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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 1  |  Issue : 2  |  Page : 113-116

Comparison of postural instability between the spastic diplegic and hemiplegic children with cerebral palsy


Department of Physiotherapy Pediatric Neurology, Sancheti Hospital, Shivaji Nagar, Pune, Maharashtra, India

Date of Web Publication7-Jan-2016

Correspondence Address:
Sachin Gawande
Sancheti Institute College of Physiotherapy, Thube Park, Shivajinagar, Pune - 411 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-4264.173455

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  Abstract 

Context: Cerebral palsy (CP) is known as a sensory and neuromuscular deficit, which is caused by nonprogressive brain defect that occurs during infancy or early childhood. Children with cerebral palsy are a heterogeneous group, varying considerably in movement abilities. Balance and postural control are the fundamental components of movement. Children with many types of motor dysfunction have complications in maintaining postural stability, as maintenance of postural stability is an integral part of all movements. These children exhibit clumsiness and frequent falls during regular activities.
Aim: To compare the postural instability between the children with cerebral palsy having spastic diplegia and hemiplegia.
Materials and Methods: Hundred age-matched children with cerebral palsy from the age group of 5 to 12 years were included in this study, with 50 children in each group of spastic diplegic and hemiplegic, respectively. They were asked to perform 2 tests for testing their postural instability. The tests were Early Clinical Assessment and Balance (ECAB) scale and Pediatric Reach Test (PRT). The total scores were then statistically compared between the groups using Mann-Whitney U-test.
Results: (A) The " P" value for ECAB was found to be 0.434 (B). The " P" value for the PRT was found to be as follows - Age group: 5-6 years: 0.68, age group: 7-8 years: 0.61, age group: 9-10: 0.28, and age group: 11-12 years: 0.58.
Conclusion: The study showed no significant difference in postural instability between the two groups.

Keywords: Cerebral palsy, instability, motor function, posture


How to cite this article:
Shroff M, Gawande S, Bedekar N, Shyam A, Sancheti P. Comparison of postural instability between the spastic diplegic and hemiplegic children with cerebral palsy . Indian J Cereb Palsy 2015;1:113-6

How to cite this URL:
Shroff M, Gawande S, Bedekar N, Shyam A, Sancheti P. Comparison of postural instability between the spastic diplegic and hemiplegic children with cerebral palsy . Indian J Cereb Palsy [serial online] 2015 [cited 2017 Apr 24];1:113-6. Available from: http://www.ijcpjournal.org/text.asp?2015/1/2/113/173455


  Introduction Top


Cerebral palsy (CP) is the sensory and neuromuscular deficit caused by a nonprogressive brain defect or lesion that occurs during the prenatal, intrapartum, perinatal, or early postnatal periods. Children with cerebral palsy are a heterogeneous group, varying considerably in movement abilities. [1] CP is one of the most common motor disabilities in childhood. Cerebral means having to do with the brain. Palsy means weakness or complications with using the muscles. The symptoms of CP vary from person to person. A person with severe cerebral palsy might need to use special equipment to be able to walk, or might not be able to walk at all and might need lifelong care. A person with mild cerebral palsy, on the other hand, might walk a little awkwardly, but might not need any special help. Cerebral palsy does not get worse over time, though the exact symptoms can change over a person's lifetime. All children with cerebral palsy have complications with movement and posture. [2] Postural stability is defined as the ability to maintain or control the center of mass in relation to the base of support (BOS) to prevent falls, and complete the desired movements. [3] Balance and upright postural control are the fundamental components of movement that involve both the ability to recover from instability (as in response to external perturbation) and the ability to anticipate and move in ways to avoid instability (as in response to an internal perturbation, or self-initiated movement). [1] The 2 broad classifications of balance are static and dynamic. Static balance is defined as the ability to maintain a posture, such as balancing in a standing or sitting position, and dynamic balance is defined as the ability to maintain postural control during other movements, such as when reaching for an object or walking across a lawn. Both static and dynamic postural control is thought to be important and necessary motor abilities. Children with many types of motor dysfunctions have complications in maintaining postural stability. Because maintenance of postural stability is an integral part of all movements, children with many types of disabilities, ranging from learning disabilities with mild motor complications to CP with more severe motor complications, have been shown to have dysfunction of postural control. These children may exhibit clumsiness and frequent falls during regular daily motor activities or may not be able to maintain a sitting or standing position independently. [3]


  Materials and methods Top


Approval was taken from the Ethical Committee to proceed with the study. A prior consent of the principals of various schools and the parents was taken to perform the study.

The design of the above study was a cross-sectional observational study. A sample size of 100 age-matched children from the age group of 5 to 12 years was selected. They were asked to perform two tests for testing their postural instability. The tests were Early Clinical Assessment and Balance (ECAB) scale and Pediatric Reach Test (PRT). [1],[4],[5]

The inclusion criteria were spastic cerebral palsy children. Cerebral palsy children from age 5 to 12 years and children with cerebral palsy of Gross Motor Function Classification System (GMFCS) levels 1 and 2. [6] The exclusion criteria were GMFCS levels 3, 4, and 5, cerebral palsy children with other movement disorders such as ataxia and athetoid disorder, and cerebral palsy children with contractures.

Various schools of CP and that of impaired ability from Pune were selected. Few children were also selected on the out-patient basis from the hospital itself. Both the groups, i.e. the spastic diplegic children and hemiplegic children were asked to perform the tests taking into consideration the safety measures.

In ECAB, the children were asked to perform the tasks given in the scale. Each child was then scored according to the precision with which they completed the task. It consisted of the components such as standing with feet close (unsupported), turning around 360° stepping up and down, sitting to standing (unsupported), etc., The children were scored on a scale of 0-3 in the ascending order of the level of difficulty.

In PRT, all the children were asked to stand parallel to the wall, to which a measuring tape was attached. The child was asked to bend as forward as possible without lifting the leg. Each child's reading was noted down, after subtracting the initial reading from the final reading. The mean of the obtained values was then compared to the mean values of the hemiplegic children for the individual age groups.


  Results Top


The data was analyzed using the Mann-Whitney U-test of the SPSS software (IBM Corporation, 2013). The significance of the study was set at "P0" ≤ 0.05. The "P" value for the ECAB scale for both the groups was calculated as 0.434.

[Table 1] shows the mean values of the spastic diplegic children with cerebral palsy which are higher than the hemiplegic children with cerebral palsy for all the age groups, except for the age group 7-8 years.
Table 1: Mean values for the Spastic Diplegic children with cerebral palsy


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[Table 2] shows the mean values for the hemiplegic children with cerebral palsy being less than the mean values of the spastic diplegic children with cerebral palsy, except the age group of 7-8 years, which has a higher mean than the other age groups.
Table 2: Mean values for the Hemiplegic children with cerebral palsy


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The P values of the PRT calculated for the age groups were as follows:

  • 5-6 years: P =0.68
  • 7-8 years: P =0.61
  • 9-10 years: P =0.28
  • 11-12 years: P =0.58.

  Discussion Top


Owing to the various complications in children with cerebral palsy, the main issue to deal with is the ability to perform functional tasks in the activities of daily living (ADLs). The ability to become independent in ADLs is determined by postural control. [8]

In this study, the lower extremities were mainly targeted, and thus, the components 8-12 of ECAB were performed on both the groups. ECAB scale scores were then compared between the 2 groups using the Mann-Whitney U-test, and the P value was obtained to be 0.434, i.e. P > 0.05. The strategies developed from the motor and sensory systems, which might have been developed in the children with spastic diplegia could be one of the reasons for the insignificant "P" value. In spastic diplegics, the abnormal standing postures can be conditioned either by reducing the range of motion in relevant joints (in the case of bilateral spastic CP), or by compensating for weakness (like in unilateral spastic CP). These result in crouched posture while standing in spastic diplegics. [8]

A study performed by van der Heide depicted that the children with GMFCS levels 1 to 3 have an intact basic level of control but have difficulties in fine-tuning the degree of postural muscle contraction to the task-specific conditions, which is a dysfunction more prominently present in children with bilateral spastic cerebral palsy than in children with spastic hemiplegia. The complications in the adaptation of the degree of muscle contraction might be the reason that children with cerebral palsy, more often than typically developing children, show an excess of antagonistic co-activation during difficult balancing tasks and a preference for cranial-caudal recruitment while reaching. This might imply that both stereotypes might be regarded as the functional strategies to compensate for the dysfunctional capacity to modulate subtly postural activity. [7]

Another study performed on the contribution of hip joint proprioception to balance in cerebral palsy children concluded that children with even the mildest forms of cerebral palsy have poor postural control along with the other motor disorders. The study included 3D motion captures of 52 participants

(19 with spastic diplegic), (13 with hemiplegic cerebral palsy), and 20 without disability. [5]

The other test used to test the postural stability is the PRT validated and proved reliable by Bartlett and Birmingham. [1] Age-matched children with cerebral palsy were assessed, and the mean for the age groups 5-6 years, 7-8 years, 9-10 years, and 11-12 years was obtained significantly more that of the hemiplegic children with cerebral palsy. The mean values and SD for spastic diplegics for the age groups obtained were 10.3 ± 2.77, 9.94 ± 2.79, 12.75 ± 5.18, and 12.42 ± 2.94, respectively. Similarly, for the hemiplegic children the mean and SD were found as 9.5 ± 2.03, 10.34 ± 2.59, 11.15 ± 2.54, and 11.64 ± 2.07, respectively. This could be owing to the fact of the postural adjustments acquired by the hemiplegic children with cerebral palsy. These patterns of adjustments have also been defined based on the relationship of the selected body segments to one another, the position of the body with reference to gravity, and the distribution of the body mass between the affected and unaffected sides on the BOS. [8]

[Table 1] and [Table 2] depict the difference between the mean of the spastic diplegics and the hemiplegic children with cerebral palsy. The mean for the age group 7-8 for the hemiplegic children was found to be more than the spastic diplegic children of the same age group. This could be because of the fact that in spite of, an atypical posture the line of gravity (LOG) does not fall out of the BOS for the hemiplegic children. Making them less prone to falls. [3]

Another study by Girolami et al. depicted the anticipatory postural adjustment's (APA's) and the center of pressure generated by the spastic diplegics were of a less magnitude, as compared to the hemiplegics resulting in greater postural instability for the spastic diplegics. [9] However, every child with cerebral palsy has a different level of disability owing to the level of affection and other co-morbid factors. [10],[11] Thus this study was found insignificant, owing to various reasons related to the LOG, [3] functional strategies, [7] and APAs [8] made by the children with cerebral palsy, depending upon the level of affection in the brain.

The limitations that the study faced were that the body mass index (BMI) of the children could not be taken into consideration, and the limited time period of the schools for performing the tests.


  Conclusion Top


There was no significant difference found in the postural instability between the 2 groups.

Scope of further study

  • Comparison between the affected and the nonaffected side in the hemiplegics could be compared
  • Every task should be scored taking into consideration the time to complete the task. It would give a better picture about the functional independence of the children.
Limitations of the study

  • Limited school timings for performing the test, it limited the attempt to perform the tests, which can be modified in further study
  • BMI of the children was not taken into consideration.
Clinical implication

To formulate an unbiased rehabilitation protocol for the children with cerebral palsy, so as to make them functionally independent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bartlett D, Birmingham T. Validity and reliability of a pediatric reach test. Pediatr Phys Ther 2003;15:84-92.  Back to cited text no. 1
    
2.
Centres for Disease Control and Prevention. Facts About Cerebral Palsy. Available from: www.cdc.gov/ncbddd/cp/facts.html.  [Last reviewed on 2015 Jan 12].  Back to cited text no. 2
    
3.
Westcott SL, Lowes LP, Richardson PK. Evaluation of postural stability in children: Current theories and assessment tools. Phys Ther 1997;77:629-45.  Back to cited text no. 3
    
4.
Chandler LS, Andrew MS, Swanson MW. Early clinical assessment of balance. Pediatr Phys Ther 2003;15:114-28.  Back to cited text no. 4
    
5.
Damiano DL, Wingert JR, Stanley CJ, Curatalo L. Contribution of hip joint proprioception to static and dynamic balance in cerebral palsy: A case control study. J Neuroeng Rehabil 2013;10:57.  Back to cited text no. 5
    
6.
Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Gross motor function classification system for cerebral palsy. Dev Med Child Neurol 1997;39:214-23.  Back to cited text no. 6
    
7.
van der Heide JC, Hadders-Algra M. Postural muscle dyscoordination in children with cerebral palsy. Neural Plast 2005;12:197-203.  Back to cited text no. 7
    
8.
Domagalska ME, Szopa AJ, Lembert DT. A descriptive analysis of abnormal postural patterns in children with hemiplegic cerebral palsy. Med Sci Monit 2011;17:CR110-6.  Back to cited text no. 8
    
9.
Girolami GL, Shiratori T, Aruin AS. Anticipatory postural adjustments in children with hemiplegia and diplegia. J Electromyogr Kinesiol 2011;21:988-97.  Back to cited text no. 9
    
10.
Randall KE, Bartlett DJ, McCoy SW. Measuring postural stability in young children with cerebral palsy: A comparison of 2 instruments. Pediatr Phys Ther 2014;26:332-7.  Back to cited text no. 10
    
11.
Brogren E, Forssberg H, Hadders-Algra M. Influence of two different sitting positions on postural adjustments in children with spastic diplegia. Dev Med Child Neurol 2001;43:534-46.  Back to cited text no. 11
    



 
 
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