cerebral palsy is caused by the development of non - progressive lesions in the brain . these 
 lesions develop during prenatal or infantile development and cause muscle paralysis , muscle 
 weakening , and coordination disorders , which hinder timely motor development . these motor 
 impairments may be accompanied by mental retardation , visual impairments , speech 
 impediments , perceptual disorders , and emotional disorders1 . insufficient trunk muscle postural control is the most serious 
 concern for those who are suffering from cerebral palsy because it causes insufficient 
 postural control and trunk stability2 . the trunk is essential for limb movements , affects motor movements , and has an 
 interdependent relationship with other body parts and nervous tissues3 . in normal developmental processes , trunk stability is 
 related to the movement of the limbs . essentially , the upper and lower limbs help to 
 compensate for any trunk instabilities that make exist ; when the trunk is stable , the upper 
 and lower limbs are freely usable for their normal purposes4 . however , children with cerebral palsy show hypotonic symptoms ; 
 weakness of the trunk muscles ; increases in upper and lower limb muscle tone ; loss or delay 
 of postural reflex ; and the loss of the ability to flexibly move the upper and lower limbs , 
 which leads to the loss of trunk stability5 . the loss of trunk control is a very important element that causes 
 difficulties not only in sitting , playing in sitting positions , and functional hand 
 movements such as eating1 , but also in 
 maintaining activities of daily living such as sitting in a wheelchair . similarly , head control is important for postural control and balance ability6 . in normal developmental processes , as the 
 development of the vertebral extensor progresses from the head to the foot , the erector 
 muscle of the upper thorax begins to become stronger and has the ability to regulate 
 antigravity7 . the babies are able to 
 pull up the chin and lift the head in supine positions at approximately six months after 
 birth . thus , children with cerebral palsy can not 
 complete these movements sufficiently due to unstable trunk muscles . delay in acquisition of 
 neck orthotopic response affects the development of the muscular strength and limits the 
 activity of the neck muscles supporting the head as well as the lack of stability of the 
 head , resulting in a lack of head control6 . this reduces the ability to maintain one s center of gravity and 
 affects orientating responses and equilibrium reactions , thereby causing serious problems 
 with balance ability8 . choi et al . reported that trunk muscle strengthening exercises positively affected 
 upper limb functions and balance ability among children with cerebral palsy9 . similarly , mcburney et al . reported that 
 when lower limb muscle strengthening exercises were applied to 11 spastic paraplegic 
 children with cerebral palsy , lower limb muscle strength , flexibility , postures , and gait 
 ability were improved ; this study s findings also emphasized the importance of strengthening 
 exercises for improving trunk stability10 . however , previous studies primarily focused on the effects of 
 strengthening of trunk muscles and certain muscles around the neck or on the analysis of 
 resulting sitting balance and gross motor functions . therefore , during normal development of 
 a child , one of the muscles does not affect the body , but it develops through complementary 
 movements , so stabilization of the neck and stabilization of the trunk should be done 
 together . and the child s balance ability is necessary for the connection to the functional 
 movement for the daily living ability11 . 
 in the previous studies , there is a lack of case study of static balance and dynamic balance 
 related with trunk and neck stabilization . therefore , the purpose of the current study to 
 examine the effects of trunk and neck stabilization exercises on the static and dynamic 
 trunk balance abilities of children with cerebral palsy . the study s participants were 11 school aged children who had paraplegia due to a premature 
 birth and were diagnosed with periventricular leukomalacia ( pvl ) through brain mri ( table 1table 
 1.general characteristics of the participants ( m  
 sd)gender ( male / female)4/7age ( month)127.9  
 32.4height ( cm)134.5  
 16.4weight ( kg)33.2  
 12.9gestational age ( week)32.2  3.0birth weight ( kg)1.9  0.8level of gmfcs ( i , ii , iii / n)4/2/5 ) . all participants 
 were recruited from the daegu k child development center from december 2015 to february 
 2016 . each participant was provided with a detailed explanation of the intent of the study , 
 indicated that they understood the intent , and agreed to participate in the experiment . the 
 mean height of the subjects was 134.45  16.40  cm and the mean weight was 33.18  12.92  kg . the participants 
 cognitive levels were evaluated using the korean wechsler intelligence scale for children - iv 
 to ensure that the subjects were able to understand and follow verbal instructions , and 
 learn . participation was limited to children who had not received any surgical treatment 
 within the previous six months and who showed gross motor functional levels corresponding to 
 gross motor function classification system ( gmfcs ) levels i  iii . assessments were conducted 
 before the first treatment session at the end of the eight weeks of treatment . stabilization exercises of neck and trunk were adopted based on previous studies proving 
 their effectiveness . each treatment session consisted of a warm - up exercise , neck and trunk 
 stabilization exercises , postural control exercises that promote a sense of equilibrium and 
 orientation responses , and cool down exercises . the first neck and trunk exercise involved 
 lifting the head in a modified bridge exercise position so that lower abdominal muscles 
 contracted when the neck was bent , thereby activating the neck flexor muscle and the lower 
 abdominal muscles simultaneously . the second exercise involved pushing the neck backward in 
 supine position to activate the erector muscles of the neck and the upper thoracic vertebrae 
 through the extension of the muscles of the back of the neck . the third exercise activated 
 the deep abdominal muscles in bridge exercise positions so that the participants would 
 experience the posterior inclined movement of the pelvis . in each posture , they were kept 
 for 10 seconds at a time and repeated 10 times with a rest interval of 3 seconds per 
 each12 , 13 . the trunk control measurement scale ( tcms ) this scale was developed to evaluate trunk control ability for children , 
 aged 815 years old , who have spastic cerebral palsy , function at the gmfcs levels i  iii , 
 and can maintain a sitting position . it is used to evaluate static balance , selective 
 movement control , and dynamic reaching in sitting positions without wearing any walking aids 
 and with the feet maintained off the ground . the tcms consists of 15 items for which scores 
 can be in a range of 058 points . it has strong reliability with inter - rater icc of 0.98 and 
 test - retest icc of 0.9714 . paired t - tests were used to compare 
 values before and after the intervention within each group . after the intervention , the analysis of tcms data showed significant effects on static 
 sitting balance , selective movement control , dynamic reaching , and total tcms scores 
 ( p<0.05 ) ( table 2table 2.comparison of pre - post test on tcms ( m  
 sd)pre - test post - test 
 static sitting balance 12.6  4.415.0  3.5*selective movement control8.63  6.4012.7  7.3*dynamic reaching 5.72  3.198.09  2.30*total tcms score27.0  12.535.8  12.2**p<0.05 , 
 tcms : trunk control measurement scale ) . this study examined the effects of neck and trunk stabilization exercises on the static and 
 dynamic trunk balance of children who have cerebral palsy due to a premature birth . results showed that the exercises had significant 
 effects on static sitting balance , selective movement control , dynamic reaching , and total 
 tcms scores . these results are similar to those of a previous study in which neck flexion 
 exercises and bridge exercises improved sitting position trunk control for children with 
 cerebral palsy15 . trunk stabilization 
 exercises are a basic component of the motility of the distal part of the body , including 
 neck movements ; several studies have shown the importance of trunk stabilization exercises 
 for these movements16 , 17 . furthermore , children with spastic cerebral palsy are 
 characterized by trunk muscle weakness , which has direct effects on the functional 
 performance of activities of daily living , and insufficient static and dynamic balance 
 abilities . therefore , the recovery of trunk stability and balance ability can be essential 
 for solving these problems among children with cerebral palsy . information coming from the body and environments is simultaneously delivered to the neck 
 and trunk to enable coordination between the head and limb motions , including those of the 
 neck muscles . the functions of the head and neck set the base of the body against the 
 surrounding environment and provide a stable base of support for the visual and vestibular 
 systems during postural control18 . in 
 particular , the trunk provides stable attachment points to those muscles that control the 
 head and neck regions19 . however , 
 premature babies have insufficient trunk development , can not grasp the concept of 
 centerlines , have acquired limited sensory information through head movements in the narrow 
 womb , are exposed to too many sensations in the environments of neonatal intensive care 
 units , and have instability in their movement and sensory systems6 . since neck muscle strength increases are connected with 
 trunk stabilization , trunk stabilization exercises are thought to have positive effects on 
 neck muscle strength . in addition , since the neck and the trunk are complementary to each 
 other , neck stabilization exercises and trunk stabilization exercises should be applied 
 together for improvement of static and dynamic balance ability . the expectation is that this 
 combination of exercises will improve balance ability , thereby leading to improved 
 functional activities . the postural control system consists of support , stability , and 
 balance and requires interactions between the head , trunk , arms , and legs to keep the body 
 upright against gravity20 . this supports 
 the results of the current study and indicates that composite exercises considering the 
 connection between the trunk and neck bring about improvement in balance ability . thus , 
 trunk exercises implemented together with neck stabilization exercises increase the effects 
 on postural balance . the causes of motor disorders among children with cerebral palsy 
 include abnormal muscle tone , muscle weakening , deficiency in balance and coordination 
 abilities , and spasticity21 . more 
 specifically , children with cerebral palsy due to premature birth do not have the ability to 
 optimize information obtained through the visual , vestibular , proprioceptive and tactile 
 senses ; they also can not integrate information gathered from these senses with information 
 from the central nervous system to initiate movements22 , and have remarkable muscle weakening and imbalance symptoms . their 
 reduced ability to maintain balance in standing and sitting positions is very important for 
 treatment interventions designed to improve of their quality of life through daily living 
 activities23 . in addition , the 
 weakening of the trunk muscles and insufficient stability shown in children with cerebral 
 palsy are obstructive factors to postural balance , which is achieved by trunk muscle control 
 and activities of daily living24 . previous studies demonstrate the effects of muscle strengthening and stabilizing exercises 
 with minimized compensatory actions and the mobilization of accurate muscles as solutions 
 for postural imbalance due to muscle weakness25 . the 
 results of the present study showed , neck and trunk stabilization exercises was the basis of 
 static and dynamic balance abilities , and that the increased neck and trunk stability might 
 have had a positive effect thereon . further studies may need to be conducted with more 
 subjects on the basis of the findings of the present study . however , this study has limitations that should be interpreted carefully because there is 
 no control group and the type of cerebral palsy is limited to spastic diplegia . based on the 
 results of the current study , additional research with larger participant groups is 
 needed .
[ purpose ] the purpose of this case series was to examination the effects of trunk and 
 neck stabilization exercise on the static , dynamic trunk balance abilities of children 
 with cerebral palsy . [ subjects and methods ] the study included 11 school aged children 
 diagnosed with paraplegia due to a premature birth . 
 each child engaged in exercise 
 treatments twice per week for eight weeks ; each treatment lasted for 45 minutes . 
 after 
 conducting a preliminary assessment , exercise treatments were designed based on each 
 child s level of functioning . 
 another assessment was conducted after the eight weeks of 
 treatment . 
 [ results ] the trunk control measurement scale evaluation showed that the 
 exercise treatments had a significant effect on static sitting balance , selective movement 
 control , dynamic reaching , and total trunk control measurement scale scores . 
 [ conclusion ] 
 the results indicate that neck and trunk stabilization exercises that require children s 
 active participation are helpful for improving static and dynamic balance ability among 
 children diagnosed with cerebral palsy .