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Association between Postural Stability and Functional Abilities in Children with Spastic Cerebral Palsy
... They stated that balance problems are frequently encountered in children with CP due to the inability of the systems that ensure the functioning of the balance mechanism to perform its task or secondary problems related to CP (Hsue et al., 2009). A large part of the studies focusing on the balance problem in children with CP agree that the balance of children with CP is affected (Cemil et al., 2023;Krishnaprasad et al., 2022;Saxena et al., 2014). In a study by Ali et al., 30 children aged 6-8 diagnosed with hemiplegic CP were treated with core exercises in addition to traditional treatment, and it was found that the group in which the exercise plan was applied had higher balance score averages compared to the control group (p <0.05) (Ali et al., 2016). ...
Background: Trunk control is necessary to maintain the body position, to ensure stabilization in the change of position, to perform activities of daily living and for activity. At the same time, it allows maintaining an upright posture, regulating weight transfer, controlled movement against gravity, controlling and changing body position for balance and function. In this study, it was aimed to examine the effects of core exercises on proprioception and balance in children with hemiplegic cerebral palsy. Material and methods: The research was conducted using a single-group pre-test post-test experimental design. The population of the study consisted of 20 people aged 4-12, diagnosed with hemiplegic cerebral palsy, who received training and treatment at a private educational institution between November 2021 and October 2022, and met the criteria for inclusion in the study. The “Trunk Impairment Scale” and “Pediatric Berg Balance Scale” were used to collect the data. In the evaluation of the data; numbers, percentages, standard deviation, mean, minimum and maximum values, Independent Samples t-test and Wilcoxon test were used. Results: It was determined that the difference between the pre-test-post-test pediatric balance scale and static sitting balance, dynamic sitting balance, coordination sub-dimensions mean scores and trunk impact scale mean scores of individuals was statistically significant (p<0.05). Conclusions: Core stability exercises applied to children with hemiplegic cerebral palsy had positive effects on proprioception and balance. Keywords: Balance, Cerebral Palsy, Proprioception, Rehabilitation
Purpose:
To determine the postural control responses' differences between children with mild spastic Cerebral Palsy (CP) and children who are typically developing (TD).
Patients and methods:
Children with spastic CP, Level I-II (n=20, mean age=9.42±4.59 years, 50% girls, 50% boys) and children with TD (N=20, mean age=9.65±3.03, 55% girls, 45% boys) were included in the study. All participants were evaluated with Computerized Dynamic Posturography, Sensory Organization Test (SOT).
Results:
There were differences between children with spastic CP and children with TD in visual and composite balance score of SOT significantly (p<0.05); there were no differences at vestibular and somatosensory scores of SOT. Children with CP had more postural sway than children with TD (p<0.05).
Conclusion:
There were differences between children with mild CP and TD in terms of postural control responses.
[Purpose] This study aimed to evaluate the relationship between gross motor function, measured using the Gross Motor Function Measure (GMFM), Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and Functional Independence Measure for Children (WeeFIM), and Function, and Activity and Participation components of the International Classification of Functioning, Disability, and Health-Child and Youth Check List (ICF-CY) in children with spastic cerebral palsy (CP). [Subjects and Methods] Seventy-seven children with spastic CP participated in the study. The GMFM, GMFCS, MACS, and WeeFIM were administered in their entirety to patients without orthoses or mobility aids. The ICF-CY was used to evaluate the degree of disability and health. [Results] The score of the ICF component of Activity and Participation had a significantly strong correlation with the scores of GMFM, GMFCS, MACS, WeeFIM, and ICF component of Function. [Conclusion] When establishing a treatment plan for children with spastic CP, the children’s physical abilities, and their limitation in activity, performance, and participation, which would be measured using the ICF-CY, should be taken into consideration.
Background:
Postural control deficits can impair functional performance in children with cerebral palsy (CP) in daily living activities.
Objective:
To verify the relationship between standing static postural control and the functional ability level in children with CP.
Method:
The postural control of 10 children with CP (gross motor function levels I and II) was evaluated during static standing on a force platform for 30 seconds. The analyzed variables were the anteroposterior (AP) and mediolateral (ML) displacement of the center of pressure (CoP) and the area and velocity of the CoP oscillation. The functional abilities were evaluated using the mean Pediatric Evaluation of Disability Inventory (PEDI) scores, which evaluated self-care, mobility and social function in the domains of functional abilities and caregiver assistance.
Results:
Spearman's correlation test found a relationship between postural control and functional abilities. The results showed a strong negative correlation between the variables of ML displacement of CoP, the area and velocity of the CoP oscillation and the PEDI scores in the self-care and caregiver assistance domains. Additionally, a moderate negative correlation was found between the area of the CoP oscillation and the mobility scores in the caregiver assistance domain. We used a significance level of 5% (p <0.05).
Conclusions:
We observed that children with cerebral palsy with high CoP oscillation values had lower caregiver assistance scores for activities of daily living (ADL) and consequently higher levels of caregiver dependence. These results demonstrate the repercussions of impairments to the body structure and function in terms of the activity levels of children with CP such that postural control impairments in these children lead to higher requirements for caregiver assistance.
[Purpose] To investigate the correlation of functional balance with the functional performance of children with cerebral palsy. [Subjects and Methods] This was a cross-sectional study of children with cerebral palsy with mild to moderate impairment. The children were divided into 3 groups based on motor impairment. The evaluation consisted of the administration of the Pediatric Balance Scale (PBS) and the Pediatric Evaluation Disability Inventory. Correlations between the instruments were determined by calculating Pearson's correlation coefficients. [Results] In Group 1, a strong positive correlation was found between the PBS and the mobility dimension of the Pediatric Evaluation Disability Inventory (r=0.82), and a moderate correlation was found between the PBS and self-care dimension of the Pediatric Evaluation Disability Inventory (r=0.51). In Group 2, moderate correlations were found between the PBS and both the self-care dimension (r=0.57) and mobility dimension (r=0.41) of the Pediatric Evaluation Disability Inventory. In Group 3, the PBS was weakly correlated with the self-care dimension (r=0.11) and moderately correlated with the mobility dimension (r=0.55). [Conclusion] The PBS proved to be a good auxiliary tool for the evaluation of functional performance with regard to mobility, but cannot be considered a predictor of function in children with cerebral palsy.
The aim of this study was to examine postural control in children with cerebral palsy performing a bilateral shoulder flexion to grasp a ball from a sitting posture. The participants were 12 typically developing children (control) without cerebral palsy and 12 children with cerebral palsy (CP). We analyzed the effect of ball mass (1 kg and 0.18 kg), postural adjustment (anticipatory, APA, and compensatory, CPA), and groups (control and CP) on the electrical activity of shoulder and trunk muscles with surface electromyography (EMG). Greater mean iEMG was seen in CPA, with heavy ball, and for posterior trunk muscles (p<.05). The children with CP presented the highest EMG and level of co-activation (p<.05). Linear regression indicated a positive relationship between EMG and aging for the control group, whereas that relationship was negative for participants with CP. We suggest that the main postural control strategy in children is based on corrections after the beginning of the movement. The linear relationship between EMG and aging suggests that postural control development is affected by central nervous disease which may lead to an increase in muscle co-activation.
In this review we explore studies related to constraints on balance and walking in children with cerebral palsy (CP) and the efficacy of training reactive balance (recovering from a slip induced by a platform displacement) in children with both spastic hemiplegic and diplegic CP. Children with CP show (a) crouched posture, contributing to decreased ability to recover balance (longer time/increased sway); (b) delayed responses in ankle muscles; (c) inappropriate muscle response sequencing; (d) increased coactivation of agonists/antagonists. Constraints on gait include (a) crouched gait; (b) increased co-activation of agonists/antagonists; (c) decreased muscle activation; (d) spasticity. The efficiency of balance recovery can be improved in children with CP, indicated by both a reduction in the total center of pressure path used during balance recovery and in the time to restabilize balance after training. Changes in muscle response characteristics contributing to improved recovery include reductions in time of contraction onset, improved muscle response organization, and reduced co-contraction of agonists/antagonists. Clinical implications include the suggestion that improvement in the ability to recover balance is possible in school age children with CP.
Following recent advances in the analysis of centre-of-pressure (COP) recordings, we examined the structure of COP trajectories in ten children (nine in the analyses) with cerebral palsy (CP) and nine typically developing (TD) children while standing quietly with eyes open (EO) and eyes closed (EC) and with concurrent visual COP feedback (FB). In particular, we quantified COP trajectories in terms of both the amount and regularity of sway. We hypothesised that: (1) compared to TD children, CP children exhibit a greater amount of sway and more regular sway and (2) concurrent visual feedback (creating an external functional context for postural control, inducing a more external focus of attention) decreases both the amount of sway and sway regularity in TD and CP children alike, while closing the eyes has opposite effects. The data were largely in agreement with both hypotheses. Compared to TD children, the amount of sway tended to be larger in CP children, while sway was more regular. Furthermore, the presence of concurrent visual feedback resulted in less regular sway compared to the EO and EC conditions. This effect was less pronounced in the CP group where posturograms were most regular in the EO condition rather than in the EC condition, as in the control group. Nonetheless, we concluded that CP children might benefit from therapies involving postural tasks with an external functional context for postural control.
Purpose: To compare construct validity, interrater and test-retest reliabilities of the Pediatric Reach Test and the Early Clinical Assessment of Balance (ECAB), and their relationships with the Gross Motor Function Measure, 66-item version, Basal and Ceiling approach (GMFM-66-B&C) to appraise clinical utility of postural stability measures for children with cerebral palsy (CP). Methods: A total of 28 children with CP, 2 to 7 years old, across all functional ability levels participated in 2 assessments over 2 weeks. Two assessors scored the measures during the first assessment. Results: Both measures demonstrated construct validity, r(s) of 0.88 (P < .001). Both measures correlated with GMFM-66-B&C, r(s) > 0.95. lnterrater and test-retest reliabilities were stronger for the ECAB than for the Pediatric Reach Test (intraclass correlation coefficients > 0.98 vs 0.87-0.94). The ECAB demonstrated lower measurement error and proportionately smaller minimal detectable change values. Conclusion: The ECAB is considered the better measure of postural stability among children with CP.
Objectives:
Validity of the Early Clinical Assessment of Balance (ECAB), to monitor postural stability in children with cerebral palsy (CP), was evaluated.
Methods:
410 children with CP, 1.5 to 5 years old, participated. Physical therapists scored children on the Movement Assessment of Infants Automatic Reactions section and Pediatric Balance Scale. Through consensus, researchers selected items from both measures to create the ECAB. Content and construct validity were examined through item correlations, comparison of ECAB scores among motor ability, age and gender groups and correlations with the Gross Motor Function Measure 66 basal and ceiling (GMFM-66-B&C).
Results:
Internal consistency was high (Cronbach's alpha = 0.92). ECAB differed significantly among motor ability, children <31 months old scored lower than older children, but there was no difference between boys and girls. ECAB and GMFM-66-B&C scores correlated strongly (r = 0.97).
Conclusion:
Validity of the ECAB was supported. Reliability and responsiveness need study.
This study aimed to systematically review the psychometric properties and clinical utility of measures of activities of daily living (ADL) for children with cerebral palsy (CP) aged 5 to 18 years.
Five electronic databases were searched to identify available ADL measures with published psychometric data for school-aged children with CP. Measures were included if at least 60% of the items addressed ADL in the full assessment or in an independent domain. A modified CanChild Outcome Rating Form was used to report the validity, reliability, responsiveness, and clinical utility of the measures.
Twenty-six measures were identified and eight met inclusion criteria. The Pediatric Evaluation of Disability Inventory (PEDI) had the strongest psychometric properties but was limited by its age range. The Assessment of Motor and Process Skills (AMPS) was the most comprehensive evaluation of underlying motor and cognitive abilities yet further psychometric testing is required for children with CP.
The PEDI should be used to measure ADL capability in elementary school aged children. The AMPS is the best measure to evaluate ADL performance or capacity and is suitable for all ages. Future research should examine the reliability of the AMPS to determine its stability in children and adolescents with CP.
The stationarity of center of pressure time-series in upright quiet bipedal standing was examined in four groups: 3- and 5-year-old children, young student adults, and an elderly group that ranged in age from 62–92 years. The young adult group showed the least absolute motion in the center of pressure with the degree of motion increasing with the child and elderly age groups. Examination of the stationarity of the center of pressure time-series for each postural trial revealed that in the time domain every trial in every condition in each age group was non-stationary. This non-stationarity was present across all frequency segments of the center of pressure dynamic in the 5-year-old, student, and elderly groups. In the 3-year-old group was there was modest evidence of the non-stationarity in the time domain being differentially present across frequencies (approx. 10% of trials). These findings are consistent with the proposition that short-term bounded non-stationarity prevails in quiet upright bipedal stance across a wide range of the lifespan. This process of non-stationarity may be a reflection of adaptation in the development of the coordination and control of posture.
The aims of the study were to: (1) build new item banks for a revised version of the Pediatric Evaluation of Disability Inventory (PEDI) with four content domains: daily activities, mobility, social/cognitive, and responsibility; and (2) use post-hoc simulations based on the combined normative and disability calibration samples to assess the accuracy and precision of the PEDI computer-adaptive tests (PEDI-CAT) compared with the administration of all items.
Parents of typically developing children (n = 2205) and parents of children and adolescents with disabilities (n = 703) between the ages of 0 and 21 years, stratified by age and sex, participated by responding to PEDI-CAT surveys through an existing Internet opt-in survey panel in the USA and by computer tablets in clinical sites.
Confirmatory factor analyses supported four unidimensional content domains. Scores using the real data post hoc demonstrated excellent accuracy (intraclass correlation coefficients ≥ 0.95) with the full item banks. Simulations using item parameter estimates demonstrated relatively small bias in the 10-item and 15-item CAT versions; error was generally higher at the scale extremes.
These results suggest the PEDI-CAT can be an accurate and precise assessment of children's daily performance at all functional levels.
The aim of this study was to validate the expanded and revised Gross Motor Function Classification System (GMFCS-E&R) for children and youth with cerebral palsy using group consensus methods. Eighteen physical therapists participated in a nominal group technique to evaluate the draft version of a 12- to 18-year age band. Subsequently, 30 health professionals from seven countries participated in a Delphi survey to evaluate the revised 12- to 18-year and 6- to 12-year age bands. Consensus was defined as agreement with a question by at least 80% of participants. After round 3 of the Delphi survey, consensus was achieved for the clarity and accuracy of the descriptions for each level and the distinctions between levels for both the 12- to 18-year and 6- to 12-year age bands. Participants also agreed that the distinction between capability and performance and the concept that environmental and personal factors influence methods of mobility were useful for classification of gross motor function. The results provide evidence of content validity of the GMFCS-E&R. The GMFCS-E&R has utility for communication, clinical decision making, databases, registries, and clinical research.
Studies on the development of balance control show a clear developmental progression of the emergence of organized muscle response patterns, with tonic background muscle activity decreasing and phasic bursts of activity emerging in all three agonist muscles in a synergic group (gastrocnemius-hamstrings-trunk extensors or tibialis anterior-quadriceps-abdominals) just prior to the onset of independent stance. The rudimentary ability to adapt postural responses to changing task conditions is present in children as young as 1 year of age. Older children with spastic diplegia have muscle activation patterns typically seen in normal children who are at the pull-to-stand stage of development, including poorly organized (proximal activated before distal muscles) responses with a high degree of antagonist co-activation. When normal children were asked to stand in a crouched posture like the CP children, the additional constraint caused muscle response patterns to resemble those of CP children, suggesting that differences in balance control in CP children are due to both CNS deficits and biomechanical changes in postural alignment.
How can the adult postural organisation be elucidated using an ontogenetic approach, and what questions can be raised about ontogenesis starting from the organisation of adult posture? These questions will be addressed taking three aspects of postural organisation. The first is the internal representation of erect posture, including the role played by the various sensory inputs in this representation. The second aspect relates to the variables which are controlled during erect posture: is it the body orientation with respect to the vertical or the localisation of the centre of gravity with respect to the feet which is controlled? The third aspect concerns the coordination between posture, equilibrium and movement, focusing on the role played by an internal representation of the external world and its interactions with the body segments in organising the anticipatory postural adjustments. The central organisation of coordinated control will also be considered. Each of these aspects will be discussed in relation to ontogenetic considerations.
Balance is a term frequently used by health professionals working in a wide variety of clinical specialities. There is no universally accepted definition of human balance, or related terms. This article identifies mechanical definitions of balance and introduces clinical definitions of balance and postural control. Postural control is defined as the act of maintaining, achieving or restoring a state of balance during any posture or activity. Postural control strategies may be either predictive or reactive, and may involve either a fixed-support or a change-in-support response. Clinical tests of balance assess different components of balance ability. Health professionals should select clinical assessments based on a sound knowledge and understanding of the classification of balance and postural control strategies.
We sought to examine whether children with cerebral palsy (CP) demonstrate anticipatory postural adjustments (APAs) similar to those observed in children with typical development (TD).
A sample of convenience of 14 children, seven with CP and seven with TD, participated in this study. The center of pressure (COP) was calculated from ground reaction force data collected from the AMTI (OR-6) force platform as the child reached forward while standing.
Posterior COP shift frequently was observed in both groups of children before arm movement. However, the children with CP showed greater variability and significantly shorter amplitude of the APA COP excursion as compared with those with TD.
The control of APAs is problematic for some children with CP and, therefore, intervention designed to facilitate APAs may be beneficial for those children.
Motor impairments in young children with cerebral palsy: Relationship to gross motor function and everyday activities
- Ostensjo S.