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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 6
| Issue : 2 | Page : 46-53 |
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Comparison of the effect of group vs. individual exercises on balance, gross motor function, and participation in children with cerebral palsy spastic diplegia
Susan Jose, Sandhya Wasnik
Department of Physiotherapy, All India Institute of Physical Medicine and Rehabilitation, Mumbai, Maharashtra, India
| Date of Submission | 16-May-2022 |
| Date of Acceptance | 17-Oct-2022 |
| Date of Web Publication | 01-Dec-2022 |
Correspondence Address:
Dr. Susan Jose
All India Institute of Physical Medicine and Rehabilitation, Haji Ali, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jsip.jsip_6_22
Background: Groups exercise platforms provide a wide range of visual and auditory feedback that can be used to facilitate desirable movement patterns. Positive and negative reinforcement strategies are given as feedback when working in a group setting. Hence, group exercises accelerate motor learning and provide a controlled environment to socialize and mutually support one another. Aim: The aim of this study was to compare the effect of group exercises vs. individual exercises on balance, gross motor function, and participation in children with cerebral palsy spastic diplegia. Materials and Methods: The study included 30 participants over a period of 4 weeks. Participants were randomly allocated to both the groups. Post and follow-up assessments were done. Statistical Analysis: Friedman test and Mann–Whitney U test was used for intragroup and intergroup comparison. Results: Statistically significant improvements were noted in the group exercises, in Gross motor function measure (P = 0.002), Paediatric Balance Scale (P = 0.002), CPQ–ADL (P = 0.02), and IADL (P = 0.004), which was also maintained over a follow-up period of 4 weeks. Conclusion: Group exercises are more effective than individual exercises in improving balance, gross motor function, and participation in children with cerebral palsy spastic diplegia, which is also maintained over a follow-up period of 4 weeks. Keywords: Gross motor function, group exercises, participation, physical therapy, spastic diplegia
How to cite this article:
Jose S, Wasnik S. Comparison of the effect of group vs. individual exercises on balance, gross motor function, and participation in children with cerebral palsy spastic diplegia. J Soc Indian Physiother 2022;6:46-53 |
How to cite this URL:
Jose S, Wasnik S. Comparison of the effect of group vs. individual exercises on balance, gross motor function, and participation in children with cerebral palsy spastic diplegia. J Soc Indian Physiother [serial online] 2022 [cited 2023 Jun 10];6:46-53. Available from: jsip-physio.org/text.asp?2022/6/2/46/362574 |
| Introduction | |  |
Cerebral palsy is a leading cause of motor disability in children, affecting 3 to 4 per 1000 children in India. Cerebral palsy (CP) is defined as a permanent, nonprogressive disorder of posture and movement caused due to injury to the developing brain. CP spastic diplegia is the most common subtype of CP in India, constituting a total of 30% of the whole spastic syndrome.[1] Spastic diplegia is characterized by the presence of grossly spastic muscles in the lower limbs, with minor motor deficits in the upper limbs. This spasticity leads to an imbalance between the agonists and antagonists mainly of the lower limbs and the trunk causing reduced coordination and increased co-contraction that manifests as inefficient postural mechanisms and delayed gross motor skill development.[2] Children with CP spastic diplegia have more stability and mobility problems when compared to the age-matched peers with typical development. As the balance is a major contributor to gait, manipulation, and mobility skills, children with CP diplegia are limited in their ability to participate in life situations.[3] Participation limitations can be minimized by managing the structural and functional impairments as well as resolving the environmental and personal barriers.[4]
The mainstay of rehabilitation has always been to achieve maximum performance by the patient to fulfill the activity and participation roles in life.[3],[5] Improvements in gross motor function and postural control are the foundation over which these participation and activity increments are gained.[6],[7] Balance training, lower limb, and trunk strengthening programs with high practice sessions are highly effective in improving function.[8],[9],[10]
But in children, self-initiation and sustenance of repetitions is difficult. It has also been noted that children require higher intensities of feedback compared to adults to cross the cognitive stage of motor learning.[11]
Hence, groups exercise platforms provide a wide range of visual and auditory feedback that can be used to facilitate desirable movement patterns. Positive and negative reinforcement strategies are given as feedback when working in a group setting.[12] This is applicable in children with CP diplegia as they generally have a near-normal intellect and speech function.[5] Hence, group exercises accelerate motor learning and provide a controlled environment to socialize and mutually support one another. Another added advantage of group exercises is that it saves resources namely manpower and clinical time.[13]
According to a study, children reported more intense physical activity when in the company of peers or close friends.[14] Correct participant selection, allocation, and instruction methods are the key to a successful group exercise program. Group exercises have emerged as a successful means of delivering physical activity to small groups with similar goals in a relatively small time frame.[15] The improvements in the peers never go unnoticed and act as a motivating factor to the children and the caregivers. In case of any negative effects of peer pressure, parents and physical therapists act as buffer systems.
A randomized control study by Pless et al.[12] to determine the effect of group motor skill training in 5–6-year-old children with developmental coordination disorder concluded that group therapy is more efficient in improving the motor skill scores in children with mild-to-moderate motor disability. The improvement was stated due to the increased repetition of the task as a result of the confidence gained by attempting it among a group and overcoming the internal demotivation.
A study by Ko et al.[16] compared the effect of group-task-oriented training (TOT) vs. individual task-oriented training (TOT) on gross and fine motor function, and activities of daily living in children with spastic CP concluded that the Group TOT showed significant improvements in the outcomes.
Blundell et al.[17] concluded in their pilot study that Group Functional Strengthening was more effective in improving strength and functional performance, in children with spastic diplegia. This was attributed to the motivation, healthy competition, and effective ways of problem-solving under the physiotherapist during the group sessions. Children added that all the treatment sessions were enjoyable and couldn’t afford to miss any of them.
Thus, group exercise programs are effective and efficient but there is limited literature supporting this type of intervention delivery program in children with CP spastic diplegia. Individual exercises being the mainstream of the current Physical therapy management, less probing researches are available to look into the short-term and long-term effects of group exercise on gross motor function, balance, and participation.
Hence, the aim of this study was to compare the effects of group exercises vs. individual exercises on balance, gross motor function, and participation in children with CP spastic diplegia of GMFCS-I, II, and III in the age group 6–12 years.
| Materials and Methods | | |
The study commenced after approval from the Institutional and Maharashtra University of Health Sciences Ethics Committee. Written informed consent was obtained from the guardians. The study included 30 participants recruited from the physiotherapy OPD of a tertiary care setup. The study included male and female children of 6–12 years diagnosed as CP spastic diplegia, GMFCS- I, II, and III (can stand for 15–30 s without support), and those who had Modified Mini metal scale score >30 (25). The study excluded patients with any other neurological, sensory, or musculoskeletal problems other than CP spastic diplegia, uncontrolled seizures with medications, uncorrected visual and auditory impairments, and those who had any lower limb surgical interventions in the last 1 year.
The study followed block randomization to equally allocate participants into the group exercise and individual exercise group. Both groups had 15 participants each. The mean age of the Group therapy group was 7.46 ± 1.59 years and the GMFCS level was II (II–III). The mean age of the Individual therapy group was 8.73 ± 2.43 years and the GMFCS level was II (II–III).
The Group therapy had 15 participants who were divided into three groups, each containing five participants. Each session lasted for 1 h, three times in a week for 4 weeks. The Group exercise program started with warm-up exercises, which included static stretching of the lower limb muscles, followed by trunk, and lower limb strengthening by bridging, curlups, stepups, and squats as shown in [Figure 1]. Balance training included static and dynamic balance training in sitting and kneeling, as shown in [Figure 2] and [Figure 3], ending with a Cooldown consisting of stretching and range of motion exercises of the lower limb muscles. The Individual therapy group received individual exercises; the protocol was the same except for the fact that it was given individually. Both groups were on home exercise programs during and after the cessation of the protocol. The home exercise program consisted of 30 min of lower limb stretching, strengthening of the trunk and lower limb, and balance training using similar exercises done during the session. | Figure 1: Group therapy session where participants are engaging in trunk strengthening exercises
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 | Figure 2: Group therapy session where the participants are engaging in a task-oriented activity that challenges sitting balance
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 | Figure 3: Group therapy session in which participants are engaging in an activity that challenges trunk and pelvic control in the kneeling position
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Reassessment of all the outcomes was done immediately after the cessation of the protocol and a follow-up assessment was done after 4 weeks.
Three outcome measures were used. The Primary measure is Gross Motor Function Measure (GMFM) 88, which is an Observational assessment tool designed to evaluate gross motor functions in CP children aged between 5 and 15 years.[18] The interpretation is by summing the scores of each domain and taking the dimension percentage score. The secondary measures are the Pediatric Balance Scale (PBS) and Child Participation Questionnaire (CPQ). Pediatric Balance Scale is intended for use with school-aged children with mild-to-moderate motor impairment in children aged 5–15 years.[19] Child Participation Questionnaire is a parent-completed questionnaire. The CPQ contains 44 activities in six submeasures, namely: activities of daily living, instrumental activities of daily living, play, leisure, social participation, and education. Each activity is scored using an ordinal scale based on the frequency of participation, child’s independence, child enjoyment, and parental satisfaction. Summing of the scores is done according to the six submeasures.[20]
The data were analyzed using GraphPad Prism 8. Statistical significance was considered at P ≤ 0.05 and the confidence interval at 95%. As the data collected were ordinal in nature, the Friedman test was used for within-group comparison and Mann–Whitney U test for between-group comparison.
| Results | | |
Baseline comparison between the Group therapy and Individual therapy showed no significant difference; hence, both groups were comparable.
[Table 1] shows the within-group comparison of Group therapy showed a statistically significant difference in GMFM, PBS, and CPQ components: ADL, IADL, and Leisure. Further post hoc analysis specifies that there are statistically significant improvements following the group exercise program, which is maintained over 4 weeks [Table 2]. | Table 1: Within-group comparison of the pre–post and FU medians of the group therapy (n = 15)
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Within-group analysis of the Individual therapy showed statistically significant differences in GMFM, PBS, and CPQ component––ADL (refer [Table 3]). [Table 4] displays the Post hoc comparisons showed that there is a statistically significant improvement noted following the individual exercises that are maintained over 4 weeks. | Table 3: Within-group analysis the pre–post and FU medians of the individual therapy (n = 15)
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Between-groups analysis showed that the Group therapy performed better in gross motor function (P = 0.002), balance (P = 0.002), and participation compared to Individual therapy as can be noted by the P values in [Table 5] and [Table 6]. [Graph 1][Graph 2][Graph 3][Graph 4][Graph 5][Graph 6] show the box plot presentation of the pre-post and follow-up median differences of the outcome measures, between the group therapy and individual therapy. | Table 5: Comparison pre–post median difference between the group therapy and Individual therapy
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 | Table 6: Comparison pre vs. FU median difference between the group therapy and individual therapy
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 | Graph 1: Gross motor function measure (GMFM) pre post between group analysis
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 | Graph 5: Child Participation Questionnaire (CPQ)-ADL pre post between group analysis
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| Discussion | | |
The results of the study show that improvements in gross motor function, balance, and participation were noted in both the Group therapy and Individual therapy group which was maintained over 4 weeks post the intervention. The Group therapy group showed significantly higher improvements in gross motor function, balance, and participation domains such as ADLS, IADLs, and leisure compared to the individual therapy group.
The results of between-groups analysis showed that the Group therapy group performed better in gross motor function compared to the individual therapy group with a median difference of 2; this can be due to two reasons.
First, the increased parental involvement during the group therapy helped the parents remember the exercises and handling techniques better, which they continued to performed as an effective home exercise program.[21],[22] This active participation of the parents in the intervention program increased the repetition of exercises throughout the day which ultimately lead to much higher motor learning.[23],[24] Our finding is in line with the randomized double-blind controlled trial, conducted by Novak (2011) where they assessed the effects of home program on patient function, quality of upper limb function, participation, and GAS goals. They found that there were significant improvements in all the outcome measures post the home exercise program.
Second, because of the motivated efforts of the children during all the exercise repetitions. The children were giving their maximal efforts during each repetition due to the competitive environment. Motivation to participate in activities is closely linked to improvement in the acquisition of motor abilities.[18] Our finding is supported by an experimental study by Ko et al.[16] on 18 children with CP using group task-oriented exercises that showed significant improvements in gross and fine motor functions. They have attributed the improvements to imitation learning and healthy competition.
The improvements in balance in the Group therapy group were statistically more significant with a median difference of 3. This may be because the trunk control and gross motor gains were more in the Group therapy group, so it is likely that the functional balance also was more. Another possible explanation for this result could be that although, the children in the Group therapy and the individual therapy group were performing similar tasks but the environments were different. According to the dynamic systems theory, movement patterns emerge as a result of the interaction of an individual, task, and environment.[24] The participants in the group exercise had a dynamic environment which gave them a wide range of sensory inputs that had to be processed at the same time as while maintaining the postural stability. This challenge was similar to the real-life situations in which the child is demanded to maintain his postural control. This similarity in the training and the real environment has led to the carryover and higher self-initiated attempts to solve the task efficiently. Motor learning via operant conditioning might also have occurred as the positive behaviors were by appreciation. This appreciation might have facilitated the other children in the group to keep up their performance.[24]
Our next outcome measure the CPQ is a parent report outcome measure that was chosen to capture the participation improvements of the child in real-life situations. It has six areas of participation, namely: ADL, IADL, play, leisure, social participation, and education.
The Group therapy group had a significant improvement in ADL with a median difference of 3 when compared to the Individual therapy group. The Group therapy group has performed better in all the submeasures of participation namely- Frequency, Independence, Child Enjoyment, and Parental Satisfaction. The increase in Frequency, of attempting independent activities may be due to the increased confidence of performing new movements amongst a group.[16] The Independence has improved because of the gross motor and balance gains that translated into function.[25],[26] The Child Enjoyment and Parental Satisfaction might have increased due to the joy of achievement of certain tasks. Parental Satisfaction might also have increased due to acceptance of the child’s condition, as they see other children with similar difficulties and their coping strategies.[27]
The improvements in IADLs were noted in the Group therapy group with a median difference of 3 between the groups. Few factors that influence IADLs of children with physical disabilities are cognitive ability, social skills, and physical access.[28] The mean GMFC level of children in both the groups was II and they had the potential for community ambulation but yet most of them were restricted in their IADLs. The improvements noted in the Group therapy group in IADLs were significant in the sub measures namely, the Frequency of independent attempts and Parental Satisfaction. This may be due to parental facilitation. The interaction of the parents with other parents and observation of children with similar difficulties and their coping strategies might have led the parents to give more opportunities to their children to explore the community by attempting the IADLs. A cross-sectional study by Dina Elad et al. stated that parents of children with disabilities are likely to perceive their child as vulnerable and of low autonomy. This perceived lower autonomy often results in overprotective behaviors. Such behaviors are predominant among parents of children with CP. Thus, the parenting style may impact child’s social engagement.[29],[30] It has been noted that when parents of children with disability interact, they are able to connect with each other and provide support and skills to deal with the day-to-day issues of raising a child with disability.[31]
Hence, Group exercises should be used for pre-adolescent and adolescent children with CP to maintain physical fitness and function. In developing countries where social support groups are sparse, therapeutic group exercise programs help in improving the social participation children with CP. Group exercises also become a forum for the parents to interact and air their doubts and learn from their experiences and coping strategies. The major limitations of our study were; comparisons between the various GMFC levels couldn’t be done due to the small sample size and children to therapist ratio was 5:1; hence, it was difficult to deliver adequate intensity of training to children across the various GMFC levels.
Future research can be done, to probe the effect of varying group sizes (large number of participants vs. small number of participants per group) on functional outcome measures. Adding an outcome measure to assess adherence to an exercise program can give further information regarding the effect of group exercise training on the efficiency of delivering home exercises.
| Conclusion | | |
It is concluded that group exercises are more effective than Individual exercises in improving balance, gross motor function, and participation in children with CP spastic diplegia of gross motor function classification––I, II, and III in the age group 6–12 years, which is also maintained over a follow-up period of 4 weeks.
Acknowledgement
I take this opportunity to thank all the hands that have joined together to make this thesis a success. It is a great pleasure and privilege to express deep-felt gratitude to my guide Ms. Sandhya Wasnik, Lecturer and HOD (PT), who rendered her knowledge to enlighten me on this subject. She provided constant encouragement and support to accomplish this thesis project. I also thank the ethical committee for providing the approval to execute this study. Also, I would like to thank all the department staff for the help they rendered during the data collection phase. I would especially want to thank Mr Sheik Abdul Khadir (PT) for his relentless assistance during the statistical analysis. Above all, I would like to thank my parents and siblings as well as my batch mates for their constant support and encouragement. Praise glory to God almighty, the source of strength and inspiration in every walk of life.
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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