Training postural control in children with cerebral palsy
University of Iceland, Faculty of Medicine
The Benefit Society of Children with Disabilities
Thorbjorg Gudlaugsdottir, PT, MSc
22
Contents
Cerebral Palsy - CP
Balance – Postural Control
Dynamic System Theory
Body Sway
Balance training
Equine Assisted Therapy
Training in a Rehabilitation Center
The study
Method, Instrumentation, Procedure
Results
Discussion
Conclusion
33
Cerebral Palsy - CP
Neurologic disorder
Deficits in movement
Deficient perception
Problems in postural control
Problems in postural control in sitting
Increased body sway
4
Postural control –
Dynamic System Theory
Musculoskeletal system:
Muscles / joints
Motor nerves
Perception
Vision
Somatosensory system
Vestibular system
Cognitive system
Organization of actions
Coordination of inputs from visual system, somatosensory system and vestibular system
55
Postural Control - Body Sway
Quiet stance → quiet dynamic
Small amounts of spontaneous postural sway
Back and forth over hips or ankles
From side to side.
Measure of functioning of the postural system
Little movement of Center of Pressure (CoP)
together with minimum velocity of CoP
6
Displacement and velocity of COP is more in children and old adults, than in young adults
Body-sway peaks at three years old
Postural control is mastered after puberty
Velocity of COP is almost the same in sitting and in standing
Displacement of COP is less in sitting than standing
(Chen et al 2007).
Postural control
Body Sway - Studies
Postural control
Fundamental for daily life activities
Problematic in children with CP
Various training methods
with beneficial results
Aim of the study
To compare equine-assisted
therapy and physiotherapy at a rehabilitation center when training postural control in sitting in two groups of
children with CP
9
Equine assisted therapy
Rhythmical movements
The spine of the horse – a moveable base
Facilitates postural control
Sitting position of the rider
Prevent unwanted synergies
Facilitates symmetry and extension of the trunk
Perception
Somatosensory system
Vestibular system
Vision
Heimild D. Riede 1986
9
(90-110/ min.)
Hippotherapy
Therapeutic Riding
10 10
Aim of the training
Better sitting balance
By increasing strength and coordination of
the postural muscles
Training
Twice a week
for total of 12 weeks
for 40 minutes.
.
11 11
Hypothesis
Balance training with
therapeutic riding leads to the same or even better results
than balance training in a
rehabilitation center when
training postural control and
sitting in children with CP
12 12
Methods - Subjects
Twenty children with CP
Criteria for participation
Born 1996-2004 (2,5-10,5 years)
Spastic CP
Gross Motor Function Classification II or III (GMFCS)
Ability to understand instructions
No orthopedic surgeries in the last 6 months
No Botox injections in muscles around the hips 3 months before the beginning of the research
No Botox injections in the hip area during the research period
Methods - Measurements
january february april mai
6 weeks 6 weeks 6 weeks
I Group A II Group A III IV
Measure ment
Therapeutic riding
Measure ment
Balance training
Measure ment
No
interve ntion
Measure ment
Group B Group B
START
Balance training
Question naire
Therapeutic riding
Question
naire END
14 14
Methods - Measurements
sEMG (KINE WORKS
CEMDD annex V)
FSA pressure-mat (Forced Sensitive Application, 3.0.)
Video recording
Questionnaire after
training intervention
15
Methods – Pressure-mat
Velocity of CoP (sm/s)
Displacement of CoP (cm2)
16 16
Methods - Questionnaire
Parents answered
Experience of the training periods
Change in quality of
sitting position
17
Methods – Data analysis
SPSS 15.0
t-test
Age of the children in the groups
Kolmogorov-Smirnov test
Non-parametric test for related groups
Friedman test
Looked at the changes of the whole group between assessment I, III and IV
Wilcoxon Signed Ranks
Attendance in the training
Changes after each training method
Changes of the whole group between assessment I and III as well as between III and IV
Questionnaire – changes between training methods
Descriptive analysis
Attendance in the training
Questionnaire
Significance level of p<0.05
18
Results - Subjects
Age in month s.
Mean age in mths
Sex
♀ ♂
GMFCS II : III
Spastic diplegic
Spastic hemipleg ic
Spastic paresis unspecifie d
Group
A 29-
130
77,9 5 : 5 9 : 1 7 1 2
Group
B 29-
90
51,3
*
3 : 7 8 : 2 6 1 3
*p=0,001 t-test
*p=0,008 Wilcoxon signed ranks
19
Results - Attending to the training
p=0,26
Mæting
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hestar Salur
Hópur A Hópur B
20
Results
Velocity of the CoP at start
0 1 2
29 29 32 33 34 35 38 40 55 78 79 83 85 88 90 94 114 130 Age in months
m/s
EMG – Data loss
•Impossible to use Centre of pressure
•Velocity ( sm/s)
•Descending due to higher age
•Radial displacement
•
Descending due to higher ageDisplacement of CoP at start
0 10 20 30 40 50 60 70 80
29 32 34 38 55 79 85 90 114
Age in months
cm2
0 1 2 3
START Horses A / Gym B Gym A / Horses B END
Group A Group B
21
Results- Velocity of the CoP (sm/s)
Friedmans I-III-IV p (velocity) =0,68
Wilcoxon I-III p(velocity)=0,10
Wilcoxon III-IV p (velocity) =0,68
22
Results
Radial displacement of the CoP (cm
2)
END After gym
After horses
12
10
8
6
4
2
0
34
HópurA, Flatarmálellipsu
START After gym After horses End
12
10
8
6
4
2
0
82
89
HópurB, Flatarmálellipsu
Friedman I-III-IV p(displacement)=0,25
Wilcoxon I-III p(displacement)=0,03
Wilcoxon III-IV p(displacement)=0,29
Group A * significant between I and II p=0,008 Group B
*
Connection of velocity and radial displacement
A START A After training B START B After training
Training in the GYM Therapy riding No specific training
Radial displacement Velocity
Results - Changes in the groups according to different training methods
Wilcoxon
p(velocity of CoP gym/horses) = 0,35
p(displacement of CoP gym/horses)=0,22
*
* p=0,008
Results - Questionnaire
Experience from the training
Every child was greatly satisfied after the training sessions in the therapeutic riding (p=0,006)
85% were very satisfied or satisfied after the training in the gym
10% were very unsatisfied or unsatisfied after training in the gym
Endurance, armrest and quality of sitting position
Insignificant difference between training methods
40-65% thought that the performance of the children was better or much better
35-60 % could not see any difference in the
performance of the children in the sitting position
25
Discussion – Velocity and radial displacement
No studies to compare
Age difference – development of the perception systems
New performance / training → increased body-sway
Older children move more to the limits of
stability
26
Discussion- Questionnaire and attendance
Training results
Experience of the training
Parents and children pleased
Horses more fun than gym
Good attendance
27 27
Conclusion
Not a significant difference between the training methods in terms of body-sway
Both training methods are effective when training postural control
More enthusiasm for therapeutic riding
No comparable results to compare therapeutic
riding and physical therapy at a rehabilitation
center
Final conclusion
Therapy riding is at least as good as conventional balance training in a
rehabilitation center
The children prefer it
Thanks
My instructor: Bjorg Gudjonsdottir
My coworker: Gudbjorg Eggertsdottir
Participants and parents
Sponsors
Rannsóknarsjóður HÍ
Æfingastöð SLF
Vísindasjóður FÍSÞ
Alcan
Stoð ehf
My family
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