ROLE OF MECHANICAL VESTIBULAR
STIMULATION ON BALANCE IN CHILDREN WITH
DOWN SYNDROME
Amr A. Ellithy1; Elham E.Salem2 ;p Nahla M. Ibrahim3
and Ehab R. Abd El Rauof 4.
1 Master Degree in Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo
University, Egypt.
2 Professor, Department of Physical Therapy for Pediatrics ,Faculty of Physical Therapy
,Cairo University,
3 Lecture, Department of Physical Therapy for Pediatrics ,Faculty of Physical Therapy
,Cairo University, Egypt.
4 Professor of Clinical Genetics , Department of Research of Children with Special
needs, National Research Center, Egypt.
ABSTRACT:
Background: Motor and cognitive development of children with Down
syndrome (DS) is delayed and inharmonic. Neuro-muscular
abnormalities, such as hypotonia, retained primary reflexes, and slow
performance of volitional reaction, result in difficulties with body
balance. Purpose and Methods: It was to investigate the effect of
mechanical vestibular stimulation on balance in children with Down
syndrome. Thirty children with Down syndrome participated in this
study. Subjects were divided into two groups group A and group B,
fifteen children in each group, the control group received a selected
physical therapy program designed for those cases and the study group
received the same program in addition to mechanical vestibular
stimulation. Children were evaluated before and after 3 successive
months of treatment program by biodex balance system to evaluate their
balance regarding anteroposterior stability index (APSI), mediolateral
stability index (MLSI) and overall stability index (OASI). Results: There
was a significant decrease in APSI, MLSI and OASI post treatment
compared with that pretreatment in the control and study groups (p >
0.0001). Comparison between both groups post treatment revealed a
significant improvement by the decrease of degrees of sway in APSI,
MLSI and OASI of the study group compared with that of the control
group(p > 0.05).
Conclusion: Results of the study suggested the use of mechanical
vestibular stimulation in addition to the designed program to improve
balance in children with down syndrome.
Key Words: Down syndrome - Biodex - balance- mechanical vestibular
stimulation
Egypt. J. of Appl. Sci., 35(9) 2020 100-107
INTRODUCTION:
Children with Down syndrome may experience difficulty in
maintaining balance due to certain cause as hypotonia, laxity of
ligaments, decrease postural control, decrease muscle strength. This is
beside the mental retardation so studies state that general at motor skills
development has been below than of normal children(1).
The Biodex balance system is a unique dynamic postural control
assessment and training system. It is a multi-axial device that objectively
measures and records the individual's ability to maintain stability under
dynamic stress. It is less expensive, more portable that include movable
platform that can be adjusted to provide varying degrees of stability and
offer computer-based data(2).
There are different methods that can improve balance in children
with down syndrome such as Facilitation of trunk control to improve
postural control from different positions (prone, supine, sitting). Balance
training was carried from different positions (quadruped, kneeling, half
kneeling and standing) on tilting board. Facilitation of righting,
protective and equilibrium reactions: These exercises were carried
through tilting from different positions (forward, backward, and
sideways) in order to improve postural mechanisms via variety of
exercises applied on medical ball and tilting board(3).
Sensory aspects components to control balance consist of The
Sensory System: Afferent information for postural control system comes
from visual, vestibular and somatosensory inputs. Visual Inputs that
report information regarding the position and motion of the head with
respect to the surrounding objects. They are an important source of
information for postural control(4)
The Vestibular System provides the Central Nervous System
(CNS) with information about the position and movement of the head
with respect to gravity, providing a gravitational frame of reference for
postural control and Somatosensory Inputs that provide information
concerning the orientation of body parts to one another and to the support
surface(4).
Vestibular stimulation is used in physical therapy for stimulating
normal development of postural control on children with
neurodevelopment disabilities. Therapeutic vestibular stimulation
increases the brain's capacity to integrate vestibular stimuli by
developing motor responses that aid integration. As tolerance in capacity
to organize vestibular stimuli increases, children with sensory motor
dysfunction begin to seek out motor activities which will stimulate their
own Vestibular System. Slow and regular stimulation can be used for
hypertonic children but fast and irregular stimulation can be used for
hypotonic children(5).
101 Egypt. J. of Appl. Sci., 35(9) 2020
Relearning of postural control through external visual, auditory and
vestibular feedback is believed to be an effective therapy for improving
balance control. It is thought that by giving patients additional visual
information, they will become more aware of the body's displacements
and orientation in space(6). Mechanical vestibular stimulation used in
remediation of sensory integrated dysfunction. Stimulation was provided
by swinging or spinning a child while he was lying or sitting in a net
hammock(7). Fast vestibular stimulation promotes a generalized
facilitation of postural tone, postural reaction, motor control and increase
arousal and attention. Therapeutically stimulation can be achieved using
variety of equipment including tilt board, scooter board or spinning chair.
Both linear and angular motion cab be use (8).
MATERIAL AND METHODS:
Ethical approval was obtained from the institutional review board
at faculty of physical Therapy, Cairo university before the commence of
the study (No: P.T.REC/012/001795).
Subjects:
Thirty children with Down syndrome had participated in this study.
They were selected from the outpatient clinic, faculty of physical
therapy, Cairo university. An informed consent was obtained by each
parent after explaining the nature, purpose and benefits of the study
protocol informing them of their right to refuse or withdraw at any time
and about the confidentiality of any obtained information.
Inclusion criteria:
The children were selected according to the following criteria:
Their age ranged from 5 to 10 years. They were able to understand the
verbal commands, Their Body Mass Index (BMI) within normal range,
their height not less than 1 meter to see the screen of Biodex balance
system, they were able to stand momently and they had history of
frequent falling during walking.
Exclusion Criteria:
The children were excluded from this study if they had any of the
following criteria: Severe Atlanto Axial instability, Severe mental
retardation and uncontrolled cardiopulmonary problems.
Children were assigned into two groups (control (A) and study (B)
group) of equal numbers. Their balance was assessed before and after 3
successive months of conduction of the treatment program.
Control Group(A)
Children in this group had received physical therapy exercise program
designed for down syndrome cases that included regular balance
exercises for one hour/day, 3 sessions/week for three successive months.
Egypt. J. of Appl. Sci., 35(9) 2020 102
Study Group(B)
Children in this group had received the same selected physical therapy
exercise program for 45 minutes in addition to mechanical vestibular
stimulation (MVS) using swing system for 15 min.
Evaluation:
1- Weight and Height scale:
a valid and reliable weight and height scale was used to measure the
weight and height of the children of both group prior to the test that used
as an entering data to the device included in the test
2-Biodex Balance System:
The Biodex balance system is a unique dynamic postural control
assessment and training system. It was used for assessment of children of
both group before and after 3 successive months of treatment
Procedure:
The child's weight, height and chronological age were entered to
control screen display located in front of the subject.
Position of the support handle and its height was adjusted according
to child height which the child asked to grasp it during initiation of
the test and leave it as the test proceeds.
Each child was tested without footwear to achieve full contact with
platform and was asked to perform two trials before recording to be
familiar with the device. Each child was asked to stand on both feet
with arms held at sides and trying to maintain balance as much as
possible.
The start key was pressed in control panel to unlock platform with
auditory alarm just before the beginning of the test.
Each child was asked to maintain balance as much as possible
because the platform was unstable just after the alarm.
Three stability indices were obtained before and after treatment
program for each subject of the study group including: Anteroposterior
stability, Medio-lateral stability index and overall stability
index. Three trials were done then average was taken.
Intervention: For control group:
Each child had received a selected physical therapy exercise program
designed for children with down syndrome that directed towards
improving both static, dynamic balance and gait as follows:
Strengthening exercise to abdomen &back, Stability training,
facilitation of different postural reactions which is essentials component
of postural control, changing positions, Righting and equilibrium
reactions and gait training activities.
For study group:
Each child in this group received the previous selected physical
therapy program in addition to Mechanical Vestibular Stimulation.
103 Egypt. J. of Appl. Sci., 35(9) 2020
Mechanical vestibular stimulation system/ Swing system:
Procedures of mechanical vestibular stimulation:
The child was placed in sitting on the platform swing and his hands
grasping ropes then the therapist stood behind him and pushed the platform
in fast arrhythmic and jerky movement in back and front for five minutes,
side to side for five minutes and in orbital direction for five minutes with the
child trying to maintain his balance.
The child was placed in sitting on the disk swing and his legs and arms
wrapped around the disk swing then the therapist stood behind him and
pushed the platform in fast arrhythmic and jerky movement in back and
front for five minutes, side to side for five minutes and in orbital direction
for five minutes with the child trying to maintain his balance.
Statistical analysis
Descriptive statistics and unpaired t-test were conducted for comparison
of subject characteristics between both groups. Chi- squared was carried out
for comparison of sex distribution between groups. Unpaired t-test was
conducted to compare the mean values of APSI, MLSI and OASI between
the control and study groups. Paired t-test was conducted for comparison
between pre and post treatment in each group. The level of significance for
all statistical tests was set at p < 0.05. All statistical analysis was conducted
through the statistical package for social studies (SPSS) version 25 for
windows (IBM SPSS, Chicago, IL, USA).
RESULTS
-Subject characteristics:
Table (1) showed the subject characteristics of the control and study
groups. There was no significant difference between both groups in age,
weight, height and BMI (p > 0.05).Also, there was no significant
difference in sex distribution between groups (p > 0.05).
Table 1. Basic characteristics of participants.
Control group Study group p-value
Age, mean± (SD), years 8.26 ± 1.16 8.33 ± 1.11 0.87
Weight, mean± (SD), kg 23.33 ± 1.34 23.6 ± 1.95 0.66
Height, mean± (SD), cm 123.73 ± 3.36 123.06 ± 4.35 0.64
BMI, mean± (SD), kg/m² 15.3 ± 0.53 15.68 ± 1.22 0.27
Sex, n (%)
Girls 3 (20%) 6 (40%)
Boys 0.23
12 (80%) 9 (60%)
SD, standard deviation; p-value, level of significance
Effect of treatment on APSI, MLSI and OASI:
- Within group comparison:
There was a significant decrease in APSI, MLSI and OASI post
treatment compared with that pretreatment in the control and study groups(p
> 0.0001). The percent of decrease in APSI, MLSI and OASI in the control
Egypt. J. of Appl. Sci., 35(9) 2020 104
group were 6.25,10.05and 7.94% respectively, while that in the study group
were 23.61, 24.42and 26.43% respectively. (Table 2)
- Between groups comparison:
There was no significant difference in APSI, MLSI and OASI between
both groups pre-treatment (p > 0.05). Comparison between both groups post
treatment revealed a significant decrease in APSI, MLSI and OASI of the
study group compared with that of the control group(p > 0.05). (Table 2).
Table 2. Mean APSI, MLSI and OASI pre and post treatment of the
control and study groups:
Control group Study group
̅± SD ̅± SD MD t- value p value
APSI
Pre treatment 3.52 ± 0.65 3.6 ± 0.58 -0.08 -0.32 0.74
Post treatment 3.3 ± 0.67 2.75 ± 0.62 0.55 2.33 0.02
MD 0.22 0.85
% of change 6.25% 23.61%
t- value 7.05 12.54
p = 0.0001 p = 0.0001
MLSI
Pre treatment 1.89 ± 0.52 1.72 ± 0.41 0.17 0.96 0.34
Post treatment 1.7 ± 0.53 1.3 ± 0.2 0.4 2.72 0.01
MD 0.19 0.42
% of change 10.05% 24.42%
t- value 5.39 5.84
p = 0.0001 p = 0.0001
OASI
Pre treatment 3.78 ± 0.49 3.67 ± 0.52 0.11 0.6 0.54
Post treatment 3.48 ± 0.54 2.7 ± 0.5 0.78 4.19 0.0001
MD 0.3 0.97
% of change 7.94% 26.43%
t- value 8.52 8.19
p = 0.0001 p = 0.001
̅, mean; SD, standard deviation; MD, mean difference; p-value, probability value
DISCUSSION:
Thirty children with Down syndrome participated in this study.
Subjects were divided into two groups, fifteen children in each group, the
control group received a selected physical therapy program and the study
group received the selected physical therapy program and mechanical
vestibular stimulation. Data obtained from both groups regarding
anteroposterior stability index (APSI), mediolateral stability index
(MLSI) and overall stability index (OASI) were statistically analyzed and
compared. Comparing the general characteristics of the subjects of both
groups revealed that there was no significance difference between the
two groups in the mean age, weight, height and BMI (p > 0.05).
Concerning the pre and post treatment results of the measured variables
(overall SI,antero-posterior SI and medio-lateral SI) of down syndrome
105 Egypt. J. of Appl. Sci., 35(9) 2020
children of both groups. the results have significant improvement in both
groups. However, more improvement with significant difference was
noticed in favor of the study group. concern the control group has significant
improvement in the post treatment mean values of the measured variables
after receiving the traditional physical therapy treatment program which
confirm the importance of physical therapy treatment of children with down
syndrome specially when concern with improving standing and walking
abilities. improvement in post treatment mean values of both groups may be
attributed to increase of activity of antigravity muscle which counteract the
force of gravity and leads to modulation of postural tone. the improvement
in the study group might be due to the mechanical vestibular stimulation
program which comes on the same line with findings of (9) who found that,
proprioceptive awareness of postures and movement is most required during
the learning of new skills. The post treatment improvements of the study
group may be due to involvement of the stimulation of many systems and
sub systems as nervous, muscular, vestibular, visual and proprioceptive
system during vestibular stimulation part of sessions. this supported by
Brooks (10) who suggested that postural control is the result of many systems
working together in a goal directed situation. It can be suggested that
integration of mechanical vestibular stimulation program with the designed
physical therapy program has a significant effect on balance in children with
down syndrome, so it should be considered as an important therapeutic
modality for treatment of these cases and adding mechanical vestibular
stimulation to the treatment sessions of down syndrome is highly
recommended.
REFERENCES
1) Cynthia, H. and S.E. Pamela (2001): How man moves:
Kinesiological studies and methods. William Heinemann, Londan.3rd
Edition, pp: 210-215.
2) Hinman, M. (2000): ''Factors affecting reliability of the biodex
balance system: a summary of four studies". Sport Rehab.,9:240-252.
3) Evans- Martin, F.(2009): Genes and disease Down syndrome,
Chelsea House, New York, 68-88.
4) Cook, A.S. and M.H. Woollacott (2001): Neural and
musculoskeletal contributions to the development of stance balance
control in typical children with cerebral palsy. Acta Pediatric suppl.,
416:58-62.
5) Helt, D.G. and R. Foulds (2004): Vestibular stimulation and its
effect on muscle tone. Bio-engineering Conference, Volume, Issue,
17-18 April pages: 7-8.
Egypt. J. of Appl. Sci., 35(9) 2020 106
6) Peppan, V. ; M. Kortsmit ; E. Lindeman and G. Kwakkel
(2006); Effect of visual feedback therapy on postural control in
bilateral standing after stroke: a systemic review. J Rehabil. Med;
38-39.
7) Ayres, J.A. (1979): Sensory integration and learning disorders.
Western psychological services, Los Angelos, pp: 127-138).
8) Heinger, M. and S. Randolph (1981):Neurophysiological
stimulation and its effects on muscle tone .Bioengineering
conference . (17-18):7-8.
9) Tristan, D. and R. Martin (2004): Understanding Balance; The
mechanics of posture and locomotion, Nelson Throne :601-605.
10) Brooks, V.B.(2003): The neural basis of motor control, oxford
University Press, new York,pp:5 :129-150.
11) Gray, H.(2004): Elevating "the gravity" from gravity. Gray's
anatomy. 29th ed.
تأثیر الت بٌیه الویکا یًکی لدهلیس الأذى عل الاتساى لدی الاطفال الوصابیی
بوتلازهة داوى
عورو عبد الغفار اللیثی 1، إلهام السید سالن 2، هًلة هحود إبراهین 3، إیهاب رجائی عبد الرؤوف 4
1یاظغرٛش انعلاض انطثٛعٙ، قغى انعلاض انطثٛعٙ لاضطشاتاخ یشاحم ان انرط سٕ ظشاحر آ ع ذُ الاطفال، کهٛح
انعلاض انطثٛعٙ، ظایعح انقا شْج، یصش
2 اعرار، قغى انعلاض انطثٛعٙ لاضطشاتاخ یشاحم ان انرط سٕ ظشاحر آ ع ذُ الاطفال، کهٛح انعلاض انطثٛعٙ،
ظایعح انقا شْج، یصش
3 یذسط، تقغى انعلاض انطثٛعٙ، لاضطشاتاخ یشاحم ان ظشاحر آ ع ذُ الاطفال، کهٛح انعلاض انطثٛعٙ، ظایعح
انقا شْج، یصش
4 أعرار عهى ان سإشح الإکهٛ ُٛکٛح، قغى انثح زٕ نلأطفال ر الاحرٛاظاخ انخاصح، ان شًکض انق یٕ نهثح زٕ، یصش
الهدف هی البحث: دساعح ذأشٛش انر ثُٛ ان ًٛکا َٛکٙ عه الاذضا نذ الاطفال ان صًاتٛ ت رًلاصیح
د أ .ٌ
هىاد البحث و اسالیبه: ذى إظشاء زْا انثحس عه شلاشٛ طفم ی الاطفال ان صًاتٛ ت رًلاصیح
دا ی انع غُٛ ی ذشا حٔد اع اًس ىْ یا تٛ خ غًح إن عششج ع إُخ قذ ذى ذقغٛ ىًٓ إن یع عًٕرٛ یرغا ٚٔرٛ :ٍ ان عً عًٕح الأ نٔ )أ( ذحر زْ ان عً عًٕح عه 15 طفلا ذى ذطثٛق
انثش اَیط انعلاظٙ ان عًراد ن ذًج عاعح ت إقع شلاز ظهغاخ اعث عٕٛا ن ذًج شلاشح ش سٕٓ. ان عً عًٕح
انصا َٛح )ب( ذحر زْ ان عً عًٕح عه 15 طفلا ذى ذطثٛق انثش اَیط انعلاظٙ ان عًراد ن ذًج 45
دقٛقح إن ظا ةَ انر ثُٛ ان ًٛکا َٛکٙ نذ هْٛض الأر ن ذًج 15 دقٛقح ت إقع شلاز ظهغاخ اعث عٕٛا ن ذًج
شلاز أش شٓ. قٔذ ذى قٛاط الاذضا نکلا ان عً عًٕرٛ قثم تعذ شلاشح أش شٓ ی ذطثٛق انثش اَیط
تاعرخذاو ظ آص انثٛ دٕکظ .
ال تٌائج: أظ شٓخ ان رُائط ا انرحغ فٙ الاذضا کا ر دلانح احصائٛح نکهرا ان عً عًٕرٛ نٔک تص سٕج اکثش ف ان عً عًٕح انثحصٛح )ب( .
الکلوات الدالة: هتلازهة داوى – البیىدکس – الاتساى – الت بٌیه الویکا یًکی لدهلیس الآذى
107 Egypt. J. of Appl. Sci., 35(9) 2020
