|Year : 2015 | Volume
| Issue : 2 | Page : 70-74
Effect of dynamic sitting balance on upper extremity motor skills in children having spastic diplegia: A correlational study
Indira Brundavanam1, Lakshmana Prasad Gadde1, Naveen Kumar Balne1, AK Purohit2
1 Department of Physiotherapy, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana, India
2 Department of Neurosurgery, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana, India
|Date of Web Publication||7-Jan-2016|
Department of Physiotherapy, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Introduction: Children having spastic diplegic cerebral palsy also have some impairment in upper extremity functions; hence, they have difficulty in performing certain activities such as pulling up to stand, support themselves to sit, and participate in surrounding environment. Trunk control is proposed to be a major contributing factor for voluntary upper limb motor functions including motor control.
Objective: To study the effect of dynamic sitting balance on upper extremity skill in children having spastic diplegia.
Material and Methods: Study Design - Randomized control trial. Participants - The children were randomly divided into experimental (n = 15) and control group (n = 15). Experimental group received dynamic sitting balance training for a period of two weeks, whereas control group received conventional physiotherapy for a period of two weeks.
Results: A significant improvement was noted in dynamic sitting balance and upper extremity skill, and a positive correlation was found between these two parameters.
Conclusion: This study showed that, for this cohort of children having spastic diplegic cerebral palsy, short duration of dynamic sitting balance training resulted in improvement in upper extremity function with improvement in dynamic sitting balance.
Keywords: Correlation, diplegia, skill, spastic, upper extremity
|How to cite this article:|
Brundavanam I, Gadde LP, Balne NK, Purohit A K. Effect of dynamic sitting balance on upper extremity motor skills in children having spastic diplegia: A correlational study. Indian J Cereb Palsy 2015;1:70-4
|How to cite this URL:|
Brundavanam I, Gadde LP, Balne NK, Purohit A K. Effect of dynamic sitting balance on upper extremity motor skills in children having spastic diplegia: A correlational study. Indian J Cereb Palsy [serial online] 2015 [cited 2019 Jul 19];1:70-4. Available from: http://www.ijcpjournal.org/text.asp?2015/1/2/70/173429
| Introduction|| |
Cerebral palsy (CP) is a disorder of posture and movement that occurs secondary to damage to the developing brain. 
Trunk is proposed to be an important contributor to voluntary upper extremity function, including motor control and dexterity in children with spasticity including spastic diplegia.  Use of hands is particularly important for a child with motor disabilities so that he can use them to support himself to sit, stand, walk, or pull himself into any position. Arm girdle and shoulder girdle stability is fundamental to most of the gross and fine motor activities.  Upper limb function is a critical determinant of the ability to perform daily activities and to participate in the surrounding environment.
Children with cerebral palsy often have difficulty in performing voluntary movements because of decreased muscle strength and abnormal muscle tone. As a result of these impairments in trunk and limbs, there is inability to generate force to maintain antigravity position leading to abnormal postures. These abnormal postures distract and discourage the patient from efficiently performing voluntary movements; thus may not be able to function properly. 
Higher levels of upper extremity function are seen when an individual is able to control his posture better. 
Children with cerebral palsy having bilateral limb involvement have more difficulty in postural adjustments to task specific circumstances than that of hemiplegic CP.  This abnormal postural activation is due to hypertonia of neck and trunk muscles also. Therapy should focus more on balancing exercises rather than to change the patterns of muscle activation. 
Dynamic sitting balance training helps the child to attain a self-sitting posture and free the upper limbs from depending on someone for maintaining balance. 
The purpose of this study was to find out the effect of dynamic sitting balance on upper extremity skill in spastic diplegia and to analyze the correlation between them in children less than 8 years of age.
| Materials and methods|| |
Thirty children with age ranging from 2 to 8 years (mean age: 5.6 years) and M: F ratio = 2:1 were enrolled into the study who were referred from neurosurgery department to physiotherapy outpatient clinic. The subject was randomly allocated into experimental and control group after thorough examination based on the following inclusion criteria and exclusion criteria:
- Spastic diplegic cerebral palsy children less than 8 years
- Good neck control, fair to good trunk, fair arm function, and poor to fair hand function of sitting assessment scale.
- Deformities/contractures in upper extremity mental retardation
- Visual impairment
- Hearing loss
- Continuous intrathecal baclofen infusion for at least 6 months in the last 1 year
- Selective posterior rhizotomy in the last 1 year
- Selective motor fasciculotomy of upper extremity in the last 6 months.
Experimental group received dynamic sitting balance training as an adjunct to conventional therapy and control group received conventional therapy for a period of 14 days.
- Swiss ball, wobble board, and inclined plane to train dynamic sitting balance
- Pencil, one inch cube, screw lid jar, 6-dice, container, cereals, and toys to assess upper extremity skill
- Couch/Mat to train exercises
- Video camera to record posture and movement for each activity of sitting assessment scale.
The parameters collected from each group are Quest, Pediatric Reach, and Sitting Assessment Scale [Appendix]. The data were collected on 1 st day and on 14 th day.
Treatment protocol: Conventional therapy
Passive stretching therapy was performed for hip flexors, hip adductors, knee flexors, ankle plantar flexors, shoulder adductors, elbow flexors, and wrist flexors.
Range of motion exercises were performed for upper and lower limbs.
Mat activities: Prone on elbows, prone on hands, quadruped, kneeling, kneel walking, and half kneeling were performed.
Pelvic bridging, abdominal, and spinal extensors strengthening exercises were performed.
Dynamic sitting balance training
Swiss ball activities
Side to side movements, forward and backward lean, unilateral to bilateral to alternate movements, adding resistance, and voluntary head and trunk movements were performed.
Wobble board activities in sitting
Anterior and posterior tilts and lateral tilting of pelvis were performed.
Activities on the mat
Sit on a mat, pull from side sitting to upright sitting was performed.
Inclined plane activities
Spinal extension and trunk rotations were performed.
- Quality of upper extremity skills test
- Pediatric reach test
- Sitting assessment scale.
| Results|| |
Wilcoxon signed rank test showed significant difference in all the components of quest score in the experimental group (Qa, Qb, Qc, Qd), whereas in the control group difference was seen only in one component (Qa) as shown in [Table 1].
|Table 1: Mean Values of Quest, PR, SAS in both groups on 1st day and 14th day |
Click here to view
SAS scores showed improvement only in the experimental group.
When compared to control group, experimental group showed significant improvement in Quest total score, PR, and SAS scores after 14 days [Table 2] and [Figure 1].
|Figure 1 : Dissociated movements, Qb: Grasp, Qc: Weight Bearing, Qd: Protective Extension, Qt: Total Quest Score, PR: Pediatric Reach, SAS: Sitting Assessment Scale, e: Experimental and c: Control|
Click here to view
Positive correlation has been noted between pediatric reach scores and quest scores in the experimental group [Table 3].
| Discussion|| |
Significant improvement in the mean PR scores in the experimental group when compared to control group over a period of 14 days suggests that dynamic sitting balance training helped in improving dynamic stability of the trunk.
This study supports previous findings of Marjorie Woollacott  who has concluded in his study that reactive balance training may be responsible for postural control organization in children with cerebral palsy, and Butler  who suggested that targeted training may be effective in improving movement control of trunk.
All the children in the experimental group showed greater improvement in upper extremity skill similar to the findings of Sherry et al.  that have shown that high frequency sequenced trunk activation protocol, which includes dynamic co-activation of trunk flexors and extensors seems to improve motor performance (hand function) when given to infants with posture and movement dysfunction over a period of 15 days.
Improvement in proximal stability might have provided a basis for improved upper limb function. Increased functional balance in sitting has allowed the upper limb to move away from the body thereby freeing the arm to reach an object.
The nature of relationship between dynamic sitting balance and upper extremity skill is of considerable relevance to clinical practice. This study has conducted a correlation analysis to assess the strength of relationship between dynamic sitting balance and upper extremity skill.
An improvement in dynamic sitting balance and upper extremity skill scores seem to follow similar trends in this and other studies, and the explanation for improvement in upper extremity skill can possibly be explained by improvement in dynamic sitting balance.
| Conclusion|| |
Based on this study, we conclude that children having spastic diplegic cerebral palsy improve in their upper extremity function on improving the dynamic sitting balance.
Further studies are needed to be conducted to study the long term effects of dynamic sitting balance training on upper extremity function.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Martin S, Kessler M. Neurological Interventions for Physical Therapists. 2 nd
ed. USA: Elseiver Publishers; 2000. p. 124.
Chung J, Evans J, Lee C, Lee J, Rabbani Y, Roxborough L, et al.
Effectiveness of adaptive seating on sitting posture and postural control in children with cerebral palsy. Pediatr Phys Ther 2008;20:303-17.
Levitt S. Treatment Procedures and Management. Treatment of Cerebral Palsy. 4 th
ed. UK: Blackwell Publishing; 2004. p. 204.
Nwaobi OM. Seating orientations and upper extremity function in children with cerebral palsy. Phys Ther 1987;67:1209-12.
Campbell FM, Ashburn AM, Pickering RM, Burnett M. Head and pelvic movements during a dynamic reaching task in sitting: Implications for physical therapists. Arch Phys Med Rehabil 2001;82:1655-60.
van der Heide JC, Begeer C, Fock JM, Otten B, Stremmelaar E, van Eykern LA, et al.
Postural control during reaching in preterm children with cerebral palsy. Dev Med Child Neurol 2004;46:253-66.
van der Heide JC, Hadders-Algra M. Postural muscle dyscoordination in children with cerebral palsy. Neural Plast 2005;12:197-203.
Rochat P, Goubet N. Development of sitting and reaching in 5 to 6 months old infants. Infant Behav Dev 1995;18:53-68.
Woollacott M, Shumway-Cook A, Hutchinson S, Ciol M, Price R, Kartin D. Effect of balance training on muscle activity used in recovery of stability in children with cerebral palsy: A pilot study. Dev Med Child Neurol 2005;47:455-61.
Butler PB. A preliminary report on the effectiveness of trunk targeting in achieving independent sitting balance in children with cerebral palsy. Clin Rehabil 1998;12:281-93.
Arndt SW, Chandler LS, Sweeney JK, Sharkey MA, McElroy JJ. Effects of a neurodevelopmental treatment-based trunk protocol for infants with posture and movement dysfunction. Pediatr Phys Ther 2008;20:11-22.
[Table 1], [Table 2], [Table 3]