efectos de la adecuación postural en eess

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The Effect of Positioningfor Children with Cerebral Palsyon Upper-Extremity Function:

A Review of the EvidenceCarrie Stavness

ABSTRACT. Context . Controversy exists about the most appropriateseating position for children with cerebral palsy (CP) to promote energyconservation and maximize upper-extremity function.

Evidence Acquisition . Sixteen journal articles published after 1980were identified by searching allied health, medical, and occupationaland physical therapy data bases and evidence-based medicine reviewsusing specific key terms (positioning, wheelchair, postural control, pos-ture, adaptive seating devices, patient positioning, cerebral palsy, move-ment disorders, upper extremity, reaching, grasping, and occupationaltherapy) and reviewing bibliographies of retrieved articles.

Evidence Synthesis. The majority of the evidence supports the posi-tive effects of a neutral to slightly forward orientation (whole chairtilted) on upper-extremity function. Only one study did not demonstrate

CarrieStavness is Research Assistant for CanChild in the area of transition to adult-hood foryouth with disabilities and an Occupational Therapist at Hamilton Health Sci-ences in the Complex Medicine Rehabilitation Unit. She is a 2004 graduate of the MSProgram in Occupational Therapy at McMaster University. She received an HonoursBachelor of Science in Kinesiology from the University of Waterloo in 1995.

Address correspondence to: Carrie Stavness (E-mail: [email protected]).The author would like to acknowledge Jackie Bosch who is an Assistant Clinical

Professor at McMaster University and a Research Associate at the Population HealthResearch Institute for her extensive support, encouragement, and input throughout thecompletion of this review paper. This review paper began as a second-year occupa-tional therapy student project at McMaster University where one of the requirementswas to critically appraise and present the evidence on a controversial topic

Physical & Occupational Therapy in Pediatrics, Vol. 26(3) 2006Available online at http://potp.haworthpress.com

2006 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J006v26n03_04 39
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such effects. Of the supporting studies, one suggested the addition of anabduction orthrosis (AO), one recommended the entire functional sittingposition (FSP) package (this orientation plus a hip-belt, footrests, AO,and cutout tray), and one established the long-term effects of the FSP.One less rigorous study opposed the addition of an AO. With the excep-tion of one study, most of the evidence states that seat angle does not af-fect functional abilities. However, some of these studies contain faultymethodology and/or their results demonstrate clinical significance.

Conclusion . Evidence supports that children with CP should be fittedfor wheelchairs that place them in a FSP, which includes; orientation inspace of 0 -15 , a hip-belt, an AO, footrests, and a cutout tray, with theaddition of a sloped forward seat of 0 -15 , to improve upper-extremityfunction. The exact seat angle and orientation in space within the 0 -15

range should be determined on an individual basis. [Article copies avail-able for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH.

E-mail address: Website: < http://www. HaworthPress.com> 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Cerebral palsy, seating, functional abilities

INTRODUCTION

Cerebral palsy (CP) is characterized by impaired voluntary move-ment, such as spasticity and ataxia and involuntary movements, both re-sulting from prenatal malformation and perinatalor postnatal damage tothe central nervous system (Case-Smith, 2001; Levih, 1982). As such, itis a non-progressive disease (Levih, 1982). Its prevalence has remainedstable (1.4-2.4 cases per 1000 births) over the last 30 years. Advances inmedicine have reduced complications during birth; however, these pos-itive impacts have been offset by the increased survival rate of prema-ture, low birth weight infants (Case-Smith, 2001). In the United States,approximately 8,000 infants and 1,200-1,500 preschool children are di-agnosed with CP every year (United Cerebral Palsy Research and Edu-cational Foundation, 2001).

Children with CP usually experience spasticity of the upper and lowerlimbs, hypotonus of the trunk, and persisting tonic reflexes. Typicallytheir shoulders and arms are flexed, their legs are extended with tighthamstrings, their pelvis is tilted backwards, their knees are extended,their hips are adducted and internally rotated, and their feet are plantarflexed (Myhr & Wendt, 1990, 1993). Because of the lower extremity ex-

40 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS
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tension pattern, children with CP sit on their sacrums rather than ischialtuberosities (Reid, 1996). To avoid falling backwards, they move theircentre of gravity forward by flexing their spinal column (Reid, 1996) and,because their trunk muscles have low tone, gravity pulls them into ex-treme forward flexion (Myhr & Wendt, 1991; Stewart & McQuilton,1987). Often children with CP lack righting and equilibrium reactions andcannot return themselves to an upright position (Myhr & Wendt, 1991).

Usually children with CP are reclined in their chairs and secured withsupports and straps to counter this adaptive positioning (Myhr & Wendt,1990, 1991, 1993; Nwaobi, 1987; Stewart & McQuilton, 1987). Myhrand Wendt (1991) and Myhr, Wendt, Norrlin, and Radell (1995) deter-mined that the majority of their subjects in studies that examined the

current seating practices for children with CP (19 of 23; 7 of 10) were ina reclined position. In this position, children must overcome gravity toraise their head and arms to see their environment and to reach andgrasp objects (Myhr & Wendt, 1990). Further, an asymmetrical tonicneck reflex may result if their head touches the head support as they tryto raise and turn their head (Myhr & Wendt, 1991). The children findthese efforts exhausting and overwhelming, leaving little energy forfunctional activities (Miedaner & Finuf, 1993; Myhr & Wendt, 1990;Stewart & McQuilton, 1987). Further, this position does not promotecoordinated hand-eye movements (Myhr & Wendt, 1990). Children areoften left in these reclined positions because they appear comfortableand relaxed; however, this does not promote the performance of func-tional activities, such as reaching and grasping to operate a communica-tion device (Nwaobi, 1987).

Although data indicate that a reclined position is not functionally opti-mal for children with CP who require seating, controversy exists aboutthe most appropriate seating position. Therefore, the following review fo-cuses on determining the most appropriate sitting position for childrenwith CP to promote energy conservation and optimal functional abilities.

REVIEW OF METHODOLOGY

Search Criteria

Key search terms included positioning, wheelchair, postural control,posture, adaptive seating devices, patient positioning, cerebral palsy,movement disorders, upper extremity, reaching, grasping, and occupa-tional therapy. Published journal articles involving experimental trials or

Carrie Stavness 41


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Miedaner & Finuf, 1993; Noronha, Bundy, & Groll, 1989) (see Table 1);two studies examined whether an anteriorly tilted pelvis achieved througha functional sitting position (FSP) improved upper extremity function(Myhr & Wendt, 1991; Myhr et al., 1995) (see Table 2); five studiesexamined the effect of seat angle on upper-extremity function (McClena-ghan, Thombs, & Milner, 1992; McPherson et al., 1991; Nwaobi, Hob-son, & Trefler, 1986; Reid, 1996; Seeger et al., 1984) (see Table 3); andfive studies evaluated the effect of body orientation (whole chair tilted15 to 30 ) on upper extremity function (Milner et al., 1991; Myhr &Wendt, 1993; Nwaobi, 1987; Pope, Bowes, & Booth, 1994) (see Table4). Two of the previously mentioned studies as well as one other ad-dressed whether an abduction orthosis (AO) (Myhr & Wendt, 1993; Ek-

blom & Myhr, 2002) or a tray (Myhr & Wendt, 1991) affected upperextremity function (see Table 5).

DISCUSSION

Neutral Pelvis Positioning

A majority of the studies are consistent regarding the positive effectof neutral positioning on functional abilities. Only one study (Noronhaet al., 1989) did not show such an effect. In this study, total scores re-vealed no difference between neutral (supported in standing frame) andposterior pelvic (unsupported sitting) positioning in reaching and grasp-ing ability and subtest scores revealed mixed results, that is, subjectswith neutral pelvic positioning took a shorter time to feed themselves,but a longer time to grasp small objects. These findings may have beendue to an inappropriate outcome measure as the distance to the tabletopwas less for sitting then for standing. As such, subjects could supporttheir elbows and forearms on the tabletop, while seated to reach andgrasp cards, checkers, and small, light, and heavy objects and, thus, mayhave augmented posterior pelvic positioning data. As simulated feedingis more of an up/down movement, external upper-extremity supportwould not be beneficial and, perhaps, the true effect of neutral pelvicpositioning could be seen in this subtest.

As only one of the studies used an experimental design, further ex-perimental studies are needed to confirm that neutral positioning has apositive effect on functional abilities. However, the consistent positiveeffects on upper-extremity function with no evidence to suggest harmsupports a neutral pelvic position.

Carrie Stavness 43


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T A B L E 1

. E f f e c t o f N e u t r a l P e l v i s P o s i t i o n i n g

o n F u n c t i o n

R e f e r e n c e

P u r p o s e

S a m p l e

M e a s u r e s

R e s e a r c h D e s i g n

R e s u l t s

M i e d a n e r a n d

F i n u f

, 1 9 9 3

E v a l u a t e r e l a t i o n s h i p

b e t w e e n u n s u p p o r t e d

s i t t i n g v e r s u s f i t t e d

w i t h w h e e l c h a i r a n d

r e a c h i n g / g r a s p i n g

C h i l d r e n w i t h

m i l d

t o s e v e r e

C P ( n =

1 2 )

C o g n i t i v e t e s t s

w i t h r e a c h / g r a s p

i t e m s

R a n d o m i z e d c r o s s

o v e r d e s i g n

G r o u p A =

F i t t e d t o

U n s u p p o r t e d

G r o u p B =

F i t t e d t o

U n s u p p o r t e d

S i g n i f i c a n t i m p r o v e m e n t i n

r e a c h / g r a s p w h e n s e a t e d

i n f i t t e d w h e e l c h a i r

( G r o u p A :

M =

1 . 5 , S D

2 . 0 7 ;

G r o u p B :

M =

5 . 2 , S D

4 . 0 2 ;

t = 3 . 6 1 ;

p 0 . 0 5 )

H u l m e

e t a l

. , 1 9 9 7

E v a l u a t e w h e t h e r

A S D s a i m p r o v e d

h e a d c o n t r o l , s i t t i n g

p o s t u r e , v i s u a l

t r a c k i n g

, r e a c h i n g ,

a n d g r a s p i n g

C h i l d r e n w i t h

C P a n d m u l t i p l e

h a n d i c a p s

( n =

1 9 ) w h o

r e q u i r e s e a t i n g

D i r e c t o b s e r v a t i o n

a n d u s i n g a s c o r i n g

s y s t e m d e v e l o p e d

a n d v a l i d a t e d b y

t h e a u t h o r s

L o n g i t u d i n a l b e f o r e

a n d a f t e r

S i g n i f i c a n t d i f f e r e n c e

b e -

t w e e n o r i g i n a l s e a t i n g p o s i -

t i o n a n d A S D s f o r s i t t i n g

p o s t u r e ( F =

3 4 . 7

; d f = 1 ,

2 0 ;

p

0 . 0 1 ) , h e a d

c o n -

t r o l ( F =

9 . 7 ;

d f =

1 , 2 0 ; p

0 . 0 1 ) , a n d g r a s p i n g ( F =

8 . 4 ; d f =

1 , 2 0 ; p

0 . 0 1 )

N o s i g n i f i c a n t d i f f e r e n c e

f o r v i s u a l t r a c k i n g a n d

r e a c h i n g

C l i n i c a l m e a n i n g f u l n e s s a s

3 7 % m o r e s u b j e c t s c o m -

p l e t e d r e a c h i n g t a s k s a t

f i n a l e v a l u a t i o n

C o l b e r t

e t a l

. , 1 9 8 6

S t u d y t h e l o n g -

t e r m e f f e c t s o f t h e

D E S E M O b o n

u p p e r e x t r e m i t y

f u n c t i o n

C h i l d r e n w i t h C P

w i t h s e v e r e m o t o r

i m p a i r m e n t s

( n =

1 2 )

Q u e s t i o n n a i r e c o m -

p l e t e d b y c h i l d r e n s

p a r e n t s , t h e r a p i s t s

,

a n d e q u i p m e n t

d e s i g n e r s

B e f o r e a n d A f t e r

I m p r o v e d u p p e r e x t r e m i t y

f u n c t i o n ( 8 / 1 0 c h i l d r e n

b r o u g h t h a n d s t o m i d l i n e

a n d o p e r a t e d a j o y s t i c k a t

f i n a l e v a l u a t i o n )

U n a b l e t o o b t a i n t w o

f i n a l

q u e s t i o n n a i r e s

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N o r o n h a e t a l .

( 1 9 8 9 )

D e t e r m i n e w h e t h e r

a p r o n e s t a n d e r c

v e r s u s a n o r m a l c h a i r

i m p r o v e d r e a c h i n g

a n d g r a s p i n g a b i l i t i e s


( n =

1 0 )

O v e r a l l t i m e ( i n s e c o n d s )

t o t u r n c a r d s , m a n i p u l a t e

s m a l l , l i g h t , a n d h e a v y

o b j e c t s , c o m p l e t e s i m u -

l a t e d f e e d i n g t a s k

, a n d

p l a c e c h e c k e r s

R a n d o m i z e d

,

C r o s s O v e r ,

R e p e a t e d

M e a s u r e D e s i g n

M e a n t o t a l s c o r e s :

n o s i g n i f i c a n t d i f f e r e n c e

b e t w e e n g r o u p s

( s i t t i n g : 7 9

. 3 2

, 6 7

. 0 4 ;

s t a n d i n g : 7 9

. 7 2

, 6 4 . 0 3 ; F =

0 . 0

3 ; p =

0 . 8

7 )

M e a n i n d i v i d u a l s c o r e s :

s i g n i f i c a n t d i f f e r e n c e

b e t w e e n g r o u p s f o r f e e d i n g

( s i t t i n g : 2 8

. 3 5

,

s t a n d i n g : 2 1

. 0 2 ;

T =

1 1 ; p 0

. 0 0 0 4 ) a n d

r e a c h i n g / h a n d l i n g s m

a l l

o b j e c t s ( s i t t i n g : 1 1 . 5 4

,

s t a n d i n g : 1 8

. 4 5 ; T = 5 5 ;

p 0

. 0 3 )

N o t e

. A S D s =

A d a p t i v e S i t t i n g D e v i c e s .

a A S D s m a i n t a i n h i p s , k n e e s , a n d a n k l e s i n a n o p t i m a l p o s i t i o n ( 9 0 ) a n d h e a d i n m i d l i n e

.

b D E S E M O i s a c u s t o m - m o l d e d s e a t i n g s y s t e m w h i c h p r o v i d e s a n e u t r a l p e l v i s p o s i t i o n

.

c A p r o n e s t a n d e r s u p p o r t s t h e p e l v i s i n a n e u t r a l p o s

i t i o n a n d p r e v e n t s t h e p e l v i s f r o m r o t a t i n g p o s t e r i o r l y .

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T A B L E 2 . E f f e c t o f A n t e r i o r P e l v i c T i l t o n F u n c t i o n

R e f e r e n c e

P u r p o s e

S a m p l e

M e a s u r e s


R e s u l t s

M y h r a n d

W e n d t ,

1 9 9 1

C o m p a r e h e a d , t

r u n k ,

a n d f o o t c o n t r o l , a n d

a r m a n d h a n d f u n c t i o n

b e t w e e n F S P a ,

o r i g i n a l s i t t i n g p o s i t i o n ,

a n d e x p e r i m e n t a l p o s i t i o n s

( t r a y a n d / o r A O )

C h i l d r e n a n d

a d o l e s c e n t s w i t h

C P a n d d y s t o n i c

s y n d r o m e

( N = 2 3 )

S A S b t o r a n k s u b j e c t s

a s t h e y r e a c h e d o u t

t o g r a s p , h o l d a n d

r e l e a s e a f a m i l i a r t o y

C r o s s - s e c t i o n a l S u r v e y

S i g n i f i c a n t d i f f e r e n c e

b e t w e e n F S P a t o t a l m e a n

s c o r e a n d t h o s e o f a l l

o t h e r p o s i t i o n s ( F S P a : 1 4 ;

o r i g i n a l : 8 ; o r i g i n a l p l u s

t r a y : 9 , F

S P a m i n u s t r a y

a n d A O : 1 1 ; o r i g i n a l p l u s

A O : 8 ; F S P a m i n u s

t a b l e :

1 2 ; p 0 . 0 0 1 )

C l i n i c a l m e a n i n g f u l n e s s

s i n c e a o n e p o i n t c h a n g e

o n s c a l e i n d i c a t e s a l a r g e

f u n c t i o n a l g a i n c

M y h r e t a l . ,

1 9 9 5

E x a m i n e d t h e l o n g -

t e r m e f f e c t s o f t h e F S P a

o n h e a d , t

r u n k , a

n d f o o t

c o n t r o l a n d a r m a n d h a n d

f u n c t i o n

C h i l d r e n w i t h s l i g h t

t o s e v e r e C P

( n = 1 0 )

S A S b t o r a n k s u b j e c t s

a s t h e y l e a n e d

f o r w a r d t o t o u c h ,

m a n i p u l a t e , a n d r e l e a s e

f a m i l i a r o b j e c t s a n d t o y s

B e f o r e a n d A f t e r

S i g n i f i c a n t d i f f e r e n c e s

b e t w e e n b a s e l i n e a n d b o t h

p o s t F S P a a n d f i v e y e a r

f o l l o w - u p t o t a l s c o r e s ( 1 1 0

,

1 3 2 , a n d 1 4 5 ; p 0 . 0 0 1 )

T w o s u b j e c t s w h o d i d n o t

c o n t i n u e t o u s e t h e

F S P a

d e m o n s t r a t e d a s i g n i f i c a n t

d e c l i n e i n t o t a l s c o r e ( 1 9 ,

3 1 , a

n d 1 7 ; p 0 . 0 0 1 )

N o t e

. F S P = f u n c t i o n a l s i t t i n g p o s i t i o n ; A O s = a b d u c t i o n o r t h o s i s ; S A S = S i t t i n g A s s e s s m e n t S c a l e

.

a A

F S P i n c l u d e s o r i e n t a t i o n i n s p a c e o f 0 - 1 5

d e g r e e s , a h i p b e l t , a n a b d u c t i o n o r t h o s i s

, f o o t r e s t s , a n d a c u t o u t t r a y .

b S A S i s a f o u r - p o i n t r a t i n g s c a l e d e s i g n e d a n d v a l i d a t e d b y a u t h o r s t o e v a l u a t e h e a d , t

r u n k a n d f o o t c o n t r o l a n d a r m a n d h a n d f u n c t i o n b e f o r e a n d a f t e r s e a t i n g i n t e r v e n t i o n s .

c T h e f o l l o w i n g i s a n e x a m p l e o f o n e s u b - s c a l e o f t h e S A S : 1 = U n a b l e t o c o n t r o l a r m s b y w i l l ; 2 = U s e s a r m s f o r s u p p o r t , b u t e a s i l y l o s e s c o n t r o l ; s t r e t c h e s a r m s t o w a r d o b j e c t s

b u t i n u n c o n t r o l l e d m o v e m e n t s ; 3 = U s e s o n e a r m f o r s u p p o r t a n d s t r e t c h e s o t h e r t o w a r d o b j e c t s i n t e n t i o n a l l y ; 4

= U s e o n e o r b o t h a r m s f o r s u p p o r t , s t r e t c h e s a r m s t o w a r d o b -

j e c t s i n t e n t i o n a l l y o r u s e s a r m s f o r f u n c t i o n a l m o v e m e n t s .

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T A B L E 3

. E f f e c t o f S e a t A n g l e o n F u n c t i o n

R e f e r e n c e

P u r p o s e

S

a m p l e

M e a s u r e s


R e s u l t s

M c C l e n a g h a n

e t a l . , 1 9 9 2

S t u d y t h e r e l a t i o n -

s h i p b e t w e e n s e a t

a n g l e ( 0

,

5

,

a n d

5 ) a n d f u n c t i o n a l

u s e

o f u p p e r e x t r e m i t y

C

h i l d r e n a n d a d o l e s -

c e n t s w i t h m i l d t o

m

o d e r a t e C P

( n =

1 0 )

T i m e a n d a c c u r a c y

t o c o m p l e t e u p p e r

m o t o r t a s k s

P r o s p e c t i v e C a s e

C o n t r o l S t u d y

S e a t a n g l e d o e s

n o t

a f f e c t u p p e r e x t r e m i t y

m o t o r p e r f o r m a n

c e

M c P h e r s o n

e t a l . , 1 9 9 1

D e t e r m i n e w h e t h e r

s e a t a n g l e ( 0

, 1 5

,

a n d

1 5 ) a l t e r e d

u p p e r e x t r e m i t y f u n c -

t i o n

A

d o l e s c e n t s w i t h

m

i l d t o m o d e r a t e C P

( n =

1 0 )

N o

. o f m o v e m e n t

s e g m e n t s t o c o m -

p l e t e r e a c h i n g t a s k

Q u a s i - E x p e r i m e n t a l

D e s i g n w i t h r a n d o m

a s s i g n m e n t t o p o s i t i o n

a n d r e p e a t e d m e a s u r e s

N o s i g n i f i c a n t d i f f e r -

e n c e i n q u a l i t y o f a r m

m o v e m e n t s d u e

t o

p o s i t i o n ( H =

1 . 5 7

,

p 0

. 0 5 )

C l i n i c a l m e a n i n g f u l -

n e s s a s s u b j e c t s

p o s i -

t i o n e d w i t h s e a t a n g l e

o f 0

a n d 1 5

r e a c h e d t a r g e t s i n 1 4

l e s s m o v e m e n t s

R e i d

, 1 9 9 6

E v a l u a t e u p p e r e x -

t r e m i t y m o v e m e n t

c o n t r o l u s i n g t h e

s a d d l e s e a t ( 1 5 )

v e r s u s a f l a t b e n c h

( 0 )

C

h i l d r e n w i t h m i l d

t o m o d e r a t e c e r e b r a l

p

a l s y

T i m e a n d p a t h

l e n g t h t o r e a c h a

t a r g e t

E x p e r i m e n t a l C r o s s

O v e r D e s i g n

N o s i g n i f i c a n t e f f e c t s

w e r e d e t e c t e d ( p =

0 . 1

7 t o 0

. 8 9 )

C l i n i c a l m e a n i n g f u l -

n e s s a s 4 / 6 s u b j e c t s

r e d u c e d r e a c h i n g p a t h

l e n g t h b y 4 t o 2 2

c e n t i m e t e r s a n d

5 / 6

s u b j e c t s r e d u c e d t i m e

t o t o u c h a t a r g e t b y

0 . 0

5 t o 0

. 1 8 s e c o n d s

47


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T A B L E 3 ( c o n t i n u e d )

R e f e r e n c e

P u r p o s e

S a m p l e

M e a s u r e s


R e s u l t s

S e e g e r e t a l . ,

1 9 8 4

I n v e s t i g a t e t h e e f f e c t

o n h a n d f u n c t i o n o f

v a r i a t i o n s i n s e a t

a n g l e ( 0

, 1 0

,

2 0 ,

a n d

3 0 )

C h i l d r e n a n d a d o l e s -

c e n t s w i t h m i l d t o

m o d e r a t e C P ( n =

9 )

T i m e a n d a c c u r a c y

t o u s e a j o y s t i c k t o

m a t c h t a r g e t s


C o n t r o l S t u d y w i t h

r a n d o m a s s i g n m e n t

t o p o s i t i o n s a n d

c a r r y - o v e r e f f e c t s

c o n t r o l l e d f o r

I n c r e a s i n g s e a t a n g l e

h a s n o a f f e c t o n h a n d

f u n c t i o n

N w

a o b i e t a l . ,

1 9 8 6

E v a l u a t e t h e e f f e c t o f

s e a t a n g l e ( 5 0

, 7 0

,

9 0

, a n d 1 1 0 ) o n u p -

p e r e x t r e m i t y f u n c t i o n


( n =

1 0 )

T i m e ( i n s e c o n d s )

t o t o u c h a t r i g g e r

s w i t c h

S i n g l e C a s e D e s i g n

w i t h r a n d o m a s s i g n -

m e n t t o p o s i t i o n s

S i g n i f i c a n t i m p r o

v e -

m e n t i n u p p e r e x t r e m -

i t y p e r f o r m a n c e w i t h

s e a t a n g l e o f 9 0

( 1 . 0

6 ) a n d t h a t

a c h i e v e d i n a l l o t h e r

p o s i t i o n s , 5 0

, 7 0

,

a n d 1 1 0

, ( 1

. 5 2 ,

1 . 5

2 ,

& 1

. 4 8 ; p 0

. 0 5 )

N o t e

. I n a l l s t u d i e s , t h e a n g l e b e t w e e n s e a t a n d b a c k w a s a l t e r e d

. 0 s e a t a n g l e =

9 0 o f h i p - f

l e x i o n .

48


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T A B L E 4

. E f f e c t o f B o d y O r i e n t a t i o n o n F

u n c t i o n

R e f e r e n c e

P u r p o s e

S a m p l e

M e a s u r e s


R e s u l t s

M i l n e r e t a l . ,

1 9 9 1

E v a l u a t e t h e s h o r t a n d

l o n g - t e r m

e f f e c t s o f a n a n t e r i o r

t i p p e d c h a i r - s e a t ( 1 0 )

v e r s u s n o r m a l c h a i r o n

u p p e r e x t r e m i t y f u n c t i o n


( n =

8 )

T i m e t o r e a c h a t a r g e t a n d

r e s p o n s e e f f i c i e n c y

a


C o n t r o l S t u d y

N o s i g n i f i c a n t

i m p r o v e m e n t s i n

m o r e

n e u t r a l p o s i t i o n s

S i g n i f i c a n t

i m p r o v e m e n t s i n

r e s p o n s e e f f i c i e n c y

P o p e e t a l . ,

1 9 9 4

D e t e r m i n e w h e t h e r t h e

S A M

b i m p r o v e d f u n c t i o n


( n =

1 0 )

T i m e t o m a n i p u l a t e b l o c k s

a n d

c o m p l e t e a n o b s t a c l e c o u r s e

o p e r a t i n g a p o w e r w h e e l c h a i r

O b t a i n e d s u b j e c t i v e r e p o r t s

f r o m p a r e n t s a n d t e a c h e r s

L o n g i t u d i n a l S t u d y

N o i m p r o v e m e n t s i n

p e r f o r m a n c e i n t i m e d

b l o c k t a s k s

I m p r o v e d a b i l i t y t o

o p e r a t e a p o w e r

w h e e l c h a i r ( 6 / 9

s u b j e c t s ) a n d c o m p l e t e

f e e d i n g a n d c o m p u t e r

a c t i v i t i e s ( s u b j e c t i v e

d a t a )

N w a o b i ,

1 9 8 7

M e a s u r e u p p e r e x t r e m i t y

f u n c t i o n i n

f o u r d i f f e r e n t s e a t i n g

o r i e n t a t i o n s ( 0

, 1 5

,

1 5

, a n d

3 0 )


( n =

1 3 )

T i m e ( i n s e c o n d s ) t o a c t i v a t e a

s w i t c h

R e p e a t e d M e a s u r e s

C r o s s - S e c t i o n a l S t u d y

w i t h r a n d o m

a s s i g n m e n t t o

p o s i t i o n s

S i g n i f i c a n t d i f f e r e n c e s

b e t w e e n n e u t r a l

p o s i t i o n a n d a l l o

t h e r

p o s i t i o n s ( F =

6 3 . 2

; p

0 . 0

5 ; 0

m e a n s =

3 8

,

3 2

. 8 ; 1 5

m e a n s

= 4 8

. 6 ,

4 4 ;

1 5

m e a n s

= 4 7

. 6 ,

4 4

. 2 ;

3 0

m e a n s =

5 4

. 5 ,

5 3 ) a n d b e t w e e n

b o t h o f t h e 1 5 p o s i t i o n s

a n d t h e 3 0

r e c l i n e d

p o s i t i o n

( p 0

. 0 5 )

N o t e

. I n a l l s t u d i e s t h e w h o l e c h a i r w a s t i l t e d i n s p a c e w i t h n o c h a n g e i n s e a t a n d b a c k a n g l e

. S A M =

S e a t i n g a n d M o b i l i t y D e v i c e

a R e s p o n s e e f f i c i e n c y i s t h e n u m b e r o f m o v e m e n t s i t t a k e s t o r e a c h a t a r g e t .

b T h e S A M s u p p o r t s t h e

t r u n k a n d p e l v i s i n a n a n t e r i o r p o s i t i o n

.

49


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Anterior Pelvic TiltThe findings from both studies were consistent regarding the short-

term positive effects of a FSP on functional abilities. Evidence also existsto support that children with CP benefit most with the entire FSP packagerather than some components, that is, minus tray and/or AO. In the lon-gitudinal study (Myhr et al., 1995), researchers did not account for matu-ration and co-intervention and did not establish a true control group.Consequently, further rigorous experimental studies need to be com-pleted to determine the long-term effects of a FSP on functional abilities.However, the current literature supports the positive immediate effects of a FSP on the upper-extremity function for children with CP.

Seat Angle

Only one study recognized the positive effects of a neutral to slightlyforward seat angle on functional abilities. All other studies identified


TABLE 5. Effect of External Devices on Function

Reference Purpose Sample Measures ResearchDesign

Results

Myhr &Wendt,1993

Monitor leg EMGactivity and theeffects of an AOin different bodyorientations(0 AO; 10 AO; 0 ; 10 ; 10 AO)

Children andadolescentswith CP anddystonictetraplegia(n = 8)

EMG activityas subjectsreached fora toy andgrasped andmoved it

ProspectiveCase ControlStudy

Significantlylower EMG ac-tivity in neutraland forwardpositions withAOs (0 AO; 10 AO)than in neutraland reclinedpositions with-out AOs (0 ;

10

) andreclined posi-tion with AO( 10 AO);p 0 .04

Ekblom &Myhr,2002

Monitor leg EMGactivity and theeffects of a FSP awith versus with-out an AO

Children withCP (n = 4;one outlierexcluded)

EMG activityand SAS bas subjectsreached fora toy andgrasped andmoved it

ProspectiveCase ControlStudy

No significantdifference inEMG activity orupper extremityfunction

Note. FSP = functional sitting position; AOs = abduction orthosis; SAS = Sitting Assessment Scalea A FSPincludesorientationin space of 0 to 15 degrees, a hip belt, an abductionorthosis, footrests, and acutout tray. bSASis a four-point ratingscale designedand validatedby authors to evaluatehead,trunkandfoot control and arm and hand function before and after seating interventions.


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that seat angle does not affect functional abilities. However, some of these studies contain faulty methodology and/or their results did notdemonstrate statistical significance but did demonstrate clinical signifi-cance. In the Reid study (1996), statistical significance may not havebeen reached because of its small sample size as a post hoc analysisrevealed it was grossly under powered. It did, however, along with oneother study (McPherson et al., 1991) demonstrate clinical significancesince a forward seat angle reduced the number of arm movements orpath length required to access a target and, thus, reduced the amount of effort required. Even though further studies need to be completed withlarger sample sizes, evidence supports the positive effects of a neutral toslightly forward seat angle on functional abilities.

Body Orientation

The two identified studies were consistent in their findings that a neu-tral position or slightly forward orientation (whole chair is tilted) hasshort- and long-term positive effects on reaching and grasping effi-ciency. There is some less rigorous evidence to support that this posi-tion also improves reaching and grasping speed.

External Devices

One study supports the positive effects of a neutral to slightly forwardorientation with the addition of an AO. Authors suggested that these posi-tions decreased the amount of energy required to contract lower extremitymusculature to stabilize the body and possibly increase upper-extremityfunction. This finding is supported by the information obtained in theFSP study for anterior pelvic positioning (Myhr & Wendt, 1991). Onestudy opposed the benefits of the addition of an AO; however, its datawas based on a very small sample size and, thus, generalizations cannotbe made. Consequently, evidence supports a neutral to slightly forwardorientation to improve children with CPs upper-extremity function.

CONCLUSION

Evidence supports that an upright position versus a reclined positionimproves a child with CPs upper-extremity function like reaching andpressing to operate a communication device. Children with CP shouldbe fitted for wheelchairs that place them in a FSP, which includes an ori-entation in space of 0 -15 , a hip-belt, an abduction orthosis, footrests,

Carrie Stavness 51


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and a cutout tray, with the addition of a sloped forward seat of 0 -15 .The exact seat angle and orientation in space within the 0 -15 rangeshould be determined on an individual basis. Therapists should ensurethat the line of gravity of the childs trunk, shoulders, and head are ante-rior to his/her ischial tuberosities. In a more upright position, childrenwould not have to waste precious energy to fight against gravity and sta-bilize their trunk. They can use this saved energy to complete tasks,such as accessing a communication device.

DIRECTIONS FOR FUTURE RESEARCH

Evidence is consistent that children with CP should be fitted forwheelchairs that place them in a FSP with an anterior slopped seat of 0-15 to improve functional abilities. However, this conclusion isbased on only a few experimental designs, a plethora of less rigorousstudies, and outdated information (only one recent study exists (Ekblom& Myhr, 2002) suggesting that therapists are just accepting standardpractice without questioning it. Therefore, it is imperative that the find-ings of this review be verified through a more rigorous research design,such as a randomized controlled trail comparing the experimental posi-tion with that of standard practice. Furthermore, all studies reviewedvaried regarding severity of CP (mild to severe). Thus, subjects alsoneed to be stratified according to a classification system.

REFERENCES

Case-Smith, J. (Ed.) (2001). Occupational therapy for children (4th ed.). St. Louis,MO: Mosby.

Colbert, A., Doyle, K., & Webb, W. (1986). DESEMO seats for young children withcerebral palsy. Archives of Physical Medicine and Rehabilitation, 67, 484-486.

Ekbolm, B., & Myhr, U. (2002). Effects of the hip abduction orthosis on muscle activ-ity inchildren with cerebral palsy. Physiotherapy Theory and Practice, 18, 55-63.

Hulme, J., Gallacher, K., Walsh, J., Niesen, S., & Waldron, D. (1987). Behavioral andpostural changes observed with use of adaptive seating by clients with multiplehandicaps. Physical Therapy, 67, 1060-1067.

Levih, S. (Ed.). (1982). Treatment of cerebral palsy and motor delay (2nd Ed.). StLouis, MD: Blackwell Publications.

McClenaghan,B.,Thombs, L.,& Milner, M. (1992). Effects of seat surface inclination

on postural stability and function of the upper extremities of children with cerebralpalsy. Development Medicine and Child Neurology, 34, 40-48.McPherson, J., Schild, R., Spaulding, S., Barsamian, P., Transon, C., & White, S.

(1991). Analysis of upper extremitymovement in four sitting positions: A compari-



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son of persons with and without cerebral palsy. The American Journal of Occupa-tional Therapy, 45, 124-129.

Miedaner, J., & Finuf, L. (1993). Effects of adaptive positioning on psychological testscores for preschool children with cerebral palsy. Pediatric Physical Therapy, 23 ,177-182.

Milner, M., Lotto, W., Koheil, R., Sochaniwskyj, A., Bablich, K., & Reid, D. (1991).Functional and clinical evaluation of the short and long term effects of anteriorlytipped seating in children with cerebral palsy. Journal of Rehabilitation Research &

Development, 28, 469-470.Myhr, U.,& Wendt,L. von (1990). Reducing spasticity and enhancingpostural control

for the creation of a functional sitting position in children with cerebral palsy: A pi-lot study. Physiotherapy Theory and Practice, 63, 65-76.

Myhr, U.,& Wendt,L. von (1991). Improvement of functional sitting position for chil-drenwith cerebralpalsy. Developmental Medicineand Child Neurology, 33, 246-256.

Myhr, U., & Wendt, L. von (1993). Influence of different sitting positions and abduc-tion orthoses on leg muscle activity in children with cerebral palsy. Developmental

Medicine and Child Neurology, 35, 870-880.Myhr, U., Wendt, L. von, Norrlin, S., & Radell, U. (1995). Five-year follow-up of

functionaling position in children withcerebral palsy. Developmental Medicine and Child Neurology, 37, 587-596.

Noronha, J., Bundy, A., & Groll, J. (1989). The effect of positioning on the hand func-tion of boys with cerebral palsy. The American Journal of Occupational Therapy,43, 507-512.

Nwaobi, O. (1987). Seating orientations andsupper extremityfunction in children withcerebral palsy. Physical Therapy, 67, 1209-1212.

Nwaobi, O., Hobson, D., & Trefler, E. (1986). Hip angle and upper-extremity move-ment time of children with cerebral palsy. Developmental Medicine and Child Neu-rology, 28, Suppl 53: 24.

Pope, P., Bowes, C., & Booth, E. (1994). Postural control in sitting the SAM system:Evaluation of the use over three years. Developmental Medicine & Child Neurol-ogy, 36, 241-252.

Reid,D. (1996). The effects of the saddle seat on seated postural control and upper-ex-tremity movement in children with cerebral palsy. Developmental Medicine and Child Neurology, 38, 805-815.

Seeger, B., Caudrey, D., & OMara, N. (1984). Hand function in cerebral palsy: Theeffect of hip flexion angle. Medicine and Child Neurology, 26, 601-606.

Stewart, P., & McQuilton, G. (1987). Straddle seating for the cerebral palsied child. British Journal of Occupational Therapy, 50, 136-138.

United Cerebral Palsy Research and Educational Foundation. (2001, October). Cere -bral PalsyFacts and figures. Retrieved January 29, 2005, from http://www.ucp.org/ucp_generaldoc.cfm/1/9/37/37-37/447.

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