Firm foundation: Better balance for young patients

After treatment with orthotic and physical therapy interventions, Emma Grace Hall, whose balance is impaired by idiopathic ataxia, no longer needs assistive devices to walk. (Photo courtesy of Morgan Hall.)

Children with neurological conditions often have balance issues, and healthy kids can struggle, too. Interventions should be tail­ored to their short attention spans and need for feedback, and include devices that improve alignment and stability and training to enhance strength and equilibrium.

By P.K. Daniel

Balance is a key component for athletes, whether it’s a beginning gymnast trying to stick the landing on her dismount or a National Football League player tip-toeing down the sideline and into the end zone. Static and dynamic balance, or postural control, is established through a complex multisensorial task based on vestibular, visual, and somatosensory information.

Some researchers and practitioners stress that the ability to neutralize forces that would otherwise disturb equilibrium is a skill that can be developed in healthy adults, youth athletes, and even in children with neuromuscular conditions. In fact, some treatment strategies commonly used to improve balance in children with neuromuscular diseases—including strengthening, balance training, and orthotic devices—also have value for managing balance issues in healthy kids.

“In my opinion, only no training

at all is worse than any training,” said Michael Wälchli, MSc, a PhD student at the University of Fribourg in Switzerland and lead author of a recent study published in Pediatric Exercise Science on age and balance training.1

Kid-friendly balance work

Some research suggests balance interventions designed for adults may not be effective in children, especially younger children. A 2011 study from a different Swiss research group found conventional balance training in young children (mean age 6.6 years) was not associated with significant improvements in postural sway, plantar flexor force, or jump height.2

With this in mind, making balance-related interventions more kid-friendly was an area of emphasis for Wälchli and colleagues.

“In neurological and typically developing populations, kids aren’t just little adults. ere are developmental considerations to understand in both sensory and motor contributions to balance.” —JosephKrzak,PT,PhD,PCS

“I believe training [for children] should be variable and challenging in the sense that the children get motivated by the training content itself,” he said. “In contrast to adults [who can motivate themselves by thinking about the outcome], children are only executing things which are exciting to them at this distinct moment.”

The goal of Wälchli’s study was to test whether postural control can be improved with child-oriented balance training in children as young as 6 years and to compare their training-induced adaptations with those of older children and adolescents.

In the five-week study, 77 participants (38 girls) were assigned to twice-weekly balance training during their physical education classes (n = 48) or to a control group that did no training other than their usual physical education classes. Between-group differences were assessed for three age groups (6-7, 11-12, and 14-15 years).

The intervention was associated with decreased dynamic postural sway, particularly in the youngest group, and increased explosive plantar flexor strength. The degree of difficulty for exercises and activities was frequently modified and adapted to avoid monotonous repetitions.

“The intervention for children should be more holistic and playful than for adults,” said Wälchli. “One important point is that the difficulty level should be adapted to the abilities of the participant.”

The decision to use static or dynamic balance-oriented interventions, he said, depends on the situation and the goal.

“Balance exercises seem to be very specific,” he said. “The main principle should be to train in the exercise in which you want to get better. So, if you want to improve static balance, it is recommended to train exactly this task. However, if your aim is to improve your ‘general’ balance abilities, I believe that the training should be as variable as possible.”

He said the main objective is to develop an interesting training program.

“A multimodal protocol offers far more possibilities to change and vary the content,” he said. “[But], if the main purpose is to improve balance, then balance training should be assessed to provoke the largest improvements possible in postural control.”

Even high-functioning youth athletes can have vestibular or proprioceptive limitations.3-5 Robbie Bowers, ATC, a certified athletic trainer at Rancho Bernardo High School in San Diego, attributes some injuries to underdeveloped neurological pathways, which can manifest in balance deficits.

“You wonder how much better an athlete this person could be if they performed with these systems functioning,” Bowers said. “Your feet and lower extremities are like another set of eyes. If they’re not communicating—or communicating well—with your central nervous system, you’re not going to function as well. It helps you understand why some have had repeat injuries.”

When using interventions to address balance deficits with youth athletes, Bowers goes back to basics. He strips away extraneous stimuli, such as opponents and moving objects. Sometimes he gets pushback from varsity athletes, and has been asked: “Why are you making me stand on one leg like a stork?”

Bowers explains to his student-athletes that just going through the motions isn’t going to get them back into the game. He places them on wobble boards and requires their attention.

“You have to make that neuro-connection first,” he said. “I have them think about their bodies’ position in space. I want them to feel with their brain, I want them to see with their brain.”

Neurological conditions and balance

Given the prevalence of balance issues in healthy children and youth athletes, it may not be surprising postural control issues also affect kids with neurological conditions, and that balance-related therapies in those populations can be equally challenging.6-11

Emma Grace Hall was on the verge of walking. But three days before her first birthday, while navigating a push-toy, she fell—hard and headfirst into a kitchen table leg. Nothing had tripped her up. Nobody ran into her. She just lost her balance.

“The fall really opened our eyes as to what was going on with her,” said her mother, Morgan Hall, who is director of public relations at Shriners Hospitals for Children Medical Center in Lexington, KY.

Emma Grace has ataxia—a neurological disorder caused by damage, degeneration, or loss of cerebellar nerve cells that affects muscle control or coordination of voluntary movements.1

In addition to affecting one’s balance, ataxia can create difficulties with speech, eye movement, and swallowing. Ataxia is the symptom, meaning there is an underlying condition. Brain degeneration, multiple sclerosis, inherited defective genes, and other factors can cause the condition,12 but in Emma Grace’s case, its cause is unknown.

Experts say interventions, such as adaptive devices, can help improve children’s balance. Orthotic devices can be helpful if a child has significant weakness, low muscle tone, or spasticity that alters foot and lower extremity positioning and affects balance and stability. Emma Grace, who turned 4 in September, was fitted for orthotic devices at age 14 months, moving on to a walker when she was aged 18 to 26 months.

“Braces are often provided as an external support for joints/body segments that a child cannot control,” said Joseph J. Krzak, PT, PhD, PCS, a senior physical therapist at the Motion Analysis Center (MAC) at Shriners Hospitals for Children—Chicago. Krzak, an assistant professor of physical therapy at Midwestern University in Downers Grove, IL, has extensive clinical experience man­aging balance deficits in children with neuromuscular and musculoskeletal disorders.

Raven Smalls, PT, DPT, who works in the rehab department and in the motion analysis lab at Greenville Shriners Hospital in South Carolina, agreed orthotic devices can provide additional support to the ankle, knee, hip, and trunk, and help improve body alignment so children with neuromuscular disorders can feel more stable standing, walking, running, jumping, and performing typical activities.

“However, it is also important to address all of the components that may be affecting a child’s ability to stay upright, which may include strength, muscle flexibility and range of motion, motor control, motor planning, and body and safety awareness,” Smalls said. “For example, if one doesn’t have the strength required to stand and perform functional tasks, or if [they can’t] scan their environment for obstacles, this can lead to tripping or falling. Additionally, it’s important to address the different aspects of the balance system, including vision, proprioception, and the vestibular system, while assessing a child’s balance and creating a treatment plan.”

Krzak echoed Smalls’ assertion that there are additional considerations when managing balance issues in this population.

“The sensory information from the environment [visual, sense of body location, and inner ear function] allows us to know where we are in space,” he said. “The motor response allows us to move where we want to move [whether from point A to point B or remaining still during an unexpected balance perturbation]. As clinicians and researchers, we need to understand the contributions of both sensory and motor impairments to balance issues, identify exactly where the deficiency occurs, and consider all components of balance when recommending specific interventions.”

Krzak emphasized that, in neurological populations as in typically developing populations, children are not just little adults. “There are developmental considerations when understanding both sensory and motor contributions to balance,” he said.

On Emma Grace’s first visit to Shriners, clinicians told her mother to prepare for the high probability her child might never walk. Treatment plans usually include physical, occupational, and speech therapies. Emma Grace receives all three. She started physical therapy (PT) and occupational therapy (OT) at Shriners three days a week at age 15 months. One day was dedicated to PT, another for OT, and a third for a combination of the two. She improved so much that when she was about two and a half, her visits were reduced to one day of PT and one of OT. And she no longer requires an assistive device for walking. Emma can also run—or at least her definition of running, which is shaky with some side-to-side movement and occasional toe dragging, according to her mom.

Hall attributes Emma Grace’s progress to the various interventions she has received. Although Emma Grace’s balance deficits still prevent her from standing on one leg or riding a bike, therapists work with her on these skills every week. The types of intervention, however, that are used for Emma Grace and other children need to be adapted to the patients’ unique learning needs.

Emphasizing play

“Interventions should be presented as play activities,” said Margaret Damron, DPT, who is Emma Grace’s physical therapist. “Kids play and like games, so a PT should plan activities to address specific areas [strength, balance, endurance] but present them as a game or an art activity or use characters/items the child enjoys.”

Damron said kids’ PT sessions should include many more activities than a traditional adult PT session because of children’s decreased attention span. An emphasis on manual cues and demonstration is also important with children because they haven’t established their best means of learning, so multiple inputs and approaches should be used, she said. These can include repeated demonstration, hand-over-hand assistance, and verbal cues.

“Children with balance issues may also demonstrate issues with motor planning and have increased difficulty learning and completing multiple-step activities,” Damron said. “Interventions should also be altered to be attainable because success increases confidence, motivation, and willingness to participate with the PT.”

Smalls noted impairments or delays in speech and cognition can be barriers to teaching, instructing, and learning.

“Even young children without cognitive delays lack the maturity and intellect to understand important concepts used in therapy,” she said. “Children may need to perform activities that make them feel off balance, or feel like they are falling, to work on the skills needed to regain their balance. However, this can be very scary to some children … Having a creative mind is very important when working in pediatrics to find ways to bypass these barriers.”

Like Damron, Smalls incorporates play into treatments for children.

“Playing is a major part of their daily activities and function,” she said. “Therefore, incorporating games, toys, and enjoyable engaging activities into their therapy sessions can help motivate children and help them to focus on the task at hand because, while they are having fun, they may not realize they are performing

challenging tasks targeted at improving their balance.”

Krzak was a coauthor of a pilot experiment that included 17 children with cerebral palsy (CP) and 68 typically developing children ranging in age from 6 to 16 years.13 The researchers included 10 typically developing children as controls and five children with diplegic CP, gross motor function classification system level II. The average age participants was 8 years in CP group (range, 6-12 years), and 12 years in the control group (range, 7-16 years).

The balance of children with CP was assessed while they were barefoot and wearing braces and standing on a force platform that unexpectedly rotated five times in a toes-up direction. The braces were bilateral plastic articulated ankle foot orthoses (AFOs). All braces were constructed with a tibial shaft length 3 cm distal to the fibular head, a rubber ankle joint allowing for free dorsiflexion with a 0° plantar flexion stop, a flexible toe break, and strapping of the tibia and over the talus to maintain the position of the hindfoot and forefoot relative to the foot plate.

When barefoot, the children with CP lost their balance after each perturbation. When braced, none fell, and their response to the perturbation improved across the five trials.

“Such findings demonstrate that once children with cerebral palsy were biomechanically aligned [and stabilized by the brace], they were able to learn from each trial and improve their strategy after each subsequent trial,” he said.

Krzak uses technology to give kids the feedback they crave when learning a new motor task.

“With the development of newer technology and gaming systems, children can be provided with real-time augmentative visual feedback characterizing their motor responses during balance training activities/treatment,” he said. “Such systems are often game-based, which provides motivation for the child to stay engaged and attentive. We’re able to quantitatively evaluate these children to get a better understanding of their sensory as well as motor contributions to balance.”

One of Krzak’s patients was a boy, aged 13 years, who presented with idiopathic toe walking. He underwent surgery, including bilateral Achilles tendon lengthening and plantar fascia release, to help lower his heels during gait. As a result, he had trouble balancing. Practitioners used computerized dynamic posturography to evaluate the sensory and motor components affecting his balance, giving the patient real-time visual feedback on how he moved in space.

An image representing the location and path of the patient’s center of gravity (COG) during weight-shifting activities was represented on a screen at eye level. As he shifted his weight, the force plate tracked and displayed his COG’s position and path. Krzak used the information to create a patient-specific prescription of exercises, games, and weight-shifting activities to retrain his balance.

The boy was treated for about four months. Following surgery and therapy, his toe walking was eliminated, his balance improved, and the quality of his ankle motion during walking more closely resembled that of typically developing children.

Rebecca Rouse, DPT, a physical therapist with Shriners Hospital for Children—Twin Cities, explained external factors, such as pavement, grass, gravel and access via ramps, stairs, and other means also need to be considered. Shriners’ Minneapolis, MN, location serves a large Amish population, she said, noting, “They often have to walk along dirt roads or over grass to not only access their homes and school but to complete their chores.”

Walking on a surface other than flat even ground involves

additional balance challenges and may require more equipment, said Rouse. “Patients are required to recruit more muscles in order to maintain balance and posture while walking over uneven ground,” she said.

She is able to replicate a similar environment. “We are lucky to have an awesome outdoor space that we can use for some ‘off-road’ training, and then make adaptations to [patients’] mobility as needed,” she said.

Static vs dynamic balance

Although studies have shown chronological age is a significant predictor of single-leg squat (SLS) performance, with younger children having poorer SLS scores than their older counterparts, children with neurological deficits have other considerations.13

Determining whether interventions should focus more on static balance or dynamic balance, Smalls said, depends on the patient’s abilities and limitations. For example, a child with CP may be able to walk 30 feet without falling but have difficulty maintaining balance when they are prompted to stand still in the school lunch line. On the other hand, Smalls noted, another child with the same diagnosis may be able to perform static standing without any difficulty but struggle with balance when asked to reach for a ball outside of their base of support or to ambulate short distances without tripping.

Damron echoed Smalls’ observation that a child can have good or fair static balance and poor dynamic balance, which will greatly affect their gross motor skills and ability to play and participate with peers.

“Focus on static or dynamic balance should be based on findings in the evaluation,” Damron said. “However, I always include static balance to address strength, stability, and proprioception as increasing these areas usual leads to global improvements.”

Balance-specific training is beneficial when one is working on a specific task and refining the patient’s skills so he or she can improve balance and perform a specific balance task safely, Smalls said.

“However, children with neuromuscular disorders are often complex, so their inability to perform a task such as single-limb stance could affect their ability to ambulate, run, and kick a ball because these are all activities that require brief moments of single-limb support,” she said. “Additionally, children may have other impairments—including decreased lower extremity strength, range of motion, increased tone, poor safety or body awareness, and impaired motor control—that may also affect their risk of falling. Therefore, a multimodal protocol can be very beneficial when developing treatment plans for children.”

Understanding the environmental conditions in which balance issues are present will help clinicians develop patient-specific interventions, Krzak said. He determines whether the child loses their balance during slips and trips or when bumped (ie, unexpected perturbations). He asks if they have balance issues when they are the ones that initiate movement, or when they are in situations with limited sensory information (visual or somatosensory).

“The ultimate goal of any form of training is to maximize functional activity and participation,” Krzak said. “Balance issues may be only one of the impairments resulting in limitations in functional activity. Also, you cannot assume that addressing sensory and motor impairments during static balance training will directly carry over to all functional activities. Once improvements in balance are achieved during therapeutic interventions, they should be applied to functional training activities based on the patient’s/family’s goals for therapy.”

  1. Wälchli, M, Ruffieux, J, Mouthon, A, et al. Is Young Age a Limiting Factor When Training Balance? Effects of Child-Oriented Balance Training in Children and Adolescents. Pediatr Exerc Sci.2017 Sep 27. [Epub ahead of print]
  2. Granacher U, Muehlbauer T, Maestrini L, et al. Can balance training promote balance and strength in prepubertal children? J Strength Cond Res 2011;25(6):1759-1766.
  3. Beckett M, Hannon M, Ropiak C, et al. Clinical assessment of scapula and hip joint function in preadolescent and adolescent baseball players. Am J Sports Med 2014;42(10):2502-2509. 
  4. Agresta C, Church C, Henley J, et al. Single leg squat performance in active adolescents aged 8-17 years. J Strength Cond Res 2017;31(5):1187-1191. 
  5. Parsonage JR, Williams RS, Rainer P, et al. Assessment of conditioning-specific movement tasks and physical fitness measures in talent identified under 16 year old rugby union players. J Strength Cond Res 2014;28(6):1497-1506. 
  6. Dewar R, Love S, Johnston LM. Exercise interventions improve postural control in children with cerebral palsy: a systematic review. Dev Med Child Neurol 2015;57(6):504-520.
  7. El Shamy SM, Abd El Kafy EM. Effect of balance training on postural balance control and risk of fall in children with diplegic cerebral palsy. Disabil Rehabil 2014;36(14):1176-1183. 
  8. Pagliano E, Foscan M, Marchi A, et al. Intensive strength and balance training with the Kinect console (Xbox 360) in a patient with CMT1A. Dev Neurorehabil 2017;1:1-4. 
  9. Fong SS, Guo X, Cheng YT, et al. A novel balance training program for children with developmental coordination disorder. A randomized controlled trial. Medicine 2016;95(16):e3492.
  10. Kim Y, Todd T, Fujii T, et al. Effects of Taekwando intervention on balance in children with autism spectrum disorder. J Exerc Rehabil 2016;12(4):314-319.
  11. Eid MA, Aly SM, Huneif MA, Ismail DK. Effect of isokinetic training on muscle strength and postural balance in children with Down syndrome. Int J Rehabil Res 2017;40(2):127-133.
  12. NINDS ataxias and cerebellar or spinocerebellar degeneration information page. National Institute of Neurological Disorders and Stroke website. Accessed November 14, 2017.
  13. Graf A, Krzak J, Harris G. Response to balance perturbation: A strategy for pediatric assessment. Foot and Ankle Motion Analysis: Clinical Treatment and Technology. Boca Raton, FL: CRC Press, 2007.
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