Under Water Exercises Versus Land Based Exercises in Treatment of Erb's Palsy

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1 Med. J. Cairo Univ., Vol. 84, No. 2, September: 45-51, Under Water Exercises Versus Land Based Exercises in Treatment of Erb's Palsy AHMED A. IBRAHIM, M.Sc.; GEHAN H. EL-MENIAWY, Ph.D. and NAHED S. THABET, Ph.D. The Department of Physical Therapy for Growth & Developmental Disorders in Children and Its Surgery, Faculty of Physical Therapy, Cairo University Abstract Background: Erb's palsy is a type of brachial plexus injury which results from an injury to the fifth and sixth cervical nerves. It constitutes about 80-90% of all brachial plexus cases. Weak muscles should be allowed to participate in normal movement patterns through different therapeutic programs to regain normal range of motion and strength for Erb's Palsy children. Aim of the Study: This study was designed to compare between underwater and land based exercises effect on range of motion and isometric strength of shoulder flexion in children with unilateral Erb's palsy. Material and Methods: Thirty children with unilateral Erb's palsy from both sexes (16 boys and 14 girls) classified as grade 3 according to Mallet score system. Their ages ranged between months, were randomly assigned into two equal groups: Under water intervention group and land based exercises group. Range of motion and isometric strength of shoulder flexion were measured by AutoCAD program and Hand Held Dynamometer respectively. Treatment program extended for 3 months, 3 sessions per week where evaluation for each child in both groups was done before and after it. Results: There was a statistically significant improvement in the measured parameters in both groups when comparing their pre and post treatment mean values. However, significant difference was recorded between post treatment mean values of the two groups after treatment in favor of underwater intervention group. Conclusion: The obtained results suggested that underwater exercises therapy is beneficial to improve range of motion and isometric strength of shoulder flexion in children with unilateral Erb's palsy. Key Words: Erb's palsy Underwater exercises Land based exercises. Introduction ERB'S Palsy (EP) is a condition where the upper part of brachial plexus (C5, C6) that innervates Correspondence to: Dr. Ahmed A. Ibrahim, The Department of Physical Therapy for Growth & Developmental Disorders in Children and Its Surgery, Faculty of Physical Therapy, Cairo University the arm is severed resulting in adducted, internally rotated shoulder and pronated forearm, typically known as waiter's tip position [1]. It constitutes a major from among Brachial Plexus Palsy (BPP) children as; it accounts about 80%-90% of all BPP cases [2]. Paralysis occurs in the deltoid, brachialis, biceps, brachioradialis, serratus anterior, and rhomboids major and minor. Levator scapulae, supraspinatus, infra spinatus, subcapularis, teres major and minor. Even through hand muscles are unaffected, functional movement of the upper limb is limited [3]. Muscles in the impaired shoulder show significantly less strength than muscles in the unaffected shoulder in all directions [4]. Various degrees of functional impairment of affected upper extremities, due to reduction in muscle power and limited Range of Motion (ROM) [5]. The objective of physical therapy program is to facilitate the highest functional outcome possible for the child. This is achieved through several ways, including facilitation of normal movement patterns while inhibiting substitutions during reaching and weight bearing activities [6]. Under Water (UW) exercises is defined as supervised exercise in warm water which is widely used in rehabilitation especially when exercising under normal conditions of gravity is difficult and painful [7]. It is the external or internal use of water in any of its forms (water, ice, steam) for health promotion or treatment of various diseases with various temperatures, pressure, duration, and site [8]. Under water exercises is based on the principles of hydrodynamics (buoyancy, relative density, viscosity, resistance, hydrostatic pressure, turbulence, and flow) which must be well known to 45

2 46 Under Water Exercises Versus Land Based Exercises in Treatment of Erb's Palsy therapist and described to the patient before starting this therapeutic modality [9]. Patients with shoulder problem can benefit from under water exercises as the buoyancy of the water assists the function upward movement of the arm when the person is unable to do so independently on land, the aim of underwater exercises program was to increase passive and active range of motion, to enhance proprioceptive input, to improve strength and to enhance psychological mood [10]. Physical therapy exercises which include range of motion exercises, stretching tight muscles, tactile stimulation and joint compression in weight bearing position are helpful to improve range of motion and facilitate weak muscles for Erb's palsy children [11]. Therefore, the purpose of this study was to compare the outcomes of underwater and Land Based (LB) treatment program on range of motion and isometric strength of shoulder flexion in Erb's palsy children. Patients and Methods Thirty unilateral Erb's palsy children aged from 26 to 39 months participated in this study. They were selected from the outpatient clinic of National Institute of Neuromotor System in the period from April to October Children were randomly assigned to either underwater or land based exercise group by opening an opaque envelop prepared by an independent subject with random number generation. Under water group included 15 children (5 boys and 10 girls) with mean age of 32.6 ±6.2 months. Land-based exercises group included 15 children (11 boys and 4 girls) with mean age of 34.0 ±5.3 months. Children in both groups participated in the study for 12 weeks, three sessions per week, and each session lasted for one hour [12]. Subjects were diagnosed as having unilateral Erb's palsy based on careful clinical assessment by a neuropediatrican. Subjects' parents signed a written consent form approved by Ethics Committee of the Faculty of Physical Therapy, Cairo University before the children participated in the study. Study design: Randomized controlled trial: A- Inclusion criteria: - Age of children ranged from 26 to 39 months. - Children had grade 3 according to Mallet score [13]. B- Exclusion criteria: - Visual or auditory problems. - Seizures. - Previous history of surgical interference (orthopedic or neurosurgeries). Instrumentation: 1- For evaluation: Photographic analysis: It was composed of digital camera and the photos were analyzed using AutoCAD program to measure active shoulder flexion range of motion. Hand Held Dynamometer (HHD): Was used to measure isometric strength of shoulder flexors. 2- For treatment: Underwater exercises group: Swimming pole for pediatric patients (Hydrotherapy Department in National Institute of Neuromotor System Giza, Egypt) equipped with chair, side bars at sides of the pool. Land-based exercises group: Physical therapy tools of different shapes in the form of: Mats, wedges, and medical balls. A- Evaluation procedures: 1- Assessment of active shoulder flexion range of motion: This procedure was classified into two main phases. Measurement phase: Child position was in supine on medical bed, adhesive dots were applied over the skin above the center of the involved joints (for shoulder joint, the center located at head of humerus while for elbow joint the center is located at an axis through the medial and lateral epicondyles). Child was instructed to make shoulder flexion through full range of motion. Video recording was done to capture the dynamic movement of the involved upper limb from lateral view. Analysis phase: The recorded video was cut into photos then analyzed. Photo which reflects the maximum angle of shoulder flexion is selected to be introduced to Auto desk AutoCAD 2014 program. The angle was measured at the intersection of two lines. First line is connected between (first point, over the center of the circle at the elbow

3 Ahmed A. Ibrahim, et al. 47 level and second point over the center of the circle at the shoulder level). Second line is connected between (first point, over the end point of the first line at the shoulder level and the second point over the horizontal line). The net result was the angle between two lines as Fig. (1). Fig. (1): Shoulder flexion angle. 2- Assessment of isometric strength of shoulder flexors: Child position, was supine lying position with the affected upper limb held in 90º degree of shoulder flexion, elbow was extended, and forearm was pronated. Therapist position was standing beside the affected shoulder of the child, therapist (proximal) hand was placed on the lateral aspect of the affected shoulder to prevent substitution by shoulder abductors, while (distal) hand was placed under the strap of HHD to give resistance just above elbow joint in order to measure shoulder flexion, therapist gave the resistance until the instrument whistled after 5 seconds which was fixed time for all cases [14]. Three repetitions were performed of the tested muscles and the main of the three times was calculated, recorded, and saved in excel sheet with the force given in kilogram. B- Treatment procedures: The underwater exercises group: Water temperature was (30ºC). Children were immerses in water to just above shoulder level. The selected program according to Mohammed et al., 2010 [10] included: - Underwater massage: Thumb effleurage and spiral massage starting from the distal part (hand) to the proximal one (shoulder and per scapular area). - Range of motion exercises: It was applied for each joint from sitting position to maintain joint mobility. - Facilitation of muscle contraction. - These exercises were being applied for the affected muscles through scratching and squeezing followed by passive movement. - Proprioceptive training: It was composed of hand weight bearing which was applied with fully extended upper extremity, and quadruped and creeping exercises that were started by quadruped with raising one upper extremity with the contralateral lower extremity, then child ambulate over four extremities, while the water level was below shoulder level. - Facilitation of righting and equilibrium reactions: It was applied from sitting position with tilting the child into a direction opposite to the direction of action of the involved muscle. - Stretching tight muscles: It was applied from sitting position to maintain flexibility of muscles and prevent soft tissues deformity. - Scapular mobilization: It was applied from sitting position with the lower border of the scapula between the thumb and index of the therapist to move the scapula in (upward, downward, lateral and medial directions) to prevent stucking of scapula. After finishing the underwater exercises the child left the pool and took a shower (25ºC) and remained in the changing room for at least 10 minutes and took a juice before leaving to avoid dehydration [15]. The land based exercises group: The selected program according to El-Khatib et al., 2013 [2] included: - Massage (thumb effleurage and spiral massage). Starting from the hand to the shoulder and per scapular area: - Range of motion exercises. It was applied for each joint from supine lying position on mat to maintain joint mobility: - Facilitation of muscle contraction of the affected muscles through (tapping and scratching followed by passive movement). - Facilitation of righting and equilibrium reactions. It was applied over a medical ball with tilting of the ball into a direction opposite to the direction of action of the involved muscle.

4 48 Under Water Exercises Versus Land Based Exercises in Treatment of Erb's Palsy - Proprioceptive training: It was composed of Hand weight bearing which was applied with fully extended upper extremity, and quadruped and creeping exercises that were started by quadruped with raising one upper extremity with the contralateral lower extremity, then child ambulate over four extremities, exercises were applied on medical mat. - Scapular mobilization: It was applied from side lying with the lower border of the scapula between the thumb and index of the therapist to move the scapula in (upward, downward, lateral and medial directions) to prevent stucking of scapula. - Stretching exercises: It was applied for subscapularis muscle from supine lying position with shoulder adducted, externally rotated until resistance is felt, biceps brachii muscle from supine lying position with shoulder abducted to 90 degree, externally rotated and elbow extended until resistance is felt, and wrist flexors from supine lying position, support the elbow and grasp on the fingers and keep them straight, extends the wrist until resistance is felt, maintain for 30 seconds, relax for 30 seconds, and repeat 3 times. Data management and statistical analysis were performed using Statistical Package for Social Sciences (SPSS) vs. 21. Numerical data were summarized using means and standard deviations. Categorical data were summarized as percentages. Comparisons between the 2 groups with were done using the t-test. For categorical variables, differences were analyzed with χ 2 (chi square) tests. All p-values are two-sided. p-values <0.05 were considered significant. Results The collected data from this study represented the statistical analysis of range of motion measured by AutoCAD program and isometric strength measured by HHD. Data were obtained from both groups; underwater exercises group and land-based exercises group before and after three months of treatment. Demographic and clinical characteristics of children in both groups: The distribution of boys and girls for underwater group was (5 boys and 10 girls), while for landbased was (11 boys and 4 girls), mean ages and standard deviation (mean ± standard deviation) of underwater and land-based group were (32.6 ±6.2) and (34.0±5.3) months respectively. There were no significant difference between both groups in their ages and their p-values was (0.511) as illustrated in (Table 1). There were no statistically significant difference in range of motion and isometric strength regarding two pretreatment values as illustrated in (Table 2). At the end of treatment, the two exercise programs resulted improvement in all tested variables as illustrated in (Tables 3,4) but the had significant improvement more than the LB ( p< 0.05) as illustrated in (Table 5). Table (1): Demographic and general characteristics of the patients for both groups (UW and LB). LB group p- (n=15) (n=150) value Age 32.6± ± Sex (M:F) 5:10 11:4 Table (2): Comparison between pretreatment mean values of range of motion degrees and isometric strength (kilogram) for both groups (UW and LB). mean ± SD LB group mean ± SD p- value Range of motion (pre) 102.5±9.3 99± Isometric strength (pre) 2± ± Table (3): Comparison between pre and post treatment mean values of range of motion degrees for both groups (UW and LB). LB group Range of motion (pre) 102.5±9.3 99± 11.1 Range of motion (post) 153± ± 15 p - value Percent of improvement 49.9% 41% Table (4): Comparison between pre and post treatment mean values of isometric strength (kilogram) for both groups (UW and LB). LB group Isometric strength (pre) 2± ±0.5 Isometric strength (post) 4.6± ±0.6 p- value Percent of improvement 146% 78.9

5 Ahmed A. Ibrahim, et al. 49 Table (5): Comparison between post treatment mean values of range of motion degrees and isometric strength (kilogram) for both groups (UW and LB). mean ± SD Range of motion (post) 153± ± Isometric strength (post) 4.6± ± Discussion LB group p- mean ± SD value The purpose of this study was to compare the effect of underwater exercises to that of land based exercises on active shoulder flexion ROM and isometric strength of shoulder flexors in children with unilateral Erb's palsy. Children with permanent EP have various degrees of functional impairment of their affected upper extremities, due to a limited ROM and a reduction in muscle power, muscle weakness and joint contractures of the affected upper limb are common in patients with EP, muscle imbalance can lead to soft tissue contractures and eventually to joint deformities which has a negative correlation with shoulder ROM [5]. Conducting this study on children aged from 26 to 39 months comes in agreement with Wilson and Kenyon, [15], who emphasized that most brachial plexus injures would recover spontaneously by 3 to 4 months of age, but recovery can occur up to 2 years of age. In addition Rust, [16] reported that after two years of injury, the spontaneous recovery become irreversible. The pretreatment mean values of ROM using AutoCAD and muscle strength using HHD that obtained from the two groups revealed that these children with EP suffering from limitation of shoulder flexion ROM and isometric strength of shoulder flexors. This agrees with Sylvain et al., [4] who reported that regarding the impaired shoulder function of children with EP compared with children with typical development, significant strength imbalances occurred in flexion-extension and internal rotation-external rotation strength ratios. Finally, impaired shoulder strength in the group with EP correlated with active range of motion. The pre-treatment data of the two groups revealed no significant difference including, mean values of age of both groups, mean values of ROM of shoulder flexion and mean values of isometric strength of shoulder flexors indicating homogeneity between both groups before starting the study and reflecting the validity of sample collection and random classification of children between both groups. The significant improvement in isometric strength of shoulder flexors for who received underwater exercise comes in agreement with Lori [17]. Who stated that buoyancy is used to unweight an extremity, and increase pain-free exercise. Buoyancy can also be used as resistance depending on equipment choices and patient positioning. Viscosity is used to provide resistance for strengthening muscles, also clinical research had shown that aquatic rehabilitation increase measures of physical performance and improve patient outcomes. Significant improvement in ROM for who received underwater exercise comes in agreement with Prins et al., [18] who said that. Neutral warmth of water plus specific aquatic joint and soft tissue mobilization techniques help the patient gain more mobility in addition that active aquatic exercise programs have been shown to increase range of motion. Patients with shoulder problem can benefit from hydrotherapy exercises as they can benefit from the upward force of buoyancy assisting the arm through its functional range of motion. The buoyancy of the water assists upward movement of the arm when the person is unable to do so independently on land exercises as reported by Mohammed et al., [10]. Improvement in range of motion and isometric strength for LB group who received land based exercise comes in agreement with Levit, [19]. Who reported that weak muscles should be allowed to participate in normal movement patterns by eliminating gravity for very weak muscles, preventing substitutions and manually guiding the extremity through movements to accomplish a task including hand to mouth, transferring objects, weight shifting on propped upper extremity in the prone position, the quadruped position, and in sitting with hands in front or back, creeping and reaching for toys placed at a variety of angles and heights from the child. Most previous UW studies in Egypt that were applied in pediatric rehabilitation sector focused on cerebral palsy children. We hope this study to be first fruits for more studies which addresses experimental trials to try to solve much of problems which faces EP children using underwater exercises.

6 50 Under Water Exercises Versus Land Based Exercises in Treatment of Erb's Palsy Conclusion: Based on our findings, both underwater and land based exercises may be useful for children with unilateral Erb's palsy by improving range of motion and isometric strength in short term. Underwater exercises is an amazing form of exercises for children with EP because it has a unique properties of water that reduces pain, assist movement, train weak muscle, represent playing activities, and enhance physiological output and psychological mood for children with Erb's palsy. Acknowledgements: The authors would like to express appreciation to all children and their parents who participated in this study and to colleagues at hydrotherapy department in National Institute of Neuromotor System, Giza, Egypt. References 1- DASARI S. and STREELAKSHMI C.: Hstolic approach to management of erb's palsy, J. Ayurveda. Integr. Med., ELKHATIB R.S., ELNEGMY E.H., SALEM A.H. and SHERIEF A.A.: Kinesio arm taping as aprophylaxis against the development of erb's engram, J. of Advanced Research, STORMENT M.: Margaret Stormont's guidelines for therapists treating children with brachial plexus injuries, SYLVAIN B., KATHARINE A. and DIANE D.: Shoulder strength profiles in children with and without brachial plexus injury HHS Public access, MIKKO O.K., YRJANA N., SANNA M.R., VILLE M.R., TIINA H.P., ILKKA J.H. and JARI I.P.: Range of motion and strength after surgery for brachial plexus birth palsy, Acta Orthop., EXNER C.E.: Development of hand skills. In: J.Case- Smith (Eds.), fifth edition: Occupational therapy for children. St. Louis, Mosby, KAMOIKA H., TSUATANI K., OKUIZUMI H., MUTOH Y., OHTA M., HNDA S., OKADA S., KITAYUGUCHI J., KAMADA M., SHIOZAWA N. and HONDA T.: Effectiveness of aquatic therapy and palneotherapy: A summary of systematic review based on randomized controlled trials of water immersion therapies. J. Epidemiol., MOOVENTHAN A. and NIVETHITHA L.: Scientific Evidence-Based Effects of Hydrotherapy on Various Systems of the Body. N. Am. J. Med. Sci., MORTIMER R., PRIVOPOULOS M. and KUMAR S.: The effectiveness of hydrotherapy in treatment of social and behavioral aspects of children with autism spectrum disorders: A systematic review, J. Multidiscip. Healthc., MOHAMMED A.H., MAHRAN H.G. and ABOELAZM S.N.: Does Hydrotherapy Improve Shoulder Abduction in Post-mastectomy Patients? International Journal of Advanced Research, EXNER C.: Development of the corticospinal system and hand motor function. Developmental Medicine and Child Neurology, HELMY A.M., SHOUKRY K.E., EL-TALAWY H.A. and ABDEL AZIM F.H.: Effect of selected underwater exercises on crouch gait in spastic diplegic children, Master Thesis, AL-QATTAM M.M. and ELSAYYED A.A.: Obstetric brachial plexus palsy: The mallet grading system for shoulder function-revisited, Biomed. Research Int., MICHENER L.A., BOARDMAN N.D., PIDCOE P.E. and FRITH A.M.: Scapular muscle tests in subjects with shoulder pain and functional loss: Reliability and construct validity. Phys. Ther., BADAWY W.M. and IBRAHIM M.B.: Comparing the effects of aquatic and land-based exercises on balance and walking in spastic diplegic cerebral palsy children. Med. J. Cairo Univ., WILSON P. and KENYON P.: Congenital brachial plexus lesion. The newsletter of children's hospital physical medicine and rehabilitation Denver, Colorado, RUST R.: Congenital plexus palsy: Where have you been and where are we now? Semin. Pediatr. Neurol., LORI T.B.: Aquatic Therapy for the Arthritic Knee Noyes' Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes (Second Edition), PRINS J.H., HARTUNG H., MERRITT D.J., BLANCQ R.J. and GOEBERT D.A.: Effect of aquatic exercise training on persons with poliomyelitis disability. Sport Medicine, Training and Rehabilitation, LEVIT K.: Optimizing Motor Behavior using the Bobath approach in Occupational Therapy for Physical Dysfunction. 6th ed. Lipincott William and Wilkins, 2008.

7 Ahmed A. Ibrahim, et al. 51