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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 94-99

Efficacy of task-oriented training on balance in children with cerebral palsy


Department of Physiotherapy and Rehabilitation, Kempegowda Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India

Date of Web Publication12-Apr-2017

Correspondence Address:
Arjun Dutt
Janani No 124/3 Surveyor Street, Basavanagudi, Bengaluru - 500 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-4264.204410

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  Abstract 


Background and Objective: Cerebral palsy (CP) is a well-recognized group of motor and postural neurodevelopmental disorders beginning in early childhood and persisting through the life span.[1] Prevalence estimates of CP ranged from 1.5 to more than 4 per 1000 live births. This single-group interventional study was conducted to know the effectiveness of task-oriented training on balance in children with cerebral palsy.
Materials and Methods: Patients included for the study were children with spastic diplegic cerebral palsy, 6–14 years of age, both male and female children, Gross Motor Functional Classification Scale levels I, II and III, Motor Assessment Scale (sitting to standing item), and Modified Modified Ashworth Scale (MMAS) grade 1 and 2. Pediatric Balance Scale (PBS), Functional Reach Test (FRT), Five Times Sit to Stand Test (5STS), and Modified Modified Ashworth Scale (MMAS) were used as the tools of assessment. Task consisting included sitting reach outs activities, sit to stand activity, squatting, step up, stepping on one leg, and step on a small ball. Descriptive and inferential statistical analyses have been carried out in the present study, Student's t-test (two-tailed, independent) has been used for intergroup analysis, and Student's t-test (two-tailed, dependent) has been used to find the significance of study parameters on continuous scale within each group. Duration of the study lasted for 12 months and frequency was 1 h per session, 5 days a week.
Results: Statistical analysis was performed using Student's t-test and significant improvement was observed in balance with task-oriented training with the mean improvement of 3.667 in PBS, 0.250 in 5STS, 0.25 in FRT, and 63% in MMAS.
Conclusion: This study suggests that the task-oriented training is effective in improving the balance of children with cerebral palsy assessed using PBS, FRT, 5STS, and MMAS.

Keywords: Functional Reach Test, Modified Modified Ashworth Scale, Pediatric Balance Scale


How to cite this article:
Dutt A, Prem Kumar B N. Efficacy of task-oriented training on balance in children with cerebral palsy. Indian J Cereb Palsy 2016;2:94-9

How to cite this URL:
Dutt A, Prem Kumar B N. Efficacy of task-oriented training on balance in children with cerebral palsy. Indian J Cereb Palsy [serial online] 2016 [cited 2018 Dec 15];2:94-9. Available from: http://www.ijcpjournal.org/text.asp?2016/2/2/94/204410




  Introduction Top


The topographic classification of cerebral palsy (CP) is monoplegia, hemiplegia, diplegia, and quadriplegia; monoplegia and triplegia are relatively uncommon. In most studies, diplegia is the most common form (30%–40%), hemiplegia is 20–30%, and quadriplegia is 10–15%.[2]

Spasticity, one of the most common problems in children with cerebral palsy and a component of upper motor neuron syndrome, is a motor disorder characterized by velocity-dependent increases in tonic stretch reflexes with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex. It was believed that weakness is not a major problem in children with cerebral palsy. Consequently, muscle strengthening has not been recommended for children with cerebral palsy because it was believed that it would lead to increased spasticity and that children with cerebral palsy would not benefit from resistance training.[3]

CP causes serious motor impairments often accompanied by disturbances of sensation and perception and is the most common cause of physical disability in early childhood.[4]

In children with cerebral palsy, impaired head and neck control is substituted by elevation of shoulder girdle which prevents developing shoulder girdle control. Muscles of trunk and abdomen are weak and inactive; hence, there is impaired thoracolumbar control which represents as kyphotic posture. Due to delay in phasic burst of muscle activities, static, active, and reactive postural control is impaired in sitting.[5]

According to recent literature, repetitive task-oriented training has proved to be effective in improving motor function and performance. This approach integrates systems theory with motor learning theory. Upper extremity motor dysfunction reduces the functional independence of the child with cerebral palsy.[6]

Task-oriented training is used as a rehabilitation strategy to improve motor skill and as a rehabilitation program for the improvement of muscle strength or function. It should include specific tasks to improve function as an effective treatment for functional improvement of patients with disorders of the central nervous system. It can be performed through repeated training of activity tasks associated with daily activity. It is a training method that supports interesting tasks for children with cerebral palsy and effectively improves functional movement.[7]


  Materials and Methods Top


Study design: Single-group interventional study.

Sample size: Thirty patients.

Materials

A stepper/stool of 5 inches height, small ball 3 inches height, height adjustable chair/stool without armrest and back support, target objects such as pen, small toys, box, and pile of books, wall bar, and walker were used in the study.

Candidates included for the study were children with spastic diplegic cerebral palsy, 6–14 years of age, both male and female children, Gross Motor Functional Classification Scale (GMFCS) levels I, II, and III, Motor Assessment Scale (sitting to standing item), and Modified Modified Ashworth Scale (MMAS) grade 1 and 2.

Evaluation

  • Pediatric Balance Scale (PBS)[8]
  • Functional Reach Test (FRT)[9]
  • Five Times Sit To Stand (5STS)[10]
  • MMAS.[11]


Methods

1. Sitting reach outs activities



2. Sit to stand activity



3. Squatting



4. Step up



5. Step on one leg



6. Step on a small ball.



Repetition: 3 sets with 10 repetitions.

Frequency

  • Sixty minutes session
  • Five times per week
  • Four weeks of training
  • Five minutes rest time for each set.


Statistical analysis

[Figure 1] shows there are total of 30 samples, in which 16 children with cerebral palsy were in the age group 6–9 years which comprised 53.3% of the sample size and 14 children with cerebral palsy were in the age group of 10–13 years which comprised 46.7% of the sample size.
Figure 1: Age distribution of patients studied

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[Figure 2] shows the evaluation of PBS on the 1st day, 14th day, and by end of the 4th week. The PBS on baseline is 24.30 ± 2.91 for the 1st day, 25.33 ± 2.92 for the 14th day, and 27.97 ± 4.28 by the end of the 4th week (P < 0.0001). PBS before the treatment was 24.30 ± 2.91 and after the treatment was 27.97 ± 4.28, with a mean improvement of 3.667. Student's t-test shows that there is a significant improvement in PBS.
Figure 2: Comparison of Pediatric Balance Scale score from baseline to post 4 weeks

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[Figure 3] shows the evaluation of 5STS score of baseline on the 1st day and by the end of the 4th week.
Figure 3: Comparison of Five Times Sit to Stand Test score from baseline to the end of the 4th week

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The 5STS scores on the baseline are 3.44 ± 0.47 for the 1st day, 3.32 ± 0.40 for the 14th day, and 3.19 ± 0.41 by the end of the 4th week (P < 0.001**). The 5STS score before the treatment was 3.44 ± 0.47 and after the treatment was 3.19 ± 0.41, with a mean improvement of 0.250. Student's t-test shows that there is a significant improvement in the 5STS scores.

[Figure 4] shows the evaluation of FRT score on baseline on the 1st day, 14th day, and by end of the 4th week. The FRT values on the baseline are 3.19 ± 0.41 for the 1st day, 3.32 ± 0.40 for the 14th day, and 3.44 ± 0.47 by the end of the 4th week (P < 0.001). The FRT score on the 1st day was 3.19 ± 0.41 and by the end of the 4th week was 3.44 ± 0.47, with a mean improvement of 0.25. The t-test shows significant improvement on FRT after treatment.
Figure 4: Comparison of Functional Reach Test score from baseline to the end of the 4th week

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[Figure 5] shows the evaluation of MMAS score on baseline on the 1st day, 14th day, and by end of the 4th week. On day 1, 20 patients had grade 3 (66.6%), 10 patients had grade 2 (33.3%), and 0 patient with grade 1.
Figure 5: Comparison of Modified Modified Ashworth Scale score from the baseline to the end of the 4th week

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By the end of the 4th week, 1 patient had grade 3 (3.3%), 13 patients had grade 2 (43.3%), and 16 (63.3%) patients comprised grade 1 (P < 0.001**).


  Discussion Top


This study was conducted to analyze the efficacy of task-oriented training on balance in children with cerebral palsy (GMFCS I–III).

In this interventional study, 30 children with spastic diplegic CP were selected, with age ranging from 6 to 14 years. There are 16 patients aged between 6 and 9 years comprising 53% of the total sample and 14 patients in the age group between 10 and 13 years, which comprises 47% of the total sample size.

Based on GMFCS and MMAS, the patients were included in the study upon which a task-oriented training protocol was administered.

The patients were assessed using PBS, FRT, 5STS, and MMAS. PBS, FRT, 5STS, and MMAS measures were used to check the efficacy of the protocol.

PBS score compared to 24.30 ± 2.91 for the 1st day showed significant improvement in balance at the end of the 4th week with mean value of 27.97 ± 4.28 (P < 0.001).

The 5STS with a mean of 3.44 ± 0.47 on the 1st day showed significant improvement by the end of the 4th week with a mean of 3.19 ± 0.4 (P < 0.001).

FRT score with a mean of 3.32 ± 0.40 on the 1st day showed significant improvement by the end of the 4th week with a mean of 3.44 ± 0.47 (P < 0.001).

MMAS showed significant improvement of 63.3% by the end of the 4th week compared to the 1st day of analysis. On day 1, 20 patients had grade 3 (66.6%), 10 patients had grade 2 (33.3%), and 0 patient with grade 1. By the end of the 4th week, 1 patient had grade 3 (3.3%), 13 patients had grade 2 (43.3%), and 16 (63.3%) patients comprised grade 1.

The results obtained from this intervention help the study to interpret that the application of task-oriented training protocol is effective in improving thee balance in children with cerebral palsy (GMFCS I–III).

Limitations

  • No long-term follow-up was carried out to assess whether patients retained the gained improvement after 4 weeks of intervention
  • The age-related ability among the patients could not be justified.



  Conclusion Top


In the study of efficacy of task-oriented training protocol on balance in children with cerebral palsy, patients showed improvement in their static balance and functional activity of sitting to standing. A 30-day intervention consisting of task-oriented training protocol proved to be effective in improving balance and functional activity of sitting to standing in children with cerebral palsy assessed using PBS, 5STS, FRT, and MMAS.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: The definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl 2007;109:8-14.  Back to cited text no. 1
    
2.
Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol 2005;47:571-6.  Back to cited text no. 2
    
3.
Menkes JH, Sarnat HB, editors. Perinatal asphyxia and trauma. In: Child Neurology. Lippincott Williams and Wilkins; 2000. p. 427-36.  Back to cited text no. 3
    
4.
Miller G. Epidemiology and Etiology of Cerebral Palsy. Available from: http://www.uptodate.com/home. [Last accessed on 2013 May 22].  Back to cited text no. 4
    
5.
Tugui RD, Antonescu D. Cerebral palsy gait, clinical importance. J Clin Med 2013;8:388-93.  Back to cited text no. 5
    
6.
Papadelis C, Ahtam B, Nazarova M, Nimec D, Snyder B, Grant PE, et al. Cortical somatosensory reorganization in children with spastic cerebral palsy: A multimodal neuroimaging study. Front Hum Neurosci 2014;8:725.  Back to cited text no. 6
    
7.
Franki I, Desloovere K, De Cat J, Feys H, Molenaers G, Calders P, et al. The evidence-base for conceptual approaches and additional therapies targeting lower limb function in children with cerebral palsy: A systematic review using the ICF as a framework. J Rehabil Med 2012;44:396-405.  Back to cited text no. 7
    
8.
Franjoine MR, Gunther JS, Taylor MJ. Pediatric balance scale: A modified version of the berg balance scale for the school-age child with mild to moderate motor impairment. Pediatr Phys Ther 2003;15:114-28.  Back to cited text no. 8
    
9.
Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: A new clinical measure of balance. J Gerontol 1990;45:M192-7.  Back to cited text no. 9
    
10.
Kumban W, Amatachaya S, Emasithi A, Siritaratiwat W. Five-times-sit-to-stand test in children with cerebral palsy: Reliability and concurrent validity. NeuroRehabilitation 2013;32:9-15.  Back to cited text no. 10
    
11.
Ansari NN, Naghdi S, Moammeri H, Jalaie S. Ashworth Scales are unreliable for the assessment of muscle spasticity. Physiother Theory Pract 2006;22:119-25.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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