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doi:10.1111/jpc.12867
REVIEW ARTICLE
Physical therapy management for balance deficits in children with hearing impairments: A systematic review Romita Fernandes, Shalini Hariprasad and Vijaya K Kumar Physiotherapy, Kasturba Medical College, Manipal University, Mangalore, India
Abstract: Childhood hearing impairment is a significant problem, associated with long-term academic, communicative and physical impairments. Studies have shown that children with hearing loss also present with balance and/or vestibular deficits along with complain of frequent falls. Various interventions have been studied to improvise postural control and balance in these children on different outcome measures. This review will provide the existing evidence on interventions to improve vestibular and/or balance functions. Three trials met our study criteria with PEDro score ≥6, and data were extracted, entered by two independent review authors. Though there was variability with regard to the focus and intensity of the intervention, subject characteristics and in outcome measures, vestibular rehabilitation has a positive influence on functional independence. Heterogeneity in the studies limits the comparisons of intervention programmes. We conclude that there was considerable evidence for a positive effect on balance outcomes among the hearing-impaired population with vestibular deficits. Further investigations of high-quality studies are needed to determine to compare interventions for improving vestibular deficits in hearing-impaired children. Key words:
deafness; exercise programme; hearing-impaired children; physical therapy; rehabilitation; sensorineural hearing impairment.
Hearing impairment is a major disability, leading individuals with such impairment to be handicapped. Childhood hearing impairment is a significant problem because it is associated with long-term developmental difficulties including language skills, communication skills, social abilities and motor development, for instance.1 According to 2005 estimates of the WHO, 278 million people world-wide have disabling hearing impairment, that is, moderate-to-profound hearing loss in both ears (i.e. >41 dB hearing loss).2 Hearing loss is the second most common cause of years lived with disability (YLD) accounting for 4.7% of the total YLD. The problem of deafness is disproportionately high in Southeast Asia with a prevalence ranging from 4.6% to 8.8%.3 The prevalence of moderate to profound hearing loss in children, including sensorineural hearing loss (SNHL) and conductive hearing loss, is one to six of 1000, of which 10% have hearing levels that fall in the profound range.4 Population-based surveys in 2003 in India using the WHO protocol estimated the
Key Points 1 Balance deficits in hearing impaired children. 2 Role of physical therapy in hearing impaired balance rehabilitation. 3 Currently, vestibular rehabilitation has a positive effect on balance outcomes. Correspondence: Mr Vijaya K Kumar, Physiotherapy, Kasturba Medical College, Manipal University, Mangalore 575001, India. Fax: 0824-2421140; email: [email protected] Conflict of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Accepted for publication 29 January 2015.
prevalence of hearing impairment at 6.3% or approximately 63 million people who suffered from significant auditory loss. The estimated prevalence of childhood onset deafness is found to be 2%.3 Several studies have shown that hearing-impaired (HI) children display motor deficits and more specifically balance deficits in the postural control.5–7 Postural stability is the integration of the visual, vestibular and somatosensory information required by the central nervous system to generate motor responses that keep the body in balance.8 The mature vestibular system contributes by maintaining visual stabilisation, neck stabilisation and also the orientation of the body in space and contributes to the postural tone necessary for the acquisition of motor developmental milestones.9 As the vestibular system and inner ear are closely associated with each other anatomically, either may be susceptible to the same noxious or developmental factors, justifying concomitant vestibular loss in HI children be it congenital or acquired.10–12 Published reports found vestibular dysfunction in approximately 30–70% of HI children with little evidence for vestibular impairment being proportional to HI.10–13 According to American speech language hearing association, there are three basic types of hearing loss: conductive hearing loss, SNHL and mixed hearing loss. SNHL is the most common type of permanent hearing impairment.14 Also, vestibular test abnormalities are more commonly associated with profound SNHL, than with acquired deafness, and some syndromes associated with deafness.15 In a cross-sectional study carried out by Cushing et al., 40 children with SNHL were investigated. It was found that 50% had an abnormality in horizontal semi-circular canal function, 38% had a dysfunction in higher frequency canal function and 40% had abnormalities of saccular function.6 The mature vestibular system generates three motor reflexes: the vestibular–ocular reflex (VOR) responsible for visual
Journal of Paediatrics and Child Health 51 (2015) 753–758 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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stabilisation, the vestibular–collic reflex (VCR) responsible for neck stabilisation and the vestibular–spinal reflex (VSR), which maintains the orientation of the body in space and contributes to the postural tone necessary for the acquisition of motor developmental milestones.16 To evaluate the VOR, traditional techniques like caloric and rotatory chair testing can examine horizontal semi-circular canal and superior vestibular nerve function. The VCR can be evaluated by the vestibular evoked myogenic potential test, in which a loud auditory stimulus induces an ipsilateral inhibition of the tonic neck muscle activity recorded on electromyography.9,16 Finally, for evaluating the VSR, posturography and balance tests enable evaluating the result of the complex interaction between cortical control of lower motor centres through pyramidal and extrapyramidal tracts, vestibular influences through the medial and lateral vestibular–spinal tracts, and the reticulospinal tract.9 A review by Rajendran and Roy indicated that the following assessment tools are frequently used in studies carried out on HI children to assess motor deficits: Bruininks-Osretsky test of Motor Proficiency, Pediatric Balance Scale, Test of Gross Motor Development, Timed Up and Go test, Peabody Developmental Motor Scale, Posturography Sensory Conditions testing, Force Platform, Movement Assessment Battery for Children, Körperkoordinations Test für Kinder, One Leg Standing test, Children Activity Scales for Teachers, Balance subset of Southern California Sensory Integration tests and Timed Static balance test.17 It is necessary to intervene vestibular issues in HI children in order to provide them with a better quality of life (QOL).18–20 Although cochlear implants are commonly provided to HI children,21 various rehabilitation techniques have been practised including a vestibular programme, which further includes visual training with and without head movement, gait training with varying base of support size and surface compliance, goaloriented movement tasks,22 eye hand co-ordination, general co-ordination activities, visual motor training, balance training emphasising visual and somatosensory awareness,23 a 15-min static balance exercise programme and24 vestibular-specific neuromuscular training.25 In recent years, few trials have been conducted on physical therapy management for balance impairment in children with hearing loss. Since there is no systematic review of physical therapy management techniques for balance impairment in children with hearing loss, the primary objective of our systematic review was to identify various management techniques used in clinical practice for balance impairment in children with hearing loss. The secondary objective is to determine the efficacy of these interventions to be implemented in clinical practice.
Key words HI children, deafness, sensorineural hearing impairment, children, exercise programme, rehabilitation, physical therapy, balance deficits, vestibular impairments, vestibular rehabilitation, motor deficits and gross motor delay. The titles and/or abstracts of these citations were reviewed to identify papers specifically detailing physical therapy rehabilitation for balance impairment in children with hearing loss. Additional articles were located by manually searching the reference lists of identified articles and directly contacting researchers actively publishing in the area.
Selection criteria Full-text randomised controlled trials (RCTs) or quasi-RCTs with PEDro score of 6/10 or more: The search was limited to studies published in English and trials that were carried out on human subjects. The study required description of the study population, the impairment, the assessment tools and details of physical therapy management used. The age of the population considered in the trials was up to 13 years of age. If an article failed to provide any of the above measures, it was removed from the review. Trials addressing deficits other than balance and with a level of evidence less than 2b based on the Sackett’s classification system26 were not included. Also excluded were those involving subjects from the adult population.
Quality assessment Once all full-text inclusion articles were acquired, each was assessed independently by two authors for quality using the PEDro scale.27
Results Of 346 studies initially identified through the database searches and 12 studies identified through hand-searching of references and searching databases using key words, only 61 studies were found to be potentially relevant based on their citations using the search strategies outlined earlier. When their abstracts and available full texts were screened, 58 were excluded as they turned out either not to meet the inclusion criteria or not to be of pre-defined quality (PEDro). The forementioned flowchart (Fig. 1) gives an overview of the selection process. The remaining three studies on effect of vestibular intervention in HI children met the inclusion criteria and underwent the data extraction and critical appraisal process.
Overview of included papers
Methods Search strategy Relevant studies of physical therapy management techniques for balance impairment in HI children from 1993 to 2013 were obtained through an extensive computerised search of the following bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, Google Scholar, MEDLINE plus, CINAHL, EBSCO and PEDro. 754
All the three papers, included studies used samples exclusively with hearing impairment. All the trials included a very small sample size (5–25 in each group), that is, total of 31 children in the intervention group and 21 in the control group. The proportion of female to male participants across studies was relatively even. The age ranges of samples were detailed in all the studies. Inclusion/exclusion criteria were provided, and clear protocols were described or referenced in all studies. All studies also provided information on their participants’ severity of HI.
Journal of Paediatrics and Child Health 51 (2015) 753–758 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Total number of articles (n = 358)
Case control studies, Case series, Case reports, Studies on adult population, Animal studies, All languages
Number of potential articles based on abstract and by pre-defined quality (n = 61)
Total number of articles included in the review (n =3)
Fig. 1
Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, Google Scholar, MEDLINE plus, CINAHL, PEDro and EBSCO (1980 to October 2013) based on the keywords
Randomised or quasi-randomised controlled trials or reviews pertaining to paediatric population
Flow chart of the review process.
The sample size, outcome measures, interventions, statistical values and the results of all the studies reviewed are summarised in Table 1.
Discussion We are the first to write a review on the effects of vestibular rehabilitation on balance deficits in HI children with or without developmental motor delay. However, others have reviewed the prevalence of balance and motor deficits and also the frequently used tools to assess the same in HI children.10–12,14,15,17–19 Results from this present review indicate that we have moved a little ahead, by focusing on interventions. During the search strategy, the first retrieved trial was by Effgen, which was the first retrievable literature available to intervene balance in HI children. This controlled trial did not show significant improvement on outcome measures but concluded that improvement in their functions.22 Later, a similar work was done by Lewis et al., and this trial also did not produce any significant difference even on subjective measures of 16 different balance tests in various dynamic positions.24 However, these studies were not included as a part of the review, as inclusion was only after 1985. There was a paucity of literature addressing these areas for more than 15 years following these studies. However, the last decade shows a few studies in the area. In the following sections, we shall point out the direction of progress. However, we will first discuss some methodological issues.
Differences among the studies In spite of some broad agreement between authors, there were differences among different studies. The outcome measures employed in different studies were different, but the last two studies in chronological order used Test for Gross Motor Development (TGMD).23,25 It was one of the tools commonly used to assess gross motor skills among HI children, but psychometric properties were not tested in this population.28 Assessment tools used to test balance were also heterogeneous in nature and not found to be reliable for HI population; however, they were all standard measures to assess balance in the general population.17,28
Similarities among the studies All the studies had a very small sample size of not more than 25, which was one of the major limitations of the study. HI children included in the trials were all of a similar age group namely between 6 and 11 years of age except a study from Rine et al included children age from 4.8 to 7.4 years. Samples were recruited from schools for the deaf, and the details about the regular medication and rehabilitative programmes, other than physical exercise, were not mentioned. All the studies lacked blinding in terms of therapist, assessor, subjects and allocation concealment thereby reducing the quality of the study. This being a major limitation was also pointed out by respective authors of the trials. All the HI children included in all the trials had the SNHL type of hearing loss in the severe to profound range, and one study also included subjects with cochlear implants.21,22,24,25
Main Findings from Reviewed Papers Rine et al. had used PDMS as an outcome measure to assess motor skills. It was tested for the HI population and for an age group higher than 7 years with ICC of 0.91 for intra-rater reliability measured between that age group and the HI population.21 However, the outcome measure for balance, posturography, was not tested. The study population was of a lesser age group when compared with others, and the author states it to be the probable critical period for the development of balance skills and to intervention for the same.21,29 Evidence shows a similar picture namely that the age range of 3–5 years is the most critical period.29,30 In his study, the control group was provided intervention similar to the intervention group after the post-test data were taken following placebo intervention. The final test data showed a significant improvement as well. Individual data pertaining to the results of the placebo group are not provided, only the merged data of all the subjects post intervention.21 In one reviewed paper, Rajendran et al.23, PedQL 4.0 was one of the outcome measures that was used rarely among HI children.21,31,32 Though it is found to be reliable in the paediatric patient population, similar evidence specific to HI children is not retrievable.17,18,28 Rajendran and Roy have earlier observed QOL
Journal of Paediatrics and Child Health 51 (2015) 753–758 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
755
756
10
10
11
11
10
–
No intervention For 12 weeks
30 min/day, 3 days/week language development
C
C
I
Intervention
No. of subjects
45 min: eye–hand and general co-ordination, visual motor training, balance training For 12 weeks
45 min, three times/week Eye–hand co-ordination, balance re- training, fundamental motor skills For 12 weeks
Balance training
10 min each Eye–hand General co-ordination Visuo-motor
I
(84.9–132.1)
101.5 (62–128) 15.5 (13.0–20.0) 72 (55–81) 95.9 (81.6–131.2)
ML sway-EC PRT: Forward reach Lateral reach One leg standing: Total TGMD
96.2
71 (45–82)
ML sway-EO
73 (54–82)
16.2 (12.5–21.0)
102 (65–134)
70 (45–85)
54.5 (36–70)
52 (38–72)
43.5 (23–55)
43.5 (24–53)
AP sway-EC
(54–82)
Sway: AP sway-EO
73
(55–81)
294 (22)
PDMS (Raw score)
Post
72
0.31 (0.75)
Vision
TGMD:
0.18 (0.86) 1.43 (0.15)
Somatosensory
Pre
Control group
PSCT−3
Outcome measure
10.6 ± 2.011
(80.6–130.5)
91.3
12.0 (10.5–16.0)
13.5 (10.9–19.0)
98 (60–125)
70 (40–80)
50 (36–70)
40 (23–53)
(53–79)
75
290 (25)
0.78 (0.20)
0.59 (0.55)
2.20 (0.03)
Pre
Intervention group
13.8 ± 1.989
(92.9–142.6)
107.0
15.6 (13.6–20.4)
20.1(17.2–20.1)
86 (55–98)
54 (35–70)
41 (30–60)
31 (20–44)
(63–84)
81
Post
Improved gross motor skills and postural balance
Improved postural control, motor skills and QOL.
development improved
Vision and somatosensory ratios, postural control and motor
Conclusion
6
6
6
PEDro score
AP, anterior posterior; C, control group; CI, cochlear implant; EC, eyes closed; EO, eyes open; I, intervention group; ML, medial lateral; PBS, pediatric balance scale; PDMS, peabody developmental motor scales; PRT, pediatric reach test; PSCT, posturography sensory conditions testing; QOL, quality of life; SNHL, sensorineural hearing loss; TGMD, test for gross motor development.
SNHL with vestibular impairment
Shah et al.25
SNHL with B/L vestibular impairment
Hearing impaired (hearing level >90) with or without CI
al.21
Subject characteristics
Rajendran et al.23
Rinne et
Author
Table 1 Summary of studies related to physical therapy management for balance deficits in children with hearing impairments
Balance rehabilitation in deafness R Fernandes et al.
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along with motor deficits in children with and without HI, and HI children with and without motor deficits, but not commented about the psychometric properties of the tool, PedsQL 4.0, pertaining to the HI population.17,18 Although PedsQL 4.0 was used as one of the primary outcome measure, the author did not mention about difficulty with ADLs among subject. Also, these subjects were picked from deaf schools and were not from outpatient departments. Shah et al. conducted a pilot study with quasi-RCT design, being one of the reasons to reduce the quality of the study. This trial shows a significant improvement (more than all other trials) on the outcome measures (TGMD-2 and PBS) following intervention (motor control programme). However, an extremely low sample size does reduce the effect size of the intervention.25 Hence, a similar study with larger sample will be necessary for further research justify the effectiveness of the intervention.
improvement on post-test measurement in intervention group.21,23,25 However, these trials did not follow-up the HI children post-intervention to study the carry over and/or determine the long-term effects. This has to be considered in further studies. No trials assessed the functional independence of the children pre- and post-intervention. Addressing this issue would further be helpful if these type of interventions can be a major part of rehabilitation, as the ultimate objective of rehabilitation is functional well-being. As the study population was of the paediatric age group, no study from the review or in the articles read through during the search process emphasised participation and activity level, in which measurement might also ensure more effective intervention of intervention as a child’s active participation can be assessed.
Clinical Implications
The present review indicates that intervention in children with HI should be employed at the age of 3–4 years, as this is the critical period of balance skill development. This also helps to improve the child’s QOL to a great extent. Future studies should address the question of whether the carry over effect of these interventions exists and if it also improves functional independence. Studies employing pure balance exercises like one leg standing and standing and walking with varying BOS do not have a clear beneficial effect on improving balance or motor development. However, intervention by means of specific vestibular training programmes, such as eye–hand co-ordination exercises, balance training and other ocular exercises are beneficial because they aim at improving balance and therefore aid motor development. Very few interventional studies were available, and all of these employed are smaller than desirable with sample size. Hence, to answer the question of whether the age at which intervention starts and the interventions are significant is a matter for future research.
HI children show vestibular deficits. Such vestibular deficits affect motor proficiency among HI children.4–8,11,12,14,15,19,20,29–32 It is necessary to reinforce vestibular system by using compensatory strategies through the proprioceptive, somatosensory and visual system.12,14,19 Hence, it is necessary to address somatosensory and visual components along with co-ordination and neuromuscular training.12,14,19,21,23 Co-ordination and balance training have proven to be the major intervention strategy to be employed in this condition.14,17,19–25,30 Also, a number of studies that have shown positive results on outcome measures have employed intervention for HI children, for about 6 or more weeks.21,23 Hence, it is suggested that any intervention programme should be extended for a considerable period of time and must be regular in nature.22–24 Trials included have not commented on any other treatment or rehabilitation measures being undergone by the children included as subjects during the study intervention. This might suggest that a multidisciplinary approach employed in handling the HI subjects would be more beneficial. In the trial by Rajendran et al. had assessed QOL among HI children on PedQOL 4.0 pre- and post-intervention in both the intervention and the control group.23 Hence, it may be understood that intervention also improves the QOL of HI children.
Future Research While most of the studies are of high quality, still, they score 6 on PEDro. The studies lack allocation concealment as also the blinding of therapist, assessor and subject. Another area that makes the review inconclusive is the estimated sample size in different trials. No trial intervened more than 25 HI children, thereby reducing the effect size of the intervention programme. Hence, a larger sample size with longer follow-up is suggested for future research. Further, a heterogeneous group of HI children can receive intervention, for instance, a mixed group of children with hearing loss and moderate to moderately severe HI children. This kind of testing may show a variation in the mode and efficacy of the intervention. The three papers reviewed show
Conclusions
References 1 McCormick B. Screening and surveillance for hearing impairment in pre- school children. In: Kerr AG, ed. Paediatric Otolaryngology, Vol. 6, 6th edn. Scott Brown’s Otolaryngology. Oxford: Butterworth Heinemann, 1996; 6/6/1–5. DA Adams, MJ Cinnamond (Volume Eds.). 2 World Health Organization. Fact sheet. Deafness and hearing impairment. 2014. Available from: http://www.who.int/mediacentre/ factsheets/fs300/en/index.html [accessed February 2014]. 3 World Health Organization. State of hearing and ear care in the South East Asia Region. 2012. WHO Regional Office for South East Asia. WHO-SEARO. SEA/Deaf/9. Available from: http://www.searo.who.int/ LinkFiles/Publications_HEARING_&_EAR_CARE.pdf [accessed February 2014]. 4 Barboza AC, Resende LM, Ferreira DB, Lepertosa CZ, Carvalho SA. Correlation between hearing loss and risk indicators in a neonatal hearing screening reference service. ACR. 2013; 18: 285–92. 5 Livingstone N, McPhillips M. Motor skill deficits in children with partial hearing. Dev. Med. Child Neurol. 2011; 53: 836–42. 6 Cushing SL, Papsin BC, Rutka JA, James AL, Gordon KA. Evidence of vestibular and balance dysfunction in children with profound sensori-neural hearing loss using cochlear implants. Laryngoscope 2008; 118: 1814–23.
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7 Gheysen F, Loots G, Waelvelde VH. Motor development of deaf children with and without cochlear implants. J. Deaf Stud. Deaf Educ. 2008; 13: 215–24. 8 Shumway-Cook A, Woolacott M. Normal postural control. In: Shumway-Cook A, Woolacott M, ed. Motor Control: Theory and Practical Application, 2nd edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2001; 163–91. 9 Nandi R, Luxon LM. Development and assessment of the vestibular system. Int. J. Audiol. 2008; 47: 566–77. 10 Shinjo Y, Jin Y, Kaga K. Assessment of vestibular function of infants and children with congenital and acquired deafness using the ice-water caloric test, rotational chair test and vestibular-evoked myogenic potential recording. Acta Otolaryngol 2007; 127: 736–47. 11 Selz PA, Girardi M, Konrad HR, Hughes LF. Vestibular deficits in deaf children. Otolaryngol. Head Neck Surg. 1996; 115: 70–7. 12 Arnvig J. Vestibular function in deafness and severe hardness of hearing. Acta Otolaryngol 1955; 45: 283–8. 13 Jones SM, Jones TA, Mills KN, Gaines CG. Anatomical and physiological considerations in vestibular Dysfunction and compensation. Semin. Hear. 2009; 30: 231–41. 14 Rajendra V, Roy FG. An overview of motor skill performance and balance in hearing impaired children. Ital. J. Pediatr. 2011; 37: 33–8. Available from: http://www.ijponline.net/content/37/1/33 [accessed February 2014]. 15 Brookhouser PE, Cyr DG, Beauchaine KA. Vestibular findings in the deaf and hard of hearing. Otolaryngol. Head Neck Surg. 1982; 90: 773–7. 16 Tribukait A, Brantberg K, Bergenius J. Function of semicircular canals, utricles and saccules in deaf children. Acta Otolaryngol. 2004; 124: 41–8. 17 Rajendran V, Roy FG. Motor development and postural control evaluation of children with sensorineural hearing loss: a review of three inexpensive assessment tools- PBS, TGMD-2, and P-CTSIB. Iran J. Child Neurol. 2010; 4: 7–12. 18 Rajendran V, Roy FG. Comparison of health related quality of life of primary school deaf children with and without motor impairment. Ital. J. Pediatr. 2010; 36: 75–80. Available from: http://www.ijponline .net/content/36/1/75 [accessed February 2014]. 19 Crowe TK, Horak FB. Motor proficiency associated with vestibular deficits in children with hearing impairment. Phys. Ther. 1988; 68: 1493–9.
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20 Krebs DE, Gill-Body KM, Riley PO, Parker SW. Double-blind, placebo-controlled trial of rehabilitation for bilateral vestibular hypofunction: Preliminary report. Otolaryngol. Head Neck Surg. 1993; 109: 735–41. 21 Rine RM, Braswell J, Fisher D, Joyce K, Kalar K, Shaffer M. Improvement of motor development and postural control following intervention in children with sensorineural hearing loss and vestibular impairment. Int. J. Pediatr. Otorhinolaryngol. 2004; 68: 1141–8. 22 Effgen SK. Effect of an exercise programme on the static balance of deaf children. Phys. Ther. 1981; 61: 873–7. 23 Rajendran V, Roy FG, Jeevanantham D. A preliminary randomized controlled study on the effectiveness of vestibular-specific neuromuscular training in hearing impaired children. Clin. Rehabil. 2012; 27: 459–67. 24 Lewis S, Higham L, Cherry DB. Development of an exercise program to improve the static and dynamic balance of profoundly hearing impaired children. Am. Ann. Deaf 1985; 130: 278–83. 25 Shah J, Rao K, Malawade M, Khatri S. Effect of motor control program in improving gross motor function and postural control in children with sensorineural hearing loss-A pilot study. Pediat. Therapeut. 2013; 3: 1–5. Available from: http://www.dx.doi.org/10.4172/ 2161-0665.1000141 [accessed January 2014]. 26 Bigby M. Ch: Hierarchy of evidence. In: Williams H, Bigby M, Diepgen T et al., eds. Evidence Based Dermatology. Edition 2. Massachusetts: Blackwell, 2008; 35–6. 27 Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. reliability of the PEDro scale for rating quality of randomized control trials. Phys. Ther. 2003; 83: 713–21. 28 Wiart L, Darrah J. Review of four tests of gross motor development. Devl. Med. Child Neurol. 2001; 43: 279–85. 29 Fewell RR, Glick MP. Program evaluation findings of an intensive early intervention program. Am. J. Ment. Retard. 1996; 101: 233–43. 30 Kaga K. Vestibular compensation in infant and children with congenital and acquired vestibular loss in both ears. Int. J. Pediatr. Otorhinolaryngol. 2007; 49: 215–24. 31 Varni JW, Seid M, Rode CA. The PedsQLTM: measurement model for the pediatric quality of life inventory. Med. Care 1999; 37: 126–39. 32 Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the pediatric quality of life inventory version 4.0 generic core scales in healthy and patient populations. Med. Care 2001; 39: 800–12.
Journal of Paediatrics and Child Health 51 (2015) 753–758 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
doi:10.1111/jpc.12867
REVIEW ARTICLE
Physical therapy management for balance deficits in children with hearing impairments: A systematic review Romita Fernandes, Shalini Hariprasad and Vijaya K Kumar Physiotherapy, Kasturba Medical College, Manipal University, Mangalore, India
Abstract: Childhood hearing impairment is a significant problem, associated with long-term academic, communicative and physical impairments. Studies have shown that children with hearing loss also present with balance and/or vestibular deficits along with complain of frequent falls. Various interventions have been studied to improvise postural control and balance in these children on different outcome measures. This review will provide the existing evidence on interventions to improve vestibular and/or balance functions. Three trials met our study criteria with PEDro score ≥6, and data were extracted, entered by two independent review authors. Though there was variability with regard to the focus and intensity of the intervention, subject characteristics and in outcome measures, vestibular rehabilitation has a positive influence on functional independence. Heterogeneity in the studies limits the comparisons of intervention programmes. We conclude that there was considerable evidence for a positive effect on balance outcomes among the hearing-impaired population with vestibular deficits. Further investigations of high-quality studies are needed to determine to compare interventions for improving vestibular deficits in hearing-impaired children. Key words:
deafness; exercise programme; hearing-impaired children; physical therapy; rehabilitation; sensorineural hearing impairment.
Hearing impairment is a major disability, leading individuals with such impairment to be handicapped. Childhood hearing impairment is a significant problem because it is associated with long-term developmental difficulties including language skills, communication skills, social abilities and motor development, for instance.1 According to 2005 estimates of the WHO, 278 million people world-wide have disabling hearing impairment, that is, moderate-to-profound hearing loss in both ears (i.e. >41 dB hearing loss).2 Hearing loss is the second most common cause of years lived with disability (YLD) accounting for 4.7% of the total YLD. The problem of deafness is disproportionately high in Southeast Asia with a prevalence ranging from 4.6% to 8.8%.3 The prevalence of moderate to profound hearing loss in children, including sensorineural hearing loss (SNHL) and conductive hearing loss, is one to six of 1000, of which 10% have hearing levels that fall in the profound range.4 Population-based surveys in 2003 in India using the WHO protocol estimated the
Key Points 1 Balance deficits in hearing impaired children. 2 Role of physical therapy in hearing impaired balance rehabilitation. 3 Currently, vestibular rehabilitation has a positive effect on balance outcomes. Correspondence: Mr Vijaya K Kumar, Physiotherapy, Kasturba Medical College, Manipal University, Mangalore 575001, India. Fax: 0824-2421140; email: [email protected] Conflict of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Accepted for publication 29 January 2015.
prevalence of hearing impairment at 6.3% or approximately 63 million people who suffered from significant auditory loss. The estimated prevalence of childhood onset deafness is found to be 2%.3 Several studies have shown that hearing-impaired (HI) children display motor deficits and more specifically balance deficits in the postural control.5–7 Postural stability is the integration of the visual, vestibular and somatosensory information required by the central nervous system to generate motor responses that keep the body in balance.8 The mature vestibular system contributes by maintaining visual stabilisation, neck stabilisation and also the orientation of the body in space and contributes to the postural tone necessary for the acquisition of motor developmental milestones.9 As the vestibular system and inner ear are closely associated with each other anatomically, either may be susceptible to the same noxious or developmental factors, justifying concomitant vestibular loss in HI children be it congenital or acquired.10–12 Published reports found vestibular dysfunction in approximately 30–70% of HI children with little evidence for vestibular impairment being proportional to HI.10–13 According to American speech language hearing association, there are three basic types of hearing loss: conductive hearing loss, SNHL and mixed hearing loss. SNHL is the most common type of permanent hearing impairment.14 Also, vestibular test abnormalities are more commonly associated with profound SNHL, than with acquired deafness, and some syndromes associated with deafness.15 In a cross-sectional study carried out by Cushing et al., 40 children with SNHL were investigated. It was found that 50% had an abnormality in horizontal semi-circular canal function, 38% had a dysfunction in higher frequency canal function and 40% had abnormalities of saccular function.6 The mature vestibular system generates three motor reflexes: the vestibular–ocular reflex (VOR) responsible for visual
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stabilisation, the vestibular–collic reflex (VCR) responsible for neck stabilisation and the vestibular–spinal reflex (VSR), which maintains the orientation of the body in space and contributes to the postural tone necessary for the acquisition of motor developmental milestones.16 To evaluate the VOR, traditional techniques like caloric and rotatory chair testing can examine horizontal semi-circular canal and superior vestibular nerve function. The VCR can be evaluated by the vestibular evoked myogenic potential test, in which a loud auditory stimulus induces an ipsilateral inhibition of the tonic neck muscle activity recorded on electromyography.9,16 Finally, for evaluating the VSR, posturography and balance tests enable evaluating the result of the complex interaction between cortical control of lower motor centres through pyramidal and extrapyramidal tracts, vestibular influences through the medial and lateral vestibular–spinal tracts, and the reticulospinal tract.9 A review by Rajendran and Roy indicated that the following assessment tools are frequently used in studies carried out on HI children to assess motor deficits: Bruininks-Osretsky test of Motor Proficiency, Pediatric Balance Scale, Test of Gross Motor Development, Timed Up and Go test, Peabody Developmental Motor Scale, Posturography Sensory Conditions testing, Force Platform, Movement Assessment Battery for Children, Körperkoordinations Test für Kinder, One Leg Standing test, Children Activity Scales for Teachers, Balance subset of Southern California Sensory Integration tests and Timed Static balance test.17 It is necessary to intervene vestibular issues in HI children in order to provide them with a better quality of life (QOL).18–20 Although cochlear implants are commonly provided to HI children,21 various rehabilitation techniques have been practised including a vestibular programme, which further includes visual training with and without head movement, gait training with varying base of support size and surface compliance, goaloriented movement tasks,22 eye hand co-ordination, general co-ordination activities, visual motor training, balance training emphasising visual and somatosensory awareness,23 a 15-min static balance exercise programme and24 vestibular-specific neuromuscular training.25 In recent years, few trials have been conducted on physical therapy management for balance impairment in children with hearing loss. Since there is no systematic review of physical therapy management techniques for balance impairment in children with hearing loss, the primary objective of our systematic review was to identify various management techniques used in clinical practice for balance impairment in children with hearing loss. The secondary objective is to determine the efficacy of these interventions to be implemented in clinical practice.
Key words HI children, deafness, sensorineural hearing impairment, children, exercise programme, rehabilitation, physical therapy, balance deficits, vestibular impairments, vestibular rehabilitation, motor deficits and gross motor delay. The titles and/or abstracts of these citations were reviewed to identify papers specifically detailing physical therapy rehabilitation for balance impairment in children with hearing loss. Additional articles were located by manually searching the reference lists of identified articles and directly contacting researchers actively publishing in the area.
Selection criteria Full-text randomised controlled trials (RCTs) or quasi-RCTs with PEDro score of 6/10 or more: The search was limited to studies published in English and trials that were carried out on human subjects. The study required description of the study population, the impairment, the assessment tools and details of physical therapy management used. The age of the population considered in the trials was up to 13 years of age. If an article failed to provide any of the above measures, it was removed from the review. Trials addressing deficits other than balance and with a level of evidence less than 2b based on the Sackett’s classification system26 were not included. Also excluded were those involving subjects from the adult population.
Quality assessment Once all full-text inclusion articles were acquired, each was assessed independently by two authors for quality using the PEDro scale.27
Results Of 346 studies initially identified through the database searches and 12 studies identified through hand-searching of references and searching databases using key words, only 61 studies were found to be potentially relevant based on their citations using the search strategies outlined earlier. When their abstracts and available full texts were screened, 58 were excluded as they turned out either not to meet the inclusion criteria or not to be of pre-defined quality (PEDro). The forementioned flowchart (Fig. 1) gives an overview of the selection process. The remaining three studies on effect of vestibular intervention in HI children met the inclusion criteria and underwent the data extraction and critical appraisal process.
Overview of included papers
Methods Search strategy Relevant studies of physical therapy management techniques for balance impairment in HI children from 1993 to 2013 were obtained through an extensive computerised search of the following bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, Google Scholar, MEDLINE plus, CINAHL, EBSCO and PEDro. 754
All the three papers, included studies used samples exclusively with hearing impairment. All the trials included a very small sample size (5–25 in each group), that is, total of 31 children in the intervention group and 21 in the control group. The proportion of female to male participants across studies was relatively even. The age ranges of samples were detailed in all the studies. Inclusion/exclusion criteria were provided, and clear protocols were described or referenced in all studies. All studies also provided information on their participants’ severity of HI.
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Total number of articles (n = 358)
Case control studies, Case series, Case reports, Studies on adult population, Animal studies, All languages
Number of potential articles based on abstract and by pre-defined quality (n = 61)
Total number of articles included in the review (n =3)
Fig. 1
Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, Google Scholar, MEDLINE plus, CINAHL, PEDro and EBSCO (1980 to October 2013) based on the keywords
Randomised or quasi-randomised controlled trials or reviews pertaining to paediatric population
Flow chart of the review process.
The sample size, outcome measures, interventions, statistical values and the results of all the studies reviewed are summarised in Table 1.
Discussion We are the first to write a review on the effects of vestibular rehabilitation on balance deficits in HI children with or without developmental motor delay. However, others have reviewed the prevalence of balance and motor deficits and also the frequently used tools to assess the same in HI children.10–12,14,15,17–19 Results from this present review indicate that we have moved a little ahead, by focusing on interventions. During the search strategy, the first retrieved trial was by Effgen, which was the first retrievable literature available to intervene balance in HI children. This controlled trial did not show significant improvement on outcome measures but concluded that improvement in their functions.22 Later, a similar work was done by Lewis et al., and this trial also did not produce any significant difference even on subjective measures of 16 different balance tests in various dynamic positions.24 However, these studies were not included as a part of the review, as inclusion was only after 1985. There was a paucity of literature addressing these areas for more than 15 years following these studies. However, the last decade shows a few studies in the area. In the following sections, we shall point out the direction of progress. However, we will first discuss some methodological issues.
Differences among the studies In spite of some broad agreement between authors, there were differences among different studies. The outcome measures employed in different studies were different, but the last two studies in chronological order used Test for Gross Motor Development (TGMD).23,25 It was one of the tools commonly used to assess gross motor skills among HI children, but psychometric properties were not tested in this population.28 Assessment tools used to test balance were also heterogeneous in nature and not found to be reliable for HI population; however, they were all standard measures to assess balance in the general population.17,28
Similarities among the studies All the studies had a very small sample size of not more than 25, which was one of the major limitations of the study. HI children included in the trials were all of a similar age group namely between 6 and 11 years of age except a study from Rine et al included children age from 4.8 to 7.4 years. Samples were recruited from schools for the deaf, and the details about the regular medication and rehabilitative programmes, other than physical exercise, were not mentioned. All the studies lacked blinding in terms of therapist, assessor, subjects and allocation concealment thereby reducing the quality of the study. This being a major limitation was also pointed out by respective authors of the trials. All the HI children included in all the trials had the SNHL type of hearing loss in the severe to profound range, and one study also included subjects with cochlear implants.21,22,24,25
Main Findings from Reviewed Papers Rine et al. had used PDMS as an outcome measure to assess motor skills. It was tested for the HI population and for an age group higher than 7 years with ICC of 0.91 for intra-rater reliability measured between that age group and the HI population.21 However, the outcome measure for balance, posturography, was not tested. The study population was of a lesser age group when compared with others, and the author states it to be the probable critical period for the development of balance skills and to intervention for the same.21,29 Evidence shows a similar picture namely that the age range of 3–5 years is the most critical period.29,30 In his study, the control group was provided intervention similar to the intervention group after the post-test data were taken following placebo intervention. The final test data showed a significant improvement as well. Individual data pertaining to the results of the placebo group are not provided, only the merged data of all the subjects post intervention.21 In one reviewed paper, Rajendran et al.23, PedQL 4.0 was one of the outcome measures that was used rarely among HI children.21,31,32 Though it is found to be reliable in the paediatric patient population, similar evidence specific to HI children is not retrievable.17,18,28 Rajendran and Roy have earlier observed QOL
Journal of Paediatrics and Child Health 51 (2015) 753–758 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
755
756
10
10
11
11
10
–
No intervention For 12 weeks
30 min/day, 3 days/week language development
C
C
I
Intervention
No. of subjects
45 min: eye–hand and general co-ordination, visual motor training, balance training For 12 weeks
45 min, three times/week Eye–hand co-ordination, balance re- training, fundamental motor skills For 12 weeks
Balance training
10 min each Eye–hand General co-ordination Visuo-motor
I
(84.9–132.1)
101.5 (62–128) 15.5 (13.0–20.0) 72 (55–81) 95.9 (81.6–131.2)
ML sway-EC PRT: Forward reach Lateral reach One leg standing: Total TGMD
96.2
71 (45–82)
ML sway-EO
73 (54–82)
16.2 (12.5–21.0)
102 (65–134)
70 (45–85)
54.5 (36–70)
52 (38–72)
43.5 (23–55)
43.5 (24–53)
AP sway-EC
(54–82)
Sway: AP sway-EO
73
(55–81)
294 (22)
PDMS (Raw score)
Post
72
0.31 (0.75)
Vision
TGMD:
0.18 (0.86) 1.43 (0.15)
Somatosensory
Pre
Control group
PSCT−3
Outcome measure
10.6 ± 2.011
(80.6–130.5)
91.3
12.0 (10.5–16.0)
13.5 (10.9–19.0)
98 (60–125)
70 (40–80)
50 (36–70)
40 (23–53)
(53–79)
75
290 (25)
0.78 (0.20)
0.59 (0.55)
2.20 (0.03)
Pre
Intervention group
13.8 ± 1.989
(92.9–142.6)
107.0
15.6 (13.6–20.4)
20.1(17.2–20.1)
86 (55–98)
54 (35–70)
41 (30–60)
31 (20–44)
(63–84)
81
Post
Improved gross motor skills and postural balance
Improved postural control, motor skills and QOL.
development improved
Vision and somatosensory ratios, postural control and motor
Conclusion
6
6
6
PEDro score
AP, anterior posterior; C, control group; CI, cochlear implant; EC, eyes closed; EO, eyes open; I, intervention group; ML, medial lateral; PBS, pediatric balance scale; PDMS, peabody developmental motor scales; PRT, pediatric reach test; PSCT, posturography sensory conditions testing; QOL, quality of life; SNHL, sensorineural hearing loss; TGMD, test for gross motor development.
SNHL with vestibular impairment
Shah et al.25
SNHL with B/L vestibular impairment
Hearing impaired (hearing level >90) with or without CI
al.21
Subject characteristics
Rajendran et al.23
Rinne et
Author
Table 1 Summary of studies related to physical therapy management for balance deficits in children with hearing impairments
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along with motor deficits in children with and without HI, and HI children with and without motor deficits, but not commented about the psychometric properties of the tool, PedsQL 4.0, pertaining to the HI population.17,18 Although PedsQL 4.0 was used as one of the primary outcome measure, the author did not mention about difficulty with ADLs among subject. Also, these subjects were picked from deaf schools and were not from outpatient departments. Shah et al. conducted a pilot study with quasi-RCT design, being one of the reasons to reduce the quality of the study. This trial shows a significant improvement (more than all other trials) on the outcome measures (TGMD-2 and PBS) following intervention (motor control programme). However, an extremely low sample size does reduce the effect size of the intervention.25 Hence, a similar study with larger sample will be necessary for further research justify the effectiveness of the intervention.
improvement on post-test measurement in intervention group.21,23,25 However, these trials did not follow-up the HI children post-intervention to study the carry over and/or determine the long-term effects. This has to be considered in further studies. No trials assessed the functional independence of the children pre- and post-intervention. Addressing this issue would further be helpful if these type of interventions can be a major part of rehabilitation, as the ultimate objective of rehabilitation is functional well-being. As the study population was of the paediatric age group, no study from the review or in the articles read through during the search process emphasised participation and activity level, in which measurement might also ensure more effective intervention of intervention as a child’s active participation can be assessed.
Clinical Implications
The present review indicates that intervention in children with HI should be employed at the age of 3–4 years, as this is the critical period of balance skill development. This also helps to improve the child’s QOL to a great extent. Future studies should address the question of whether the carry over effect of these interventions exists and if it also improves functional independence. Studies employing pure balance exercises like one leg standing and standing and walking with varying BOS do not have a clear beneficial effect on improving balance or motor development. However, intervention by means of specific vestibular training programmes, such as eye–hand co-ordination exercises, balance training and other ocular exercises are beneficial because they aim at improving balance and therefore aid motor development. Very few interventional studies were available, and all of these employed are smaller than desirable with sample size. Hence, to answer the question of whether the age at which intervention starts and the interventions are significant is a matter for future research.
HI children show vestibular deficits. Such vestibular deficits affect motor proficiency among HI children.4–8,11,12,14,15,19,20,29–32 It is necessary to reinforce vestibular system by using compensatory strategies through the proprioceptive, somatosensory and visual system.12,14,19 Hence, it is necessary to address somatosensory and visual components along with co-ordination and neuromuscular training.12,14,19,21,23 Co-ordination and balance training have proven to be the major intervention strategy to be employed in this condition.14,17,19–25,30 Also, a number of studies that have shown positive results on outcome measures have employed intervention for HI children, for about 6 or more weeks.21,23 Hence, it is suggested that any intervention programme should be extended for a considerable period of time and must be regular in nature.22–24 Trials included have not commented on any other treatment or rehabilitation measures being undergone by the children included as subjects during the study intervention. This might suggest that a multidisciplinary approach employed in handling the HI subjects would be more beneficial. In the trial by Rajendran et al. had assessed QOL among HI children on PedQOL 4.0 pre- and post-intervention in both the intervention and the control group.23 Hence, it may be understood that intervention also improves the QOL of HI children.
Future Research While most of the studies are of high quality, still, they score 6 on PEDro. The studies lack allocation concealment as also the blinding of therapist, assessor and subject. Another area that makes the review inconclusive is the estimated sample size in different trials. No trial intervened more than 25 HI children, thereby reducing the effect size of the intervention programme. Hence, a larger sample size with longer follow-up is suggested for future research. Further, a heterogeneous group of HI children can receive intervention, for instance, a mixed group of children with hearing loss and moderate to moderately severe HI children. This kind of testing may show a variation in the mode and efficacy of the intervention. The three papers reviewed show
Conclusions
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