Effect of dual-task training on postural stability in children with infantile hemiparesis
Identifieur interne : 000124 ( Pmc/Checkpoint ); précédent : 000123; suivant : 000125Effect of dual-task training on postural stability in children with infantile hemiparesis
Auteurs : Elbadawi Ibrahim Mohammad Elhinidi ; Marwa Mostafa Ibrahim Ismaeel ; Tamer Mohamed El-SaeedSource :
- Journal of Physical Therapy Science [ 0915-5287 ] ; 2016.
Abstract
[Purpose] The aim of this study was to evaluate the influence of using a selected dual-task training program to improve postural stability in infantile hemiparesis. [Subjects and Methods] Thirty patients participated in this study; patients were classified randomly into two equal groups: study and control groups. Both groups received conventional physical therapy treatment including mobility exercises, balance exercises, gait training exercises, and exercises to improve physical conditioning. In addition, the study group received a selected dual-task training program including balance and cognitive activities. The treatment program was conducted thrice per week for six successive weeks. The patients were assessed with the Biodex Balance System. These measures were recorded two times: before the application of the treatment program (pre) and after the end of the treatment program (post). [Results] There was a significant improvement for both groups; the improvement was significantly higher in the study group compared to the control group. [Conclusion] The selected dual-task training program is effective in improving postural stability in patients with infantile hemiparesis when added to the conventional physical therapy program.
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DOI: 10.1589/jpts.28.875
PubMed: 27134376
PubMed Central: 4842457
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Effect of dual-task training on postural stability in children with infantile
hemiparesis</title><author><name sortKey="Elhinidi, Elbadawi Ibrahim Mohammad" sort="Elhinidi, Elbadawi Ibrahim Mohammad" uniqKey="Elhinidi E" first="Elbadawi Ibrahim Mohammad" last="Elhinidi">Elbadawi Ibrahim Mohammad Elhinidi</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Ismaeel, Marwa Mostafa Ibrahim" sort="Ismaeel, Marwa Mostafa Ibrahim" uniqKey="Ismaeel M" first="Marwa Mostafa Ibrahim" last="Ismaeel">Marwa Mostafa Ibrahim Ismaeel</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="El Saeed, Tamer Mohamed" sort="El Saeed, Tamer Mohamed" uniqKey="El Saeed T" first="Tamer Mohamed" last="El-Saeed">Tamer Mohamed El-Saeed</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27134376</idno><idno type="pmc">4842457</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842457</idno><idno type="RBID">PMC:4842457</idno><idno type="doi">10.1589/jpts.28.875</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000518</idno><idno type="wicri:Area/Pmc/Curation">000518</idno><idno type="wicri:Area/Pmc/Checkpoint">000124</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Effect of dual-task training on postural stability in children with infantile
hemiparesis</title><author><name sortKey="Elhinidi, Elbadawi Ibrahim Mohammad" sort="Elhinidi, Elbadawi Ibrahim Mohammad" uniqKey="Elhinidi E" first="Elbadawi Ibrahim Mohammad" last="Elhinidi">Elbadawi Ibrahim Mohammad Elhinidi</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Ismaeel, Marwa Mostafa Ibrahim" sort="Ismaeel, Marwa Mostafa Ibrahim" uniqKey="Ismaeel M" first="Marwa Mostafa Ibrahim" last="Ismaeel">Marwa Mostafa Ibrahim Ismaeel</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="El Saeed, Tamer Mohamed" sort="El Saeed, Tamer Mohamed" uniqKey="El Saeed T" first="Tamer Mohamed" last="El-Saeed">Tamer Mohamed El-Saeed</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Physical Therapy Science</title><idno type="ISSN">0915-5287</idno><idno type="eISSN">2187-5626</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>[Purpose] The aim of this study was to evaluate the influence of using a selected
dual-task training program to improve postural stability in infantile hemiparesis.
[Subjects and Methods] Thirty patients participated in this study; patients were
classified randomly into two equal groups: study and control groups. Both groups received
conventional physical therapy treatment including mobility exercises, balance exercises,
gait training exercises, and exercises to improve physical conditioning. In addition, the
study group received a selected dual-task training program including balance and cognitive
activities. The treatment program was conducted thrice per week for six successive weeks.
The patients were assessed with the Biodex Balance System. These measures were recorded
two times: before the application of the treatment program (pre) and after the end of the
treatment program (post). [Results] There was a significant improvement for both groups;
the improvement was significantly higher in the study group compared to the control group.
[Conclusion] The selected dual-task training program is effective in improving postural
stability in patients with infantile hemiparesis when added to the conventional physical
therapy program.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Belen I, Ve" uniqKey="Belen I V">VE Belen’kiĭ</name></author><author><name sortKey="Gurfinkel, Vs" uniqKey="Gurfinkel V">VS Gurfinkel’</name></author><author><name sortKey="Pal Sev, Ei" uniqKey="Pal Sev E">EI Pal’tsev</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Blanchard, Y" uniqKey="Blanchard Y">Y Blanchard</name></author><author><name sortKey="Carey, S" uniqKey="Carey S">S Carey</name></author><author><name sortKey="Coffey, J" uniqKey="Coffey J">J Coffey</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Palluel, E" uniqKey="Palluel E">E Palluel</name></author><author><name sortKey="Nougier, V" uniqKey="Nougier V">V Nougier</name></author><author><name sortKey="Olivier, I" uniqKey="Olivier I">I Olivier</name></author></analytic></biblStruct><biblStruct><analytic><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Phys Ther Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Phys Ther Sci</journal-id><journal-id journal-id-type="publisher-id">JPTS</journal-id><journal-title-group><journal-title>Journal of Physical Therapy Science</journal-title></journal-title-group><issn pub-type="ppub">0915-5287</issn><issn pub-type="epub">2187-5626</issn><publisher><publisher-name>The Society of Physical Therapy Science</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27134376</article-id><article-id pub-id-type="pmc">4842457</article-id><article-id pub-id-type="publisher-id">jpts-2015-871</article-id><article-id pub-id-type="doi">10.1589/jpts.28.875</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Effect of dual-task training on postural stability in children with infantile
hemiparesis</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Elhinidi</surname><given-names>Elbadawi Ibrahim Mohammad</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Ismaeel</surname><given-names>Marwa Mostafa Ibrahim</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>El-Saeed</surname><given-names>Tamer Mohamed</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref rid="cor1" ref-type="corresp"><sup>*</sup></xref></contrib><aff id="aff1"><label>1)</label> Department of Physical Therapy for Neuromuscular Disorders and Surgery, Faculty of Physical Therapy, Cairo University, Egypt</aff><aff id="aff2"><label>2)</label> Department of Physical Therapy for Growth and Developmental Disorders in Children and its Surgery, Faculty of Physical Therapy, Cairo University, Egypt</aff><aff id="aff3"><label>3)</label> Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Aljouf University, Saudi Arabia</aff></contrib-group><author-notes><corresp id="cor1"><label>*</label>Corresponding author. Tamer Mohamed El-Saeed, Department of Physical Therapy for Growth and Developmental
Disorders in Children and its Surgery, Faculty of Physical Therapy, Cairo University: 7
Ahmed Elzayyat Street, Bein Essarayat, Giza, Egypt. (E-mail:
<email xlink:href="tmelsaeed@pt.cu.edu.eg">tmelsaeed@pt.cu.edu.eg</email>)</corresp></author-notes><pub-date pub-type="epub"><day>31</day><month>3</month><year>2016</year></pub-date><pub-date pub-type="ppub"><month>3</month><year>2016</year></pub-date><volume>28</volume><issue>3</issue><fpage>875</fpage><lpage>880</lpage><history><date date-type="received"><day>21</day><month>10</month><year>2015</year></date><date date-type="accepted"><day>11</day><month>12</month><year>2015</year></date></history><permissions><copyright-statement>2016©by the Society of Physical Therapy Science. Published by IPEC
Inc.</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/4.0/"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. </license-p></license></permissions><abstract><p>[Purpose] The aim of this study was to evaluate the influence of using a selected
dual-task training program to improve postural stability in infantile hemiparesis.
[Subjects and Methods] Thirty patients participated in this study; patients were
classified randomly into two equal groups: study and control groups. Both groups received
conventional physical therapy treatment including mobility exercises, balance exercises,
gait training exercises, and exercises to improve physical conditioning. In addition, the
study group received a selected dual-task training program including balance and cognitive
activities. The treatment program was conducted thrice per week for six successive weeks.
The patients were assessed with the Biodex Balance System. These measures were recorded
two times: before the application of the treatment program (pre) and after the end of the
treatment program (post). [Results] There was a significant improvement for both groups;
the improvement was significantly higher in the study group compared to the control group.
[Conclusion] The selected dual-task training program is effective in improving postural
stability in patients with infantile hemiparesis when added to the conventional physical
therapy program.</p></abstract><kwd-group><title>Key words</title><kwd>Infantile hemiparesis</kwd><kwd>Postural stability</kwd><kwd>Dual-task training</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="s1"><title>INTRODUCTION</title><p>Postural control is considered an automatic system. However, recent studies suggest the
involvement of attentional processes in the regulation of posture during simple or more
complex tasks, especially when the latter involves attentional processes<xref rid="r1" ref-type="bibr">1</xref>,<xref rid="r2" ref-type="bibr">2</xref>,<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>.</p><p>It is well known that visual information plays an important role in postural control in
children; visual inputs are known to require attention, and the execution of eye movements
involves attention<xref rid="r4" ref-type="bibr">4</xref>,<xref rid="r5" ref-type="bibr">5</xref>,<xref rid="r6" ref-type="bibr">6</xref><sup>)</sup>.</p><p>Several structures in the central nervous system, the cerebral cortex (frontal, parietal,
and occipital), and the brainstem (paramedian pontine reticular formation and superior
colliculus) play an important role in postural control as well as in the programming and
execution of eye movements. Consequently, one could expect interferences between oculomotor
and postural control. Studies on the effects of eye movements on posture in normal children
are nonexistent. The few studies available have focused only on adult subjects, and their
results are discordant<xref rid="r7" ref-type="bibr">7</xref><sup>)</sup>.</p><p>The body position in space maintained by the postural control for the dual purposes of
stability and orientation. Postural dysfunction in cerebral palsy is due to the decreased
capacity to modulate postural activity in certain situations. Recently, researchers have
suggested that postural control requires significant attention<xref rid="r8" ref-type="bibr">8</xref>,<xref rid="r9" ref-type="bibr">9</xref>,<xref rid="r10" ref-type="bibr">10</xref><sup>)</sup>. Researchers have demonstrated the attentional demands of
maintaining an upright posture by using the dual-task paradigm with postural control chosen
as the primary task. A dual-task condition is a situation in which a person performs two
attention-demanding tasks simultaneously. Most of our environments consist of background
noise, obstacles, and distracting visual and auditory stimuli<xref rid="r11" ref-type="bibr">11</xref>,<xref rid="r12" ref-type="bibr">12</xref>,<xref rid="r13" ref-type="bibr">13</xref><sup>)</sup>.</p><p>In our daily life with or without our attention, we perform dual tasks. Typically,
developing children are capable of dividing their attention between tasks within a limit,
such that neither of the tasks is affected. Dual-task interference occurs due to the
conflict arising in resolving the allocation of attention between two tasks<xref rid="r14" ref-type="bibr">14</xref><sup>)</sup>. Blanchard along with Pellecchia were the
first researchers to demonstrate the interaction between the cognitive process and motor
control in the pediatric population<xref rid="r15" ref-type="bibr">15</xref>, <xref rid="r16" ref-type="bibr">16</xref><sup>)</sup>. Various studies demonstrate the combined
effects of physical and cognitive tasks on postural sway in both adults and children with
spastic cerebral palsy. Recently, there have been an increasing number of studies showing
the attentional requirements in young and older children during postural tasks and in
various neurological conditions<xref rid="r2" ref-type="bibr">2</xref>, <xref rid="r17" ref-type="bibr">17</xref><sup>)</sup>.</p><p>However, there is a lack of literature examining the postural sway during the attentional
demands of a concurrent cognitive task in children with cerebral palsy. These children often
encounter numerous dual-task situations in their daily living activities. Therefore, there
is a need to identify whether dual-task conditions affect the postural control of children
with cerebral palsy to pinpoint the importance of the rehabilitation needs and to decrease
the risk of falls<xref rid="r18" ref-type="bibr">18</xref><sup>)</sup>. The purpose of this
work is to study the effect of dual-task training on postural stability in children with
infantile hemiparetic cerebral palsy.</p></sec><sec sec-type="methods" id="s2"><title>SUBJECTS AND METHODS</title><p>Thirty children with spastic hemiparesis (infantile type) between the ages of nine to
fifteen years participated in this experimental study. Participants were recruited from our
clinic, Faculty of Physical Therapy, Cairo University. The degree of spasticity of all
participants ranged from grade 1 to grade 2, measured according to the modified Ashworth
Scale. Participants could stand and walk independently and they could understand and follow
verbal commands and instructions during both testing and training sessions. We excluded
children with fixed deformities of upper and lower limbs or had significant perceptual,
cognitive, visual and auditory disorders.</p><p>The children were assigned into two groups of equal number, a control group, and a study
group. Each group consisted of fifteen participants. Ethical approval was obtained in
accordance with the ethical principles of the Declarations of Helsinki.</p><p>The Biodex Balance System (AESCULAP-MEDITEC GMBH, Holland) was used to measure postural
stability parameters of all participants. The study procedure was explained to each patient.
Informed consent was filled and signed by the father or the mother. Care was taken not to
interrupt the recording procedure to maintain the child in a relaxed position. Each child
was instructed to take off their shoes before standing.</p><p>To ensure the safety of every patient, the session started with the balance platform in the
“locked” or static position. Before beginning the evaluation on the Biodex system, the
supporting structures above and below the examined joints were adequately fixed to stabilize
the balance device. We positioned the display at the patient’s eye level to ensure comfort
and safety. To protect the patient against sudden or unexpected movement on the platform,
the patient was asked to stand in the center of the platform and grasp the support handle,
then progress to standing without grasping the support handle. Three trials were performed
before testing. For static balance testing, the “default settings” were preselected with
three trials per side. The pre-trial testing assists with the learning curve and provides a
better average of the data. The system’s microprocessor-based actuator controls the degree
of surface instability.</p><p>The assessment of postural stability was performed pre and post treatment program for each
participant in both groups. The Postural Stability test emphasizes a patient’s ability to
maintain their center of mass. The patient’s score on this test assesses deviations from the
center; thus, a lower score is more desirable than a higher score. In this study platform,
stability was selected to be at one level (i.e.) level eight. The testing menu screen was
selected from the main menu. The patient setup information screen was displayed on Postural
Stability. The patient’s name, age, and range of height were selected. The foot position and
angle for each patient was recorded on the control display by using the alpha numeric grid
on the platform. The foot position and angle for each patient were constant during pre- and
post-test. The stance type was adjusted at a two-leg stance. The start button was pressed to
activate the cursor, and the patient was asked to move the cursor to the center point on the
grid. The record button was pressed to bring up the patient position entry screen. Using the
keypads, the patient’s left foot, left heel, right foot, and right heel positions were
entered with the midline of the foot and the platform grid as reference points. The stance
button was touched at the postural stability testing screen to scroll through the three
stance positions provided: left, right or both. The test trial time was set at 20 seconds.
The initial and ending platform stability settings were entered at level eight, with three
trials for each patient. The (OK) button was touched to confirm selections and to return to
the postural stability testing screen. With the patient ready to begin the test, the collect
data button was touched. The screen provided a three-second countdown before beginning the
first of three test trials. The display screen showed total trial time, platform setting,
and stance to the left of the grid. This displayed the trial number and score to the right
of the grid. After the first trial, the screen displayed “Trial 1 Complete,” the platform
returned to the locked position, and a ten-second rest countdown began for the second trial.
The data were collected and the second test trial started and continued. After completing
the test, a “Test Complete” message was displayed. The Results button was touched to advance
to the postural stability test results screen. The Print button was touched to automatically
generate a printed report at the postural stability test results screen. The (Save Results)
button was touched to save the test data and then (OK) was touched in response to the “Save
Results for later reporting or export”. The data generated from this test were in the form
of a balance index. This included the overall balance index, which represents the patient’s
ability to control his balance in all directions. High values mean balance disturbance
(increase rate of body swaying during the test). In addition, the results included the
anterior/posterior (A/P) index, which represents the patient’s ability to control his
balance in a front to back direction. High values indicate balance disturbance. Moreover,
the medial/lateral (M/L) index represents the patient’s ability to maintain his balance from
side to side. High values indicate balance disturbance. The (Home) button was touched to
return to the opening menu from the postural stability test results screen.</p><p>Children in the control group received a specially designed exercise program based on
balance activities while those in the study group received the same program in conjunction
with selected cognitive activities (<xref rid="tbl_001" ref-type="table">Table
1</xref><table-wrap id="tbl_001" orientation="portrait" position="float"><label>Table 1.</label><caption><title>Therapeutic intervention for both groups</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="center" rowspan="1" colspan="1">ITEM</th><th align="center" rowspan="1" colspan="1">Primary (Balance) activities</th><th align="center" rowspan="1" colspan="1">Secondary (Cognitive) activities</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">1st week</td><td align="left" rowspan="1" colspan="1">• Sit to stand</td><td align="left" rowspan="1" colspan="1">• Counting backward (e.g., by twos, threes): Patients were asked to
count backward from specific start number (e.g., from forty) and subtracting three
each time. It means patient will count (forty, thirty-seven, thirty-four,
thirty-one, twenty-eight and so on).</td></tr><tr><td colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">2nd week</td><td align="left" rowspan="1" colspan="1">• Stand with narrow B.O.S, with his or her eye closed.<break></break>• Standing
semi-tandem with eye open.<break></break>• Stand with stepping forward, backward, and sideways.<break></break>•
Sit to stand and walk.</td><td align="left" rowspan="1" colspan="1">• N-Back task: recite numbers, days, or months backward (December
to January).<break></break>• Tell story: tell any story such as what they did in the morning,
what they did on their vacation, and so on.</td></tr><tr><td colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">3rd week</td><td align="left" rowspan="1" colspan="1">• Standing semi-tandem with eye closed.<break></break>• Stand on foam, eyes open.<break></break>•
Sit to stand and pick up objects from the floor.<break></break>• Walk narrow B.O.S.<break></break>• Walk around
obstacles.<break></break>• Walk narrow B.O.S holding a toy.</td><td align="left" rowspan="1" colspan="1">• Random digit generation: randomly name the numbers between 0 and
300 (e.g., two hundred seventy four, thirty-nine, eighty-six, seven, and so on).<break></break>•
Tell opposite direction of action: name the opposite direction of their actions.
For example, they were required to name “left” when they move their right leg.
</td></tr><tr><td colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">4th week</td><td align="left" rowspan="1" colspan="1">• Stand on foam, eyes open.<break></break>• Stand and move hip in abduction and
adduction.<break></break>• Stand with stepping forward, backward, and sideways.<break></break>• Stand narrow
B.O.S and reach different directions.<break></break>• Sit to stand and stop with varied speed.<break></break>•
Walk narrow B.O.S.</td><td align="left" rowspan="1" colspan="1">• Name things and words: name things such as types of flowers,
states, and men’s names (e.g., mention name of men start with digit “M”, So he
said “Mohammed”, “Mustafa”, “Mounier”, “Mohsen” and so on).<break></break>• Subtract or add
number to letter: give the letter as result of the equation (e.g., K − 1 = J).<break></break>•
Stroop task: name the color of the ink while ignoring the meaning of the word
(e.g., see a paper written on it word “black” but written in red ink, So say “red”
and so on).</td></tr><tr><td colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">5th week</td><td align="left" rowspan="1" colspan="1">• Stand narrow B.O.S, with eyes closed.<break></break>• Stand semi-tandem, with
eye open.<break></break>• Stepping sideways.<break></break>• Roll the stick with foot.<break></break>• Stand narrow B.O.S and
reach different directions.<break></break>• Throw a ball.<break></break>• Sit on a ball and perturb.<break></break>• Walk
narrow B.O.S.</td><td align="left" rowspan="1" colspan="1">• Remembering things: memorize telephone numbers, prices, objects,
or words (e.g., mention price of last electric bill or grocery).<break></break>• Visual imaginary
spatial task: imagine and tell the road direction (e.g., the road direction from
their home to the mosque or supermarket).<break></break>• Auditory discrimination tasks: identify
noises or voices from a compact disc such as identifying voices (man, woman,
child) and identifying noises (hand clap, door close, cat meow).</td></tr><tr><td colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">6th week</td><td align="left" rowspan="1" colspan="1">• Stand and move hip and knee in flexion and extension.<break></break>• Stepping
sideways.<break></break>• Sit to stand on different chair heights.<break></break>• Walk with narrow B.O.S.<break></break>• Walk
and kick a ball.</td><td align="left" rowspan="1" colspan="1">• Spell the word backward: spell a word backward such as “apple,”
“bird,” and “television” (e.g., when patient spelling “apple” backward, he will
spell “E” then “L” then “P” then “P” then “A”).<break></break>• Visual discrimination tasks: they
were shown the pictures before and after performing the balance tasks. They were
asked to memorize the pictures and to respond if the pictures were the same.</td></tr></tbody></table></table-wrap>). Each treatment session lasted one hour and was conducted five times/week for
six successive weeks, approximately 30 sessions.</p><p>Data analyses were performed using SPSS 17 for Windows. The collected data of demographic
and other baseline characteristics were statistically treated to show mean, range and
standard deviation of measured parameters. χ<sup>2</sup> test and independent t-test were
used to compare baseline characteristics between both groups. A repeated measures 2-way
analysis of variance (ANOVA) was performed to compare changes in stability indices according
to two rehabilitation programs. Post hoc test was conducted following ANOVA when statistical
significant differences between data collected before and after treatment within each group
and between groups were found. P-value (<0.05) was considered statistically
significant.</p></sec><sec sec-type="results" id="s3"><title>RESULTS</title><p><xref rid="tbl_002" ref-type="table">Table 2</xref><table-wrap id="tbl_002" orientation="portrait" position="float"><label>Table 2.</label><caption><title>Demographic and baseline characteristics</title></caption><table frame="hsides" rules="groups"><thead><tr><th colspan="2" align="center" rowspan="1">Item</th><th align="center" rowspan="1" colspan="1">Control group</th><th align="center" rowspan="1" colspan="1">Study group</th></tr></thead><tbody><tr><td align="left" rowspan="2" colspan="1">Age (years)</td><td align="center" rowspan="1" colspan="1">Mean±SD</td><td align="center" valign="top" rowspan="1" colspan="1">12.6±1.8</td><td align="center" valign="top" rowspan="1" colspan="1">12.73±1.83</td></tr><tr><td align="center" rowspan="1" colspan="1">Range</td><td align="center" valign="top" rowspan="1" colspan="1">9–15</td><td align="center" valign="top" rowspan="1" colspan="1">9– 5</td></tr><tr><td align="left" rowspan="2" colspan="1">Weight (kg)</td><td align="center" rowspan="1" colspan="1">Mean±SD</td><td align="center" valign="top" rowspan="1" colspan="1">40.07±4.67</td><td align="center" valign="top" rowspan="1" colspan="1">41.2±4.74</td></tr><tr><td align="center" rowspan="1" colspan="1">Range</td><td align="center" valign="top" rowspan="1" colspan="1">33–48</td><td align="center" valign="top" rowspan="1" colspan="1">33– 7</td></tr><tr><td align="left" rowspan="2" colspan="1">Height (meters)</td><td align="center" rowspan="1" colspan="1">Mean±SD</td><td align="center" valign="top" rowspan="1" colspan="1">1.41±0.046</td><td align="center" valign="top" rowspan="1" colspan="1">1.42±0.042</td></tr><tr><td align="center" rowspan="1" colspan="1">Range</td><td align="center" valign="top" rowspan="1" colspan="1">1.35–1.52</td><td align="center" valign="top" rowspan="1" colspan="1">1.35–1.48</td></tr><tr><td align="left" rowspan="2" colspan="1">Frequency distribution of gender</td><td align="center" rowspan="1" colspan="1">Male</td><td align="center" valign="top" rowspan="1" colspan="1">8</td><td align="center" valign="top" rowspan="1" colspan="1">9</td></tr><tr><td align="center" rowspan="1" colspan="1">Female</td><td align="center" valign="top" rowspan="1" colspan="1">7</td><td align="center" valign="top" rowspan="1" colspan="1">6</td></tr><tr><td align="left" rowspan="2" colspan="1">Frequency distribution of affected side</td><td align="center" rowspan="1" colspan="1">Right side</td><td align="center" valign="top" rowspan="1" colspan="1">9</td><td align="center" valign="top" rowspan="1" colspan="1">10</td></tr><tr><td align="center" rowspan="1" colspan="1">Left side</td><td align="center" valign="top" rowspan="1" colspan="1">6</td><td align="center" valign="top" rowspan="1" colspan="1">5</td></tr><tr><td align="left" rowspan="3" colspan="1">Frequency distribution of spasticity grading</td><td align="center" rowspan="1" colspan="1">Grade 1</td><td align="center" valign="top" rowspan="1" colspan="1">4</td><td align="center" valign="top" rowspan="1" colspan="1">6</td></tr><tr><td align="center" rowspan="1" colspan="1">Grade 1<sup>+</sup></td><td align="center" valign="top" rowspan="1" colspan="1">5</td><td align="center" valign="top" rowspan="1" colspan="1">4</td></tr><tr><td align="center" rowspan="1" colspan="1">Grade 2</td><td align="center" valign="top" rowspan="1" colspan="1">6</td><td align="center" valign="top" rowspan="1" colspan="1">5</td></tr></tbody></table></table-wrap> presents a summary of demographic and other baseline characteristics at entry
including age, weight, height, frequency distribution of gender, frequency distribution of
affected side, and frequency distribution of spasticity grading. There were no significant
differences between both groups (p>0.05).</p><p>A significant statistical difference was observed in the stability indices, including
medio-lateral, antero-posterior and overall indices, after three months of application of
the rehabilitation program (p<0.05), either when comparing mean values within each group
or when comparing mean values between groups concerning post treatment results as shown in
<xref rid="tbl_003" ref-type="table">Table 3</xref><table-wrap id="tbl_003" orientation="portrait" position="float"><label>Table 3.</label><caption><title>Comparing mean values of stability indices in both control and study
groups</title></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="3" align="center" valign="middle" colspan="1">Stability index</th><th colspan="2" align="center" rowspan="1">Control group</th><th colspan="2" align="center" rowspan="1">Study group</th></tr><tr><th colspan="2" rowspan="1"><hr></hr></th><th colspan="2" rowspan="1"><hr></hr></th></tr><tr><th align="center" rowspan="1" colspan="1">Pre treatment</th><th align="center" rowspan="1" colspan="1">Post treatment</th><th align="center" rowspan="1" colspan="1">Pre treatment</th><th align="center" rowspan="1" colspan="1">Post treatment</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Medio-lateral</td><td align="center" rowspan="1" colspan="1">2.03±0.44</td><td align="center" rowspan="1" colspan="1">1.54±0.52 *</td><td align="center" valign="top" rowspan="1" colspan="1">1.96±0.49</td><td align="center" valign="top" rowspan="1" colspan="1">1.19±0.38 * #</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Antero-posterior</td><td align="center" valign="top" rowspan="1" colspan="1">2.28±0.6</td><td align="center" valign="top" rowspan="1" colspan="1">1.74±0.53 *</td><td align="center" valign="top" rowspan="1" colspan="1">2.2±0.74</td><td align="center" valign="top" rowspan="1" colspan="1">1.23±0.36 * #</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Overall</td><td align="center" valign="top" rowspan="1" colspan="1">2.9±0.73</td><td align="center" valign="top" rowspan="1" colspan="1">2.29±0.69 *</td><td align="center" valign="top" rowspan="1" colspan="1">2.96±0.86</td><td align="center" valign="top" rowspan="1" colspan="1">1.82±0.51 * #</td></tr></tbody></table><table-wrap-foot><p>*Significant difference between pre and post treatment mean values. <sup>#</sup>Significant difference between post-treatment mean values of both groups
in favor of study group</p></table-wrap-foot></table-wrap>. The interaction between all variables was studied and there was no
significant difference.</p></sec><sec sec-type="discussion" id="s4"><title>DISCUSSION</title><p>In this study, dual-task training focusing on balance and cognitive tasks may improve
postural stability compared with those focusing only on conventional balance training in
children with infantile hemiparesis. Postural stability depends on the on appropriate
integration of visual, proprioceptive, and vestibular signals, which accordingly leads to
the generation of an optimal motor response to counteract a postural perturbation<xref rid="r19" ref-type="bibr">19</xref><sup>)</sup>. Swan et al.<xref rid="r20" ref-type="bibr">20</xref><sup>)</sup>, proposed that performing a secondary cognitive task
directs attention away from balance-related cues, thereby preventing over-corrections.</p><p>Cognitive therapy is important to reduce fall risk. Although hemiplegics have complex
impairments involving cognitive, sensory, and motor functions, they receive therapies
focused on a single aspect at a time. For example, a physical therapist provides treatment
for motor impairments or poor balance control, whereas an occupational therapist provides
cognitively oriented therapy. However, many tasks in a community setting require an
interplay of motor, sensory, and cognitive functions. The interventions that were provided
to the dual-task group in this study help patients with stroke adapt to the real-world
environment. Therefore, our findings that dual-task training focusing on balance control and
cognitive function improved postural stability have important clinical implications and
suggest that this type of dual-task training might be helpful for reducing fall risk and
helping patients with stroke adapt to new strategies<xref rid="r21" ref-type="bibr">21</xref><sup>)</sup>.</p><p>These results suggest that patients in the dual-task group reduce their risk of falling or
becoming unstable during activities that require weight shifts. In addition, significant
decreases in sway area and sway length were observed only in the dual-task group during
steady standing, which represents steadiness and postural control<xref rid="r22" ref-type="bibr">22</xref>, <xref rid="r23" ref-type="bibr">23</xref><sup>)</sup>. Lee et
al.<xref rid="r24" ref-type="bibr">24</xref><sup>)</sup>, reported that visual feedback
training improves sitting balance and visual perception in patients with chronic stroke. The
dual-task training we provided was task oriented and of high intensity. Dual-task programs
trigger the conscious control mechanisms and attention strategies and reduce automatic
control during activities. The automatic control of movement involves the supplementary
motor area (SMA) which receives its major input from the basal ganglia (BG)<xref rid="r25" ref-type="bibr">25</xref><sup>)</sup>. The potent effect of dual-task programs
may be attributed to the efficacy of attention in generating cortical plasticity in the
primary somatosensory and motor cortex and improvement in the motor memory<xref rid="r26" ref-type="bibr">26</xref><sup>)</sup>. Holschneider et al.<xref rid="r27" ref-type="bibr">27</xref><sup>)</sup>, also stated that long-term dual-task programs elicit
plastic changes in the brain. These changes result in a combination of increase in the
efficiency of neural processing (sensorimotor cortex, striatum, vermis) and enforcement of
the cerebellar-cortical circuit.</p><p>In the current study, improvement in the postural stability parameters can be explained by
the potent effect of the dual-task program on activating an alternate pathway containing the
cerebellum, sensorimotor cortex, and lateral premotor cortex. In this pathway, the
cerebellum is responsible for movement timing. The premotor cortex may be responsible for
scaling the motor activity when facilitated by somatosensory cues related to any task (i.e.
walking). This means that recruitment of these structures can compensate for inefficient
BG<xref rid="r28" ref-type="bibr">28</xref>, <xref rid="r29" ref-type="bibr">29</xref><sup>)</sup>. Chen et al.<xref rid="r30" ref-type="bibr">30</xref><sup>)</sup>compared the between effects of simple versus dual-task training on dynamic balance but in
children with attention deficit hyperactivity disorder as they found it effective in favour
to dual-task training. Future studies should investigate the effect of various cognitive
skills on balance through postural sway<xref rid="r31" ref-type="bibr">31</xref><sup>)</sup>. Additionally, future research should investigate the different
effects of dual motor task training in patients with neurological deficits from various
viewpoints depending upon activities of daily living and gait<xref rid="r32" ref-type="bibr">32</xref>,<xref rid="r33" ref-type="bibr">33</xref>,<xref rid="r34" ref-type="bibr">34</xref>,<xref rid="r35" ref-type="bibr">35</xref>,<xref rid="r36" ref-type="bibr">36</xref>,<xref rid="r37" ref-type="bibr">37</xref><sup>)</sup>.</p></sec></body><back><ref-list><title>REFERENCES</title><ref id="r1"><label>1</label><mixed-citation publication-type="journal"><person-group><name><surname>Belen’kiĭ</surname><given-names>VE</given-names></name><name><surname>Gurfinkel’</surname><given-names>VS</given-names></name><name><surname>Pal’tsev</surname><given-names>EI</given-names></name></person-group>: <article-title>[Control elements of voluntary movements]</article-title>.
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