Effectiveness of Modified Trunk Dissociation Retrainer in Improving Trunk Control in subjects with Infantile Hemiplegia

 

Chakravarthi V.1, Meera R.2, Arunachalam R.3, Sujatha B.4, Dr. M. Manoj Abraham5

1BPT Final Year, Saveetha College of Physiotherapy, Saveetha University, Chennai.

2BPT Final Year, Saveetha College of Physiotherapy, Saveetha University, Chennai.

3Professor and HOD, Madhav College of Physiotherapy, Madhav University.

4Assistant Professor, Saveetha College of Physiotherapy, Saveetha University, Chennai.

5Principal, Saveetha College of Physiotherapy, Saveetha University, Chennai.

*Corresponding Author E-mail: chakravarthi.varthala@gmail.com

 

ABSTRACT:

Aim of the study is to find the effectiveness of Modified Trunk Dissociation Retrainer in improving trunk control in infantile hemiplegic subjects and objective is to determine trunk control following trunk dissociation retraining in infantile hemiplegic subjects. Sample size is 10 selected based on inclusion and exclusion criteria with convenient sampling method from out-patient department of SMCH, Chennai. Study design: Quasi experimental study. Materials required: Modified Trunk Dissociation Retrainer. Outcome measures: trunk control measurement scale. A baseline measurement of trunk control is taken before intervention. Intervention was given by researcher for a duration of 3 weeks as 5 days/week. After the 3rd week of intervention first post-test was taken and second post-test in the 6th week. Analysis of post-test values showed that there was significant difference between pre-test and post-test values and also the results sustained from post-test I and post-test II values. Hence the conclusion the study was that the Modified Trunk Dissociation Retrainer is an effective tool to improve trunk control in subjects with infantile hemiplegia.

 

KEYWORDS: Modified Trunk Dissociation Retrainer, Infantile Hemiplegia, Trunk Control Measurement.

 

 


INTRODUCTION:

Trunk dissociation is the chief component of movements in human body. Trunk dissociation patterns are involved in almost all the activities of daily living. The trunk dissociation takes place in three different planes and along three different axes. There are frontal plane movements that take place along sagittal axis. These movements are predominantly side to side i.e., when the upper body segment moves to right lateral side the lower body segment moves to the left side and vice versa. During such activities the trunk’s side flexors, on one side works concentrically to give direction to the movement and on the other side works eccentrically to conventional the movement.  There are sagittal plane movements that take place along coronal axis.

 

These movements are predominantly anterior and posterior. i.e., when the upper body segment moves forward the lower body segment moves backwards and vice versa. During such activities the trunk flexors and extensors work reciprocally in concentric and eccentric manner.  There are transverse plane movements that take place along vertical or longitudinal axis. These movements are predominantly rotator in nature i.e., when the upper body segment moves towards internal rotation the lower body segment moves towards external rotation and vice versa1.

 

Anticipatory postural adjustment is a normal phenomenon in which the line of gravity shifts to the ipsilateral side on reaching out to one side and back to normal when lower limbs move to the contralateral side2,3. This pattern is compromised in infantile hemiplegia. There are various condition that lead to infantile hemiplegia in paediatric population such as cerebro vascular malformation, vasculitis, metabolic and genetic disorders. Lack of trunk control affects the child’s day-to-day functional activities4.

 

Trunk Dissociation Retrainer (TDR) is equipment used for the rehabilitation of stroke patients which concentrates on the wider aspects of the disability rather than just motor rehabilitation. It was used for retraining coordination, balance, functional activities and trunk control in hemiplegic5. In a study done in 2015 it was concluded that, Trunk Dissociation Retainer is a better alternative tool in improving coordination, balance, functional activities and trunk control in hemiplegic subjects compared to manual trunk dissociation training (Arunachalam et al, 2015)6,7. Any exercise when performed through equipment, always has an added effort from the subject. The equipment based exercises are always target oriented. The user can perform several repetitions in lesser duration and more effectively8.

 

Congenital or infantile hemiplegia refers to brain injuries that occur before or at birth and lead to hemiplegia. Hemiplegia is the physical manifestation of an injury to a specific area of the brain that controls motor function9.

 

Hemiplegia may develop suddenly, or evolve over days, weeks or months. In addition, some infants who appear normal in the newborn period may show symptoms of hemiplegia only after voluntary hand use develops, at about 4-5 months of age. Hemiplegia can also be short-lived or permanent10.

 

The commonest etiologic categories for stroke in paediatrics include arteriopathies, cardiac disease (congenital and acquired), hematological disease, and infection. Multiple risk factors are often present at the time of stroke, including acute or chronic disease and prothrombotic states (primary or secondary)11,12.

 

Symptoms often include:

·        Seizures, especially in new-borns

·        Keeping one hand in a fist position, especially in infants

·        Worsening or sudden headaches

·        Sudden difficulty speaking, slurring of words or trouble understanding speech

·        Hemiparesis, or a weakness on one side of the body

·        Sudden loss of vision or abnormal eye movements

·        Sudden loss of balance or trouble walking

 

The Trunk Dissociation Retrainer was found to effectively improve the trunk function in hemiplegic patients and it was also found to be safe for rehabilitation13. The present study will find the effectiveness of MTDR for the paediatric population with necessary changes in the equipment for the benefit of the children with infantile hemiplegia14.

 

Modified Trunk dissociation Retainer consists of two units, the wheel and the patient unit. The wheel unit consists of a metal upright with a central pivot. The axis of the central pivot is maintained at the umbilical level of the patient. The patient unit consists of a seat of adjustable height. The patient seated holds on to the gripping provided on the wheel unit and places the feet on the foot rest. Three different movements are performed with MTDR that is, when the upper end of the upright rod is moved to affected side the lower limb moves to the opposite side. The second movement is front and back, that is, when the upper end of the upright rod moved anteriorly, the lower limb moves posteriorly provides the patient unit is kept static by fixing the seat in these two movements. The third movement is rotation of the trunk that takes place by making the patient unit dynamic and the patient carries out rotation of the trunk by holding onto the wheel unit for support15,16.

 

MATERIAL AND METHODS:

Study design: Quasi experimental study

Study setting:     Saveetha Medical College and Hospital, Physiotherapy outpatient department, Saveetha University, thandalam, Chennai – 602105

Sampling method: Convenient sampling

Sample size: 10 subjects

 

Inclusion criteria:

·        Subjects of age group – 8 to 12 years.

·        Of both genders.

·        Children with infantile hemiplegia

·        With poor trunk performance

 

Exclusion criteria:

·        Patients who do not comprehend to instructions.

·        With sensory and cognitive developmental delay.

·        Anxiety disorders

·        Attention deficit

·        Children with fixed deformities

·        With seizures

 

Materials required:

·        Modified Trunk Dissociation Retrainer

 

Outcome measures:

·        Trunk Control Measurement Scale

 

Procedure:

10 individuals with infantile hemiplegia were selected based on inclusion and exclusion criteria by an independent person who is related to the study and who is a physiotherapist with minimum 5 years of clinical experience in handling pediatric patients. Detailed procedure was explained in patient’s familiar language and those who are interested, informed consent was obtained from all the participants.

 

The treatment protocol consists of a pre-test, intervention and 2 post-tests. A baseline analysis of trunk control will be done before the intervention begins.

 

The intervention was given by researcher for a duration of 3 weeks, 5 days a week and each session that lasts for 90 minutes, which comprises of 60 minutes of conventional physiotherapy that comprises of Functional training, balance and co ordination training and reaching activities including rest period. And 30 minutes of TDR- 7 minutes of sagittal plane movement, 7 minutes of frontal plane movements, 7 minutes of rotational movements with 3 minutes of rest after each 7 minute session.

 

Three weeks of intervention was given to the subjects following which first post-test were conducted and subjects were asked for a follow up on 6th week. No dropouts were there.

 

TREATMENT SESSION:

Duration of each session                : 90 min

Sessions                                             : 1 session/day

Frequency                          : 5 days/week

Duration                                            : 15 d

 

TABLE: 1 Pre-test and post-test values of TCMS

 

Test

Mean

Standard deviation (SD)

P value

TCMS

Pre test

13.6

2.009975124

 

P <.05

Post test I

34.4

1.854723699

Post test II

38.5

0.921954446

 

TABLE: 2 Non – parametric analysis- Ranking scale

Source

SS

Df

MS

 

Between ANALYSIS

3564.8667

2

1782.4333

F = 577.7395

Within-ANALYSIS

83.3

27

3.0852

 

Total

3648.1667

29

 

 

TABLE: 3 Turkey HSD Analysis

Treatments pair

Turkey HSD Q statistic

Turkey HSD p-value

Turkey HSD

inference

PRE vs POST I

37.4475

0.0010053

** p<0.01

PRE vs POST II

44.8290

0.0010053

** p<0.01

POST I vs POST II

7.3815

0.0010053

** 0.01

 

 

Fig. 1: Graph showing pre-test and post-test values of TCMS

 

RESULT:

From statistical analysis made with the quantitative data revealed statistically significant difference between the pre-test and post-test values within the group.

 

TRUNK CONTROL MEASUREMENT SCALE:

The pre-test mean value of TCMS was 13.6 (SD 2.01) and post-test I mean value of TCMS was 34.4 (SD 1.85) and post test II mean value is 38.5 (SD 0.92). This shows that post-test is greater than pre-test with P value (p <.05). Comparison between the mean values of post-test I and post-test II shows that the results have sustained.

 

Repeated scale ANOVA analysis was done for TCMS for which the “F” value was calculated as 577.7395. Hence we rejected our null hypothesis and concluded that the compared groups differed significantly with p value <.05.

 

Multiple level comparison for TCMS was done using Turkey HSD analysis (table- 3) which showed that there was significant difference between pre-test and post-test I and also pre-test and post-test II. There was no significant difference between post-test I and post-test II which shows that there was progressive improvement in the subjects but the effect of training did sustain.

 

DISCUSSION:

The loss of balance and instability due to poor trunk control is major problem in infantile hemiplegic children. Trunk dissociation is seen to be the cause of these instabilities in children. There are many conventional treatment procedures that are being practiced for improving balance such as the swiss ball, but there is no much focus on the dissociation. The Modified Trunk Dissociation Retrainer provides training in the sitting position unlike any other conventional treatment. Manual effort of the therapist required is reduced to more than half of that which is required during other conventional methods of treatment. Time consumption is also less while working with TDR.

 

There were 10 children who participated in the study, there were no drop outs, and each child was different. Handling paediatric subjects was a challenge. Most of them were apprehensive in the beginning and later got comfortable with the equipment and the surrounding. There was nothing playful to retain the attention of the children during treatment. Few children were very cooperative during the study. Some children were short for the equipment irrespective of their age.

 

The treatment duration was 15days and improvement was seen in most of the subjects by the end of 2nd week itself. Trunk control is increased in the subjects by 3 weeks. The post –test II also proved that the effects had sustained over a period of 3weeks.

 

This study provides a good clinical implication to therapist. Thus, TDR can be an effective tool compared to the already existing manual techniques in improving trunk control in infantile hemiplegic children.

 

CONCLUSION:

From the result of the analysis, we got the conclusion that Modified Trunk Dissociation Retrainer is an effective tool to improve trunk control in the subjects with infantile hemiplegia.

 

ACKNOWLEDGEMENT:

The authors are grateful to the authorities of Saveetha College of Physiotherapy, Chennai.

 

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

 

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Received on 02.03.2018         Modified on 07.09.2018

Accepted on 13.11.2018      © RJPT All right reserved

Research J. Pharm. and Tech. 2019; 12(3): 1141-1144.

DOI: 10.5958/0974-360X.2019.00188.4