The Effect of Action Observation Therapy on Spasticity, Motor Function, and Balance in Children With Cerebral Palsy

In this study, G*Power 3.1.3 program was used to calculate the minimum sample size in each group (control group (group 1), group 2 and group 3), in other words, the number of individuals in the groups. In this context, the effect size was taken as d = 1.1, the significance level was α = 0.05, and the minimum number of individuals in each group was calculated as 11 (33 in total) for a power of 0.80 (80%). Similar studies (Sgandurra 2013, Kim 2018) were taken into consideration in obtaining these parameters. The number of individuals in each group (+10%) was planned to be at least 12 (36 in total), taking into account individuals who were missing, incorrect or excluded from the study.

In order to prevent bias in terms of participants meeting the inclusion criteria, sociodemographic and clinical characteristics, criteria such as age, cerebral palsy type, GMFCS level and presence of comorbidities were taken into account in assigning individuals to groups in the study, and the stratified randomization method will be used. Accordingly, the age ranges are taken as 5-7, 8-10, 11-13, and the cerebral palsy type is; spastic diplegic and hemiplegic, GMFCS level; It will be taken as I-III and the stratification process will be done accordingly. Before the study, written and verbal "Informed Consent Form" will be obtained from the parents of all participants in the study and control groups. The content of the study will be explained to the children who will participate in the study in a way that the child can understand, and the child's consent will be obtained. After recording the sociodemographic data of the participants for both the experimental and control groups, their spasticity was measured by the Modified Ashworth Scale (MAS), their gross motor function levels were measured by the Gross Motor Function Measurement (GMFM), their participation was measured by the Child and Adolescent Participation Survey (CASP), and their balance was measured by the Timed Up and Go Test ( TUG), Pediatric Reach Test (PRT) and Pediatric Balance Scale (PDS), and the extent to which the individual goal has been achieved will be evaluated by the Goal Attainment Scale (GAS). Assessments will be administered the day before starting treatment, after completing the 6-week Action Observation Therapy, and after a 3-month follow-up period.

Treatment Program of the Control Group (Group 1): This group will not be shown any video clips, and general physiotherapy methods will be applied to their current needs, 2 sessions a week for 6 weeks. This method includes stretching exercises for spastic muscles, strengthening exercises for the antagonist of the spastic muscle, and stabilization exercises.

Group 2: Action Observation Therapy for the lower extremities will be applied to this group by their parents at home, 2 sessions a week for 6 weeks. Participants will be shown a video of a task by their parents at home. The video to be watched will include a total of 6 activities planned to be watched every week. These 6 activities; squatting and getting up by picking up an object from the ground, walking 10 steps between parallel lines, transferring weight forward with the right and left feet, walking 5 steps sideways to the right and left, kicking the ball, climbing the step from the front and side. The video clips will be watched 3 times and after a 1-minute rest following each viewing, the participants will be asked to repeat each activity in the videos 3 times and at the end of each clip.

Group 3: Action Observation Therapy for the lower extremities will be applied by the therapist to this group, 2 sessions a week for 6 weeks. Participants will watch a video of a task presented by a therapist. The video to be watched will include a total of 6 activities planned to be watched every week. These 6 activities; squatting and getting up by picking up an object from the ground, walking 10 steps between parallel lines, transferring weight forward with the right and left feet, walking 5 steps sideways to the right and left, kicking the ball, climbing the step from the front and side. The video clips will be watched 3 times and after a 1-minute rest following each viewing, the participants will be asked to repeat each activity in the videos 3 times and at the end of each clip. After each session of Action Observation Therapy, 20 minutes of physiotherapy will be applied towards the goals of 6 activities. The scope of physiotherapy to be applied will consist of activity-based exercises for the lower extremities, stepping, weight transfer, balance and functionality.

Inclusion criteria

• 5-13 years old

• Diagnosis of spastic hemiplegic and diplegic cerebral palsy
• Gross Motor Function Classification System (GMFCS) Level I-III
• Consent to participate in the study

Exclusion criteria

Exclusion criteria

from the study:

• Spastic hemiplegic and diplegic disease not associated with cerebral palsy
• Presence of contractures affecting functional movement in the affected extremity
• Presence of cardiopulmonary disease or severe visual and hearing impairments
• Children who have had a seizure in the last 6 months
• Children who have had any surgery or received botulinum injections within the last 6 months or during the study period.