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How Physical Therapy Improves Balance in Seniors

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    This literature review will cover how physical therapy can be used to improve balance in seniors who have spastic hemiplegia cerebral palsy. Most of the research available pertains to adolescence and not the senior population. With that said this literature review looks at how physical therapy improves balance in adolescence and how those techniques could be used for the elderly.

    Introduction

    Cerebral palsy (CP) is considered to be the most common childhood disability affecting 2-2.5 out of 1000 births. (1) Cerebral palsy is a blanket term used to categorize individuals that have a static neurological disability resulting from lesions on either the prenatal, perinatal or postnatal brain. (2)(3) This disability is characterized by motor impairment and postural instability. (2) Some individuals will also have other health conditions that are associated with this diagnosis, including but not limited to, muscle spasticity, cognitive impairments, hearing and vision problems, and seizures. (2) There are also reports of premature aging. Cerebral palsy has 3 different types. The most common type of Cerebral Palsy is Spastic CP, which affects about 70-80% of the diagnosed population. (3) Spastic, which refers to the tightness/stiffness o`f the muscles, can cause balance disorders and movement to be uncoordinated. The affected limbs may suffer from some common symptoms such as deep tendon reflexes, hypertonic muscles and decrease voluntary muscle control, which can lead to contractors and deformities. (3) Spastic CP is broken down into 3 different categories determined by the affected location. Our focus is on Spastic Hemiplegia CP, which is the most common form of Spastic CP. This is when an arm and leg on the same side of the body is affected while the other side is not. It is common for children to be developmentally delayed and have difficulty in balancing with this form of CP. It is also important to mention that a quarter of them have intellectual disabilities.

    As mentioned above, Cerebral Palsy is non-progressive. That means the brain injury causing this disability will not get worse however the parts of the body that are affected with symptoms of CP can worsen overtime if there is no intervention. Limitations in the simplest activities such as standing and walking can occur. This will lead to the dependence on others and on medical equipment to complete daily activities. In order to maximize physical independence, physical therapy is needed.

    Physical therapy plays an important role in managing the severity of the effects Cerebral palsy has on the musculoskeletal system. Standing and walking is majorly affected because you need balance in order to obtain control of your standing and movement. “Balance is the ability to maintain a functional posture through motor actions that distribute weight evenly around the body’s Center of Gravity, both statically and dynamically.” (4) So to have balance you need to have postural stability. As we know, those diagnosed with CP are more than likely to have postural instability.

    The purpose of this literature review is to see how PT is used to increase balance in the senior population that has SHCP. Due to the lack of research involving the senior population, the literature being gathered will be on children and adolescents. From the gathered knowledge, it will be determined what techniques should be used for the elderly in order for them to achieve maximum independence through balance.

    Methods

    Several databases were used in this search such as Medline, PubMed, CINAHL, Sage Premier, and ScienceDirect. Google scholar was also used. All articles included Spastic Cerebral Palsy. All ages were included in the search.

    Results

    Out of the 25 articles found, 9 were used in this literature review.

    Some types of physical therapy techniques were researched in order to determine their effect on balance and increased posture stability/control. Those techniques included, whole body vibration, core stability programs, and vestibular rehabilitation,

    Whole body vibrations & core stability programs

    One study hypothesized that core stability and strengthening programs can increase balance, postural control, and stability. This was tested in comparison to whole body vibration (WBV) technique.

    60 participants diagnosed with spastic cerebral palsy between the age of 5 and 6 were randomly place into two different categories, group A and group B. Group A participated in the regular physical therapy program (RPTP) and a core stability program (CSP). The RPTP consisted of “neurodevelopmental techniques, balance exercises, facilitation of milestones and postural reaction” an hour a day, three times a week for 12 weeks. The CSP consisted of a 30 min session where certain core exercises were completed. Group B participated in RPTP along with 10 minutes of whole body vibration program (WBV). WBV is where the child is sitting on a vibrating platform for a certain amount of time, with a specific frequency, and amplitude (5).

    The result of the data analyses concludes that there was a statistically significant difference (P=Vestibular rehabilitation

    Another study looked at vestibular stimulation and how it affects balance in children. The vestibular system is extremely important because it coincides with visual and proprioceptive systems to achieve balance.

    In this study, 30 children with spastic hemiplegia cerebral palsy, aged 5-8, are split into two different groups. Group A will participate in traditional physical therapy (TPT) while group B will participate in TPT and vestibular stimulation (VS). The TPT included neurodevelopmental techniques, active ROM exercises, mat exercises, balance exercises, gait training, stairs case climbing training, and stretching exercises. VS consisted of 30 min sessions for 8 week. During the sessions, the child was directed to sit on a piece of equipment (toy horse, tilting board, or scooter board) and hold onto the handlebars while the therapist rocked the equipment back and fourth. If there were improvements being made, the difficulty was increase. Dynamic balance was assessed with the Biodex Balance System pre and post treatment (4).

    The statistical results concluded that there was significant difference between both groups and pre and post treatments. Though there were balance improvements in both groups, group B increased more when compared to group A (4).

    Discussion

    The purpose of this literature review is to see how physical therapy can improve balance in children with spastic hemiplegia cerebral palsy and then use that information to make suggestions on how it can improve balance in the elderly. According to the literature, WBV, CSP, VS, and TPT can improve balance in children with SHCP. Though these techniques may be too much for the elderly to participate in, I believe they could be modified with a less intense regiment but still provide improvements in balance. Also due to the cognitive disability that may come with SHCP many of theses therapies might need to be adjusted to the level of cognitive function the individuals have regardless of age.

    In conclusion, CP is the most common childhood disability, however these children do grow into adults and adults do become seniors but it seems they are forgotten. There is no information out there that pertains to the elderly population with CP let alone SHCP. More research is drastically needed on this topic of CP. Future research to consider: How physical therapy is used to improve quality of life for elderly individuals with spastic hemiplegia cerebral palsy that have a state appointed guardian.

    References

    1. Kenis-Coskun, O., Giray, E., Eren, B., Ozkok, O., & Karadag-Saygi, E. (2016). Evaluation of postural stability in children with hemiplegic cerebral palsy. Journal of physical therapy science, 28(5), 1398–1402. doi:10.1589/jpts.28.1398
    2. Lawrence, H., Hills, S., Kline, N., Weems, K., & Doty, A. (2016). Effectiveness of Exercise on Functional Mobility in Adults with Cerebral Palsy: A Systematic Review. Physiotherapy Canada. Physiotherapie Canada, 68(4), 398–407. doi:10.3138/ptc.2015-38LHC
    3. Krigger KW. Cerebral palsy: An overview. Am Fam Physician. 2006;73(1):91–100.
    4. Ahmed K. S., El-negamy E. H., Salem A. H. and Ibrahim M. B. Effect of Vestibular Stimulation on Balance in Children with Hemiparetic Cerebral Palsy. Med. J. Cairo Univ. 2017. 85 (4): 1417 – 1423.
    5. Ali, Mostafa & Awad, Ahmed & Elassal, PhD. (2019). The effect of two therapeutic interventions on balance in children with spastic cerebral palsy: A comparative study. Journal of Taibah University Medical Sciences. 14. 10.1016/j.jtumed.2019.05.005.
    6. Saether, R., Helbostad, J.L., Riphagen, I.I. and Vik, T. (2013), Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review. Dev Med Child Neurol, 55: 988-999. doi:10.1111/dmcn.12162
    7. Haak, P., Lenski, M., Hidecker, M. J., Li, M., & Paneth, N. (2009). Cerebral palsy and aging. Developmental medicine and child neurology, 51 Suppl 4(0 4), 16–23. doi:10.1111/j.1469-8749.2009.03428.x
    8. Tugui, R. D., & Antonescu, D. (2013). Cerebral palsy gait, clinical importance. Maedica, 8(4), 388–393.
    9. Das, S. P., & Ganesh, G. S. (2019). Evidence-based Approach to Physical Therapy in Cerebral Palsy. Indian journal of orthopaedics, 53(1), 20–34. doi:10.4103/ortho.IJOrtho_241_17

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