Effect of Whirlpool Therapy Combined With Botulinum Toxin in Children With Cerebral Palsy

This study was designed as a prospective, randomized, single-blind (assessor-blinded), parallel-group controlled clinical trial investigating the effects of combining whirlpool therapy with botulinum toxin type A (BoNT-A)-assisted rehabilitation on spasticity, gait, and motivation in children with hemiplegic cerebral palsy.

A total of 81 patients with hemiplegic cerebral palsy who had received botulinum toxin type A (BoNT-A) injections to selected lower extremity muscles within the previous week were initially evaluated. After applying the inclusion and exclusion criteria, 43 participants were enrolled in the study, and 38 patients were excluded. All botulinum toxin injections were performed using onabotulinumtoxinA by an experienced physiatrist with more than five years of clinical experience. Injection planning was individualized according to body weight, severity of spasticity, and targeted muscle groups.

Participants were randomly assigned in a 1:1 ratio to two groups (22 in the intervention group and 21 in the control group). Randomization was performed using a computer-generated random sequence by an independent researcher who was not involved in treatment or assessment. Allocation concealment was ensured using sequentially numbered, opaque, sealed envelopes. The study was conducted as a single-blind trial in which the outcome assessors were blinded to group allocation, while participants and therapists were not blinded because of the nature of the intervention.

Both groups received a conventional rehabilitation program for 4 weeks, 5 days per week, 1 hour per day. The program included range of motion (ROM) exercises for the upper and lower extremities, stretching and strengthening exercises, balance and coordination training, endurance exercises, and ambulation training, all delivered under physiotherapist supervision according to a standardized protocol.

In addition to conventional rehabilitation, the intervention group received whirlpool therapy three times per week for 4 weeks, with each session lasting 20 minutes, for a total of 12 sessions. All whirlpool therapy sessions were conducted under physiotherapist supervision.

Outcome measures were assessed at three time points: baseline (T0, week 0, pre-treatment), post-treatment (T1, week 4), and follow-up (T2, week 12). Spasticity was evaluated using the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale (MTS). Functional mobility and standing/walking abilities were assessed using the Gross Motor Function Measure-88 (GMFM-88) dimensions D and E. Motivation was evaluated using the Pediatric Motivation Scale. Gait kinematics, including joint range of motion and peak flexion and extension angles of the hip, knee, and ankle, were analyzed using the DIERS 4D Motion Lab system. Functional walking performance was assessed using the 10-Meter Walk Test (10MWT).

• Conventional Rehabilitation (Behavioral): Standard rehabilitation program including range of motion exercises, stretching, strengthening, balance, coordination, endurance, and gait training, 5 days per week for 4 weeks under physiotherapist supervision.
• Whirlpool Therapy (Other): Whirlpool therapy administered 3 times per week for 4 weeks, 20 minutes per session (total 12 sessions), in addition to conventional rehabilitation.

Primary outcomes

• Gross Motor Function Measure-88 (GMFM-88) - Dimension E (Walking, Running and Jumping) [Baseline (Week 0), Week 4 (post-treatment), Week 12 (follow-up)]: The primary outcome measure was the Gross Motor Function Measure-88 (GMFM-88) Dimension E, which evaluates walking, running, and jumping abilities in children with hemiplegic cerebral palsy. Each item is scored on a 4-point scale (0-3), and raw scores are converted to percentage values (0-100). Dimension E consists of 24 items, with a maximum raw score of 72 points.

Secondary outcomes

• Modified Ashworth Scale (MAS) [Week 0, Week 4, Week 12]: Spasticity was assessed using the MAS. Scores were recorded for the hamstring, gastrocnemius, and adductor muscles of the affected side. The MAS is a 6-point ordinal scale (0, 1, 1+, 2, 3, and 4) used to assess resistance to passive movement, with higher scores indicating greater muscle spasticity.
• Pediatric Motivation Scale [Week 4, Week 12]: Motivation was assessed using the Pediatric Motivation Scale (PMS), a validated self-report instrument designed to evaluate children's motivation toward rehabilitation. The scale consists of 21 items and includes six domains: effort-importance, interest-enjoyment, competence, relatedness, autonomy, and value-usefulness. The first 19 items are rated on a 6-point Likert scale ranging from 1 ("not at all true") to 6 ("very true"), while the remaining two items are open-ended questions. Total and domain scores are calculated from the Likert-scale items. Higher scores indicate greater motivation, stronger engagement in rehabilitation activities, and a higher degree of internally regulated motivation.
• DIERS 4D Motion Analysis System [Baseline (Week 0), Week 4, Week 12]: Three-dimensional gait kinematics were assessed using the DIERS 4D motion analysis system. Maximum hip, knee, and ankle flexion and extension angles of the hemiparetic limb were recorded. Additionally, bilateral knee valgus and varus angles were measured during gait. All data were automatically stored in the system memory for further analysis.
• 10-Meter Walk Test (10MWT) [Baseline (Week 0), Week 4, Week 12]: Walking performance was assessed using the 10MWT. Participants walked a 10-meter straight path at their comfortable walking speed. Time was recorded in seconds, and gait speed (m/s) and cadence (steps/min) were calculated. Two trials were performed, and the best performance was recorded.
• Gross Motor Function Measure-88 (GMFM-88) - Dimension D (Standing) [Baseline (Week 0), Week 4, Week 12]: The GMFM-88 Dimension D was used to assess standing ability in children with hemiplegic cerebral palsy. This domain consists of 13 items evaluating static and dynamic standing activities. Each item is scored on a 4-point scale (0-3), and raw scores are converted to percentage values (0-100) based on the maximum achievable score.
• Modified Tardieu Scale (MTS) [Week 0, Week 4, Week 12]: Spasticity was assessed using the MTS for the hamstring and gastrocnemius muscles of the affected side. Passive movement was performed at V1 (slow velocity) and V3 (fast velocity). Muscle reaction quality, R1, R2, and R2-R1 values were recorded.

Sex: All, ages: 3 Years to 10 Years

Inclusion Criteria:

* Diagnosis of hemiplegic cerebral palsy
* Age between 3 and 10 years
* Gross Motor Function Classification System (GMFCS) levels I-II
* Sufficient cognitive level to follow instructions
* Ability to walk at least 10 meters with an orthosis and/or walking aid
* Receipt of botulinum toxin injection to the lower extremity within the past week
* Ability to walk independently for 1 minute without orthosis or assistive device

Exclusion Criteria:

* Uncontrolled epilepsy
* Urinary incontinence
* Presence of lower extremity contractures
* History of previous orthopedic surgery
* Presence of hip subluxation
* Ataxic or dyskinetic cerebral palsy
* History of any botulinum toxin injection within the 6 months prior to the current 1-week post-injection period
* Inability to cooperate during clinical assessments

• DAMLA CANKURTARAN, MD, Principal investigator, Ankara Etlik City Hospital