Does a physiotherapy programme of gross motor training influence motor function and activities of daily living in children presenting with developmental coordination disorder?

Background Children with developmental coordination disorder (DCD) lack motor coordination and have difficulty performing motor skills and activities of daily living. Research shows these children do not outgrow their motor difficulties and without intervention do not improve. Physiotherapy is relevant for these children, but due to limited clinical protocols for DCD the aim of this study was to determine the effect of a gross motor training programme for 6–12-year-old children with DCD. Methods This randomised pre-test, post-test study recruited 64 children with scores of 15th percentile or below using the Movement Assessment Battery for Children (M-ABC). The children were divided equally into an intervention group receiving 8 weeks of gross motor training for core stability, strengthening exercises, balance and coordination with task-specific activities for 30 min per week, while the control group continued with general therapy and activities of daily living. The M-ABC and Developmental Coordination Disorder Questionnaire (DCDQ) were used to assess each child before and after 8 weeks. Results Sixty children completed the study, with 43 males and 17 females (mean age 10.02 years, SD = 2.10). There were no adverse reactions to the programme and M-ABC scores for the intervention programme improved by 6.46%, ball skills (3.54%) and balance (4.80%) compared with the control (0.17%) and (0.15%), respectively. There were significant (p < 0.05) improvements in DCDQ scores, but teachers allocated lower scores than parents. Conclusion This study supports 8 weeks of gross motor training which can be a beneficial intervention for physiotherapists to improve gross motor function for DCD.

Coordinated movements are regarded as mapping of perceptual (input) to motor (output) actions. This requires information processing at four sites which are sensation and perception, decision-making and planning, movement execution and feedback. A deficit in any one or more of these can result in poor motor co-ordination (Wilson & McKenzie 1998). The World Health Organisation introduced the International Classification of Functioning, Disability and Health (ICF 2001) which provides a framework for classification at three levels viz. body function and structures (impairment), activities (activity limitations) and participation (participation restrictions). This is based on the concept that impairments at the level of body function or structure influence the child's ability to perform activities and participate in daily life and motor impairments leading to activity limitations and participation (Mandich, Polatajiko & Rodger 2003). Children with a diagnosis of DCD demonstrated greater amounts of muscular activity around the hip and shoulder musculature in comparison with children of similar ages (Johnston et al. 2002). They use 'fixing' of their joints during activities requiring stabilising one joint or part of the body so that another part can be moved with better control leading to stiff, awkward and clumsy movements and fatigue following their 'fixing' strategies (Missiuna et al. 2003). Additionally, children presenting with DCD activate their muscles during unilateral reaching movements by co-activation and delaying the onset of antagonist muscle activity with a longer duration of agonist activity. In asymmetrical bilateral reaching they change the onset of one or both agonist and antagonist muscle groups compared to normal developing children who change only the duration of antagonist muscle activity (Missiuna et al. 2003). A summary of clinical presentations of children with DCD is shown in Table 1.
Often children with DCD obtain poor grades at school, have poor core stability, endurance, difficulty with gross motor tasks such as throwing and catching a ball, learning and carrying out multiple and new tasks (Kolehmainen et al. 2011). This leads to non-participation in school activities and diminished motivation to interact socially. This results in the child having a low self-esteem and anxiety with a vicious cycle of spending less time with physical activities, developing inefficient motor and movement patterns and leading a sedentary lifestyle (Rivilis et al. 2011).
As a result of the complex clinical presentation of DCD there is uncertainty and controversy in the literature about the philosophies and intervention approaches for managing DCD. Studies have shown the importance of physical activity for health, growth and development for children with DCD and that without interventions to improve motor skills, physical and activities of daily living will not improve (Barnhart et al. 2003). A possible strategy to manage children with DCD to reach full movement potential and minimise coordination challenges and emotional and social problems is to vary the teaching strategies, content and therapy (Mandich et al. 2001 Therefore this study was designed to (1) determine the effect of an 8-weeks gross motor training programme using

Presentation of children with DCD Authors
Completion of class work within normal time frame is challenging. They become distracted and frustrated with a straightforward task

Study design and sample selection
These randomised pre-test and post-test studies recruited children who were lagging behind their peers in motor proficiency at the Livingston Primary School in Durban. This is an English medium short-term remedial school for children experiencing learning difficulties such as dyslexia, dyspraxia, speech and language deficits, and hearing loss. The school has classes from Grades 1 to 7, providing holistic academic, therapeutic and cultural activities with children referred from mainstream schools within the Durban area.
There is a social worker and there are rehabilitation services offering speech and audiology, occupational services and physiotherapy. After intensive interaction with the child for 2 to 3 years the child can return to mainstream schooling.
The children were identified by teachers in consultation with a senior occupational therapist as observation and clinical judgment are valid options to identify children with coordination difficulties (Miyahara & Wafer 2004). On identification, the children were included in this study if they had an M-ABC score of ≤ 15 th percentile, were in good general health and had the ability to comply with the gross motor training programme. Children having an IQ of less than 70, attending private physiotherapy or other physical activity programmes were excluded. Informed consent was obtained from teachers, parents and assents from the children to be assessed and participate in the study.
The M-ABC is considered the international gold standard for measuring motor coordination difficulties and has been purported to be a good indicator for the incidence of DCD (Dunford et al. 2004). The M-ABC is reliable, valid, responsive and precise, and is a standardised instrument to measure children with motor impairments and assess the efficacy of treatment programmes with a manual test-retest reliability score of 0.75 (Henderson & Sugden 1992). The DCDQ consists of 15 items with an overall sensitivity of agespecific cut-off scores exceeding 84% and specificity of 71% and correlates with M-ABC scores and is regarded as a valid screening tool for children ageing 5-15 years (Wilson et al. 2009). Sixty-six children between the ages of 6-12 years were identified with two children excluded because they scored above the 15th percentile. This resulted in a study sample of 64 children with the flow of the participants shown in Figure 1.
Ethical approval was obtained by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BE287/12) and conformed to the Helsinki Declaration standards (WMA 2013). Permission to use the school was granted by the principal and KwaZulu-Natal Department of Education. The study was conducted from February to November 2013 and participation in the study was voluntary, with the child allowed to withdraw at any point. Confidentiality was maintained by coding all data and files, storing them in a computer and securing them by a secret password accessed only by the researchers.

Procedures
A draft gross motor training programme was developed by reviewing the programme of play and group therapy used by the therapists at the school. Based on a literature review of exercise programmes for children with impairments, feedback from clinicians and what senior therapists experienced in neuro-developmental therapy, the draft programme was reviewed for strengthening exercises, core stability, balance and coordination. This was based on the researcher's view that best practices emerge from published evidence, expert opinion and the patient's needs and preferences (Sackett et al. 1996).
The DCD attending a private facility, and after feedback from parents, teachers and therapists a final programme was designed. This was an 8-week gross motor training programme for core stability, strengthening exercises, balance and coordination with task-specific activities for 30 min per week to improve ball skills, balance, bilateral hand function, postural control and core stability (Appendix A). A school term consists of approximately 10 weeks which was sufficient for the eight weeks of gross motor training and pre-and posttesting.
These 64 children were divided equally into an intervention or control group using simple randomisation by means of the Clinstat computer programme which was administered by the school secretary who allocated the groups and was independent of the study. The control group continued with general therapy and activities of daily living in their classrooms during which children in the gross motor training programme performed their activities in small groups of seven or eight in the Occupational Therapy Department which was set to specifications as stipulated in the M-ABC manual (Henderson & Sugden 1992). Based on ethical requirements, on completion of the study children in the control group crossed over and received the gross motor training programme. The procedure for testing and scoring of the M-ABC test is shown in Table 2. All pre-tests' and posttests' scores were recorded by two research assistants who were experienced with the instrument and independent of the study. Pre-and post-DCDQ scores were recorded by teachers and parents. As a safety precaution, a first-aid kit was available for any minor injuries, and a nurse and doctor were 'on call' in the event of any adverse reactions during the activities.

Data analysis
Analysis of data was performed by means of the SAS software version 9.3 (SAS Institute Inc., Cary). Normality of data was assessed using the Shapiro-Wilk test with data normally distributed, and an intention to treat (ITT) analysis was done by means of imputation of the mean of the other group (MOTH). Means and standard deviations were used to show M-ABC and DCDQ scores with ball and balance skills, measured before and after intervention. An unpaired t-test and analysis of variance (ANOVA) were used to compare the control and intervention groups by comparing the scores of ball and balance skills to determine the impact of the intervention. Results are depicted by means of tables and graphs using Microsoft Excel 2010. Statistical significance was noted if p < 0.05.

Results
Sixty-four children satisfied the inclusion criteria, but two from the control and one from the gross motor training programme withdrew for personal reasons. A child from the gross motor training programme was transferred to another school, resulting in 60 children completing the study for data analysis. The flow of the participants is shown in Figure 1. There were 43 boys and 17 girls with mean age of 10.02 years (SD = 2.10). The mean age of children in the gross motor training programme was 10.11 (SD = 1.98) and the control 9.9 (SD = 2.44) years with no significant difference between groups (p = 0.893). The M-ABC assessment ranged between the 1st percentile and the 15th percentile, and the postintervention scores ranged from the 1st percentile to the 32nd percentile with the scores categorised as category 1 (below 5th percentile); category 2 (from the 5th percentile to the 15th percentile) and category 3 (above the 15th percentile). There were no deviations from the protocol or adverse reactions during and after the gross motor training programme.
There were significant (p = 0.031) improvements post-testing for M-ABC scores with a mean increase of 6.46% compared to children in the control who increased their scores by 0.33%. From the 14 children in category 1, six moved to category 2; and from the 16 children in category 2, ten moved into category 3 and were considered 'normal', no longer requiring physiotherapy. The control group had 6 children in category 1 and 24 in category 2 with no significant changes in any of their scores (Table 3). M-ABC scores for ball skills and balance improved by an average of 3.54% and 4.80%, respectively, in the gross motor programme group compared with the control group, improving by an average of 0.17% and 0.15%, respectively. The DCDQ scores for children in the gross motor training programme also improved significantly with no significant improvements for those in the control group. It was noted that although parents and teachers showed higher DCDQ scores, there were no significant differences between their scores (p = 0.069) after the gross motor training programme. However, teachers allocated lower scores for the child compared with the parents with five teachers and twelve parents scoring the child into a higher category. The significant improvements within the intervention group in ball skills (p = 0.021), balance (p = 0.033) and DCDQ scores of parents (p = 0.038) and teachers (p = 0.044) and between group significance for the intervention with M-ABC (p = 0.041); ball skills (p = 0.048); balance (p = 0.034) and DCDQ for parent (p = 0.024) and teachers (p = 0.045) are shown in Tables 3, 4 and 5 respectively.

Discussion
Studies of children presenting with DCD show that boys are more affected than girls, but when engaging in physical activities they overcome their poor movement patterns and impairments by improving their motor skills, muscle strength, endurance and activities of daily living (Barnhart et al. 2003;Pieters et al. 2011;Riethmuller, Jones & Okely 2009). The results of this study support these studies as more boys than girls were affected and following the gross motor training programme of exercises there were significant improvements in M-ABC and DCDQ scores. However, this study is contrary to the study by Pless and Carlsson (2000) who indicated that there were no significant differences in M-ABC scores after an exercise programme for DCD children having borderline motor problems and recommended that the children would require more specific therapy. This study supports exercises used in physiotherapy as being relevant and specific, as the researchers were physiotherapists and facilitated the exercise programme ensuring that each movement pattern was emphasised, repeated and adhered to basic movement patterns for stability and coordination which is required to improve the activity (Wilson 2005). The programme also incorporated star jumps, skipping, throwing and catching to improve inter-limb and eye-hand coordination with physical, visual and verbal prompts, which may have improved motor scores. It is noted that children with DCD have difficulty with visual-spatial processing and sensory integration. This affects perception There is also evidence that maturation did not improve balance in children with DCD, but that balance activities in a structured environment were necessary (Fong, Tsang & Ngo 2012). The improvement in balance following the gross motor programme may be related to balance being either 'static', requiring maintaining different postures, or 'dynamic', requiring activities while moving. This could have been facilitated by the child engaging in the programme requiring perception of the centre of gravity with timely motor response to realign the centre of gravity. This would be possible by the perceptual motor activity that involves the sensory and motor systems, which are activated by the sensory system receiving information from the environment and forwarding this information to the central nervous system for a reaction (Cherng, Hsu & Chen 2007).
A study on a strengthening programme for a child with DCD found that muscle strength, body awareness and   Participation in activities is important for a child's development. This enables them to attain the social and physical competencies required to provide social and emotional harmony, sense of meaning and purpose in life with successful outcomes motivating the child to try new challenges (Kolehmainen et al. 2011). It is possible that by participating in the gross motor programme with purposeful and enjoyable play activities, the children were motivated to interact with their peers. This is supported by anecdotal reports from parents and teachers who indicated that they observed secondary emotional and behavioural changes as the children enjoyed working in groups and cooperated in the activities. They also seem to have improved their listening and attention skills by complying with instructions and waiting patiently for their turn to share equipment.
Although this study found significant improvements in DCDQ scores, some teachers scored the children much lower than their parents. The researchers presume that this may relate to teachers having more knowledge of children with DCD and spend more time with the children in a structured environment, where they experience the children coping with motor functions in the classroom and the playground (McDavid, Cox & Amorose 2012). This is supported by Wilson et al. (2012) that a lower percentage of parents were aware of coping strategies compared with teachers.

Conclusion
This study supports an 8-week gross motor training programme for use by physiotherapists as a potential exercise intervention for 6-12-year-old children with DCD because the results improved M-ABC and DCDQ scores. Anecdotal reports also indicate that the children enjoyed the programme and that their participation improved their social interactions. Currently, the number of children attending remedial schools is increasing with the ratio of therapists to manage them posing a challenge. The use of the 8-week gross motor training programme and small group interactions will therefore be a beneficial exercise intervention for physiotherapists to improve the management and activities of daily living in children with DCD. However, further research is required to determine whether the improvements obtained will be evident later in their lives or be sufficient to meet participation levels for activities like sports and games that require more complex information processing.
Some of the limitations of this study were the time constraints of the academic term of 10 weeks. Additionally, standardised tests, such as M-ABC, do not measure the quality of movement, motor-planning problems and psychosocial consequences, such as self-esteem and confidence, which are functional problems often reported in children with DCD. Other limitations of this study were: it was a single-centred study where therapists and teachers could have been biased as they were in daily contact with the children, there was no attempt to stratify by age and the carry-over effect of the intervention was not determined. As the age range of the children in this study is fairly broad, further research is warranted to stratify children by age to determine if this programme can serve as an early intervention approach. A further study of the carry-over effect to determine how often the programme should be repeated to ensure optimal maintenance of function would also be useful. 9. Children to stand on wobble boards in front of each other, throw a tennis ball to each other, which must bounce in the centre. 10. Tandem walking along a 5 meter line (6)(7)(8) year olds to walk forward and 9-12 year olds to walk backwards).
Cool down: deep breathing exercises and stretches.

Week 5
Warm up