DE LA SALLE MEDICAL AND HEALTH SCIENCE INSTITUTE

COLLEGE OF REHABILITATION SCIENCES

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“EFFECTS OF PROPOSED LESSONS OF PERCEPTUAL MOTOR TRAINING

PROGRAM IN IMPROVING GROSS MOTOR FUNCTION IN SCHOOL-AGED

CHILDREN WITH CEREBRAL PALSY IN CARMONA, CAVITE ”

An undergraduate Thesis Proposal Presented to the Faculty of De La Salle Medical

Health Sciences Institute

In fulfillment of the Requirements for the Degree of Bachelor of Science in Physical

Therapy

Group 10

Albornoz, Blitz Rainhardt

Alejo, Alexis Julian

Angue, Patrick Daniel

Barrera, Nieles Christian

Jalea, Jemie Rose Pauline

Adviser:

Mr. Aranella D. Villaluz

2018

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CHAPTER 1

INTRODUCTION

Background Of The Study

Cerebral palsy (CP) is the leading cause of disability in children with prevalence

rates being in the region of 2 to 2.5 per 1000 live births (Winter et al., 2002). Cerebral

palsy is a non-progressive medical condition resulting from damage to the developing

brain, which depending on the location, can result in difficulties with movement,

spasticity, cognition, communication and behaviour (Carlon et al., 2010). It is the

most common lifelong disability affecting motor development. CP has traditionally

been refered to as an “umbrella term”. As such the term for CP involves several

different etiologists for the permanent lesion in the developing brain, which by

convention occurred before the age of two. But is also illustrates the heterogeneity of

clinical symptoms, where the degree of motor and other non-motor neurological

involvement span a wide spectrum, ranging from mild sometimes and barely

noticeable, to severe disability.

Cerebral palsy is divided into subtypes (spastic, dyskinetic and ataxic), based

upon the predominant motor impairment. The category spastic cerebral palsy is also

subdivided, based upon the number of limbs affected, for example hemiplegia affects

one side of the body, diplegia affects the legs only, while quadriplegia impacts on all

four limbs. Dyskinetic cerebral palsy (athetoid and dystonic) is associated with

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fluctuating or rigid muscle tone, while ataxic conditions are associated with problems

with co-ordination, muscle tone and balance.

According to American Medical Association (AMA) “cerebral palsy (CP) is a

term that describes non progressive but sometimes changing disorders of movement

and posture” theses movement problems are due to brain function that may affect

muscle strength and coordination. The pathophysiology behind paresis in CP is

primarily due to deficient recruitment of motor neurons and consequently incomplete

activation of the motor unit. This has been shown in studies comparing children with

CP to children with typical motor development (Elder et al., 2003;Rose and McGill,

2005;Stackhouse et al., 2005). In addition to motor impairment, children with cerebral

palsy may also experience learning difficulties, have difficulty feeding and have seizure

conditions. Moreover, many children may experience sensory impairments and have

difficulties communicating (Pellegrino, 1997; Shapiro & Capute, 1999)

Rose and McGill investigated muscle strength, neuromuscular activation, and

motor‐ unit firing characteristics in subjects with CP and in age‐matched controls

(Rose and McGill, 2005). Babies with cerebral palsy are slow to reach motor

developmental milestones. They may not smile, roll over, sit up, crawl, or walk at the

expected times. CP may be noted in the infancy and may continue into adult life and

one major risk factor may happen during pregnancy and may be observe upon giving

birth and noted as birth defect which is defined as a problem that can occur when a

baby is still developing in the womb according to Karen Gill, MD birth defect can affect

the appearance, organ function and physical and mental development; it can be

caused by genetics, lifestyle choices and behaviors, and infections during pregnancy.

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Some birth defects are harmless others require long-term medical treatment specially

the ones that affect the development or functions of a child that may cause the body or

system not to work properly.

Furthermore American Medical Association (AMA) stated that “Cerebral palsy

cannot be cured. However, quality of life can be improved for most children if they

receive support and coordinated care” which perceptual motor training can be

implemented in helping children develop their full potential by addressing physical,

mental, and emotional needs; Shahbazi S et al stated that Perceptual-motor training

programs, are valid physical education programs which are regulated based on the

level of maturity, and have many of the same elements. The purpose of these

programs, are increasing academic achievement or progress in school readiness.

Increased body awareness, space, and time are as a medium to guide children to the

increased motor control and movement ability. For the child with CP, difficulties in

physical functioning and movement may lead to challenges to independence and

autonomy, and subsequently impact on quality-of-life (Bjornson et al., 2008; Sparkes &

Hall, 2007; Viehweger et al., 2008). At a time when socialising with peers is crucial for

developing one’s identity and independence from the family (Erikson, 1968), children

with physical disabilities tend to spend more time in isolation and away from their

peers (Cole & Cole, 1993). Research has also shown that children with disabilities are

at an increased risk of developing mental health difficulties, including emotional or

conduct disorders (Goodman, 2002; Goodman & Graham, 1996; Rutter et al., 1970).

Thus the investigation into quality-of-life is deemed important when considering a

holistic approach to care and well-being.

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Perceptual-motor activities play an important role in the development of the

child's motor abilities According to Jill A. Johnstone and Molly Ramon perceptual-

motor activities provide a proven way to improve children’s health and learning in all

aspects and children’s who participate in this program demonstrate significant

improvement in all areas of the learning process. Participation in perceptual-motor

activities enables students to develop greater levels of body control. Young children

who possess adequate perceptual-motor skills enjoy better coordination, greater body

awareness, stronger intellectual skills, and a more positive self-image. In contrast,

children’s who lack these skills often struggle with coordination, possess poor body

awareness, and feel less confident. Furthermore perceptual-motor training builds a

strong base to support future learning.

Review Of Literature

Definition of Cerebral Palsy and the nature of the condition

Cerebral palsy is defined by (Shankaran, 2008) as a group of permanent

disorders of the development of movement and posture, causing activity limitation, that

are attributed to non-progressive disturbances that occurred in the developing fetal or

infant brain. There is no specific cause for cerebral palsy, mostly the cases is

unknown. Damaging the brain could happen during or after birth. A prenatal cause

involves maternal infection such as German measles, radiation, oxygen deficiency,

toxemia, and maternal diabetes. Causes at the time of the birth include trauma during

the delivery, anoxia, prematurity, and multiple births. During infancy brain infection,

head trauma, anoxia, brain tumor and cerebrovascular lesion can be a factor that

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could develop cerebral palsy Funk & Wagnalls (2017,). Cerebral palsy hinders the

body’s ability to move in coordinated and purposeful way. It also can affect other body

functions that involve motor skills and muscles, like breathing, bladder and bowel

control, eating, and talking (Shrader, 2018).

Cerebral palsy can be classified into 3 classifications (Lewis, 2012). (1)

Topography which parts of the body are involved; (2) the nature of the motor

impairments whether the motor system is stiff and spastic, loose and hypotonic or

experienced fluctuation in motor control classifies as athetotic or ataxic. (3) Based on

the severity categorized to mild, moderate or severe.

Cerebral palsy can be classified based on the topographical features (Howard,

2005) and these are namely: hemiplegia, diplegia, tetraplegia.

 Quadriplegia denotes the involvement of all limbs with the arms being equally or

more affected than the legs. Quadriplegia is also known as tetraplegia and

double hemiplegia (Stanley, 2000)

 Diplegia is described more severe involvement of the legs than the arms.

Clinicians distinguish between diplegia I which the arms are normal or minimally

affected and diplegia II which the arms are perceptibly affected (Stanley, 2000)

 Hemiplegia is the involvement of the right and the left side of the bod, with the

upper limbs is more affected than the lower limb (Stanley, 2000)

Cerebral palsy is classified as to the nature of the motor impairments (1)

spasticity (2) dyskinesia (3) ataxia.

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 Spasticity is the most common type of motor impairment with about 80% of

reported cases is spastic. It is characterized by abnormal control of voluntary

limb muscled and also associated with positive Babinski reflex. The presence of

clasp knife effect and by the exaggerated reflex and or clonus.

 Dyskinetic cerebral palsy usually presents with voluntary motion disorders with

increased involuntary movements which may show various combined

symptoms such as torsion spasm, dystonia, chorea, athetosis (Hou, 2006)

 Ataxic cerebral palsy presents with an impairment of the coordination of goal-

directed movements, resulting in gait and trunk disturbances, intention tremor

and slurred speech (Eggink, 2017)

Cerebral palsy classification based on the level of severity (1) mild (2) moderate

(3) (Stern, nd)

 Mild Cerebral Palsy means a child can move without assistance; his or her

daily activities are not limited.

 Moderate Cerebral Palsy means a child will need braces, medications, and

adaptive technology to accomplish daily activities.

 Severe Cerebral Palsy means a child will require a wheelchair and will have

significant challenges in accomplishing daily activities.

Prevalence of cerebral palsy

According the study Cerebral palsy is the most common motor disability in the

childhood. It is describe as permanent disorders of movement and posture. The

estimated prevalence of cerebral palsy ranges from 1.5 to more than 4 per 1000 live

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births or children age range (10-14). The overall birth prevalence of CP is

approximately 2 per 1000 live births (Stavsky, 2017). The predominant abnormality

among the children born is spasticity which is velocity dependent increase in muscle

tone (Shankaran, 2008). Meanwhile according to a study conducted, 25% of the

spastic cerebral palsy had hemiplegia, 37.5% had quadriplegia, and 37.5% had

diplegia. In the Philippines, according to Philippine cerebral palsy Incorporated (2012),

there are more patients with CP than those with polio, spinal lesions and movement

disorder combined which approximately 1-2% of the total population.

Gross motor skill

Gross motor (physical) skills are those which require whole body movement

and which involve the large (core stabilising) muscles of the body to perform everyday

functions, such as standing, walking, running, and sitting upright. It also includes eye-

hand coordination skills such as ball skills. It is the abilities required to control the large

muscles of the body for walking, jumping, skipping, and more. Developing these skills

helps a child's ability to do more complex skills in future activities (Thayer, 2014).

Children achieve different gross motor milestones over time. Some children

experience developmental delay in terms of their gross motor skill, or dyspraxia

(Team. n.d). Gross motor development refers to control over larger movement skills

that tend to be less refined, such as crawling, standing and walking (Berk, 2005). The

development of gross motor abilities occurs in the motor cortex, the region of the

cerebral cortex that controls voluntary muscle groups." Development of gross motor

skills during infancy takes a step by step basis, each stage (age) there is a specific

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skill that needs to be mastered in order to progress to the next one (Esposito & Vivanti,

1970).

Gross motor skills involve the development of large body movements related to

balance and arm, leg, and torso movement. For example, in typical development, by

the time they are 2 years old, children are able to jump 2 inches on both feet, walk up

and down three stairs, and throw a small ball 3–5 feet in the direction of a target.

However, researchers have reported that many children with ASD do not develop

foundational gross motor skills if they are not directly taught them (e.g., Ozonoff et al.,

2008). Gross motor skills (GMS) are a vital component of a child’s development.

Monitoring levels and correlates of GMS is important to ensure appropriate strategies

are put in place to promote these skills in young children (Veldman, Jones, Jones,

Santos, Sousa-Sá &Okely, 2018).

Physical activity is important for the wellbeing of children. It contributes

markedly to their physical development and also greatly impacts on their emotional,

cognitive and social development (Ashiabi, 2007; Gabbard, 2008; Gallahue & Ozmun,

2006). As children learn to become more independent, they develop the capacity to

cope with the stress and challenges of their environment (Elliott, 2005). It has been

noted that, ‘Physical activity and attention to gross motor skills provide children with

the foundations for their growing independence and satisfaction in being able to do

things for themselves’ (Australian Government Department of Education, Employment

and Workplace Relations for the Council of Australian Governments, 2009, p. 30). The

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emphasis on the development of children’s gross motor skills is crucial in teaching

young children about physically active lifestyles (Schneider & Lounsbery, 2008).

In a study conducted regarding the use of locomotor training with functional electrical

stimulation by E. Nikityuka, I, et al it was concluded that “it contributes to the

improvement of vertical posture control in children with severe cerebral palsy” it can

therefore be applied also in mild cases of cerebral palsy with a greater and much

better results.

Patient who undergone physical therapy program has shown an improvement in

balance according to the study conducted by B. Bonneche`re et al it is stated that

“these patients enjoyed playing and did not experience any difficulties to play the

games because those games are specially adapted for this pathology and are highly

configurable and therefore adapted for each patient and each pathology”

Some CPGs generate locomotor movements in lower vertebrates such as the

lamprey. In addition, there is evidence from studies of higher vertebrates such as cats

of CPG‐controlled locomotion (Forssberg et al., 1980;Grillner, 2006). In humans,

purposeful locomotion functions are mostly controlled by supraspinal circuits, although

it appears that even in humans, some aspects of locomotion are controlled by the

spinal cord (Dietz et al., 1994).

Human gait is bipedal and plantigrade (heel‐toe strike), which is unique in the

mammalian world. Primates walk on two legs but not with a plantigrade gait. The

plantigrade gait pattern contributes to increased stability and is less energy

consuming. Development of the heel strike is of particular importance (Forssberg H.,

2003). Prior to independent or unsupported gait, children with spastic CP exhibit a gait

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pattern that is similar to that of children with typical motor development (Leonard et al.,

1991). However, plantigrade gait fails to develop and instead children with CP typically

continue to display a digitigrade gait pattern with higher levels of coactivation and

premature activation of the plantar flexors before foot contact. In plantigrade gait,

major calf muscle contraction occurs at the end of the supportive phase (stance),

acting as a strong forward propulsive force. In digitigrade gait, the "forward energy" of

the gait is decreased due to premature calf muscle contraction. Many ambulatory

children with CP develop contractures and musculoskeletal malformations; these

constraints and other developmental changes eventually alter locomotion from the

original gait pattern seen in CP resembling that of infant stepping. However, a variety

of different patterns may arise depending on the individual potential of the child

(Forssberg H, 1992).

According to Bax 1964 and Mutch et al., 1992, motor deficits are the hallmark of

CP. Earlier definitions and classifications have focused on this aspect. Efforts

toquantity the level of functional motor ability coupled with expanded knowledge about

the impact of non-motor neurodevelopment problems encountered in CP have created

a need for a new and more comprehensive definitions and classifications.

According to Murphy et al., 2000 and Michelsen et al., 2006, in contrast to the

historical viewpoint, this new definition illuminates neurological “comorbidities”. The

role such problems is becoming increasingly recognized in relation to the growth of a

child into an adult with CP.

The classification has four components:

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1. First, the most dominant motor disorder, which may be spastic, dystonic,

athetotic or ataxic, is addressed along with. The extent to which individual

are limited by their motor function. Gross motor function Classification

system is internationally validated, accepted and commonly used for this

purpose (Palisano et al,. 1997).

2. According to Surveillance of Cerebral Palsy in Europe (SCPE) 2000, in

many children with CP, motor impairments interfere with activities of daily

life and these may be equally or more troublesome for the individual than

the characteristic of other symptoms.

From a motor control perspective, CP is best described as a set of different

motor disorders with motor dysfunction that varies in scope and type. For simplicity,

symptoms may be categorized as excess symptoms, which are added onto normal

motor behavior, and deficit symptoms, in which the normal motor repertoire fails to

develop (Forssberg H., 2003). Furthermore, high‐functioning children with unilateral or

mild bilateral spastic CP have been found to be weaker than typically developed (TD)

children in all major muscle groups of the lower extremities (Wiley and Damiano,

1998). In a recent study by Ross and Engsberg, spasticity, strength and functional

outcome, as assessed by GMFM‐66 and a range of gait analysis parameters, were

tested in 97 children with CP and GMFCS level I‐III. They found that spasticity only

accounted for a maximum of 8% of the variance in gait and gross motor function,

whereas moderate to high correlations were found between strength and these

functions, where strength accounted for up to 69% of the variance (Ross and

Engsberg, 2007).

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Perceptual Motor Program

Perceptual motor program trains the nervous system so that a child develops

the ability to remember patterns of movement, sequences of sounds and the look and

feel of things. When movement, tasks are fully integrated, children are able to perform

them automatically. There are several key areas wherein perceptual motor program is

performed: Gross motor skills which are for the acquisition of large scale movements

while fine motor skills for the acquisition of small scale movements. It also isolates

various fingers, using tools, copying precise actions without overflow. It aims to assist

patients to acquire efficient movement, to promote and improve sensory function and

to develop a positive self-image. According to Resnick (1967), defines perceptual

motor skills as those that underlie higher-order conceptual functioning. This includes

such things as the ability to use one’s body efficiently with awareness to position in

space, and the ability to make a wide range of sensory discrimination. This includes

both gross and fine motor skills. The sensory skills are that range of visual, auditory,

and haptic perception and discrimination behaviors which are virtually synonymous

with the child’s earliest concepts.

Ross and Engsberg (2002) refuted the belief that strengthening caused excess

spasticity in a study that examined these parameters in a group of 60 subjects with CP

and 50 with TD. They found no relationship between spasticity and strength, either

within the same muscle group or in opposing muscle groups of the knee and ankle

joints in the patients with CP (Ross and Engsberg, 2002).

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It is essential for children to experience perceptual motor program, because it

allow sensory information to be successfully obtained and understood with appropriate

reaction. Perceptual deals with obtaining information and motor refer to the outcome of

movement. According to Glen Iris Primary School (n.d.), there are two main reasons

for perceptual motor program; first is learning readiness influence on non-impaired

children and remediation influence on children requiring remedial programs for

perceptual motor skills. According to Brinning (n.d.), the needs of the handicapped

child for a strong program of gross motor activities must be recognized. Through the

following suggested activities which will be adapted to the needs of the individual child,

he would have an opportunity for greater perceptual-motor development.

Effects of perceptual motor training, according to Cratty (1972) points out that

since several of the programs do contribute to the development of motor skills,

children have benefited in this manner even though increased academic performance

may have been the objective of the program. If perceptual motor training positively

influences self-concept because of the success oriented nature of many of the

programs, this may result in increased academic performance. However, this

presupposes that pelf is not situation specific and that it positively influences

classroom performance.

In the RCT by Wilson et al.,29 it was evident that perceptual motor training results in

improved motor performance. Here, 13 of the 17 children in the perceptual motor

training group exceeded the upper limit of the 95% CI for comparisons. Moreover,

Peens et al.23 showed that a combination of motor- and psychological-based

intervention improved motor proficiency in Cerebral Palsy . The findings from our

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meta-analysis showed that children with CP benefit the most from task-oriented

approaches; we recommend that perceptual motor training adopts a task-specific

approach.

During perceptual motor program, patients may show simple reflex response,

participate coactively in body awareness activities and balance momentarily, when

supported by an adult in either a sitting or standing position. Patients may also

develop their interpersonal trait by occasionally appear alert and ready to focus their

attention on certain people.

Gross Motor Function Assessment

The gross motor function of the children included was repeatedly assessed

using the Gross Motor Function Measure (GMFM) (Russell et al., 1989;Russell et al.,

2000;Russell et al., 2002).This valid and reliable measure is frequently used to assess

motor development and interventions in children with CP. It assesses five dimensions

of activity: (1) lying and rolling, (2) sitting, (3) crawling and kneeling, (4) standing, and

(5) walking, running, and jumping. Maximum achievement according to GMFM is

that attained by a five‐year‐old child with typical motor development. The original

GMFM‐ 88 included 88 items (Russell et al., 1989). The GMFM‐66 was developed

using Rasch analysis to improve sensitivity and interpretability of the test. GMFM‐66

uses 66 of the 88 items (Russell et al., 2000).

In about half of the cases, assessments were based on GMFM‐88; subsequently,

however, results from the original protocols were recalculated to GMFM‐66 using the

specifically developed computer‐assisted software program: Gross Motor Ability

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Estimator (GMAE), provided by Mac Keith Press and Blackwell Publishing (Russell et

al., 2002). All results are therefore provided according to GMFM‐ 66.

Gross Motor Function Measure- 66 and -88

According to Beckers and Bastiaenen (2015) The Gross Motor Function

Measure-66 (GMFM-66) is an observational clinical measure designed to evaluate

gross motor function in children with Cerebral Palsy (CP). It is the shortened version of

GMFM-88. They also mentioned that GMFM-66 is often seen as an improvement on

the GMFM-88 but still has its own strength and should be the preferred instrument in

certain situation.

According to Alotaibi, et al (2013) A crucial element for assessing intervention

effectiveness for children with CP is the capability of being able to reliably measure

responsiveness to change in gross motor abilities. Over the past 25 years, the Gross

Motor Function Measure (GMFM) and its subsequent revisions, has become the most

common functional outcome measure used by rehabilitation specialists to measure

gross motor functioning in children with CP. The earliest version of the GMFM is

known as the GMFM-88 and the most recent version is referred to as the GMFM-66.

Both tools are standardized criterion referenced measurement tools designed to

measure gross motor function over time for children with disabilities, ages 5 months to

16 years of age. Each tool has been validated to measure change in children with CP.

The uniqueness of these tools lies in the fact that the tools provide outcome

scores that reflect how much of an activity a child can accomplish (function) rather

than how well the activity is performed. The scores provide an enhanced

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understanding of activity outcomes; ultimately leading towards achievement of

contextual participation goals specific to the individual child. Although specialist

training is not required to administer the tool, the authors recommend that

administrators need to be familiar with assessing motor skills in children and the

GMFM administration guidelines.

Wang, HY et al. differentiated the original version of GMFM which is GMFM-

88 to its second version GMFM 86 in terms of improvement of gross motor function in

children diagnosed with cerebral palsy the study says that “GMFM-66 was more

responsive than the GMFM-88 with respect to consistency with therapist clinically

meaningful judgments.” However, both of the outcome measure used in the study is

effective and is widely used in patients diagnosed with CP.

Delalic, A. et al conducted a study to assess motor function of post-operative

rehabilitation of patients diagnosed with CP using GMFM-88; the study stated that

“improvement of motor function and reduction of the degree of disability in children

after postoperative rehabilitation was achieved. Motor activity was enhanced after

completion of postoperative rehabilitation and the assessment done by GMFM score

indicates an increase in the value of the total sum for all the developmental stages as

well as the values of certain developmental phases, with a highly significant statistical

significance” furthermore the researchers concluded that “Surgical intervention

performed on the lower extremities in children with cerebral palsy may improve motor

function in all developmental stages and reduce the degree of disability with intensive

rehabilitation.”

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Ko, JY., conducted a study that would investigate the applicability of GMFM-88

in planning intervention in patients diagnosed with CP; the study used the GMFM-88

outcome measure to take the baseline score during the initial treatment and compare it

to the score in the end of the treatment in which the researchers concluded that “the

GMFM-88 item-based training would be used to plan activity-oriented intervention both

in clinic and home in each CP child.” Because of a marked increased in the scores

results during the last encounter of the said population.

Waghavkar, S., conducted a study that uses GMFM-86 the second version of

GMFM outcome measure in preterm children in the functional and motor abilities in

which the study concluded that “This study confirms a significant difference between

functional motor abilities of preterm children compared with normal full-term children”

meaning GMFM-86 outcome measure is efficient outcome measure in measuring

motor functions.

Theoretical Framework

As a recent theory state that the use of perceptual motor training improves

motor problem of children with CP. The perceptual motor intervention is based on the

ecological approach and emphasizes spontaneous movement based on environmental

affordances. Self-initiated, functionally directed movement is the focus of intervention.

Perceptual motor intervention consists of activities that include handling, which gently

drives the child’s attention to the support surface, and sets up the environment to

produce small increments of movement that the child can utilize to solve a movement

problem. Passive movements are not used in this approach. According to Brigette et,

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al., 2016, there was increased variability of active movement is encouraged, and

movements that are considered abnormal in other approaches are not blocked or

discouraged. These results are in agreement with a younger cohort of children with CP

who received the perceptual motor intervention in the first 2 years of life and improved

sitting postural control (Harbourne et al., 2010). This is the first study to demonstrate

that the specific perceptual motor intervention is effective in improving gross motor

behavior in sitting in older children with moderate and severe CP. Fundamentally,

perceptual motor experiences offer the opportunity for broad development and in other

domains, such as social and cognitive development (Dusing et al., 2013; Lobo et al.,

2013). In typically developing children, the attainment of motor skills like sitting and

reaching are temporally linked to the development of complex play behavior (Rochat

and Goubet, 1995).

Conceptual Framework

Gross Motor Proposed Lessons Improving Gross

Function using of Perceptual Motor Motor Function
Training Program
GMFM 88 and After as to;
66 score on; Selected lessons
 Lying and Rolling
on “Perceptual-
 Lying and Rolling  Sitting
motor activities for
 Sitting  Crawling and
children: an Kneeling
 Crawling and
Kneeling
evidence-based  Standing
 Standing guide to building  Walking,
 Walking, Running physical and Running and
and Jumping cognitive skills” by Jumping
Jill a. Johnstone
Of children with Of children
and Molly Ramon
Cerebral palsy Cerebral palsy
(2011)
1. Unilateral activities
2. Bilateral activities
3. Combines activities

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 This study will determine the effects of proposed lessons of perceptual motor training

in program gross motor function in school-aged children with cerebral palsy. The

factors that can affect the program are: 1.) Pre assessment before using GMFM 88

and 66 as to Lying and Rolling, Sitting, Crawling and Kneeling, Standing/Walking,

Running and Jumping 2 Selected lessons on “Perceptual-motor activities for

children : an evidence-based guide to building physical and cognitive skills” by Jill a.

Johnstone and Molly Ramon (2011) using Unilateral, Bilateral and Combined

activities of unilateral and bilateral 3.) Post assessment after using GMFM 88 and 66

as to Lying and Rolling, Sitting, Crawling and Kneeling, Standing/Walking, Running

and Jumping. This framework will help the researchers in obtaining appropriate data

to their research which is the effects of proposed lessons of perceptual motor

training program in improving gross motor function as to Lying and Rolling, Sitting,

Crawling and Kneeling, Standing and Walking, Running and Jumping based on

GMFM 88 and 66

Statement Of The Problem

Are the proposed lessons of perceptual motor training program effective in

improving the gross motor function of children with cerebral palsy in Carmona, Cavite?

Objective Of The Study

General Objective:

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To determine the effects of proposed lessons of perceptual motor training

program in improving gross motor function in school-aged children with cerebral

palsy

Specific Objectives

 Specific objective

1. To determine the pre-test score of Cerebral palsy patient using the GMFM 88

and 66 before receiving perceptual motor training as to;

a) Lying and Rolling

b) Sitting

c) Crawling and Kneeling

d) Standing

e) Walking, Running and Jumping

2. To determine the post-test score of Cerebral palsy patients using the GMFM 88

and 66 after receiving perceptual motor training as to;

a) Lying and Rolling

b) Sitting

c) Crawling and Kneeling

d) Standing

e) Walking, Running and Jumping

3. To determine the significant difference between pre and post test score of

Cerebral palsy patients using the GMFM 88 and 66 as to;

a) Lying and Rolling

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b) Sitting

c) Crawling and Kneeling

d) Standing

e) Walking, Running and Jumping

Hypothesis

Null hypothesis

Perceptual motor training program will not improve gross motor function of

children with cerebral palsy.

Alternative hypothesis

Perceptual motor training program will improve gross motor function of children

with cerebral palsy

Definition Of Terms

For a better understanding of this study, the important terms used in this study

have been defined.

The terms used are:

Balance refers to the ability of the children with cerebral palsy to move with falling.

Cerebral palsy is a disorder that affects child’s movement, motor skills and

muscle strength. This will be the primary focus of this research.

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Children refers to an offspring. This will serves as the population and the primary

topic of the study.

Effectiveness refers to the outcome of the of the research itself

Gross motor function Refers to the skill that our research will improve

Locomotor refers to the ability of the children with cerebral palsy to perform

movement from one place to another such as Crawling, rolling, walking, Running

hopping and jumping.

Non-locomotor refers to the ability of the children with cerebral palsy to move in

place such as twisting, bending, rotating with arms and head movements

Perceptual motor function program prescribes by the Physical therapist to help

improve gross motor function of children with cerebral palsy

Scope And Delimitation

This study will be conducted for 6 weeks in Person with Disability Affairs Office.

These clinics are located in Carmona,Cavite. In line with this, the participants in

this study will be children with gross motor problems. Moreover, they will be

subjected to a perceptual motor training program in order to assess its

effectiveness in the improvement of the gross motor functions, particularly; to

Lying and Rolling, Sitting, Crawling and Kneeling, Standing and Walking, Running

and Jumping based on GMFM 88 and 66, of the said participants. This study will

not cover any data about emotional or mental conditions, and thus, will not be

discussed or analyzed in any way.

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Significance Of The Study

The study will benefit and contribute to physical therapist, readers, medical

professionals, researchers and future researchers.

1. Physical therapist It will help physical therapist who treat patients with cerebral

palsy to assess and improve gross motor function using perceptual motor

training. Likewise, the results of the study can also urge physical therapy

students to aim for excellent performance not only with the common treatment

but also using perceptual motor training in their plan of care.

2. Readers This study will provide information to the readers about the effects of

proposed lessons of perceptual motor training program in improving gross

motor function in school-aged children with cerebral palsy. This will increase

their level of awareness and their knowledge.

3. Medical Professionals All the information gathered here in the study will

further help medical professionals by providing the right instructions to patients

to children. They can also determine if perceptual motor training is really

effective to children with gross motor problems.

4. Researchers The result of this study will help researchers in gathering

information regarding this study, and this will also help them in further improving

the said study.

5. Future Researchers This study will guide the future researchers who would

pursue a study regarding the effects of proposed lessons of perceptual motor

training program in improving motor function in school-aged children with motor

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problems. Through this study, future researchers can do further studies in order

to improve and be able formulate approaches to increase awareness.

6. Society This study will increase awareness among the society by providing

specific information about the effects of proposed lessons of perceptual motor

training program on how it works and what can be done for it to be effective.

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CHAPTER II

RESEARCH METHODOLOGY

Research Design

A Descriptive quantitative research design, Quasi-experimental is a type of research

that utilizes statistics and percentage to gather unbiased data from a specific

population. The researchers will be conducting a quantitative study in order to

determine the effects of proposed lessons of perceptual motor training program in

improving gross motor function in school-aged children with cerebral palsy. The

researchers will be using a GMFM (Gross Motor Function Measure) Outcome

measure to determine the change in gross motor function over time in children with

Cerebral Palsy. This research study requires on-hand assessment in order to analyzed

and gain data from children with cerebral palsy.

Population and Sampling

The researchers used purposive sampling method to gather respondents to the

study. The researchers chose purposive method to target specific respondents to the

study and also considering the limited numbers of participants. The target population

of the study focused on the PDAO Carmona, cavite. The numbers of participants will

depend on the availability of the participants.

The following criteria will be used for selecting the respondents:

1. Children was diagnosed with cerebral palsy

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2. Female/male mean age of 5-16 yrs.’ old

3. GFMCS level of I-III

4. Already receiving PT treatments

Research Instrument

The research instruments that the researchers will utilize are GMFM-88 and

GMFM-66 scoring. It is a standardized observational instrument designed and

validated to measure change in gross motor function over time in children with

cerebral palsy. This tool is developed to assess change in gross motor function in

children with cerebral palsy. The tool has 88 items each scored on a 4-point ordinal

scale of 0 to 3, where 0 indicates that the child does not initiate the task; 1 indicates

that the child initiates the task (completes some of the activity); 2 indicates that the

child partially completes the task (completes half of the activity); 3 indicates that the

child completes the task and NT indicates that the child was not tested. The 88 items

are grouped into five dimensions: 1) lying and rolling, 2) sitting, 3) crawling and

kneeling, 4) standing, and 5) walking, running and jumping.

A maximum of three trials is allowed for each item and the best trial is recorded.

Scores for each dimension are expressed as a percentage of the maximum score for

that dimension and the total score is obtained by averaging the percentage scores

across the five dimensions. The goal of the research instrument is to obtain effects of

proposed lessons of perceptual motor training program in improving gross motor

function in school-aged children with cerebral palsy. Intervention will be done by the

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researchers, and the subjects for actual test will be obtained by probability simple

random sampling form the list of Cerebral Palsy patients in PDAO Carmona, Cavite

Data Gathering Procedure

First, the researchers will submit a letter of permission addressed to the

municipal mayor of Carmona, Cavite through respective Head of PDAO and will be

addressed and approved by the research adviser and the dean of the college. Once

it is approved, the researchers will have an informed consent given to the

parents/guardians of the participants and assent letter for the participants itself. The

informed consent will be written in English and Filipino. Together with the informed

consent, they will also hand a copy of Gross Motor Function Measure or GMFM

scoring sheet, in order for them to have an idea or background on what will the

researchers measure and the proposed list of selected perceptual motor training

program. The GMFM is a standardized observational instrument designed and

validated to measure change in gross motor function over time in children with

Cerebral Palsy. Later on when the results is published, the parents/ guardian will

have the copy. The implementation will last for 4 weeks and will be 3 times per

week. We will have a hired PT to be the assessor this study that will supervise and

document this study.

The intervention will consist of 3 sets of activities; unilateral, bilateral and combined

activities, which will be done during Monday, Wednesday and Friday with the same

set of activities. Maximum hours for the exercises will be 60 minutes. During

Monday and Wednesday, there will be same sets of bilateral and unilateral activities

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and during Friday, there will only be 2 activities of combined activities of unilateral

and bilateral activities. After the 1 month interventions, we will have another GMFM

88 and 66 for post assessment. After all the data gathered, we will get the

significance of the pre and post assessment.

Data Analysis

The data collected from the pre-test and post-test were summarized,

analyzed, and computed to be able to correlate using paired t-test. For the

researchers to be able to further understand the study, the following were used to

know how to interpret the data:

Gross motor function measure

The GMFM is a standardized observational instrument designed and validated to

measure change in gross motor function over time in children with cerebral palsy.

The scoring key is meant to be a general guideline. However, most of the items have

specific descriptors for each score. It is imperative that the guidelines contained in

the manual be used for scoring each item.

SCORING KEY

0 = does not initiate

1 = initiates

2= partially completes

3 = completes

9 (or leave blank) = not tested (NT)

Wilcoxon Rank Signed Test

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It is used to test the null hypothesis that the median of a distribution is equal to some

value. It can be used a) in place of a one-sample t-test b) in place of a paired t-test or

c) for ordered categorical data where a numerical scale is inappropriate but where it is

possible to rank the observations.

Methodological Limitations

This study is mainly a Quasi- Experimental type of study which is limited to specific

type of respondents and that respondents are the patient of PDAO Carmona, Cavite.

The data that will be gathered will only be limited to children ages 5-16 y/o diagnosed

with cerebral palsy since the instrument tool are only valid for use with children who

have cerebral palsy and only the gross motor function in perceptual motor training are

the ones recorded in this study. The outcome of the intervention of the researchers is

also limited by just using both GMFM-88 and 66 scoring will not be controlled by the

researchers. Also, the truthfulness and nature of answering due to being observed will

not be controlled.

Another limitation is when it comes to availability of related literature when it comes

to the objective of the study. The researchers were not able to find any article that is

very similar to this study. Therefore, future studies are highly recommended to conduct

more research about the perceptual motor training in improving gross motor function in

children with cerebral palsy; especially when it comes to the effectiveness.

Ethical Considerations

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This study would assure that it complied with all ethical considerations. The

participants were given an informed consent letter prior to the intervention. The

informed consent gave thorough information regarding the procedures that the

researchers will follow and the participants will undergo. The study included tool that

will determine the effects of proposed lessons of perceptual motor training program in

improving gross motor function in school-aged children with cerebral palsy. The

Parents/ Guardian of the participant have been given the choice to refuse to respond

to the informed consent form provided if they decided to do so as well as the

participants itself which will be given a assent form. All the participants included in the

study consented voluntarily and participated in the intervention. No one, besides the

researchers, knows the data gathered during the study.

All the personal information obtained by the researchers through the

intervention, such as name and contact number, was kept hidden and confidential. All

the data that was gathered was stored away after the study for the reference of the

future researchers. Prior to the implementation of the study, the researchers also sent

a letter to the administration of the PDAO in order to obtain a list of the treated

children with cerebral palsy patients and to reach out to the potential participants in the

study, the necessary information that the researchers needed was given to them and

nothing more. All the information gathered was kept confidential.

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