Zancolli classification hand function scale was formed by Eduardo Zancolli in 2003. He first used this scale in assessing the children with cerebral palsy who underwent reconstructive surgery. In this scale he explained about the grasping and release patterns between the wrist and fingers and hand appearance of the spastic children. He explained the hand appearance in degrees and that, degrees of extension can be measured using goniometer. The responses of the scale was scored as 0, 1, 1a, 2a, 2b and 3.
Scoring:
0: Patients can extend the wrist more than 20 0 with the fingers extended.
1a: Patients can extend the wrist between 0 and 20 0 with the fingers extended
1b: Patients can extend the wrist between -200 and -10 with the fingers
extended
2a: Patients can extend the wrist with the finger flexed.
The fingers can also be extended, but with more than 20 0 of wrist flexion.
2b: Patients cannot extend the wrist with the finger flexed.
The fingers can be extended, but with more than 200 of wrist flexion.
3: Extension of the fingers and wrist is impossible.
Interpretation:
Maximum score is 3
Minimum score is 0.
The lowest score indicates no deformity and highest score indicates severe deformity.
3.8.3. Cryotherapy:
The term “cryotherapy” comes from the Greek word cryo means cold and the word therapy means cure. It has been around since the 1880-1890s. The ancient Greeks knew the secrets of wellness Cryotherapy (Greek “cryo” – cold, “therapeia” – cure) is a term used for treatment based on exposing the human body to very low temperatures for brief periods at a time. Cryotherapy came into broad use in the care of sports injuries during the 1970s.
Articles Needed:
1. A plinth to position the subject
2. Ice Packs
3. A stopwatch
4. Towels – 2
5. Bowl with cotton ball
6. Spirit
7. Goniometer
Procedure:
Step 1: Explain the procedure to the care giver
Step 2: Arrange all the articles
Step 3: Prepare the child by removing the clothing from the elbow to fingers
Step 4: Level of spasticity and hand function is assessed using Ashworth scale
and zancolli classification hand function scale.
Step 5: Wrap the ice pack in a wet towel.
Step 6: The area is cleaned with spirit cotton and the upper limb of the child
was positioned on pillow.
Step 7: Place the wrapped pack on the flexor compartment of the forearm
Step 8: Leave the pack in place with dry towel
Step 9: After 5 minutes assess for any adverse effects like rashes.
Step 10: The ice pack was applied for 20 minutes and then removed and dried
Step 11: Make the child comfortable
Step 12: Replace the articles
Step 13: Level of spasticity and hand function is measured after 10 days.
3.9. HYPOTHESES
H01: There is no significant difference between experimental group and control group in the level of spasticity and hand function before cryotherapy among children with cerebral palsy.
H1: There is a significant difference in the level of spasticity and hand function before and after cryotherapy among children with cerebral palsy of experimental group.
H02: There is no significant difference in the level of spasticity and hand function before and after intervention among children with cerebral palsy of control group.
H2: There is a significant difference between experimental and control group in the level of spasticity and hand function after cryotherapy among children with cerebral palsy.
3.10. PILOT STUDY
Pilot study was conducted to find out feasibility and practicability, validity and reliability of the study. The study was conducted at Aashirwad special school for a period of 6 days. A total of 6 samples were selected for the study in simple random sampling technique. Personal information was collected. A pre assessment was done using Ashworth scale and Zancolli classification hand function scale followed that cryotherapy was administered by the researcher for 30 minutes daily for each child for a period of 6 days. Post test was done on the 6th day. Data collected was tabulated and analyzed using descriptive statistical methods. The results showed that, there was a significant improvement in children after cryotherapy. Hence the study was feasible and practicable.
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3.11. MAIN STUDY
The main study was conducted to meet the objectives of the present study. The data was collected at Families for Children for a period of 30 days. The children were selected according to purposive sampling technique. Total of 30 samples were allocated alternatively into experimental and control group. The researcher explained the procedure to care givers of the children and obtained consent from the care givers. Demographic data was collected first. A pre assessment was done using Ashworth scale and Zancolli classification hand function scale for the children with cerebral palsy. Cryotherapy was administered to the child by the researcher for duration of 20 minutes daily for a period of 10 days to each child in a comfortable environment. The post test was done using the same tool at the end of 10th day of intervention.
3.12. TECHNIQUE OF DATA ANALYSIS AND INTERPRETATION
A frequency table was formulated for all significant information. Descriptive and inferential statistical method was used for data analysis. ‘t’ test for dependent samples was used to find the significance of cryotherapy. ‘t’ test for independent samples was used to find out the comparison of post test scores among experimental and control group.
DATA ANALYSIS AND INTERPRETATION
The effectiveness of cryotherapy prior to passive stretching on the level of spasticity and hand function among children with CP was assessed and analyzed. The participants of the study were children with spastic cerebral palsy. Totally 30 samples were selected for the study and randomly divided into experimental and control group. The intervention selected for the present study was cryotherapy for 20 minutes before passive stretching on the level of spasticity and hand function. The level of spasticity was assessed before and after cryotherapy by using Ashworth scale. Hand function was assessed before and after cryotherapy using Zancolli classification hand function scale.
The collected data were grouped and analyzed using descriptive and inferential statistical methods.
SECTION – I
4.1. DEMOGRAPHIC VARIABLES
The following demographic variables are distributed in the form of tables and graphs. The demographic variables are age (in years), sex and types of cerebral palsy among children with spastic cerebral palsy.
TABLE 4.1.
DISTRIBUTION OF DEMOGRAPHIC VARIABLES
AMONG CHILDREN WITH CEREBRAL PALSY
(N=30)
Demographic
Variables
Experimental group
Control group
No. of participants
Percentage
(%)
No. of participants
Percentage
(%)
Age (years)
6-9
3
20
5
33
9-12
5
33
7
47
12-15
7
47
3
20
Sex
Male
5
33
4
27
Female
10
67
11
73
Types of CP
Diplegic
5
33
7
47
Quadriplegic
10
67
8
53
The table shows the distribution of demographic variables like age (years), sex, and type of CP that are children with spastic cerebral palsy. The age distribution children with spastic cerebral palsy range from 6-15 years in which 47% of children from experimental group range from 12-15 years and in control group they range from 9-12 years respectively. 20% of children from experimental group and control group range from 6-9 years and 12-15 years respectively. 33% of children from experimental group and control group range from 9-12 years and 6-9 years respectively. In both the group majority of children were female while 33% in experimental group and 27% in control group were male. In both groups, majority of children were quadriplegic while 33% in experimental group and 47% in control group were diplegic.
FIG 4.1
AGE DISTRIBUTION OF CHILDREN WITH SPASTIC CEREBRAL PALSY
FIG 4.2
GENDER DISTRIBUTION OF CHILDREN WITH SPASTIC
CEREBRAL PALSY
FIG 4.3
DISTRIBUTION OF TYPES OF CP AMONG CHILDREN
WITH CEREBRAL PALSY
SECTION II
4.2. 1. ASSESSMENT ON THE LEVEL OF SPASTICITY AMONG
CHILDREN WITH CEREBRAL PALSY
The ashworth scale consists of 5 point scale used to assess the level of spasticity among children with cerebral palsy in both experimental and control group. The assessment was done for both the hands before and after cryotherapy.
TABLE 4.2.
ASSESSMENT ON THE LEVEL OF SPASTICITY (ON RIGHT HAND) AMONG CHILDREN WITH CEREBRAL PALSY BEFORE AND AFTER CRYOTHERAPY
(N=30)
Level of spasticity
Experimental group
Control group
Before
After
Before
After
n
%
n
%
n
%
n
%
No spasticity
–
–
1
3
–
–
–
–
Mild spasticity
1
3
11
37
2
7
2
7
Moderate Spasticity
14
47
3
10
13
43
13
43
The table shows that in experimental group majority of children with spasticity (47%) had moderate spasticity before the intervention whereas majority (37%) had mild spasticity after intervention. In control group there was no changes after intervention. The scores on comparison showed reduction in the level of spasticity among children with cerebral palsy on right hand.
TABLE 4.3.
ASSESSMENT ON THE LEVEL OF SPASTICITY (ON LEFT HAND) AMONG CHILDREN WITH CEREBRAL PALSY BEFORE AND AFTER CRYOTHERAPY
(N=30)
Level of spasticity
Experimental group
Control group
Before
After
Before
After
n
%
n
%
n
%
n
%
No spasticity
–
–
1
3
–
–
–
–
Mild spasticity
1
3
12
40
2
7
6
20
Moderate Spasticity
14
47
3
10
13
43
9
30
The table shows that in experimental group majority of children with spasticity (47%) had moderate spasticity before the intervention whereas majority (40%) had mild spasticity after intervention. In control group majority (43%) had moderate spasticity before intervention and mild difference occurs after intervention. The scores on comparison show reduction in the level of spasticity among the experimental group children with cerebral palsy on left hand.
4.2.2. ASSESSMENT ON HAND FUCTION AMONG CHILDREN WITH
CEREBRAL PALSY
The zancolli classification hand function scale used to assess hand function among children with cerebral palsy in both experimental and control group. The assessment was done for both the hands before and after cryotherapy.
TABLE 4.4.
ASSESSMENT ON HAND FUNCTION AMONG CHILDREN WITH CEREBRAL PALSY BEFORE AND AFTER CRYOTHERAPY
(N = 30)
Hand
Experimental Group
Control Group
Before
After
Before
After
Mean
Mean%
Mean
Mean%
Mean
Mean%
Mean
Mean%
Right
3.2
64
1.86
37
2.6
53
2.66
53
Left
3.1
62
1.7
34
2.73
55
2.53
51
Hand function on both right and left hand among children with cerebral palsy of experimental group shows that there was an improvement in hand function after intervention, when compared with the scores before intervention. In control group there was a mild changes in the right and left hand assessment scores after intervention. Thus the score reveals that the experimental group children had positive improvement in the hand function compared to control group children.
SECTION – III
4.3.1. COMPARISON ON THE LEVEL OF SPASTICITY AND HAND
FUNCTION AMONG CHILDREN WITH CEREBRAL PALSY IN
EXPERIMENTAL AND CONTROL GROUP BEFORE INTERVENTION
Before intervention, assessment on the level of spasticity and hand function was done among experimental and control group. The obtained scores were analyzed using ‘t’ test for independent samples, to prove the effectiveness of the intervention.
TABLE 4.5.
COMPARISON ON THE LEVEL OF SPASTICITY AND HAND FUNCTION AMONG CHILDREN WITH CEREBRAL
PALSY IN EXPERIMENTAL GROUP AND CONTROL GROUP BEFORE INTERVENTION
Group
Level of spasticity
Hand function
Right Hand
Left hand
Right Hand
Left hand
Mean
Mean %
Standard Deviation
‘t’
Mean
Mean
%
Standard Deviation
‘t’
Mean
Mean
%
Standard Deviation
‘t’
Mean
Mean %
Standard Deviation
‘t’
Experimental
2.26
57
0.5
0.3
2
50
0.51
1.2
3.2
64
0.84
1.6
3.1
45
0.83
0.4
Control
2.3
58
0.3
2.6
57
0.57
2.6
52
1
2.7
54
0.9
(N=30)
The above table depicts the obtained ‘t’ value calculated for the level of spasticity and hand function of experimental group and control group before intervention. The level of spasticity on right hand of children among experimental group the mean percentage score was 57% (0.57) and the control group was 58% (0.3). The level of spasticity on left hand of children among experimental group the mean percentage score was 50% (0.51) and the control group was 57% (0.57). The hand function on right hand of children among experimental group the mean percentage score was 64% (0.84) and the control group was 52% (1.07). The level of spasticity on right hand of children among experimental group the mean percentage score was 45% (0.8) and the control group was 54% (0.9). Thus the mean percentage scores show that there is a positive difference in the level of spasticity and hand function among children with cerebral palsy.
‘t’ test for independent samples is used to test the significance in mean difference among the experimental and control groups. The calculated ‘t’ value on the level of spasticity, the right hand score (0.33) and left hand score (1.26) are lesser than the table value at 0.05 level of significance. The calculated ‘t’ value on hand function, the right hand score (1.62) and left hand score (0.38) are lesser than the table value at 0.05 level of significance. Hence the null hypothesis, “There is a no significant difference between experimental group and control group in the level of spasticity and hand function before cryotherapy among children with cerebral palsy” is accepted.
4.3.2. ANALYSIS ON THE LEVEL OF SPASTICITY AND HAND FUNCTION
AMONG CHILDREN WITH CEREBRAL PALSY
Using ashworth scale, the level of spasticity and hand function among the children with cerebral palsy was assessed in both experimental and control group. The assessment was done for both the hands. The obtained scores are analyzed using ‘t’ test dependent samples, to test the effectiveness of cryotherapy prior to passive stretching.
TABLE 4.6.
MEAN, STANDARD DEVIATION, ‘t’ VALUE ON THE LEVEL OF SPASTICITY AND HAND FUNCTION (ON RIGHT HAND) BEFORE AND AFTER CRYOTHERAPY
(N=30)
Group
Level of spasticity
Hand Function
Before
After
Mean difference
‘t’
Before
After
Mean difference
‘t’
Mean
Standard deviation
Mean
Standard deviation
Mean
Standard deviation
Mean
Standard deviation
Experimental
2.26
0.57
1.13
0.5
1.13
10.41**
3.2
0.8
1.86
0.7
1.33
9.8**
Control
2.3
0.3
2.2
0.7
0.13
1.46
2.6
1.07
2.6
1.01
0.06
0.74
** Significant at 0.01 level
The above table reveals the distribution of mean and standard deviation of the obtained scores before and after cryotherapy among experimental group and control group children with cerebral palsy. The level of spasticity among experimental group showed a mean difference of 1.17 while there was mild difference in the control group. Thus the mean score in the level of spasticity shows that there was a positive difference in the reduction of spasticity among children with cerebral palsy of experimental group. Hand function of the experimental group showed a mean difference of 1.33 and the control group mean difference is about 0.06 Thus the mean scores show that there is a positive improvement in hand function among children with cerebral palsy of experimental group.
‘t’ test was used to test the significance in mean difference. The calculated ‘t’ value on the level of spasticity in the experimental group was 10.4 which was compared with the table value at 0.01 level of significance. The calculated ‘t’ value on hand function in the experimental group was 9.8 which was compared with the table value at 0.01 level of significance. The calculated value was higher than the table value. Hence the research hypothesis, “There is a significant difference in the level of spasticity and hand function before and after cryotherapy among children with cerebral palsy of experimental group” is accepted. The calculated ‘t’ value in control group on the level of spasticity was 1.46 and hand function was about 0.7 which was found to be lesser than the table value. Therefore the null hypothesis, “There is no significant difference in the level of spasticity and hand function before and after cryotherapy among children with cerebral palsy of control group” is accepted. Thus the mean value reveals that cryotherapy prior to passive stretching was effective in reducing the level of spasticty and improving hand function among children with cerebral palsy of experimental group.
TABLE 4.7.
MEAN, STANDARD DEVIATION, ‘t’ VALUE ON THE LEVEL OF SPASTICITY AND HAND FUNCTION (ON LEFT HAND) BEFORE AND AFTER CRYOTHERAPY
(N=30)
Group
Level of spasticity
Hand Function
Before
After
Mean difference
‘t’
Before
After
Mean difference
‘t’
Mean
Standard deviation
Mean
Standard deviation
Mean
Standard deviation
Mean
Standard deviation
Experimental
2
0.51
1.13
0.34
0.86
9.5**
3.1
0.83
1.7
0.61
1.4
8.57**
Control
2.26
0.57
2
0.63
0.2
1.87
2.7
0.97
2.53
0.9
0.2
1.87
** Significant at 0.01 level
The above table reveals the distribution of mean and standard deviation of the obtained scores before and after cryotherapy among experimental group and control group children with cerebral palsy. The level of spasticity among experimental group showed a mean difference of 0.86 while there was mild difference in control group. Thus the mean score in the level of spasticity shows that there was a positive difference in the reduction of spasticity among children with cerebral palsy of experimental group. Hand function of the experimental group showed a mean difference of 1.4 and while there was 0.2 mean difference in the control group. Thus the mean scores show that there is a positive improvement in hand function among children with cerebral palsy of experimental group.
‘t’ test was used to test the significance in mean difference. The calculated ‘t’ value on the level of spasticity in the experimental group was 9.5 which was compared with the table value at 0.01 level of significance. The calculated ‘t’ value on hand function in the experimental group was 8.57 which were compared with the table value at 0.01 level of significance. The calculated value was higher than the table value. Hence the research hypothesis, “There is a significant difference in the level of spasticity and hand function before and after cryotherapy among children with cerebral palsy of experimental group” is accepted. The calculated ‘t’ value in control group on the level of spasticity was 1.87 and hand function was about 1.87 which was found to be lesser than the table value. Therefore the null hypothesis, “There is no significant difference in the level of spasticity and hand function before and after cryotherapy among children with cerebral palsy” is accepted. Thus the mean value reveals that cryotherapy prior to passive stretching was effective in reducing the level of spasticity and improving hand function among children with cerebral palsy of experimental group.
FIG 4.4
COMPARISON ON THE LEVEL OF SPASTICITY BEFORE AND AFTER INTERVENTION OF EXPERIMENTAL GROUP AND CONTROL GROUP
FIG 4.5.
COMPARISON ON HAND FUNCTION BEFORE AND AFTER INTERVENTION OF EXPERIMENTAL GROUP AND CONTROL GROUP
4.3.3. COMPARISON ON THE LEVEL OF SPASTICITY AND HAND
FUNCTION AMONG CHILDREN WITH CEREBRAL PALSY IN
EXPERIMENTAL AND CONTROL GROUP AFTER INTERVENTION
After intervention, assessment on the level of spasticity and hand function was done among experimental and control group. The obtained scores were comparatively analyzed using ‘t’ test for independent samples, to prove the effectiveness of the intervention
TABLE 4.8.
COMPARISON ON THE LEVEL OF SPASTICITY AND HAND FUNCTION AMONG CHILDREN WITH CEREBRAL PALSY IN EXPERIMENTAL GROUP AND CONTROL GROUP AFTER INTERVENTION
Group
Level of spasticity
Hand function
Right Hand
Left Hand
Right Hand
Left Hand
Mean
Mean %
Standard Deviation
‘t’
Mean
Mean
%
Standard Deviation
‘t’
Mean
Mean %
Standard Deviation
‘t’
Mean
Mean %
Standard Deviation
‘t’
Experimental
1.13
28
0.5
4.8**
1.13
28
0.34
4.5**
1.86
37
0.71
2.74*
1.7
34
0.61
3.53*
Control
2.2
55
0.7
2
50
0.6
2.6
52
1
2.5
51
0.9
* Significant at 0.05 level
The above table depicts the obtained ‘t’ value calculated for the level of spasticity and hand function of experimental group and control group after intervention. The level of spasticity on right hand of children among experimental group the mean percentage score was 28% (0.5) and the control group was 55% (0.7). The level of spasticity on left hand of children among experimental group the mean percentage score was 28% (0.34) and the control group was 50% (0.6). The hand function on right hand of children among experimental group the mean percentage score was 37% (0.71) and the control group was 52% (1). The hand function on left hand of children among experimental group the mean percentage score was 34% (0.6) and the control group was 51% (0.9). Thus the mean percentage scores show that there is a positive difference in the level of spasticity and hand function among children with cerebral palsy.
‘t’ test for independent samples is used to test the significance in mean difference among the experimental and control groups. The calculated ‘t’ value on the level of spasticity, the right hand score (4.87) and left hand score (4.5) are higher than the table value at 0.01 level of significance. The calculated ‘t’ value on hand function, the right hand score (2.74) and left hand score (3.53) are higher than the table value at 0.05 level of significance. Hence the hypothesis, “There is a significant difference between experimental group and control group in the level of spasticity and hand function after cryotherapy among children with cerebral palsy” is accepted. This proves that, cryotherapy prior to passive stretching has its influence in reduction of spasticity and improvement in hand function.
RESULTS AND DISCUSSION
The study was conducted at Families for Children, Coimbatore, with the focus on determining the effectiveness of cryotherapy prior to passive stretching on the level of spasticity and hand function among children with cerebral palsy. The samples of the study were 30 children with spastic cerebral palsy at Families for Children, and they were randomly allocated to experimental and control group. Cryotherapy was applied prior to passive stretching, to reduce the level of spasticity and improve hand function. To assess the level of spasticity and hand function, the researcher used Ashworth Scale and Zancolli classification hand function scale. The intervention was provided for 20 minutes prior to passive stretching for 10 days. The pretest score and post test scores were compared. The findings are discussed under the following headings.
5.1. FINDINGS RELATED TO DEMOGRAPHIC VARIABLE
5.1.1. Age Distribution
In the present study, out of 30 samples, 15 children were randomly assigned to experimental group and 15 children were assigned to control group. Age distribution in experimental group revealed that, majority of children with spastic cerebral palsy (47 %) were between 12-15 years of age, 33% were between 9-12 years and 20 % were between 6-9 years. Age distribution in control group revealed that, majority of children (47 %) were between 9-12 years, 33% were between 6-9 years and 20% were between 12-15 years. Boyd RN (2012) conducted an interventional study by providing progressive resistance training for CP children (between the age group of 6-15 years) who are ambulatory in order to improve muscle strength. The study findings showed improvement in muscle strength though there was no change in the walking ability.
5.1.2. Gender Distribution
Gender distribution of children showed that, majority of children was females in both experimental (67 %) and control (73 %) group. A study on effectiveness of neuromuscular electrical stimulation over cryotherapy along with passive stretching as a common protocol on improving hand function in patients with spastic cerebral palsy by Devidas S Patil (2011) showed that, improvement of hand function was seen in both male and female children.
5.1.3. Type of Cerebral palsy
Assessment on the type of cerebral palsy showed that, majority of children were quadriplegic in both experimental (67 %) and control (53%) group. A study on efficacy of cold therapy on spasticity and hand function in children with cerebral palsy by Gehan et al.,(2010) revealed that, cryotherapy was effective in reducing spasticity and improving hand function in both diplegic and quadriplegic children.
5.2. ASSESSMENT OF LEVEL OF SPASTICITY AND HAND FUNCTION
AMONG CHILDREN WITH CEREBRAL PALSY
The children with the diagnosis of mild and moderate spastic cerebral palsy were selected for the study. The level of spasticity was measured using Ashworth scale. The tool is a 5 point scale in which the researcher extends the limb from the maximal flexion to maximal extension until the soft resistance is felt. The child limb moved through its full range of motion with one second by counting “one thousand and one”. The level of resistance felt is scored using 5 point scale. Hand function was assessed using Zancolli classification hand function scale in which the researcher assesses the degree of flexion and extension in the wrist and finger flexors by using goniometer. The degree of responses was scored as 0, 1a, 1b, 2a, 2b, 3.
Akinbo et. al., (2007) conducted a similar study on effect of neuromuscular electrical stimulation and cryotherapy on spasticity and hand function. A quasi experimental pretest posttest control design was adopted in the study with sample size of 20. The level of spasticity was assessed using Ashworth scale in which the patient limb was extended from the maximal flexion to maximal extension until the soft resistance is felt. Hand function was assessed using zancolli classification hand function scale. The degree of flexion and extension was assessed using goniometer.
5.3. ADMINISTER CRYOTHERAPY PRIOR TO PASSIVE STRETCHING
AMONG CHILDREN WITH CEREBRAL PALSY
After assessing the level of spasticity and hand function, Cryotherapy was administered prior to passive stretching. The child is placed in a supine position with upper limb supported on a pillow. The area is cleansed with spirit and cotton. The wrapped ice pack is placed on the flexor compartment of the forearm for 20 minutes and then dried. Then the child had passive st
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