Biodex Balance Training Versus Conventional Balance .
ng withhips in 90 flexion, the tester passively drove the leg from 90 to 45 knee flexion and maintained the leg at the target anglefor 10 s before returning to the initial position. The testerused 15 /s. angular velocity and paused for 5 s beforerepeating the cycle. Subjects pushed the button once they feltPlease cite this article in press as: El-gohary TM, et al., Biodex balance training versus conventional balance training for children with spastic diplegia,Journal of Taibah University Medical Sciences (2017), http://dx.doi.org/10.1016/j.jtumed.2017.07.002
3Biodex balance training versus conventional balance trainingAssessed patients for eligibilityn 64Excluded n 8Not meeting inclusion criteria n 7Declined to participate n 1Randomized n 56Withdrew at baseline n 2Group B (Study Group)Group A (Control Group)PT Program Biodex Balance System, n 27PT Program, n 27Withdrew, n 3Withdrew, n 3Reasons: Surgery (n 1)Reasons: Respiratory problems (n 1)Hospital Admission (n 2)Hospital admission (n 2)Completed the training: 24Completed the training: 24Included in the final analysis: 24Included in the final analysis: 24Figure 1: Flowchart of children’s retention and recruitment.the target angle. The tester recorded the time elapsed andidentified the angle. The average of three readings wascalculated using the absolute difference between theperceived- and the target-angle.Treatment proceduresincludes maintaining a quadruped position, kneeling,standing, and shifting weight to balance on one limb. Dynamic balance training measures the ability to control thebody when the support surface is unstable. The researcherused a gym ball to train automatic postural reactions. Dynamic disturbance prompts an equilibrium reaction on oneside and a protective reaction on the other side, in addition torighting reactions on the axial body.The control groupChildren were given a traditional physical therapy programme in addition to postural control exercises. The therapist used a one-hour session, 3 /wk for three successivemonths. A number of therapeutic activities were used, asstated in Appendix A.A conventional balance training programme includesstatic and dynamic balance training. Static balance trainingThe study groupChildren in the study group received dynamic balancetraining using the Biodex balance system, in addition totraditional physical therapy programme. After familiarization, each child was instructed to stand with both legs on the“locked” platform. The researcher advanced the platform toan unstable state while instructing the child to focus on theTable 1: Characteristics of participants in the study.AgeP 0.05GenderWeightP 0.05HeightP 0.05OrthoticsAssistive devicesMASGroup A8.63 SD 0.7111 F13 M29.2 SD 0.97131 SD 1.4 cm12 using walker1þ Ten1 FourteenGroup B8.93 SD 0.5510 F14 M27.9 SD 1.1129 SD 2.1 cm12 using AFO4 using KAFO8 using med. shoes9 using AFO5 using KAFO10 using med. shoes3 using walker1þ Thirteen1 ElevenPlease cite this article in press as: El-gohary TM, et al., Biodex balance training versus conventional balance training for children with spastic diplegia,Journal of Taibah University Medical Sciences (2017), http://dx.doi.org/10.1016/j.jtumed.2017.07.002
4T.M. El-gohary et al.Figure 2: Pre- and post-intervention mean values of the PaediatricBerg balance scale.visual feedback screen. Arms were free at the side of the bodyand not grasping handrails. A stability level of 6 was suitablefor the majority of the children as a starting training level.Fourteen children were trained starting with a stability levelof 8, while 10 were trained starting with a stability level of 6.The transition between levels was based on the progress ofbalance capability.comparison within and between groups was performed usinga Wilcoxon signed rank test and a ManneWhitney U-test.SPSS 22 was the software used for all data analysis. Statistical significance was set at alpha level 0.05.Statistical analysisResultsUsing the ShapiroeWilk test, the Paediatric Berg balancescale data were normally distributed, while those of theGMFMS were not. Descriptive statistics, includingmean standard deviation, were calculated for the Bergbalance scale data for both groups. A paired sample t-testwas used to ascertain within group differences. The unpairedsample t-test was used for between group differences in allpost-intervention outcome measures. For GMFMS,The total number of children studied, from screening toanalysis, is shown in (Figure 1). The paired sample t-test wascarried out to check for any differences between pre- andpost-mean values of the paediatric Berg balance scale.Children’s mean values are included in (Table 1). The meanvalues of the pre- and post-balance training scores for thecontrol and study groups are shown in (Figure 2). All posttreatment mean values were significantly greater than theFigure 4: Pre and post treatment values of GMFMS (walkingdimension) for both groups.Figure 3: Pre and post mean values of dimension D (standing) of GMFMS.Please cite this article in press as: El-gohary TM, et al., Biodex balance training versus conventional balance training for children with spastic diplegia,Journal of Taibah University Medical Sciences (2017), http://dx.doi.org/10.1016/j.jtumed.2017.07.002
5Biodex balance training versus conventional balance trainingpretreatment mean values for both the study and the controlgroups (P 0.05) (see Figures 3 and 4).The unpaired sample t-test was carried out to determinethe difference in the post-treatment mean values of bothgroups. Children in the study group had mean values of40.04 2.17 compared with 38.70 2.25 for the controlgroup. This difference indicates superior improvement of thestudy group. The post-treatment mean value of the studygroup was significantly greater than the post-treatment meanvalue of the control group (P 0.05).Regarding GMFMS, the pre-test scores of both groupsdisplayed no statistical significant difference (P 0.05),which established baseline equivalency. In the study group,the difference in the mean from the pre-test to post-test wasstatistically significant (P 0.05). In the control group, theimprovement was statistically significant with P 0.05. Bothgroups displayed a statistically significant improvement, withP values less than 0.05 (Table 2). In the post-treatmentgroups, the results showed statistically significant differences between the groups, with the Biodex training groupfavoured (see Tables 3e5).DiscussionCerebral palsy is one of the most prevalent and oftenencountered health conditions that can benefit from physicaltherapy intervention. It has also been extensively studied,based on evidence in the current literature.16 In the presentstudy, children in the study group who received balancetraining using the Biodex balance system in addition to thetraditional physical therapy programme showed moreimprovement as measured by post-treatment mean valuesthan the control group who received the conventional balance training in addition to the traditional physical therapyprogramme. The progress can be described and illustrated byimprovements in: first, neuromotor planning strategy;Table 2: Continuous variables of the paediatric Berg balancescale scores for both groups.Paediatric Berg Mean SDbalance scalePret-valueP-valuePost36.58 2.20 38.70 2.25 7.647 0.000*35.91 1.74 40.04 2.17 13.621 0.000*Group AGroup B*Significant difference, P value: probability value, SD, standarddeviation.Table 3: Mean SD of dimension D (standing) of gross motorfunction measures within and between the Biodex and conventional balance training groups.GMFMS“D” (%)Mean SDPrePostGroup AGroup BUP value73.54 5.2873.08 4.53264.000.61878.00 4.6781.042 3.544191.50.04Z-valueP value 3.87 4.310.000*0.000**Significant difference; P value: probability value; SD: standarddeviation.Table 4: Mean SD of dimension E (walking) of gross motorfunction measures within and between the Biodex and conventional balance training groups.GMFMS“E” (%)Group AGroup BUP valueMean SDPrePost66.50 3.767.75 4.93246.000.38572.05 3.7075.67 4.99152.50.005Z-valueP value 4.33 4.270.000*0.000**Significant difference; P value: probability value; SD: standarddeviation.Table 5: Pre and post mean values of angular error of the kneefor the control and study groups.GroupMean SDPreControl groupStudy groupt-valueP valuet-value P valuePost13.1 1.803 11.000 1.685 14.68513.5 1.316 9.95 0.94511.4610.1002.4300.050.020.0000.000second, sensory-perceptual motor integration; and third,neuromusculoskeletal functional capabilities.First, children with spastic diplegia have differentrecruitment patterns compared with non-disabled children,and tend to have a limited capacity to modulate posturalactivity.17 Kane and Barden6,7 reported that postural controldifficulties may be associated with delayed anticipatoryadjustment and inconsistent preparatory activation.Biodex balance training might subtly have modulated therecruitment pattern and the anticipatory adjustmentmechanisms through targeting the somatosensory andneuromuscular aspects of balance control. The labile supportsurface disturbs balance, which prompts the child to maintain the centre of gravity within the base of support. Theinstantaneous feedback while training on the Biodex systemhelps the child to relate body parts and repeat the motion aswell as restore kinaesthetic sense for proper body positioningto maintain balance. This result is in harmony with thefinding reported by Zadnikar and Kastrin8 who showed thatadequate anticipatory postural adjustments, which precedeactive movement, are essential to having coordinatedvolitional movement.Second, children with cerebral palsy tend to have balanceimpairments.18 Consequently, they rely on visual input toenhance their control, which may reflect impairments inproprioception.19 Wingert et al.10 examined joint-positionsense and kinaesthesia in children with CP and in agematched controls. Their results showed that participantswith cerebral palsy have proprioception impairments in alllimbs.The Biodex balance training system might haveimproved the integration of different types of sensory information, promoting better balance and postural controlthrough providing gradual challenges to the children toimprove their motor abilities to meet the demands ofmotor control in sensory conflict conditions. Children withPlease cite this article in press as: El-gohary TM, et al., Biodex balance training versus conventional balance training for children with spastic diplegia,Journal of Taibah University Medical Sciences (2017), http://dx.doi.org/10.1016/j.jtumed.2017.07.002
6T.M. El-gohary et al.SDCP tend to stand on tiptoes. The perturbation of thebalance base allows the feet to touch the platform whilethe children look at the peripheral visual signals. Thecentral nervous system incorporates the peripheral somatosensory, visual and vestibular inputs, integrates them,and selects the most appropriate muscular responses tocontrol body posture.Biodex balance system training could also have influenced the process of integration between the central andperipheral nervous systems to have a meaningful bodycontrol response.20,21 This concept is in agreement with thefindings of Mawase et al.,22 who reported a larger posturalsway when there was loss of somatosensory feedbackinformation from the feet.,Additionally, it is supported bythe findings of Tomita et al.,23 who showed that sensoryperceptual motor training for children with SDCP had ameasurable, significant effect that was greater than that ofthe controls.Third, SDCP children tend to suffer from poor posture andpoor balance.24 Poor posture results in poor kinematics, trunkinstability25,26 and poor coordination.8,9 Ju et al.27 reportedthat trunk instability is exhausting for children with SDCP.Borstad et al.28 revealed that exhaustion and muscle fatiguecontribute to the poor kinematics and are potential riskfactors for the continuation of the poor mechanicsassociated with the physical disorder. El-gohary et al.29found measurable differences in muscle endurance ability atdifferent ranges of spine kinematics. Heyrman et al.26 addedthat children with SDCP tend to show significantly higherkinematic parameters than typically developing children.The Biodex balance training system might have improvedthe neuromusculoskeletal functional abilities throughdecreasing postural mal-alignment and improving spinalkinematics with subsequent improvement in balance control. The findings of the present study coincide with thefindings of Bahramizadeh et al.30 and El-shamy and Abd Elkafy11 who recorded progress in postural control afterbalance training. They added that postural adjustmentplays a substantial role in quality of movement by creatinga stable foundation during the active movement ofextremities. Lacoste et al.31 added that maintenance ofadequate postural stability is the foundation for functionalmotor activities. Liao et al.19 agreed with the role offunctional strengthening exercises for improving functionalmotor abilities in SDCP children. Auld and Johnston32showed that children with cerebral palsy had significantimprovement in balance and strength even when practisinglow doses of group exercises. Artilheiro et al.33 and Liaoet al.19 concluded that functional muscle strengthcorrelates with gross motor skills in children with mildspastic diplegia.The improvements in the passive reproduction of movement could be attributed to the relaxation and the control ofspasticity when using Biodex balance training. This finding isin harmony with Chrysagias et al.,34 who studiedkinaesthetic ability in a group of children with spasticcerebral palsy, compared with a control group. Researchersfound a difference in outcome measures that was attributedto the kinaesthetic deficits in children with cerebral palsy.Promoting relaxation helps to control muscle tone, whichhas a significant relationship to improvement in passivereproduction of movement.In essence, the labile standing surface of the Biodex balance training system is more likely to simulate the unstablenature of a walking terrain. Moreover, Biodex balancetraining provides a gradual, step-by-step functional trainingsimulation.ConclusionIn conclusion, the Biodex balance training system is aneffective and efficient tool that can be used to improve balance and gross motor capabilities in children with SDCP.FundingNone.AuthorshipThis work is original, has not been published and is notunder consideration elsewhere.Authors’ contributionsTME and HAE conceived and designed the study andconducted the data collection. TME and FAH analysed andinterpreted the data in addition to reviewing the final results.TME and AMA provided logistical support and wrote theinitial and final drafts of the article. All authors are responsible for the findings and have critically reviewed andapproved the final draft of the article.Conflicts of interestThe authors have no conflict of interest to declare.AcknowledgmentThanks to children and families who participated in thestudy and to the therapists at the outpatient clinic of themedical rehabilitation hospital, Almadinah Almunawwarah,KSA.Appendix A. Supplementary dataSupplementary data related to this article can be found eferences1. Richards CL, Malouin F. Cerebral palsy: definition, assessmentand rehabilitation. Handb Clin Neurol 2013; 111: 183e195.2. Molina M, Kudlinski C, Guilbert J, Spruijt S, Steenbergen B,Jouen F. Motor imagery for walking: a comparison betweencerebral palsy adolescents with hemiplegia and diplegia. ResDev Disabil 2015; 37: 95e101.3. Emara HA, El-gohary TM, Al-Johany AH. Effect of bodyweight suspension training versus treadmill training on grossmotor abilities of children with spastic diplegic cerebral palsy.Eur J Phys Rehabil Med 2016; 52: 356e363.Please cite this article in press as: El-gohary TM, et al., Biodex balance training versus conventional balance training for children with spastic diplegia,Journal of Taibah University Medical Sciences (2017), http://dx.doi.org/10.1016/j.jtumed.2017.07.002
Biodex balance training versus conventional balance training4. Brien M, Sveistrup H. An intensive virtual reality programimproves functional balance and mobility of adolescents withcerebral palsy. Pediatr Phys Ther 2011; 23: 258e266.5. Hwang JH, Lee C-H, Chang HJ, Park D-S. Sequential analysisof postural control resource allocation during a dual task test.Ann Rehabil Med 2013; 37: 347e354.6. Kane K, Barden J. Frequency of anticipatory trunk muscleonsets in children with and without developmental coordinationdisorder. Phys Occup Ther Pediatr 2014; 34: 75e89.7. Kane K, Barden J. Contributions of the trunk muscles toanticipatory postural control in children with and withoutdevelopmental coordination disorder. Hum Mov Sci 2012; 31:707e720.8. Zadnikar M, Kastrin A. Effects of hippotherapy and therapeutic horseback riding on postural control or balance in children with cerebral palsy: a meta-analysis. Dev Med Child Neurol2011; 53: 684e691.9. Tarakci D, Ozdincler AR, Tarakci E, et al. Wii-based balancetherapy to improve balance function of children with cerebralpalsy: a pilot study. J Phys Ther Sci 2013; 25: 1123e1127.10. Wingert JR, Burton H, Sinclair RJ, Brunstrom JE,Damiano DL. Joint-position sense and kinesthesia in cerebralpalsy. Arch Phys Med Rehabil 2009; 90: 447e453. http://dx.doi.org/10.1016/j.apmr.2008.08.217.11. El-Shamy SM, Abd El kafy EM. Effect of balance training onpostural balance control and risk of fall in children with diplegiccerebral palsy. Disabil Rehabil 2013: 1e8.12. Numano
compared the Biodex balance system with the conventional balance approach for improving balance and motor control in children with SDCP. Therefore, this study was designed to examine the effect of using the Biodex balance system for improving the balance scores and gross mot
Balance tests were performed using the Biodex Balance System (Biodex Balance System, BBS; Biodex Inc., Shirley, NY), which can accurately reflect the balance performance. Static test: Performed on right leg, left leg and posture positions on
BALANCE SYSTEM SD OPERATION/SERVICE MANUAL 950-440 950-441 950-444 BIODEX . Assessing Limits of Stability With The Biodex Balance System Understanding Patient Performance . CAUTION: Federal Law restricts this device to sale by, or on the order of a medical practitioner.
way, the Biodex stability system (BSS) (Biodex 945-302, Biodex Medical Systems Inc; Shirley, New York) pre-sents a system that can provide specific ankle and hip postural strategy training with external visual biofeed-back as a guide to improve the im
Biodex Balance Assessment is conducted using either the versatile Balance System SD or portable BioSway. The Balance System SD is a sophisticated measuring and training device for static and dynamic balance testing and training. The BioSway is a portable balance device, with a static-only platform. The CTS
2 BALANCE SYSTEM SD (version 4.x) AND BIOSWAY This Normative Data document provides data sets for the Balance System SD and BioSway. Additional information and resources are available upon request or directly from the Biodex
Interaction on Balance using the BioDex Balance System SD (Biodex Medical Systems Inc., New York, USA). The objective of this test is to quantify how well a patient can integrate various forms of sensory inputs with respect to balance and also compensate when one or m
Biodex Balance System SD, *designed and supported by Biodex - Patient testing shall be conducted in an area designated by the Department of Athletic Training Services. All reasonable steps will be taken to ensure the p
The Baldrige framework and core values provide a useful foundation for educational planning and implementation (Belohlav, Cook & Heiser 2004). Research indicates that the Baldrige/Excellence in Higher Education framework, when used as the basis of organizational self-assessment programs, broadens knowledge, clarifies strengths and priorities for
