Efficacy of fine motor and balance exercises on fine motor skills in children with sensorineural hearing loss

Abstract

Background:

Childhood hearing impairment is a major disability associated with delayed motor development. The affected Fine motor performance in children with sensorineural hearing loss (SNHL) could be due to dynamic balance deficits and visual-motor incoordination.

Objective:

This study was designed to investigate the effects of fine motor exercises with or without balancing exercises on fine motor skills in children with SNHL.

Methods:

One hundred and eighty (180) children their age ranged from 8 to 18 years old diagnosed with SNHL were selected. They were divided into three groups, 60 children (control group) practiced only their ordinary activities of daily living, 60 children (fine motor exercises group) practiced fine motor exercises, and 60 children (fine motor and balance exercise) group practiced fine motor and balance exercises. The outcomes were assessed by the Bruininks Oseretsky Test of the motor proficiency second edition scale (BOT-2).

Results:

Generally, there was a statistically significant difference between control group and fine motor exercises group where (p < 0.05), besides, there was a statistically significant difference between control group and fine motor and balance exercises group where (p < 0.05). But, there was no statistically significant difference between fine motor exercises group and fine motor and balance exercises group where (p > 0.05).

Conclusions:

The Fine Motor performance of children with SNHL has been improved by Fine motor with or without balancing exercises according to (BOT-2).

Keywords

Hearing loss fine motor balance exercises

1 Introduction

Hearing impairment (HI) in both adolescence and childhood is an important public Health problem which is known as a major disability. Childhood hearing impairment is a significant problem because it is associated with long-term developmental difficulties as language skills, communication skills, social abilities, and motor development (McCor-mick, 2018). In general, deaf children had both dynamic balance deficit and visual-motor incoordination which affect fine and gross motor activity (Wiegersma & Velde, 1983).

More than 5% of individuals worldwide –or 466 million people –have hearing impairment (432 million adults and 34 million children). It is estimated that by 2050 above 900 million people will suffer disabling hearing loss (WHO, 2020). In Egypt, HI occurrence in children ranged from 13.8% to 20.9% and was more frequent with increased age (Hamed et al., 2010; Taha et al., 2010).

According to American speech language hearing association, there are three basic types of hearing loss: conductive hearing loss, sensorineural hearing loss and mixed hearing loss. Sensorineural hearing loss (SNHL) is the most common type of permanent hearing impairment (Rajendra & Roy, 2011).

Hearing impairment (HI) children show vestibular deficits. Such vestibular deficits affect motor proficiency among HI children (Fernandez et al., 2015). The literature indicates that hearing-impaired children display motor deficits and more specifically balance deficits in the postural control (Kamel et al., 2021; Livingstone & McPhillips, 2011; De Kegel et al., 2011).

Similarly, the children with (SNHL) exhibit postural instabilities, as well as balance and gait disorders, due to the vestibular dysfunction that they are prone to display as a consequence of inner ear injury. Thus, some experiments have proposed vestibular rehabilitation exercises programs as a treatment to improve these motor skills in children with SNHL (Renato et al., 2019).

Moreover, a systematic review confirms that ba-lance impairments was associated with hearing impairment (Rajendran et al., 2012) which could be attributed to vestibular dysfunction due to embryological and anatomical connection between the cochlea and vestibular end-organs and their shared sensory microstructure and genetics (Colebatch, 2019).

This was confirmed in a systematic review by Verbecque et al. (2017) who demonstrated a significantly higher occurrence of vestibular dysfunction in children with SNHL compared to normal-hearing children in all included studies.

The vestibular end organs play an essential role in the maintenance of balance control and gaze stabilization during posture and movements (Rine & Wiener-Vacher, 2013). Several studies in young children with a bilateral severe vestibular dysfunction have shown a reduced balance performance and a delayed acquisition of gross motor milestones (e.g. head stabilization, sitting and independent walking) (Ionescu et al., 2019; Kimura et al., 2018; Maes et al., 2014).

Vestibular dysfunction can also influence fine motor skills, as well as writing, reading and learning skills, and may even hamper the cognitive and socio-emotional development of children (Lacroix et al., 2020; Bigelow et al., 2019; Popp et al., 2017).

In typically developing children, the development of fine motor skills occurs rapidly during the first years of life with a subsequent refinement throughout childhood (Eliasson et al., 2006). There are acquisitions for normal development of fine motor skills necessary to accomplish various daily living activities at an early age (Gaul & Issartel, 2016).

These essential elements are precise control of fingers, coordinated hand, arm movements and visual-motor integration (Gerber et al., 2010). From infancy, skilled postural control is a prerequisite for optimal reaching and grasping behaviors’ acquisition (De Graaf-Peters et al., 2007; Lobo & Galloway, 2008).

A review by Rajendran et al. (2012) reported that the Bruininks-Oseretsky Test of the motor proficiency second edition scale (BOT-2) is an assessment tool for HI children with motor deficits. (BOT-2) has an appropriate validity and reliability as well as high sensitivity and can be used to evaluate motor skills (Gharaei et al., 2019). This result is consistent with the studies of simultaneous validity of the (BOT-2) (Vinçon et al., 2017; Schulz et al., 2011).

So this study was conducted to investigate the effect of Fine motor with or without balance exercises on fine motor skills in children with sensorineural hearing loss.

1.1 Subjects

In terms of design, the study design is Randomized Control-Group Pretest Posttest Design. This study was administered for three months from October 2020 to December 2020. One hundred and eighty children, their age ranged from 8 to 18 years old diagnosed with SNHL, selected from Public School for the Deaf and Hard of Hearing in Al-Minia district- Minia, Egypt. A total of 180 children were randomly divided into three groups. Simple randomization by tossing a coin was the method used to randomly assign patients to groups, 60 children (control group) practiced the ordinary daily living activities, 60 children (fine motor exercises group) practiced fine motor exercises, and 60 children (fine motor and balance exercises group) practiced fine motor and balance exercises as presented in Fig. 1.

Fig. 1

Flow Chart.

Before data collection, Research Ethical Committee was obtained from the faculty of physical therapy, Cairo University (NO: P.T.REC/012/002583), Informed consent was obtained from the parents of all participants. Applicants were examined to guarantee meeting the following criteria: Both males & females diagnosed with (SNHL) only, their age range from eight to eighteen years old, can comprehend simple commands by sign language, can use pen and write individually.

Exclusion criteria were any cognitive, physical, visual, or neurological conditions (other than SNHI and vestibular impairment). Also, exclude those with lower limbs and hand deformities. Confirm all of these by medical records and examination by Audiologist, Neurologist, and physiotherapist.

1.2 Methods and measures

The outcomes were assessed by (BOT-2) before and after interventions to measure fine motor skills (Fine motor precision and Fine motor integration). The (BOT-2) is a norm-referenced standardized motor assessment available in a complete form with 53 items and a short form with fourteen items selected from the complete one. It is suitable for use in children aged four to twenty-one years old (Bruininks, 2005).

Both versions are classified into four composite motor domains, each containing 2 motor subtests, but we used only Fine Manual Control that contains Fine Motor Precision and Fine Motor Integration. Total motor composite and subtest measures are available as a raw score, standard score, percentile rank, and descriptive categories. Gender-related normative scores were used as the developers of (BOT-2) reported them as being more precise than combined gender norms (Bruininks, 2005).

The (BOT-2) uses a subtest &composite structure that indicates motor performance in the broad functional areas of stability, mobility, strength, coordination and object manipulation. We used the Fine Manual Control composite to measure control and coordination of the distal musculature of the hands and fingers, especially for grasping, drawing, and cutting.

The (BOT-2) uses a subtest and composite structure that indicates motor performance in the broad functional areas of stability, mobility, strength, coordination and object manipulation. We used the fine manual control composite to measure control and coordination of the distal musculature of the hands and fingers, especially for grasping, drawing, and cutting through Fine Motor Precision and Fine Motor Integration subtests.

The Fine Motor Precision subtest (1) is a series of activities that require accurate control of fingers and hand movement. The object is to draw, fold, or cut within a specified boundary. A child’s score is consistent with individuals who generally make no errors when drawing a line through a crooked path (3 mm wide, 20 cm long) and can remain within a boundary 1 cm wide when cutting out a circle as presented in Fig. 2.

Fig. 2

BOT-2 fine motor form.

The Fine Motor Integration subtest (2) requires the examinee to reproduce drawings of many geometric shapes that range in difficulty from a circle to overlapping pencils. The child’s score is consistent with individuals who, when copying from pictures, can precisely draw different geometric figures such as a triangle and a wavy line, besides more composite designs such as a five-point star and overlapping pencils as presented in Fig. 2.

1.3 Interventions

The exercise program was carried out for 30 min session/3 times per week for 12 weeks (Rine et al., 2004). Each activity pre-determined and demonstrated to all participants until it was cleared. For adequate communication, the teachers of the respective classes helped us in this issue.

The fine motor exercise group (Group A): received a physical therapy program in the form of fine motor exercises besides ordinary daily living activities. The physical therapy program consists of all the components used in the scale for assessment.

The fine motor and balance exercises group (Group B): received a physical therapy program in the form of fine motor and balance exercises besides ordinary daily living activities. They received fine motor exercises as the first study group beside balance exercise; the child jumps up and down on the trampoline, being on the balance board, and in a quadruped then kneeling positions (hold on for 10 seconds). After that, the child stands on a balance board (hold on for 10 seconds), walks with a narrower base of support, walks heel-to-toe (did all exercises with open/ closed eyes).

The control group (Group C): practiced their ordinary daily living activities at the school, home, and play activities.

2 Statistical analysis

Statistical analysis was done using SPSS, version 23 for Windows; SPSS Inc., Chicago, Illinois, USA. Descriptive statistics for patients’ characteristics, and the dependent variable (subset 1, Subset 2) were calculated as a mean and standard deviation. One way analysis of variance (ANOVA) test was carried out for comparison of mean values of subtest one and subtest two between the three groups. Unpaired t test was used to identify the significant difference between every two groups. The alpha level of significance (α) was set less than 0.05.

2.1 Patient characteristics

One way ANOVA Test revealed that there was no statistically significant difference between groups regarding age, weight, and height where (p > 0.05) as presented in Table 1.

Table 1
Patient characteristics

Primary FM female Primary FMB female Primary control female F value P value

Age (Mean±Standard deviation) 10.5±1.24 10.66±1.04 10.48±1.28 0.059 0.942

Weight (Mean±Standard deviation) 32.89±7.91 33.56±6.65 32.56±8.79 0.861 0.441

Height (Mean±Standard deviation) 121.44±9.03 121.44±8.47 121.67±9.3 0.089 0.914

Primary FM male Primary FMB male Primary control male F value P value

Age (Mean±Standard deviation) 10.49±1.16 10.56±1.07 10.64±1.13 0.096 0.909

Weight (Mean±Standard deviation) 30.8±6.83 31.9±7.12 31.4±7.28 0.121 0.886

Height (Mean±Standard deviation) 128.25±11.05 129.5±10.99 128.7±10.32 0.069 0.934

Preparatory FM female Preparatory FMB female Preparatory control female F value P value

Age (Mean±Standard deviation) 13.54±0.97 13.49±0.99 13.42±1.04 3.713 0.051

Weight (Mean±Standard deviation) 49.38±10.81 49.5±10.04 47.5±11.01 1.039 0.379

Height (Mean±Standard deviation) 141.12±10.36 141.38±13.22 139.38±11.69 0.833 0.455

Preparatory FM male Preparatory FMB male Preparatory control male F value P value

Age (Mean±Standard deviation) 13.81±0.85 13.91±0.83 13.75±0.93 0.086 0.918

Weight (Mean±Standard deviation) 51.6±11.65 53.9±9.19 51.5±11.81 3.022 0.074

Height (Mean±Standard deviation) 143.2±11.67 145.2±10.55 142.4±11.72 2.901 0.081

Secondary FM female Secondary FMB female Secondary control female F value P value

Age (Mean±Standard deviation) 16.8±0.86 16.94±0.79 16.94±0.87 0.046 0.955

Weight (Mean±Standard deviation) 52.6±6.43 54.6±8.88 54±9.64 0.074 0.929

Height (Mean±Standard deviation) 158.8±8.23 159±8.48 158.2±8.19 0.012 0.987

Secondary FM male Secondary FMB male Secondary control male F value P value

Age (Mean±Standard deviation) 16.7±1.01 17.04±0.92 16.69±0.96 0.339 0.716

Weight (Mean±Standard deviation) 57.12±8.72 60.12±8.39 57.75±8.05 0.284 0.755

Height (Mean±Standard deviation) 160±8.04 163.38±6.05 158.25±6.67 1.118 0.345

Primary FM female	Primary FMB female	Primary control female	F value	P value
Age (Mean±Standard deviation)	10.5±1.24	10.66±1.04	10.48±1.28	0.059	0.942
Weight (Mean±Standard deviation)	32.89±7.91	33.56±6.65	32.56±8.79	0.861	0.441
Height (Mean±Standard deviation)	121.44±9.03	121.44±8.47	121.67±9.3	0.089	0.914
	Primary FM male	Primary FMB male	Primary control male	F value	P value
Age (Mean±Standard deviation)	10.49±1.16	10.56±1.07	10.64±1.13	0.096	0.909
Weight (Mean±Standard deviation)	30.8±6.83	31.9±7.12	31.4±7.28	0.121	0.886
Height (Mean±Standard deviation)	128.25±11.05	129.5±10.99	128.7±10.32	0.069	0.934
	Preparatory FM female	Preparatory FMB female	Preparatory control female	F value	P value
Age (Mean±Standard deviation)	13.54±0.97	13.49±0.99	13.42±1.04	3.713	0.051
Weight (Mean±Standard deviation)	49.38±10.81	49.5±10.04	47.5±11.01	1.039	0.379
Height (Mean±Standard deviation)	141.12±10.36	141.38±13.22	139.38±11.69	0.833	0.455
	Preparatory FM male	Preparatory FMB male	Preparatory control male	F value	P value
Age (Mean±Standard deviation)	13.81±0.85	13.91±0.83	13.75±0.93	0.086	0.918
Weight (Mean±Standard deviation)	51.6±11.65	53.9±9.19	51.5±11.81	3.022	0.074
Height (Mean±Standard deviation)	143.2±11.67	145.2±10.55	142.4±11.72	2.901	0.081
	Secondary FM female	Secondary FMB female	Secondary control female	F value	P value
Age (Mean±Standard deviation)	16.8±0.86	16.94±0.79	16.94±0.87	0.046	0.955
Weight (Mean±Standard deviation)	52.6±6.43	54.6±8.88	54±9.64	0.074	0.929
Height (Mean±Standard deviation)	158.8±8.23	159±8.48	158.2±8.19	0.012	0.987
	Secondary FM male	Secondary FMB male	Secondary control male	F value	P value
Age (Mean±Standard deviation)	16.7±1.01	17.04±0.92	16.69±0.96	0.339	0.716
Weight (Mean±Standard deviation)	57.12±8.72	60.12±8.39	57.75±8.05	0.284	0.755
Height (Mean±Standard deviation)	160±8.04	163.38±6.05	158.25±6.67	1.118	0.345

2.2 Subtest 1 and subtest 2 results

One way ANOVA Test revealed that there was no statistically significant difference between groups regarding pre-treatment data. But, there was a statistically significant difference between groups regarding post-treatment data where (p < 0.05) as presented in Table 2.

Table 2
One way ANOVA test of subtest 1 & subtest 2 pre and post treatment of the three groups

Variable Subtest Category Sex Fine motor Group (A) (Mean±Standard deviation) Fine motor and balance Group (B) (Mean±Standard deviation) Control Group (C) (Mean±Standard deviation) F value P value

Pre Subtest 1 High Male 21.5±1.93 21.88±2.17 21.62±1.99 0.07 0.93

Female 25±2.55 25.2±1.92 25.2±2.39 0.013 0.99

Preparatory Male 15±3.05 15.7±3.06 15.1±3.14 0.15 0.86

Female 17.88±2.03 18±1.6 17.38±1.85 0.26 0.77

Primary Male 14.85±3.031 15.05±2.66 15.25±3.04 0.09 0.91

Female 17.33±1.41 17.56±1.74 17.22±1.72 0.09 0.9

Subtest 2 High Male 19.88±2.29 20.75±2.71 20.38±2.39 0.25 0.78

Female 22.6±3.05 22.8±2.77 23±3.16 0.007 0.99

Preparatory Male 14.4±2.76 14.8±2.66 14±3.13 0.19 0.82

Female 22.38±1.99 21.88±1.88 21.63±1.99 0.3 0.74

Primary Male 16.45±4.36 16.65±4 17.25±4.2 0.19 0.82

Female 14.89±2.52 15.33±2.18 15±2.59 0.08 0.92

Post Subtest 1 High Male 24.88±3.27 28.12±4.61 21.62±1.99 7.05 0.004^*

Female 30±2 31.2±4.6 25.2±2.39 4.89 0.028^*

Preparatory Male 21.20±6.37 22.8±5.49 15.4±2.95 5.72 0.008^*

Female 24.75±2.82 25.38±2.87 17.5±2 22.77 < 0.00001^*

Primary Male 19.95±4.211 22.95±4.28 15.95±3.22 15.92 < 0.00001^*

Female 23.11±3.02 24.11±4.83 17.67±1.8 9.09 0.001^*

Subtest 2 High Male 25.13±3.13 26.38±11.69 20.38±2.39 8.83 0.002^*

Female 28.6±2.97 30±4 23±3.16 5.91 0.016^*

Preparatory Male 20.3±6.24 21.7±4.5472 14.2±3.19 6.84 0.004^*

Female 26.25±1.98 25.25±2.96 22.13±2.47 5.89 0.009^*

Primary Male 20.95±4.99 22.1±4.58 17.7±4.1 4.98 0.01^*

Female 20.22±3.23 26.33±4.44 15.44±2.92 20.77 < 0.00001^*

Variable	Subtest	Category	Sex	Fine motor Group (A) (Mean±Standard deviation)	Fine motor and balance Group (B) (Mean±Standard deviation)	Control Group (C) (Mean±Standard deviation)	F value	P value
Pre	Subtest 1	High	Male	21.5±1.93	21.88±2.17	21.62±1.99	0.07	0.93
			Female	25±2.55	25.2±1.92	25.2±2.39	0.013	0.99
		Preparatory	Male	15±3.05	15.7±3.06	15.1±3.14	0.15	0.86
			Female	17.88±2.03	18±1.6	17.38±1.85	0.26	0.77
		Primary	Male	14.85±3.031	15.05±2.66	15.25±3.04	0.09	0.91
			Female	17.33±1.41	17.56±1.74	17.22±1.72	0.09	0.9
	Subtest 2	High	Male	19.88±2.29	20.75±2.71	20.38±2.39	0.25	0.78
			Female	22.6±3.05	22.8±2.77	23±3.16	0.007	0.99
		Preparatory	Male	14.4±2.76	14.8±2.66	14±3.13	0.19	0.82
			Female	22.38±1.99	21.88±1.88	21.63±1.99	0.3	0.74
		Primary	Male	16.45±4.36	16.65±4	17.25±4.2	0.19	0.82
			Female	14.89±2.52	15.33±2.18	15±2.59	0.08	0.92
Post	Subtest 1	High	Male	24.88±3.27	28.12±4.61	21.62±1.99	7.05	0.004^*
			Female	30±2	31.2±4.6	25.2±2.39	4.89	0.028^*
		Preparatory	Male	21.20±6.37	22.8±5.49	15.4±2.95	5.72	0.008^*
			Female	24.75±2.82	25.38±2.87	17.5±2	22.77	< 0.00001^*
		Primary	Male	19.95±4.211	22.95±4.28	15.95±3.22	15.92	< 0.00001^*
			Female	23.11±3.02	24.11±4.83	17.67±1.8	9.09	0.001^*
	Subtest 2	High	Male	25.13±3.13	26.38±11.69	20.38±2.39	8.83	0.002^*
			Female	28.6±2.97	30±4	23±3.16	5.91	0.016^*
		Preparatory	Male	20.3±6.24	21.7±4.5472	14.2±3.19	6.84	0.004^*
			Female	26.25±1.98	25.25±2.96	22.13±2.47	5.89	0.009^*
		Primary	Male	20.95±4.99	22.1±4.58	17.7±4.1	4.98	0.01^*
			Female	20.22±3.23	26.33±4.44	15.44±2.92	20.77	< 0.00001^*

Regarding post-treatment data of subtest one and subtest two in male and female groups, Unpaired t test generally revealed that there was a statistically significant difference between fine motor exercises group control group where (p < 0.05). Also, there was a statistically significant difference between fine motor and balance exercises group and control group where (p < 0.05). But, there was no statistically significant difference between fine motor exercises group and fine motor and balance exercises group where (p > 0.05).

Regarding subtest one, there was no statistically significant difference between fine motor exercises group and control group in the male students of the preparatory school. There was a statistically significant difference between fine motor exercises group and fine motor and balance exercises group in the male students of the primary school. Regarding subtest two, there was a statistically significant difference between fine motor exercises group and fine motor and balance exercises group in the female students of the primary school.as presented in Table 3.

Table 3

Unpaired t test results of subtest 1 & subtest 2

Category	Subtest	Sex	Comparison	T value	P value
High	Subtest 1	Male	A versus B	– 1.62	0.126
			A versus C	2.39	0.03^*
			B versus C	3.66	0.0026^*
		Female	A versus B	– 0.53	0.607
			A versus C	3.45	0.0087^*
			B versus C	2.59	0.032^*
preparatory		Male	A versus B	– 0.6	0.555
			A versus C	2.61	0.017
			B versus C	3.75	0.0015^*
		Female	A versus B	– 0.44	0.67
			A versus C	5.94	0.000036^*
			B versus C	6.36	0.000018^*
primary		Male	A versus B	– 2.23	0.031^*
			A versus C	3.37	0.0017^*
			B versus C	5.84	< 0.00001^*
		Female	A versus B	– 0.53	0.61
			A versus C	4.64	0.00027^*
			B versus C	3.75	0.0017^*
High	Subtest 2	Male	A versus B	– 0.76	0.459
			A versus C	3.41	0.004^*
			B versus C	4.07	0.0011^*
		Female	A versus B	– 0.63	0.547
			A versus C	2.89	0.02^∗
			B versus C	3.07	0.015^∗
preparatory		Male	A versus B	– 0.57	0.57
			A versus C	2.75	0.013^∗
			B versus C	4.27	0.0005^∗
		Female	A versus B	0.793	0.22
			A versus C	3.68	0.0025^∗
			B versus C	2.29	0.038^∗
primary		Male	A versus B	– 0.76	0.45
			A versus C	2.25	0.03^∗
			B versus C	3.2	0.0028^∗
		Female	A versus B	– 3.34	0.004^∗
			A versus C	3.29	0.0046^∗
			B versus C	– 6.14	0.00001^∗

3 Discussion

The current study was designed to investigate the efficacy of the fine motor exercises with or without balance exercises on fine motor skills in children with SNHL. The results of this study showed a highly significant improvement of the Fine motor precision and integration in fine motor exercises group and fine motor and balance exercises group when compared with the control group. But, almost there was no significant difference between fine motor exercises group and fine motor and balance exercises group.

The first explanation for the improvement of fine motor skills in study groups could be attributed to enhanced sensorimotor integration and learning-dependent neural plasticity as the motor skill training can induce cortical plasticity (Cole et al., 2014). These changes involve enhancement of pattern of work of local brain areas and global brain network connectivity (Zatorre et al., 2012).

Hearing disability from birth brings about functional plastic changes within the central nervous system (CNS). One in all the changes is that the activation of the “meaning brain areas” by enhancing different sensory sources by the role of visual input. The defects are corrected through the strategy of compensation whereby input from proprioception, visual and other sensory systems substitute for the absent peripheral vestibular input. The observed recovery could potentially be substituted by a network of other brainstem, cerebellar or cortical pathways (Suarez et al., 2021).

Motor learning by physical-practice involves both motor and sensory processes (Haith & Krakauer, 2013). Indeed, during physical practice we face the dual challenge of determining and refining the somatosensory goals of our movements and establishing the best motor commands to achieve our ends (Vahdat et al., 2014). Similarly, during physical practice, the sensorimotor pathway is strongly engaged and inhibitory mechanisms are partially involved (Kang et al., 2012; Shin et al., 2012).

The gained experience from acquiring a new skill or information will modulate the brain pathways made up of a countless number of neurons and synapses (Wall et al., 2002). There are several neurophysiological processes associated with learning and sensory-motor adaptation (DeFeudis & DeFeudis, 1977). They include changes in the neuronal cell surface and its filaments, sprouting of cell dendrites and axons, growth of new synaptic connections, and neurotransmitter release changes at the synapses.

During skill learning or repeated stimulations or experiences, relevant neurons fire and wire together. The associated neurons of a given response will fire simultaneously in response to future similar stimuli. Learning experiences optimize the function of the existing brain areas or mechanisms via neurogenesis, gliogenesis, or synaptogenesis (Ponti et al., 2008).

The results of this study agree with a study on children with (SNHL) and concurrent vestibular dysfunction. The intervention with exercises improved the sensory organization of postural control and delayed the progressive delay in motor development (Rine et al., 2004).

In a line with the other researchers, Soori and his colleagues mentioned that exercise training was effective in improving motor skills, as well as the use of this training is recommended to increase the level of motor performance (Soori et al., 2019)

Besides, the post-treatment results of the study revealed that there was no statistically significant difference between female students in control group and their peers in fine motor exercises group & fine motor and balance exercises group in high school, male students in preparatory school, and male students in primary school. These results could be attributed to insufficient length of learning that can induce activity-dependent neural plasticity in macro- or micro-structures as the developed brains may restructure themselves due to extensive or rigorous skill learning lasting months or following a short period of practice (Taubert et al., 2010).

An explanation for the previously mentioned non-significant differences between groups may be attributed to that the students may suffer from vestibular dysfunction and needed more intervention time to show more satisfactory results.

The vestibular dysfunction was not evaluated by this study as well as a study conducted by Effgen, (1981) whose sample could contain children with vestibular dysfunctions, who may have required a longer intervention time than that proposed (15 min). Thus, the effect of intervention may have been underestimated since the vestibular function of the sample was not controlled.

According to Hartman et al. (2011) children with SNHL have alterations in the picking up objects with controlling balls. So, sports and recreational practice, stimulating for the child and increasing treatment adherence. (Melo et al., 2020). In order to improve fine motor skills, occupational therapy and tasks as drawing lines through paths-crooked, drawing lines through drawing paths-curved, folding paper, Copying a diamond, and Copying overlapping pencils can be practiced by children with SNHL.

3.1 Limitations

Several limitations are worthy mentioned, the first was concerning with the sample selected where the sample was convenient sample rather than a random selected sample, the second was lack of blinding, the third was the absence of vestibular evaluation.

Finally, further studies should be conducted to evaluate efficacy of fine motor and balance exercises on fine motor skills in children with sensorineural hearing loss over long period of time to provide better statistical analysis taking into consideration evaluation of the vestibular function.

4 Conclusion

Hearing impairment prevents the optimal development of children with (SNHL), especially fine motor skills. According to results, fine motor exercises with or without balance exercises improve the fine motor skills of children with (SNHL).

Conflict of interest

The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. The authors report no involvement in the research by the sponsor that could have influenced the outcome of this work.

Also, neither the submitted material nor portions thereof have been published previously or are under consideration for publication elsewhere.

Authors’ contributions

Author Elsayed S. Mehrem has given substantial contributions to the conception or the design of the manuscript, author Roshdy M. Kamel to acquisition, analysis and interpretation of the data. All authors have participated to drafting the manuscript, authors Said Mohamed and Lamyaa A. Fergany revised it critically. All authors read and approved the final version of the manuscript.

Footnotes

Acknowledgments

The authors acknowledge all sign language teachers for their help to communicate with deaf students and help them to understand the tasks required. Also, acknowledge all students and their parents for their co-operation.

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