Proposal for a body balance training program for children through an integrative literature review

Corresponding address: Marta de Vargas Romero Estrada Antônio Inácio de Ávila, 450, casa 33 CEP: 97095-040 Santa Maria, Rio Grande do Sul, Brasil E-mail: mvromero@bol.com.br ABSTRACT Objective: to verify, in the literature, the proposals to rehabilitate the vestibular function, so as to propose a training program for body balance for children. Methods: this article sought studies that proposed to rehabilitate or train body balance in the Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed) and Scientific Electronic Library Online (SCIELO) databases, in addition to digital sources from Brazilian public universities. As descriptors, the terms “rehabilitation”, “balance” and “child” were used, combined with the Boolean operator AND. The variables analyzed were: public submitted to the intervention, number of subjects and age group, number and frequency of sessions, number and/or time of execution of the exercise, duration of the session and the program. Results: 17 (60.74%) articles were Brazilian, 14 (50%) used the Cawthorne and Cooksey protocol, 9 (32.14%) studied children, and the majority (67.85%) organized the program in weeks. A body balance training program, stimulating the three body balance systems, consisting of 30-minute sessions twice a week for 7 weeks, totaling 14 sessions, was developed. Conclusion: the analysis of the variable related to the protocol/strategy to rehabilitate the vestibular function indicated that no study proposed the stimulation of the three body balance systems, with no standardization for children, adults and the elderly. A vestibular function rehabilitation program was developed for children, with stimulation of these three systems, expanding the therapeutic possibilities in this area.


INTRODUCTION
Body balance is a complex sensorimotor phenomenon generated by the integration of information from three sensory systems (visual, proprioceptive and vestibular) and processed in the Central Nervous System 1 .
Changes in maintaining body balance can cause symptoms such as tinnitus and hearing loss 2 . Pediatric vestibular disorders are of great importance in the course of child development, as they can have a series of repercussions, such as delayed motor development and learning, potentially interfering with language, speech, writing and reading 3 .
In addition to identifying schoolchildren at risk for otoneurological disorders, and thus minimizing their effects on child development and academic performance, it is urgent to prepare teachers to recognize these complaints in their students. Moreover, parents should be instructed to take their child through a complete otoneurological assessment in the event of complaints of this nature 4 .
In the search to remedy or alleviate symptoms related to changes in the vestibular system, researchers sought alternatives for their treatment. There are several forms of treatment for vestibular disorders, especially drugs, surgeries, nutritional guidance, correction of inappropriate habits, psychotherapy and vestibular rehabilitation (VR) 5 . National 6,7 and international [8][9][10][11][12][13] studies have proposed rehabilitating children from VR, with some proving that this treatment is effective and safe for children 8,9 .
The objective of this study was to verify, in the scientific publications, the proposals to rehabilitate the vestibular function, and based on the data from the integrative review, to propose a body balance training program for children.

METHODS
This is an integrative review, of a documental character, whose research took place in the period from March to September 2018.
The first stage was the selection of studies that dealt with VR. The survey was carried out on the Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed) and Scientific Electronic Library Online (SCIELO) databases, in addition to the virtual sources of public institutions of Higher Education: Federal University of Santa Maria (UFSM), Federal University of São Paulo (USP) and Federal University of Rio Grande do Sul (UFRGS). A total of 3743 studies were obtained, which were repeated in more than one base of papers.
National and international material was searched by combining the following descriptors in English (DeCS), without restriction of period, language or nationality, using the Boolean operator "AND": 1. Rehabilitation AND vestibular; 2. Balance AND rehabilitation; 3. Rehabilitation AND vestibular AND child.
The inclusion criteria for selecting the material were: a) Full text; b) Free access; c) To present a therapeutic program or strategy to rehabilitate or train vestibular function (unpublished, adapted or replicated). After the analysis of the studies, those who did not adhere to the theme of that study or who were repeated in more than one database were excluded. Academic works and texts that were not available in full were also excluded. Thus, a total of 28 studies met the inclusion criteria and were used in this study.
The following analysis variables were considered: a) Public submitted to the intervention, including the number of subjects and age group; b) Number and frequency of intervention sessions; c) Number/time of repetitions of the exercise and/or duration of the session; d) Total duration of the program.
The data were analyzed descriptively by means of percentage, which were presented by means of Chart.
The second stage of this study was the elaboration of the BB training program aimed at children. For the elaboration, the following were determined: frequency of sessions, duration and/or number of repetition of the activity, session time and period of application of the protocol.
The following domains were determined: activity to be performed, focus (BB system prioritized in that activity specifically), duration and/or number of repetition and material to be used.

LITERATURE REVIEW
Chart 1 shows the selected studies. This Chart includes the authors and country in which was developed, the protocol or rehabilitation strategy or vestibular training used, the audience studied, the number of sessions performed by the researcher and the frequency, the number of repetitions of the exercises, the duration of the session and the therapeutic program.
As shown in Chart 1, it was found that 17 of the selected studies (60.74%) were carried out in Brazil, with the predominant use of the Cawthorne and Cooksey protocol (50%), both in isolated form (32.15%), as associated with other strategies (17.85%).
Regarding to the public studied, the results indicated that nine (32.14%) of the studies investigated the child/ adolescent public, which is also the target public of the present study, and the others (67.86%) dealt with the adult and/or elderly public.
Analyzing the studies presented in Chart 1, the number of sessions showed important variability, starting from a single session (7.14%) to 112 sessions (3.57%), predominantly studies that proposed a variable number of sessions (14.28%). Just a study (3.57%) that did not specify the number of sessions.
As well as the number of sessions scheduled, the frequency of these therapeutic sessions was also variable, ranging from single session (7.14%), through biweekly and monthly (7.14%) to daily (3.57%). Two studies (7.14%) did not specify the frequency of the session. Finally, the periodicity prevalent among the selected studies was two weekly sessions, with nine (32.14%) studies adopting this conduct.
Among the studies dedicated to children present in Chart 1, one study (11.11%) stood out that indicated that the exercises were repeated 10 times, while two studies (22.22%) indicated the time between one and three minutes per exercise. Finally, one study (11.11%) indicated both the number of repetitions (three to 10) and the duration (one to two minutes).
Concerning the duration of the session, among the studies in Chart 1 with children's samples, only three (33.33%) indicated in their methodologies the duration of the session, with estimates varying from 20 to 60 minutes, with an average among the three studies of 41 minutes.
From the detailed analysis of the results in Chart 1, the training program presented in Chart 2 was elaborated. The activity, focus and number of repetitions or execution time were presented, and finally the material used. To walk in a straight line between 2 tapes with 20 cm between them and 5 m long (in the first free attempt, being able to look at the floor, and in the next ones looking at a fixed point on the wall) .*

Vestibular Visual
To take the round trip 3 times Blue adhesive tape To walk in a straight line between 2 tapes with 20 cm between them and 5 m long with closed eyes * Vestibular To take the round trip 3 times Blue adhesive tape To look to the right without visual stimulation (only eyes move, the head remains immobile). Stay in position for 10 seconds.
Return to the Center.

Repeat 3 times _______
To look to the left without visual stimulation (only eyes move, the head remains immobile). Stay in position for 10 seconds.
Return to the Center.

Repeat 3 times _______
To look up without visual stimulation (only eyes move, the head remains immobile). Stay in position for 10 seconds. Return to the center.

Repeat 3 times _______
To look down without visual stimulation (only eyes move, the head remains immobile). Stay in position for 10 seconds.
Return to the center.

Repeat 3 times _______
Play: imitation of animals (in group).
To reinforce trained movements and postures Each child was given the figure of 1 animal to imitate.
Colleagues should guess. The results indicated that most studies (67.85%) proposed therapeutic programs organized in weeks, with an average of eight weeks. Still, it was found that four studies (14.28%) did not specify the time required by the therapeutic program, while two studies (10.52%) indicated a single therapeutic session.
To walk in a straight line between 2 tapes with 15 cm between both and 5 m long with closed eyes. *

Vestibular Somatosensory
To take the round trip 3 times Blue adhesive tape    To keep your eyes fixed on an object (ball) and turn your head towards NO.  Care, no Brazilian studies were identified, indicating that in Brazil the VR seems to still be restricted to academy.
In general, the protocols and strategies selected by the studies in Chart 1 primarily stimulated one or another of the pillars of the vestibular system. The vestibular and visual systems are primarily stimulated in the Cawthorne and Cooksey protocol, with an emphasis on eye, head and trunk movement 16 , and by virtual reality strategies 19 . The somatosensory system is privileged in the sensory integration strategy 26 . Again, this seems to be linked to the fact that existing and published studies were restricted to research, when only one element is focused, seeking to understand the impact of this element on the others.
Concerning the age of the participants, there was no uniformity in the classifications of the age groups, with the age of 16, being considered "child" 22 and "adult" 30 . Likewise, some studies consider age over 60 to be "adult" [19][20][21][22]27,31 , while others consider the age of 60 as the lower limit to consider the "elderly" subject [23][24][25] . The body balance system, whose development occurs throughout life, has peculiarities in each phase, which are relevant and must be considered. For example, changes in BB predispose the elderly to fall, while for the child, the vestibular system represents a regulator and mediator for new motor learning 32 . Adopting a consolidated classification, such as that provided for by child and adolescent statute (Law # 8069/1990) 32 can prevent research bias, attributing greater reliability.
Another highlight is that from the union of the selected studies (Chart 1) with the participation of adults and the elderly, many with overlapping ages (similar ages), it was found that 67.76% of the selected studies deal with this audience. This confirms that the occurrence of complaints and otoneurological symptoms prevails among the older age groups 33 , while the child audience, despite presenting similar symptoms, they present difficulties in identifying and expressing them 34 .
According to the Orientation Guide on the performance of the speech therapist in the assessment and rehabilitation of body balance 35 , the treatment time is variable and will depend on the otoneurological picture, As explained in Chart 2, the three systems of body balance were contemplated, namely: visual, somatosensory and vestibular. These systems were worked on in some activities in isolation and in others simultaneously. In addition to the directed activities, games were proposed to resume the movements or skills stimulated in the directed activity. The directed exercises were progressively increasing the difficulty.
The Cawthorne and Cooksey protocol was adopted as the basis for eye and body movements. However, striving to include the proprioceptive system in the training program, activities were included with some sensory integration strategies (such as staying with and without shoes, on a stable or unstable basis, etc.). The main focus (BB system) was indicated in each activity.
The total number of sessions of the studies shown in Chart 1 was 287 sessions, which divided by the studies that made this specification (23), an average of 16.87 sessions was obtained. For the present program, 14 training sessions were proposed.
It was found the use of repetitions in numbers and in time (isolated or simultaneously) in the selected studies, with values between three and 10 repetitions, and the repetition time between one and three minutes. Therefore, seeking to establish values similar to these, the present program proposes counting the numbers of the exercises (between three and five) and staying between 10 seconds and 1 minute in each exercise.
Among the studies with children's samples that pointed out the duration of each session in their methodologies (Chart 1), there were times between 20 and 60 minutes. Making the average among all, the value of 41 minutes was obtained. For the present program, a 30-minute session was proposed.
The results showed that most of the studies presented in Chart 1 (67.85%) proposed therapeutic programs organized in weeks, and thus the present program was also organized. The average number of weeks foreseen by these studies was calculated, checking the value of eight weeks. Therefore, the present study organized the body balance training program in seven weeks, staying one week (closing eight) as a technical reserve for possible session recovery.
There was a recurrence of studies addressing the VR in Brazil, given the high percentage of Brazilian studies 6,7,14-28 on the subject. However, this context seems to be restricted to universities, still in the field of research, because in a systematic review 29 on the effectiveness of vestibular rehabilitation in Primary Health existence of comorbidities, age and the period in which the therapeutic intervention was started. The analysis of the studies in Chart 1 seems to strengthen this position, since there was considerable variability in the duration of the programs presented.
In the BB training program proposed in Chart 2, guided and playful activities were developed, as indicated by some authors 11 , the first of which progressively increased the degree of difficulty 8,[12][13][14] .
The present program is dedicated to application especially for children, who, according to the Child and Adolescent Statute 32 , are individuals up to 12 years old.
However, activities require a certain motor and cognitive demand, in addition to the child's active participation, and are not suitable for children under four years old 11 .
As in other studies [36][37][38] , a program was proposed using the combination of strategies in both directed activities. However, only in this study, all BB systems were stimulated, giving this program an unprecedented character of integral intervention.

CONCLUSION
From the variables in this integrative review, especially regarding the protocol or strategy used for the rehabilitation of the vestibular function, no study was found proposing the stimulation of the three BB systems, and those found emphasized one or two of these systems, depending on the study. Still, the lack of standardization found in the analyzed variables, indicated that there is no uniformity regarding the rehabilitation of vestibular function in children, adults and the elderly.
In the present study, a body balance training program was developed, whose domains were adopted based on the integrative review, highlighting the fact that the application of this program in full, guarantees the stimulation of the three systems that make up the BB. Considering the lack of programs for rehabilitation of vestibular function for children, it is estimated that this study has contributed to expand the possibilities in this area.
As a suggestion for future studies, it is considered that the application of this program to the child audience represents an important step towards speech rehabilitation and related areas.