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Journal of Back and Musculoskeletal Rehabilitation -1 (2017) 1–7 1

DOI 10.3233/BMR-170813
IOS Press

Effectiveness of Neuro-Developmental
Treatment (bobath concept) on postural
control and balance in Cerebral Palsied
Children
Fatih Tekin, Erdogan Kavlak∗ , Ugur Cavlak and Filiz Altug
Pamukkale University, School of Physical Therapy and Rehabilitation, Denizli, Turkey

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Abstract.

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BACKGROUND AND OBJECTIVE: The aim of this study was to show the effects of an 8-week Neurodevelopmental Treat-
ment based posture and balance training on postural control and balance in diparetic and hemiparetic Cerebral Palsied children
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(CPC).
METHODS: Fifteen CPC (aged 5–15 yrs) were recruited from Denizli Yağmur Çocukları Rehabilitation Centre. Gross Motor
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Function Classification System, Gross Motor Function Measure, 1-Min Walking Test, Modified Timed Up and Go Test, Paedi-
atric Balance Scale, Functional Independence Measure for Children and Seated Postural Control Measure were used for assess-
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ment before and after treatment. An 8-week NDT based posture and balance training was applied to the CPC in one session
(60-min) 2 days in a week.
RESULTS: After the treatment program, all participants showed statistically significant improvements in terms of gross motor
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function (p < 0.05). They also showed statistically significant improvements about balance abilities and independence in terms
of daily living activities (p < 0.05). Seated Postural Control Measure scores increased after the treatment program (p < 0.05).
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CONCLUSIONS: The results of this study indicate that an 8-week Neurodevelopmental Treatment based posture and balance
training is an effective approach in order to improve functional motor level and functional independency by improving postural
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control and balance in diparetic and hemiparetic CPC.

Keywords: Cerebral palsy, postural control, balance, bobath concept

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1 1. Introduction tor skills. The balance creates the background for these 10

movements. One of tasks of the central nervous sys- 11

2 Cerebral Palsy (CP) is a clinical process that ef- tem is making possible movements that require high- 12

3 fects child’s neurological development; characterized level skills by providing the control of posture and bal- 13

4 by bad muscle tone and posture, lack of movement and ance. Reciprocal innervation of muscles working re- 14

5 balance; going with sensitive, cognitive, perceptual verse each other, is not the only way using for coor- 15

6 problems and epileptic seizures, causes from several dination. The synergist muscle groups contract for fix- 16

7 factors in prenatal, perinatal or postnatal term [1,2]. ation in the adjacent joints at the same time. Some- 17

8 Normal posture is necessary for both the develop- times antagonist muscles must contract with agonist 18

9 ment of new motor skills and success of current mo- muscle. This mechanism is especially used for proxi- 19

mal joint stabilisation during the distal movements and 20

it’s named as “co-contraction”. Reciprocal innervation 21

∗ Corresponding author: Erdogan Kavlak, Pamukkale Univer- and cocontraction mechanisms are very important neu- 22
sity, School of Physical Therapy and Rehabilitation, Kınıklı Kam-
püsü, 20070 Denizli, Turkey. Tel./Fax: +90 258 2964257/+90 258 rophysiological to provide balance and to regulate pos- 23

2964246; E-mail: kavlake@hotmail.com. tural tone during normal movements. But these mech- 24

ISSN 1053-8127/17/$35.00
c 2017 – IOS Press and the authors. All rights reserved
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2 F. Tekin et al. / Effectiveness of NDT (bobath concept) on postural control and balance in CPC

25 anisms do not work properly in cerebral palsied chil- 2.1.1. Inclusion criteria 70

26 dren (CPC). CPC have some difficulties in providing – Accepting whose child’s participation in the study 71

27 postural control and balance, because of living without (by parents and/or their legal representatives) 72

28 these mechanisms. Thus, CPC cannot achieve essential – CP diagnosed 73

29 motor skills and get dependent to their families in daily – Ages between 5–15 74

30 living activities [2]. – Clinical types diparesis and hemiparesis 75

31 Managing the complicated process of CP, the phys- – Cooperative 76

32 ical therapy and rehabilitation is used to be an ef- – Walking independently or at least with a walking 77

33 fective method for years. Neuro-Developmental Treat- aid (Gross Motor Function Classification System 78

34 ment (NDT), also known as Bobath Concept, was de- (GMFCS) Level I, II or III) 79

35 veloped by physical therapist Berta Bobath and her

36 neurologist husband Karel Bobath to use for treating 2.1.2. Exclusion criteria 80

37 movement disorders in young and adult people. Since – Different diagnosis from CP 81

38 the year 1940, NDT was developed based on the re- – Different clinical types of CP 82

39 searches about brain functions and neurophysiology, – Children who cannot walk independently or at 83

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40 and NDT is a common physical therapy approach to- least with a walking aid (GMFCS Level IV or V) 84

41 day. Providing purposive neuromotor and postural con- – To be not attended the assessments or the therapy 85

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42 trol is aimed within NDT. The main objective of NDT sessions regularly. But all the participants were at- 86

is improving children to the maximum independence tended every session properly.

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43 87

44 level as much as possible within the age and abil-

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2.2. Measurements
45 ity limits. Treatment sessions are planned for a cer- 88

46 tain function and the patient’s active participation is

Participants’ first name, surname, gender, age,
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47 prompted as much as possible. Physical therapist helps 89

48 and guides less as much as the child accomplishes the height, weight, Body Mass Index (BMI), CP’s clinical 90

postural and motor requirements [2,3]. NDT provides type, limb involvement, number of brothers, presence
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49 91

50 normal movement experience in CPC and has 3 car- of disabled brother, medical histories, using of walking 92

51 dinal principles; facilitation, stimulation and commu- aids, surgical operation history and NDT history were 93
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52 nication. It is known that NDT has positive effects on saved in registration forms. 94

53 postural control and balance defects with the methods GMFCS and Gross Motor Function Measure-88 95
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54 based on these 3 principles. (GMFM-88) were used to assess gross motor func- 96

The aim of this study is to assess the effects of an 8- tions. GMFCS was developed to provide a simple 97
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55

56 week NDT based posture and balance training on pos- method for classifying children with CP aged 18 years 98

57 tural control and balance in CPC. or less on the basis of functional abilities and lim- 99
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itations. The GMFCS includes five levels and four 100

age bands. Distinctions between levels represent dif- 101

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58 2. Material and methods ferences in gross motor function that are thought to 102

be meaningful in the daily lives of children with 103

CP [4]. GMFM-88 is used to measure changes in 104

59 This study was done between February 2015 and
gross motor function in children with CP and has 105
60 December 2015 in Denizli Yağmur Çocukları Special
been commonly used by researchers. The GMFM-88 106
61 Education and Rehabilitation Centre with permission.
consists of 88 items in five dimensions: lying and 107
62 Informed Consent Forms were taken from all the par-
rolling (GMFM-A); sitting (GMFM-B); crawling and 108
63 ents. The study was approved by Pamukkale Univer-
kneeling (GMFM-C); standing (GMFM-D); and walk- 109
64 sity Non-invasive Clinical Research Ethics Committee
ing, running and jumping (GMFM-E). The GMFM- 110
65 in 13.01.2015 with the number 60116787-020/4199.
88 comprises 88 items, of which only seven were not 111
66 Declaration of Helsinki was complied during the study.
found to be at the level of activities and participa- 112

tion of the International Classification of Functioning, 113

67 2.1. Participants Disability and Health (ICF) [5]. Functional Indepen- 114

dence Measure for Children (WeeFIM) was used to as- 115

68 Fifteen children were included in the study accord- sess functional independence levels. WeeFIM is an 18- 116

69 ing to the inclusion criteria’s. item, 7-level ordinal scale instrument that measures a 117
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F. Tekin et al. / Effectiveness of NDT (bobath concept) on postural control and balance in CPC 3

118 child’s consistent performance in essential daily func- forget to touch the star, come back and sit down.” Tim- 169

119 tional skills. Three main domains (self-care, mobil- ing was started as the child left the seat, rather than on 170

120 ity, and cognition) are assessed by interviewing or the instruction “go” and stopped as the subject’s bot- 171

121 by observing a child’s performance of a task to cri- tom touched the seat, in order to measure “movement 172

122 terion standards. WeeFIM is categorized into 2 main time” only. A practice trial was given to the subject. 173

123 functional streams: “Dependent” (i.e., requires helper: Thereafter, the test was conducted thrice and respective 174

124 scores 1–5) and “Independent” (i.e., requires no helper: time was recorded. The time was measured in seconds. 175

125 scores 6–7). Scores 1 (total assistance) and 2 (maximal The mean of three values was documented and used for 176

126 assistance) belonged to the “Complete Dependence” analysis. The investigator sat on a chair in clear view 177

127 category. Scores 3 (moderate assistance), 4 (minimal of the subject. Subjects were tested in small groups. 178

128 contact assistance), and 5 (supervision or set-up) be- Every completed MTUGT was scored and noted. The 179

129 longed to the “Modified Dependence” category. Scores same investigator conducted all the testing procedures 180

130 6 (modified independence) and 7 (complete indepen- for the study [8]. 181

131 dence) belonged to the “Independent” category [6]. PBS, a modification of Berg’s Balance Scale, was 182

132 Balance skills were evaluated with 1 Minute Walk- developed as a balance measure for school-age chil- 183

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133 ing Test (1MWT), Modified Timed Up and Go Test dren with mild to moderate motor impairments. PBS is 184

134 (MTUGT), and Paediatric Balance Scale (PBS). For easy to administer, does not require specialized equip- 185

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135 1MWT, one assessor explained the protocol to each ment, and can be completed in 20 minutes. A 0 to 4 186

subject before the test, demonstrated one lap of the grading scale provides a quantitative and qualitative

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136 187

137 track and gave the order to start and stop. A sec- measure of performance. An overall numeric score is 188

obtained at the conclusion of testing [9].

138 ond assessor recorded the total distance walked. Dur-
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139 ing testing children wore their own comfortable cloth- Lastly, postural control skills were evaluated with 190

ing, shoes and splints (as appropriate), and used their Seated Postural Control Measure (SPCM). SPCM is a
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140 191

141 walking aid/s as appropriate. On each occasion par- 34-item, criterion-referenced, evaluative measure and 192

142 ticipants were asked to complete two 1-min walks us- was developed by a team of clinicians and researchers 193
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143 ing the following procedure: following a 5 min seated at Sunny Hill Health Centre for Children. The SPCM 194

144 rest, children stood at a starting point inside the out- was designed to measure specific aspects of postu- 195
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145 line of an oval 20 m level track (track width 30 cm at ral alignment and functional movement that are ex- 196

146 both venues). They were given the following instruc- pected to change as a result of adaptive seating inter- 197
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147 tion: ‘Once you are given the instruction to start, you vention [10]. 198

148 should walk as fast as possible around the track for

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149 1 min, until you are asked to stop. You are not allowed 2.3. Treatment 199

150 to run’. Distance was calculated to the nearest metre

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151 using markings on the track. During the test children Individual NDT programs were applied participants 200

152 were informed after 30 s had elapsed and again when by a specialist physiotherapist who has 3 years of ex- 201

perience in NDT, for 8 weeks in one session (60 min.)

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153 10 s remained. A 10 min seated rest was given between 202

154 tests [7]. 2 days in a week. Participants were assessed twice (be- 203

155 For MTUGT, the following instructions were deliv- fore and after the NDT programs) and obtained data 204

156 ered to the subject slowly and clearly: “This test is to were saved. 205

157 see how you can stand up, walk, and touch the star, then NDT programs were planned specially for each pa- 206

158 come back to sit down. The stopwatch (of cell phone) tient according to their needs. Besides the NDT pro- 207

159 is to time you.” Subjects wore their regular footwear or grams generally contain: 208

160 orthosis, and were allowed to use walking aid, but were – Vestibular and proprioceptive training on balance 209

161 not allowed to be assisted by another person during the board 210

162 performance of the test. There was no time limit for – Vestibular and proprioceptive training on exercise 211

163 the performance of the test, and they may stop and take balls in different sizes 212

164 rest (but not sit down) if they needed to do so. Instruc- – Dynamic balance training in sitting, kneeling and 213

165 tions given were “After I say ‘go,’ stand up, walk up to standing position (eyes open and closed) 214

166 and touch the star, and then come back and sit down. – Balance exercises in front of the mirror 215

167 Remember to wait until I say ‘go.’ This is not a race; – Standing on one foot for improving the proprio- 216

168 you must walk and not run, and I will time you. Don’t ceptive input (eyes open and closed) 217
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Table 1
218 – Balance training on the trampoline Demographic data
219 – Sensory stimulation for foot soles with various
Data X ± SD Median Min-Max
220 materials
Age (months) 120.4 ± 31.69 123 60–176
221 – Weight bearing exercises in sitting, crawling, Height (cm) 133 ± 18.87 133 105–170
222 kneeling and standing position Wight (kg) 30.8 ± 12.82 30 17–65
223 – Functional reaching and ball throwing-keeping BMI (kg/cm2 ) 16.75 ± 2.99 16.33 10.88–22.49
224 exercises in various positions Total received NDT 106.73 ± 28.56 109 52–153
before (months)
225 – Multi-task trainings
BMI: Body Mass Index.
226 – Walking trainings in different types
227 – Climbing up & stepping down the stairs (suppor-
Table 2
228 ted-unsupported, symmetric, reciprocal etc.) [2]. Gross Motor Function Classification System
GMFCS BT n (%) AT n (%)
229 2.4. Statistical analysis Level I 3 (20%) 10 (66.7%)
Level II 8 (53.3%) 4 (26.7%)
230 Power analysis results is estimated to be 15 people Level III 4 (26.7%) 1 (6.7%)

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231 working at the 95% confidence reached 90% power. BT: Before Treatment; AT: After Treatment; Marginal Homogeneity
232 Data were analysed using the Statistical Package for Test: p < 0.05.

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233 Social Science (v21.0). Continuous variables are ex-
pressed as mean ± standard deviation and median function levels based on GMFCS are given as numeric 261

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234

235 (minimum – maximum values), while categorical vari- and as percentage in Table 2. Before treatment; 3 of 262

CPC were in Level-I and after treatment there were no

236 ables were expressed as numbers and percentages. In
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237 dependent group comparisons, Paired Samples t Test changes; 8 of CPC were in Level-II and after treatment 264

was used when parametric test assumptions are pro- 7 of them raised up to Level-I; 4 of CPC were in Level-
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238 265

239 vided, and Wilcoxon Signed Rank Test was used when III and after treatment 3 of them raised up to Level- 266

240 parametric test assumptions are not provided. Marginal II. These changes were statistically significant (p < 267
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241 Homogenity test was used for to examine before – af- 0.05) according to the marginal homogeneity test. In 268

242 ter treatment difference for categorical variables. The this case, NDT improved the gross motor function lev- 269
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243 p values below 0.05 were considered statistically sig- els of CPC. 270

244 nificant.
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3.3. Sitting skill levels 271

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245 3. Results All CPC’s sitting skill levels were evaluated by 272

SPCM. Fourteen of participants were suitable with 273

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246 3.1. Demographic data “keeps position, doesn’t move” option and one of par- 274

ticipants was suitable with “shifts his/her body ante- 275

rior” option.
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247 Fifteen CP diagnosed children ages between 5–15, 276

248 clinical types diparesis or hemiparesis, cooperative and

249 walk independently or at least with a walking aid (GM- 3.4. Comparison of before-after tests 277

250 FCS Level I, II or III) were included in the study. Seven

251 children were girls, and eight children were boys. De- Comparison of participants’ balance skills and func- 278

252 mographic data are summarized in Table 1. tional independence levels before and after treatment 279

253 All participants’ cognitive skills were available to are given in Table 3. All of the results were statistically 280

254 understand all the directions and all participants were significant (p < 0.05). This has led to the develop- 281

255 cooperative. Four of participants were using walking ment of walking and balance skills and independence 282

256 aid and thirteen of them had surgical operation history. of daily activities in children with CP at the end of the 283

257 Eight of participants’ limb involvement were diparesis treatment period. 284

258 and seven of theirs were hemiparesis. Statistics about participants’ postural control skills 285

before and after treatment according to SPCM Align- 286

259 3.2. Gross Motor Function Classification System ment and Function parameters are given in Table 4. 287

Changing’s in Alignment and Function parameters 288

260 CPC’s before and after treatment gross motor were statistically significant (p < 0.05). However, after 289
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Table 3
Comparison of balance skills and functional independence levels before and after treatment
Assessment method X ± SD Median Min-Max p
1MWT (m) BT 43.86 ± 19.89 45 5–70 0.0001α
AT 55.06 ± 19.13 57 16–76
MTUGT (sec) BT 18.73 ± 23.82 11 7–102 0.001β
AT 9.60 ± 5.61 7 5–28
PBS BT 47.2 ± 9.65 51 22–56 0.001α
AT 52.33 ± 5.20 55 38–56
WeeFIM BT 112.1 ± 13.34 114 85–126 0.001α
AT 118.3 ± 9.03 120 96–126
BT: Before Treatment; AT: After Treatment; α: Paired Samples t Test: p < 0.05; β: Wilcoxon Signed Rank Test: p < 0.05.

Table 4
Comparison of postural control skills before and after treatment
Postural assessment X ± SD Median Min-Max P
Alignment BT 71.66 ± 4.04 72 60–77 0.0001α

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AT 81.53 ± 5.24 83 66–87
Function BT 45.8 ± 1.27 45.7 44–48 0.0001β
AT 48 ± 0 48 48–48

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BT: Before Treatment; AT: After Treatment; α: Paired Samples t Test: p < 0.05; β: Wilcoxon Signed Rank Test: p < 0.05.

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Table 5
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Comparison of gross motor function levels before and after treatment
Gross motor function levels X. ± SD Median Min-Max p
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GMFM-88-D BT 83.8 ± 13.25 87 62–100 0.0001α
AT 94.26 ± 6.76 97 79–100
GMFM-88-E BT 79.93 ± 17.28 85 54–100 0.0001α
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AT 88.6 ± 12.25 94 69–100

GMFM-88 BT 92.2 ± 6.21 94 81–100 0.0001α
AT 96.53 ± 3.68 99 90–100
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BT: Before Treatment; AT: After Treatment; α: Paired t Test: p < 0.05.
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290 the treatment program all participants got full points which is the first milestone of postural control is an 309

291 from Function tests. Thus, this parameter’s standard early sign of normal motor development deficiency in 310
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292 deviation was zero. After the NDT procedure, CPC’s CPC [12]. Impairments in sitting postural control can 311

293 body alignment and upper extremity functions have effect a child’s motor development significantly and 312
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294 improved. can limit eventual independent movement [13,14]. 313

295 Statistics about participants’ gross motor function Trahan and Malouin [15] applied NDT to 50 spas- 314
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296 skills before and after treatment according to GMFM- tic CPC (quadriplegia (n = 24), hemiplegia (n = 16), 315

297 88 are given in Table 5. Changing’s in GMFM-88- and diplegia (n = 10)) aged between 12 and 79 months 316

298 D (standing) and GMFM-88-E (walking) sections and and assessed participants’ gross motor function skills 317

299 GMFM-88 total points were statistically significant by GMFM-88. After 8-month treatment period, im- 318

300 (p < 0.05). Thus, it was determined that NDT in- proving in CPC’s gross motor function skills were sig- 319

301 creased gross motor functions in CPC. Before and af- nificant [15]. Although the number of patients with 320

302 ter treatment participants’ GMFM-88-A, GMFM-88-B quadriplegia was high in Trahan and Malouin’s study, 321

303 and GMFM-88-C points were full, thus this sections CPC’s gross motor functions were developed in paral- 322

304 weren’t added to statistics. lel with the present study. This was probably due to the 323

length of the treatment. 324

Bower and McLellan [16] recruited 30 spastic CPC 325

305 4. Discussion ages between 18 months – 8 years from four different 326

centres and separated them as control and intervention 327

306 CPC have some limitations about postural control group. Then applied NDT for 6 months to interven- 328

307 in static and dynamic tasks like sitting, standing and tion group and nothing for control group. They found 329

308 walking [11]. Particularly delay in independent sitting no statistically significant difference between groups 330
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331 in the assessment made by GMFM-88 [16]. The rea- tory in favour of NDT group, is also consistent with the 382

332 son for not achieving a significant difference with this improvement of daily living activities and gross motor 383

333 6-month NDT in this study is that the treatment ef- functions of CPC in the present study. 384

334 fect of the children included in the study in their cen- In the present study, after treatment mean scores 385

335 tres is different, so some of them are better at starting of 1MWT, MTUGT, PBS and WeeFIM changed posi- 386

336 treatment and some are behind. At the beginning of the tively compared before treatment mean scores. In that 387

337 study, children with poor motor function skills and de- case, NDT based posture and balance training im- 388

338 velopment status were prevented from getting signifi- proved gait and balance skills and independence level 389

339 cant outcomes. in daily living activities of CPC. 390

340 Gross motor function level of participants increased Jonsdottir and Fetters [19] applied NDT to spastic 391

341 in present study. This means NDT based posture and CPC in intervention group, and made participants in 392

342 balance training is effective on gross motor functions control group play computer games in sitting position. 393

343 in a short period of 8 weeks. After treatment period they found no significant chang- 394

344 In Harbourne et al.’s study [17], fifteen typically de- ing in the assessment made by Modified Postural As- 395

345 veloping infants were followed longitudinally during sessment Scale [19]. Kluzik et al. [20], applied NDT to 396

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346 sitting development to use as a comparison on postural 5 spastic CPC ages between 7–12 years for 4 weeks. 397

347 control variables, and thirty-five infants with risk fac- They assessed CPC’s upper extremity movement skills 398

and speeds by video kinematic analysis, and after treat-

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399
348 tors and delays in achieving sitting were recruited for
ment they found significant increase in upper extrem- 400
the study. Infants with delays were randomly assigned

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349
ity movement skills and speeds [20]. In the present 401
350 to either a home program group, or a perceptual-motor
study, SPCM-Alignment and SPCM-Function param- 402
351 intervention group. After the 8 weeks of treatment pro-
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eters were improved after NDT program. Eight-week 403
352 cess data obtained from GMFM-88 and Centre of Pres-
NDT based posture and balance training improved pos- 404
sure device showed that the results were in favour
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353
tural control skills and upper extremity functions in 405
354 of the intervention group [17]. In Harbourne et al.’s
sitting position of CPC. Although these two studies 406
355 study, similar to present study, 8-week of NDT pro-
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showed similarity to the present study in terms of their 407

356 gram which was applied by specialist physiotherapist results, there was no more related study to the present 408
357 improved the gross motor functions and balance of study in the literature. Butler and Darrah [21] made a
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409
358 CPC. systematic review researching the effects of NDT on 410
359 Ketelaar and Vermeer [18] included 55 spastic CPC CPC. They investigated evidence-based studies about 411
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360 (median age = 57 months, average = 55 months, range this topic and found that NDT improves postural con- 412
361 = 24–87 months; n = 32 with hemiplegia, n = 11 trol and balance in CPC [21]. Carlsen [22] made a
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413
362 with diplegia, n = 12 with quadriplegia) to their study study with 12 CPC ages between 1–5 years, and ap- 414
363 and separated the children in two groups. They ap- plied NDT to intervention group for 6 weeks. CPC’s 415
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364 plied classic physiotherapy one of these groups and before and after treatment motor development ages de- 416
365 NDT for the other one. The groups were assessed with fined by Bayley Scales of Infant and Toddler Devel- 417
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366 GMFM-88 and Paediatric Evaluation of Disability In- opment. They found significant improvements in mo- 418

367 ventory in the 6th , 12th and 18th months. There were tor development ages in intervention group [22]. In this 419

368 no differences according to GMFM-88, but there were study, after treatment mean scores of GMFM-88-D, 420

369 statistically significant differences according to Paedi- GMFM-88-E and GMFM-88 increased. In that case, 421

370 atric Evaluation of Disability Inventory in favour of NDT based posture and balance training improved 422

371 NDT group [18]. The reason for not achieving a signif- CPC’s gross motor function skills and related to this 423

372 icant difference with this 6-month NDT in terms of the it also improved postural control and balance skills. 424

373 GMFM-88 is that the children recruited for the study These two studies indicate that there is an increase 425

374 have poor motor function skills and development sta- in postural control, balance and motor development 426

375 tus compared to the children in the present study at the stages in CPC as well as in the present study. This sup- 427

376 beginning of the study. The children’s GMFCS level ports the development of postural control, balance and 428

377 was at least 3, so this means all of the children in the gross motor functions in the present study. 429

378 present study could walk. This has increased the oppor- Limitations of this study: 430

379 tunity to benefit from NDT of these children. The situ- – There was no control group to compare the result 431

380 ation that there were statistically significant differences of treatments. 432

381 according to Paediatric Evaluation of Disability Inven- – Evaluator was not double blind to the study. 433
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434 5. Conclusion [7] McDowell BC, Humphreys L, Kerr C and Stevenson M. Test – 474
retest reliability of a 1-min walk test in children with bilateral 475
spastic cerebral palsy (BSCP). Gait Posture 2008; 29: 267-69. 476
435 Eight-week NDT based posture and balance train- [8] Dhote SN, Khatri PA and Ganvir SS. Reliability of “Modified 477
436 ing applied to diparetic and hemiparetic CPC improved timed up and go” test in children with cerebral palsy. J Pediatr 478

437 their functional motor level with together postural con- Neurosci 2012; 7(2): 96-100. 479

438 trol skills, thus independence levels in daily living ac- [9] Franjoine MR, Gunther JS and Taylor MJ. Paediatric Balance 480
Scale: A Modified Version of the Berg Balance Scale for the 481
439 tivities. Improving in CPC’s balance made them walk School-Age Children with Mild to Moderate Motor Impair- 482
440 safer and faster. ment. PED-PT 2003; 15(2): 114-28. 483

441 It is very important that clinicians and researchers [10] Field DA and Roxborough LA. Responsiveness of the Seated 484

442 working with diparetic and hemiparetic CPC should Postural Control Measure and the Level of Sitting Scale in 485
children with neuromotor disorders. Disabil Rehabil Assist 486
443 focus more intensively on NDT programs to improve Technol 2011; 6(6): 473-82. 487
444 motor development levels, postural control skills, bal- [11] Wollacott MH and Shumway-Cook A. Postural dysfunction 488

445 ance and functional independence in daily living activ- during standing and walking in children with cerebral palsy: 489

446 ities of these cases. what are the underlying problems and what new therapies 490
might improve balance? Neural Plast 2005; 12: 211-219. 491
[12] Campbell SK. The child’s development of functional move- 492

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