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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 100-104

Comparison of dynamic balance between deaf and normal children using the functional reach test: An observational study


Department of Paediatric Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission14-Mar-2019
Date of Decision29-Jul-2019
Date of Acceptance02-Aug-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Deepa C Metgud
KAHER Institute of Physiotherapy, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_5_19

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  Abstract 


Background: Deafness refers to complete loss of hearing ability. Children with hearing impairment have deficits in motor development majorly in balance. Vestibular system maturation is achieved by age of 10-14 years which is related to motor development. As dynamic balance is more affected than static balance in deaf children, Functional Reach Test (FRT) is used to measure dynamic balance. Hence there was a need to compare dynamic balance in deaf and normal children in the age group 7-18.
Objectives: To compare dynamic balance in normal and deaf children using FRT and to find the common strategy used by these children for dynamic balance.
Materials and Methods: An observational study with 191 deaf and normal children in age group of 7-18 years with no physical impairments were recruited in the study using convenience sampling as per the inclusion criteria. The outcome measure used for the study was FRT. It is the maximum distance one can reach beyond arm's distance while maintaining a fixed base of support in standing position. The test was administered in both the groups and their results were compared and the most common strategy used to perform the test was noted.
Results: There was significant difference in dynamic balance between both the groups (P = 0.006). Normal children used hip strategy more frequently as compared to deaf children while ankle strategy was used twice as much in deaf children compared to normal children.
Conclusion: The present study concluded that dynamic balance is reduced in deaf children in the age group 7 to 18 years.

Keywords: Deafness, Dynamic balance, Functional reach test, Hip and ankle strategy, Vestibular system


How to cite this article:
Metgud DC, Parikh Y, Kharith Y. Comparison of dynamic balance between deaf and normal children using the functional reach test: An observational study. Indian J Phys Ther Res 2019;1:100-4

How to cite this URL:
Metgud DC, Parikh Y, Kharith Y. Comparison of dynamic balance between deaf and normal children using the functional reach test: An observational study. Indian J Phys Ther Res [serial online] 2019 [cited 2020 Feb 28];1:100-4. Available from: http://www.ijptr.org/text.asp?2019/1/2/100/273721




  Introduction Top


Deafness refers to complete hearing loss in one or both the ears and is the most common sensory deficits in humans.[1] In India, 4 in every 1000 children suffer from significant hearing loss. The major causes of deafness in India are ear wax (15.9%), middle ear infection such as chronic suppurative otitis media (5.2%), and bilateral genetic and congenital deafness (0.2%).[2] Deafness is associated with certain consequences on the child's cognitive, emotional, social, and neuromotor development. Children with hearing impairment majorly show deficits in motor development in balance.[3]

To achieve balance, the sensory system must be perfectly integrated. The vestibule-cochlear system is situated in the inner ear and has two main functions that includes cochlea which is responsible for hearing and the vestibule for balance. However, the primary function of the auditory organ is to maintain balance, while hearing is the secondary function.[4] A report suggested that 20%–70% of children with hearing loss of various etiology show vestibular dysfunction, in which 30% of children perform poorly on balance skills. This is due to the cochlea and vestibular end organs which are closely related anatomically; thus, injury or trauma during perinatal or postnatal period may cause damage to the systems. Damage to any portion of the vestibulocochlear nerve can be a cause of sensorineural hearing loss.

Balance is an even distribution of weight, enabling an individual to remain upright and steady. It is an essential component to perform various functional tasks that require static balance control which allows the body to remain stationary and dynamic balance control which stabilizes the body while the supporting surface is in motion.[5]

Balance examination is an important part in physical therapy examination; various balance assessment tools are available. Functional reach test (FRT) is one of the commonly used tools to measure dynamic balance that is easy to understand, administer, score, and cost-effective.[6]

The concept of postural strategies includes both muscle synergies and movement patterns. Postural response “strategies” include ankle strategy, hip strategy, and mixed strategy which are used to maintain equilibrium during forward reach. As a result of slow and small displacement in the anteroposterior direction, there is a repositioning of centre of gravity (COG) by swaying at the ankle with little hip and knee movement; this pattern of muscle activation is an ankle strategy which uses distal to proximal muscle activation with >5° ankle plantar flexion and <20° of hip flexion. In postural response to larger and faster displacement, the action mainly occurs at the hip, resulting in trunk movement called as the hip strategy which uses proximal to distal muscle activation with 20° of hip flexion and 5° of ankle plantar flexion, and displacement of any speed results in mixed hip and ankle strategy.[7],[8],[9]

There was a need to compare dynamic balance in deaf and normal children in the age group of 7–18 years as the vestibular system maturation is achieved by the age of 10–14 years which is related to motor development, and there were no comparative studies conducted. Furthermore, there are no reported studies on FRT values for deaf children; hence, the present study was done to find FRT values for deaf children to evaluate their dynamic balance and compare it with age-matched normal children and the commonly used strategy while performing FRT to maintain dynamic balance.


  Materials and Methods Top


This observational study was approved by the Institutional Review committee. After obtaining informed assent, 93 deaf and 98 normal children in the age group of 7–18 years were included in the study. Those with musculoskeletal disorders, neurological and psychological disorders, visual deficits, limb length discrepancy, recent injury, and mental retardation were excluded.

Outcome measures

Functional reach is a measure of dynamic balance. It is the maximum distance one can reach forward beyond arm's length while maintaining a fixed base of support (BOS) in the standing position.[10] This test is easy to understand, administer, score, and cost-effective.[6] The inter-rater reliability of 0.98, intra-rater reliability of 0.83 and test–retest reliability of 0.75 has been reported.[11]

Procedure

Children in the age group of 7–18 years were included in the study and their demographic data were recorded. The procedure to perform the FRT was explained and demonstrated by the research assistant to the teachers of deaf children so that they could explain the same to them in the language they understand (sign language). FRT to the normal children was explained by the research assistant till they had clearly understood the steps of performing the test. To perform FRT, children were asked to wear comfortable clothes and will stand barefoot. Appropriate verbal instructions were given that included standing with feet parallel, dominant arm raised to 90° with the elbow extended, measuring the distance from acromion process to the third metacarpal. Children were then asked to move forward as far as possible and maintain it for a few seconds without losing balance. The difference between both the measurements was recorded. The strategy was observed and recorded by the amount of forward reach the child could perform and amount of displacement made; hip strategy was used with large displacement and ankle for small. Three trials were given and the best of three was recorded.

Data analysis

Statistical analysis was done Using Statistical Package of Social Sciences version 23 (IBM Corp., Armonk, NY, USA) so as to verify the results obtained. Comparison of deaf and normal children with respect to pretest and posttest was done using the Mann–Whitney U-test to check dynamic balance. Mean standard deviation and percentage were used to explain the demographic data. The level of significance for all the tests was set at 0.05.


  Results Top


In the present study, 191 children participated in the age group of 7–18 years. The demographic profile of the participants in the study is depicted in [Table 1]. [Table 2] presents gender distribution in deaf with 14 males and 79 females. There were more number of female children since the data were collected from girls' school and normal children with 40 males and 58 females [Table 2]. There was a statistical significance in terms of of dynamic balance between both the groups in which it was observed that normal children had better balance than deaf with P = 0.006 [Table 3]. Both the groups used all the strategies with the hip strategy being used frequently by the normal children in the age group of 11–18 years, ankle strategy being used in the age group of 7–10 years frequently in deaf children, and mixed strategy used frequently in the age group of 15–18 years by deaf children [Table 4] and [Table 5].
Table 1: Demographic characteristics of the study participants

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Table 2: Gender distribution of the study participants

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Table 3: Comparison of Group A and B with respect to pre- and posttest using Mann-Whitney U-test (between-group analysis - independent test)

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Table 4: Comparative analysis of strategy used by normal and deaf children

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Table 5: Comparison of Group A and Group B with respect to age versus hip, ankle, and mixed strategy

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  Discussion Top


The present study was conducted to compare the dynamic balance among deaf and normal children (n = 191) in the age group of 7–18 years and also to find the most commonly used strategy by these children. There was a difference in the dynamic balance between deaf and normal children. Normal children used hip strategy more frequently as compared to deaf children, and ankle strategy was used two times more in deaf children compared to normal children.

A cross-sectional study on 93 children in the age group of 6–16 years found that deafness was associated with certain consequences on the child's cognitive, emotional, social, and neuromotor development, and children with hearing impairment have majorly shown deficits in motor development in balance. To achieve balance, the sensory system must be perfectly integrated. Vestibular dysfunction is seen in children with hearing loss of various etiologies, of which 30% perform poorly on balance skills. This is due to the cochlea and vestibular end organs which are closely related anatomically; thus, injury or trauma during perinatal or postnatal period may cause damage to the systems.[3]

FRT values in the present study are in accordance with another study by Gayle and Pohlman which reported that there is a significant difference of dynamic and rotator balance between deaf and normal children and no difference in static balance.[12],[13] A cross-sectional study in 88 children in the age group of 7–17 years reported that deaf children did not have significant differences in static balance when compared with their age-matched normal children, but their difficulties were most definite during dynamic activities.[4]

In the present study, the range difference was 10–14 cm, 12–22 cm, and 15–25 cm in deaf children and 10–16 cm, 15–25 cm, and 17–29 cm for ankle, hip, and mixed strategy, respectively, in normal children which suggests that there was a significant difference in the FRT range in the age group of 7–18 years.

In the present study, FRT was taken as an outcome measure as it is easy to understand, administer, score, and cost-effective. Among the measures of dynamic postural control developed, FRT demonstrates excellent precision and interobserver reliability and can be easily performed in homes and outpatient clinical settings in nursing homes.[14]

The concept of postural strategies includes both muscle synergies and movement patterns. Postural response “strategies” include ankle strategy, hip strategy, and mixed strategy which are used to maintain equilibrium during forward reach.[6] In the present study, children were permitted to use the lower limb strategies of their choice during the FRT. In the age group of 11–14 and 15–18 years, there was a significant use of hip strategy in normal children than the deaf children as there is more displacement of COG in hip strategy as compared to other strategies, so it was convenient for the children to shift the COG out of their BOS. Previous studies reported that while performing FRT, the hip strategy was adopted by vestibular-impaired patients.[15]

In the age group of 7–10 years, the ankle strategy was used more frequently in deaf children than the normal children. A study reported that in the age group of 7–10 years, there was a moderate risk of fall, so greater cocontraction of antagonists results in ankle joint stiffness as a strategy to maintain postural stability.[4],[16]

As the vestibular system maturation is related to motor development which is achieved by 10–14 years, in the age group of 15–18 years, there was a significant difference in the use of mixed strategy in the deaf group than the normal group as there is maximum displacement of center of gravity (COG) outside the BOS.[9] A study done on deaf children with vestibular impairment suggested that the standing position was difficult to maintain when the visual and somatosensory input was removed, but when these inputs were enabled, children showed values of postural control similar to the normal children.[17]

While conducting the test, it was difficult to explain the procedure to deaf children. This study can be continued further using a larger sample size and in a greater geographical area and classify strategies based on the severity of hearing loss. This study can also be used to initiate early intervention program for the deaf children who showed impaired dynamic balance.


  Conclusion Top


The present study concludes that dynamic balance in deaf children was reduced as compared to normal children in the age group of 7–18 years.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Reddy MV, Sathyanarayana VV, Sailakshmi V, Hemabindu L, Usha Ran P, Reddy PP. An epidemiological study on children with syndromic hearing loss. Indian J Otolaryngol Head Neck Surg 2004;56:208-12.  Back to cited text no. 1
    
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Varshney S. Deafness in India. Indian J Otol 2016;22:73.  Back to cited text no. 2
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3.
Fellinger MJ, Holzinger D, Aigner M, Beitel C, Fellinger J. Motor performance and correlates of mental health in children who are deaf or hard of hearing. Dev Med Child Neurol 2015;57:942-7.  Back to cited text no. 3
    
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Melo RD, Silva PW, Tassitano RM, Macky CF, Silva LV. Balance and gait evaluation: Comparative study between deaf and hearing students. Rev Paul Pediatr 2012;30:385-91.  Back to cited text no. 4
    
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Kisner C, Colby LA, Borstad J. Therapeutic Exercises. Foundations and Techniques. 6th ed. Philadelphia: Jaypee; 2013. p. 260-5.  Back to cited text no. 5
    
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Yuksel E, Ozcan Kahraman B, Nalbant A, Kocak UZ, Unver B. Functional reach and lateral reach tests in Turkish children. Phys Occup Ther Pediatr 2017;37:389-98.  Back to cited text no. 6
    
7.
Horak FB, Henry SM, Shumway-Cook A. Postural perturbations: New insights for treatment of balance disorders. Phys Ther 1997;77:517-33.  Back to cited text no. 7
    
8.
Gatev P, Thomas S, Kepple T, Hallett M. Feedforward ankle strategy of balance during quiet stance in adults. J Physiol 1999;514 (Pt 3):915-28.  Back to cited text no. 8
    
9.
Volkman KG, Stergiou N, Stuberg W, Blanke D, Stoner J. Factors affecting functional reach scores in youth with typical development. Pediatr Phys Ther 2009;21:38-44.  Back to cited text no. 9
    
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O'Sullivan SB, Schmitz TJ, Fulk G. Physical Rehabilitation. 6th ed. Philadelphia: Jaypee; 2014. p. 965-8.  Back to cited text no. 10
    
11.
Deshmukh AA, Ganesan S, Tedla JS. Normal values of functional reach and lateral reach tests in Indian school children. Pediatr Phys Ther 2011;23:23-30.  Back to cited text no. 11
    
12.
Gayle GW, Pohlman RL. Comparative study of the dynamic, static, and rotary balance of deaf and hearing children. Percept Mot Skills 1990;70:883-8.  Back to cited text no. 12
    
13.
Melo RS, Marinho SE, Freire ME, Souza RA, Damasceno HA, Raposo MC. Static and dynamic balance of children and adolescents with sensorineural hearing loss. Einstein (Sao Paulo) 2017;15:262-8.  Back to cited text no. 13
    
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Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: A new clinical measure of balance. J Gerontol 1990;45:M192-7.  Back to cited text no. 14
    
15.
Liao CF, Lin SI. Effects of different movement strategies on forward reach distance. Gait Posture 2008;28:16-23.  Back to cited text no. 15
    
16.
Nagai K, Yamada M, Uemura K, Yamada Y, Ichihashi N, Tsuboyama T. Differences in muscle coactivation during postural control between healthy older and young adults. Arch Gerontol Geriatr 2011;53:338-43.  Back to cited text no. 16
    
17.
Gheysen F, Loots G, Van Waelvelde H. Motor development of deaf children with and without cochlear implants. J Deaf Stud Deaf Educ 2008;13:215-24.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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