Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore
Annexure II
1.
Name of the candidate and
address (in block letters)
THAKKAR PRIYA JANAK
Dr.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY,
VIDYA NAGAR, KULOOR,
MANGALORE-575013
2.
Name of the Institution
Dr. M. V. SHETTY COLLEGE OF
PHYSIOTHERAPY
3.
Course of study and subject
MASTER OF PHYSIOTHERAPY (MPT)
(PEDIATRIC PHYSIOTHERAPY)
4.
Date of admission
23 JUNE 2011
5.
Title of the Topic
A STUDYANALYZING THE EFFECTIVENESS OF
PEDIATRIC BALANCE SCALE (PBS) AS AN
OUTCOME MEASURE FOR BALANCE IN
CHILDREN SUFFERING FROM DOWN’S
SYNDROME.
6.
Brief Resume of the Intended Work
6.1) INTRODUCTION AND NEED OF THE STUDY:
Down Syndrome (DS) is a chromosome abnormality and is one of the most common genetic
causes of the developmental disabilities.Individuals with DS have three number 21 chromosomes
instead of two in some or all cells.They have unique physical,neurological,musculoskeletal,and
sensorimotor and learning and communication characteristics than can impact each other as well
as the individual’s ability to develop age appropriate skills.Individuals with DS tend to exhibit
joint laxity,excessive hip abduction and external rotation, asymmetrical or excessive range of
motion and difficulty in initiating movement.They tend to avoid weight bearing,weight shifts and
trunk rotation and have difficulty with equilibrium,balance,protective response and graded muscle
movement. All of these factors contribute to the use of wide base of support in sitting and
standing and delay in locomotion.1 Ligamentous laxity,decreased strength and hypertonia are
thought to contribute to delays in motor development2. Children with DS also have low scores on
balance and agility tasksas well as on running speed, strength and visual-motor control than do
children with other mental impairments3, 4.
Movement is a critical aspect of life in down syndrome children and it is also very essential aspect
in their ability to walk and perform functional task. John Langdon Down,a British doctor
described this syndrome in1866 and named it as Down’s Syndrome.5Down’sSyndrome is a
condition in which extra genetic material causes delays in the way a child develops,and often
leads to mental retardation.6.It also affects the children with cognitive abilities in different
ways.Studies reported that these children have been shown to have poor postural control that
significantly affects their motor skill performance with other cognitive task.However,as the life
expectancy of Down’s Syndrome individual increases,their intellectual disabilities and early onset
dementia pose increasing personal and societal burden7.
However the most common chromosomal abnormality is caused by the presence of an extra
chromosome 21, and sometimes by the translocation of chromosome 14 or 15 and chromosome 21
or 22.8 The individual will have varying degrees of mental problems and multiple defects and is
associated with maternal age9.The suspected diagnosis should always be confirmed
throughgenetictesting.Along with these conditions Down’s Syndrome has cognitive deficits and
they are also associated with mental retardation10.Usually mental development and physical
development are slower in people with Down’s Syndrome than in those without the condition.
The number of developmental abnormalities has been described in the Down’s Syndrome
individuals. Such abnormalities were usually diagnosed at the time of birth, based on
characterized physical appearance. There is some evidence of abnormalities occurring earlier in
development, and not all infants with Down’s Syndromehave all of these characters. Children
with Down’s Syndrome can learn, and are capable of developing skills throughout their lives.
They simply reach goals at a different pace in abnormal way.
Even though most of these features can be found in normal individuals, combination of motor task
which include different functional activity could raise the suspicion of Down’sSyndrome. Hence it
will be important to determine precise sequence of developmental abnormalities that occurred in
this syndrome. Also these children may have some physical and mental features in common.
Symptomsof Down’s Syndrome can range from mild to severe. Most of the people with Down’s
Syndrome have IQwhich fall in the mild –moderate range of mental retardation. Results show
mental retardation is a disability that causes intellectual abilities and adaptive behavior
(conceptual, social and practical skills people use to function in everyday lives).
Various studies reported that the fine motor (grasping, writing etc.) and gross motor (walking,
jumping, running etc.)skills both were delayed in Down’s Syndrome children as compared to
normal children, which is because Down’s Syndrome children have very poor muscle tone, weak
and floppy muscles. Motor delay in Down’s Syndrome varies in individuals ranging from mild to
moderate.
While considering gross motor functions in Down’s Syndrome, it can be assessed using gross
motor functional scale and also can be used to classify the Down’s Syndrome patients on the basis
of their functional ability. Gross motor functional scale has levels I-V which descends on severity
of the functional disability. Majorityof Down’s Syndrome children are found on level I and II of
the gross motor functional scale.
Functional mobility in Down’s Syndrome will be delayed as they have hypotonicity as well as
joint instability. So these children will face many difficulties in day to day activities to check the
degree of functional mobility delay, there are different scales and tests introduced by many
researchers.
Balance and postural stability refers to the state of bodily equilibrium or the ability to maintain the
Centre of body mass over the base of support11. Balance is the ability to maintain the position of
the body relative to the limits of stability.12It involves controlling the body’s position in space for
the purposes of stability limits and orientation and controlling the body’s position without change
in base of support13.
In 1851 AD, Romberg used different balance tests to assess static standing skill. Many tools have
since been developed to attempt to describe and measure balance.14 To maintain the postural
stability,the integration of visual, vestibular and proprioceptive neural input to the central nervous
system is required11.It provides the sensory information necessary for balance.
The
visual
system
detects
information
regarding
motion
of
self
in
regard
to
stationaryenvironment, to the objects, and to moving objects or people. If the visual system does
not distinguish between self-motion and surrounding motion, there may be misinterpretation with
resultant inaccurate motor output12.
Somatosensory (proprioception, kinesthesia) input provides information regarding the body with
reference to the supporting surface. Slopes and uneven ground are best detected by somatosensory
perception. Proprioception is a distinct component of balance. It is the cumulative neural input
from the mechanoreceptors in the joint capsules,ligaments,muscle tendons and the skin to CNS
and when these structures are subjected to mechanical deformation, action potentials are
conducted to the CNS and contribute to the body’s ability to maintain postural stability11.
Vestibular information signals the head’s position and movement, the semicircular canals detect
angular acceleration of the head, and the otoliths signal linear position and acceleration. Gravity is
a stimulus and therefore the otoliths detect position in relation to vertical. Identification of any
vestibular impairments contribution to imbalance impairment. Gaze stabilization during head
movements is a major function of vestibular system. Righting reactions and the equilibrium
reactions which emerge with the maturation of brainstem and the cortex respectively also plays an
important role in the maintenance of balance.12
Need of the Study:
 Pediatric Balance Scale (PBS) is a scale widely used in normal pediatric subjects. But
there are very few studies in which the effectiveness of PBS as an outcome measure for
balance in Down’s Syndrome has been evaluated.
 Pediatric Balance Scale (PBS) is an easy and time effective scale which if usable in
Down’s cases would be a good predictor of prognosis regarding the balance parameter and
the assessment using PBS would make the procedure faster and easier.
Hence there is a need to prove the effectiveness of PBS as an outcome measure in Down’s
Syndrome.
Research Question:
Will Pediatric Balance Scale prove to be an effective outcome measure to assess balance among
children with Down’s Syndrome?
Hypothesis:
 Research hypothesis: Pediatric Balance Scale (PBS) may prove to be an effective outcome
measure to assess balance in Down’s Syndrome cases.
 Null hypothesis: Pediatric Balance Scale (PBS) may not be an effective outcome measure
to assess balance in Down’s Syndrome cases.
6.2) REVIEW OF LITERATURE :
SamiaA.AbdelRahman, AfafA.M.Shaheen in Jan 2010, determined the effect of
weight bearing exercises on balance in children with Down’s Syndrome. The study concluded that
a well-organized program of weight bearing exercises could improve both static and dynamic
balance for children with Down’s Syndrome.
Whitne. WrisleyD, Furmany S J in 2003,investigated a study regarding the concurrent
validity of the Berg Balance Scale(BBS) by comparing it with Dynamic gait index in people with
vestibular dysfunction. The study concluded that, though boththese measures provide valuable
information regarding functional balance capabilities, but there was lack of perfect correlation
which indicated that BBS is not a sensitive assessment tool to identify balance in people with
vestibular disorder.
In 2002 KembhaviG, Dorrah et alused BBS to distinguish balance abilities in children with
cerebral palsy. The result suggested that BBS can be considered as a clinical measure of balance
for children with cerebral palsy and functional classification system can be used to group children
more homogeneously than traditional class by diagnosis.
In 2003, a study of BBS with children as subjects was done by Franjoineand
colleagues.BBS was administered to children in the age group of 4-12 years. Preliminary results
revealed unsatisfactory test-retest reliability. On the basis of the result obtained, Berg’s scales
were modified to create a pediatric version. The modifications were minor and included,reordering of test items and reducing the time standards for static postures. Test items within the
BBS are organized by increasing the difficulty of task and the items were reordered into
functional sequences.
Franjoinedid a study of the newly modified Pediatric BalanceScale (PBS) for the purpose
of determining its test-retest reliability. The test-retest reliability was extremely
high(Icc3,I=0.85).The study concluded that PBS has beendemonstrated to have good test-retest
and interrater reliability when used with school children (5-15 years)with mild to moderate
impairments.
Anuja A and SavitaR, on 2005,conducted a study to determine the age of attainment of
balance using PBS and also to see if there is a correlation between age and PBS.The result showed
a significant positive correlation between age and PBS.Most children aged nine years scored
maximum of 56 therefore PBS shows the age of attainment of balance in children as 9 years.
Hubber,KellyA,Franjoine,Mary rose et al in 2006conducted a study to examine the effects
of imposing concurrent cognitive tasks during an upright postural control training program on
functional balance and the mobility as measured by changes on the Pediatric Balance
Scale(PBS)and pediatric standardized walking obstacle course. They reported that the study
supports the use of dual-tasks training to promote automaticity of balance skills in children. They
suggest that postural control training for functional mobility under dual tasks conditions promotes
improved task functional mobility performance in school aged population.
Podsiadlo D, Richardson S. in 2001,reported that The Time “Up & Go” Test A Test of
Basic Functional Mobility for Frail Elderly Persons modifies the original test by adding a timing
component to performance. They concluded that TUGT is a reliable and valid test for quantifying
functional mobility that may also be useful in following clinical change over time.
Ng SS et al in 2005examined the test retest reliability of The Time Up and Go Test (TUGT) in
stroke patients and found it reliable and valid.
Dan Gordon in May 2006 did a study on the benefits of exercise and training for a reference
population. He thereby concluded that a program is developed, which is structured , stimulated
and confirms to the needs of the Down’s Syndrome individuals, taking into account their specific
physiological needs.
6.3) OBJECTIVES OF STUDY:
1. To evaluate the effectiveness of balance training in above average IQ Down’s cases.
2. To evaluate the effectiveness of Pediatric Balance Scale (PBS) as an outcome measure in
Down’s Syndrome children.
MATERIALS AND METHODS:
7.
7.1) STUDY DESIGN:
Experimental study design.
7.2)SOURCE OF DATA:
The sources of data were the children of both sexes in the age group of 6-12 years. They were
selected from various special schools in and around Mangalore city. Prior to the selection of data a
brief explanation of the procedure was explained to the principal, teachers and parents so as to
make them understand that it was a simple non-invasive method of testing.
7.2(I)DEFINITION OF THE STUDY SUBJECTS:
Children with Down’s Syndrome in the age group of6-12years will be included in the study
keeping in mind the inclusion and exclusion criteria.
7.2(II)INCLUSION AND EXCLUSION CRITERIA:
INCLUSION CRITERIA :
The subjects will be taken if they meet the following criteria:






Children of age group of 6-12 years.
Children of both sexes will be included.
More than or equal to 50 IQ level.
Subjects who are able to walk.
Subjects who are able to follow commands.
Informed consent.
EXCLUSION CRITERIA :
The subjects will be excluded from the study if they have the following conditions.











Children with age less than 6 and more than 12 years will not be included.
Less than 50 IQ level.
Other major disabilities affecting balance and gait.
Fracture or injury of both upper and lower limbs
Congenital heart disease
Visual defects
Head injuries
Vestibular problems
Mental retardations
Poor comprehensions
Delayed milestones



Musculoskeletal and soft tissue injuries that prevents the child from performing the
task
Epilepsy
Uncooperative children
7.2 III STUDY SAMPLE DESIGN, METHOD, SIZE:
Sample design:
Purposive random sampling.
Methods of Collection of data:
Subjects in the age groupof 6-12 years will be included from various special schools in
and around Mangalore.
Sample size:
60 subjects in the age group of 6-12 years from the special schools in and around
Mangalore fulfilling the inclusion and exclusion criteria will be included in the study.
7.2 IV FOLLOW UP:
Pretest will be conducted before starting the intervention and at the end of every week the
Post test will be conducted till the end of 6th week of intervention.
7.2 V PARAMETERS USED FOR COMPARISON AND STATISTICAL TEST:
Paired t-test and Unpaired t-test.
7.2 VI DURATION OF STUDY:
Duration of the study will be 8-10 months.
7.2 VII METHODOLOGY:

60 subjects will be assessed and included into the study from various special schools in
and around Mangalore fulfilling the inclusion and exclusion criteria.

They will be randomly divided into 2 groups: group A and group B.

30 subjects will be taken in group A as an experimental group.

The remaining 30 subjects will be taken into group B as a control group.
Group A as well as Group B will be tested with the Time Up and Go Test (TUGT) and Pediatric
Balance Scale (PBS) for comparing the test results of both the scales and the similarity of scores
would be noted for analysis.
The following parameters are used for the Time Up and Go Test (TUGT) 15, 16: Standard Arm
chair: seat height-18 inches and arm height: 25.6inches; Tape measure; Tape; Stop watch.
 The test will begin with the subject sitting correctly in a chair an arm support. The
subjects back should be stable and positioned such that it will not move when the
subject moves from sitting to standing.
 A piece of tape or other marker will be placed on the floor 3metres (10 inches) away
from the chair so that it is easily seen by the subject.
 Instructions: On the word “GO”, the patient will be asked to stand up, walk to the line
on the floor, turn around and walk back to the chair and sit down. Ask the patient to
walk at his regular pace.
 Start timing on the word “GO” and stop timing when the subject is seated again
correctly in the chair with their back resting on the back of the chair.
 The subject should wear regular footwear and may use any gait aid that they normally
use during ambulation, but may not be assisted by another person. There is no time
limit. They may stop and rest (but not sit down) if they need to.
 Normal healthy elderly usually completes the task in 101 seconds or less. Very frail
or weak elderly with poor mobility may take 2min or more.
 The subject will be given a practice trial that is not timed before testing.
 Results co-relate with gait speed, balance, functionallevel, the ability to go out and
can follow change over time.
 Interpretation more than or equal to 10 seconds-Normal



More than or equal to 20 seconds-good mobility, can go out alone,
mobile without a gait aid.
More than 30 seconds-problems, cannot go outside alone, requires a
gait aid.
A score of more than or equal to 14 seconds has been shown to
indicate high risk or falls.
Parameters used for PBSare: Adjustable height bench, chair with back support, arm rest, masking
tape-1 inch wide,a step stool 6 inches in height,chalkboard eraser, ruler or yardstick, a small level.
The following items are optional and may be helpful during test administration:2 child-size
footprints,blindfold ,a bright colored object of at least two inches in size, flash cards,2 inches of
adhesive-backed hooked Velcro, two 1 foot strips of loop Velcro.
The following steps are used in PBS:
1. Sitting to Standing
2. Standing to Sitting
3. Transfers
4. Standing unsupported
5. Sitting unsupported
6. Standing with eyes closed
7. Standing with feet together
8. Standing with one foot in front
9. Standing on one foot
10. Turning 360 degrees
11. Turning to look behind
12. Retrieving object from floor
13. Placing alternate foot on floor
14. Placing alternate foot on stool
15. Reaching forward with outstretched hand
 Demonstrate each task and give instructions as written. A child may receive a practice
trial on each item. If the child is unable to complete the task based on their ability to
understand the directions, a second practice trial will be given. Verbal and visual
directions will be clarified through the use of Physical prompts.
 Each item will be scored utilizing the 0 to 4 scale. Multiple trials are allowed on many
of the items. The child’s performance should be scored based upon the lowest criteria,
which describes the child’s best performance. If on the first trial a child receives the
maximal score of 4, additional trials need not be administered. Several items require
the child to maintain a given position for a specific time. Progressively, more points
are deducted if the time or distance requirements are not met, if the
subject’s performance warrants supervision; or if the subject touches an external support or
receive assistance from the examiner. Subjects should understand that they must
maintain their balance while attempting the tasks. The choice of which leg stand or
how far to reach is left to the subject. Poorjudgment will adversely influence the
performance and the scoring. In addition to scoring items 4, 5,6,7,8,9,10 and 13, the
examiner will record the exact time in seconds.
The TUGT and PBS scores which are taken pre-test will be noted for both the groups.Group A
will then be started on the intervention of 6 weeks.
At the end of every week the TUGT and PBS scores will be assessed and compared.
The program of intervention will include the following: Balance, equilibrium, and protective
reactions, vestibular functioning (i.e., the ability to orient our self when you move your head or
body; to maintain a stable position), muscle tone and strength, joint and postural stability,
weight bearing, weight shifts, trunk rotation, sensory awareness and processing, sensorimotor
integration, awareness of the body in space, bilateral integration, positioning and position
transitions, locomotion, abdominal strength (these muscles are the central control area for
Postural stability, respiration, and breath support of speech).1
Weight-bearing exercises provide improved and more consistent proprioceptive feed-back that in
turn improves control of movement. Functional weight-bearing exercise programs have been
shown to have effects on balance, gait, and lower-limb strength among subjects with moderate
or no cognitive and physical impairments. On other hand weight-bearing exercises allow for
reactivation of the proprioceptors, whose role is to sense the amount, speed and timing of joint
positioning17. In a closed chain environment, proprioceptors respond to such extrinsic factors as
change in terrain, footwear, ground reaction forces, speed and direction of activity. The patient
needs to be placed in an environment that is biomechanically and clinically safe to induce
proprioceptive enhancement via closed kinetic chain exercises18.
Jump
Jumping activity might be added to the program of treatment to effectively evoke the automatic
and dynamic postural control. Moreover, the floor-walk and beam walk performances might be
improved due to the transferred effects via the practice of dynamic jumping activity19. In
addition aerobic conditioning and strength training for a child with DS displayed improvement
in cardiovascular variables and strength measures and also demonstrated improved balance,
coordination and power in gross motor tasks20.
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during closed kinetic chain rehabilitation of the lower extremity.
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