EFFECT OF TASK ORIENTED TRAINING ON BALANCE IN CHILDREN WITH HEMIPARETIC CEREBRAL PALSY

EFFECT OF TASK ORIENTED TRAINING ON
BALANCE IN CHILDREN WITH HEMIPARETIC
CEREBRAL PALSY
Hamada T. Mohamed 1 ; Gehan M. Abd El-Maksoud2 ;
Heba H. Abd El-Wahaab3 and Amr A. Azam4
1 Physical Therapist, The National Institute Of Neuromotor System , Egypt.
2 Professor of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo
University, Egypt.
3 Lecturer of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo
University, Egypt.
4 Consultant of Orthopedic Surgery, The National Institute of Neuromotor System,
Egypt.
Key Words: Balance, Cerebral palsy, Hemiplegia, Pediatric balance
scale and Task Oriented Training.
ABSTRACT
Background: Task oriented training is widely recognized as an effective
method to enhance balance. Purpose: The aim of this study was to
investigate the effect of task oriented training on balance in children with
hemiplegic cerebral palsy. Subjects and Methods: Fourteen children
with hemiplegic cerebral palsy, aged from 6 to 9 years of both sexes were
participated in this study. They were selected from the outpatient clinic
of the National Institute of Neuromotor System. They were assigned into
one group, (study group). They received task oriented training program.
The treatment program was conducted for one hour, three times per week
for three successive months for this group. Pre- and post-treatment
assessments of balance were performed by Pediatric Balance Scale
(PBS). Results: This group showed significant improvement in balance
(p<0.000) after treatment protocols. Conclusions: Task oriented training
may be used as an effective method in the rehabilitation program for
children with hemiplegic cerebral palsy to improve their balance.
INTRODUCTION
Cerebral palsy (CP) describes a group of permanent disorders of
the development of movement and posture, causing activity limitations
that are attributed to non-progressive disturbances in the developing fetal
or infant brain ( Rosenbaum et al., 2006). It is also defined as neurodevelopmental
condition beginning in early childhood and persisting
throughout one’s life span. The average incidence is approximately 2-2.5
per 1000 live births (Odding et al., 2006).
Egypt. J. of Appl. Sci., 36 (1) 2021 1- 9
Hemiplegic cerebral palsy (HCP) is a unilateral paresis, with upper
limbs more severely affected than the lower limbs. Hemiplegia accounts
for 20% to 30% of all cases of CP, and is caused predominantly by
unilateral damage of the developing brain which leads to unilateral,
asymmetric muscle tone abnormalities, and deformities. As a
consequence, patients with HCP show unilateral, irregular movements
and limitations in range of motion (Feltham et al., 2010).
In order to orient the body, while keeping balance, visual,
vestibular and somatosensory modalities are also involved. Every
directed activity implies that the body was previously oriented, although,
any part of the body surface can influence the control and perception of
body orientation (Jauregui, 2013).
Children with spastic hemiplegia experience decreased balance
ability and abnormal gait because of decreased weight-bearing in the
paretic leg. Diminished motor ability in the paretic leg causes weakening
of the quadriceps, ankle plantar flexors, and ankle dorsiflexors (Ki et al.,
2015).
Task-oriented training is defined as the repetitive training of
significant, functional activities or element of such activities, to acquire
well-organized and effective motor skill. It used as a rehabilitation
strategy to improve motor skill and as a rehabilitation program for
improvement of muscle strength, balance and function (Leroux et al.,
2006). It should include specific tasks to improve function as an effective
treatment for functional improvement of patients with disorders of the
central nervous system (CNS) (Bayona et al., 2005).
Task oriented training is a form of motor learning that focus on
skill acquisition in the context of a particular functional activity. Skill is
the ability to achieve the goal with consistency, flexibility and
efficiency. Task oriented training for patient with CNS lesion results in
motor relearning by enhancing skill in meaningful functional activity
with adaptive neuroplastic changes in the cerebral cortex, brain stem,
cerebellum and spinal cord. There is a growing interest in the phenomena
of neural plasticity following CNS injury and its critical link to
taskoriented training (Stein, 2009). Also, Ching et al. (2013) concluded
that, task oriented training improves motor performance, motor control
strategies, sensory recovery, balance and daily function more than the
traditional treatment. The aim of this study was to investigate the effect
of task oriented training on balance in children with hemiparetic CP.
MATERIALS AND METHODS
Study Design
This study was a Quasi-experimental study that was conducted
from April 2019 up to July 2019.
2 Egypt. J. of Appl. Sci., 36 (1) 2021
Subjects
A sample of fourteen children with hemiplegic CP of both sex
agreed to participate in the present study with their ages ranged from six
to nine years. They were selected from the outpatient clinic of the
National Institute of Neuro Motor System. They had a diagnosis of
hemiplegic cerebral palsy that was obtained from their medical records
and confirmed by radiological examination and neurologist. They had
spasticity grade 1 and 1+ according to Modified Ashwarth Scale. The
children were at level I and II on Gross Motor Function Classification
System (GMFCS) and able to follow instructions during evaluation and
treatment procedures. Participants were excluded from this study if they
had any of the following; fractures of upper and lower limbs, visual,
auditory, or perceptual deficits, surgical interference for the lower limb,
seizures or epilepsy, received botulinum toxin in the lower extremity
musculature during the past 6 months.
Approval by the Ethical Committee of the Faculty of Physical
Therapy, Cairo University (012\002186), and written consent forms
from parents of children, were obtained at the beginning of the study.
Procedures
A) Evaluative procedure
Balance was evaluated for all children participated in this study
using pediatric balance scale pre and post treatment in order to track
progress in a rehabilitation program.
Pediatric Balance Scale (PBS) was developed by Franjoine et al.
(2003). The purpose of PBS is to examine functional balance in the
context of daily life’s activities in the pediatric population. It contains
functional measured items, which are sitting to standing, standing
unsupported, standing to sitting, sitting unsupported, transfer standing
with eyes closed, standing with feet together, standing with one foot in
front, standing on one foot, turning 360°, turning to look behind,
retrieving object from floor, placing alternate foot on stool and reaching
forward with outstretched arm. The score level of each item will be
recorded on a five-point liker scale (from 0 to 4), depending on the
quality of performance. Total score ranged from 0 to 56. Higher score
indicates better functional balance ability (Lei et al., 2017).
Pediatric balance scale was used to assess balance for all children
participated in this study. It contains 14-item. Scoring for each item is
scored 0 points (lowest function) to 4 points (highest function), with a
Egypt. J. of Appl. Sci., 36 (1) 2021 3
maximum score of 56 points. Calculation of the total score by summation
of the score of the 14 items (Franjoine et al., 2010).
B) Treatment procedures
Children in this study group received task-oriented training
program for one hour, three sessions per week for three successive
months according to the protocol of Citation and Ostwal (2016). The
program included the following exercises: -
1) Reaching in different directions for objects located beyond arm’s
length
2) Sit-to-stand from various chair heights
3) Kicking ball
4) Walking forward, sideway and backward
5) Jumping from different height
6) Standing on one limb
7) Up and down stairs training
8) Stepping forward and backward onto blocks of various heights
9) Stepping sideways onto blocks of various heights
10) Forward step-up onto blocks of various heights
11) Raising and lowering heel while maintaining a standing posture.
12) In addition to the previous program, the children received the
following exercises:
a. Stretching exercises for shortened muscles.
b. Strengthening exercises for weak muscles.
c. Balance exercises on balance board
Data Analysis
Data were statistically described in terms of mean standard
deviation (SD), or frequencies (number of cases) and percentages.
Numerical data were tested for the normal assumption using Kolmogorov
Smirnov test and Shapiro Wilk test. Student t- test was used to compare
the pre and post treatment results of the study group. P values less than
0.05 was considered statistically significant. All statistical calculations
were done using computer program IBM SPSS (Statistical Package for
the Social Science; IBM Corp, Armonk, NY, USA) release 22 for
Microsoft Windows.
RESULTS
Seventeen children with hemiplegic CP children were screened for
participation in the current study. Two children were excluded because
they failed to fulfill the inclusion criteria, and one child’s parents refused
to participate in the study. The remaining fourteen children were
4 Egypt. J. of Appl. Sci., 36 (1) 2021
allocated into one group. This study group received a designed taskoriented
training program.
Demographic and clinical data of the subjects
Table (1) reveals the mean values of age and the distribution of
gender, affected side, grade of spasticity and level of GMFCS of the
study sample. The mean values of age were 6.96 ± 0.987 years old of
study sample. The gender distribution revealed the number (percentage)
of boys and girls in this study sample which were and 8 (57.1%), 6
(42.9%) respectively. The affected side distribution the number
(percentage) of right and left side affection in the study sample which
were 10 (71.4%) and 4 (28.6%), respectively. The grade of spasticity
distribution revealed the number (percentage) of grade 1 and 1+ in this
study which were 2(14.3%), 12 (85.7%) respectively. Gross Motor
Function Classification System distribution revealed the level 1 and 2 in
this study group which were 5 (35.7%) and 9 (64.3%), respectively.
Table (1): Demographic and clinical data of subjects
Item Number (percentage)
Gender
Girls
Boys
6 ( 42.9 %)
8 (51.15 %)
Affected side
Right
Left
10 (71.4 %)
4 (28.6 % )
Spasticity
Grade 1
Grade 1+
2 (14.3 % )
12 (75.7 % )
GMFCS
Level I
Level II
5 (35.7 % )
9 ( 64.3 % )
Age(Years)
Xˉ ± SD
6.96 ± 0.987
GMFCS: Gross motor functional classification system, Xˉ ± SD: Mean ± Standard
deviation
Pediatric balance scale results
Table (2) represents the comparisons of pre and post treatment
mean values of PBS of the study sample. The mean values of pre- and
post-treatment of PBS were 36.14±6.024 and 46.71±4.795, respectively.
The statistical analysis by Student t test revealed that there was a
statistical significant improvement (P<0.05) of PBS in post-treatment
compared to pre-treatment values within the study sample.
Egypt. J. of Appl. Sci., 36 (1) 2021 5
Table (2): Comparison of mean values of pediatric balance scale preand
post-treatment within the study sample.
Items PBS
Pre-treatment 36.14±6.024
Post-treatment 46.71±4.795
T-value -15.081
P-value 0.000
Significance S
Data are expressed as mean and standard deviation (SD) P-value: probability S:
significant
DISCUSSION
The aim of this study was to investigate the effect of task oriented
training on balance in children with hemiparetic cerebral palsy.
Cerebral palsy may affect the child on several health dimensions;
the motor signs include primary neuromuscular deficits, such as
spasticity, muscle weakness, imbalance and decreased selective motor
control and secondary musculoskeletal problems such as bony
malformations and
contractures (Siri et al., 2010).
Choosing the age of the children was in agreement with Eccles
(1999) who reported that child has a good balance like adult between age
of 5 and 10 years.
It was intended to assess the balance for children with HCP which
comes in accordance with Flodmark (2003) who found that HCP child
has difficulty in balance and walking which is manifested by a shorter
step length and more stiffness of the affected side when compared with
normal child of the same age. Also, Torres and Ting (2007) who
reported that the ability of the human to maintain normal balance
depends on activity of group of muscles that balance the spinal column
while there is a difficulty in HCP children to overcome the spasticity.
Significant improvement of balance in this study is supported by
the findings of Kyung and Yijung (2016) who examined the effects of
Task-oriented training for gait and balance in
cerebral palsy. Twelve patients were experimental group who
executed the task-oriented training (5 times/wk.) for 4 weeks. They
found significant increase of balance and gross motor function.
Moreover, the results of this study agree with findings of Franklin
(2016) who explore the effectiveness of task oriented training on
mobility and balance among spastic diplegic cerebral palsy children.
Twenty spastic diplegic CP fulfilled inclusion and exclusion criteria were
6 Egypt. J. of Appl. Sci., 36 (1) 2021
selected for the study and randomly divided into two groups A and B.
Group A received task oriented training and group B received
conventional physiotherapy for a period of six weeks.
Before starting the treatment, mobility and balance were measured
by timed up and go test and pediatric balance scale respectively. The
measurements were repeated after six weeks. The results showed that
both task oriented training and conventional physiotherapy were effective
in improving mobility and balance among spastic diplegic children, but
when comparing both task oriented training group showed more
improvement in mobility and balance among spastic diplegic children
than conventional physiotherapy group.
The current study has some limitations such as the small sample
that it may not be possible to generalize these results to the whole
population of children with hemiplegic CP. Further studies on a larger
population of children with hemiplegic CP have to be carried out.
Additionally, the children who participated in this study were restricted
to one type of CP with the age group from six to nine years. So, more
studies are needed on other types of CP.
CONCLUSION
Based on the results of this study, task oriented training program
may be a beneficial method in the rehabilitation of children with
hemiplegic CP to improve balance.
ACKNOWLEDGMENTS
The authors thank all the children and parents who participated in
this study.
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تأثير التدريب الموجه عمى الات ا زن لدى الأطفال المصابين بالفالج الشقى
، حمادة ثابت محمد 1 ، جيهان مسعد عبد المقصود 2 ، هبة ه ا زع عبد الوهاب 3
عمرو عبد الله ع ا زم 4
-1 اخصائى علاج طبيعى بالمعيد القومي لمجياز العصبى الحرکى مصر.
2 - أستاذ بقسم العلاج الطبيعي للأطفال - کمية العلاج الطبيعي - جامعة القاىرة.
-3 مدرس بقسم العلاج الطبيعي للأطفال - کمية العلاج الطبيعي - جامعة القاىرة.
-4 استاذ ج ا رحة العظام ،المعيد القومى لمجياز العصبي الحرکى.
الخمفية: يعتبر التدريب الموجو وسيمة فعالة لتحسين التوازن. الغرض : اليدف من ىذه الد ا رسة
ىو معرفة تأثير التدريب الموجو نحو الميام عمى التوازن لدى الأطفال المصابين بالفالج الشقى .
الطرق :شارک في ىذه الد ا رسة 41 طفلا ا مصاابا بالفالج الشقى ممن ت ا روحت أعمارىم من ٦ إلى
٩ سنوات من کلا الجنسين .تم اختيارىم من العيادة الخارجية لممعيد القومي لمجياز العصبى
الحرکى .احتوت ىذه الد ا رسة عمى مجموعة واحدة .تمقت مجموعة الد ا رسة برنامج التدريب
الموجو نحو الميام .تم تطبيق برنامج العلاج لمدة ساعة واحدة , ثلاث م ا رت في الأسبوع لمدة
ثلاثة أشير متتالية ليذه المجموعة .تم إج ا رء تقييمات التوازن قبل وبعد العلاج بواسطة مقياس
توازن الأطفال .النتائج : أظيرت النتائج تحسن ذو دلالة احصائية فى التوازن بعد انتياء مدة
العلاج.
الاستنتاجات : يمکن استخدام التدريب الموجو نحو الميام ضمن برنامج التأىيل کوسيمة فعالة
لتحسين التوازن عند الاطفال المصابين بالفالج الشقى.
الکممات المفتاحية :الشمل الدماغي , الشمل النصفى , التدريب الموجو نحو الميام , التوازن ,
مقياس توازن الأطفال.
Egypt. J. of Appl. Sci., 36 (1) 2021 9