|Year : 2015 | Volume
| Issue : 2 | Page : 101-107
Feasibility of multisensory training and its effects on balance control in school going children with cerebral palsy
Bhakti Patel, S Karthikbabu, Nafeez Syed
Department of Physiotherapy, School of Allied Health Sciences, Manipal Hospital, Manipal University, Bengaluru, Karnataka, India
|Date of Web Publication||7-Jan-2016|
Department of Physiotherapy, School of Allied Health Sciences, Manipal Hospital, Manipal University, Old Airport Road, Bengaluru - 560 017, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Involvement of sensory system affects the motor performance of children with cerebral palsy, and the literature on sensory-based balance training is scarce in such children.
Aim: To test the feasibility of administering multisensory training in school going children with cerebral palsy and its effects on balance control as measured by Balance Evaluation - Systems Test (BESTest).
Settings and Design: School setting and a baseline-pre-post feasibility trial.
Subjects and Methods: Seventeen children with cerebral palsy (gross motor function classification system level 1-3) aged between 6 and 16 years participated in sensory-based balance training encompassing inputs from visual, vestibular, and proprioceptive systems. Children with mental delay, hearing, and visual impairments and those who underwent treatments such as BOTOX, tendon lengthening, derotation surgery, or selective rhizotomy in the past 6 months were excluded. Following 2 months run-in period, each child underwent 45 min of training per session; a total of 18 sessions over 2 months duration.
Statistical Analysis and Results: Repeated measures ANOVA and post-hoc test was done to analyze within-subject changes and with respect to time. P < 0.05 was statistically significant. After training, all the components of BESTest showed statistically significant change (P < 0.05).
Conclusion: Multisensory training is a feasible mode of practice in a school setting and is beneficial in improving balance control in children with cerebral palsy.
Keywords: Balance control, Balance Evaluation - systems Test, cerebral palsy, multisensory training
|How to cite this article:|
Patel B, Karthikbabu S, Syed N. Feasibility of multisensory training and its effects on balance control in school going children with cerebral palsy
. Indian J Cereb Palsy 2015;1:101-7
|How to cite this URL:|
Patel B, Karthikbabu S, Syed N. Feasibility of multisensory training and its effects on balance control in school going children with cerebral palsy
. Indian J Cereb Palsy [serial online] 2015 [cited 2017 Mar 25];1:101-7. Available from: http://www.ijcpjournal.org/text.asp?2015/1/2/101/173448
| Introduction|| |
Muscular spasticity, proximal to distal muscle co-activation, increased co-contraction, slow muscle responses, muscular weakness, altered proprioception, and contractures are commonly observed findings in children with cerebral palsy (CP). ,, Children are involved with reduced anticipatory and reactive postural responses which are essential for maintaining normal balance control. There was a greater variability in the center of pressure excursions and anticipatory postural adjustment toward the backward direction in children with cerebral palsy compared to healthy children.  Liu et al.  reported that children with cerebral palsy demonstrated a posterior shift in the center of pressure prior to arm movement, and the amplitude was significantly different compared to typically developing children. This suggests that controlling the anticipatory postural adjustments by shifting weight backward is a challenge in CP. Deficits in sensory-motor systems could be one of the potential reasons for impaired postural control mechanism observed in children with cerebral palsy. 
The sensory deficits in children with cerebral palsy due to the involvement of thalamocortical pathways were confirmed with an imaging study.  Sensory deficits in school going children with cerebral palsy were determined by clinical sensory battery and somatosensory evoked potential tests.  Sensory inputs are a necessary component for motor control and movement performance. Interaction among somatosensory, visual, and vestibular systems is essential for normal motor responses, balance control, and mobility. The correct signals from visual and vestibular systems are required to restore the normal postural control of head and neck. Due to the poor dynamic stability of neck in children with cerebral palsy, greater head sway is observed during postural transitions.  Ability to stand upright poses, a challenge in rhythmic weight shifting ability for children with cerebral palsy especially in those with altered sensory conditions; sway referred somatosensory, and visual conditions. As a result, they tend to walk at slower speed with greater physiological cost compared to typically developing children.  Impaired balance ability in children with cerebral palsy was also related to poor walking function.  Visual feedback-based balance training was beneficial in enhancing the symmetrical walking pattern in hemiplegic cerebral palsy children. 
Various training regimes such as neurodevelopmental therapy, task related intensive practice, strength training, and treadmill training have been tested for balance alone.  The exercise programs with and without altered sensory inputs were helpful to improve standing balance in people with neurological disorders.  However, there is a paucity of literature testing the effects of sensory based exercise training on the balance control using Balance Evaluation - Systems Test (BESTest) in CP.  Hence, we studied the feasibility of administering multisensory practice in school going children with cerebral palsy and its effects on balance control.
| Subjects and methods|| |
This baseline-pre-post feasibility study was approved by the Institutional Review board of Manipal University, Bengaluru and Ethics Committee of Spastic Society of Karnataka, India. A written informed assent form was obtained from the parents before the child was assessed as per the protocol. Children diagnosed with cerebral palsy were screened for the eligibility and those who met the criteria were enrolled. Children aged between 6 and 16 years, diagnosed with diplegia, hemiplegia, dyskinesia, and/or secondary quadriplegia, able to understand and follow simple verbal commands with gross motor function classification system (GMFCS) levels 1, 2, and 3 were included in the trial. Children who underwent BOTOX therapy for the muscles of spastic lower limb and/or surgical procedures such as tendon release, derotation osteotomies, and selective rhizotomy in past 6 months were excluded.
BESTest, an outcome measure that evaluates the underlying balance function has six sub-components: Biomechanical constraints, stability limits, anticipatory postural adjustments, reactive postural response, sensory orientation, and stability in gait. Inter-rater reliability (r = 0.91), Kendall coefficient of concordance (r = 0.46-1.00), and concurrent validity of the correlation with balance self-efficacy (r = 0.636) were reported for BESTest.  The pediatric values of functional reach distance were considered for testing functional reach forward and reach lateral under the stability limits section of BESTest. The scores of BESTest were collected at 3-time points (baseline, pre- and post-interventions) by a therapist who was not involved in administering the training to children. Baseline and preintervention values were separated by a span of 2 months. Children were not given the study intervention during these 2 months period which happened to be the 2 months of school vacation. This run-in period was included in the study to find whether the status of balance recovery was stable or not in the absence of any therapy services.
After the school reopened, children included in the study participated in multisensory balance training with each child undergoing 45 min training per session and for about 2-3 sessions a week. During each training session, the child was given graded sensory inputs with different sensory altered conditions using visual, vestibular, and proprioceptive senses. All the children completed a total of 18 sessions over 2 months of practice period. If few sessions were missed out during this period, an extra 1 week time was given to match the number of sessions. The level of exercises was standardized based on the performance of an individual child and their GMFCS levels. All the exercise sessions were supervised by therapist and caregivers. Children were allowed to use their mobility aids and assistive devices during training sessions if required. The progression of multisensory training was made from sitting balance to standing balance and functional walking.
Multisensory training regime
Exercises in standing included those with eyes open and then closed emphasizing the proprioceptive training. Children were asked to sense the weight distribution on their soles; shift weight from side to side; forward and backward; move arms in different directions and march on the spot with and without therapist's/caregiver's guidance. Progression of these exercises in standing was done using a balance cushion, foam or trampoline. Children were asked to pay attention to weight distribution on the feet while walking on the surfaces which were uneven and with different textures [Figure 1].
Vestibular training and control of eye movements were administered in sitting and standing and are as follows, eyes open following a moving target with the head kept still; moving head in all directions while the eyes open and are kept still; eyes open and following head moving in all directions, and repeat with eyes closed; quick turning of the head with fixed gaze followed by eyes tracking the head movements. Reactive postural control strategies involved standing on a turning disc which is rotated randomly in both directions with eyes open and closed. Combined proprioceptive and vestibular training was performed while the therapist supported the child during walking and bouncing on a trampoline. Anticipatory postural control strategies in standing involved reaching for an object in different directions; catching and throwing a ball; the quickly right to left turning while keeping a balloon in the air.  For children those who cannot perform functional walking without manual assistance from therapists and caregivers, the exercise on turning disc and trampoline were discontinued.
The data were analyzed using (SPSS Inc.) SPSS version 16.0 and a level of significance was set at P < 0.05. Demographic variables such as age, gender, GMFCS level, height, weight, and body mass index, were reported with descriptive statistics. To check the normality of distribution among children a one-sample Kolmogorov-Smirnov test was done. The raw scores of all the components of BESTest were converted into percentages and were presented for analysis. Repeated measures ANOVA for BESTest was conducted to analyze the within-subject effect and time-subject effect.
| Results|| |
The study enrolled 17 children with cerebral palsy. Descriptive statistics of study children is shown in [Table 1]. Eleven children were in GMFCS level 2. There were two children each falling into GMFCS level 1 and 3 conditions. Majority of study children were with spastic diplegia (n = 7) and secondary quadriplegia (n = 6). Three children were hemiplegic cerebral palsy, and one was a dyskinetic child. Of 17 children included in the study, 7 had earlier been undergone tendo achilles release with or without hamstrings and adductor repair. Smirnov test showed a normal distribution of the study group and there are no outliers in the following data discussed in this section. Within-subject analysis showed no significant difference between the BESTest scores taken at baseline and preintervention in all the six components. However, there was a significant change observed between the scores taken at baseline and postintervention in all the components of BESTest.
There was no change in overall total BESTest score during run-in phase, but the change was 17% following multisensory-based balance training. The mean difference between baseline and preintervention (2 months run-in period) for all the components of BESTest was within 5 percentile change. This indicates that the recovery of balance control in the study children attained a plateau state and was not altered by any physical or social factors. Following the intervention, the most changes were seen in stability limits section (mean change of 29) followed by 28% change in sensory orientation component, 19% change in reactive postural response, and 17% in anticipatory postural adjustments. Of least, 10% and 13% changes were noticed for stability in gait component and biomechanical constraints of the BESTest, respectively. The change scores of all the components of BESTest during run-in phase and intervention period are presented in [Table 2] and [Figure 2].
|Figure 2: (a-f) Components of Balance Evaluation - Systems Test. (a) Biomechanical constraints. (b) Stability limits. (c) Anticipatory postural adjustment. (d) Reactive postural response. (e) Sensory orientation. (f) Stability in gait|
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|Table 2: Change scores for all the sections of BESTest between run-in and intervention periods (n=17) |
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| Discussion|| |
The aim of this study was to test the feasibility of multisensory training and its effects on balance control in school going children with cerebral palsy. Similar scores at baseline and preintervention levels show that there was no change in balance control ability for children with cerebral palsy in the absence of physiotherapy training during school vacation phase. Nevertheless, the significant changes observed in all the sections of BESTest following multisensory training indicates that such training regime was a feasible mode of practice and beneficial in improving balance control in school going children with cerebral palsy.
Recognizing the involvement of sensory deficits in school going hemiplegic children  and poor tactile discrimination ability in children with diplegia  necessitates that the repeated somatosensory inputs and sensory integration are important for balance control. Sensory orientation component showed the highest level of improvement among all the sections of BESTest following training. This could be attributed to the fact that repeated feedback from somatosensory modalities may be responsible for the improved balance control mechanism. This is in line with the findings of Goble et al.  who reported that children with hemiplegic cerebral palsy use proprioceptive feedback for goal-directed behavior. Westlake and Culham  supports this hypothesis too by reporting that administration of sensory-specific balance training in older adults enhanced the postural responses through proprioceptive reintegration for a short period of time. Ledebt et al.  suggested that balance training with visual feedback is useful to decrease the amplitude of postural sway during quiet standing and increases the amplitude of the voluntary weight shift during standing.
Another noteworthy change was seen instability limits which could be attributed to the self-initiated perturbations during training as it improves the recruitment of muscles from distal to proximal. Liao et al.  suggested that rhythmic weight shifts would improve walking performance in children with cerebral palsy. According to Woollacott et al.,  massed practice of reactive postural control training on the moveable platform could show an improved neuromuscular response during balance recovery.  In the current study, we noted a moderate improvement in anticipatory postural adjustments and reactive postural response which is in line with the findings of Liu et al.  They had suggested that posterior shift in the center of pressure during anticipatory postural adjustment is difficult for children with cerebral palsy and intervention to facilitate it may be beneficial.
Moderate change noted in the biomechanical constraints component of BESTest is in agreement with Woollacott and Crenna, who stated that children with cerebral palsy tend to develop atypical anthropometric changes.  Anthropometric changes with muscular stiffness across joints and the altered mechanical loading on the lower limbs for prolonged periods under static and dynamic conditions may limit their stability in gait. This in turn increases the passive stiffness in both contractile and noncontractile components of muscle-tendon unit, further leading to a crouched posture and gait in CP. ,,
We warrant caution to interpret the study results as this study had no control group and the gains at postintervention levels were not followed up. Furthermore, the study children were not from a homogenous group. We did not assess the severity of somatosensory deficits at the time of study enrollment. Future studies assessing the extent of sensory deficits in children with cerebral palsy may provide additional information about structuring multisensory exercise protocol. Another limitation is that lower limb muscular strength was not performed as many of study children had their tendon release surgeries done at some time point in their life. Assessment of muscular strength and daily functional activities in the future multisensory trial could further provide a value about their role on balance control.
| Conclusion|| |
We conclude that multisensory training is a feasible means of practice for school going children with cerebral palsy. The benefits on balance control improvement following the multisensory training emphasize that the sensory reeducation should not be overlooked and need be incorporated along with motor rehabilitation protocols in children with cerebral palsy. The future randomized clinical trial is recommended to affirm the statement.
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.
We are grateful to all children with cerebral palsy, their parents, Mr. Maxim, Head, Rehab Unit and Mrs. Subhashini, Physiotherapist, SSK, Bengaluru.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wingert JR, Burton H, Sinclair RJ, Brunstrom JE, Damiano DL. Joint-position sense and kinesthesia in cerebral palsy. Arch Phys Med Rehabil 2009;90:447-53.
Van Vulpen LF, De Groot S, Becher JG, De Wolf GS, Dallmeijer AJ. Feasibility and test-retest reliability of measuring lower-limb strength in young children with cerebral palsy. Eur J Phys Rehabil Med 2013;49:803-13.
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.
Woollacott MH, Burtner P, Jensen J, Jasiewicz J, Roncesvalles N, Sveistrup H. Development of postural responses during standing in healthy children and children with spastic diplegia. Neurosci Biobehav Rev 1998;22:583-9.
Liu WY, Zaino CA, McCoy SW. Anticipatory postural adjustments in children with cerebral palsy and children with typical development. Pediatr Phys Ther 2007;19:188-95.
Hoon AH Jr, Stashinko EE, Nagae LM, Lin DD, Keller J, Bastian A, et al.
Sensory and motor deficits in children with cerebral palsy born preterm correlate with diffusion tensor imaging abnormalities in thalamocortical pathways. Dev Med Child Neurol 2009;51:697-704.
Cooper J, Majnemer A, Rosenblatt B, Birnbaum R. The determination of sensory deficits in children with hemiplegic cerebral palsy. J Child Neurol 1995;10:300-9.
Saavedra S, Woollacott M, van Donkelaar P. Head stability during quiet sitting in children with cerebral palsy: Effect of vision and trunk support. Exp Brain Res 2010;201:13-23.
Liao HF, Jeng SF, Lai JS, Cheng CK, Hu MH. The relation between standing balance and walking function in children with spastic diplegic cerebral palsy. Dev Med Child Neurol 1997;39:106-12.
Opheim A, Jahnsen R, Olsson E, Stanghelle JK. Balance in relation to walking deterioration in adults with spastic bilateral cerebral palsy. Phys Ther 2012;92:279-88.
Ledebt A, Becher J, Kapper J, Rozendaalr RM, Bakker R, Leenders IC, et al.
Balance training with visual feedback in children with hemiplegic cerebral palsy: Effect on stance and gait. Motor Control 2005;9:459-68.
Papavasiliou AS. Management of motor problems in cerebral palsy: A critical update for the clinician. Eur J Paediatr Neurol 2009;13:387-96.
Bayouk JF, Boucher JP, Leroux A. Balance training following stroke: Effects of task-oriented exercises with and without altered sensory input. Int J Rehabil Res 2006;29:51-9.
Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther 2009;89:484-98.
Padgett PK, Jacobs JV, Kasser SL. Is the BESTest at its best? A suggested brief version based on interrater reliability, validity, internal consistency, and theoretical construct. Phys Ther 2012;92:1197-207.
Kristinsdottir EK, Baldursdottir B. Effect of multi-sensory balance training for unsteady elderly people: Pilot study of the "Reykjavik model". Disabil Rehabil 2014;36:1211-8.
Sanger TD, Kukke SN. Abnormalities of tactile sensory function in children with dystonic and diplegic cerebral palsy. J Child Neurol 2007;22:289-93.
Goble DJ, Hurvitz EA, Brown SH. Deficits in the ability to use proprioceptive feedback in children with hemiplegic cerebral palsy. Int J Rehabil Res 2009;32:267-9.
Westlake KP, Culham EG. Sensory-specific balance training in older adults: Effect on proprioceptive reintegration and cognitive demands. Phys Ther 2007;87:1274-83.
Shumway-Cook A, Hutchinson S, Kartin D, Price R, Woollacott M. Effect of balance training on recovery of stability in children with cerebral palsy. Dev Med Child Neurol 2003;45:591-602.
Woollacott MH, Crenna P. Postural control in standing and walking in children with cerebral palsy. In: Hadders-Algra M, Carlberg EB, editors. Postural Control: A Key Issue in Developmental Disorders. London: Wiley-Blackwell; 2008.
Kadhim M, Miller F. Crouch gait changes after planovalgus foot deformity correction in ambulatory children with cerebral palsy. Gait Posture 2014;39:793-8.
Kwak YH, Kim HW, Park KB. Muscle-tendon lengths according to sagittal knee kinematics in patients with cerebral palsy: Differences between recurvatum and crouch knee. J Pediatr Orthop B 2014;23:76-85.
[Figure 1], [Figure 2]
[Table 1], [Table 2]