COMPARISON OF KNEE JOINT PROPRIOCEPTION IN SPASTIC DIPLEGIC AND TYPICALLY DEVELOPING CHILDREN OF AGE 5-12 YEARS; A CROSS-SECTIONAL STUDY

1 2 2 Megha D. Panchal , Abraham M Joshua , Jaya Shanker Tedla

ijcrr 1A/12 Shabnam, 18 off Juhu Lane, Andheri West, Mumbai Vol 03 issue 12 2Department of Physiotherapy, Kasturba Medical College (a constituent Category: Research institute of Manipal University), Bejai, Mangalore Received on:06/10/11 Revised on:17/10/11 Accepted on:26/10/11 E-mail of Corresponding Author: [email protected]

ABSTRACT Objective: To compare quantitatively the error made in knee joint proprioception by typically developing and spastic diplegic children of age 5-12 years. Design: Cross sectional. Participants: A total of 100 subjects were recruited, out of which, 80 (40 males, 40 females) were typically developing children (mean ± standard deviation of age was 8.88± 2.29 years) and 20(13 males, 7 females) were children with (mean ± standard deviation of age was 9.54± 2.44 years). Methods: Passive reproduction of joint position of knee was checked by using a universal goniometer. Relative error was measured in degrees. Results: Mean ± standard deviation of relative error in knee joint proprioception was 12.91±5.63 degrees for children with spastic diplegia and 1.80±2.15 degrees for typically developing children respectively. Comparison of the relative error between spastic diplegic children and typically developing children using the Mann-Whitney U test was highly significant with p value < 0.001 Conclusions: There was significant error in proprioception of knee joint in children with spastic diplegia as compared to typically developing children. ______

Key words: Spastic Diplegia, Cerebral derived from sources outside the body. Palsy, Proprioception, Knee Joint. Interoceptive sensations are those arising from internal organs of the body. Sense of INTRODUCTION position, passive movements, vibrations and Sensory integrity is the ability to organize deep pain are the proprioceptive sensations and use sensory information. Sensory derived from the body itself.2 Out of these, testing examines sensory integrity by proprioception plays an important role in determining the individual‘s ability to the maintenance of joint stability and interpret and discriminate amongst regulation of joint motion.3 incoming sensory information.1 Proprioception can be defined as the According to Sherrington sensations are of perception or awareness of change in three types: exteroceptive, proprioceptive muscle length, muscle tension in addition to and interoceptive. Pain, light touch and perception of joint position and motion.4 temperature are the exteroceptive sensations The main proprioceptors are muscle

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spindle, Golgi tendon organs and joint evaluation of proprioception could not be receptors, all these receptors contribute to retrieved. over all proprioceptive functions.5 Of all the sensory modalities proprioception is METHODOLOGY perhaps the one most closely linked to A total of 100 subjects were recruited, out locomotor activity. For motor functions to of which, 80 were typically developing precede normally the nervous system must children and 20 were children with spastic be continually appraised of the position of diplegia. Typically developing children the body and the limbs.6 The functions of with a mean age of 8.88  2.29 years were proprioception are to increase body taken from schools by random sampling. awareness and to contribute to motor Inclusion criteria were typically developing control and motor planning.7 Maturation of children between 5-12 years of age. the proprioceptive function occurs by Children with any musculoskeletal, approximately 3 to 4 years of age.8 neurological, cardiopulmonary disorders Injury, surgery, arthritis, and and medical issues affecting proprioception other kinds of brain damage, and poorly were excluded. Children with spastic modulated muscle tone can result in diplegia with a mean age of 9.54  2.44 diminished proprioceptive perception and years were taken from tertiary care hospital 9 awareness. Children with spastic cerebral and special schools by convenient palsy have deficits in proprioception, sampling. Inclusion criteria were children 10 stereognosis, and 2-point discrimination. with spastic diplegia between 5-12 years of In hemiplegic cerebral palsy proprioception age, knee extension at least 900 of flexion is one of the chief modalities affected to 100 flexion on the right side of the lower 11 bilaterally. limb, Modified Child Mini Mental State Proprioception can be tested in different Examination (MCMMSE) 15 scores of >24 ways that is qualitatively and quantitatively. for 3-5 years,>28 for 6-8years,>30 for 9-11 Qualitative tests include ability to detect years and > 35 for 12-14 and Gross Motor passive movement and recognition of Function Classification System Expanded 12 direction of movement. Quantitative and Revised (GMFCS-E&R) 16,17 level of assessment can be done by passive or active function II & III. reproduction of joint position using Children with spastic diplegia with fixed equipments like isokinetic dynamometer, deformities of lower limb, with lower limb 13 goniometer. Qualitative proprioceptive surgeries at hip and knee, with acute deficits have been investigated in children orthopedic problems of knee, hip and back, with cerebral palsy (CP) and specifically in who are un co-operative and who were 10 children with spastic diplegia. A review of under any medication which would affect the literature reveals a large array of data on muscle tone such as botulinum toxin, quantitative proprioceptive examination in phenol, etc were excluded. 14 adults. Similar studies need to be done The tester was a qualified physical on spastic diplegic children. therapist. Equipments used were Universal There are studies on qualitative Goniometer, velcro straps, ruler, non toxic proprioceptive deficit in children with CP water soluble marker, chair, black ribbon. and specifically in children with spastic Approval was taken from institutional diplegia. However, studies on quantitative ethical committee. Block education officer was visited. Permission for conducting the

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study in schools was obtained. Approval readings of the right knee of each subject. was also taken from Principals of schools Relative error was noted in degrees. Mean and special schools. In brief the procedure was taken of the three values. At the end of was explained to the children and written the procedure the markings made on the consent was taken from parents of children subjects were cleaned. Intra-rater reliability who fulfilled the inclusion criteria. was also calculated by using these (MAS) 18, 19 was measurements. used to measure the of knee flexors in side lying position. Each child Statistical Analysis was made to sit on a chair or a bench Relative error in knee proprioception sense without arm support and arms hanging by of typically developing children and the side, with trunk-hip at 90 degrees, hip- children with spastic diplegia was knee flexion at 90 degrees.1-2 inch space calculated. Mann Whitney U test was used was kept between popliteal fossa and chair. to compare data obtained in typically Greater trochanter, lateral femoral developing children and children with epicondyle and lateral malleolus were spastic diplegia. Intra-rater reliability of marked with water soluble marker pen. A goniometer was calculated and Alpha value line was drawn from greater trochanter to was obtained. SPSS version 13.0 was used. lateral epicondyle of femur and another p value less than 0.05 was taken as from lateral epicondyle to the lateral significant. malleolus. Goniometer was placed with fulcrum on lateral epicondyle, fixed arm RESULTS along greater trochanter and movable arm A total of 100 subjects were taken to along lateral malleolus. Both arms of the measure relative error made in knee joint goniometer were secured with four Velcro proprioception, out of which 20 were straps. children with spastic diplegia and 80 were Right hand of the tester was placed on typically developing children. lower end of leg of the subject. The tester All children with spastic diplegia had full placed the knee joint of the subject at 450 range of knee flexion but knee extension towards extension. Subject was clearly range was not complete for all; 70% of instructed to note this position with eyes children had complete extension whereas open. Then subject was asked to note the 30% had 10 degrees extension lag. MAS same position when blind folded and was used to measure spasticity. 4 spastic remember it. The tester then moved knee diplegic children had MAS score of I and joint to starting position and extended the 16 had score of II for knee flexors. knee. The limb was moved slowly towards GMFCS-E&R was used to determine extension. child‘s present abilities and limitations in Subject was clearly instructed that he/she gross motor function. Out of 20 children had to say ―STOP‖ as soon as the same with spastic diplegia, 4 children were at position he/she had previously noted and GMFCS-E&R level III and 16 were at supposed to remember had reached. When GMFCS-E&R level II. Mean Modified the subject said stop; corresponding angle child MMSE score was 32.90. was noted with the goniometer. A practice Characteristics of children with spastic session of two trials was given to the diplegia were specified in Table-1. subject. This was followed by taking three

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Three readings of knee joint as indicated by made by spastic diplegic children is highly children were taken with a universal significant as compared to typically goniometer. Alpha values were calculated developing children. to know the intra-rater reliability of Results of this study co-relate with the universal goniometer used in the study. previous study by Opila et.al where Alpha value was found to be 0.96 and 0.79 kinesthetic recall of shoulder was checked respectively for both children with spastic in normal, and diplegia and typically developing children athetoid cerebral palsy children. In that indicating the strong reliability of the study error made by spastic CP children instrument. was significantly higher (p<0.05) as Mean and standard deviation of measured compared to normals and athetoid CP .20 In knee angle was 45.02±14.40 for children this study we examined the passive with spastic diplegia and 44.60±2.79 for reproduction of joint position of knee and typically developing children. Mean found that error made by children with relative error in knee joint proprioception spastic diplegia is statistically significant was 12.91 for spastic diplegics and 1.80 for as compared to typically developing typically developing children (Graph-1). children (p value <0.001). Comparison of the relative error between The knee joint proprioception may be spastic diplegic children and typically affected in children with spastic diplegia developing children using the Mann- due to increase in muscle tone, abnormal Whitney U test was highly significant with firing of muscles, abnormal weight bearing p value < 0.001 (Table-2). and postures. Experience of movement and Comparison of relative error made by feedback that a child receives continually children with spastic diplegia MAS score I influences the development of motor and II was done and it was found that control and proprioception. Since spastic children with MAS score II had greater children experience diminished movement error as compared to those with MAS score and consequently reduced kinesthetic input, I which was statistically significant (Table- they may make more errors on a kinesthetic 3). task. These expectations are consistent with re-afference theory, which contends that DISCUSSION sensory feedback generated by a movement Proprioception refers to sensation of (re-afference) is compared to the efferent movement that includes speed, rate, signal generated. If the re-afference is sequencing, timing, force and joint position identical to the efferent signal, then this .The role of proprioception is to provide match is stored for future use called the motor system with a clear unambiguous ‗comparator storage‘. Since normal map of the external environment and of the children experience many movements, their body. ‗comparator storage‘ is finely tuned in In this study we compared the error made efferent-re-afferent trace combinations. by spastic diplegic children and typically Children with spastic cerebral palsy move developing children in knee joint infrequently and therefore have the least proprioception. A total of 100 children amount of motor memories available to were recruited, of which 80 were typically them.20 Delayed myelination of fiber tracts developing and 20 were children with also contribute. All the above factors are spastic diplegia. The results show that error the reasons ascribed for significant

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proprioceptive error found in as compared to typically developing proprioception of knee in children with children (1.80 ± 2.15 degrees). spastic diplegia. Error found in children with spastic REFERENCES diplegia and MAS score II was higher and 1. Thomas J. Sensory assessment. In: statistically significant as compared to error Sullivan SO. Physical rehabilitation - made by children with MAS score I. This assessment and treatment. 4th ed. maybe attributed to greater spasticity in India: Jaypee Brothers; 2001. p. 133- MAS scores II in children with spastic 55. diplegia. Increased tone may cause 2. DeJong R. The neurological abnormal posturing and weight bearing examination. The sensory system- which might be the cause of increased error proprioceptive sensations.5th ed. in proprioception. Excessively high tone Philadelphia: J.B. Lippincott Company; may be associated with poorly modulated 2005. p. 70-4. proprioceptive sense.9 3. Yamashita T, Takebayashi T, Sekine. GMFCS classification score indicated Proprioceptors physiologic and clinically a greater proprioceptive error at morphologic characteristics. Jpn J Phys level II then at level III but this was not Fitness Sports Med 2006; 55: 207-15. statistically significant .The ability to stand 4. Lephart S, Pincivero D, Rozzi S. or ambulate could not be co-related with Proprioception of the ankle and knee. the proprioception error as number of Sports Med 1998; 25: 149-55. diplegics who were unable to ambulate 5. Bertoti D. Functional were only 2 as compared to 18 ambulatory Neurorehabilitation through the life children. span. The essentials of Neuroanatomy Limitations of this study include small and neurophysiology: A rehabilitation sample size of children with spastic application approach. Philadelphia: diplegia as compared to typically F.A. Davis Company; 2004. p. 35-37. developing children. Goniometer used in 6. Fredrick C, Saladin L. Pathophysiology this study may not be as accurate as of motor systems. Basic sensory sophisticated instruments like isokinetic mechanisms and somatosensory dynamometer, electro-goniometer. system. Philadelphia: F. A. Davis Future study maybe conducted on the Company. p. 96-101. proprioceptive error in children with 7. Kranowitz C. The out of sync child has spastic diplegia, with a larger sample size. fun. Body position sense.1st edition. Similar research can also be done using New York: Berkley publishing group; more accurate instruments like electro- 2003. p. 88-90. goniometer and isokinetic dynamometer. 8. R Steindl, K Kunz; A Fischer. Effect Further studies are also warranted to check of age and sex on maturation of proprioception at other joints in spastic sensory systems and balance control. diplegics. Dev Med Child Neurol 2006; 48: 477- 82. CONCLUSIONS 9. D. Brown. Feeling the Pressure: The There was significant error in Forgotten Sense of Proprioception. proprioception of knee joint in children California deaf blind services. with spastic diplegia (12.91 ± 5.63 degrees) Resources fall 2005; 12: 1-4.

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10. Felix S, Nowbar S, Ferrel A, Bjornson Expanded and Revised. Down loaded K, Hays RM. Lower extremity sensory from can child website at: function in children with cerebral http://motorgrowth.canchild.ca/en/GM palsy. Pediatr Rehabil 2005; 8: 45-52. FCS/resources/GMFCS-ER.pdf. 11. Cooper J, Majnemer A, Rosenblatt B, 17. Palisano R, Rosenbaum P, Walter S, Birnbaum R. The determination of Russell D, Wood E, Galuppi B. sensory deficits in children with Development and reliability of a hemiplegic cerebral palsy. J Child system to classify gross motor function Neurol 1995; 10: 300-9. in children with cerebral palsy. Dev 12. Grob K, Kuster M, Higgins S, Lloyd G. Med Child Neurol 1997; 39: 214-223. Lack of correlation between different 18. Bohannon R.W., Smith M.B. Interrater measurements of proprioception in the reliability of a modified Ashworth knee. J Bone Jt Surg 2002; 84: 100-1. scale of muscle spasticity. Phys Ther 13. Martijn H, DirkJan H. Veeger, Peter A. 1987; 29: 206-7. Proprioception of the shoulder after 19. Pandyan A.D., Price C, Barnes M.P., Stroke. Arch Phys Med Rehabil 2008; Johnson G.R. A biomechanical 89: 333-38. investigation into the validity of the 14. Redmond J, Cross D, Shahani T. modified Ashworth Scale as a measure Variability of quantitative sensory of elbow spasticity. Clin Rehabil 2003; testing: implications for clinical 17: 290-4. practice. Henry Ford Hosp Med J 1990; 20. Opila J, Short M, Trombly C. 38: 62–7. Kinesthetic recall of children with 15. Jain M, Passi G.R. Assessment of a athetoid and spastic cerebral palsy and modified mini mental scale for of non-handicapped children. Dev cognitive function in children. Indian Med Child Neurol 1985; 27: 223-30. Pediatr 2005; 42: 907-12. 16. Palisano R, Rosenbaum P, Bartlett D, Livingston M. GMFCS – E & R Gross Motor Function Classification System

Table 1: Description of spastic diplegic children

MAS Grades for Mean Total Knee Extension GMFCS Full Range Knee Flexors MMSE Spastic Levels Knee Score Diplegia Flexion Full 10 Children range Lag I II II III

20 20 14 6 4 16 4 16 32.90

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Table 2: Comparison of relative error between children with spastic diplegia and typically developing children

Group N MeanSD Mann Whitney U test p value

Children with spastic diplegia 20 12.915.63

6.87 <0.001* Typically developing 80 1.802.15 children

Table 3: Comparison of relative error and MAS score for knee flexors in children with spastic diplegia

MAS Grades for Knee Flexors N MeanSD Mann-Whitney U Test p value

I 4 7.502.89

II 16 14.275.37 -2.33 .020

Total 20 12.925.64

Graph-1: Comparison of relative error between children with spastic diplegia and typically developing children

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Proprioceptive Error in Degrees Errorin Proprioceptive 0 Spastic Typically Diplegia Developing

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