EFFECT OF THE LEG ROTATION CONTROL SPLINT ON ROTATIONAL GAIT PATTERN IN CHILDREN WITH HEMIPLEGIA

EFFECT OF THE LEG ROTATION CONTROL SPLINT
ON ROTATIONAL GAIT PATTERN IN CHILDREN
WITH HEMIPLEGIA
Abd El-Rahman A. Abd El-Hafeez1* ; Gehan H. Elmeniawy2 ;
Hassan M. Elbarbary3 and Amira M. Abd-ElMonem4
1Master Degree in Physical Therapy for Pediatrics Department, Faculty of Physical
Therapy, Cairo University, Egypt.
2Professor, Physical Therapy for Pediatrics Department, Dean of Faculty of Physical
Therapy, Cairo University, Egypt.
3Professor, Orthopedics Department, Faculty of Medicine, Cairo University, Egypt.
4Assistant Professor, Physical Therapy for Pediatrics Department, Faculty of Physical
Therapy, Cairo University, Egypt.
ABSTRACT
Background: Rotational deformities of the lower extremities are common
in children with cerebral palsy and may lead to abnormal gait pattern.
Objective: To determine the effect of leg rotation control splint on outtoeing
gait pattern in spastic hemiplegic children. Subjects and methods:
Thirty spastic hemiplegic children with out-toeing gait pattern from both
genders; age ranged from 24 to 60 months; participated in this study. They
were randomly allocated from the Specialized Damietta Hospital, Damietta
Governorate. They were divided into two groups of equal numbers (control
and intervention). The control group received a designed physiotherapy
program based on neurodevelopmental approach for 60 minutes in addition
to gait training for 30 minutes while the intervention group received the
same physiotherapy program while wearing the leg rotation control splint
during the gait training.
Craig’s test and foot progression angle were used to measure the femoral
ante-version angle and angle of toe out respectively. Each child was
measured 2 times, at baseline (pre) and after 3 months (post). Results: The
pre-treatment comparison between groups showed non-statistically
significant difference in all measured variables.
Regarding the rotational profile parameters, the within group showed nonstatistically
significant difference in the trochanteric prominence and foot
progression angles. While, there was significant improvement in cadence,
speed, step length and stride length while non-statistically significant change
was recorded in the step width. Finally, post-treatment comparison showed
non-statistically significant difference between the two groups in all
measured variables. Conclusion: Physiotherapy program either applied
alone or combined with leg rotation control splint improved spatiotemporal
gait parameters but didn’t change lower limb rotational profile.
Key Words: Cerebral palsy, Hemiplegia, Leg rotation control splint,
Rotational gait pattern.
Egypt. J. of Appl. Sci., 35 (7) 2020 57-74
INTRODUCTION
The term cerebral palsy (CP) is a neurological condition resulting in
different types and levels of impairments. CP may occur at birth where specific
parts of the brain have been damaged as a result of a medical complications
(Foose and Ardovino, 2008; SwannGuerrero and Mackey, 2008). However,
CP can occur before or right after birth due to, for example, brain haemorrhage,
tumor or an injury / trauma that damage the brain. Similarly, as the brain
communicates multiple messages to different parts of the body that performs
different bodily functions (such as the movement of muscles, the processing of
information and coordination), any damage to the brain can result in a range of
different impairments depending upon which part of the brain has been effected
(Tecklin, 2008; Stanton, 2012; Porretta, 2017).
Spastic hemiplegia, unilateral CP, is a neuromuscular condition of
spasticity that results in the muscles on one side of the body being in a constant
state of contraction. About 20– 30% of people with CP have spastic hemiplegia.
Due to brain or nerve damage, the brain is constantly sending action potentials
to the neuromuscular junctions on the affected side of the body. The affected
side of the body is rigid, weak and has low functional abilities ( Brashear,
2010).
Gait is a fundamental function that is important for life. Gait is achieved
by coordinated movements of body segments, taking advantage of an
interaction between internal and external factors, and is accomplished through
the action of the neuromusculoskeletal system. Normal gait is both stable and
flexible, allowing for changes in speed and maneuvering in different terrains
while maintaining energetic efficiency ( Fritz and Lusardi, 2009). Rotational
deformities are common lower extremity abnormalities in children with CP,
which include in-toeing and out-toeing. In-toeing is caused by one of the three
types of deformity: increased femoral anteversion, internal tibial torsion, and
metatarsus varus, while out-toeing, the less common form, is caused by femoral
retroversion and external tibial torsion. Rotational deformities lead to an
ineffective gait pattern since they affect the lever arm of the foot during gait (
Inan et al., 2009).
Different conservative methods were used in treatment of rotational gait
profile such as medical shoes, spiral strapping and tapping. However, the
effectiveness of these methods on rotational deformities is still debatable.
Therefore, the current study aimed to investigate the effect of leg rotation
control splint on out-toeing gait pattern in spastic hemiplegic children. We
hypothesized that; leg rotation control splint has no effect on out-toeing gait
pattern in spastic hemiplegic children.
MATERIALS AND METHODS
Study design: A randomized trial was conducted from January 2017 to
January 2020 at the Outpatient Clinic, Specialized Damietta Hospital,
Damietta governorate.
58 Egypt. J. of Appl. Sci., 35 (7) 2020
Ethical approval
The current study was approved by the ethical committee of the
Faculty of Physical Therapy, Cairo University and strictly adhered to the
criteria proclaimed in the latest version of the Declaration of Helsinki code
of ethics. Additionally, a signed consent form with parents allocated to
participate in this study was obtained before starting the study procedures.
Subjects
Subjects included 30 volunteer children diagnosed as spastic
hemiplegic CP. These children were extracted from a dataset of 89 children
who are diagnosed with CP and receive regular physical therapy treatment at
Out-patient Clinic, Specialized Damietta Hospital, Damietta Governorate.
Children who met the eligible criteria (30 children) were enrolled in the
current study and allocated into either control group or intervention group of
equal numbers (15 children each).
Inclusive criteria:
1. A diagnosis of spastic hemiplegic CP.
2. Aged from 24 to 60 months.
3. They did not participate in any previous trials with adhesive tape or spiral
strapping to the lower limbs.
4. Grade of spasticity is 1 to 2 (according to modified Ashworth scale) in
order to allow the children to be ambulant which in turn made the gait
training program convenient for them ( Ansari et al., 2008).
5. Level I-II motor function according to GMFCS.
6. Walk with abnormal pattern of gait in the form of out-toeing (according
to foot progression angle more than 6.5 degrees), (Thompson, 2003).
7. Able to follow simple commands and instructions.
Exclusive criteria:
Children were excluded if they had any of the following:
1. Significant visual, auditory or perceptual deficits.
2. Fixed or structural deformities in the lower limb.
3. Surgical interference in the lower limb in the past 6 months.
4. Uncontrolled seizures or epilepsy.
5. Botox injection in past 6 months in the lower limbs.
6. Fracture of the lower limb in the past 6 months.
Randomization:
A person not otherwise involved in the trial randomly allocated participant,
to the control or intervention group using closed envelops.
Control group: The 15 children in this group received a designed physical
therapy program based on neurodevelopmental approach (NDT) for 60
minutes in addition to gait training for 30 minutes.
Intervention group: The 15 children in this group received the same
designed physical therapy program given to the control group while wearing
the leg rotation control splint during the gait training.
Egypt. J. of Appl. Sci., 35 (7) 2020 59
The treatment was conducted 3 days/week for 12 successive weeks for the
two groups. Children in both groups received a home based routine program
for 90 minutes per day in the other three days of the week giving one day
rest.
Materials:
I- Materials for subject selection:
The following instruments were used for subject selection according to the
inclusive criteria:
1- Modified Ashworth scale
It was used to assess the degree of spasticity. It is frequently used to evaluate
the muscle tone changes during passive stretch to the investigated muscles
through the full ROM. It is based on six point ordinal scale (0,1,1+,2,3,4)
with normal muscle tone referred as zero, whereas a score of 4 is assigned
for severe spasticity with no motion is possible (Ansari et al., 2008).
2- Foot progression angle
The foot progression angle (FPA) was used to determine the degree of
angle of toe-out. It is defined as the angle between the line from the
calcaneous to the second metatarsal and the line of progression averaged
from heel strike to toe off during the stance phase of walking for each step (
Xu et al., 2017).
3- Gross motor function classification system
The GMFCS was used to determine the level of motor function based
on functional and walking abilities in children with CP and on their
chronological age. The scale classify children intone of five levels according
to their functional abilities. Children with GMFCS level I can walk without
Limitations, whereas those with level V have severe head and trunk control
limitations and require physical assistance. The current study included
children with level I-II (Palisano et al., 2007).
II- Materials for assessment:
1- Weight and height scales: The Hanson professional scale was used to
measure the weight and height.
2- Foot progression angle and spatial gait parameters:
The FPA was measured by obtaining foot print while the child walked
at regular self-speed with bare feet. Gait analysis using footprint impressions
is a simple and inexpensive method of obtaining valuable information
relating to foot dynamics. Powdered footprint is a reliable and repeatable
method for measuring FPA, step length and step width (Taranto et al.,
2005).
3- Temporal gait parameters:
A stop watch was used to determine the walking speed and cadence
while the child was asked to walk on a five meters walk way.
4- Craig’s test:
This test is known as hip rotation range of motion (ROM) (Sangeux ,
et al., 2014) . It was used to determine the trochanteric prominence angle
(TPA) using goniometer. Hip rotation ROM may be an appropriate clinical
60 Egypt. J. of Appl. Sci., 35 (7) 2020
measure to estimate FV, as it is commonly performed during clinical
examination, has good reliability and is associated with FV (Ejnisman, et
al., 2013) . Increased FV values are associated with decreased hip external
rotation and increased internal rotation ROM, while decreased FV may
contribute to decreased internal rotation ROM increased external rotation
ROM ( Uding et al., 2019). Chung et al., (2010) reported Craig’s test as
being both accurate and valid for determining femoral version (FV)
compared to CT. He also found high correlations between Craig’s test and
CT values in children with CP.
III-Materials for treatment:
● Physical therapy tools
The following therapeutic tools were used to conduct the designed physical
therapy program for the two groups including gymnastic balls, wedges,
rolls, tilting boards of different sizes and mattresses, in addition to stepper,
wall bar, stand bar and large mirror for gait training.
● The leg rotation control splint:
It was used aiming to correct the out-toeing gait pattern in the
intervention group (Figure 1).
Figure (1): The leg rotation control splint
1). It is a commercially available splint that is frequently used in children
with abnormal lower limb rotational profile e.g. CP (available at 2020
from www.performancehealth.ca/leg-rotation-control). The splint consists
of:
1- Pelvic belt.
2- Shoe hooks.
3- An elastic spiral strap that is attached to the shoe hook and extend on the
affected limb (spiral) up to the pelvic belt. The strap serves as a counter
rotation force that allows maintaining the foot in neutral position and
decreases of the leg (out-toeing).
Egypt. J. of Appl. Sci., 35 (7) 2020 61
4- Two elastic straps connected to the pelvic belt posteriorly (directed
upward) and turn above the shoulder girdles to be connected anteriorly
again in the belt, these straps guard against the downward slippage of the
belt due to the equinus foot (optional).
Methods:
The child’s name, weight, sex, affected side; height and age for each
child were recorded before preceding the study procedures.
I- Methods for assessment
● Foot progression angle and spatiotemporal gait parameters
Footprint data were obtained using white paper sheet [5 meters (m)
length, 100 centimeter (cm) width]. The sheet was put over an elevated
walkway of 5m length. The child’s feet were placed in a container of red
colored powder and gently shaken off to remove any excess powder. The child
was instructed to walk normally to the other end, looking straight ahead,
commencing with the affected foot. For accuracy, the first two steps were
excluded from measurement. Marker pen, a stainless steel ruler, a transparent
plastic protractor and a transparent grid, made up of parallel lines was used to
measure lengths and angles (see figure 2). The longitudinal border of the grid
was aligned with the apex of the hallux and the medial side of the forefoot. To
ensure parallel placement of the grid, the distance between the top and bottom
margins of the grid and the border of the paper were measured. The grid was
used to draw 2 lines parallel to each other representing the apex of the hallux
and at the posterior aspect of the heel. The longitudinal border of the grid
adjacent to the medial side of the forefoot was marked at either end. The grid
was removed and the two points joined to formulate the line of progression
(LOP). The intersection between LOP and the foot axis (line intersecting the
center of the heel and the second toe) constructs FPA. Spatiotemporal
parameters [stride length in cm, step length in cm, step width in cm, cadence in
steps/minute, and speed in kilometers/hour (km/h)] were measured by using
foot print ( Taranto et al., 2005).
Figure (2): Placement of transparent grid (LOP = line of progression).
Adopted from ( Taranto et al., 2005)
62 Egypt. J. of Appl. Sci., 35 (7) 2020
● Trochanteric prominence angle
Femoral ante-version is described as the angular difference between the
axis of the femoral neck and trans-condylar axis of the femur or simply
torsion of the femur. Measurement of ante-version by physical
examination is done with the child in the prone position, measuring
internal and external rotation of the hip, and making sure there is no
rotation of the pelvis. The degree of internal rotation is measured as the
angle subtended by the tibia to the vertical line (See figure 3).
Figure (3): (A) Anteversion measured by medial rotation of hip and ( B)
lateral rotation of hip ( Wells, 2004).
II- Methods for treatment:
The two groups received the same designed physical therapy program while
children in the intervention group performed the program while using the leg
rotation control splint during the gait training. The splint should be worn from
down upwards, the elastic strap should not be slack and should rotate two
rotations around the lower limb one of them in the popliteal fossa and the other
posteriorly to be attached to the pelvic belt. The program includes:
● Neurodevelopmental approach which was directed towards inhibiting
abnormal muscle tone and abnormal postural reflexes and facilitation of
normal movement patterns of postural control through reflex inhibiting
positions using proximal and distal key points of control.
● Facilitation of righting, equilibrium and protective reactions to improve
postural mechanisms via variety of exercises applied on balance board
through tilting from different positions in forward, backward and sideways.
● Stretching exercises to maintain the length and the elastic properties of the
muscles which are liable for shortening especially Achilles tendon,
hamstrings, hip flexors and adductors of the affected lower limb while in the
Egypt. J. of Appl. Sci., 35 (7) 2020 63
upper limb the shoulder internal rotators, elbow and wrist flexors, pronators
and ulnar deviators.
● Hand weight bearing and stretching exercises to improve the hand function,
also facilitation of reaching, grasping and release according to the child
abilities.
● Gait training activities including:
− Sideway, forward and backward walking training in front of a large mirror
using stepper.
− Training of walking in open environment by placing obstacles across walking
tract as rolls of different diameters and wedges of different heights.
− Training of walking on different floor surfaces (Spongy, sandy and hard
surfaces) on mat, on the floor and on the carpets ( Levitt, 2004).
RESULTS
I- General characteristics of the study groups:
Table (1) shows the general characteristics of the study groups. The
mean age, weight, and height as well as, the frequency distribution of
gender and affected limb showed non-statistically significant difference
between the study groups (p< 0.05).
Table (1): Analysis of the general characteristics of the study groups
Item Control group Intervention group Test of sig P-value
Gender N/(%) Boy 8 53.3% 5 33.3% χ2= 1.222 0.269
Girl 7 46.7% 10 66.7%
Affected side Right 4 26.7% 9 60% χ2= 3.394 0.065
Left 11 73.3% 6 40%
Age (months) ±SD
41.27± 12.09 42.71± 12.63 t= 0.317 0.753
Height (cm) ±SD
96.51± 7.34 96.23± 10.54 t= - 0.081 0.936
Weight (Kg) ±SD
14.97± 2.15 14.76 ± 3.22 t= -0.208 0.837
SD: Standard deviation (%): percentage χ2: Chi-square test P-value:
probability value T: t-test : mean
II- Pretreatment comparison of the study groups:
The pretreatment comparison of lower limb rotational profile
parameters and spatiotemporal gait parameters are determined in (Table
2). The results showed non-statistically significant difference between the
two groups regarding FPA, TPA, cadence, speed, step length, stride
length and, step width (p< 0.05).
64 Egypt. J. of Appl. Sci., 35 (7) 2020
Table (2): Pre-treatment comparison of lower limb rotational profile
and spatiotemporal parameters in the two groups:
Item Control group Intervention group Test of sig P-value
Foot progression angle (degree) 27 (12-45) 26 (12-51.3) z= - 0.062 0.637
Trochanteric prominence angle
(degree)
35.73 ± 2.72 35.87± 2.05 t= - 0.152 0.880
Cadence (Step/min) 98.13 ±22.70 97.80± 24.32 t= 0.039 0.969
Speed (Km/h) 1.7 (0.85-3.40) 1.62 (0.72-4.28) z= - 0.415 0.678
Step length (Cm) 40.08 ± 6.77 41.27 ± 12.43 t= 0.362 0.774
Stride length (Cm) 65.12 ± 11.21 69.02 ± 23.14 t= 0.587 0.562
Step width (Cm) 24.45± 4.93 24.35± 4.83 t = 0.056 0.956
T: t-test SD: Standard deviation P-value: probability value Z: Mann-Whitney
test (%): percentage : mean
III-Pre and post-treatment comparison of the control group
The pre and post treatment comparison of the rotational profile
parameters (FPA, TPA) and step width shows no statistically significant
difference (p< 0.05), while the spatiotemporal gait parameters (step
length, stride length, cadence, speed) show statistically significant
difference as demonstrated in (Table 3) (p> 0.05).
Table (3): Pre and post treatment comparison of lower limb
rotational profile and spatiotemporal gait parameters of
the control group
Item
Control group
Test of sig P-value
Pre-treatment Post-treatment
Foot progression angle (degree) 27 (12-45) 30 (12-46) z= - 0.059 0.956
Trochanteric prominence angle
(degree)
35.73 ± 2.72 35.67 ± 3.04 t= 0.133 0.896
Cadence (Step/min) 98.13 ±22.70 113.13±22.70 t= - 7.061 <0.001*
Speed (Km/h) 1.7 (0.85-3.40) 3 (2-6.1) z= - 2.670 0.008*
Step length (Cm) 40.08 ± 6.77 61.11± 6.43 t= - 24.344 <0.001*
Stride length (Cm) 65.12 ± 11.21 105.12±13.39 t= - 31.813 <0.001*
Step width (Cm) 24.45± 4.93 2 4.59± 5.74 t= - 0.351 0.731
T: t-test SD: Standard deviation P-value: probability value Z:
Mann-Whitney test : mean
IV-Pre and post-treatment comparison of the intervention group
The pre and post treatment comparison of the rotational profile
parameters (FPA, TPA) and step width shows no statistically significant
difference (p< 0.05), while the spatiotemporal gait parameters (step
length, stride length, cadence, speed) show statistically significant
difference as demonstrated in (Table 4) (p> 0.05).
Egypt. J. of Appl. Sci., 35 (7) 2020 65
Table (4): Pre and post treatment comparison of lower limb
rotational profile and spatiotemporal gait parameters of
the intervention group
Item Intervention group Test of sig P-value
Pre-treatment Post-treatment
Foot progression angle (degree) 26 (12-51.3) 29 (13-52) z= - 0.268 0.789
Trochanteric prominence angle
(degree)
35.87± 2.05 35. 9 3± 2.70 t= - 0.135 0.894
Cadence (Step/min) 97.80± 24.32 117 . 80±24.32 t= - 5.727 <0.001*
Speed (Km/h) 1.62 (0.72-4.28) 3.2 (1.9-6.1) z= - 3.408 0.001*
Step length (Cm) 41.27 ± 12.43 63. 0 9± 21.81 t= - 6.510 <0.001*
Stride length (Cm) 69.02 ± 23.14 110 ± 38.84 t= - 7.457 <0.001*
Step width (Cm) 24.35± 4.83 24. 4 2± 5.14 t = -0.201 0.845
● T: t-test SD: Standard deviation P-value: probability value Z:
Mann-Whitney test : mean
V- Post-treatment comparison of the study groups:
The post-treatment comparison of lower limb rotational profile
parameters and spatiotemporal gait parameters are determined in (Table
5). The results showed non-statistically significant difference between the
two groups regarding FPA, TPA, cadence, speed, step length, stride
length and, step width (p< 0.05).
Table (5): Post-treatment comparison of lower limb rotational
profile and spatiotemporal parameters in the two
groups:
Item Control group Group intervention Test of sig P-value
Foot progression angle (degree) 30 (12-46) 29 (13-52) z= - 0.145 0.902
Trochanteric prominence angle
(degree)
35.67 ± 3.04 35.93± 2.70 t= - 0.254 0.801
Cadence (Step/min) 113.13±22.70 117.80±24.32 t=-0.534 0.591
Speed (Km/h) 3 (2-6.1) 3.2 (1.9-6.1) z= - 0.208 0.838
Step length (Cm) 61.11± 6.43 63.09± 21.81 t= -0.337 0.738
Stride length (Cm) 105.12±13.39 110 ± 38.84 t= -0.460 0.649
Step width (Cm) 24.59± 5.74 24.42± 5.14 t= 0.084 0.934
T: t-test SD: Standard deviation P-value: probability value Z: Mann-Whitney
test : mean
DISCUSSION
This study was conducted to investigate the effect of the leg rotation
control splint on the rotational gait pattern in hemiplegic children. We
hypothesized that; leg rotation control splint has no effect in improving the
rotational gait pattern in children with hemiplegia. For this purpose, thirty
hemiplegic children were allocated from the Specialized Damietta Hospital,
Damietta Governorate. Both sexes were involved with age ranged from 24 to 60
66 Egypt. J. of Appl. Sci., 35 (7) 2020
months. Subjects were divided into two groups of equal number (control and
intervention), 15 children in each group.
The main outcomes of the current study revealed within group and between
groups non-statistically significant difference of FPA and TPA mean values.
While there was significant improvement of cadence, speed, step length and
stride length in the two groups with non-statistically significant difference
regarding the step width. However, post-treatment comparison between the two
groups showed non-statistically significant difference in respect with cadence,
speed, step length, stride length and the step width.
The current study included children with hemiplegic CP with out-toeing
gait profile. This selection was accredited to the fact that, children with
hemiplegic CP have a wide variety of gait deviations related to the abnormal
tone, lack of selective motor control and musculoskeletal disorders.
Consequently, those children have lower limb rotational abnormalities and
abnormal spatio-temporal parameters when compared with typically developing
age matched children. This is supported by previous studies documented that,
children with spastic hemiplegic CP exhibit several musculoskeletal
abnormalities of the lower extremities that result in gait and balance disorders.
In a child with spastic CP, the relationships between the different symptoms of
the upper motor neuron lesions; weakness, spasticity, co-activation, loss of
movement selectivity; and gait parameters or effective performance remain
debatable. The abnormal gait patterns among this population are a mixture of
primary (disordered motor control) and secondary (musculo-skeletal
deformities (Gage et al., 2009; Stebbins et al., 2010; Kedem and Scher,
2015; Gross et al., 2015). Sikina et al., (2012) documented that, the gait
pattern of the paretic and non-paretic sides of hemiparetic children are different
compared to healthy subjects. They show shorter stance phase; significantly
reduced velocity, stride length, step length and cadence compared to healthy
subjects. However step width is increased considerably.
The age of children representing the sample of this study ranged from 24
to 60 months with the mean value of 42.71± 12.63 months for the intervention
group and 41.27± 12.09 months for the control group. The selected age was
based on the fact that, the development of lower limb rotational profile is
achieved in infancy and early childhood through weight bearing activities such
as walking. This is supported with Schoenecker et al., (2014) who reported
that, in-toeing and out-toeing may be accentuated between six months and five
years of age, when children are developing their walking and coordination
skills. Normal growth and improved coordination typically lead to spontaneous
resolution of rotational variations.
The non-significant changes recorded in FPA and TPA can be attributed
to the ineffectiveness use of leg rotation control splint which intended to
achieve improvement in FPA and TPA. This could be attributed to type of splint
used in the current study which is a commercially available splint that can be
easily obtained and applied. The authors noticed that, parents preferred this type
of splint as it is light in weight, can be worn under the child clothes and easily
Egypt. J. of Appl. Sci., 35 (7) 2020 67
applied. However, the degree of tension of the elastic rope of the splint is
variable as the elasticity changes after time and is subjectively adjusted to
maintain the foot in appropriate position. Moreover, it is comfortable and does
not cause tension on the soft tissues therefore children did not show any
rejection regarding the orthosis.
This is confirmed by Staheli, (2008) who reported that, bracing and
twister cables are ineffective in correcting the version of the femur. Derotational
osteotomy may be indicated in patients with hip pain, severe gait disturbance, or
cosmetic deformity. Our results are consistent with Schoenecker et al., (2006)
who concluded that, non-operative interventions (e.g., shoe inserts, braces,
twister cables, casting) are ineffective in the treatment of internal and external
tibial torsion and increased femoral ante-version and femoral retroversion.
This comes in agreement with Behnam et al., (2007) who reported that,
out-toeing is less common than in-toeing, and its causes are similar but opposite
to those of in-toeing. In most cases, the abnormality improves with time. A
careful physical examination, explanation of the natural history, and serial
measurements are usually reassuring to the parents. Treatment is usually
conservative. Special shoes, cast, or braces are rarely beneficial and have no
proven efficacy. Surgery is reserved for older children with deformity from
three to four standard deviations from the normal.
The results can be also attributed to the concept that, the leg rotation
control does not provide proprioceptive feedback unlike other orthosis and
Kinesio tape. This comes in line with Öhman, (2013) who stated that, the tape
provides proprioceptive feedback to achieve and maintain preferred body
alignment. It is a complementary treatment and is designed to facilitate the
body’s natural healing process while allowing support and stability to muscles
and joints without restricting the body’s range of motion.
The results of the current study also revealed significant improvement in
spatio-temporal gait parameters in both the control and intervention group. This
could be attributed the NDT based physical therapy program and gait training
which intended to inhibit hypertonicity of the muscles, improve motor control,
increase strength and muscle endurance, facilitate gross motor performance and
improve balance as well as gait. This comes in agreement with previous studies
stated that, functional gait training in children with CP allows for repetition of
motor task to drive skill acquisition. Targeting improved walking ability, with
training, may lead to gains in increased independence and follow with increased
participation in daily life (French et al., 2010; Langhorne et al., 2011).
Herskind et al., (2016) conducted a pilot study to investigate the effects
of intensive gait training in toddlers with CP. The gait training was conducted
for one hour/day, five days/week for three consecutive months. This pilot study
suggests that intensive gait training may increase muscle volume, improve
walking skills and reduce passive muscle stiffness in toddlers with CP.
Functional gait training allows for repetition of motor task to drive skill
acquisition. It can be defined as actively practicing the task of walking, to
improve walking ability ( Langhorne et al., 2011; Yang et al., 2013).
68 Egypt. J. of Appl. Sci., 35 (7) 2020
It has been reported that, the use of NDT for children with CP improved
motor skills functionality. It may be that, NDT treatment effects are obvious in
the postural control used for gross motor performance and caused improved
functional ability ( Labaf et al., 2015).
The results can be also attributed to potential benefits of NDT and gait
training program applied in a critical age of this study sample. This is supported
with who stated that, it is crucial to ensure development of the motor skills
required for children with CP to become physically active early in life to avoid
atrophy and loss of function (Herskind et al., (2016). Similarly, previous
studies reported that, the young brain appears to be more plastic and thus more
susceptible to intervention than the adult brain (Friel et al., 2012; Herskind et
al., 2015). Furthermore, Yang et al., (2013) suggested that gait training in
toddlers with an early brain lesion may positively affect functional ability and
cause plastic changes in the corticospinal pathway.
The improvement recorded in the two groups can be attributed to the
duration and frequency of the treatment. The statistical analysis revealed
significant improvements in all measured variables after treatment in both
groups as the main effect of time was statistically significant. The two groups
received a treatment program which was conducted for 90 minutes three-times a
week for three successive months in addition to home routine program in the
other three days giving one day rest per week, which is considered as an
intensive program. Trahan and Malouin, (2002) and Tsorlakis et al., (2004)
stated that increasing the frequency and duration of therapy sessions may
produce significant and long-lasting changes in strength, tone, posture and gross
motor performance; however, the success of any therapy depends on the
commitment of the parents, caregivers, child and therapists. Polovina et al.,
(2010) reported that, intensive treatment was found to have a greater effect than
non-intensive one. A treatment was defined to be intensive if it was undertaken
for more than three times per week.
Similarly, a recent randomized controlled study conducted by Park,
(2016) who investigated the effect of physical therapy frequency based on NDT
on gross motor function in children with CP concluded that intensive physical
therapy is more effective for improving gross motor function in children with
CP. In particular, crawling and kneeling, and standing ability showed greater
increases with intensive physical therapy.
Limitations
Overall, our study supports the hypothesis that leg rotation control splint
has no effect on improving the rotational gait pattern in children with
hemiplegia. However, this study is not exempt of limitations. The major
limitations of the current study were lack of reevaluation and follow-up after
completion of the intervention. Another limitation was that, the selected sample
had out-toe gait pattern which is less common than in-toeing therefore the
sample size was relatively small to generalize the results. Finally, the body mass
index was not estimated which is essential indicator for weight control among
children with disabilities. These potential sources of bias should be controlled in
Egypt. J. of Appl. Sci., 35 (7) 2020 69
future studies to provide a better understanding and overview about the role of
conservative orthotic management of lower limb abnormal rotational profile in
children with CP.
Acknowledgements
We would like to express our sincere appreciation to all physiotherapists
and nurses working at the Out-patient Clinic, Specialized Damietta Hospital,
Damietta Governorate who participated in the study procedures. The authors
cannot forget to thank all children and their parents, for their collaboration in
this study.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the
research, authorship, and/or publication of this work.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
REFERENCES
Ansari, N.N. ; S. Naghdi ; T.K. Arab and et al. (2008). "The interrater and
intrarater reliability of the Modified Ashworth Scale in the assessment
of muscle spasticity: limb and muscle group effect".
NeuroRehabilitation., 23 (3): 231–237.
Brashear, A. (2010). Spasticity: Diagnosis and Management. New York:
Demos Medical.
Chung, C.Y. ; K.M. Lee ; M.S. Park and et al. (2010). Validity and reliability
of measuring femoral anteversion and neck-shaft angle in patients
with cerebral palsy. JBJS, 92(5): 1195-1205.
Ejnisman, L. ; M.J. Philippon ; P. Lertwanich and et al. (2013).
Relationship between femoral anteversion and findings in hips with
femoroacetabular impingement. Orthopedics.,36:293–300.
Foose, A. and P. Ardovino (2008). Therapeutic Recreation and Developmental
Disabilities. In: Robertson, T. and Long, T., eds. Foundations of
Therapeutic Recreation: perceptions, philosophies and practices for
the 21st century. Champaign, IL: Human Kinetics, 127-144.
French, B. ; L. Thomas ; M. Leathley and et al. (2010). Does repetitive task
training improve functional activity after stroke? A Cochrane
systematic review and meta-analysis. J Rehabil Med; 42: 9–14.
Friel, K. ; S. Chakrabarty ; H.C. Kuo and et al. (2012). Using motor
behavior during an early critical period to restore skilled limb
movement after damage to the corticospinal system during
development. J Neurosci; 32(27):9265–76.
Fritz, S. and M. Lusardi (2009). White paper: "walking speed: the sixth vital
sign". J. Geriatr Phys Ther., 32: 46-49.
70 Egypt. J. of Appl. Sci., 35 (7) 2020
Gage, J. ; M. Schwartz ; S. Koop and T. Novacheck (2009): The
identification and treatment of gait problems in cerebral palsy. 2nd
edition. Mac Keith Press, London,p 34.
Gross, R. ; F. Leboeuf ; N.J. Hardoui and et al. (2015): Does muscle
coactivation influence joint excursions during gait in children with and
without hemiplegic cerebral palsy? Relationship between muscle
coactivation and joint kinematics. Clinical Biomechanics. Dec;
30(10):1088-1093.
Gulan, G. ; D. Matovinović ; B. Nemec and et al. (2000). Femoral neck
antever Values, development, measurement,common problems.
Collegium Antropologicum, 24(2): 521–527.
Herskind, A. ; G. Greisen and J.B. Nielsen (2015). Early identification and
intervention in cerebral palsy. Dev Med Child Neurol; 57(1):29–36.
Herskind, A. ; M. Willerslev-Olsen ; A. Ritterband-Rosenbaum and et al.
(2016). Intensive gait training in toddlers with cerebral palsy: A pilot
study. Adv Pediatr Res., 3:8. doi:10.12715/apr.2016.3.8
Inan, M. ; F. Altintaş and I. Duru (2009). ‘The evaluation and management
of rotational deformity in cerebral palsy’, Acta Orthopaedica et
Traumatologica Turcica, 43(2): 106–112.
Kedem, P. and D. Scher (2015): Foot deformities in children with cerebral
palsy. Journal of Current opinion in pediatrics; 27(1):67-74.
Labaf, S. ; A. Shamsoddini and A. Shakibaee (2015). Effects of
Neurodevelopmental Therapy on Gross Motor Function in Children
with Cerebral Palsy. Iran J Child Neurol ;9 (2): 36-41.
Langhorne, P. ; J. Bernhardt and G. Kwakkel (2011): Stroke rehabilitation.
Lancet; 377 (12): 1693–1702.
Levitt, S. (2004). Treatment of cerebral palsy and motor delay, 2nd ed. Black
well scientific publisher, London.
Mooney, J.F. (2014). Lower extremity rotational and angular issues in children.
Pediatr Clin North Am.; 61(6):1175–1183.
Öhman, A.M. (2013). Kinesiology Taping a Therapeutic Tool in the Paediatric
Population? J Nov Physiother 3:5 http://dx.doi.org/10.4172/2165-
7025.1000173
Palisano, R. ; P. Rosenbaum ; D. Bartlett and et al. (2007). Gross Motor
Function Classification System Expanded and Revised. Reference:
Dev Med Child Neurol, 39, 214–223. https://doi.org/10.1111/j.1469-
8749.2. Reference: Dev Med Child Neurol, 39, 214–223.
Park, E. (2016). Effect of physical therapy frequency on gross motor function
in children with cerebral palsy. J. Phys. Ther. Sci., 28: 1888–1891.
Egypt. J. of Appl. Sci., 35 (7) 2020 71
Polovina, S. ; T. Sâkoric ; P. Andrea and et al. (2010). Intensive
Rehabilitation in Children with Cerebral Palsy: Our View on the
Neuronal Group Selection Theory. Coll. Antropol., 34 (3): 981-988.
Porretta, D.L. (2017). Cerebral Palsy, Traumatic Brain Injury, and Stroke. In:
Winnick, J P and Porretta, D L., eds. Adapted Physical Education and
Sport. 6 th ed. Champaign, IL: Human Kinetics, 217-290.
Sangeux, M. ; J. Mahy and H.K. Graham (2014). Do physical examination
and ctscan measures of femoral neck anteversion and tibial torsion
relate to each other? Gait Posture., 39:12–16.
Schoenecker, P.L. and M.M. Rich (2006). The lower extremity. In: Lovell
and Winter's Pediatric Orthopaedics, 6th ed, Morrissy RT, Weinstein
SL (Eds), Lippincott Williams & Wilkins, Philadelphia., p.1158.
Schoenecker, P.L. ; M.M. Rich and J.E. Gordon (2014).The lower extremity.
In: Lovell and Winter’s Pediatric Orthopaedics, 7th ed, Weinstein SL,
Flynn JM (Eds), Wolters Kluwer Health, Philadelphia., p.1261.
Sikina, A. ; N. Xiao ; Y. Chen and et al. (2012). Spatiotemporal and Joint
Kinematic Analyses in Hemiparetic Cerebral Palsy Children During
Stance Phase.
Staheli, L.T. (2008). Lower limb. In: Fundamentals of Pediatric Orthopedics,
4th ed, Lippincott Williams & Wilkins, Philadelphia., p.135.
Stanton, M. (2012). Understanding Cerebral Palsy: A Guide for Parents and
Professionals. London: Jessica Kingsley Publishers.
Stebbins, J. ; N.M. Harringto ; N. Thompson and et al. (2010): Gait
compensations caused by foot deformity in cerebral palsy. Gait
Posture; 32(2):226-230.
Swann-Guerrero, S. and C. Mackey (2008). Wellness through Physical
Activity. In: Robertson, T. and Long, T., eds. Foundations of
Therapeutic Recreation: perceptions, philosophies and practices for
the 21st century. Champaign, IL: Human Kinetics, 199-216.
Taranto J, Taranto M J, Bryant A et al. (2005). Angle of gait: A comparative
reliability study using footprints and the EMED-SF®. Foot, 15(1): 7–
13.
Tecklin, J.S. (2008). Pediatric Physical Therapy. 4 th ed. London: Lippincott
Williams & Wilkins
Thompson, G.H. (2003). Gait disturbances. In: Kliegman RM, ed. Practical
strategies in pediatric diagnosis and therapy, ed 2. Philadelphia: WB
Saunders; 823-843.
Trahan, J. and F. Malouin (2002). Intermittent intensive physiotherapy in
children with cerebral palsy: a pilot study. Dev Med Child Neurol.;
44:233-9.
72 Egypt. J. of Appl. Sci., 35 (7) 2020
Tsorlakis, N. ; C. Evaggelinou ; G. Grouios and et al. (2004). Effect of
intensive neurodevelopmental treatment in gross motor function of
children with cerebral palsy. Dev Med Child Neurol; 46:740-745.
Uding, A. ; N.J. Bloom and P.K. Commean (2019). Clinical tests to
determine femoral version category in people with chronic hip joint
pain and asymptomatic controls. Musculoskeletal science & practice,
39: 115–122.
Wells L. (2004). / Evaluation / Foot Progression Angle Femoral Anteversion /
Evaluation / Foot Progression Angle Tibial Rotation.
Xu, J. ; T. Bao ; U.H. Lee and et al. (2017). Configurable, wearable sensing
and vibrotactile feedback system for real-time postural balance and
gait training: Proof-of-concept. Journal of NeuroEngineering and
Rehabilitation. 14. 10.1186/s12984-017-0313-3.
Yang, J.F. ; D. Livingstone ; K. Brunton and et al. (2013). Training to
enhance walking in children with cerebral palsy: are we missing the
window of opportunity? Semin Pediatr Neuro., 20(2):106-15.
تأثیر جبیرة التحکم فی التفاف الطرف السفمی فی تحسین طریقة المشی الممتف
عند الأطفال المصابین بالفالج الشقی
عبد الرحمن أحمد عبد الحفیظ 1, جیهان حسن المنیاوی 2, حسن مجدی البربری , 3
أمیرة محمود عبدالمنعم 4
1 ماجستیر العلاج الطبیعی للأطفال, کمیة العلاج الطبیعی,جامعة القاىرة, مصر .
2 أستاذ العلاج الطبیعی للأطفال وعمید کمیة العلاج الطبیعی , جامعة القاىرة, مصر.
3 أستاذ العظام, کمیة الطب, جامعة القاىرة, مصر .
4 أستاذ مساعد العلاج الطبیعی للأطفال, کمیة العلاج الطبیعی , جامعة القاىرة, مصر.
الخمفیة : التفاف اللأط ا رف السفمیة شائعة عند الأطفال المصابین بالشمل الدماغی وقد تؤدی إلى
نمط مشیة غیر طبیعی .الأىداف: تأثیر جبیرة التحکم فی التفاف الطرف السفمی فی تحسین
طریقة المشی الممتف عند الأطفال المصابین بالفالج الشقی .العینة/طرق التقییم و العلاج:
شارک فی ىذه الد ا رسة ثلاثون طفلاً مصابین بالفالج الشقی مع نمط مشیة التفاف القدم لمخارج
من کلا الجنسین ت ا روحت أعمارىم من 42 إلى 00 شی اً ر. تم اختیارىم من مستشفى دمیاط
التخصصی بمحافظة دمیاط. تم تقسیمیم بشکل عشوائی إلى مجموعتین من أعداد متساویة
)الضابطة والمجموعة العلاجیة(. تمقت المجموعة الضابطة برنامج علاج طبیعی مصمم عمى
أساس نیج النمو العصبی لمدة 00 دقیقة بالإضافة إلى التدریب عمى المشی لمدة 00 دقیقة
بینما تمقت المجموعة العلاجیة نفس البرنامج مع إرتداء جبیرة التحکم فی التفاف الطرف السفمی
أثناء التدریب عمى المشی. تم استخدام اختبار کریج و ا زویة تقدم القدم لقیاس ا زویة التفاف أ رس
Egypt. J. of Appl. Sci., 35 (7) 2020 73
و رقبة عظمة الفخذ للأمام و ا زویة التفاف القدم لمخارج عمى التوالی. تم تقییم کل طفل مرتین ,
قبل فترة العلاج )قبل( وبعد 0 أشیر من العلاج )بعد( النتائج: أظیرت مقارنة ما قبل الد ا رسة
بین المجموعات عدم وجود فرق ذات دلالة إحصائیة فی جمیع المتغی ا رت المقاسة. فیما یتعمق
بمعاملات التفاف الطرف السفمی , أظیرت القیاسات داخل کل مجموعة عمى حدة عدم وجود
فرقًا ذی دلالة إحصائیة فی ا زویة التفاف أ رس و رقبة عظمة الفخذ للأمام وزوایا تقدم القدم. بینما
کان ىناک تحسن کبیر فی عدد الخطوات وسرعة وطول الخطوة بینما تم تسجیل عدم وجود فرق
ذی دلالة إحصائیة فی عرض الخطوة. أخی اً ر, أظیرت مقارنة ما بعد العلاج عدم وجود فرقًا ذی
دلالة إحصائیة بین المجموعتین. الخلاصة: تطبیق برنامج العلاج الطبیعی بمفرده أو مع جبیرة
التحکم فی التفاف الطرف السفمی حَسَّنَ معاملات المشی الزمنیة المسافیة باستثناء عرض
الخطوة, لکنو لم یحسن معاملات إلتفاف الطرف السفمی.
الکممات الدالة: الشمل الدماغی , الفالج الشقی , جبیرة التحکم فی التفاف الساق , نمط المشی
الممتف.
74 Egypt. J. of Appl. Sci., 35 (7) 2020