Review of the efficacy and effectiveness of adaptive seating for children with cerebral palsy

Effect of Adaptive Seating Systems on Postural Control and Activity Performance: A Systematic Review

PURPOSE

To systematically review the effectiveness of adaptive seating systems on sitting posture, postural control, and seated activity performance in children with cerebral palsy (CP).

SUMMARY OF KEY POINTS

From 5 databases, 3 of 21 (14%) articles were of good quality based on the Downs and Black checklist. Commercial modular contoured seating and paper-based low-cost, and contoured foam seating were effective at improving sitting posture, postural control, and seated activity performance. Parents and service providers reported that seating systems reduced stress, burden and psychosocial well-being, and quality of life in children with CP.

CONCLUSION

Limited evidence demonstrated that adaptive seating systems were effective at improving sitting ability and postural control. Randomized controlled trials with objective outcome measures of seating performance in children with CP are needed to evaluate effectiveness.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Adaptive seating devices are preferred by parents and therapists for children with CP; however, objective measures of seating outcomes are needed.

The clinical effectiveness of custom-contoured seating for wheelchair users with neuromuscular disorders: a scoping review

Despite its widespread use, the clinical effectiveness of custom-contoured wheelchair seating for individuals with neuromuscular disorders remains unclear. A scoping review was conducted using PubMed, Scopus, and Web of Knowledge databases in November 2021 and updated April 2022. A total of 17 full text articles were included. Discussion themes were grouped based on three outcomes of interest: (1) posture and musculoskeletal deformity, (2) quantitative measures of body structures and functions, and (3) qualitative perceptions, opinions, and quality of life indicators. This review highlighted the lack of literature exploring the impact of custom-contoured seating on cardiopulmonary function, pressure injury management, and upper limb function; although, there was no indication that risk is increased compared to alternative seating and it performed well in terms of perceived user satisfaction, comfort, and function. The findings also demonstrated immediate benefits to postural alignment, although, the longitudinal effect on progression of musculoskeletal deformity compared to alternative seating is more ambiguous. This review aimed to scope the evidence-base for custom-contoured seating for wheelchair users with neuromuscular disorders to synthesize information from the existing literature, inform current practice, and identify knowledge gaps for further experimental investigation.

Wheelchair appropriateness in children with cerebral palsy: A single center experience

BACKGROUND

Although wheelchair appropriateness has been studied in general wheelchair users and spinal cord injury patients, it has not been studied in children with cerebral palsy yet.

OBJECTIVE

To describe the wheelchair appropriateness in children with cerebral palsy.

MATERIALS AND METHODS

Thirty children with cerebral palsy were included. Demographical and clinical features of the children were noted. All wheelchair parts were evaluated by the same rehabilitation physician who has attended a wheelchair-training course. Overall, the wheelchair was accepted as inappropriate if at least three parts were inappropriate.

RESULTS

There were 30 children (15 M, 15 F) with a mean age of 10.8 ± 3.5 years. Seat depth (n= 21, 70%), cushion (n= 17, 56.7%), seat height (n= 16, 53.3%), and footrest (n= 16, 53.3%) were the most common inappropriate parts. Overall, 24 (80%) of the children use inappropriate wheelchair. Two (6.7%) children obtained wheelchairs by prescription, 28 (93.3%) obtained without prescription. Twenty-nine wheelchairs were manual and one wheelchair was motorized. Among 30 children, five (16.7%) experienced at least one wheelchair-related fall.

CONCLUSION

In the light of our results, 80% of the children with cerebral palsy seem to use inappropriate wheelchair. Individually designed wheelchairs should be maintained for these children.

Occupational therapy for children with cerebral palsy: a systematic review

Objective: Occupational therapy (OT) for cerebral palsy focuses on the development of skills necessary for the performance of activities of daily living. The aim of this systematic review was to determine whether OT interventions improve outcome for children with cerebral palsy (CP).

Methods: An extensive search in MEDLINE, CINAHL, EMBASE, AMED and SCISEARCH was performed. Studies with controlled and uncontrolled designs were included. Six intervention categories were distinguished and individually analysed using a best-evidence synthesis. This synthesis is based on the type of design, the methodological quality, the type of outcome measures and the statistical significance of the findings.

Results: Seventeen studies were included in this review, seven of which were randomized controlled trials (RCTs). One RCT had a high methodological quality. The analyses resulted in insufficient evidence of the efficacy of occupational therapy in all intervention categories, due to the low methodological quality of studies presenting statistically nonsignificant results.

Conclusion: Despite the reasonable number of studies identified, the inconclusive findings regarding the efficacy of occupational therapy for children with cerebral palsy may be a reflection of the difficulties in efficacy research in OT for children with CP. Future research should critically reflect on methodological issues.

An Exploration of Comfort and Discomfort Amongst Children and Young People with Intellectual Disabilities Who Depend on Postural Management Equipment

BACKGROUND

The natural response to the intrusive bodily sensation is positional change. This study explored how children and young people (CYP) with intellectual disabilities had their comfort needs met when using adaptive positioning equipment.

METHODS

Thirteen qualitative case studies were undertaken. A parent, a teacher/key worker and a therapist for each CYP were interviewed, and daily routines were observed, with selective video recording. Single case and cross case analyses were undertaken.

RESULTS

Attentive caregivers read the behavioural expressions of the CYP and responded reassuringly, safeguarding them from discomforting experiences. Threats to comfort include the restrictive nature of some equipment accessories, positioning errors and procedural stretching.

CONCLUSIONS

The same item of equipment can be both comfortable and uncomfortable. Given the social and interactional world in which the CYP live and learn, it is others who must accept responsibility for ensuring their optimal level of comfort.

The Client-Centred Evidence-Based Practice of Occupational Therapy

Evidence-based practice has its roots in evidence-based medicine. This term refers to the formulation of treatment decision using the best available research evidence. While the concept has gained increased attention among health care workers in the recent past, practice based on scientific evidence has been recommended for over 300 years. However, all health-related professions continue to report difficulties adopting evidence-based practice. Notably, practitioners are often concerned that results of population-based research may not be relevant for their specific patients.

This may be of particular concern for occupational therapists who aim to provide client-centred intervention, taking into consideration individual characteristics of the client, the environment and the occupation. As well, those wishing to practice evidence-based occupational therapy must determine which decisions are made during the course of therapy and what evidence may impact on these decisions. The Occupational Performance Process Model (Fearing, Law & Clark, 1997) outlines the occupational therapy problem solving process and assists therapists to integrate knowledge from both client and therapist. A framework for evidence-based occupational therapy is presented, based on this model.

Adaptive seating systems in children with severe cerebral palsy across International Classification of Functioning, Disability and Health for Children and Youth version domains: a systematic review

AIM

The aim of this study was to systematically review the effect of adaptive seating systems (AdSSs) in young people less than 19 years of age with severe cerebral palsy (CP), with particular focus on child-related outcomes across all components of the functioning and disability domains of the International Classification of Functioning, Disability, and Health for Children and Youth version (ICF-CY).

METHOD

Literature searches of studies published from 1975 to October 2014 were performed. Methodological quality and the risk of bias were analysed using Sackett's level of evidence, the American Academy for Cerebral Palsy and Developmental Medicine guidelines, and Mallen criteria for observational studies.

RESULTS

Nine studies fulfilled the selection criteria. All studies had level IV evidence and were of moderate methodological quality. The results focused on the effects of AdSSs on postural control and on upper extremity function and on additional child-related outcomes. The results suggested that AdSSs that include trunk and hip support devices may improve postural control outcomes, and that special-purpose AdSSs may improve self-care and play behaviour at home.

INTERPRETATION

Because of a low level of evidence and the moderate methodological quality of the studies available, no robust conclusions can be drawn. Nevertheless, the data suggest that AdSSs may be able to improve activity and participation at home among children with severe CP. More studies of high methodological quality addressing the effect of AdSSs on activity and participation are urgently needed. Suggestions for future research are provided.

Two Seating Systems' Effects on an Adolescent With Cerebral Palsy and Severe Scoliosis

BACKGROUND AND PURPOSE

To compare physiological functioning, communication switch activation, and response accuracy in a 19-year-old young man with quadriplegic cerebral palsy and neurological scoliosis using 2 seating systems within the school setting.

METHODS

Prospective single-subject alternating treatment design with 2 conditions: baseline phase with standard planar inserts (A1), custom-molded back with original seat (B), and return to baseline (A2). Measures included oxygen saturation (SaO2), heart rate (HR), respiration rate (RR), body temperature (BT), processing time to activate switches, and response accuracy.

RESULTS

SaO2 levels increased from "distressed" to "normal"; variability decreased. HR, RR, and BT fluctuations decreased with the custom-molded back. Processing time decreased with increased variability, affected by subject's motivation; accuracy improved slightly. Reported social approachability and student-initiated communication increased.

CONCLUSIONS

SaO2 increased and HR, RR, and BT fluctuations decreased with a custom-molded back. Graphing data may help determine seating effect with complex clients.

A systematic review of interventions for children with cerebral palsy: state of the evidence

AIM

The aim of this study was to describe systematically the best available intervention evidence for children with cerebral palsy (CP).

METHOD

This study was a systematic review of systematic reviews. The following databases were searched: CINAHL, Cochrane Library, DARE, EMBASE, Google Scholar MEDLINE, OTSeeker, PEDro, PsycBITE, PsycINFO, and speechBITE. Two independent reviewers determined whether studies met the inclusion criteria. These were that (1) the study was a systematic review or the next best available; (2) it was a medical/allied health intervention; and (3) that more than 25% of participants were children with CP. Interventions were coded using the Oxford Levels of Evidence; GRADE; Evidence Alert Traffic Light; and the International Classification of Function, Disability and Health.

RESULTS

Overall, 166 articles met the inclusion criteria (74% systematic reviews) across 64 discrete interventions seeking 131 outcomes. Of the outcomes assessed, 16% (21 out of 131) were graded 'do it' (green go); 58% (76 out of 131) 'probably do it' (yellow measure); 20% (26 out of 131) 'probably do not do it' (yellow measure); and 6% (8 out of 131) 'do not do it' (red stop). Green interventions included anticonvulsants, bimanual training, botulinum toxin, bisphosphonates, casting, constraint-induced movement therapy, context-focused therapy, diazepam, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care, and selective dorsal rhizotomy. Most (70%) evidence for intervention was lower level (yellow) while 6% was ineffective (red).

INTERPRETATION

Evidence supports 15 green light interventions. All yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions should be discontinued since alternatives exist.

Clinical tools that measure sitting posture, seated postural control or functional abilities in children with motor impairments: a systematic review

OBJECTIVE

To identify and critically appraise clinical measurement tools used to assess sitting posture, seated postural control or functional abilities for children with motor impairment who are candidates for seating interventions.

DATA SOURCES

Searches were run in 15 electronic databases along with hand searching. The search included articles published in English to December 2011.

REVIEW METHODS

Key terms included: posture, sitting, sitting posture, seated posture, seated postural control, sitting position, seating, wheelchair(s), outcome and assess(ment). The PRISMA statement was followed with inclusion criteria set a priori. Two reviewers independently screened titles, reviewed abstracts and identified full-text articles that met criteria. Data extraction included tool description and clinical utility. Two quality-rating scales were used to evaluate conduct of the studies and psychometric properties of the tools.

RESULTS

Of the 497 titles found in the search, 29 full-text articles met the inclusion criteria and 19 tools were identified. Tools represented all components of the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY), with emphasis on body structure and function and activity components. Evidence supporting reliability and validity varied, with small sample sizes influencing quality ratings. Evidence of the tools' reliability was more prevalent than evidence of the tools' validity. Only four tools reported on responsiveness, an important consideration for evaluating change. Little information on clinical utility was provided.

CONCLUSION

Although a number of tools are available, evidence supporting their use for seating interventions is limited, as is the evidence supporting the strength of their measurement properties. Few tools address participation, environmental factors or the child's and family's perspective.

Functional Seating for School-Age Children With Cerebral Palsy: An Evidence-Based Tutorial

Purpose

This tutorial is designed to teach speech-language pathologists (SLPs) best practices to support functional seating of children with cerebral palsy (CP) in the classroom and in school-based therapy sessions. This tutorial teaches SLPs to (a) recognize the positive effects of seating intervention, (b) identify the characteristics of functional seating that may produce these positive effects, and (c) realize their role in supporting functional seating for school-age children with CP.

Method

The research reporting positive effects of seating intervention for school-age children with CP is presented according to the International Classification of Functioning, Disability and Health (World Health Organization, 2001). Recommended guidelines for functional seating for school-age children with CP are gleaned from the research evidence. The specific role of the SLP in providing functional seating for children with CP is then discussed.

Conclusion

Seating intervention may produce positive body structure and function, activities, and participation effects for school-age children with CP when appropriate equipment is provided for weight bearing, the pelvis is positioned for stability and mobility, and the body is properly aligned. SLPs can support functional seating for school-age children with CP by communicating with professionals with seating expertise and by invoking and monitoring recommended guidelines for children with basic and complex seating needs, respectively.

The use and impact of assistive devices and other environmental modifications on everyday activities and care in young children with cerebral palsy

PURPOSE

The study describes use of assistive devices and other environmental modifications, and their impact on everyday activities and care in young children with cerebral palsy (CP).

METHOD

Ninety-five children (55 boys, 40 girls; mean age 58 months, SD 18 months) and their parents were studied using a cross-sectional design. The Pediatric Evaluation of Disability Inventory (PEDI) was applied to assess daily activities using the three measurement scales: functional skills, caregiver assistance, and modifications of the environment. Use of modifications was described related to the five severity levels of the Gross Motor Function Classifications System (GMFCS). Impact was rated on the Caregiver Assistance scale of the PEDI and on a five-point Likert scale.

RESULTS

Out of the 1075 provided environmental modifications, 980 were in regular use to support mobility, self-care and social function among 84 children. The number increased with GMFCS levels; children at levels IV and V used 80% of the modifications, with large variations between the children at same level. Adaptations of housing and transportation facilitated effective use of assistive devices. Half of the parents rated the modifications to have moderate to very large effect on the child's mobility, 25% on self-care skills, and 20% on social function. Furthermore, 65% reported that the modifications lightened the caregiving for mobility, 75% for self-care and 25% for social function. Functional independence and care demands often benefited from different types of modifications.

CONCLUSION

The variations in use and benefits of environmental modifications indicate need of comprehensive assistive technology assessments, including child factors, family factors, technology factors and service system factors.

Effectiveness of adaptive seating on sitting posture and postural control in children with cerebral palsy

PURPOSE

We reviewed research on the effect of adaptive seating on sitting posture/postural control in children with cerebral palsy. Second, we examined whether changes in postural control related to changes in other aspects of functioning.

METHODS

Electronic database/hand searches were undertaken to locate studies published in English. Reviewers screened studies for inclusion criteria, extracted data, indexed outcomes to the International Classification of Functioning, Disability and Health, assigned levels of evidence, and assessed study quality.

RESULTS

Thirteen of 14 articles used group designs and the other a single-subject design. Conflicting findings were reported for saddle seats and optimal seat/back angle for improving sitting posture/postural control. Significant improvements were reported with seat inserts, external supports, and modular seating systems. Evidence supporting effects of postural control on functional abilities was limited.

CONCLUSIONS

Future studies on the effects of adaptive seating should describe participants with standardized classification systems and employ stronger research designs.

Community-Based Performance of a Pelvic Stabilization Device for Children With Spasticity

We developed a new type of pelvic stabilization device designed to help children be better positioned in their wheelchairs. The device replaces a wheelchair lap belt by providing firm anterior pelvic support for the seated user. We developed, tested, and evaluated instructions for installing, fitting, and using the device to study its performance in "typical" community settings in Toronto, Canada. Each of four therapists worked with a local rehabilitation technology supplier to install and fit the device onto an adaptive wheelchair seating system for a young child between 5 and 10 years of age. Therapists assessed the system's positioning effects, and children used the system for 12-14 days. Following the trials, therapists, parents, and children reported their levels of satisfaction with the performance of the device as compared with the children's existing lap belts. Participating therapists confirmed that the device provided better anterior pelvic stability for their clients. Parents felt that their children were generally better positioned in their seats and thought that the device was easy to use. Children had similar perspectives. Suppliers were confident that they could readily install the devices following the instructions provided. Based on the opinions of participants and our inspection of the installed devices, we proposed that minor modifications be made to the product design and instructions for installation, fitting, and use.

Critical Review of the Research Literature of Seating Interventions: A Focus on Adults with Mobility Impairments

An expanding area in rehabilitation practice is the prescription of seating interventions for clients with mobility impairments. The goal of this intervention is to enhance comfort and functional performance. The purpose of this paper is to review the body of knowledge from the research literature concerning the effectiveness or impact of seating interventions for adults who have mobility impairments. In this review both the scope and the gaps in the literature are defined to identify areas for future research. Specifically, this review was undertaken to identify what outcomes have been examined and what methods have been used in carrying out the research studies. A content analysis based on the conceptual framework of the modified International Classification of Impairment, Disability, and Handicap (ICIDH) and review guidelines for evaluating the quality of research studies has been helpful in informing future research design in this area. The results of the 16 studies that comprised this review indicate that the majority of research conducted thus far has numerous methodological limitations, which in turn limits the extent to which this body of research can be drawn upon to provide evidence for effectiveness in seating interventions. There was an emphasis on constructs at the impairment level and inadequate attention to functional and psychosocial issues. Recommendations regarding future research required to support this specific type of intervention are presented. This research review is an important first step in facilitating discussion among researchers, clinicians, research funders, and seating device users regarding future priorities for research and development in this practice area.

Effects of a wheelchair-mounted rigid pelvic stabilizer on caregiver assistance for children with cerebral palsy

A within-subjects repeated measures (A1, B, A2) design was used to study the impact of a rigid pelvic stabilizer (RPS) compared with a traditional lap belt on the caregiver assistance requirements of six children with cerebral palsy as they completed functional tasks from their wheelchair seating system. Study participants wore a lap belt during the 3-week baseline phases (A1 and A2). The RPS was used during the 5-week intervention phase (B). At baseline, each child and parent identified five bimanual or reaching tasks with which the child had difficulty. Using a six-point scale, each parent (caregiver) rated the degree of assistance the child required to do each task. Parents also maintained a log, recording how many times the child was repositioned daily. The RPS appeared to impact directly on reducing caregiver assistance for 30% of the tasks, as the need for assistance was less during phase B when the RPS was used and was greater during phases A1 and A2 when the lap belt was worn. Five children required repositioning less often during phase B than during the A phases. The RPS reduced the child's need for caregiver assistance for some bimanual and reaching tasks as well as for repositioning.