SEREBRAL PALSİLİ ÇOCUKLARDA KAS İÇİ GERME İLE PASİF GERME YÖNTEMLERİNİN SPASTİSİTE ÜZERİNE AKUT ETKİLERİ

Öz

Amaç: Serebral palsi (SP) rehabilitasyonunda spastisiteyi azaltma amacıyla birçok yöntem kullanılır. Bu yöntemlerden birisi de germe uygulamalarıdır. Bu çalışmanın amacı bilateral spastik tip SP’li çocuklarda kas içi germe ve pasif germenin spastisite üzerine akut etkilerini karşılaştırmaktı. Yöntem: Çalışmamıza 5-13 yaş arasında (12 erkek ve 10 kız çocuk, ortalama yaş=6,45±1,96 yıl), plantar fleksör kaslarında spastisitesi olan, bilateral spastik tip SP’li çocuklar dâhil edildi. Tüm çocuklara kişiye özel fizyoterapi programı uygulanmaktaydı. Çocukların fizyoterapi programına ek olarak bir taraf plantar fleksör kas grubuna kas içi germe uygulanırken, diğer taraf plantar fleksör kas grubuna pasif germe uygulandı. Spastisite değerlendirmeleri Modifiye Ashworth Skalası (MAS), Modifiye Tardieu Skalası (MTS) ve Silfverskiold testi ile yapıldı. Değerlendirmeler uygulamalardan önce ve sonra yapıldı ve iki taraf değerleri birbiri ile karşılaştırıldı. Sonuçlar: Tedavi öncesi ve sonrası değerleri karşılaştırıldığında kas içi germe yapılan tarafta (MAS p=0,024, MTS R2-R1 p<0,001, Silfverskiold test p=0,002) ve pasif germe yapılan tarafta (MAS p=0,014, MTS R2-R1 p=0,001, Silfverskiold test p=0,003) anlamlı fark görüldü. Ancak iki taraf arasında anlamlı fark yoktu (p>0,05). Tartışma: Bilateral spastik tip SP’li çocuklarda kas içi germe ve pasif germe yöntemleri spastisiteyi azaltmakta etkili yöntemlerdir ve akut etkileri benzerdir.

Anahtar Kelimeler

• Serebral Palsi
• Masaj
• Kas Spastisitesi
• Kas Germe Egzersizleri
• Kas Tonusu

ACUTE EFFECTS OF INTRAMUSCULAR STRETCHING AND PASSIVE STRETCHING ON SPASTICITY IN CHILDREN WITH CEREBRAL PALSY

Abstract

Purpose: Several methods are used to reduce spasticity in cerebral palsy (CP) rehabilitation. One of these methods is stretching. This study aimed to compare the acute effects of intramuscular stretching and passive stretching on spasticity in children with bilateral spastic CP.
Methods: The study included a total of 22 children (12 boys and 10 girls) with bilateral CP, between the ages of 5 and 13 years (mean age=6.45±1.96 years), who had spasticity in the plantar flexor muscle groups. All children were under an individualized physiotherapy program. In addition to the physiotherapy program, intramuscular stretching was applied to the plantar flexor muscles on one side, whereas passive manual stretching was applied to the other side. The Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), and Silfverskiold test were used to assess the spasticity. Evaluations were performed before and after the applications.
Results: There was a significant difference between pre and post-treatment comparisons in the intramuscular stretching side (MAS p=0.024, MTS R2-R1 p<0.001, Silfverskiold test p=0.002) and the passive stretching side (MAS p=0.014, MTS R2-R1 p=0.001, and the Silfverskiold test p=0.003). On the other hand, there was no difference between the intramuscular and passive stretching sides (p>0.05).
Conclusion: Both intramuscular and passive stretching are effective methods for reducing spasticity in children with bilateral spastic CP, and their acute effects are similar.

Keywords

• Cerabral Palsy
• Massage
• Muscle Spasticity
• Muscle Stretching Exercises
• Muscle Tone

References

1. 1. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007;109:8-14. 2. Surveillance of cerebral palsy in Europe. Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE). Dev Med Child Neurol. 2000;42(12):816-24.
2. 3. Hagglund G, Wagner P. Development of spasticity with age in a total population of children with cerebral palsy. BMC Musculoskelet Disord. 2008;9:150.
3. 4. Guissard N, Duchateau J. Neural aspects of muscle stretching. Exerc Sport Sci Rev. 2006;34(4):154-8.
4. 5. Sanger T. D, Delgado MR, Gaebler-Spira D, Hallett M, Mink JW. Classification and definition of disorders causing hypertonia in childhood. Pediatrics. 2003;111(1):e89-97.
5. 6. Beckung E, Hagberg G. Neuroimpairments, activity limitations, and participation restrictions in children with cerebral palsy. Dev Med Child Neurol. 2002;44(5):309-16.
6. 7. Priori A, Cogiamanian F, Mrakic-Sposta S. Pathophysiology of spasticity. Neurol Sci. 2006;27(4):s307-s9.
7. 8. Vattanasilp W, Ada L, Crosbie J. Contribution of thixotropy, spasticity, and contracture to ankle stiffness after stroke. J Neurol Neurosurg Psychiatry. 2000;69(1):34-9.
8. 9. Mohagheghi AA, Khan T, Meadows TH, Giannikas K, Baltzopoulos V, Maganaris CN. (2007). Differences in gastrocnemius muscle architecture between the paretic and non-paretic legs in children with hemiplegic cerebral palsy. Clin Biomech. 2007;2(6):718-24.

9. 10. Booth CM, Cortina-Borja MJ. Theologis TN. Collagen accumulation in muscles of children with cerebral palsy and correlation with severity of spasticity. Dev Med Child Neurol. 2001;43(5):314-20.
10. 11. Dabney KW, Lipton GE, Miller F. Cerebral palsy. Curr Opin Pediatr. 1997;9(1):81-8.
11. 12. Flett PJ. Rehabilitation of spasticity and related problems in childhood cerebral palsy. J Paediatr Child Health. 2003;39(1):6-14.
12. 13. Smania N, Picelli A, Munari D, Geroin C, Ianes P, Waldner A, Gandolfi M. Stretching exercises create mechanical changes in the musculotendinous unit, reducing spindle sensation and gamma activity, relieving muscle tension and reducing susceptibility. Eur J Phys Rehabil Med. 2010;46;423-38.
13. 14. Theis N, Korff T, Mohagheghi AA. Does long-term passive stretching alter muscle-tendon unit mechanics in children with spastic cerebral palsy? Clin Biomech. 2015;30(10):1071-6.
14. 15. Pin T, Dyke P, Chan M. The effectiveness of passive stretching in children with cerebral palsy. Dev Med Child Neurol. 2006;48(10):855-62.
15. 16. Macgregor R, Campbell R, Gladden MH, Tennant N, Young D. Effects of massage on the mechanical behaviour of muscles in adolescents with spastic diplegia: a pilot study. Dev Med Child Neurol. 2007;49(3):187-91.
16. 17. Malila P, Seeda K. Machom S. Eungpinithpong W. Effects of Thai Massage on Spasticity in Young People with Cerebral Palsy. J Med Assoc Thai. 2015;5:S92-6.
17. 18. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E. and Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39, 214-223.
18. 19. Fosang AL, Galea MP, McCoy AT, Reddihough DS, Story I. Measures of muscle and joint performance in the lower limb of children with cerebral palsy. Dev Med Child Neurol. 2003;45(10):664-70.
19. 20. Mehrholz J, Wagner K, Meissner D, Grundmann K, Zange C, Koch R, Pohl M. Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study. Clin Rehabil. 2005;19(7):751-9.
20. 21. Berweck S, Heinen F. Treatment of Cerebral Palsy with Botulinum Toxin A - Principles, Clinical Practice, Berlin: Child&Brain; 2003.
21. 22. Bovend'Eerdt TJ, Newman M, Barker K, Dawes H, Minelli C, Wade DT. The effects of stretching in spasticity: a systematic review. Arch Phys Med Rehabil. 2008;89(7):1395-406.
22. 23. Tremblay F, Malouin F, Richards CL, Dumas F. Effects of prolonged muscle stretch on reflex and voluntary muscle activations in children with spastic cerebral palsy. Scand J Rehabil Med. 1990;22(4):171-80. 24. O'Dwyer N, Neilson P, Nash J. Reduction of spasticity in cerebral palsy using feedback of the tonic stretch reflex: a controlled study. Dev Med Child Neurol. 1994;36(9):770-86.
23. 25. Fragala MA, Goodgold S, Dumas HM. (2003). Effects of lower extremity passive stretching: pilot study of children and youth with severe limitations in self-mobility. Pediatr Phys Ther. 2003;15:167-75.
24. 26. Novak I, Mcintyre S, Morgan C, Campbell L, Dark L, Morton N, et al Systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol. 2013;55(10):885-910.
25. 27. Theis N, Korff T, Kairon H, Mohagheghi AA. (2013). Does acute passive stretching increase muscle length in children with cerebral palsy? Clin Biomech. 2013;28(9-10):1061-7.
26. 28. Kalkman BM, Bar-On L, Cenni F, Maganaris CN, Bass A, Holmes G. Medial gastrocnemius muscle stiffness cannot explain the increased ankle joint range of motion following passive stretching in children with cerebral palsy. J Exp Psychol. 2017; 1;103(3):350-357.
27. 29. Yoon YS, Yu KP, Lee KJ, Kwak SH, Kim JY. Development and application of a newly designed massage instrument for deep cross-friction massage in chronic non-specific low back pain. Ann Rehabil Med.2012;36(1):55-65.
28. 30. Rasool F, Memon AR, Kiyani MM, Sajjad AG. The effect of deep cross friction massage on spasticity of children with cerebral palsy: A double-blind randomised controlled trial. J Pak Med Assoc.2017;67(1):87-91.
29. 31. Hernandez-Reif M FT, Largie S, Diego M, Manigat N, Seoanes J, Bornstein J. (2005). Cerebral palsy symptoms in children decreased following massage therapy. Early Child Dev Care. 2005;175:445-56.