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October2013 Vol.50 Issue:      4 Table of Contents
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Modulation of Lower Extremity Rotational Deformities Using TheraTogs™ and Strapping System in Children with Spastic Diplegia

Ehab M. Abd El Kafy, Samah A. El-Shemy

Department of Physical Therapy for Growth and Developmental  Disorders in Children and its Surgery,

Faculty of Physical Therapy, Cairo University, Egypt



ABSTRACT

Background: Rotational abnormalities are a common in many neuromuscular disorders, such as cerebral palsy. Objective: This study was conducted to investigate the effect of TheraTogs™ and strapping system on femoral anteversion and external tibial torsion in children with spastic diplegia and to determine its effect on the child’s gait. Methods: Thirty children with spastic diplegia from both sexes were randomly assigned into two equal groups. Their age ranged from six to eight years. Control group (A) treated by a designed gait training program, study group (B) received the same program as group (A) in addition to TheraTogs orthotics undergarment and lower extremity strapping bilaterally. Pro-Reflex 3-D system was used to measure rotation angles of hip and knee joints, gait velocity and foot progression angle. Pre and post assessment were performed for both groups following 3 months intervention phase (post1), another assessment time (post2) was added in group B during wearing TheraTogs and strapping system. Results: There was no significant difference in all measuring variables in group (A) when comparing its pre and post assessment. Significant improvement was observed in all measuring variables in group (B) when comparing its pre, post1 and post2assessment and when comparing the post treatment results of the two groups in favor of group (B) (P-value < 0.05). Conclusion: The current study showed positive effect of using Theratogs™ and strapping system on rotational abnormalities and gait pattern from a biomechanical perspective. [Egypt J Neurol Psychiat Neurosurg.  2013; 50(4): 397-402]

Key Words: Spastic Diplegia, femoral anteversion,tibial torsion,TheraTogs™.

Correspondence to Samah A. ElShemy, Department of Physical Therapy for Growth and Developmental Disorders in Children and its Surgery, Faculty of Physical Therapy, Cairo University, Egypt.Tel.: +20 01005014313   e-mail:samah_elshemy@yahoo.com






INTRODUCTION

 

Cerebral Palsy (CP) is a disorder of movement and posture that appears during infancy or early childhood. It is not a single disease but a wide variety of static neuromotor impairment syndromes occurring secondary to a lesion in the developing brain. Progressive musculoskeletal pathology occurs in most affectedchildren.1 Children with CP present with three types of motor problems. The primary impairments of muscle tone, balance, and strength are directly related to damage in the central nervous system (CNS). Secondary impairments of muscle contractures and deformities develop over time in response to the primary problems and musculoskeletal growth.2

Abnormal segment position may be seen in gait such as abnormal rotation at the hip, knee and ankle joints during gait.3 Medial femoral torsion, lateral tibial torsion, with foot valgus and abduction are commonly observed in patients with diplegic cerebral palsy children who walk with a crouch gait.4,5

Femoral Anteversion refer to the relationship between the axes of the femoral neck and the femoral condyles. Femoral ante-version is naturally increased in all babies and regresses as the child grows. Persistent femoral ante-version causes scissoring. Compensatory tibial external torsion is often secondary to femoral anteversion and causes pes-valgus in many children.6 Tibial torsion deformity is characterized by excess twisting about the bone’s long axis. It was postulated that excess tibial torsion reduces the ability of muscles to extend the joints, which may contribute to the crouched posture observed in some patients.7,8 It may also contribute to an external foot progression angle and has been associated with progressive equinovalgus.9,10

Many techniques are used to correct the deformities in the sagittal plane like (Ankle foot orthosis, Posterior knee cage) but there is no specific technique used to correct these rotational deformities. Many clinicians used the twister cable or a spiral strapping from the leg till the pelvic in one direction but it will increase the lateral tibio-fibular rotation.11

TheraTogs™, an orthotic undergarment fabricated from Delta-flex, a lightweight, breathable fabric that is Velcro sensitive, have been developed to provide a gentle, passive force to correct imbalance or alignment through the combination of a trunk and shorts system along with a customized external strapping system. This system can improve joint stability, posture, and gait skills. Adding spiral strapping make the femur externally rotated versus to another one which make the tibia medially rotated in a combination with gait training, may help posture alignment during walking and improve joints angles of lower limbs in transverse and sagittal plane.12,13

 

Aim of work

The aim of the present study was to examine the effect of TheraTogs™ and strapping system on lower extremities rotational deformities (femoral anteversion and external tibial torsion) which affecting the hips and knees rotational angles of both lower limbs during gait cycle and to determine its effect on the gait pattern in children with spastic diplegic CP.

 

SUBJECTS AND METHODS

 

This study was conducted under the guidelines and the approval of Ethics Review Committee of the Faculty of Physical Therapy, Cairo University. Parents signed a consent form authorizing the child’s participation. The participated children were recruited from outpatient clinic of Faculty of Physical Therapy, Cairo University.

Fifty spastic diplegic cerebral palsied children from both sexes were initially screened and assessed to determine age, diagnosis and inclusion and exclusion criteria. Their age ranged from 6 to 8 years. The degree of spasticity in involved lower extremities ranged from 1 to 1+according to Modified Ashworth Scale.14The level of gross motor function ranged from I to II according to Gross Motor Function Classification System (GMFCS).15 Allchildren were cognitively competent and able to understand and follow instructions.

External tibial torsion ranged from 20° to 30°, femoral anteversion ranged from 15° to 30° according to rotational profile.16,17The exclusion criteria include children with major lower extremities rotational mal-alignment, with allergic reactions to the adhesive tape, children with visual, auditory, perceptual deficits or with surgical interference for the lower limbs.

Thirty children had met the inclusion and exclusion criteria and represent the sample of this study. They were assigned randomly into two equal groups. The randomization was computerized based. The control group (A) included (8 boys and 7 girls) treated by a designed physical therapy program without spiral strapping. The study group (B) included (9 boys and 6 girls) treated by TheraTogs orthotics undergarment and strapping system bilaterally in addition to the same physical therapy program given to group (A).

All children in both groups were subjected to pre and post assessment following 3 months intervention phase (post1) of both hip and knee rotation angles and selected gait parameters (foot progression angle and gait velocity) during gait cycle using the pro-reflex 3-D system. All entire gait cycle was captured within the volume from initial contact of one foot to the second toe-off of the other foot. Another assessment time (post2) was added in group B during wearing Theratogs and strapping system following 3 months intervention phase.

The designed treatment protocol addressed postural reactions facilitation from standing position, exercises for postural correction during walking and gait training using different obstacles. The designed treatment program was applied for all children three sessions per week,2 hours each for three months.

The study group (B) engaged in TheraTogs™ and strapping system. They wore vest and short pieces of the TheraTogs™ undergarment. Lower extremity strapping in the form of femoral and tibial spiral strapping was applied for management of femoral anteversion and tibial external rotation. The strapping technique consists of four pieces of the TheraTogs™ elastic strap applied for each femur and each tibia in a spiral manner.18The intervention phase of this study was adapted from Flanagan and colleagues.13 It consisted of wearing an individualized TheraTogs and strapping system for 12 successive weeks, 12 h/day except weekend where the children had no strapping.

 

Statistical Analysis

The obtained data were collected and statistically analyzed using the arithmetic mean and standard deviation. Paired t-test was used for comparison of means pre and post treatment within each group. Unpaired t-test for comparison of means pre and post treatment of the two independent groups. Comparison within the group B (pre), (post1) and (post2) mean values were performed using one way ANOVA test. P value less than 0.05 was considered significant.

 

RESULTS

 

The results of this study showed no significant differences (P>0.05) in the pre-treatment mean values in all measured variables in both groups (Table 1).

There was a no statistical significant difference (P>0.05) in pre and post1 treatment mean values of rotation angles for bilateral hips and knees joints, foot progression angle and gait velocity in group A (Table 2). There were significant differences in the mean values of all measured variables in group (B)when comparing its pre and post1 and post2 treatment mean values P<0.05 (Tables 3). Post-treatment comparison (post1) of both groups showed significant differences in treatment mean values in all measured variables in favor of group B (Tables 4).


Table 1. The mean values of right and left hips and knees rotation angles, foot progression angle and gait velocity pre treatment in both groups A and B.

 

Variables

Group A (Pre)

Group B (Pre)

P-value

Mean ±SD

Mean ±SD

Right hip angle (°)

47.86± 3.44

48.6± 3.01

0.540

Left  hip angle (°)

44.73± 3.2

45.46± 3.31

0.548

Right knee angle (°)

33.6±2.89

34.53±3.44

0.428

Left  knee angle (°)

30.4± 1.95

31.4±3.68

0.361

Right foot progression angle (°)

27.06 ± 1.86       

27.86 ± 1.84

0.248

Left foot progression angle (°)

25.26 ± 3.23       

26.13± 2.74

0.436

Gait Velocity (m/min)

39±3.09

39.86±2.72

0.42

SD: standard deviation, P>0.05 is not Significant.

 

Table 2. The mean values of right and left hips and knees rotation angles, foot progression angle and gait velocity pre and post1 treatment in the control group (A).

 

Variables

Pre

Post1

P-value

Mean±SD

Mean±SD

Right hip angle (°)

47.86± 3.44

47.66±3.24

0.082

Left  hip angle (°)

44.73± 3.2

44.53±3.31

0.08

Right knee angle (°)

33. 6±2.89

33.4±2.99

0.082

Left  knee angle (°)

30.4± 1.95

30.2±1.93

0.082

Right foot progression angle (°)

27.06± 1.86

26.6±2.22

0.169

Left foot progression angle (°)

25.26± 3.23

25.06±3.28

0.082

Gait Velocity (m/min)

39±3.09

39.2±3

0.082

SD standard deviation  

P>0.05 is not Significant.

 

Table 3. Post hoc comparison among the three evaluation times (pre, post1 and post2) for all measured variables in the study group B.

 

 

Variables

Pre

Post1

Post2

Pre vs post1

Post1vs post2

Pre vs post2

Mean±SD

Mean±SD

Mean±SD

Mean

Difference

Mean Difference

Mean Difference

Right hip angle (°)

48.6±3.01

44.53±3.06

40±2.92

4.06

4.53

8.6

 

 

 

 

P =0.001*

P =0.000*

P = 0.000*

Left  hip angle (°)

45.46±3.31

38.73±3.26

34.66±3.08

6.73

4.06

10.8

 

 

 

 

P =0.000*

P =0.001*

P = 0.000*

Right knee angle (°)

34.53±3.44

30.13±2.85

24.46±3.75

4.4

5.66

10.06

 

 

 

 

P =0.000*

P =0.000*

P = 0.000*

Left  knee angle (°)

31.4±3.68

27.0± 3.27

21.4±3.56

4.2

5.8

10

 

 

 

 

P =0.002*

P =0.000*

P = 0.000*

Right foot progression angle (°)

27.86±1.84

24±2.29

20.6±1.8

3.86

3.4

7.26

 

 

 

 

P =0.000*

P =0.000*

P = 0.000*

Left foot progression angle (°)

26.13±2.74

21.13±1.99

18.4±2.97

5

2.73

7.73

 

 

 

 

P =0.000*

P =0.006*

P = 0.000*

Gait Velocity (m/min)

39.86±2.72

45.8±3.83

49.66±3.65

5.93

3.86

9.8

 

 

 

 

P =0.000*

P =0.004*

P = 0.000*

SD standard deviation *Significant at P<0.05

 

Table 4. The mean values of right and left hips and knees rotation angles, foot progression angle and gait velocity post treatment in both groups A and B.

 

Variables

Group A Post1

Group B Post1

P-value

Mean±SD

Mean±SD

Right hip angle (°)

47.66±3.24

44.53± 3.06

0.001*

Left hip angle (°)

44.53± 3.31 

38.73± 3.26

0.000*

Right knee angle (°)

33.4± 2.99

30.13±2.85

0.005*

Left knee angle (°)

30.2± 1.93

27.0± 3.27

0.005*

Right foot progression angle (°)

26.6± 2.22

24± 2.29

0.004*

Left foot progression angle (°)

25.06± 3.28

21.13± 1.99

0.000*

Gait Velocity (m/min)

39.2±3

45.8±3.83

0.000*

SD standard deviation *Significant at P<0.05

 

 


                                                DISCUSSION

 

The results of this study proved the effectiveness of this preventive and conservative type of orthotic intervention in children with spastic diplegia. It could be helpful in preventing further lower extremity rotational deformities, improving gait function and limiting the development of abnormal gait patterns.

In this study, selection of children was delimited to those with external tibial torsion between 20-30°, femoral anteversion within 15-30°. This strict delimitations aimed to get the children most benefits and fitted for this type of conservative intervention.19,20 When treating children with diplegia Gaston and colleagues.21 drew attention to that all segments must be considered and not only sagittal but transverse planes of movement also must be considered and examined with instrumented gait analysis.

The significant reduction in the mean values of bilateral hips and knees angles in the transverse plan during gait cycle in group B could be explained by the effect of TheraTogs and spiral strapping in managing tibial external rotation and femoral anteversion. This dynamic splinting is certainly a viable and useful physical therapy intervention tool for management of biomechanical malalignment and poor postural control in children with CP. Many researchers proposed that therapeutic taping would provide the foundation for increasing proprioceptive and tactile facilitation; controlling trunk movement in the frontal and sagittal  planes; restoring optimal muscle length to provide a foundation for normal firing and recruitment patterns; orienting the muscle force along more normal vectors; finally assisting with static and dynamic balance.22-26

Significant differences between the mean values of (pre), (post1) and (post2) treatment measurements for both hip and knee rotation angles in group B were observed. This difference become highly significant in (post2) when TheraTogs orthotics undergarment and spiral strapping were applied which is the biomechanical effect. Theratogs and strapping system affects the muscle imbalance (the soft tissue factors) as well as it helps the muscle action, and realigning of the position of both hip and knee joints. Correction of the proprioceptive input from the peripheral muscles and joints to central nervous system is considered as the prolonged effect (neurodevelopmental effect).

The post-treatment results of the study group reinforced the effectiveness of TheraTogs orthotics undergarment and strapping system on improving body awareness, postural stability, and resting and functional joint alignment during therapy, as well as during performance of activities of daily living. TheraTogs apply prolonged, low load (gentle) forces to the musculoskeletal system to affect changes in muscle recruitment strategies and with fulltime use, in muscle physiology and bone geometry.13Theratogsand strapping system improve percept of correct spatial orientation and mapping and increase trunk stiffness, which improved proximal stability and reduce the number of body segments needed to coordinate when trying to balance and move.27-29

The way of application of the elastic straps assist the muscle action by helping the correction of the soft tissues and muscles imbalance, and realigned the position of the joints of lower limbs. This comes in agreement with Bar-haimand colleagues.30who stated that, the placement of the elastic straps can assist weak muscles and correct abnormal body positions or movement patterns from non-structural sources (such as tight muscles rotating the legs).

The post-treatment results of the study group (B) come in agreement with Flanagan and colleagues13, who found that TheraTog™ orthotic garment worn for a successive 12-week period, 12 hours daily could improve gait and functional skills in some children with diplegic CP. This agrees with Siracusa and colleagues31, who reported that TheraTogs™ soft garment with strapping system could improve temporal/distance gait factors, functional abilities and range of motion in some children with diplegia when applied over an 8 week time period. Lower extremity strapping applications can gently rotate the leg unit as needed to improve foot alignment and function. It can reduce hip adduction and keep the legs apart to correct scissoring gait. In addition, it can reduce trunk, hip, and knee flexion.32,33

There was improvement in gait parameters recorded in this study in group B through the reduction in bilateral foot progression angles and the increment of gait velocity due to spiral strapping managing femoral anteversion and external tibial torsion. Proper lower limb segmental alignment in the transverse plane (the foot is not excessively rotated, either externally or internally) relative to the knee flexion-extension axis is required for the internal plantar flexor moment to most effectively facilitate knee extension in single support.34-37Aionaand colleagues38stressed on that correction of external tibial torsion in ambulatory patients with CP improves the kinematic and kinetic deviations identified by gait analysis.

Ho and colleagues39investigated the influence of foot progression angle on the ankle joint and the gait patterns and mechanisms in skeletally normal preschool children. They suggested that toe-in and toe-out are related to walking speed, which has distinct influences on the kinematics and kinetics of the ankle joint. Lythgo and colleagues40 documented that foot angle was significantly less (less toe-out) for the fast speed than the slow speeds in healthy primary school-aged children and young adults.

Conclusion

From this study, it could be concluded that wearing TheraTogs orthotics undergarment and strapping system during standing and walking, might be helpful in minimizing the future development of rotational deformities of affected lower extremities and in improving gait parameters in spastic diplegic children.

 

[Disclosure: Authors report no conflict of interest]

 

REFERENCES

 

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24.     Cusick B. Lower extremity management for children with CNS dysfunction: Developmental and closed-chain biomechanics: casting, orthotic and taping implications. Course Materials October 1997; 18–24.

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32.     Maguire C, Sieben J, Frank M, Romkes J.  Hip abductor control in walking following stroke – the effect of canes, taping and TheraTogs on recovery of muscle activity. Clin Rehabil., 2010; 24(1): 37-45.

33.     Engelmeyer P, Kelly ST. The effect of TheraTogs on gait in a 5-year-old with spastic hemiplegia. Poster session presented at: APTA Combined Sections meeting of School of Physical Therapy, Maryville University; 2007 Feb 14-18; St. Louis, MO.

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الملخص العربى

 

تعديل التشوهات الالتفافية للأطراف السفلية باستخدام الثيراتوجز والتربيط الحلزوني

فى الأطفال ذوي الشلل التقلصي المزدوج

 

تهدف هذه الدراسة إلى تقييم تأثير الثيراتوجز والتربيط الحلزوني علي تعديل التشوهات الالتفافية للأطراف السفلية عند الأطفال ذوي الشلل التقلصي المزدوج. تم إجراء هذا البحث على ثلاثين طفل وطفلة تراوحت أعمارهم من ستة إلي ثمانى سنوات. تم تقسيم المرضى عشوائياً إلى مجموعتين متساويتين: المجموعة أ (المجموعة الضابطة) والمجموعة ب (مجموعة الدراسة). تلقت المجموعة أ برنامج علاج طبيعى مصمم لتدريبات المشى بينما تلقت المجموعة ب نفس برنامج تدريبات المشى ولكن أثناء ارتداء الثيراتوجز والتربيط الحلزوني للأطراف السفلية. و تم قياس زاويا مفصلي الفخذ والركبة أثناء دورة المشي من المقطع العرضي وكذلك قياس زاوية تقدم القدم وسرعة المشى بواسطة معمل تحليل الحركة ثلاثي الأبعاد. وقد تم إجراء القياس للمجموعتين قبل وبعد الانتهاء من العلاج بثلاثة اشهر (بعد-1) وتم إضافة قياس ثالث للمجموعة بحين ارتداء الثيراتوجز والتربيط الحلزوني  (بعد-2). وقد أظهرت النتائج عدم وجود فروق ذات دلالة إحصائية عند مقارنة نتائج ما قبل وبعد العلاج فى المجموعة أ. بينما لوحظ وجود فروق ذات دلالة إحصائية لمجموعة ب في نتائج الثلاث قياسات عند مقارنة نتائج ما قبل العلاج بنتائج ما بعد العلاج مع زيادة هذا الاختلاف بشكل اكبر وملحوظ حين ارتداء الثيراتوجز والتربيط الحلزوني. كما أسفرت النتائج عن وجود فروق ذات دلالة إحصائية لمجموعة الدراسة ب عند مقارنة نتائج ما بعد العلاج للمجموعتين. ومن هنا يتضح أن استخدام الثيراتوجز والتربيط الحلزوني له تأثير إيجابي فى تعديل التشوهات الالتفافية للأطراف السفلية وكذلك تحسين أنموذج المشى عند الأطفال ذوي الشلل التقلصي المزدوج.



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