INTRODUCTION:
Pediatric
physical therapy is a well known specialty in the field of physical therapy (1). Cerebral palsy
is most common condition that is treated under this specialty. Cerebral palsy
is a disorder of movement and posture that is resulted when there is lesion in
immature brain (2). Cerebral palsy
has no cure yet (3). Lesion to
brain tissue is permanent. Hypoxia, birth asphyxia and prematurity are
considered leading cause for cerebral palsy. Brain is central organ in human
body that controls each and every thing. Motor areas in brain control the
movement of muscles. Many techniques and therapies have been used to manage
cerebral palsy but no therapy and technique is considered best yet. Intensive
physical therapy treatment is one of them. Intensive pediatric physical therapy
is different from traditional physical therapy because it uses latest trend and
techniques in the form of spider web, spider cage, thera suit, thera togs along
with other physical therapy treatments. In intensive physical therapy a child
is involved for longer session usually for 05 hours, 05 days in a weak and for
03 to 04 week (4). Frequent
assessment and outcome measurement is also another feature of intensive physical
therapy for children. Concept of motor learning and neuroplasticity is very
helpful when treating the children with cerebral palsy and also adult patient
with stroke. Training and retraining of brain by utilizing high repetition of
movement pattern is key features of intensive protocols (5). Intensive
pediatric physical therapy has greater effectiveness as compared to traditional
protocols (6). The studies
and research work on intensive pediatric physical therapy is limited and
further studies are needed (7). Intensive protocol
is used with traditional therapy but duration of single session is much greater
and longer. Treatment session is usually 03 to 04 hours, 05 days in a week and
continuous for 03 weeks (8). After 03 weeks
changes are measured and for 01 week child is given rest completely.
Concept
of intensive pediatric physical therapy is not new but still in Pakistan it is
not practice. This short commentary will present an awareness of intensive
pediatric physical therapy among the physical therapist that working with
pediatric population. Intensive physical therapy is largely practices in
western countries and all around the world; it should also b started in
developing countries in cerebral palsy centers. Still we are using the
conventional physical therapy treatment in the form of stretching exercises,
orthotic devices and range of motion exercises for children with cerebral
palsy. There is need to improve the intervention in the field of physical
therapy.
Many
interventions like strength training, functional training, conductive
education, sensory integration, constrain induce movement therapy, and
neurodevelopmental techniques can be used with intensive protocols. Recently
use of therasuit, theratogs, spider web, and universal exercise unit is
increasing in intensive physical therapy in children (9).
Therasuit
is a use of special cloth for optimum and accurate joint position and it is
known with many different names like Adeli suit, Pedia suit and Penguine suit (10). Therasuit is
considered as a dynamic splint (11). It can be used
for cerebral palsy, stroke and children with autism. Use of theses cloths as a
dynamic splint is explainable because in cerebral palsy there are problems in
posture and movements (6). These suits
help the child to keep his/her body part in an accurate position and help the
brain to learn normal synergies (10). Elastic cords
in these clothes provide a sensory input and stimulate the properiception and
vestibule system also act as an external support to trunk and skeleton thus
helping to restore normal posture. These two systems play very important role
in the rehabilitation of neuromuscular disorders (12). Suit therapy is a modification and adaptation
from space suit that is used to minimize the effects of weightlessness in space
and osteoporotic effects of weightlessness (13). Cause of motor
function in cerebral palsy is different from astronauts, but suit therapy is
effective when used with intensive protocols (14). U.S. Food and
Drug Administration (FDA) classified therasuit as a properoceptive orthotic
device under the category of class 1 limb orthosis (15). Vest, shorts,
head piece, knee piece and shoes with hooks are the parts of a therasuit (15). Benefits of
Suit therapy includes external stabilization, normalizing muscle tone, aligns
the body to as close to normal as possible, normalizing gait pattern, providing
tactile stimulation, influencing the vestibular system, improving balance, supports weak muscles, providing resistance
to strong muscles to further enhance strength, helping to decrease contractures
and improving coordination (15).
Although
therasuit method is used largely in many areas of the world but evidence of its
effectiveness is questionable because there is very limited data on its
effectiveness. Elizabeth C S Datorre used therasuit along with strength
training by using universal exercise unit in her case report on 12 years old
male with spastic quadriplegic cerebral palsy (9). Gross Motor
Functional Measure (GMFM) was used as outcome measurement tool. She concluded
that an intensive pediatric physical therapy can improve the motor function of
child with spastic cerebral palsy. Another study on therasuit was conducted by
Bailes et al by using therasuit with intensive protocols. Study was conducted
with control and experimental groups. They found significant improvement on
Gross Motor Functional Measure (GMFM) and Pediatric Evaluation of Disability
Inventory (PEDI) after 09 weeks of therapy (16). A modified
suit therapy was conducted in 2011 and concluded that modified suit therapy
along with conventional combination therapy is effective in improving gross
motor function (15).
Unit
universal exercise has been used in pediatric intensive unit since 1999 by
Richard and Isabella and use of universal exercise unit in strength training
was introduced by Professor Diga in Poland in 1940s (17). Now, it has
two modifications, the system of pulleys and suspension system. Unit universal
exercise is widely used in the United States and many countries in the centers
of cerebral palsy (18). Unit universal
exercise stimulates the system of proprioception and it can be used with conventional
therapy. Universal exercise unit is used with elastic bands and cords that are
used to hold the body parts of patient in this cage and elastic resistance of
the cords can be used for strength training (17).
CONCLUSION:
There
is very limited data on the effectiveness of intensive protocols and also on
techniques that are used in intensive protocols. Present works on intensive
physical therapy are case reports. It is concluded that more focus studies with
control group and larger sample size should be conducted on intensive
protocols. Concept of intensive pediatric physical therapy is not new but still
in Pakistan it is not practice. This short commentary will present an awareness
of intensive pediatric physical therapy among the physical therapist that
working with pediatric population. Intensive physical therapy is largely
practices in western countries and all around the world; it should also b
started in developing countries in cerebral palsy centers. Still we are using
the conventional physical therapy treatment in the form of stretching
exercises, orthotic devices and range of motion exercises for children with
cerebral palsy. There is need to improve the intervention in the field of
physical therapy.
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