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OJHAS Vol. 9, Issue 4:
(Oct-Dec, 2010) |
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| Effect of Modified Suit Therapy
in Spastic Diplegic Cerebral Palsy - A Single Blinded Randomized Controlled
Trial |
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Jagatheesan Alagesan, Associate
Professor, KJ Pandya College of Physiotherapy, Sumandeep University, Vadodara,
Angelina Shetty, Senior
Physiotherapist, Mobility India, Bangalore |
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Address For Correspondence |
Associate Professor,
KJ Pandya College of Physiotherapy,
Sumandeep Vidyapeeth,
Piparia, Waghodia,
Vadodara, India - 391760.
E-mail:
jagatheesanmpt@yahoo.com |
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Alagesan J, Shetty A. Effect of Modified Suit Therapy
in Spastic Diplegic Cerebral Palsy - A Single Blinded Randomized Controlled
Trial. Online J Health Allied Scs.
2010;9(4):14 |
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Submitted: Jul 26,
2010; Accepted: Nov 2, 2010; Published: Jan 20, 2011 |
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| Abstract: |
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Background
& Objective: Development
of gross motor function in children with cerebral palsy has been a primary
goal of physical therapists for decades. Suit therapy has been proposed
as an adjunct to conventional physiotherapy to treat the impairments
associated with cerebral palsy. Providing an orthosis along with the
conventional therapy improves the motor performance of the child. Hence,
this study aimed to determine the effect of modified suit therapy in
gross motor function of spastic diplegic children. Method: A simple random
sample of 30 spastic diplegic subjects in age group of 4-12 years fulfilling
inclusion criteria from Mobility India, Bangalore was included. The
outcome was evaluated using Gross Motor Function Measure-88 scale before
and after the intervention. Suit therapy along with the conventional
therapy is given for 2hrs daily for duration of 3 weeks. Results
& Conclusion: Wilcoxon signed
rank test and Mann-Whitney U test were used to find the significance
of improvement before and after the intervention. There was statistically
significant difference between the experimental and control groups (P=0.030).
It is concluded that modified suit therapy along with conventional physiotherapy
is effective in improving the gross motor function of children with
spastic diplegic cerebral palsy.
Key Words:
Cerebral palsy; Spastic diplegia; Modified Suit therapy
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Cerebral
palsy describes a group of disorders of the development of movement
and posture, causing activity limitation that is attributed to non-progressive
disturbances that occurred in the developing brain. The motor disorders
of cerebral palsy are often accompanied by disturbances of sensation,
cognition, communication, perception and behaviour and by seizure disorder.(1) Around 8000-10000 babies and infants are diagnosed annually
with cerebral palsy. Cerebral palsy is the second most common neurological
impairment in childhood. The incidence of cerebral palsy is 2-2.5 per
1000 live births. The incidence of spastic cerebral palsy is more common
than the other types of cerebral palsy which accounts 50% of identified
cases.(2)
Treatment
program is use of specific sets of exercise to work towards 3 important
goals, preventing the weakening or deterioration of muscles that can
follow disuse, avoiding contractures and to improve the child’s motor
development. It also includes activities and education to improve flexibility,
strength, mobility and function.(3)
A
variety of functional aids are available for therapy programs for cerebral
palsy children like the prone or supine board, corner chair, feeding
chair, other adaptive seating arrangements, sensory and motor stimulating
toys, standing tables, etc. Use of brace together with a therapy program
has both components and detractors. Therapy and bracing may be mutually
supplemental in helping to achieve functional development. Use of braces
should be task oriented like, in standing or weight bearing. As the
child develops toward weight bearing and ambulation, appropriate use
and progression to walker, crutches and canes must be considered.(4-6)
Suit
therapy has been proposed as an alternative to conventional therapy
to treat the impairments associated with cerebral palsy. Suit therapy
also known as the Adeli suit, polish suit, therapy suit and penguin
suit. It is a modification of a space suit. This therapy is based on
a suit originally designed by the Russians for use by cosmonauts in
space to minimize the effect of weightlessness. Although the cause of
motor dysfunction between cerebral palsy patients and astronauts are
different, results of a treatment trial with the Penguin suit to rehabilitate
children with cerebral palsy appeared promising.(7)
Therasuit
is a soft dynamic proprioceptive orthotic device, which is classified
as class I Limb Orthosis by the U.S. Food and Drug Administration. (8)
It consists of a vest, shorts, headpiece and knee piece, and shoes with
hooks. Suit therapy has been proposed as an alternative to conventional
physiotherapy to treat the impairments associated with cerebral palsy.(7) Providing an orthosis along with the conventional therapy improves
the motor performance of the child.
Hence, the purpose of this study is to determine the effect of modified
suit therapy in spastic diplegic children aimed at making the child
more independent.
The objective of the study was to
determine the effect of Modified Suit Therapy in gross motor function
of children with spastic diplegic cerebral palsy.
Source of
data: Children
with spastic diplegic cerebral palsy, between 4 and 12 years of age
from Mobility India, Bangalore were selected for the study. Both sexes
were included for the study. Subjects with subluxation or dislocation
of hip, fracture of spine or limbs, severe scoliosis, seizures, mental
retardation, severe spasticity with contractures and any other congenital
deformity were excluded from the study.
Sampling
technique: 30
children fulfilling inclusion criteria were selected with informed consent
from their parents and assigned randomly into two groups with 15 in
each by lottery method. Group-A, Experimental group receiving Modified
Suit therapy along with conventional therapy and Group-B, Control group
receiving only conventional therapy.
Study design: Single
Blinded Randomized Controlled Trial.
Ethical
Clearance: The study was approved by Institutional Ethical Committee.
Intervention: Control
group received conventional therapy, which includes available active
movements of the limbs, strengthening of the muscles, stretching, weight
bearing on both the feet first supported and later unsupported standing,(4)
weight bearing facilitation with proper rotation of trunk and pelvis.(3)
It also included weight shifts, correction of abnormal postures and
deformities, technique to improve the stability, balance training technique
to train standing and counterpoising using the facilitation of arm.(4)
Facilitation of walking using techniques of balance and posture control,
Gait training and stair climbing.(3)
Experimental
group received conventional therapy while wearing Modified Suit consisting
of a vest, shorts, knee pad and shoe attachments.(9,10) Both
groups were treated for 2 hours daily with short breaks of around 20
minutes for duration of 3 weeks.(10)
Outcome
measure: Gross Motor Function Measure-88 scale was used to evaluate all
subjects before and after the intervention.
Tester: The
data were collected by a blinded tester working as Associate Professor
in Physiotherapy for a teaching institute in Bangalore.
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Data Analysis and Results |
The
data were put for analysis using SPSS 11.5
software, to compare the pre and post therapy test scores and to find
out the significance of the data by using Wilcoxon signed rank test
and Mann Whitney U-test.
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Table
1: Age and Sex distribution of subjects
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Age
(yrs) |
Experimental Group |
Control Group |
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Male |
Female |
Total |
Male |
Female |
Total |
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4-6 |
1 |
1 |
2 |
5 |
2 |
7 |
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7-9 |
6 |
3 |
9 |
3 |
2 |
5 |
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10-12 |
2 |
2 |
4 |
3 |
0 |
3 |
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Total |
9 |
6 |
15 |
11 |
4 |
15 |
It is observed in the
study that, of the 15 subjects from experimental group there were 2
(13.3%) belong to 4-6 years of age, 9 (60.0%) were from 7-9 years of
age and 4(26.7%) had belonged to 10-12 years of age. In the
control group, of the 15 subjects, 7 (46.7%) were from 4-6 years of
age, 5 (33.3%) from 7-9 years of age and only 3 (20.0%) had belonged
to 10-12 years of age.
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Table 2:
Comparison within the group
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Study
group |
Pre treatment |
Post treatment |
z-value |
p-value |
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Mean
± SD |
Mean ± SD |
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Experimental |
59.22 ± 9.41 |
63.16 ± 10.25 |
5.525 |
<0.001 |
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Control |
51.7 ± 12.97 |
53.25 ± 13.25 |
4.298 |
<0.001 |
Comparison
within group was done by using Wilcoxon signed rank test and it is observed
that in the experimental group the mean ± SD of pre-treatment is 59.22 ±
9.41 and in post-treatment is 63.16 ± 10.25. The difference in the mean
from the pre-test to post-test is statistically significant with z=5.525
and p<0.001. In the control group, the mean ± SD of pre-treatment is 51.7 ±
12.97 where as in post-treatment it is 53.25 ± 13.25. The improvement is statistically
significant with z=4.298 and p<0.001. Both groups displayed statistically
significant improvement with p value less than 0.001.
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Table 3:
Comparison between
the groups
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Treatment |
Experimental group |
Control group |
z-value |
p-value |
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Mean
± SD |
Mean ± SD |
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Pre |
59.22 ± 9.41 |
51.70 ± 12.97 |
1.818 |
0.080 |
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Post |
63.16 ± 10.25 |
53.24 ± 13.25 |
2.293 |
0.030 |
The
comparison between the experimental and control group was done by using
Mann Whitney U-test. The pre-test scores of both groups displayed no
statistically significant difference with z=1.818 and p=0.080 which
proves the experimental and control groups were homogenous before treatment.
In the post-treatment, the mean ± SD for experimental group is 63.16 ±
10.25 and for control group is 53.24 ± 13.25 with z=2.293 and p value being
0.030 showing statistically significant difference between groups.
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Graph 1: Graphical representation of Pre and Post treatment mean values
of the experimental and control groups. |
A
spastic diplegic child usually stands on the toes, Standing on the toes
does not allow for proper weight bearing on the heels. In addition,
it will increase the muscle tone in the calf muscles. Also, when standing
on the toes with the upper extremities abducted, and flexed, the entire
body tilts forward displacing the center of gravity forward. Hence it
would be difficult to maintain adequate balance and weight shifting.(9,11) Studies show that a CP person would use 3 times more energy performing
the same activity as a non-affected peer. Therefore fatigue and lack
of endurance is very common.(12)
The
therasuit provides external stabilization to the trunk and therefore
allows more fluent and coordinated movement for both upper and lower
extremities. The vestibular system, through the position of the body,
records space and analyzes the muscle tone necessary to execute the
movement. Patients with ataxia and athetosis benefit from the use of
the therasuit through stabilization effect to the trunk.(9) The theory
behind the Suit therapy is that it induces a strong afferent proprioceptive
input, which stimulates the formation of cerebral systems whose postnatal
development has been delayed.
Benefits
of Suit therapy includes external stabilization, normalizing muscle
tone, aligns the body to as close to normal as possible, normalizing
gait pattern, providing tactile stimulation, influencing the vestibular
system, improving balance, supports weak muscles, providing resistance
to strong muscles to further enhance strength, helping to decrease contractures
and improving coordination. When modified suit is applied, very specific
and precise placement of the elastic bands moves the entire body back
on the heels and into, a more vertical position. Center of gravity moves
back in between the feet. Very noticeable changes in muscle tone take
place. A more relaxed and upright posture with corrected alignment of
lower and upper extremities is noted immediately. This is how the orthosis
normalizes muscle tone through the postural changes. This restoration
of posture and proper function of postural muscles allows the child
to learn (or relearn) proper patterns of movement.(9)
Bar-Harim
et al on Comparison of efficacy of Adeli suit and neurodevelopmental
treatments in children with cerebral palsy stated that improvements
in motor skills and their retention 9 months after treatment were not
significantly different between the two treatment modes.(10)
A
study by Elizabeth Datorre on intensive therapy combined with strengthening
exercises using the Therasuit in a child with cerebral palsy concluded
that the therasuit with intensive program including aquatherapy, hippotherapy
helps to improve patient’s functional abilities.(13)
Raouf
Seifeldin et al in a pilot study on the use of Suit Therapy in childhood
cerebral palsy suggested that the combination of suit therapy with a
short course of intensive physiotherapy may sufficiently reduce the
functional limitation of children with cerebral palsy.(14)
Koscielny
and Koscielny in a study on the effectiveness of therasuit method confirmed
that there is high level of effectiveness of the intensive exercise
method in conjunction with the soft dynamic proprioceptive orthosis.(15)
Semenova,
claims positive clinical effects of dynamic proprioceptive correction
with orthosis in 70% of patients with residual-stage infantile CP, including
improvements in walking and self-care. These effects were demonstrated
by EEG, EMG, studies of somatosensory evoked potentials, and studies
of the vestibular system.(16)
The result of this is matching with the present study, but in this study
the effects were demonstrated using the GMFM-88 scale.
Alexander
Frank et al reported a marginal improvement in control group and suit
therapy group without any statistical difference in results between
the groups.(17)
Limitations of the Study
- Treatment was given
for a short duration (3 weeks) and long term effects were not intended.
- The study was conducted
on a small population.
This
study concludes that modified suit therapy along with conventional physiotherapy
is effective in improving the gross motor function in children with
spastic diplegic cerebral palsy.
The authors wish to acknowledge Dr. Anandbabu Ramadass, Associate Professor in
Physiotherapy, Bangalore worked as blinded tester of this study and Mr. Soikat
Ghosh Moulic, Assistant Director, Rehab & Technical Services, Mobility India,
Bangalore for providing technical support in making of the orthosis.
- United Cerebral
palsy Research and Educational Foundation. Developmental medicine &
Child Neurology. 2005;47:571-576
- Rosen MG, Dickinson
JC. The incidence of cerebral palsy. Am J Obstet Gynecol 1992;167:417-423
- Scherzer AL, Tscharnuter I. Early Diagnosis and Therapy in Cerebral Palsy: A Primer on infant Development Problems. 2nd ed. Pediatric
Habilitation Series, Vol 6. Marcel Dekker Inc.; New York, NY 10016. 1990
- Levitt S. Treatment
of Cerebral Palsy and Motor Delay. 3rd edition. Blackwell Science; Cambridge, Mass., USA. 1995. pp191-217
- Freeman M, Bachrach SJ. Cerebral Palsy: A Complete Guide for Caregiving.
Johns Hopkins University Press, Baltimore, Maryland 1995
- Liptak GS. Complementary
and alternative therapies for cerebral palsy. Ment Retard Dev Disabil
Res Rev.2005;11(2):156-63
- Aetna Clinical Policy
Bulletins – Suit Therapy for Cerebral Palsy. Available at
http://www.aetna.com/cpb/data/CPBA0696.html
- U.S. Food and Drug
Administration (FDA). Code of federal regulations. Title 21; vol. 8. 2006.
- Koscielny R.
Strength Training and cerebral palsy. Cerebral Palsy Magazine. June
2004;2(1):12-14
- Bar-Haim S, Harries
N, Belokopytov M, Frank A, Copeliovitch L, Kaplanski J, Lahat E. Comparison
of efficacy of Adeli suit and neurodevelopmental treatments in children
with cerebral palsy. Dev Med Child Neuro. May 2006;48(5):325-330
- Woollacott MH, Shumway-Cook A. Postural dysfunction during standing and walking in
children with cerebral palsy: what are the underlying problems and what
new therapies might improve balance? Neural Plast. 2005;12(2-3):211-219
- LeMura LW,
Von Dulliard SP. Clinical Exercise Physiology-Application and
Physiological Principles. Lippincott Williams & Wilkins. 2004
- Datorre ECS.
Intensive Therapy Combined with Strengthening Exercises Using the Thera
Suit in a child with CP: A Case Report. American Association of Intensive
Pediatric Physical Therapy. 2005. Available at
http://www.suittherapy.com/pdf%20research/Int.%20Therapy%20%20Research%20Datore.pdf
- Seifeldin R,
Noble C, Jackson A, Northrup J. The Use of Suit Therapy
in Childhood Cerebral Palsy-A Pilot Study; Developmental Medicine &
child Neurology. 2004;46:740-745
- Koscielny I, Koscieln R. The effectiveness of therasuit method and the therasuit.
American Association of Intensive Pediatric Physical Therapy. 2004
- Semenova KA. Basis
for a method of dynamic proprioceptive correction in the restorative
treatment of patients with residual-stage infantile cerebral palsy.
Neuro science behaviour physiology. Nov-Dec 1997;27(6):639-43
- United Cerebral
Palsy Research & Educational foundation; The Adeli Suit [research
fact sheet: diagnosis and treatment]. Washington, DC: Mar 1999 Accessed
from http://www.ucp.org/ucp_generaldoc.cfm/1/4/24/24-6608/82
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