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​Jelena Špionjak, bacc.physioth.
Day care for rehabilitation – Little House, Baštijanova 1D, Zagreb, Croatia

 

 

CASE STUDY
Vibroacoustic Therapy in combination with Physiotherapy treatment

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1. CLIENT MEDICAL AND SOCIAL ANAMNESIS

The boy L.L. was born 3/1/2001. in 27. week of gestation. He had perinatal infection, asphyxion, hypoxic-ischemic lesion and intraventricular bleeding III degree. As consequence of intaventricular bleeding, periventricular leucomalation (PVL) was developed. In medical documentation the client has diagnosis:  SyWest, Retardatio psychomotorica, Retinopathia praematurus V degreee, Amaurosis.
Epilepsy is controlled with antiepileptic medicaments. The boy is first child in family. Mother and father are employed.

According to neurological symptoms written in medical documentation from specialist neuropediatrics and thrue child observation, the client has classification of changeable muscle tone in the lower extremities (from hypotonic to hypertonic).

According to GMFCS (Gross Motor Functional Classification System for Cerebral Palsy)
- functional classification of gross motor function for the lower extremities, the client is classified in V degree, which means that self-mobility is severly limited even with use of assistive technology.

According to MACS (Manual Ability Classification System for Cerebral Palsy)
- functional classification of fine motor function for the uper extremities; the client is classified in V degree, which means that he can not handle objects in daily activities. He has severly limited ability to perform even simple actions, and he requires total assistance.

The client also has often repeated stereotype movement, turning the head and putting his fingers in mouth, which interfere his attention to environment. He is also hypersensitive to tactile input. He has good reactions to vibrations and concrete proprioceptive inputs on his joints. He is interested in auditory objects and objects which he can activate by pressing down. Expressive speach is not developed. From time to time he articulates sounds without specific meaning. At program activities, communication is stimulated  with demonstration of specific symbol for the beginning and ending a certain activities, and with application of gesture.

2. INDICATION FOR INCLUDING CLIENT IN VIBROACOUSTIC TRETAMENT
The client is included in vibroacoustic treatment because he has changeable tone in the lower extremities. He does not touch the surface with his feet, which make impossible his weigth bearing from sitting to standing position.
Second indication for including client in vibroacoustic treatment is often repeated stereotype movement with his head which interfere his attention to environment.
After converstaion with the parents, and after examination of medical documentation, I conclude that there is no contraindication for including this client to vibroacoustic treatment. Epilepsy wich is written in medical documentaion is not contraindicated  because  it is controlled with antiepileptic medicaments.

 

 

3. THERAPY GOALS
Normalization of muscle tone in the lower extremities.
After normalization of muscle tone client feet will accept surface as base of support, in sitting position on a bench through 1 minute during program and home activities. Accepting the surface as base of support is a  prerequisite for transfer in standing position.

Assumption 1 – It will be improvement in gross motor function. At the final evaluation, result in GMFM-a (Gross Motor Function Measurement) will be improved.

Assumption 2 – Stereotype movement of head will  decrease  and client will have better attention during sitting activites.

4. THREATMENT PARAMETERS
Sine Wave Type: low frequency sine wave, transmitting in all directions
Duration:  23 minutes
Audio Frequency: 40 Hz.  Standard VAT frequency by Olav Skille
Treatment Frequency: once a week
Number of Anticipated Treatments: 11
Equipment and Software: MULTIVIB mattress by ACOUVE.
Working area:  room for physiotherapy

In the first 10 minutes of  adaptation to vibrations the client was in lying position on matrress (MULTIVIB equipment). After 10 minutes of adaptation, physiotherapy treatment was applied in sitting and kneeling position on matress, and sitting position on the small bench with the feet supported on the transducers. Intensity level in lying position on matrress was 19 dB, when client was in sitting position on matrress intensity level was 20 dB.

It is important to note that vibroacoustic treatment was applied from the end of January until the end of April 2009., with two weeks of pause because of Easter holiday.

5. OBSERVATION AND EVALUATION OF THE TREATMENT
During the treatment frequency of stereotype movement was observed, also as vocalization, but frequency of those variables was not meassured.
The main goal was to examine if the vibroacoustic treatment in combination with physiotherapy tretament world have influence in normalization of muscle tone in lower extremities and improvement in gross motor function .

Effect of treatment was evaluate with GMFM (Gross Motor Function Measurement) initially in January  2009.  and finallly at the beginning of May 2009.
GMFM is a standardized  observational instrument designed and validated to measure change in gross motor function over time in children with cerebral palsy. GMFM (66 tasks) can be applied for children with cerebral palsy, GMFM (88 tasks) can be applied for children with Down syndrom and Cerebral Palsy.
It can be used from 4 months of age until any year, until child does not perform motor skills. A child with normal development can perform those motor skills until the age of 5.

Evaluation looks for quantity, not quality of movement. Characteristic of this instrument is that it observes and evaluates the chili’s abilities to perform task without any help. Observation is applied in 5 dimensions of activities :  1. lying position 
2. sitting position
3. crawling and kneeling 
4. standing
 5. running and jumping.

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Every task in those dimensions is valuate with scores:
0=does not initiate performance of task
1=initiates 
2=partially completes
3=completes
NT=Not tested
For this client I decided to use GMFM (88) because it is more sensible than GMFM (66), and  it would be possible to observer more tasks . In consideration that the client is blind and non verbal I had to adjust assessment in a way that he had enough time for motor response. During the assessment I used tactile and auditive inputs to stimulate motivation for movement.

According to initial assessment of gross motor function GMFM (88) the client in prone position has  weight bearing on elbow and reaches for the object extending the opposite elbow.
He can transfer himself from  supine lying to sitting position over the right side.
In sitting position on the floor, he reaches for the object in front of him, and returns to starting position without hands supporting.
He touches the toy which is placed lateral. He sitts independently on the bench without hand and feet supporting.  He brings himself partially from the prone to crawling position. When I help him to come in kneeling position he can hold that position for 10 seconds, supporting with his hands. He often sits in cross leg position which stimulates flexion, abduction and external rotation. That pattern is present in prone and in sitting position on bench, which cause that feet do not accept surface as base of support, and also cause feet valgus. In sitting position he has trunk extension which makes weight bearing on feet impossible .

 

 

6. THE TREATMENT PROCEDURE
Vibroacoustic treatment was applied by physiotherapist and special education teacher in combination. With the teamwork we  in the best way can stimulate all developmental areas at the same time, which is important for a child with multiple disabilities.
Mattress and  CD player were prepared before every treatment. Before the tretament I put in the CD player CD with 40 Hz (Multivib Software), volume on  the CD player is allways put on 0. Directly before the vibroacoustic treatment I show the client a symbol – a little vibration toy, which represents that activity.  After that client was positioned on the mattress, shoulders, trunk, pelvis and lower extremities were on the transducers.
After good positioning I told the client that vibrations will be gradually increasing. During the first minute I gradually introduced vibrations, until we reached the right volume when I could feel vibrations on a client sternum and pelvis. During  determination of the intensity level I also observed breathing, eye movements, body language and facial expression. Duration of introduction  time was 10 minutes. After third minute therapists implemented pattering in supine and prone lying position, with the goal to strenghten proprioceptive input and to stimulate central nervous system with normal movement patterns.

After 10 minutes  the active fase started, I facilitated client transfer in sitting position, and implemented neurodevelopmental treatment (NDT).
I also stimulated side sitting, because client usual sits with crossed legs, wich cause the feet valgus. I facilitate rotation from left to right side sitting, with goal to give the clients information about movement. It is important to emphasize that therapists had always on their mind thai the client should not lose contact with transducers. I also stimulate pelvis stability in kneeling position, while I take care that the knees of the client are not directly in contact With the transducers, because of the pressure. In the sitting position at the bench I stimulate acceptance of the surface as base of support with client feet, the feet were leaned on transducers. During all those positionings the special education teacher  stimulated hands activity, and guiding the attention toward tactile and auditory inputs, in order to inhibit stereotype behaviours. He also stimulated vocalization and social interaction.
      
At the final phase, after 23 minutes, the CD player automaticaly lowered intensity of vibrations and the treatment was ending. Directly before ending the treatment physiotherapist and special education therapist were gradually finishing with stimulations. At the end of the treatment therapist showed the client the symbol from the beginning of therapy, and gestured “finish” which symbolized the end of activities.

COMMENT: In consideration that the client often did not accept supine lying position (it was not enough stimulation for him), only one period of time from January to April the adjustment to vibrations was done in lying position. In situations when client did not accept lying position, adjustment to vibrations was done in sitting position, in that case we could not implement pattering.
    

7. RESULTS
Result from initial assessment GMFM(88) was 30.14%, result from final assessment was 35,63%, which is present in graph 1. 

Graph 1. Results from initial and final assessment of gross motor functions.





















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After final assessment GMFM(88) the client showed improvement in pivoting in prone position and in transfer from supine to sitting position over left side. The client has also improvement in transfer from sitting to prone position. At the final assessment client could crawl up to 1 meter. From prone lying position he initiated transfer to 4 point position. In the final assessment of maintaining standing position the klient managed holding the position for 3 seconds, while holding hands. In standing position right feet were in valgus. Stereotype movement was decreased during standing position.
Client has had improvement in gross motor functions which was the goal for inclusion in Vibroacoustic therapy. Because the vibrations are proprioceptive input, stereotype behaviour was decreased so client has had better attention on activities. This could be explained by the influence of vibrations on reticular formation, respectively  nucleuses of truncus encephali which are responsible for condition of arousal, readiness and consciousness and for regulation of concentration and attention.
The client has also improvement in placing the feet on the floor, which is a prerequisite for transfer in standing position and holding the standing position. He could achieve that because the vibrations influenced the normalization of muscle tone in lower extremities. It is also important to emphasize that during the treatment client has had improvement in vocalization.

8. CONCLUSION
Results after final assessment are maybe numerously small, but for the child with multiple disabilities that is a huge improvement.
After influence of vibrations client could finally experience standing position, in which stereotype behaviors decreased because of demanding antigravity activities.
Because the client has shown initiation for walking, I decided that vibroacoustic treatment should be continued with the goal to improve stability in standing position. Stability in standing position is prerequisite for walking and exploring the environment. Walking should be done with walking aid, but first of all I had to stimulate acception of aid holding hands, because the client is tactile hypersensitive. Vibroacoustic tretment  will help because the proprioceptive input will help the client to modulate the tactile input.
Vibroacoustic treatment has  shown to be very good for integration with physiotherapy treatment, because it enables the therapist easier realization of setting tasks.  Proprioceptive input which vibrations are  influencing  better body scheme, which is specially important for children with visual impairments and other disabilities. Physiotherapist are often helpless when children have high muscle tone, in that case vibrations help the child and therapist in dealing with it. Vibrations have influence on tone normalization, which enable the implementation of functional activities.
I think that there is no contraindications for integration of vibroacoustic therapy in physiotherapy tretament, because I can do physiotherapy treatment without any restriction, while vibrations are the medium which will improve and make the physiotherapy prosess easier.

AUTHOR'S BIOGRAPHY:

Jelena Špionjak was born in December 28, 1980 in Pozega, Croatia. She graduated Physiotherapy study at University of Applied Health Studies in Zagreb, Croatia, in 2003.
From 2003. she is employed in Day care center – for rehabilitation of  children with visual impairments and other disabilities - Little house, Zagreb, on position of physiotherapist.
She completed the course for vibroaccoustic therapy in 2009. From 2005. she has educations in Osteopathy approach. She finished musculosceletal part, but now she has educations in visceral part.
2007. she has started the educations in field of Vibroacoustic therapy. She has also started the education in sensory integration.
Her domain of interests is Vibroacoustic therapy in integration with physiotherapy, osteopathy approach and sensory integration. She likes to work with multiply disabled children, especially with children with cerebral palsy. She works with children in early intervention, from birth until age of 3 years. She also works in program activities  with children from age of 3 until the age of 17. She does assessment of gross motor functions in early intervention and in program activities.
She is an assistant at Medical associate-degree college, Physiotherapy study, Zagreb from 2007.  She is active participatant in congresses and presents the effects and results of integrating Vibroacoustic therapy in  physiotherapy treatment.