Gait & Posture 62 (2018) 20–26

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Gait & Posture

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Full length article

Reactive balance performance and neuromuscular and cognitive responses T

to unpredictable balance perturbations in children with developmental
coordination disorder
⁎
Yoyo T.Y. Chenga, William W.N. Tsangb, Catherine Mary Schoolinga,c, Shirley S.M. Fonga,
a
School of Public Health, University of Hong Kong, Hong Kong
b
Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hong Kong
c
Graduate School of Public Health and Healthy Policy, City University of New York, New York, NY, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Developmental coordination disorder (DCD) is a common motor disorder affecting balance performance.
Dyspraxia However, few studies have investigated reactive balance performance and the underlying mechanisms in chil-
Postural control dren with DCD. This study aimed to compare the reactive balance performance, lower limb muscle reflex
Neuromuscular reaction time contraction latency and attention level in response to unpredictable balance perturbations between 100 typically
Mental concentration
developing children and 120 children with DCD (with and without comorbid autism spectrum disorder) aged
6–9 years. Reactive balance performance was evaluated using a motor control test (MCT) conducted on a
computerized dynamic posturography machine. The lower limb postural muscle responses and attention level
before, during and after a MCT were measured using surface electromyography and electroencephalography,
respectively. The results revealed that relative to typically developing children, those with DCD had a sig-
nificantly longer MCT latency score in the backward platform translation condition (p = 0.048) but a sig-
nificantly shorter latency score in the forward platform translation condition (p = 0.024). The MCT composite
latency scores and the corresponding lower limb muscle onset latencies were similar between the groups.
Children with DCD also demonstrated a lower attention level during and after sudden backward (p = 0.042) and
forward (p = 0.031) platform translations, compared to typically developing children. Children with DCD were
less attentive in response to postural threats, and their balance responses were direction-specific. Balance
training for children with DCD might require an additional emphasis on sudden posterior-to-anterior balance
perturbations, as well as on problems with inattention.

1. Introduction our knowledge, only 3 research teams have assessed reactive balance
performance and the associated neuromuscular responses in this po-
Developmental coordination disorder (DCD) is a neurodevelop- pulation [4–6]. Williams and Castro [5] first reported that children with
mental disorder affecting approximately 5–6% of primary school-aged and without DCD exhibited similar latency in postural muscle activa-
children [1]. This disorder, which is more common in boys than in girls, tion onset in response to an unexpected platform translation. This
affects motor planning and coordination and severely interferes with a finding was concurred by Geuze [6], who perturbed participants at the
child’s daily activities and academic performance [1]. Impaired balance trunk level to elicit postural responses. However, when using a setup
control is the most significant of the many motor deficits presenting in similar to that used in the study by Geuze [6], we recently found that
children with DCD, affecting 73–87% of the DCD population [2]. Spe- children with DCD had delayed lower limb muscle activation onset
cifically, reactive balance control is the most concerning issue for par- times, which were related to poor motor (ball) skills [4]. We postulated
ents and children, as it is the first line of defense against unexpected that this discrepancy in findings between studies could be attributed to
balance perturbations and is essential for many daily activities, such as differences in experimental setups and methodologies. Therefore,
standing in a moving bus [3,4]. standardized laboratory measures were needed to verify the results.
To date, few studies have investigated reactive balance performance Balance reactions are not fully automatic reflex actions. Emerging
and the underlying mechanisms in children with DCD. To the best of evidence has shown that these reactions require attention, especially in

⁎
Corresponding author at: School of Public Health, University of Hong Kong, Pokfulam, Hong Kong.
E-mail address: [email protected] (S.S.M. Fong).

https://doi.org/10.1016/j.gaitpost.2018.02.025
Received 8 July 2017; Received in revised form 24 December 2017; Accepted 21 February 2018
0966-6362/ © 2018 Elsevier B.V. All rights reserved.
Y.T.Y. Cheng et al. Gait & Posture 62 (2018) 20–26

children with disabilities [7,8]. For example, children with dyslexia had to recover from an unexpected platform perturbation. Before the test,
significantly impaired balance reactions when their attention was split each participant was instructed to stand with their bare feet placed
between a balance task and a secondary counting/reaction time task shoulder width apart, eyes open and arms by the side of the body on the
[7]. Additionally, we found that children with DCD exhibited inferior dual forceplates of the CDP machine. Next, the platform was translated
motor and functional balance performances and were less attentive to posteriorly or anteriorly at 3 amplitudes (in inches)—small
movements than were their typically developing peers. Inattention ex- (0.5 x height/72), medium (1.25 x height/72) and large (2.25 x height/
plained 14.1–17.5% of the variances in motor performance (including 72)—scaled to the height of the participant. Each platform translation
balance performance) in the DCD population [9]. However, no previous was completed in < 1 s, and each testing condition comprised 3 trials.
study has specifically examined attention during reactive balance tasks The CDP machine automatically calculated the latency score (in ms),
in children with DCD. defined as the time between the onset of the platform translation and
Therefore, the present study aimed to compare the reactive balance the force response in each lower limb registered by the dual forceplates.
performances, lower limb muscle reflex contraction latencies and at- A latency score was then obtained for each lower limb per condition,
tention levels in response to unpredictable balance perturbations be- with a higher score indicating a prolonged reactive postural response
tween children with DCD and typically developing children. This study [14]. The latency scores of the dominant lower limb during the
hypothesized that children with DCD would exhibit inferior reactive medium-amplitude anterior and posterior platform translations were
balance control, a longer leg muscle reflex contraction latency and a selected for analysis because they best reflect the reactive balance re-
lower attention level in response to unpredictable balance perturba- sponse of the children participants. The composite latency score (i.e.,
tions, compared to their typically developing peers. the average of all condition-specific latency scores during medium- and
large-amplitude platform translations) [14] was also used in the ana-
2. Methods lysis.
Lower limb postural muscle responses to the MCT support surface
2.1. Participants perturbation were measured using surface electromyography (EMG)
(Biometrics, Newport, UK). An accelerometer (ACL300, Biometrics) was
Children with DCD and typically developing children were recruited attached to the movable platform on the afore-mentioned CDP machine
from local primary schools, non-government organizations that provide to register the initiation of translation. Postural muscle activities (i.e.,
rehabilitation services for children with special needs, child assessment the medial hamstrings and gastrocnemius for backward platform
centers where DCD was diagnosed, parent groups and our database of translation, and the rectus femoris and tibialis anterior for forward
DCD participants via poster-based advertising, invitation letters, platform translation [3,4]) were monitored before and after the plat-
WhatsApp and online social media. All children were screened by two form movement. It is because physiologically, a sudden backward
experienced physiotherapists via telephone and face-to-face assess- platform translation would trigger reflexive contractions of the ham-
ments, using the following criteria. The inclusion criteria for the DCD strings and gastrocnemius, and a sudden forward platform translation
group were: an age of 6–9 years, a formal diagnosis of DCD based on the would trigger reflexive contractions of the rectus femoris and tibialis
Diagnostic and Statistical Manual of Mental Disorders 5 [1], a total anterior, allowing the participant to maintain postural stability [3,4].
impairment score corresponding to ≤15th percentile on the Movement Circular Ag/AgCl bipolar surface EMG active electrodes (dia-
Assessment Battery for Children (MABC) [10], a total score of ≤46 (5–7 meter = 1 cm, between electrode distance = 2 cm) were placed long-
years 11 months old) or ≤55 (8–9 years 11 months old) on the DCD itudinally at the center of each muscle belly and a reference electrode
questionnaire 2007 [11], attendance at a mainstream school, an in- was fixed on the ipsilateral lateral malleolus. The skin at the electrode
telligence level within the normal range and no experience with the placement sites was prepared by cleansing with alcohol swabs, and hair
Brain Computer Interface system or a similar apparatus. The inclusion was shaved whenever necessary to reduce skin impedance [15]. The
criteria for the control group (i.e., typically developing children) were EMG signals were sampled at 1000 Hz and amplified by a gain factor of
similar to those of the DCD group, except that children in the control 1000. Other parameters included a bandwidth of 20–460 Hz, an input
group did not have a diagnosis of DCD nor meet the criteria of DCD on impedance of > 1015 Ω and a common mode rejection ratio of > 96 dB
MABC. [16].
The exclusion criteria for both groups were: comorbid attention All electrodes were connected to a DataLOG (Biometrics) that was
deficit hyperactivity disorder (ADHD) or a T score of ≥70 on the Child securely attached to the participant’s waist to reduce artifacts. The
Behavior Checklist (CBC) [12]; any significant cognitive, psychiatric DataLOG employed both a high-pass filter (20 Hz) and a low-pass filter
(comorbid autism spectrum disorder [ASD] was included), congenital, for frequencies > 450 Hz and stored EMG data for offline analysis.
musculoskeletal, movement, neurological or cardiopulmonary disorder Signals from the EMG electrodes and the accelerometer were post-
that could affect cognitive or motor performance; receipt of active processed using the Biometrics EMG analysis software. The accel-
treatments; demonstration of excessive disruptive behavior or an in- erometer signal onset was defined as the point at which the signal
ability to follow instructions. amplitude differed from the resting value by 0.20 m/s2, whereas the
Ethical approval was provided by the Human Research Ethics postural muscle response onset was defined as an EMG value 2 standard
Committee of the University of Hong Kong. A detailed explanation was deviations from the mean resting EMG value with a duration of > 25
given to each participant and parent and written informed consent was ms [17]. The muscle onset latency, defined as the time interval (in ms)
obtained. Data collection was performed by two experienced phy- between the onset of the accelerometer signal and the first discernible
siotherapists and trained research assistants in the Balance and Neural EMG activity in each muscle, was then extracted [17]. The average
Control Laboratory of the Hong Kong Polytechnic University. All pro- muscle onset latencies of 3 medium-amplitude anterior and posterior
cedures were performed in accordance with the principles of the platform translation trials were calculated and used for analysis.
Declaration of Helsinki [13]. The attention level during MCT was measured concurrently using a
Mindwave Mobile electroencephalographic (EEG) headset recording
2.2. Outcome measurements device (NeuroSky Inc., San Jose, CA, USA). This instrument is valid and
accurate for measuring the attention levels of children with DCD [18].
Reactive balance performance was measured using the standardized The active electrode of the headset was placed on the left forehead
motor control test on a computerized dynamic posturography (CDP) (position Fp1 [19]), and a reference electrode was clipped to the left
machine (Smart Equitest, NeuroCom International Inc., Clackamas, OR, earlobe. EEG activity in the prefrontal cortex was recorded 3 s before,
USA) [14]. The motor control test (MCT) assesses a participant's ability during and 3 s after the MCT platform perturbation. EEG signals were

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Y.T.Y. Cheng et al. Gait & Posture 62 (2018) 20–26

Table 1
Characteristics of the participants.

DCD group (n = 120) Control group (n = 100) p value

Age (years) 7.38 ± 1.25 6.73 ± 1.12 < 0.001*

Sex (male/female, n) 99/21 79/21 0.511
Body weight (kg) 26.10 ± 7.21 23.31 ± 5.87 0.002*
Height (cm) 124.16 ± 8.94 120.39 ± 8.54 0.002*
Body mass index (kg/m2) 16.66 ± 2.72 15.87 ± 2.26 0.020*
Physical activity level (metabolic equivalent hours per week) 10.03 ± 9.80 12.78 ± 12.22 0.065
Movement Assessment Battery for Children total impairment score 18.23 ± 8.99 4.70 ± 2.55 < 0.001**
Movement Assessment Battery for Children balance subscore 3.75 ± 4.17 0.28 ± 0.59 < 0.001**
DCD questionnaire 2007 total score 36.58 ± 9.65 43.46 ± 10.10 < 0.001*
Child Behavioral Checklist attention problem score 61.48 ± 10.32 61.07 ± 8.56 0.752
Child Behavioral Checklist attention problem percentile 83.76 ± 16.90 83.29 ± 14.97 0.831
Comorbidities (n and%)
Autism spectrum disorder 58 (48.3%) –
Dyslexia 11 (9.2%) –

Means ± standard deviations are presented unless otherwise specified.

Abbreviation: DCD = developmental coordination disorder.
* Indicates p < 0.05.

sampled at 512 Hz, filtered by a band-pass filter (0.5–30 Hz) and sub- between the two groups using the independent t-test. To address the
jected to a notch filter for noise at 50 Hz. Other known noise fre- potential confounding effect of comorbid ASD on postural control, the
quencies were also excluded using proprietary algorithms [20]. Data MANCOVA were repeated after separating data collected from children
obtained using the headset were transmitted via Bluetooth to the with DCD and ASD (DCD + ASD), children with DCD and without ASD
NeuroView data acquisition software (NeuroSky Inc.) installed on a (DCD − ASD), and children with typically development (controls). The
laptop. The software then transformed raw prefrontal cortex EEG sig- MCT composite latency score was compared among the three groups
nals into an attention index using a Fast Fourier Transform and pre- using the one-way analysis of covariance (ANCOVA). The indicated
configured proportions of EEG alpha (8–12 Hz), beta (12–30 Hz), theta effect sizes for between-group comparisons were calculated using the
(4–7 Hz) and delta (0.1–3 Hz) activities. This attention index, for which partial eta-squared (MANCOVA) or Cohen’s d (independent t-test) test.
possible values ranged from 0 to 100, was generated during each By convention, partial eta-square values of 0.01, 0.06 and 0.14 and
second of EEG recording and used to classify the attention level as very Cohen’s d values of 0.2, 0.5 and 0.8 indicate small, medium and large
low (0–20), low (21–40), average (41–60), moderate (61–80) or high effect sizes, respectively. A significance level of 0.05 (two-tailed) was
(81–100) [20]. The attention levels before the platform perturbation adopted for all statistical tests.
and throughout and after the perturbation process in each platform
translation direction were averaged and used for the analysis.
Information about demographic factors, medical histories and ex- 3. Results
ercise habits were obtained by interviewing the participants and their
parents. The physical activity level (in metabolic equivalent [MET] Between March 2015 and March 2016, a total of 275 children were
hours per week) was calculated with reference to the Compendium of screened and 220 of them were considered eligible to participate in the
Energy Expenditures for Youth [21]. The body mass index (BMI) was study. Of these, 120 children were classified as DCD and 100 were
calculated from the body weight and height. In addition, the motor classified as typically developing. Fifty-five children were excluded
performance of each participant was assessed using the MABC. Parents because they had ADHD or attained a T score of ≥70 on the CBC.
were invited to complete the DCD questionnaire, 2007 version [11] and Detailed characteristics of the participants are presented in Table 1.
a Child Behavioral Checklist [12]. Since significant differences in age and BMI were observed between the
two groups, these demographic variables were treated as covariates in
the multivariate analyses.
2.3. Statistical analyses The MCT results revealed that children with DCD had a longer la-
tency score in the backward platform translation condition (14.83 ms,
Sample size calculation was performed using G*Power 3.1.0 95% confidence interval [CI]: 1.08 to 28.59, p = 0.048) but a shorter
(Universitat Kiel, Germany) and was based on a statistical power of 0.8 latency score in the forward platform translation condition (-12.26 ms,
and a 2-tailed alpha level of 0.05. With reference to our previous studies 95% CI: −24.30 to −0.22, p = 0.024) when compared to typically
[4,22], a conservative medium effect size of 0.4 was assumed for this developing children overall. The composite latency scores were similar
study. Therefore, a minimum of 100 participants per group was re- between the two groups (Table 2). Subgroup analysis revealed that only
quired. children with DCD and without ASD had a longer latency score in the
All data were analyzed using the SPSS Statistics 20.0 software backward platform translation condition when compared to typically
package (IBM Corp., Armonk, NY, USA). Descriptive statistics was used developing children (p = 0.048). For the forward platform translation
to describe all the variables. Data normality was checked using histo- condition, children with DCD and ASD demonstrated a shorter latency
grams and/or Shapiro–Wilk tests. Continuous and categorical demo- score (p = 0.004). The composite latency score was higher in the DCD
graphic variables were compared between the 2 groups using the in- − ASD group when compared with the DCD + ASD group (p = 0.036)
dependent t-test and chi-square test, respectively. Next, the following 3 (Table 3). The corresponding lower limb muscle onset latencies (Fig. 1)
sets of outcome variables were compared between the 2 groups using a during the two MCT testing conditions were similar between the DCD
multivariate analysis of covariance (MANCOVA): (1) MCT backward group and control group (Table 2); and between the three groups
and forward platform translation latency scores, (2) corresponding (Table 3).
EMG lower limb muscle onset latencies during MCT, and (3) EEG-de- Regarding the EEG-derived attention scores, children with DCD
rived attention scores before, during and after MCT platform pertur- exhibited lower attention scores when compared with typically devel-
bation. In addition, the MCT composite latency score was compared oping children both during and after a backward platform translation

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Y.T.Y. Cheng et al. Gait & Posture 62 (2018) 20–26

Table 2
Comparison of outcome measurements between children with DCD and typically developing children.

Outcome measure DCD group (n = 120) Control group (n = 100) Mean difference between groups (DCD children – Typically p value Effect size
developing children) (95% confidence interval)

Motor control test latency scores (ms)

Backward platform translation 118.67 ± 45.37 103.84 ± 54.86 14.83 (1.26, 28.41) 0.048* ηP2 = 0.019
Forward platform translation 138.85 ± 51.60 151.11 ± 34.28 −12.26 (−24.30, −0.22) 0.024* ηP2 = 0.024
Composite 82.69 ± 68.40 88.69 ± 68.22 −5.99 (−24.54, 12.54) 0.524 d = 0.088
EMG muscle onset latencies during motor control test (ms)
Backward platform translation
Hamstrings 123.04 ± 57.09 123.59 ± 58.77 −0.55 (−16.67, 15.56) 0.549 ηP2 = 0.002
Gastrocnemius 103.82 ± 37.88 102.01 ± 47.37 1.81 (−10.10, 13.71) 0.925 ηP2 < 0.001
Forward platform translation
Rectus femoris 151.29 ± 44.12 148.42 ± 39.25 2.87 (−8.87, 14.61) 0.741 ηP2 < 0.001
Tibialis anterior 131.66 ± 35.55 130.22 ± 36.34 1.44 (−8.64, 11.52) 0.758 ηP2 < 0.001
EEG-derived attention score during motor control test
Before backward platform 50.87 ± 18.88 56.92 ± 17.98 −6.05 (−11.40, 0.70) 0.062 ηP2 = 0.019
translation
During and after backward platform 50.55 ± 9.16 53.79 ± 9.07 −3.24 (−5.88, −0.60) 0.042* ηP2 = 0.023
translation
Before forward platform translation 46.37 ± 15.23 49.46 ± 14.71 −3.09 (−7.40, 1.23) 0.153 ηP2 = 0.011
During and after forward platform 47.33 ± 9.77 51.72 ± 9.77 −4.39 (−7.21, −1.58) 0.018* ηP2 = 0.030
translation

Means ± standard deviations are presented unless otherwise specified.

Abbreviations;: DCD = developmental coordination disorder; EEG = electroencephalography; EMG = electromyography; d = Cohen’s d; ηP2 = partial eta-squared.
* Indicates p < 0.05.

(−3.24 points, 95% CI: −5.88 to −0.60, p = 0.042) and a forward backward platform perturbation but more rapidly in response to a
platform translation (−4.39 points, 95% CI: −7.21 to −1.58, forward platform perturbation. The presence of ASD could be a con-
p = 0.031) overall (Table 2). Further analyses showed that only chil- founding factor that shortened the postural response time in children
dren with DCD and ASD had a lower attention score when compared with DCD. Children with DCD alone had longer response latency than
with typically developing children during and after a forward platform typically developing children. It may be because children with DCD
translation (p = 0.015) (Table 3). The attention scores of the two/three have altered structures and activation patterns in various brain regions
groups were similar before the backward/forward platform translations and neuronal networks. Specifically, corticocerebellar dysfunction in
(Tables 2 and 3). children with DCD contributes to the deficits in motor control and
timing [23]. This may explain why force responses in the legs of chil-
dren with DCD during the MCT backward platform translation condi-
4. Discussion
tion were delayed (i.e., reacted slower), as detected by the force plat-
form.
4.1. Reactive balance performance
When the platform translated forward, the COG of the participant
was displaced backward. Although the timing of movement control
This study presents the novel finding that the reactive balance
could be delayed in children with DCD, they had a decreased maximum
performance of children with DCD (with and without comorbid ASD) is
excursion of LOS in the backward direction [24]. They needed to re-
direction-specific. When compared with their typically developing
spond more rapidly to maintain the COG within the base of support
peers, children with DCD reacted more slowly in response to a

Table 3
Comparison of outcome measurements between children with DCD and ASD, children with DCD and without ASD, and typically developing children.

Outcome measure DCD + ASD group (n = 58) DCD – ASD group (n = 62) Control group (n = 100) p value Effect size (ηP2)

Motor control test latency scores (ms)

Backward platform translation 112.16 ± 55.87 124.03 ± 33.99a 103.84 ± 54.86 0.054* 0.028
Forward platform translation 127.65 ± 62.85a 148.06 ± 38.19 151.11 ± 34.28 0.005* 0.051
Composite 64.90 ± 69.91b 97.32 ± 64.04 88.69 ± 68.22 0.028* 0.034
EMG muscle onset latencies during motor control test (ms)
Backward platform translation
Hamstrings 129.53 ± 68.37 118.38 ± 47.49 123.59 ± 58.77 0.585 0.005
Gastrocnemius 105.16 ± 47.45 102.85 ± 29.58 102.01 ± 47.37 0.979 < 0.001
Forward platform translation
Rectus femoris 151.19 ± 45.11 151.37 ± 43.78 148.42 ± 39.25 0.996 < 0.001
Tibialis anterior 134.53 ± 40.50 129.60 ± 31.73 130.22 ± 36.34 0.680 0.004
EEG-derived attention score during motor control test
Before backward platform translation 49.74 ± 20.55 51.64 ± 17.78 56.92 ± 17.98 0.148 0.021
During and after backward platform translation 50.50 ± 11.24 50.59 ± 7.51 53.79 ± 9.07 0.118 0.023
Before forward platform translation 46.17 ± 15.25 46.52 ± 15.35 49.46 ± 14.71 0.361 0.011
During and after forward platform translation 45.91 ± 10.23a 48.33 ± 9.39 51.72 ± 9.77 0.039* 0.035

Means ± standard deviations are presented unless otherwise specified.

Abbreviations;: DCD = developmental coordination disorder; ASD = autism spectrum disorder; EEG = electroencephalography; EMG = electromyography; ηP2 = partial eta-squared.
*
Indicates p ≤ 0.05.
a
Indicates p < 0.05 when compared with the control group.
b
Indicates p < 0.05 when compared with the DCD – ASD group.

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Y.T.Y. Cheng et al. Gait & Posture 62 (2018) 20–26

Fig. 1. Comparison of muscle activation patterns in a boy with developmental coordination disorder (A) and a boy with typical development (B), illustrating muscle activation patterns in
response to a backward platform translation (forward body sway) during the motor control test. Shown is the hamstrings (yellow curve) and gastrocnemius (pink curve) EMG responses
and the accelerometer signal (red curve) with time on the x-axis. The hamstrings and gastrocnemius muscle onset latencies [i.e. the time interval between the onset of the accelerometer
signal (arrow on the left hand side) and the first discernible EMG activity in hamstrings (arrow on the right hand side) or gastrocnemius (arrow in the middle)] are similar between the
two children. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

(BOS) to prevent falling in the backward direction. Therefore, the force significant differences in the lower limb muscle onset latencies in re-
platform detected an earlier force response in the legs (i.e., faster re- sponse to both the forward and backward platform translations be-
action) in the legs of children with DCD (with and without comorbid tween the two/three groups. Our findings exactly agreed with those of
ASD) during the MCT forward platform translation condition. Subgroup Williams and Castro [5], who reported that the average onset latency of
analysis further revealed that only children with both DCD and ASD postural muscle activation in response to a sudden, unexpected plat-
reacted faster to a forward platform translation compared to typically form translation was similar between children with and without DCD.
developing children. It may be related to their anticipation of the However, our previous study demonstrated that if the unexpected
platform perturbation or other neurological dysfunctions associated perturbation was executed at the trunk level (instead of a platform
with ASD [25]. perturbation), children with DCD demonstrated longer hamstring and
For the overall reactive balance performance, as children with DCD gastrocnemius neuromuscular reaction times than did typically devel-
(with and without comorbid ASD) exhibited faster reactions in one oping children [4]. Therefore, we postulated that children with DCD
movement direction but slower reactions in another, the MCT compo- might respond in a timely manner to a soleus/gastrocnemius stretch
site latency scores, which comprise the average values of all direction- (induced by a platform perturbation), but not a hamstring stretch (in-
specific latency scores, of children with DCD were no different from duced by a trunk perturbation). Certainly, further study is needed to
those of typically developing children. However, in the subgroup ana- specifically examine the postural stretch reflexes in children with DCD.
lysis, results revealed that children with both DCD and ASD reacted
faster than children with DCD alone. Further study is needed to ex- 4.3. Cognitive responses to unpredictable balance perturbations
amine the reactive balance control and the underlying mechanisms in
children with DCD and ASD. To the best of our knowledge, this is the first study to investigate the
attention levels of children with DCD during a reactive balance task.
4.2. Neuromuscular responses to unpredictable balance perturbations The results revealed that before the unexpected platform perturbation
(at baseline), both children with DCD and their typically developing
Although the reactive balance performances differed between chil- peers exhibited a similar attention levels. However, both during and
dren with DCD and their typically developing peers, we observed no after the MCT backward/forward platform perturbations (i.e., during

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Y.T.Y. Cheng et al. Gait & Posture 62 (2018) 20–26

the reactive balance task), the attention levels of children with DCD, School, Tai Kok Tsui Catholic Primary School, Tai Kok Tsui Catholic
especially those children with both DCD and ASD, were much lower Primary School (Hoi Fan Road), Tak Sun School, The ELCHK Faith
than those of typically developing children. These findings were similar Lutheran School, The H.K.C.W.C. Hioe Tjo Yoeng Primary School,
to those reported by Fong et al. [9], who demonstrated that children Xianggang Putonghua Yanxishe Primary School of Science and
with DCD had significantly lower attention levels during functional Creativity, Yan Chai Hospital Law Chan Chor Si College, Yuen Long
tasks and that this phenomenon was associated with poor motor per- Merchants Association Primary School, Yuen Long Public Middle
formance. Although the exact underlying neurophysiological mechan- School Alumni Association Primary School) and Heep Hong Society.
isms remain unclear, this difference might may be related to the lower The work described in this paper was partially supported by a General
attention capacity [26,27] or under-activation of brain areas re- Research Fund (17658516) and an Early Career Scheme grant
sponsible for motor tasks in children with DCD [23,28,29]. Further (27100614) from the Research Grants Council of the Hong Kong Special
multi-channel EEG device-based investigations involving various re- Administrative Region, China.
active balance tasks are therefore needed.
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