CHAPTER 2

REVIEW OF LITERATURE

This chapter presents a review of previously published scientific literature

relevant to the study topic. The topics reviewed here are arranged under the sections

in the following manner.

2.1 Static Postural Control in Children with Cerebral Palsy

2.2 Self-Care Activities / Functional Independence in Children

with Cerebral Palsy

2.3 Relationship Between Postural Control and Self-Care/ADL

Performance in Children with Cerebral Palsy

___________________________________________________________

2.1 Static Postural Control in Children with Cerebral Palsy

Szopa and Domagalska-Szopa (2024) assessed static postural stability

in children with mild cerebral palsy using a force platform, comparing them with

typically developing peers, and also identifying differences between children with

hemiplegic and diplegic CP. The study included 45 children with hemiplegic CP and

45 children with diplegic CP classified at GMFCS levels I and II. Assessment

involved analysis of body weight distribution and center of pressure (CoP)

measurements. The results demonstrated that children with CP showed significantly

1
higher values across all analyzed postural instability indexes compared to their

typically developing peers. Children with diplegic CP exhibited weaker mediolateral

stability in standing, whereas children with hemiplegic CP showed reduced anterior-

posterior stability.

Palluel et al. (2019) examined the effects of dual tasking on postural and gait

performances in children with cerebral palsy compared to healthy children. The study

found that postural control deficits in children with CP were further compounded

during dual-task conditions, reflecting the limited neural resources available for

simultaneous motor and cognitive demands. The findings highlighted the complexity

of postural control impairments in this population beyond simple static conditions.

Monica et al. (2021) investigated the relationship between trunk position

sense and trunk control in 24 children with spastic CP aged 8 to 15 years. Trunk

control was assessed using the Trunk Control Measurement Scale (TCMS) and trunk

position sense was evaluated using a digital goniometer. A significant negative

correlation was found between trunk position sense and TCMS scores. Children with

better trunk position sense demonstrated superior performance in static sitting balance

tasks, suggesting that proprioceptive feedback plays a central role in static postural

stability among children with CP.

2.2 Self-Care Activities in Children with Cerebral Palsy

Kim et al. (2022) conducted a study to verify the validity and reliability of

the Functional Independence Measure for Children (WeeFIM) for children with

cerebral palsy using Rasch analysis. A total of 105 children with CP aged 6 months to
7 years and 11 months were included. The WeeFIM assessed 18 items across three

domains: self-care (8 items), motor (5 items), and cognition (5 items). Within the self-

care domain, bathing was identified as the most difficult item, while eating and

bladder management were the easiest. The separation reliability for the self-care

domain was reported at 0.87, confirming the tool's strong reliability and validity for

use in children with CP.

Janssen-Potten et al. (2023) conducted a prospective clinical study examining

the effectiveness of functional intensive therapy on mobility and self-care activities in

children and adolescents with cerebral palsy. The findings indicated that functional

intensive therapy was feasible and effective in improving treatment goals focused on

mobility and self-care performance, even in older and more severely affected children

and adolescents with CP. The study underscored the importance of targeted therapy

approaches to promote functional independence in this population.

Ghorbani et al. (2023) investigated factors affecting the independence level in

self-care and home participation among 4 to 6-year-old children with CP. The study

used the Involvement in Children Participation Questionnaire (I-CPQ) in which

parents rated their children's performance in self-care and daily activities. The

findings revealed that independence in self-care and home participation varied

considerably among preschool-aged children with CP and was influenced by motor

function level, reinforcing the need for early occupational therapy intervention

targeting ADL performance.

2.3 Relationship Between Static Postural Control and Self-Care

 Activities in Children with Cerebral Palsy

Sanz-Mengibar et al. (2024) conducted a feasibility observational study

exploring whether clinical assessment of postural control could explain self-care,

mobility, and participation in 25 children with CP. Trunk control was assessed using

the Trunk Control Measurement Scale (TCMS) and functional abilities were

evaluated using the Pediatric Evaluation of Disability Inventory (PEDI). The results

revealed a strong correlation, confirming that children with higher levels of trunk

control demonstrated better self-care, mobility, and participation capacities. The study

concluded that more mature locomotor stages require higher levels of trunk control,

directly benefiting self-care and social functions.

Maryam et al. (2023) emphasized that trunk control provides an essential

framework for postural control and is the foundation for developing goal-directed

activities critical for independent living. The study, involving children with CP, found

that insufficient postural control and trunk instability were serious concerns that

significantly limited functional activities. A stable trunk was identified as a key

biomechanical component influencing head stability, visual field orientation, and

hand manipulation — all of which are prerequisites for effective self-care

performance in children with CP.

Krishnaa et al. (2026) conducted a cross-sectional study to evaluate the

relationship between postural control, quality of upper limb skills, and functional

independence in 36 children with cerebral palsy aged 3 to 8 years (GMFCS levels I–V

and MACS levels I–V). Postural control was assessed using the Early Clinical

Assessment of Balance (ECAB), upper limb skills were evaluated with the Quality of

Upper Extremity Skills Test (QUEST), and functional independence was measured
through the Pediatric Evaluation of Disability Inventory – Computer Adaptive Test

(PEDI-CAT, Daily Activities domain). Statistical analysis using Spearman's

correlation revealed strong positive correlations between postural control and

functional independence (ρ = 0.781, p < 0.01), and between upper limb skills and

functional independence (ρ = 0.872, p < 0.001). The findings confirmed that

limitations in postural control and upper limb function significantly reduce a child's

independence in daily living activities, reinforcing the need to address postural

stability as a primary goal in occupational therapy intervention for children with CP.
 CHAPTER 3

METHODOLOGY

This chapter represents the following headings

3.1 Ethical Clearance

3.2 Research Design

3.3 Sampling

3.4 Screening Criteria

3.5 Instrument Used

3.6 Data Collection Procedure

3.7 Data Analysis Procedure

3.1 Ethical Clearance

3.2 Research Design

It is a quantitative cross sectional research design

3.3 Sampling

Convenience study design was utilized for the research. The sample size

was 50 in and around Chennai.

3.4 Screening Criteria

3.4.1 Inclusion Criteria

 Diagnosed with cerebral palsy

 Age 5 to 12 years

 Able to follow simple instructions

3.4.2 Exclusion Criteria

 Severe cognitive impairment

 Recent surgery (within in 6 months)

 Uncontrolled Seizures

3.5 Instrument Used

3.5.1 Functional Independence Measure for Children (WeeFIM)

The WeeFIM (Functional Independence Measure for Children)

is a standardized, 18-item assessment used by occupational therapists to

measure a child's functional performance and independence in daily activities.

Typically applied to children aged 6 months to 7 years (or up to 21 for

developmental disabilities), it evaluates self-care, mobility, and cognition

across 7 levels of assistance.

 Scoring and Interpretation

It has 3 main domains (18 items total): (self-care, mobility, and cognition)

Self-Care : (6 items )

• Eating

• Grooming

• Bathing

• Dressing – Upper Body

• Dressing – Lower Body

• Toileting

• Bladder Management

• Bowel Management

SCORE LEVEL

• 7 - Complete independence

• 6 - Modified independence

• 5 - Supervision

• 4 - Minimal assistance

• 3 - Moderate assistance

• 2 - Maximal assistance

• 1 - Total assistance
 Interpretation

• minimum score: 18

• maximum score: 126

• The higher the score, the more independent the patient.

Psychometric Properties

Internal consistency (Cronbach’s alpha), ICC, and PSI values of the

WeeFIM motor and cognitive scales were high ( >0.90) . Interrater reliability

was excellent with ICC values of 0.98 and 0.93 for the motor and cognitive

scales respectively.

3.5.2 Posture and Postural Ability Scale (PPAS)

The Posture and Postural Ability Scale (PPAS) is an assessment tool

that allows for posture and postural ability to be assessed independently.

Scoring and Interpretation

The PPAS assesses 4 positions:

• Standing

• Sitting

• Supine

• Prone

Each position is assessed according to:

1. Postural Ability

2. Quality of Posture

Postural Ability seven levels are designated, ranging from Level 1 =

'Unplaceable in an aligned posture' to 7 = 'Able to move into and out of

 position

Quality of Posture comprises of six items, each looking at a specific body

region. These items are observed in the frontal view and then in the sagittal

view. Scoring of the Quality of Posture is given either as a 1 or 0. The value 1

= postural symmetry and alignment, while 0 = asymmetry and deviation from

the midline. The total score is calculated separately for each position in the

frontal plane and the sagittal plane .

Psychometric Properties

• Cronbach’s alpha = 0.95 – 0.97

• Inter rater reliability = 0.77-0.99

3.6 Data Collection Procedure

 After obtaining approval from the Institutional Ethics Committee, the study will
be conducted in selected pediatric rehabilitation centers and special schools.
Participants will be recruited based on the inclusion and exclusion criteria.

• The purpose of the study will be explained to the parents or caregivers,

and written informed consent will be obtained prior to participation.

• Basic demographic and clinical details of the children, including age,

gender, type of cerebral palsy, and Gross Motor Function Classification
System (GMFCS) level, will be recorded using a structured data
collection form.

• Each participant will then undergo assessment of static postural

control using the Posture and Postural Ability Scale (PPAS). The
child will be evaluated in standardized positions such as sitting
and standing .

• Self-care activities will be assessed such as

dressing ,eating ,grooming ,bathing . These will be evaluated
using standardized tool such as Functional Independence
Measure for Children (WEEFIM).

3.7 Data Analysis Procedure

Data was analyzed using SPSS version 26