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นำเสนอโดย นางสาวจินดาพร ยิ้มดี รหัสประจำตัว 493090242-7
Seminar in Current Topic นำเสนอโดย นางสาวจินดาพร ยิ้มดี รหัสประจำตัว อาจารย์ที่ปรึกษา ผู้ช่วยศาสตราจารย์พิศมัย มะลิลา
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Arch Phys Med Rehabil ,June 2009;90:966-74
Seminar in Current Topic Immediate and Long-Term Effects of Hippotherapy on Symmetry of Adductor Muscle Activity and Functional Ability in Children With Spastic Cerebral Palsy McGibbon NH, Benda W, Duncan BR, Silkwood- Sherer D. Arch Phys Med Rehabil ,June 2009;90:966-74
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หัวข้อการนำเสนอ Background Method Result Discussion Conclusion Research critique
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Background
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Cerebral palsy disorder of mvt. & postural control
> 70% in United states with spasticity Background
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Characterized Excessive muscle tone Velocity-dependent overactivity
Restricted movement Abnormal distribution of postural tone Background
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Spasticity Distributed unevenly
Major cause of abnormal posture as well as Lt.-Rt. asymmetry between homologous muscle groups Background
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- uneven weight- bearing - hip, knee and ankle malalignment
Spastic CP asymmetric hyperactive - uneven weight- bearing - hip, knee and ankle malalignment efficient walking Background
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Physical therapy for children with adductor spasticity
Highest functional ability Background
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Treatment children with spasticity
HPOT PT treatment (hippotherapy) Used for over 25 years Using equine mvt. Treatment children with spasticity Background
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Improve gross motor function Improve walking energy expenditure
HPOP (hippotherapy) Improve gross motor function Improve walking energy expenditure Improve trunk coordination but no studies have focused specifically on adductor muscle activity using sEMG Background
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The effect of HPOP on variety of asymmetric muscle groups
Benda et al 2003 Remote sEMG The effect of HPOP on variety of asymmetric muscle groups 8 min. HPOP 8 min. stationary barrel No single muscle group showed significant improvement Greatest was found in adductor muscles Background
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Effect of body asymmetry on APA during a standard load-release task
Asymmetrical APA EMG pattern associated with asymmetrical body positioning Body asymmetries play an important role in control of upright posture Aruin 2006 Background
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Trunk and LE muscle activity and postural change
different Khabbaz et al 2008 Background
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Aims to expand the pilot study by Benda et al using a similar design but with a larger number of subjects to focus specifically on changes in adductor muscles to enhance the scientific rigor of the Benda study by using digitized sEMG synchronized with videotape of all walking trials
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Method I
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Method
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Diagnosis of spastic CP made by a pediatric neurologist Age 4-16 years
Inclusion criteria Diagnosis of spastic CP made by a pediatric neurologist Age 4-16 years Ability to walk independently with or without an assistive device Method
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Inclusion criteria 4. Ability to comply with the study protocol and follow verbal directions 5. Sufficient hip abduction to sit astride a horse or barrel with no evidence or report of hip dislocation Method
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Previous history of selective dorsal rhizotomy
Exclusion criteria Previous history of selective dorsal rhizotomy Tonic clonic seizures uncontrolled by medication Known allergy to horses, dust, or electrode adhesive 4. Surgical procedures, BTX-A injection, or lower-extremity casting within 6 months prior to testing 5. Hippotherapy or horseback riding experience within 6 months prior to testing Method
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Intervention HPOP barrel Method
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Table 1: Phase I Subject Demographics
Demographics Horse Group Barrel Group Summary Sex (n Male Female Age Mean y5mo y8mo NA Range y1mo–16y8mo y0mo–13y6mo NA Diagnosis (n) Spastic diplegia Spastic quadriplegia hemiplegia Mixed GMFCS (n) I II III IV Abbreviation: NA, not applicable. Method
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Outcome measure and testing protocol
sEMG Method
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Data aggregation and analysis
Difference in mean mV between Lt. and Rt. analyzed SPSS 15.0 visual inspection Kolmogorov-Smirnov test nonparametric (within gr.) Wilcoxon signed-rank test (between gr.) Mann-Whitney U test Method
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Results I
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Table 2: Within-Group Comparison of Mean Asymmetry Scores
Results:Phase I Table 2: Within-Group Comparison of Mean Asymmetry Scores Group Test n Mean Asymmetry Wilcoxon (T) Transformed Exact Significance Effect Size Scores (mV) % Confidence Interval to z Score (2-tailed) Cohen d HPOT Pretreatment –182.45 Posttreatment –125.07 Change ↓ (T_10.67) * ‡ Barrel Pretreatment –192.95 Posttreatment –228.70 Change ↑ (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.
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Table 3: Between-Group Comparison of Mean Asymmetry Scores
Results:Phase I Table 3: Between-Group Comparison of Mean Asymmetry Scores Test Group n Median Range Mann-Whitney U Exact Significance Effect Size (2-tailed) Cohen d Pretreatment Hippotherapy –830.7 Barrel – * Posttreatment Hippotherapy –731.36 Barrel – † ‡ *No significant difference between the groups pretreatment (P.05). †Statistically significant difference between the groups posttreatment (P.05). ‡Large effect size.
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Results:Phase I Activity: Number of Children According to GMFCS Level
Table 4: Phase I Changes in Symmetry of Adductor Muscle Activity: Number of Children According to GMFCS Level Horse Group Barrel Group GMFCS Better Worse Better Worse Level I Level II Level III Level IV
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Method II
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Table 5: Phase II Subject Demographics
Participants Table 5: Phase II Subject Demographics Subject no. Age (y) Sex Type of CP GMFCS Walking Aids/Orthotics M Spastic diplegia II Bilateral AFOs F Spastic diplegia III Posterior walker; bilateral AFOs M Spastic quadriplegia with mild athetoid movement III Posterior walker F Spastic diplegia II No aids or orthotics M Spastic diplegia III Posterior walker; bilateral AFOs M Spastic quadriplegia IV Posterior walker with seat; bilateral AF Abbreviations: AFO, ankle-foot orthosis; F, female; M, male.
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Phase II design and intervention
Fig 2. Phase II testing (T) intervals. *T1phase I pretest.
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Outcome measures and testing protocol
- Adductor muscle activity using sEMG Gross Motor Function Measure-66 The self-perception Profile for children, age 8 to 13, and the Pictorial self-perception Profile for young children, ages 4 to 7
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Results II
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Table 6: Phase II Adductor Muscle Asymmetry Scores* at Each
Testing Interval 12 Weeks Immediately Immediately Weeks Pre-HPOT Pre-HPOT Post-HPOT Post-HPOT Subject T T T T4 † ‡
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Table 7: Phase II: GMFM66 Scores at Each Testing Interval
12 Weeks Immediately Immediately Weeks Pre-HPOT Pre-HPOT Post-HPOT Post-HPOT Subject T T T T4 Table 7: Phase II: GMFM66 Scores at Each Testing Interval Abbreviation: HPOT, hippotherapy.
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Table 8: Pictorial Self-Perception Profile for Young Children
12 Weeks Immediately Immediately Weeks Pre-HPOT Pre-HPOT Post-HPOT Post-HPOT T T T T4 Subject 1 Peer acceptance Physical competence Maternal acceptance Global self- worth* Subject 2 Peer acceptance competence acceptance worth* Table 8: Pictorial Self-Perception Profile for Young Children NOTE: 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
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Table 9: Self-Perception Profile for Children
12 Weeks Immediately Immediately Weeks Pre-HPOT Pre-HPOT Post-HPOT Post-HPOT T T T T4 Table 9: Self-Perception Profile for Children Subject Unable to comply with test directions Subject 4 Cognitive competence Social acceptance Athletic competence Physical appearance Behavioral acceptance Global self-worth* Subject 5 Cognitive competence Social acceptance Athletic competence Physical appearance Behavioral acceptance Global self-worth* Subject 6 Cognitive competence Social acceptance Athletic competence Physical appearance Behavioral acceptance Global self-worth*
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Discussion & conclusion
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Hippotherapy how much better the child appeared to be walking
The rhythmic repeatedly shifting Sustained stretch to spastic adductor m. Normal sense of midline and symmetrical weight bearing
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Fig 3. GMFM-66 score changes after baseline, treatment, and posttreatment
phases.
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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
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Additional impairments
Future research Additional impairments Positively affected by HPOP
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Study limitation Inability to measure adductor activity during other functional motor tasks Blocked randomization by GMFCS level The diversity of subjects
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Research critique
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Title Purpose - สอดคล้องกับวัตถุประสงค์ ชัดเจน น่าสนใจ
- ครอบคลุมปัญหาการวิจัย สอดคล้องกับชื่อเรื่องและวิธีการวิจัยในครั้งนี้
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Background - สะท้อนถึงปัญหาที่ต้องการศึกษาชัดเจน และมีงานวิจัยอื่นๆสนับสนุน Methods - มีความชัดเจน โดยพิจารณาจากการที่ผู้วิจัยได้ระบุถึงประชากรเป็นใคร มีจำนวนเท่าใด ระบุถึงเกณฑ์คัดเข้า-ออกอย่างชัดเจน รวมถึงวิธีการสุ่มตัวอย่าง
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Intervention Data analysis
- ได้มีการระบุถึงวิธีการศึกษา เครื่องมือที่ใช้ในการวิจัย รวมถึงตัวแปรที่จะใช้ในการศึกษาในครั้งนี้ด้วย Data analysis - มีความเหมาะสมโดยระบุสถิติที่ใช้ในการคำนวณ รวมไปถึงแหล่งข้อมูลที่จะนำมาวิเคราะห์ด้วย
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Discussion and conclusion
Results - การนำเสนอผลงานวิจัยมีความสอดคล้องกับวัตถุประสงค์ เสนอในรูปแบบตารางทำให้สามารถเข้าใจภาพรวมได้ดีขึ้น Discussion and conclusion - ในการอภิปรายผล ผู้วิจัยได้ยกงานวิจัยที่เกี่ยวข้องที่ได้ผลสอดคล้องกันมาอ้างอิง ทำให้ข้อมูลจากผลงานวิจัยมีความน่าเชื่อถือมากยิ่งขึ้น และยังได้ระบุถึงข้อจำกัดของงานวิจัย รวมไปถึงข้อเสนอแนะในงานวิจัยต่อไปอีกด้วย
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Thank you for your attention
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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
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GMFM Standardized observational instrument to measure change in gross motor function overtime in children with CP Scoring key 0 = does not initiate 1 = initiate 2 = partially complete 3 = complete NT = not test
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GMFM Dimention Lying & Rolling Sitting Crawling & Kneeling Standing Walking, Running & Jumping
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Selective dorsal rhizotomy
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Selective dorsal rhizotomy
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Movement of HPOP
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Bilateral AFO
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Posterior walker
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Posterior walker with seat
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