Combination of Trunk Mobilization and Neuro Development

Treatment against Spasticity Reduction of Spastic Type Cerebral

Palsy

Siti Sarah Bintang*, Miftahul Zannah, Isidorus Jehaman, Elsaria Br Sembiring, Raynald Ignasius

Ginting and Sabirin Berampu

*Faculty of Nursing and Physiotherapy, Institut Kesehatan Medistra Lubuk Pakam, Indonesia

Keywords: Cerebral Palsy, Spastisitas, Mobilisasi Trunk, Neuro Development Treatment

Abstract: Spastic cerebral palsy is a type of brain damage that occurs in the extreme part of the pyramids that results in

an increase in reflexes that make muscle tone higher than normal. This study aims to look at the effect of a

combination of Trunk Mobilization and Neuro Development Treatment on reducing spasticity in spastic type

cerebral palsy children. The research design used was one group pre and post test design. Test Results for the

results of reducing spasticity in cerebral palsy children before and after the intervention of Trunk Mobilization

and Neuro Development Treatment, it can be seen that the value of p = 0.157 which means greater than 0.05

(p> 0.05) so that the null hypothesis (Ho) accepted and the alternative hypothesis (Ha) was rejected. So the

conclusion with the acceptance of Ho means there is no effect of a combination of Trunk Mobilization and

Neuro Development Treatment to reduce spasticity in children with cerebral palsy after intervention.

1 INTRODUCTION

Cerebral palsy or abbreviated (CP) is a disability that

was first raised by William Little in the 1840s. This

condition is a diagnostic and therapeutic challenge

which is quite large (Bajraszewski, 2014). There are

mild degrees with minimal disabilities up to severe

degrees. Disability that occurs for a lifetime, will

generally be the cause of autism and mental

retardation which causes difficulties for the impact on

their individuals and families (Myoung and MPH,

2017).

Cerebral palsy is a disorder of motion and attitude.

This is defined as a non progressive disorder of

posture, motor disturbances and secondary disorders

that occur due to lesions or anomalies that occur in

the brain that arise in the early stages of development.

Primary lesions or static injuries will affect the

growth and development of plasticity and maturity of

the central nervous system (Myoung and MPH,

2017). Cerebral palsy occurs worldwide 2-2.5/1000

births. One cause is trauma at birth, and the progress

of neonatal management has not been able to show a

decrease in the incidence of CP patients (Ryan and

Sandra, 2011).

The neurologic impairment is nonprogressive,

although secondary disability can occur.

Characteristics of cerebral palsy change with

developmental stages, especially in the first few years

of life. This impairment and resultant disability are

both permanent (Bosanquet, 2013).

The prevalence of people with Cerebral Palsy at

birth is based on research data from health care

centers in the United States from mild to severe

ranging from 1.5 to 2.5 per 1000 live births. Research

data on school-age children, the prevalence of

cerebral palsy found 1.2 - 2.5 children per 1,000

population. At least 5,000 new cases of cerebral palsy

occur each year. From these cases 10% to 15% of

cerebral palsy found a brain disorder that is usually

caused by infection or trauma after the first month of

life (Surakarta,2013).

The incidence of cerebral palsy patients in

Indonesia based on data from the Ministry of Health

in 2011 is estimated to be around 1 - 5 per 1,000 live

births and the number of people with disabilities is

around 7-10% of Indonesia's population. More men

than women. Generally found in the first child. The

incidence rate is higher in babies born prematurely,

twin births and mothers who are over 40 years old.

Almost half this disability is experienced in children

Bintang, S., Zannah, M., Jehaman, I., Sembiring, E., Ginting, R. and Berampu, S.

Combination of Trunk Mobilization and Neuro Development Treatment against Spasticity Reduction of Spastic Type Cerebral Palsy.

DOI: 10.5220/0009840304830490

In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 483-490

ISBN: 978-989-758-460-2

483

born prematurely and children born normal (Depkes,

2011).

Pathogenesis of CP occurs from the first

gestational age to 24 weeks. Cortical neurogenesis

occurs characterized by poliferation, migration, and

neuronal processes of neuron precursor cells (Dutt,

2015). Genetic deficits or disorders such as viruses or

toxicity result in malformations such as issencephaly

or agyria-pachygria, nodular heterotopias,

polymicrogyria, schizencephaly, and cortical

dysplasia. Growth and differentiation events (axonal

and dendritic growth, synapse formation and

myelination) as well as the process of neural

apoptosis, neuron regression, redundant synapse

elimination. Environmental factors also affect such as

hypoxia ischemia. In addition, the process of forming

an immature brain structure will change a series of

developmental events, therefore CP is the result of

destructive and developmental mechanisms

(Stephaniie,2013).

The etiology of CP is very diverse and

multifactorial the causes are congenital, genetic,

inflammatory, contagious, anoxic, traumatic and

metabolic. Injury tothe brain can occur in the

prenatal, or postnatal period of CP is more common

in children born very premature or full term. Even

though term babies have a relatively low absolute

risk, the term birth represents the majority of all

births, like as well as about half of all child births with

cerebral palsy. Prenatal risk factors include

intrauterine infection, teratogenic exposure, placental

complications, multiple birth, and motherly

conditions like mentality retardation, seizures, or

hyperthyroidism. The incident CP is higher among

twins and triplets than singles bleeding, seizures,

hypoglycemia, hyperbilirubinemia, and significant

birth asphyxia. Perinatal arterial ischemia stroke has

been identified as another possible cause which

causes CP hemiplegia in many babies (Sankar, 2005).

To aid in confirming the diagnosis and ruling out

neoplastic or progressive causes for motor disability

such as metabolic and neurodegenerative disorders,

magnetic resonance imaging (MRI) is usually

indicated. The imaging can usually wait until a child

can undergo the study without sedation or done in

conjunction with another procedure. Other diagnostic

testing may include cultures, immune status,

metabolic screening, karyotyping, genetic probes or

confirmatory tests for other specific disorders

(Bosanquet, 2013).

Impaired oxygen supply to the fetus and brain

Asphyxia is classically considered as the main cause

of explaining CP later. But clinically defined birth

injury or birth asphyxia accounts for a small

proportion of CP cases (Ferluga, 2013). CP is rarely

due to brain malformations due to a unique genetic

deficit or perinatal damage that is obtained due to a

unique acute asphyxic event. Generally CP, the

causative factors do not act separately, but in synergy

to create interference (Stephaniie,2013).

CP is classified into topographic-based subtypes,

diplegia, hemiplegia, or extrapyramidic disorders.

This classification arises in various areas of the

nervous system that develop during the process of

fetal development in the womb, during labor and after

birth during the first 2 years of life. Gestational age

also influences the development of brain structure and

the type of disability associated with CP (Ryan and

Sandra, 2011). Topographic of Cerebral Palsy can be

seen in the picture below in Figure 1.

Figure 1: Topographic of Cerebral Palsy.

There are three types of cerebral palsy that can be

distinguished by their symptoms and management

approaches. The types of CP men are Spastic, Ataxic

and Athetoid brain paralysis (Hartono, 2004). Spastic

CP type is CP that has spasms characterized by

unique muscle tightness the patient has muscle

flexibility. This type of CP occurs in at least 70% of

all CP cases in the world. In the case of CP seizures,

this disorder can be more easily managed compared

to other types since treatment through treatment can

be taken in a number of neurological and orthopedic

approaches. Muscle spasticity causes other symptoms

of muscle stress that may include tendinitis and

arthritis in individuals aged 20-30 years. This type of

CP can be managed using occupational and physical

therapy where it can strengthen, stretch, exercise and

the other. Physical activity is used to manage daily

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

484

disruptions. The disorder can also be overcome using

drugs that eliminate flexibility by killing the nerves

that cause the disorder (Kumar and Parveen, 2018).

Pain is a common problem in the brains of

children of all ages. Many children are very patient

and don't need to ask about pain. That pai most often

felt due to musculoskeletal disorders, spasms and

spasticity or digestive problems like as reflux and

constipation. It is important for children with cerebral

palsy to look for and eliminate the causes of pain and

to treat pain passionately without complaining.

Muscle cramps due to fatigue (Bosanquet, 2013).

Type of Cerebral Palsy can be seen in the picture

below in Figure 2.

Figure 2: Type of Cerebral Palsy

Spasticity is an increase in stretch reflexes and tendon

reflexes that originate from excessive excitability of

stretch reflexes in limb abnormalities. Postural tone

abnormalities will result in impaired coordination and

poor balance. So that spasticity becomes a problem

solving that must be considered. Rhines and Magoun

said the emergence of spasticity is a result of an

imbalance between alpha and gamma motor neurons

which is a consequence of the imbalance between the

facilitation center and the inhibition center (Susanto,

2014).

The physiotherapy approach that is commonly

used for handling disorders in Cerebral Palsy children

such as Neurostructure, Brain gym, (Neuro

Development Treatment) NDT, Trunk mobilization.

In this study the methods used are two of the above

interventions and then combined to reduce spasticity

in children with Cerebral Palsy.

Trunk mobilization is a passive stretching

technique that extends soft tissue. Passive stretching

is expected to provide a relaxing effect on spastic

muscle groups, increase postural mobility and control

abnormal movements that arise, thereby reducing

stiffness or spasticity in the trunk region towards

lower extremity (Kisner, 2013).

Trunk mobilization is a passive stretching

technique that extends soft tissue. Passive stretching

is expected to provide a relaxing effect on spastic

muscle groups, increase postural mobility and control

abnormal movements that arise, thereby reducing

stiffness or spasticity in the trunk region towards

lower extremity (Kisner, 2013).

NDT (Neuro Development Treatment) or Bobath

Method. The concept of this method is to affect

muscle tone and increase postural balance. This

method is able to treat motor control disorders of

cerebral palsy spectrum (Kavlak et al., 2018).

NDT is

a training method to stimulate the response of

neuromuscular mechanisms through proprioceptor

stimulation. NDT (Neuro Development Treatment)

techniques include: inhibition of spasticity,

facilitation and stimulation to improve abnormal

movement patterns, normalizing tone and optimizing

postural control functions. Before implementing the

NDT (Neuro Development Treatment) method, it is

first performed proper examination, determination of

physiotherapy diagnoses and plan of therapeutic

program for sufferers of spastic type cerebral palsy

(Surakarta,2013).

In a state of normal activity needed background

movement which is normal and functional skills.

Normal Postural Reflexology Mechanisms are

dynamic response in every answer activity changes.

The reactions are Encourage NPRM: Righting

reaction Consists of: labyrintine righting, neck

righting, body on body righting reaction, body on

head righting reaction and optical righting reaction.

Equilibrium reaction and Protective reaction.

The nature of the Trunk Mobilization method and

NDT (Neuro Development Treatment) is suppressing

pathological abnormal / postural reflexes which

causes normal movements to be inhibited and

stimulation in the form of touch, exercises shown to

stimulate neurons in children in normal growth and

development. But the process requires quite a long

time. Early and intensive treatment will provide

optimal results, because it will continuously improve

abnormal patterns in children (Surakarta,2013).

Ashworth scale is a degree or scale used to

measure the level of muscle spasticity / tone. The

Ashworth scale is one of the physiotherapy measuring

devices, part of the Bobath concept. Initially used to

see the reaction of antispastic drugs in

multipleschelosis. In 1987 developed by Bohannon

and Smith, so this measurement was used to measure

Combination of Trunk Mobilization and Neuro Development Treatment against Spasticity Reduction of Spastic Type Cerebral Palsy

485

the spastic value of the problem of the central nervous

system (Surakarta,2013).

2 RESEARCH METHOD

The research was carried out in the Physiotherapy

room at Deli Serdang Lubuk Pakam Distric Hospital

right on Thamrin street number 1 Lubuk Pakam for

1 month starting on june 6, 2016 until june 30, 2016.

The sample of study consisted of 12 people obtained

from the calculation of the Pocock formula (Pocock,

2014).

Spasticity measurements are carried out using

the Asworth scale. The Asworth scale has been

widely used in the population of children with

cerebral palsy. Asworth scale is an instrument used

to assess the intensity of spasticity. Asworth scale

value:

 Value 0: There is no increase in tone.

 Value 1: An increase in muscle tone is marked

by the feeling of minimal resistance at the end of

ROM when the joint is moved flexion and

extension.

 Value 2: There is a slight increase in tone

marked by the cessation of movement and the

appearance of a minimum resistance along the

rest of theROM.

 Value 3: There is an increase in muscle tone

more pronounced along most of the ROM.

Explain to sufferers that right angle means no

pain, middle means moderate pain and left angle

means very painful (front VAS).

 Value 4: Increased tone is very real, passive

motion is difficult tomove.

 Value 5: Stiff joints and extremities for flexion

and extension

Research flow can be seen in the picture below in

Figure 3.

Figure 3: Research flow.

Trunk mobilization is a passive stretching technique

that extends soft tissue. Passive stretching is expected

to provide a relaxing effect on spastic muscle groups,

increase postural mobility and control abnormal

movements that arise, thereby reducing stiffness or

spasticity in the trunk region towards lower extremity

(Kisner and Colby,2007).

The mechanism of exercise in trunk mobilization

is to improve the co-contraction of trunk muscles and

to gain flexibility from the trunk. At the end of the

passive movement can be accompanied by stretching

(stretching soft tissue) and elongation (trunk

lengthening towards the top) (Humaira, 2014).

Extending carried out passively will be able to

lengthen the soft tissue so that it decreases stiffness or

spasticity. Passive stretching is expected to provide a

relaxing effect on spastic muscle groups.

Neuro Development Treatment was developed by

Dr. Kr Bobath and Mrs. Berta 1997. This method is

specifically used to deal with central nervous

disorders in infants and children. The main principle

that underlies this method is the normalization of

muscle tone, facilitating normal movement patterns in

daily activities.

The mechanism of neuro development treatment

(NDT) is the inhibition of abnormal reflex activity

patterns and the facilitation of normal motor patterns.

Physiologically spasticity results from excess

abnormal tonic reflexes due to UMN lesions

(Richard, 2008). The provision of continuous therapy

provides direct inhibition of spastic muscles. By

doing the inhibition technique, it will stretch both the

extrafusal muscle and the muscle spindle of the

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

486

muscle. Then the muscle spindle responds by sending

a series of spindle impulses to the spinal cord.

Afferent fibers in the dorsal radix that carry

impulses form synapses with motoneuron which are

then excited and cause muscle contraction. This

occurs when afferent fibers from the spindle muscle

give a collateral branch to a group of intermediary

neurons in the grisea substrate (Koman, 2014). These

neurons are inhibitors and send their axons to the

motor neurons that innervate the antagonistic

muscles. Explanation of the example above illustrates

the muscle spindle by means of afferent impulses

monosympathetically activating motorneuron which

invests extrafusal muscle causing contraction of the

muscle and causes relaxation of the antagonist, which

means reduced spasticity (Pariera,2011).

3 RESULT AND DISCUSSION

3.1 Characteristics of Respondents

The study was conducted on subjects, namely

children with a diagnosis of Cerebral palsy in Lubuk

Pakam District Hospital and from those selected as a

whole (total sampling) aged between 1-6 years. From

the results of the study can be described as the

following analysis.

The gender of men is 6 people or 50%, women are

6 people or 50%. While the respondents based on

gender the majority of women are 9 people or 75% of

the total 12 respondents from the two intervention

groups. Characteristics of Respondents by sex can be

seen the below in able 1.

Table 1: Characteristics of Respondents by sex.

Sex n Persentation (%)

Male 6 50 %

Female 6 50 %

Based on the table below it appears that the

majority of research subjects at the RSUD are ages 1-

2, as many as 4 people with 33.3 presentations, then

at the age of 3-4 years, as many as 7 people with a

percentage of 58.3 and children aged 5-6 years, as

many as 1 person with a percentage of 8.3, the mean

results obtained are 1.75 and SD are 0,622.

Characteristics of Respondents by age can be seen the

below in Table 2.

Table 2: Characteristics of Respondents by age

Age n Persentation

(%)

1-2 th 4 30 %

3-4 th 7 50 %

5-6 th 1 7 %

Based on the table above, it appears that most of the

research subjects at the Lubuk Pakam Regional

Hospital based on body weight, namely 10 kg body

weight by 3 people with a percentage of 25.0 and then

followed by each different body weight ie 8 kg body

weight by 1 person with a percentage of 8 , 3%, 9 kg

body weight 2 people with a percentage of 16.7%, 12

kg body weight 2 people with a percentage of 16.7,

body weight 16 kg 2 people with a percentage of

16.7%, body weight 20 kg 1 person with a percentage

of 8.3%, 14 kg body weight of 1 person with a

percentage of 8.3 with a mean of 12.17 and an

elementary school of 3.639. Characteristics of

Respondents based on body weight can be seen in

Table 3.

Table 3: Characteristics of Respondents based on body

weight.

Body Weight n Persentation

(%)

8 1 8 %

9 2 16 %

10 3 25 %

12 2 16 %

14 1 8 %

16 2 16 %

20 1 8 %

3.2 Spasticity Measurement Results

Based on the table above, it appears that the research

subjects at Deli Serdang Lubuk Pakam Hospital with

their severity based on the Asworth scale obtained the

results that with a spasticity (pre test) the maximum

value is 5 while the minimum value is 2 with a Mean

of 2.58 and a Standard Deviation (SD) 0.996, while

after the intervention (post test) it is known that the

value of spasticity in cerebral palsy children with a

maximum value of 4 while the minimum value of 2

with a mean of 2.42 and a standard deviation (SD)

0,793. Spasticity measurement results can be seen in

Table 4.

Combination of Trunk Mobilization and Neuro Development Treatment against Spasticity Reduction of Spastic Type Cerebral Palsy

487

Table 4: Asworth scale values before and after the

intervention

Asworth scale

Before After

4

2

3

2

5

2

3

2

Mean 2,58 2,42

3.3 The Effect of Trunk Mobilization

and Neuro Development Treatment

on Decreasing Spasticity

The results of data processing using paired t- test,

before and after the administration of the

intervention. the results of data analysis found that

there was no effect of the intervention so that the

intervention did not affect the reduction of spasticity

in children with cerebral palsy with indicated p value

= 0.157 which means p value greater than 0,05

(p>0,05). Results can be seen in the Table 5.

Table 5: Pre test and Post Test

Group n x

± SD

Pre-tes

12 2,58 ± 0,28 0,15

Pos

-tes

12 2,42 ± 0,22

This shows that the results obtained are not in

accordance with the theory and purpose of the

combination method of Trunk Mobilization and NDT

which have a role to reduce Spasticity. In this study,

researchers have not yet gotten the results from

providing a combination of Trunk Mobilization and

NDT in reducing spasticity in spastic-type Cerebral

palsy children, for their spasticity the patient did not

change due to the nature of the Trunk Mobilization

and NDT (Neuro Development Treatment) methods.

The mechanism of intervention is suppressing

pathological abnormal / postural reflexes which

causes normal movements to be inhibited and

stimulation in the form of touch, exercises shown to

stimulate neurons in children in normal growth and

development (Kisner, 2013). But the process requires

quite a long time. Early and intensive treatment will

provide optimal results, because it will continuously

improve abnormal patterns in children (Pickles, Altun

and Yurdalan, 2016).

In a study by Tri Sarjono Waluyo, statistical tests

showed that there was an effect of trunk mobilization

on decreasing spasticity in spastic cerebral palsy in

sample 12 according to the largest age group between

ages 3-4 years with results (p = 0.046)) (Waluyo,

2010). Research by Bar-Haim et al., 2006 with the

title "comparison of efficacy of adeli suit and

neurodevelopment mental treatment in children with

cerebral palsy" influence on reducing spasticity in

Spastic type Cerebral Palsy children, with a sample of

12 cerebral palsy children (9 boys and 3 girls) with an

age range of 5-13 years, for brackets of 4 weeks or 1

month (2 hours per day, 5 days a week, in 20 sessions)

with significant results p <0.05. The researchers'

assumption that the giving of an intervention needs to

be given attention to the accuracy of the intervention

(Stevness,2009).

4 CONCLUSION

Based on the results of the statistical tests and the

discussion above, it can be concluded that there is no

effect of reducing spasticity onspastic-type Cerebral

Palsy children in the administration of a combination

method of the combination of Trunk Mobilization and

NDT.

5 SUGGESTION

To find out whether the therapy is successful or not,

as a physiotherapist should use a measuring tool to

measure the results before and after being given an

intervention so that it always gets an evaluation.

Adjusting the patient's exact position when doing

activities or at rest against the spasticity pattern so

that the spastic muscles can elongate and can prevent

contractures. The length of time given.

ACKNOWLEDGEMENTS

Researchers thank all those who have helped during

the research process and all the staff of the Institute

for Health Medistra Lubuk Pakam.

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

488

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