Authors: Ehab Mohamed Abd El-Kafy, PhD Heba M. Youssr M. El-Basatiny, PhD

Cerebral Palsy

Affiliations: From the Department of Physical Therapy for Disturbances of Growth and Developmental Disorders in Children and Its Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt (EMAE-K, HMYME-B); and Department of Physical Therapy, Faculty of Applied Medical Sciences, Umm Al Qura University, Makkah, Saudi Arabia (EMAE-K).

Correspondence: All correspondence and requests for reprints should be addressed to: Ehab Mohamed Abd El-Kafy, Faculty of Physical Therapy, Cairo University, 7 Ahmed Elzaiat St., Ben Elsaryat, EI Dokki-Giza, Egypt 12612.

Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

0894-9115/14/9311-0938 American Journal of Physical Medicine & Rehabilitation Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000109

ORIGINAL RESEARCH ARTICLE

Effect of Postural Balance Training on Gait Parameters in Children with Cerebral Palsy ABSTRACT Abd El-Kafy EM, El-Basatiny HMYM: Effect of postural balance training on gait parameters in children with cerebral palsy. Am J Phys Med Rehabil 2014;93:938Y947.

Objective: The aim of this study was to evaluate the effect of dynamic bilateral postural stability on balance control and gait parameters in children with cerebral palsy.

Design: Thirty children with spastic diplegia (8Y10 yrs) were included in this study. The children were randomly assigned into two groups: control group A and study group B. The children in both groups received traditional physical therapy program, 2 hrs per day for group A and 1.5 hrs followed by 30 mins of dynamic postural stability training program using the Biodex Stability System for group B. The treatment frequency was three sessions per week for 8 consecutive weeks on two stability levels (7 and 8). The participating children received pretreatment and posttreatment assessments using the Biodex Stability System to evaluate the stability indices (anteroposterior, mediolateral, and overall) at the two stability levels (7 and 8) and three-dimensional motion analysis system (pro-reflex system) to evaluate the spatiotemporal parameters including step length, velocity, cycle time, stance, and swing phase percentage.

Results: The children in both groups showed significant improvements in the mean values of all measured variables after treatment indexed by a significant reduction in stability indices and improvement in gait parameters. The results also showed significant differences in all measured parameters in favor of group B, when compared with those in group A (P G 0.01).

Conclusions: Balance training on the Biodex Stability System could be a useful tool in conjunction with traditional physical therapy program for improving balance control and gait functions in children with spastic diplegic cerebral palsy. Key Words:

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Cerebral Palsy, Balance, Gait

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erebral palsy (CP) is a neurodevelopmental disorder caused by nonprogressive brain damage in fetal life or early infancy.1 It is well known that brain damage is associated with lack of coordination of voluntary muscles, restricted balance performance, gait deviations, and poor postural control of movement. Postural control is fundamental for the efficient performance of all activities of daily living.2 Because walking capabilities of subjects are the basic requirements for many activities of daily living, increased gait variability in children with CP certainly leads to difficulties in locomotion, play, and participation at home and in school.3 Children with CP showed a number of expected gait variations, specifically reduced speed and stride length, longer stance phases and decreased foot strike, and lift-off pitch angles.4 The major component of the gait disorder in these children is the deficits in balance and postural control.5 It has been proven that children with CP have larger postural sway than the typically developed children in static stance.6 Spastic diplegia is the most prevalent type of CP. It is characterized by a wide range of ambulatory outcomes.7 Children with diplegic-type CP have impaired motor control, which frequently leads to limitations in their mobility. As a result, the balance control and the corresponding walking functions are impacted.8 Optimization of walking ability is often a treatment goal for children with CP.9 Because a relation between constraints on balance control and walking limitations in children with CP has been established, increased efficiency of postural balance control may be necessary to facilitate their functional performance.10 Therefore, many researchers have suggested that balance perturbation intervention should be a crucial component of any regular rehabilitation program for these children. It is able to modify postural balance control and establish correct posture in the line of gravity.11 Two types of balance training have been studied in children with CP. One type is based on using a moving platform for repetitive stance perturbation to improve their stability recovery after an external perturbation.12 The second type of balance training aimed to improve the patients’ awareness about their postural sway by using visual feedback during unperturbed stance.13 Concomitantly, there are a number of tests for measuring balance performance and detecting posture deficits. The most commonly effective methods used in balance analysis laboratories is the use of a balance platform.2

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Measures of gait can also be used to assess balance after brain injuries. Among the many relevant measurements, spatiotemporal parameters are widely used in the clinical context. These quantitatively describe the main events of gait and therefore reflect the ability of the patient to fulfill the general requirements of gait, that is, the weight acceptance, the single limb support, and the swing limb advancement.14 Commonly used spatiotemporal parameters for assessing and analyzing gait in children with CP are stride length, step length, step time, step width, velocity, base of support, cadence, cycle duration, and single and double stance.15,16 Dynamic postural stability (DPS) can be quantified by the Biodex Stability System (BSS), which is a unique balance assessment and training device. It is designed to assess the neuromuscular control and to stimulate joint mechanoreceptors.10 The Biodex Balance device has high acceptable reliability. It measures the ability of the subject to control the platform’s angle of tilt, which is noted as a stability index.17 The objective of this study was to evaluate the effect of dynamic postural balance training using the BSS on improving spatiotemporal parameters of gait and stability index scores in children with spastic diplegic CP.

METHODS Participants The study was approved by the Ethics Review Committee of the faculty of physical therapy, Cairo University, and parents signed a consent form authorizing the child’s participation. The participating children were recruited from the pediatrics outpatient clinic of the Faculty of Physical Therapy & Al Kaser Al Eini Hospital, Cairo University. The study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 1983. Fifty-seven children with spastic diplegic CP were initially screened and assessed to determine age, diagnosis, and inclusion and exclusion criteria. The inclusion criteria were as follows: the participating children had a confirmed diagnosis of spastic diplegic CP in the prenatal, perinatal, or postnatal period confirmed by magnetic resonance images obtained from medical records or personal physicians. Their ages ranged from 8 to 10 yrs in both sexes. Their heights were more than 100 cm and weights were more than 20 kg, which are the lower limits of height and weight needed by the BSS. The degree of spasticity in involved lower extremities according to the Modified Ashworth Scale Effect of Balance on Gait Parameters

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ranged between grades 1, 1+, and 2. The levels of gross motor function were between levels I and II according to the Gross Motor Function Classification System. They had balance problems as confirmed by the tilt board balance test, which was performed under two conditions, tilting boardYeyes open and tilting boardYeyes closed. The child was considered to have balance problems when the mean sums of the maximum degrees of tilt in four directions (anterior and posterior as well as medial and lateral) done with both eyes open and eyes closed were less than 32.1 and 25.8, respectively. The children were cognitively competent and able to understand and follow instructions. There were no serious or recurring medical complications according to the medical report signed by their physician. The exclusion criteria were as follows: (1) any orthopedic conditions or fixed deformities that interfere with lower limb functions, (2) perceptual deficits or seizures, (3) surgical interference for the lower limb, and (4) received botulinum toxin in the lower extremity musculature during the past 6 mos or received medication within 3 mos of pretreatment testing.

Study Design Among the screened children, only 33 fulfilled the aforementioned criteria, of which 3 children apologized for not being able to continue the study because of transportation difficulties. The remaining 30 children were randomly distributed into two groups (control group A and study group B), 15 children each. The demographic characteristics of the participating children are presented in Table 1. Randomization process was run using the Statistical TABLE 1 Demographic characteristics of participants Variables Age, mean (SD), yrs Sex (boys/girls) Height, cm Weight, kg Spasticity grades 1 1+ 2 GMFCS level I II

Group A (n = 15)

Group B (n = 15)

8.7 (0.71) 8 boys 7 girls 121.9 (1.81) 26.4 (1.6)

8.9 (0.77) 5 boys 10 girls 120.7 (1.87) 27.1 (2.8)

6 7 2

3 9 3

6 9

7 8

Spasticity grades according to the Modified Ashworth Scale. GMFCS, Gross Motor Function Classification System.

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FIGURE 1 Biodex Stability System. Package for the Social Sciences computer program (version 16 windows).

Procedures for Evaluation Dynamic Balance Measurements (BSS) The BSS (Biodex Medical Systems, Shirley, NY) was used to quantify bilateral standing balance.18 The system consists of support handle, platform, and LCD display and printer (Fig. 1). It has eight levels of dynamic platform tilt (level 8 is the most stable whereas level 1 is the least stable). The LCD display screen, located at eye level, provides visual feedback via a circular grid that visually shows a cursor tracing of the subject’s stability performance. All children in both groups received an explanatory session about the test steps before the evaluative procedure. Each child was asked to stand on the center of the locked platform with two-legged stance. Safety support rails and biofeedback display were adjusted for each child to ensure comfort and safety. The display was adjusted so that the child could look straight at it. Each child was instructed to do his/her best to maintain the cursor in the middle of bull’s-eye on the screen as long as possible during the test trial. All children were tested on two stability levels (8 and 7) with open eyes and without hand support. For each level of stability measured, three trials were performed; the duration of each trial was 20 secs, and the mean was calculated. Every child was assessed before and immediately after the treatment program. The DPS test includes measurement of the following indices: overall stability index, anteroposterior (A/P) index, and mediolateral (M/L) index, which

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TABLE 2 Traditional physical therapy program The Order of Training Exercises

Duration

1. Stretching exercises for both hip flexors and adductors, knee flexors, and ankle plantar flexors 2. Reflex inhibiting patterns for both lower limbs 3. Strengthening exercises for trunk and both lower limb muscles Rest 4. Gait training exercises Rest 5. Balance training exercises in all directions (A/P and M/L) from standing position using wooden balance board

15 mins

represent the child’s ability to control his/her balance in all directions. High values of the indices represent a lot of platform movement, less stability, and difficulty in balance control. On the other hand, lower values of the indices are indicative of a better balance performance and control.

15 mins 20 mins 5 mins 30 mins 5 mins 30 mins

interface. Two unsaved trials for familiarizing the child with the system were done before the actual recording trial was captured. The following spatial and temporal kinematic gait parameters were calculated: step length for feet, velocity, cycle time, and stance and swing phase percentage.

Spatiotemporal Gait Parameter Measurements Gait parameter evaluation was carried out for every child before and immediately after the treatment by using the pro-reflex systems (motion analysis system). It consists of an 8-mYlong wooden walkway, a three-dimensional infrared camera system with six cameras arranged equally on both sides of the walkway, and a personal computer with the Q-Trace software installed to analyze the motion pattern. Reflective markers, each of 9 mm in diameter, were enclosed in the pro-reflex system. They were suitable for optimizing the focus setting of the camera. Twelve markers, in this study, were fixed at the selected bony prominences by a sticky material. Before starting gait analysis procedure, the camera system was calibrated by a reference structure. The child was prepared for evaluation by attaching the 12 reflective dots (markers) bilaterally on the following landmarks: superior border of the patella, laterally at the knee joint line, tibial tuberosity, lateral malleolus, heel posterior of the calcaneus, and between the second and third metatarsal heads.19 Then, the child was asked to walk at the walkway (8 m) once, while being videotaped. The marker displacements were analyzed with the Q-gait

Treatment Protocol The control group A received regular neurodevelopmental physical therapy program, as shown in Table 2. The study group B received the same program as applied for group A, except for the performance of balance training exercises in the form of DPS using the BSS, as shown in Table 3. This balance regimen trained the child’s ability to control the platform angle of tilt. The children in both groups received the training program for 2 hrs, three sessions per week, for 8 successive weeks.

The DPS Training Protocol The training task of the program required the children in group B to control their body movement and balance to maintain the cursor on the center of the circular grid as much as possible throughout the training sessions. The training was conducted while the child was in standing position, barefoot, without any hand support, and in the same feet position used during every evaluating and training session. Every participating child in group B trained on stability level 8 for 4 wks followed by training on stability level 7 during the next 4 wks.

TABLE 3 DPS training protocol Weeks

SL First Trial

First 4 wks SL 8 Second 4 wks SL 7

2 mins 2 mins

Rest Second Trial Rest Third Trial Rest Fourth Trial Rest Fifth Trial 3 mins 3 mins

2 mins 2 mins

4 mins 4 mins

3 mins 3 mins

3 mins 3 mins

4 mins 4 mins

4 mins 4 mins

5 mins 5 mins

SL, stability level.

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TABLE 4 Comparison between the mean values of the DPS indices before and immediately after treatment in both control group (A) and study group (B) at stability levels 8 and 7 SI Overall SI

Stability level 8 Stability level 7

A/P SI

Stability level 8 Stability level 7

M/L SI

Stability level 8 Stability level 7

Pretreatment, Mean (SD)

Posttreatment, Mean (SD)

t

P

1.83 (0.45) 1.82 (0.34) 5.36 (0.77) 5.18 (0.59) 1.33 (0.35) 1.22 (0.47) 3.7 (0.96) 3.51 (0.55) 1.39 (0.36) 1.34 (0.35) 3.85 (0.79) 3.59 (0.75)

1.7 (0.32) 1.23 (0.88) 4.96 (0.58) 3.07 (0.82) 1.23 (0.33) 0.95 (0.08) 3.33 (0.98) 2.23 (0.5) 1.31 (0.33) 0.98 (0.16) 3.12 (0.71) 2.15 (0.49)

2.83 3.44 3.05 16.76 3.84 2.49 2.42 10.43 4.08 5.42 8.28 14.28

0.002a 0.001a 0.001a 0.000a 0.001a 0.002a 0.002a 0.000a 0.001a 0.001a 0.000a 0.000a

GA GB GA GB GA GB GA GB GA GB GA GB

a

Statistically significant. GA, group A; GB, group B; SI, stability index.

Statistical Analysis The results were expressed as mean (standard deviation). For all measured parameters, comparison of assessments before and immediately after treatment in each group (A or B) was performed using paired t test, whereas the comparison of assessments between both groups before and immediately after treatment was carried out using an unpaired t test. The Statistical Package for the Social Sciences computer program version 16.00 was used for data analysis. P value of less than 0.01 was considered to be statistically significant.

RESULTS Thirty children normally and randomly distributed into two groups participated in this study. The results of this study regarding the mean values of the three parameters measured in the DPS test,

including overall stability index, A/P stability index, and M/L stability index, at levels (7 and 8) of stability from pretreatment to posttreatment showed significant lowering of these values at both levels in both groups (A and B) as shown in Table 4 (P G 0.01). The lowering values recorded for group B were better than that registered for group A. The same significant improvements from pretreatment to posttreatment were recorded in both groups in spatiotemporal gait parameters (including step length, velocity, cycle time, and stance and swing phase percentage), as elucidated in Table 5, with better mean values recorded for group B than for group A (P G 0.01). Comparing the results of all measured variables (stability indices and spatiotemporal gait parameters) between both groups in pretreatment indicated no significant differences, whereas their comparison after treatment as shown in Tables 6 and 7 and

TABLE 5 Comparison between the mean values of the kinematics gait parameters (spatiotemporal) before and immediately after treatment in both control group (A) and study group (B) Gait Parameters Right step length, cm Left step length, cm Velocity, m/sec Cycle time, secs Stance phase, % Swing phase, % a

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Group A Group B Group A Group B Group A Group B Group A Group B Group A Group B Group A Group B

Pretreatment, Mean (SD)

Posttreatment, Mean (SD)

t

P

0.28 (0.08) 0.31 (0.07) 0.30 (0.07) 0.32 (0.04) 0.36 (0.09) 0.33 (0.09) 0.36 (0.05) 0.33 (0.10) 72.6 (1.7) 71.37 (1.6) 27.40 (1.3) 28.63 (1.8)

0.34 (0.72) 0.40 (0.07) 0.33 (0.07) 0.39 (0.04) 0.53 (0.10) 0.72 (0.14) 0.49 (0.07) 0.63 (0.12) 68.6 (1.3) 62.47 (4.5) 31.40 (1.7) 37.53 (1.5)

j2.78 j16.07 j4.26 j9.37 j6.99 j9.64 j7.14 j7.46 7.14 7.64 j7.75 j20.74

0.005a 0.000a 0.001a 0.000a 0.000a 0.000a 0.000a 0.000a 0.000a 0.000a 0.000a 0.000a

Statistically significant.

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TABLE 6 Comparison between the mean values of the DPS indices before and immediately after treatment between both control group (A) and study group (B) at stability levels 8 and 7 SI Overall SI

Stability level 8 Stability level 7

A/P SI

Stability level 8 Stability level 7

M/L SI

Stability level 8 Stability level 7

Group A, Mean (SD)

Group B, Mean (SD)

t

P

1.83 (0.45) 1.76 (0.37) 5.36 (0.77) 4.96 (0.58) 1.33 (0.35) 1.23 (0.34) 3.72 (0.96) 3.45 (0.93) 1.39 (0.36) 1.31 (0.33) 3.85 (0.79) 3.12 (0.71)

1.82 (0.34) 1.23 (0.88) 5.18 (0.59) 3.07 (0.82) 1.22 (0.47) 0.95 (0.08) 3.51 (0.55) 2.23 (0.5) 1.34 (0.35) 0.98 (0.16) 3.59 (0.75) 2.15 (0.49)

0.09 2.17 0.73 7.29 0.75 3.13 0.75 4.49 0.40 3.45 0.89 4.38

0.93 0.003a 0.47 0.000a 0.46 0.001a 0.46 0.001a 0.69 0.001a 0.38 0.001a

Pretreatment Posttreatment Pretreatment Posttreatment Pretreatment Posttreatment Pretreatment Posttreatment Pretreatment Posttreatment Pretreatment Posttreatment

a Statistically significant. SI, stability index.

Figures 2 to 5 demonstrated significant differences in favor of the study group B (P G 0.01).

DISCUSSION Posture balance control is fundamental for efficient performance of all activities of daily living. Balance control deficit in children with CP, of course, could influence their abilities to consistently perform motor tasks, reduce their self-confidence, and make them unable to keep up with their peer group. In this study, the effects of dynamic postural balance training, using the BSS, on scores of stability indices and spatiotemporal parameters of gait were examined in children with spastic diplegic CP. The findings of this study showed a remarkable improvement in postural balance control in children participating in group B after completion of the balance training program than those in group A.

This was made clear by the significant lowering in stability indices registered immediately after treatment for group B than group A. The balance performance progression was functionally reflected on spatiotemporal gait parameters, which significantly improved in both groups after treatment, with better mean values recorded for group B. The improvement in balance control and walking abilities in all participating children in both groups might be a result of the provision of sufficient opportunities to practice balance training because continuous and repetitive training of motor skills is essential for gaining and perfecting of motor functions. The significant improvements in all measured variables recorded for the children in group B when compared with those in group A might be a direct consequence of application of the balance training program using the BSS. It was clear that the learning effect and habituation of the children in group B with

TABLE 7 Comparison between the mean values of the kinematics gait parameters (spatiotemporal) before and immediately after treatment between both control group (A) and study group (B) Gait Parameters Right step length, cm Left step length, cm Velocity, m/sec Cycle time, secs Stance phase, % Swing phase, % a

Pretreatment Posttreatment Pretreatment Posttreatment Pretreatment Posttreatment Pretreatment Posttreatment Pretreatment Posttreatment Pretreatment Posttreatment

Group A, Mean (SD)

Group B, Mean (SD)

t

P

0.28 (0.08) 0.34 (0.07) 0.30 (0.07) 0.33 (0.07) 0.36 (0.09) 0.53 (0.10) 0.36 (0.05) 0.49 (0.07) 72.6 (1.7) 68.60 (1.3) 27.40 (1.3) 31.40 (1.7)

0.31 (0.07) 0.40 (0.07) 0.32 (0.04) 0.39 (0.04) 0.33 (0.09) 0.72 (0.14) 0.33 (0.1) 0.63 (0.12) 71.37 (1.6) 62.47 (4.5) 28.60 (1.8) 37.53 (1.5)

j1.23 j2.35 j1.12 j3.03 0.98 j4.10 1.12 j3.79 1.31 5.17 j1.88 j10.66

0.23 0.003a 0.27 0.005a 0.34 0.000a 0.28 0.001a 0.20 0.000a 0.07 0.000a

Statistically significant.

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FIGURE 2 Comparison between the posttreatment mean values of the stability indices (SIs) for control group (A) and study group (B) at stability level 8.

the posttreatment DPS test, which they already trained on in the rehabilitation program, enabled them to gain more balance control and improvements in gait parameters. This was not available to the children in group A, who were trained on another balance program. These recorded improvements might be attributed to the improvement in the spatial and temporal aspects of postural muscles response during the recovery of stability after an unexpected perturbation. This includes faster activation of muscle contraction, which allows children with spastic diplegia to recover stability faster instead of delayed onset of muscle activity,20 in addition to better sequencing within a muscle synergy and emergence of distal to proximal muscle sequence unlike proximal to distal muscle activation pattern in these children.21 The reason for significant improvement in the A/P index after treatment as proposed by Runge et al.22 and Chen and Woollacott23 might be the earlier activity or response of the gastrocnemius muscle, which made the center of mass not move far away from the base of support, keeping the center of pressure near the middle, producing small amplitude of center of pressure motion, decreasing the child’s postural sway, and minimizing the time and force needed for balance restoration to achieve

quiet stance and balance control. The better sequencing and coordinated action of the hip abductors and adductors might be the cause of the significant improvement in M/L stability index recorded after treatment as documented by De Graaf-Peters et al.24 Another possible explanation for the better improvement of postural balance control after treatment in the children included in group B might be the increment of their abilities in modulating the amplitude of muscle activity (increased amplitude of agonist and decreased amplitude of antagonist) than reducing the abnormal coactivation. This strategy did not target specific muscle but improved the overall efficiency of balance recovery. Improving the ability to modulate the amplitude in these children could have resulted from practicing balance training on different levels of stability.10,20,21 These results may be also attributed to the effect of postural balance control training routine using the BSS on improving the agonist/antagonist relationship of the lower limb muscles through loading and unloading (joints distraction and/or approximation), resulting in improvement of weight-bearing activities through alteration of the proprioceptive sense. The results of this study agree with Stillman,25 who reported that proprioceptive awareness of postures

FIGURE 3 Comparison between the posttreatment mean values of the stability indices (SIs) for control group (A) and study group (B) at stability level 7.

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FIGURE 4 Comparison between the posttreatment mean values of spatiotemporal gait parameters (step length, velocity, and cycle time) for control group (A) and study group (B). LT indicates left; RT, right.

and movements is most required during the learning of new skills. Westcott et al.26 reported that children with CP at 7Y10 yrs of age begin to use somatosensory information appropriately to maintain and restore balance because they demonstrate balance defect. They are also able to resolve a sensory conflict and appropriately use the vestibular system as a reference. Accordingly, they recommended the importance of enhancement of proprioceptive awareness for these children at this age group. The positive and leading gait parameter results recorded for group B than those for group A were most probably caused by the improvement in balance capabilities gained by the children participating in this group. Damiano and Abel27 stated that temporal-distance parameters are more sensitive indicators of the degree of motor and balance involvement in CP when compared with singlejoint kinematics. According to Liao et al.,28 balance and locomotor abilities are positively correlated in children with spastic diplegia. They added that these children had a decreased rhythmic shifting ability when compared with children without CP, and this ability was correlated with walking function. Chang et al.29 proved that children with spastic diplegic CP walk

with reduced walking speed and stride length and increased stride time and step width, indicating reduced gait efficiency. In addition, Katz-Leurer et al.30 found a significant linear inverse correlation between balance performance and step length variability among children with traumatic brain injury. Ambulatory children after severe traumatic brain injury had decreased gait speed when compared with agematched healthy controls. The improvement in gait parameters achieved in this study agrees with Ledebt et al.,13 who concluded that, after balance training, the children with spastic hemiplegia improved their performances on the tasks that were trained, by reducing the amplitude of postural sway and enlarging the area of possible weight shift without making a step or fall. In addition, the walking pattern became more symmetric after the training. The results of this study suggested that clinicians should consider balance training during rehabilitation of children with CP. It should be included in combination with regular treatment. The results also recommended using the BSS as an efficient balance trainer system, with the concentration on PDS training program for improving balance performance in these children.

FIGURE 5 Comparison between the posttreatment mean values of spatiotemporal gait parameters (stance phase percentage and swing phase percentage) for control group (A) and study group (B). www.ajpmr.com

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There are some limitations of this study, one of them being the lack of control of the children’s activities outside the training sessions. The lack of follow-up for the children in both groups several months after training to evaluate the long-lasting effect of balance training might be considered as another limitation of this study. Future work needs to target different types of CP, different age intervals, and a large sample of children with CP to provide more generalization. More researches evaluating the effects of different balance training programs on gait parameters in different types of CP should be run to improve gait performance in these children. Finally, further studies are needed to determine the effectiveness of balance training on development and enhancement of different motor skills performance other than gait functions.

CONCLUSIONS DPS training, using different levels of stability on the BSS, in conjunction with neurodevelopmental physical therapy program, is effective in improving balance and gait abilities in children with spastic diplegic CP. ACKNOWLEDGMENTS

The authors thank the children, parents, and their colleagues who volunteered for their contribution in the evaluation and intervention phases. REFERENCES 1. Kothari R, Singh R, Singh S, et al: Neurophysiologic findings in children with spastic cerebral palsy. J Pediatr Neurosci 2010;5:12Y7 2. Kazon S, Grecco LAC, Pasini H et al: Static balance and function in children with cerebral palsy submitted to neuromuscular block and neuromuscular electrical stimulation: Study protocol for prospective, randomized, controlled trial. BMC Pediatr 2012; 12:53 3. Wren TA, Gorton GE III, Ounpuu S, et al: Efficacy of clinical gait analysis: A systematic review. Gait Posture 2011;34:149Y53 4. Bre´gou Bourgeois A, Mariani B, Aminian K, et al: Spatio-temporal gait analysis in children with cerebral palsy using, foot-worn inertial sensors. Gait Posture 2014;39:436Y42

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Effect of postural balance training on gait parameters in children with cerebral palsy.

The aim of this study was to evaluate the effect of dynamic bilateral postural stability on balance control and gait parameters in children with cereb...
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