and nitric oxide through improving mitochondrial function in both neurons and glial cells and may even promote neurogenesis of endogenous neural stem cells (Lin et al., 2012).

Efrati and Ben-Jacob (2014),who mentioned that some weeks would be necessary for brain tissue regeneration and angiogenesis and they also reported that the brain of the child with cerebral palsy suffered from neurological insult since birth, so it would take time for the brain repair to become clinically apparent.

The sooner the ozone therapy is started the better, because there is no hope of reviving dead neurons. Controlled administration of ozone can be helpful (Bocci, 2007).

Acupuncture treatment for cerebral palsy is still considered relatively new. Only a few in-depth studies have been done, but the results so far have been positive. (Neoh Choo et al., 2017).

Western medical science so far has not found a proven explanation for the success of Chinese scalp acupuncture in treating central nervous system disorders and specifically with treating cerebral palsy. There is a growing amount of clinical evidence that scalp acupuncture can improve or remove symptoms in patients with cerebral palsy (Lin et al., 2012).

Conclusion:

Hyperbaric oxygen therapy HBOT have the best results in this study followed by ozone followed by acupuncture.

Physiotherapy (PT) and occupational therapy (OT) are very important methods in management of children with cerebral palsy

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