The study compared the effectiveness of two novel balance training programs (Functional Movement-Power Training and Functional Movement Training) to no training in children with Developmental Coordination Disorder. 161 children were randomly assigned to one of the three groups and underwent their respective interventions twice a week for 3 months. Outcome measures of balance strategies and neuromuscular performance were taken before and after the intervention period using computerized dynamic posturography and manual muscle testing. The results showed that both novel training programs improved balance and strength to a greater extent than no training.

1. INTERVENTIONS TO IMPROVE BALANCE IN
CHILDREN WITH DEVELOPMENTAL
CO-ORDINATION DISORDER (DCD)

2. INTRODUCTION
• The American Psychiatric Association (2013) diagnoses these children who
have remarkedly reduced co-ordination abilities, which lead to difficulties
in daily life and poor academic achievement compared to typically
developed children with the same chronological age, as Developmental Co-
ordination Disorder (DCD).
• Previous researcher describes the state of poor motor co-ordination ability
with various term, such as clumsy child syndrome, developmental
dyspraxia , perceptuo-motor dysfunction, specific developmental disorder
of motor function , play ground disability, deficits in attention, motor
control, and perception (DAMP).

3. PREVALENCE
• Based on the DSM-V criteria, DCD is common in both males and females 1:1.

4. ETIOLOGY
At risk: Birth H/O: perinatal
abnormalities (jaundice),
LBW, premature
Genetic predisposition
Impairment in information
processing/ improvised
environment
Brain damage /dysfunction
(prenatal , natal , postnatal incident)
LBW divided in to 4 groups (acc. to abnormal
CT scans) germinal matrix haemorrhage ,
intraventricular haemorrhage , parenchymal
involvement, poor prolonged flares, premature
Comorbid conditions: visual
impairment, thyroid
malformation, congenital
hypothyroidism, mild CP, early
stages of muscular dystrophy.

5. DCD
Overweight, Obesity
Psychological issues Reduced physical activities
Poor basic motor skills
Sensory processing issues
Cardiovascular disease
Behavioural issues
Motor co-ordination deficit
CLINICAL MANIFESTATIONS

6. DIAGNOSTIC CRITERIA
• Based on (Diagnostic and Statistical Manual of Mental Disorder) DSM -V :
Criterion A: The acquisition and execution of co-ordinated motor skills is
substantially below that expected given the individual’s chronological age and
opportunity for skill learning and use. Difficulties are manifested as clumsiness
(e.g., dropping or bumping in to objects) as well as slowness and inaccuracy of
performance of motor skills (e.g., catching an object, using scissors or cutlery,
handwriting, riding a bike, or participating in sports).

7. Criterion B: The motor skills deficit in Criterion A significantly interferes
with activities of daily living appropriate to chronological age (e.g., self
care and self maintenance) and impacts academic/school productivity,
prevocational and vocational activities, leisure and play.
Criterion C: Onset of symptoms is in the early developmental period.
Criterion D: The motor skills deficits are not better explained by
intellectual disability (intellectual development) or visual impairment are
not attributable to a neurological condition affecting movement (e.g., CP,
muscular dystrophy, degenerative disorder).

8. ASSESMENT
Careful history taking is essential to support the application of Criteria A,B,C,D. History
should include following aspects
1. Parental report
• Family history including DCD , comorbidities, environmental factors (e.g. psychosocial
factors), neurological disorders, medical diseases, mental disorders, social condition of the
family.
• Personal history including exploration of resources and possible aetiology, ( e.g., pregnancy,
birth, milestones, achievements, social contacts, kindergarten, school (grade levels), previous
and present disorders, especially neurological disorders, sensory problems (previous
assessment) ), accidents.
• History of the disorder (child) including DCD and comorbidities and exploration and
exploration of resources , ADL and participation, individual/personal factors, burden of
disease, consequences of the DCD.
• Exploration of problems: present level /deficits of motor functions, ADL and participation.

9. 2. Teacher report
• Motor functions, activities/participation, environmental factors/support systems,
individual/personal factors (ICF)
• School-based behaviour that bears on comorbidity for attentional disorders,
autistic spectrum, learning disorders
• Academic achievement
3. Views of the child should be taken into account child-adapted questionnaires
(see above) may be useful, but cannot be generally recommended

10. CLINICAL EXAMINATION
• Neuromotor status (exclusion of other movement disorders or neurological
dysfunction)
• Medical status (e.g. obesity, hypothyreosis, genetic syndromes, etc.)
• Sensory status (e.g. vision, vestibular function)
• Emotional and behavioural status (e.g. attention, autistic behaviour, self-esteem)
• Cognitive function should there be a history of learning difficulties at school

11. ASSESSMENT OF MOTOR SKILLS
• Norm referenced standardized scales can be used such as:
(Movement Assessment Battery for Children)MABC-2 , (Bruininks- Oseretsky Test of
Motor Proficiency)BOTMP-2 ,Developmental Co-ordination Disorder Questionnaire ,
Test Of Motor Impairment (TOMI), Body Co-ordination Test for Children (BCTC) ,
Test of Gross Motor Development 2nd edition (TGMD-2), Neuro-Sensory Motor
Developmental Assessment (NSMDA), the Wechsler Intelligence Scale for Children,
the Balance Test; the Kaufman Brief Intelligence Test, 2nd edition (KBIT-2)

13. Missiuna, Polatajko, and Pollock (2015) classify and suggest 4 levels
of a DCD management scheme for children as follows:
1) Level 1: Management at a School/Population Level
2) Level 2: Management at a Group Level
3) Level 3: Management of Individual Children in Context
4) Level 4: Management of Individual Children who are Complex.
MANAGEMENT

14. LEVEL 1: MANAGEMENT AT A
SCHOOL/POPULATION LEVEL
It is significant to identify children with DCD early and to provide early
intervention in order to minimize the problems of children with DCD.
improvement of teachers’ and parents’ perception of children with DCD and a
reconstruction of educational curriculum for students who have poor motor
ability are required as a first step.

15. LEVEL 2: MANAGEMENT AT A GROUP LEVEL
At this level, children with DCD may have secondary health issues and academic failure due
to their poor coordination ability, so children with DCD should be identified as early as
possible Early identification of DCD allows teachers and parents to share the characteristics of
children with DCD in order to form appropriate environments for them. This may result in
providing achievable tasks to children with DCD and avoiding repetitive unsuccessful
experiences, and therefore, the role of teacher at this level is emphasized Generally, the
Neurorehabilitation Training Toolkit (NTT), a therapeutic program which is being developed
by Smits-Engelsman and colleagues that utilizes motor learning teaching principles, is
recommended as an effective way to learn fundamental motor skills of children.

16. LEVEL 3: MANAGEMENT OF INDIVIDUAL
CHILDREN IN THE CONTEXT
The motor impairment of children with DCD is a long-term problem, The motor
impairment of children with DCD is a long-term problem, Therefore, it is required to
accept the difficulties of children with DCD and to provide an appropriate environment
to easily participate in physical activities. Thus teachers are important in the process of
establishing individualized plans for children with DCD, and strategies, such as
“MATCH: Teacher can Modify the task, Alter their expectations, Teach strategies,
Change the environment, and Help by understanding”, might be applied effectively.

17. LEVEL 4: MANAGEMENT OF INDIVIDUAL CHILDREN
WHO ARE COMPLEX
DCD is strongly associated with attention deficit hyperactivity disorder (ADHD), speech and
articulation difficulties (specific language impairment), language-based learning disabilities
and other difficulties. If these disabilities are accompanied with DCD, the negative effects can
possibly be aggravated. Therefore, special intervention that considers the child’s age, severity
of the motor difficulties, evidence of secondary consequences and etc. is required in this case.
At this level, the COOP (Cognitive Orientation to daily Occupational Performance) approach
is used as an effective intervention for school-age children with DCD Within this model,
occupation therapists provide related knowledge of DCD to teachers and parents, and
construct a mutual cooperation system rather than provide the service directly. Thus, this
cooperative work provides an appropriate environment for children with DCD to solve
various problems.

18. MANAGEMENT

19. JOURNAL Clinical Rehabilitation
AUTHOR /
TITLE
Nick Preston et al (2017).
A systematic review of high quality randomized controlled trials investigating motor skill
programmes for children with developmental coordination disorder
REVIEW METHOD Two reviewers critically appraised and categorized articles by effect size (including confidence
intervals), inclusion of power calculations and quality using the Physiotherapy Evidence
Database (PEDro) scale. Only studies scoring seven or more on the PEDro scale (classed by the
PEDro as high reliability) were retained.
RESULTS No systematic reviews met our criteria for inclusion from 846 articles yielded by the systematic
search. Nine randomized control trials investigating 15 interventions to improve motor skills met
our inclusion criteria for ‘high quality’. Nevertheless, not all included studies were adequately
powered for determining an effect.
CONCLUSION Large effect sizes associated with 95 % confidence intervals suggest that ‘Neuromotor Task
Training’, ‘Task-oriented Motor Training’ and ‘Motor Imagery + Task Practice Training’ are the
most effective reported interventions for improving motor skills in children with developmental
coordination disorder.
MOTOR SKILLS

20. JOURNAL School of Public Health, Physiotherapy and Population Science
AUTHOR /
TITLE
Caitriona Morton et al (2015)
The effect of a group motor skills programme on participation and movement ability of
children with DCD
METHOD 30 participants, 7-10 year old children with DCD were included, participants allocated in to
intervention and control group. Intervention was for 1 hour weekly for 10 weeks.
OUTCOME
MEASURES USED
Children’s Assessment of Participation and Enjoyment (CAPE), Movement Assessment
Battery for Children (MABC)
CONCLUSION This intervention improved participation and motor performance in children with DCD, with
results maintained at 8 months.
MOTOR SKILLS TRAINING

21. JOURNAL Research in Developmental Disabilities
AUTHOR /
TITLE
Shirley SM Fong et al (2013)
Differential effect of Taekwondo training on knee muscle strength and reactive and static balance
control in children with developmental coordination disorder: A randomized controlled trial
METHOD 44 children with DCD , randomly allocated in TKD training group (n=21); control group (n=23);
typically developing children – (no training)control group (n=18)
OUTCOME
MEASURES USED
Isokinetic strength – machine; Motor Control Test (MCT), Unilateral Stance Test (UST)
CONCLUSION The above intervention resulted in improvements isokinetic knee muscle strength at 180 degrees
and single leg stance balance control, but do not benefit reactive balance control.
STRENGTH TRAINING

22. JOURNAL Clinical Rehabilitation
AUTHOR /
TITLE
Mei K Au et al (2014)
Core stability exercise is as effective as task-oriented motor training in improving motor proficiency
in children with developmental coordination disorder: A randomized controlled pilot study
METHOD 22 children diagnosed with DCD of age group 6-9 year were randomly allocated to the core stability
program or the task oriented motor program.
OUTCOME
MEASURES USED
Bruininks Oseretsky Test of Motor Performance (BOTMP-2), Sensory Organization Test (Pre and
post intervention)
CONCLUSION The core stability exercise program is as effective as task oriented training in improving motor
proficiency among children with DCD.
CORE STABILITY TRAINING

23. JOURNAL Physical Therapy
AUTHOR /
TITLE
Leandra Gonsalves et al (2015).
Children with developmental coordination disorder play active virtual reality games differently than
children with typical development.
METHOD 21 children with DCD of age group 10-12 year and typically developing children played a match of
table tennis on each AVG type.
MODALITY Linear mixed model analyses – Move and Kinect AVG type for forehand and back hands
CONCLUSION If a therapeutic goal o]is to promote movement quality in children with DCD, clinical judgement is
required to select the most appropriate AVG and determine whether movement quality is adequate for
unsupervised practice
ACTIVE VIRTUAL GAMING

24. JOURNAL Physical Therapy
AUTHOR /
TITLE
Debbie J Silkwood –sherer et al (2012)
Hippotherapy—an intervention to habilitate balance deficits in children with movement
disorders: A clinical trial
METHOD 16 children (9 M; 7 F) of age group 5-16 year underwent intervention of 45 min hippotherapy
session twice/week for 6 weeks.
OUTCOME
MEASURES USED
Paediatric Balance Scale (PBS), Activities Scale for Kids – performance (ASKp)
CONCLUSION The hippotherapy may be a viable strategy for reducing balance deficits and improving the
performance of daily life skills in children with mild to moderate balance performance.
HIPPOTHERAPY

25. AQUATIC AND REBOUND THERAPY
JOURNAL Research in Developmental Abilities
AUTHOR /
TITLE
Paraskevi Giagazoglou et al (2015)
Can balance trampoline training promote motor coordination and balance performance in
children with developmental coordination disorder?
METHOD 20 children indicating DCD disorder , 20 students diagnosed DCD were equally separated in to
experimental and control group.
MODALITY EPS platform – static balance
CONCLUSION Balance training with the use of attractive equipment such as trampoline can be an effective
intervention for improving functional outcomes and can be recommended as an alternative
mode of physical activity.

26. TASK-ORIENTED APPROACH:
NEUROMOTOR TASK TRAINING
JOURNAL Research in Developmental Abilities
AUTHOR /
TITLE
G.D. Ferguson et al (2013)
The efficacy of two task-orientated interventions for children with developmental coordination
disorder: Neuromotor task training and Nintendo Wii Fit training.
METHOD 6-10 year old children < 16th percentile on MABC-2 and whose teacher reported a functional
motor problem, were allocated in to either NTT (n=37) or Wii training (n=19) groups
depending on attendance.
OUTCOME
MEASURES USED
Movement Assessment Battery for Children-2 (MABC-2) , Functional strength measure (hand
held dynamometer), muscle power sprint test (20m shuttle run test)
CONCLUSION Use of both the Wii training and NTT for children with DCD is effective.

27. BALANCE
JOURNAL Arch Argent Paediatric
AUTHOR /
TITLE
Hasan kordi et al (2016)
The effect of strength training based process approach intervention on balance of children with
DCD
METHOD 30 children of 7-9 year old were randomly allocated in to experimental and control groups.
Intervention duration – 12 weeks and 24 sessions. Experimental group= strength training-
theraband , control group= routine exercises in physical education class.
OUTCOME
MEASURES USED
BOT-2
CONCLUSION The strength training leads to static balance improvements in children with DCD. But no
improvements seen in dynamic balance.

28. JOURNAL Human movement science
AUTHOR /
TITLE
Dorothee Jelsma et al (2014)
The impact of Wii Fit intervention on dynamic balance in children with portable DCD and
balance problems
METHOD 28 children with balance problem (BP)and 20 typically developing children , all children with
BP received 6 weeks of Wii fit intervention
OUTCOME
MEASURES USED
MABC-2, BOT 2
CONCLUSION The Wii fit intervention is effective and is potentially a method to support treatment of
(dynamic) balance control problems in children

29. FMT AND FMPT
PROTOCOLS

30. A NOVEL BALANCE TRAINING PROGRAM FOR
CHILDREN WITH DEVELOPMENTAL COORDINATION
DISORDER A RCT
Shirley S.M. et al
JOURNAL : Medicine Journal
YEAR: 2016
Impact Factor:

31. OBJECTIVE
• Compare the effectiveness of a specific functional movement–power
training (FMPT) program, a functional movement training (FMT)
program and no training in the improvement of balance strategies, and
neuromuscular performance in children with developmental coordination
disorder (DCD).

32. • Sample size: 161 children with DCD
• Age group: 6-10 year
• Study design: Randomized, single blinded, stratified, parallel group controlled trial.
• Study setting: local child assessment centers, hospitals, schools, non government
organizations and parent groups by means of website and poster advertising.
• Interventions: 2 groups FMPT (Functional Movement Power Training)
FMT (Functional Movement Training)
• Duration: Twice a week for 3 months
METHODOLOGY

33. INCLUSION CRITERIA EXCLUSION CRITERIA
Diagnosis of DCD based on DSM IV Diagnosis of an emotional , neurological , or
other movement disorder
Comorbid attention deficit hyperactivity
disorder, attention deficit disorder, dyslexia
and suspected autism spectrum disorder were
allowed
significant congenital, musculoskeletal, or
cardiopulmonary disorders that might affect
motor performance
A gross motor composite score of 42/ less on
BOTMP
Active treatment; disruptive behavior
Age group 6-10 years An inability to follow instructions
No intellectual impairment

34. INTERVENTIONS
FMT,FMPT

35. OUTCOME MEASURES
• Primary outcomes:
Sensory Organization Test (SOT)
Force platform of a computerized dynamic posturography machine
• Secondary outcomes
Lafayette Manual Muscle Test System
Standardized manual muscle testing procedures
Dynamometer placements.

36. PSYCHOMETRIC PROPERTIES
Secondary outcome: ICC: 0.81–0.98

37. STATISTICALANALYSES
• The pilot trial, was estimated that a sample of 45 participants per group would provide at
least 80% power to detect a between-groups difference in a mean change from baseline to
3 months of 0.335 points in the primary outcomes, assuming a 25% attrition rate, at a 2-
tailed alpha level of 5%. These predicted mean point differences equate to a medium to
large effect size of 0.67.
• All of the analyses were conducted on an intention-to-treat basis (last-observation-carried-
forward method). The between groups differences in demographic variables were assessed
with 1-way analysis of variance for continuous data and with a Chi-square test for
categorical data.

38. • Any changes in the primary and secondary outcomes following the intervention were
quantified by subtracting the baseline scores from the postintervention scores.
• The differences from the baseline in each outcome measure were analyzed with mixed-
model repeated-measures analysis of variance (between-subjects factor: group; and within-
subject factor: time) followed by post-hoc tests.
• All P values were corrected using Bonferonni method to maintain the overall significance
level at 5% (2-tailed).
• The results are presented as means with SDs or 95% confidence intervals (CIs). All of the
statistical analyses were performed with SPSS 20.0 (IBM).

39. BASELINE
CHARACTERISTICS

40. FLOW CHART OF
PARTICIPANTS
RESULTS

41. OUTCOME
VARIABLES:
PRIMARY
OUTCOME

42. OUTCOME
VARIABLES:
SECONDARY
OUTCOME

43. MEAN CHANGES
BETWEEN GROUPS
FROM BASE LINE

44. MEAN CHANGES IN
ALL OUTCOMES
3-6 MONTHS

45. DISCUSSION
• This study is the first to show that a 3-month program of twice-weekly FMPT was more effective
than FMT alone or no training in improving balance strategies (i.e., a decrease in reliance on the hip
strategy and an increase in reliance on the ankle strategy) in a sensorially challenging environment
(e.g., only vestibular input was available in SOT condition 6) in children with DCD. The
improvements were maintained for 3 months after the cessation of training.
• This finding supports our hypothesis that the balance strategies of children with DCD can be
improved most by treating both their CNS and neuromuscular deficits. Theoretically, FMT can
induce neuroplastic changes in the CNS (e.g., modification of Purkinje cell synapses in the
cerebellum), and power training can increase the speed of muscle contraction (force production) via
several neuromuscular mechanisms: earlier motor unit activation, enhanced maximal motor unit
firing rate in the initial stages of activation, increased efferent neural drive to the agonist muscles,
improved intermuscular and intramuscular coordination, and improved force control.

46. • Although only the FMPT improved balance strategies, both the FMPT and FMT were effective in
improving the overall standing balance performance in children with DCD. In addition, the
improvement was maintained at 6 months in the FMT group, probably because FMT required the
children to practice the balancing movements repeatedly with EMG biofeedback, which can
effectively enhance CNS plasticity.
• In addition, the increased concomitant muscle force production speed of the knee flexors in the
FMT group at 6 months may also have contributed to the improvement in balance performance.
The present study demonstrated that integration of power training with FMT can improve the
overall standing balance performance, balance strategies, and knee muscle strength in children
with DCD.

47. CONCLUSION
• FMPT led to better results than conventional FMT in the
improvement of balance strategies in a sensorially challenging
environment, and the neuromuscular performance of children with
DCD. FMPT appears to be effective as a stand-alone intervention
designed to improve balance strategies, postural stability, and leg
muscle performance in children with DCD.

48. LIMITATIONS
• Exploration of the relationships among balance performance, balance strategies, and
muscle force production speed in children with DCD.
• Participants were not blinded to the group assignment, given the nature of exercise
training.
• Participants who were assigned to the intervention groups may have had expectations
about the benefits of exercise, which may have introduced some biases in the results.
• The balance strategies were estimated from the horizontal AP shear forces detected by
the force plate.
• EMG biofeedback was used during FMT but the signals were not captured
• This was a laboratory-based study.

49. PEDro SCORES
• Eligibility criteria were specified : Yes
• Subjects were randomly allocated into groups: Yes
• Concealed allocation : Yes
• The groups were similar at baseline regarding the most important prognostic indicators: Yes
• There was blinding of all subjects: No
• There was blinding of all therapist who administered the therapy: No
• There was blinding of all assessor who measured at least one key outcome: No
• Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to the group:
Yes
• All subjects for whom outcome measures were available received the treatment or control condition as allocated or,
where this was not the case, data for at least one key outcome was analysed by “intention to treat “ : Yes
• The results between group statistical comparisons are reported for at least one key outcome : Yes
• The study provides both point measures and measures of variability for at least one key outcome: Yes
SCORE = 7/10

50. COMPARISON WITH SIMILAR STUDIES

51. JOURNAL European journal of physical education and sports science
AUTHOR /
TITLE
Sofia G. Monastiridi et al (2020)
Positive relations of physical fitness and exercise intervention programs with motor
competence and health related quality in life in DCD: A systematic review
OUTCOME
MEASURES USED
HRQOL(Health Related Quality Of Life)
CONCLUSION There are positive relationships between fitness and exercise intervention program , motor
competence and HRQOL in children and adolescents with DCD

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