EFFECT OF SPRING GRAVITY BAR ON KNEE JOINT ANGLE IN CHILDREN WITH SPASTIC DIPLEGIA

EFFECT OF SPRING GRAVITY BAR ON KNEE JOINT
ANGLE IN CHILDREN WITH SPASTIC DIPLEGIA
Baseem Z. Mahmoud1 ; Kamal E. Shoukry2 ; Mohamed Tag Eldeen3
and Nahla M. Ibrahim4
1 BSc Degree in physical therapy, October 6 University, Egypt.
2 Professor at pediatric physical therapy department, Faculty of physical therapy ,
Cairo University.
3 Lecturer of orthopedic surgery, Orthopedic department, kasralainy. Faculty of
medicine, Cairo University.
4 Lecturer at pediatric physical therapy department, Faculty of physical therapy , Cairo
University.
1 E- mail - baseem2022@gmail.com
key Word: spastic diplegia , spring gravity bar , two dimension gait
analysis.
ABSTRACT
Objective: to investigate the effect of spring gravity bar on knee joint
angle during gait in children with spastic diplegia.Method: thirty-six
children of both sexes (aged 7-10 years) with diplegic cerebral palsy were
enrolled in this study. They were randomly assigned into two groups of
equal number: the control and study groups. Evaluation was held before
and after 3 successive months of treatment using two dimension of gait
tracker video analysis to evaluate knee joint angle during gait cycles. Both
groups had received the conventional physical therapy program for one
hour / day three sessions per week. The study group additionally received
gait training on a spring gravity bar while the control group received the
classical gait training program. Results: A statistical significant
improvement in both groups was noted when comparing the mean value
of all measured variables before and after treatment (p≤ .05). there were
significant differences between the control and study groups with respect
to all measured variables which favored the study group when comparing
the post-treatment outcomes (p≤.05). Conclusion: Adding spring gravity
bar to gait training program had a beneficial effect in modulating knee
joint excursion in children with spastic diplegia.
INTRODUCTION
Children with spastic diplegia usually walk independently but most
have an easily recognised disorder of gait which may include deviations
in the sagittal plane such as toe-walking, flexed-stiff knees, flexed hips
and an anteriorly tilted pelvis with lumbar lordosis (Rodda et al., 2004).
Crouch gait, the most prevalent and debilitating gait disorder in spastic
diplegia, is characterized by excessive knee flexion in early and/or mid
Egypt. J. of Appl. Sci., 36 (5-6)2021 84-93
stance. Muscle weakness, spasticity, contractures, and impaired selective
motor control have all been shown to contribute to crouch gait to varying
degrees across individuals (Shdeler et al., 2020).
Excessive knee flexion in stance was very common, being present in
more than 60% of participants in GMFCS levels II to IV, and in more
than 45% of those in level I. Odds of having excessive knee flexion in
stance increased with increasing age in GMFCS levels I, II, and
III.(Rethlefsen et al., 2016).Excessive knee flexion throughout stance
(i.e. crouch gait) is a major sequela of spastic cerebral palsy (CP) and is
sometimes associated with knee pain. Knee pain is hypothesized to result
from quadriceps and patellar tendon forces being approximately 2 to 8
times larger in crouch gait than upright gait. (Pelrine et al., 2019).
Two-dimensional (2D) video analysis may provide an accessible and
affordable means of quantifying postural control deficits that can be
implemented across a spectrum of care settings. Angular joint measures
during weight lifting obtained using 2D motion analysis software have
been shown to be highly correlated to goniometric measures. This system
has also been shown to be reliable in quantifying range of motion during
reaching and walking/running tasks (Paul et al., 2016).
Gait training is often a significant focus of physical therapy
intervention, with increased attention to practice in the child’s natural
environment. Newer methods, which allow partial body weight support
and treadmill training, provide an opportunity for increased practice and
show promise for improving the gait and functional skills of young
children with CP (Gage et al., 2009).
Spring gravity bar is a modification of the gravity force
system ;which most studies focus on walking on fixed(stable) two gravity
bar as :
 In using gravity force system , a lot of vestibular and righting
reflexes are used to promote movement. For example: the child stand
on the surface of one beam while the therapist holds him at his ankles.
He has to balance his body as he receives strong gravitational signals
through the vestibular system while his ankles are challenged to find a
secure position due to the narrow support (Cuevas, 2004).
 Gravity force stimulation program helped the diplegic children to
organize sensory information from the visual, somatosensory and
vestibular systems (sensory strategies) for postural control thus
creating internal neural representation which is necessary for
coordinated postural abilities (Cuevas, 2004).
85 Egypt. J. of Appl. Sci., 36 (5-6)2021
 Walking on a narrow beam is a demanding motor skill that requires
the control of dynamic stability, defined as the ability to reduce
self-initiated or external perturbations via inherent restoring
moments to avoid loss of balance. Due to the reduced base of
support of the beam and the intrinsic variability of the human,
walking tends to become unstable in the medio-lateral (ML)
direction (Chiovetto et al., 2018).
For this spring gravity bar place spring to two gravity bar to add improve
to joint angle as knee joint plus to improvement in balance. Therefore the
purpose of this study was to investigate the effect of spring gravity bar on
changing excessive knee flexion during gait in diplegic children with
crouch gait.
SUBJECTS AND METHODS
Subject:
Thirty-six children with diplegia CP of both genders ( 27 boys and 9 girls)
were recruited from the faculty physical therapy outpatient clinic , Cairo
university and Prof Dr Kamal Shoukry Pediatric rehabilitation center.
Inclusion criteria:
1-Their age extended from seven to ten years.
2-They could walk with limitation or holding on according to GMFCS
(level II & III)
3-They can understand and follow instruction.
Exclusion criteria:
1-Children had any recent surgical interference in the lower limb.
2-Children with fixed structural deformities lower limb.
3-Children had any recent botox injection.
4-Children with sever visual or auditory problems.
Data collection procedures
All procedures were performed at baseline (pretreatment) and at the
end of 3 successive months of treatment (posttreatment) in a warm,
lighted and quiet room.
Materials:
For evaluation:
The participants received baseline and post-treatment assessments after
three month training period by using the following tool:
Two dimension (2D), video based gait assessment system:
Two dimension technique is proposed to perform lower limb sagittal
plane kinematic analysis using a single video camera. It provides
unilateral joint kinematics of hip and knee and ankle in the sagittal plane
Egypt. J. of Appl. Sci., 36 (5-6)2021 86
along with the estimation of gait events and spatiotemporal parameter.
The accuracy of the spatiotemporal parameters estimation was found
suitable for clinical use (Baker, 2006).
Procedure:
 Adhesive skin markers were applied over the skin on specific sites :
greater trochanter , tibial tuberosity and lateral malleolus for right
and left side.
 Children were asked to walk along 2m walkway and velocity didn’t
determine.
 A digital video camera was set up so that it could record from
sagittal plane , perpendicular to the center of the pathway and at
level of knee.
 The angle chosen for this analysis was knee flexsion/extension.
 The video was transferred from camera to the hardware (laptop)
through memory card.
 The tracker software was opened on the laptop.
 Importing a video which analysis.
Intervention
Spring Gravity Bar Features
The spring gravity bar (figure 1) comprises the following: (1) two
wooden board length (160 cm) and width (15 cm) (2) non skid wooden
board (3) wooden board won’t break down when child bounce (4)
durable spring at every end of board (5) two wooden board connect in
the middle (6) Fulcrum in middle of wooden board.
Fig 1: Spring gravity bar.
87 Egypt. J. of Appl. Sci., 36 (5-6)2021
Physical therapy exercise program:
Children of both groups had received the following exercise program
for 1 hour per day, 3 sessions /week for successive 3 months:
(1) flexibility training for iliopsoas, adductor and calf muscles of both
lower limbs 3-5 times per session
(2) strength training for hip extensors , hip abductors , hip external
rotators , knee extensors and ankle dorsiflexors
(3) standing exercise which include sitting on small bench ask child to
stand and standing against wall ask child to squat and standing
holding on and ask child to lift on foot on block
In addition to 30 minutes gait training for both groups as follow:
For control group : gait training which include Walking in all directions
(forward, backward, and sideways) and obstacles (include rollators ,
wedges and stepper) were used on the walkway inside and outside the
parallel bar and walking on wedges with different height and walking on
rollator and walking on stepper and walking on balance board with
stepper on it.
For study group: received the same physical therapy program given to
the control group for 30 minutes and additionally received gait training
on spring gravity bar for 30 minutes, which included the following steps:
(1) therapist provided all instructions and supervision or guarding as
needed
(2) therapist place child in front of spring gravity bar
(3) child was asked to place on foot on bar and try to keep balance as
much as possible then brought other foot on bar and try to keep
balance as much as possible
(4) therapist encourage child to walk on spring gravity bar
(5) child was asked to walk slowly and press spring down during each
step with try to keep his balance
(6) at end of bar ; child was asked to stand on bar to maintain balance
before descend from it.
Statistical analysis
The results were expressed as mean (standard deviation). Data was
analyzed using the Statistical Package for Social Sciences (SPSS
computer program version 25). Paired t-test was used to compare
between the mean values of all measured parameters pre and
post-treatment in each group. While the comparison between both groups
pre and post treatment was carried out by using an unpaired t-test. A
probability of P ≤ 0.05 was considered to be statistically significant.
Egypt. J. of Appl. Sci., 36 (5-6)2021 88
RESULTS
Table 1: represents general characteristics of age, weight, and height
of children in study and control groups.
Items Study groups,
mean (SD)
Control groups,
mean (SD)
Comparison value
ª
P value
Age ( years) 7.83 (1.8 ) 7.83 (1.8) 00.00 1.00*
Weight ( kg) 27.2 (10.56) 24.27 (7.71) 22.07 0.524*
Height (cm) 99.9 (45.69) 109.98 (16.87) 10.08 0.536*
*Non-significant ª From unpaired test
Table 2: represents Comparison between pre and post mean values
of right knee angles in both groups :
Angles of right knee
degree
Stance phase SWING PHASE
IC LR MS TS P
Swing
ISW MSW TSW
pre
mean
difference
2.45 5.50 6.23 3.55 5.25 3.46 .141 .475
T- value .489 1.8 1.65 .737 1.17 1.137 .029 .087
P- value .634 .098 .127 .477 .266 .28 .977 .932
Significant NS
post
mean
difference
1.48 7.13 2.05 5.93 7.15 9.3 5.65 .99
T- value .355 1.73 .539 1.83 1.22 1.49 1.35 .355
P- value .011 .016 .002 .007
Significant S
Table 3: represents Comparison between pre and post mean values
of left knee angles in both groups :
Angles of left knee
degree
Stance phase SWING PHASE
IC LR MS TS P
Swing
ISW MSW TSW
pre
mean
difference
1.00 10.49- 8.98 .42 6.32 2.66 4.15 7.38
T- value .254 2.87 1.99 .171 1.44 11.08 16.41 16.67
P- value .804 .075 .072 .867 .175 .500 .472 .108
Significant NS
post
mean
difference
3.08 7.72 6.85 1.48 2.57 1.02 .533 .858
T- value .944 1.993 2.568 .701 .734 0317 .149 .261
P- value .026 0.007 0.003 .0001 0.00 .001 .000 .0001
Significant S
DISCUSSION
This study was conducted to evaluate the effect of spring gravity
bar program in addition to conventional physiotherapy program on knee
flexion in crouch gait in children with spastic diplegia . The results
concluded that spring gravity bar program can be added to conventional
89 Egypt. J. of Appl. Sci., 36 (5-6)2021
physical therapy program to improve knee joint angle of crouch gait in
children with spastic diplegia.
Children with spastic diplegia develop abnormal muscle tone and
involuntary motor control that may affect their ability to play , this was
consistent with the reporting of Ju y-h et al., (2012) who reported that
Children with spastic diplegic CP, which is characterized by increased
muscle tone, paresis, and involuntary motor control, and by more severe
involvement of the lower extremities than of other parts of the body,
usually have difficulty in maintaining balance in an upright posture
because of the posture’s unstable condition of a high center of mass and a
small base of support.
Children with spastic diplegia suffer from poor activates of daily
living due to lack of sensory integration which is a necessary component
for motor control and movement performance , and this comes in
agreement with the findings of Girolami et al.,(2011) Children with
diplegic CP encounter difficulties in sensory processing and integration
which influence the achievement of mature postural control,
consequently, they have balance impairments in altered sensory
environments, and tend to depend excessively on visual input to maintain
posture and to position their limbs during gait.
In this study work with pattern of spastic diplegic gait described by
Rise and Schwartz (2018) Crouch gait was defined as excessive knee
flexion coupled with excessive dorsiflexion in stance for a limb (i.e. true
crouch gait). As such, the objective criteria used to identify crouch gait
was mean knee flexion in stance angle more than 24.7° (>2SD from
normal) and mean ankle dorsiflexion in single support angle more than
7.3° (more than normal).
The pretreatment results of our study may be contributed to
weakness of muscles around joints which lead to reduces range of motion
, this comes in agreement with the finding of Thompson et al., 2011 who
found that children with spastic CP have smaller and weaker muscles
than healthy children. Muscle strength correlates with gait and motor
function and strength is more highly related to function than spasticity.
Spastic muscles respond positively to strength training and strength gains
have been shown to be similar or greater than those reported in the
healthy population.
The post treatment mean values of measured variables showed
significant improvement toward study group that may be attributed to the
effect of spring gravity bar program which appeared in abilities of child
to develop normal gait pattern with greater precision and ease of
movement. Spring gravity bar program improves joint angle of hip and
knee toward extension especially during stance phase of gait cycle and
that may be due to effect of vestibular stimulation during walking on
Egypt. J. of Appl. Sci., 36 (5-6)2021 90
spring gravity bar. Development of antigravity muscle strength could
resulted in improve balance that lead to improve of postural alignment.
This agreement with Unayik & Kahiyan (2011) Reported that vestibular
system is important in the achievement of normal motor development
and treatment approach to cerebral palsy child should consist of
physiotherapy programs toward the development of postural reactions,
proprioceptive and vestibular stimulation for the development of
visual-motor coordination and normalization of muscle tone.
The result of study group showed that there was significant
reduction in hip and knee flexion especially loading stance, mid-stance
and terminal stance phases in both lower limb and that lead to improve
gait pattern. These improvement may be result from vestibular
stimulation by bouncing on spring gravity bar , develop resistance
exercise to strength extensor muscles of lower limb by press on spring
and develop balance by decrease base of support by walking on narrow
bar of spring gravity bar.
The findings of our study is confirmed by the study of Cuevus
(2004) which concluded that GFS provokes central nervous system to
produce new antigravity postural control reactions by providing the less
possible external support. It poses a physical challenge to the child’s
brain which would create the appropriate internal response. It has strong
impact on the sensory system of the child helping normalize the system
through exercises that send strong messages to the brain to regulate the
tactile, proprioception and vestibular components.
This agreement with Germain et al., (2019) who reported that
rebound therapy enhances cardiovascular and pulmonary functions,
modulates of muscle tone, improves kinesthetic awareness and also
improves postural control. It helps the children with CP to improve their
postural balance and enhances their muscular tone , resultantly improving
their motor performance.
CONCLUSION
From the previous discussion of the results of this study, it can be
suggested that using of spring gravity bar can be effective in improving the
gait pattern through improving knee joint angle in children with spastic
diplegia.
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د ا رسة تاثير العلاج بالمشى عمى شريط الجاذبية الزنبرکى عمى مفصل الرکبة اثناء
المشى عند الاطفال المصابين بالشمل التقمصى المزدوج
باسم زکى محمود 1 ، أ.د/ کمال السيد شکرى ، د/ محمد تاج الدين محمد العمرى ،
د/ نهمة محمد اب ا رهيم
-1 بکالوريوس علاج طبيعي ، جامعة 6 أکتوبر ، مصر.
-2 استاذ متفرغ بقسم العلاج الطبيعى للاطفال کمية العلاج الطبيعى - جامعة القاىرة
-3 مدرس بقسم ج ا رحة العظام کمية الطب - جامعة القاىرة
-4 مدرس بقسم العلاج الطبيعى للاطفال کمية العلاج الطبيعى - جامعة القاىرة
ييدف ىذا البحث الى تقييم تاثير العلاج بالمشى عمى شريط الجاذبية الزنبرکى عمى مفصل الرکبة
اثناء المشى عند الاطفال المصابين بالشمل التقمصى المزدوج بعد المشارکة فى برنامج العلاج
الطبيعى الذى يتکون من برنامج من التمرينات العلاجية المختارة و برنامج شريط الجاذبية الزنبرکى
ثلاث م ا رت فى الاسبوع لمدة ثلاث اشير. ستة وثلاثون طفلا مصابا بالشمل التقمصى المزدوج من
کلا الجنسين . تت ا روح اعمارىم بين السابعة و العاشرة من العمر، تم اختيارىم من العيادة الخارجية
بمستشفى الاطفال بجامعة القاىرة و مرکز کمال شکرى لاعادة التاىيل . و قد تم تقسيميم بشکل
عشوائى الى مجموعتين متساوتين ف العدد)مجموعة الد ا رسة و مجموعة الضابطة( . اظيرت
نتائج ىذه الد ا رسة تحسنا ذا دلالة احصائية فى المتغي ا رت المقاسة لمجموعو الد ا رسة و الضابطة
عند المقارنة قيم المتوسطات قبل و بعد العلاج . وفى الختام تشير النتائج الى انو يمکن تضمين
التدريب عمى المشى عمى شريط لبجمذبية الزنبرکى کطريقة علاجية بديمة لتعزيز المشى و الوظيفة
الحرکية لدى الاطفال المصابين بالشمل التقمصى المزدوج.
الکممات الدالة: التقمصى المزدوج ، شريط الجاذبية الزنبرکى ، تحميل ثنائى الابعاد.
93 Egypt. J. of Appl. Sci., 36 (5-6)2021