Effect of adapted trunk-hip strengthening on gait and balance in children with spastic diplegic cerebral palsy: A randomised control trail

Cerebral palsy (CP) is a common physical disability in children (Hutton, 2006;

Meihuizen-de Regt et al., 2015). It is a permanent neurological disorder caused by non-

progressive brain injury or malformation in the developing brain (Meihuizen-de Regt et al.,

2015; Rose- nbaum et al., 2007). It is the most common type of childhood disability with an

estimated prevalence ranging from 1.5 to 2.5 per 1000 live births (Graham et al.,

2016; Oskoui, Coutinho, Dykeman, Jette, & Pringsheim, 2013). Primary impairments include

disturbances of movement and posture, which often cause activity limitation as well as

disturbances in sensation, perception, cognition, communication and behavior (Graham et al.,

2016; Rosenbaum et al., 2007; O. Verschuren, Ketelaar, Takken, Helders, & Gorter, 2008).

The severity of impairments depends on size and location of the lesion and maturational stage

of the brain when the lesion occurs (Graham et al., 2016; Rosenbaum et al., 2007). Level of

gross motor function is evaluated and categorized from infancy to 15 years of age by the

Gross Motor Function Classification System (GMFCS) (Palisano et al., 1997). Severity of

impairment varies significantly and can be categorized into 5 different levels of function.

GMFCS I indicates minor physical impairments with no real need of assistance whereas

individuals in GMFCS V are severely affected with limited mobility and requires daily

assistance (Palisano et al., 1997).

Cerebral palsy (CP) is a neurodevelopmental disorder that results in the abnormal

development of movement and posture, often associated with sensory impairments, affecting

the individual’s ability to move, participate in activities, solve problems, and live

independently. Although there is no evidence that damage to the brain in CP can be reversed

(Ketelaar et al., 2001), a creative intervention could allow children and adolescents with CP

to think about using movement differently, as well as being open to new movement ideas

(Chen, 2001; Joung and Lee, 2019). Children with Spastic Diplegia often suffer from many

functional deficits due to the emergence of numerous musculoskeletal defacements like mal

alignment in their pelvis (M, Feliciangeli A, Sciuto L, Gericke C, Vianello A. Dev Med Child

Neurol et. al., 2001). It is necessary to have a good synchronization between the pelvis and

inferior limbs for a healthy pattern of gait (Crosbie J, Vachalathiti R et. al., 1997). The

deviation of pelvic alignment in the standing position is a common problem in children with

CP. Such children retain an anterior pelvic tilt due to the contracture of the iliopsoas muscle

as well as weakness in the trunk flexors and hip extensors. Problems associated with anterior

pelvic tilt include femoral anti-torsion and medial shift of the patella to the sagittal plane

bisection of the knee joint. Therefore, a major goal of movement training is reciprocal control

of the pelvis by improving interplay among the abdominal obliques, rectus abdominal is,

quadrates lumborum and lumbar extensor muscles (Beverly D et. al.,1990). Trunk control

abnormalities are a major limitation to the motor development in children with diplegic CP

(Prosser LA, Lee SC, VanSant AF, Barbe MF, Lauer RT et. al., 2010). Trunk instability in

children with diplegic CP is evident from the greater oscillations of the center of pressure

observed in the anteroposterior and mediolateral directions, which leads to alteration in

balance (Carlberg EB, Hadders-Algra M et. al., 2005).

According to the International Classification of Functions (ICF) of the World Health

Organization (WHO), participation consists of taking part or being involved in everyday lifeactivities and roles. Thus, participation in leisure activities has emerged as an important

health outcome for children with disabilities. In children with CP, impaired mobility leads to

decreased participation in the community and reduced contact with peers in activities and

play (Fauconnier et al., 2009; Imms, 2008; Michelsen et al., 2009; Parkes, McCullough &

Madden, 2010; Pratt, Baker & Gaebler-Spira, 2008; Shikako-Thomas, Majnemer, Law &

Lach, 2008). This decrease in participation correlates positively with increased gross motor

impairments (Parkes et al., 2010)

Therefore, rehabilitation interventions should not only focus on functional skill

development, but also on providing new opportunities and challenges that encourage

individuals with CP to develop their maximum movement potential, as well as to achieve a

positive attitude toward being challenged to explore new movement possibilities and to enjoy

moving (Verschuren et al., 2012). The main objective of introducing dance form based

intervention in order to strengthen hip-trunk is to deliver physical rehabilitation through the

execution of artistic movement in a group setting where the children participated by their own

choice and perceived enjoyment. Current literature stresses the need for newer, task-related

and intense programs of therapy with life-style modifications (Bower, Michell, Burnett,

Campbell & McLellan, 2001; Damiano, 2006, 2009).

Research Question:

"How does the integration of trunk-hip strengthening exercises using dance forms impact gait

patterns in children diagnosed with spastic diplegic cerebral palsy?"

HYPOTHESIS

Null Hypothesis:

H (0): There will be no significant effect of trunk-hip strengthening exercises with dance

forms on gait in children with spastic diplegic cerebral palsy

H (0): There will be no significant effect of trunk-hip strengthening exercises with dance

forms on balance in children with spastic diplegic cerebral palsy

Alternative Hypothesis:

H (1): There will be significant effect of trunk-hip strengthening exercises with dance forms

on gait in children with spastic diplegic cerebral palsy

H (1): There will be significant effect of trunk-hip strengthening exercises with dance forms

on balance in children with spastic diplegic cerebral palsy