1 นำเสนอโดย นางสาวจินดาพร ยิ้มดี รหัสประจำตัว 493090242-7 Seminar in Current Topicนำเสนอโดยนางสาวจินดาพร ยิ้มดีรหัสประจำตัวอาจารย์ที่ปรึกษาผู้ช่วยศาสตราจารย์พิศมัย มะลิลา
2 Arch Phys Med Rehabil ,June 2009;90:966-74 Seminar in Current TopicImmediate and Long-Term Effects of Hippotherapy on Symmetry of Adductor Muscle Activity and Functional Ability in Children With Spastic Cerebral PalsyMcGibbon NH, Benda W, Duncan BR, Silkwood- Sherer D.Arch Phys Med Rehabil ,June 2009;90:966-74
9 Physical therapy for children with adductor spasticity Highest functional abilityBackground
10 Treatment children with spasticity HPOTPT treatment(hippotherapy)Used for over 25 yearsUsing equine mvt.Treatment children with spasticityBackground
11 Improve gross motor function Improve walking energy expenditure HPOP (hippotherapy)Improve gross motor functionImprove walking energy expenditureImprove trunk coordinationbut no studies have focused specifically on adductor muscle activity using sEMGBackground
12 The effect of HPOP on variety of asymmetric muscle groups Benda et al 2003Remote sEMGThe effect of HPOP on variety of asymmetric muscle groups8 min. HPOP8 min. stationary barrelNo single muscle group showed significant improvementGreatest was found in adductor musclesBackground
13 Effect of body asymmetry on APA during a standard load-release task Asymmetrical APA EMG pattern associated with asymmetrical body positioningBody asymmetries play an important rolein control of upright postureAruin 2006Background
14 Trunk and LE muscle activity and postural change differentKhabbaz et al 2008Background
15 Aimsto expand the pilot study by Benda et al using a similar design but with a larger number of subjectsto focus specifically on changes in adductor musclesto enhance the scientific rigor of the Benda study by using digitized sEMG synchronized with videotape of all walking trials
18 Diagnosis of spastic CP made by a pediatric neurologist Age 4-16 years Inclusion criteriaDiagnosis of spastic CP made by a pediatric neurologistAge 4-16 yearsAbility to walk independently with or without an assistive deviceMethod
19 Inclusion criteria4. Ability to comply with the study protocol and follow verbal directions5. Sufficient hip abduction to sit astride a horse or barrel with no evidence or report of hip dislocationMethod
20 Previous history of selective dorsal rhizotomy Exclusion criteriaPrevious history of selective dorsal rhizotomyTonic clonic seizures uncontrolled by medicationKnown allergy to horses, dust, or electrode adhesive4. Surgical procedures, BTX-A injection, or lower-extremity casting within 6 months prior to testing5. Hippotherapy or horseback riding experience within 6 months prior to testingMethod
22 Table 1: Phase I Subject Demographics Demographics Horse Group Barrel Group SummarySex (nMaleFemale AgeMean y5mo y8mo NARange y1mo–16y8mo y0mo–13y6mo NADiagnosis (n)Spastic diplegiaSpasticquadriplegiahemiplegiaMixedGMFCS (n)IIIIIIIVAbbreviation: NA, not applicable.Method
23 Outcome measure and testing protocol sEMGMethod
24 Data aggregation and analysis Difference in mean mV between Lt. and Rt.analyzedSPSS 15.0visual inspection Kolmogorov-Smirnov testnonparametric (within gr.) Wilcoxon signed-rank test(between gr.) Mann-Whitney U testMethod
26 Table 2: Within-Group Comparison of Mean Asymmetry Scores Results:Phase ITable 2: Within-Group Comparison of Mean Asymmetry ScoresGroup Test n Mean Asymmetry Wilcoxon (T) Transformed Exact Significance Effect SizeScores (mV) % Confidence Interval to z Score (2-tailed) Cohen dHPOT Pretreatment –182.45Posttreatment –125.07Change ↓ (T_10.67) * ‡Barrel Pretreatment –192.95Posttreatment –228.70Change ↑ (T_8.70) †*Statistically significant decrease in adductor asymmetry in the hippotherapy group (P.001).†No significant decrease in adductor asymmetry in the hippotherapy group (P.05).‡Very large effect size.
27 Table 3: Between-Group Comparison of Mean Asymmetry Scores Results:Phase ITable 3: Between-Group Comparison of Mean Asymmetry ScoresTest Group n Median Range Mann-Whitney U Exact Significance Effect Size(2-tailed) Cohen d Pretreatment Hippotherapy –830.7Barrel – *Posttreatment Hippotherapy –731.36Barrel – † ‡*No significant difference between the groups pretreatment (P.05).†Statistically significant difference between the groups posttreatment (P.05).‡Large effect size.
28 Results:Phase I Activity: Number of Children According to GMFCS Level Table 4: Phase I Changes in Symmetry of Adductor MuscleActivity: Number of Children According to GMFCS LevelHorse Group Barrel GroupGMFCS Better Worse Better WorseLevel ILevel IILevel IIILevel IV
30 Table 5: Phase II Subject Demographics ParticipantsTable 5: Phase II Subject DemographicsSubject no. Age (y) Sex Type of CP GMFCS Walking Aids/OrthoticsM Spastic diplegia II Bilateral AFOsF Spastic diplegia III Posterior walker; bilateral AFOsM Spastic quadriplegia with mild athetoid movement III Posterior walkerF Spastic diplegia II No aids or orthoticsM Spastic diplegia III Posterior walker; bilateral AFOsM Spastic quadriplegia IV Posterior walker with seat;bilateral AFAbbreviations: AFO, ankle-foot orthosis; F, female; M, male.
31 Phase II design and intervention Fig 2. Phase II testing (T) intervals. *T1phase I pretest.
32 Outcome measures and testing protocol - Adductor muscle activity using sEMGGross Motor Function Measure-66The self-perception Profile for children, age 8 to 13, and the Pictorial self-perception Profile for young children, ages 4 to 7
34 Table 6: Phase II Adductor Muscle Asymmetry Scores* at Each Testing Interval12 Weeks Immediately Immediately WeeksPre-HPOT Pre-HPOT Post-HPOT Post-HPOTSubject T T T T4†‡
35 Table 7: Phase II: GMFM66 Scores at Each Testing Interval 12 Weeks Immediately Immediately WeeksPre-HPOT Pre-HPOT Post-HPOT Post-HPOTSubject T T T T4Table 7: Phase II: GMFM66 Scores at Each Testing IntervalAbbreviation: HPOT, hippotherapy.
36 Table 8: Pictorial Self-Perception Profile for Young Children 12 Weeks Immediately Immediately WeeksPre-HPOT Pre-HPOT Post-HPOT Post-HPOTT T T T4Subject 1Peer acceptancePhysicalcompetenceMaternalacceptanceGlobal self-worth*Subject 2Peer acceptancecompetenceacceptanceworth*Table 8: Pictorial Self-Perception Profile for Young ChildrenNOTE: Age 4y to 7y mean scores at each testing interval for each domain.Abbreviation: HPOT, hippotherapy.*Feelings about self that are independent of a specific area of competence
37 Table 9: Self-Perception Profile for Children 12 Weeks Immediately Immediately WeeksPre-HPOT Pre-HPOT Post-HPOT Post-HPOTT T T T4Table 9: Self-Perception Profile for ChildrenSubject Unable to comply with test directionsSubject 4Cognitive competenceSocial acceptanceAthletic competencePhysical appearanceBehavioral acceptanceGlobal self-worth*Subject 5Cognitive competenceSocial acceptanceAthletic competencePhysical appearanceBehavioral acceptanceGlobal self-worth*Subject 6Cognitive competenceSocial acceptanceAthletic competencePhysical appearanceBehavioral acceptanceGlobal self-worth*
39 Hippotherapy how much better the child appeared to be walking The rhythmic repeatedly shiftingSustained stretch to spastic adductor m.Normal sense of midline and symmetrical weight bearing
40 Fig 3. GMFM-66 score changes after baseline, treatment, and posttreatment phases.
41 Improve adductor asymmetry after HPOP Strong effect size (Benda et al)Improve GMFM scores(McGibbon et al: twice-weekly HPOP for 8 weeks)(Casady&Nichols-Larsen: weekly HPOP for 10 weeks)HPOP can improve adductor muscle symmetry during walking and can also improve other functional motor skills
42 Additional impairments Future researchAdditional impairmentsPositively affected by HPOP
43 Study limitationInability to measure adductor activity during other functional motor tasksBlocked randomization by GMFCS levelThe diversity of subjects
50 GMFCS levels - Level I: walks without restriction - Level II: walks without assistive devices but with some limitations- Level III: walks with assistive device- Level IV: walks short distances with assistive devices or use power mobility
51 GMFMStandardized observational instrument to measure change in gross motor function overtime in children with CPScoring key0 = does not initiate1 = initiate2 = partially complete3 = completeNT = not test