Effect of Segmental Trunk Support on Posture and Reaching in Children With Cerebral Palsy

The relationship between segmental trunk control and gross motor performance in low birth weight born infants

OBJECTIVE

Trunk control is associated with gross motor development. This study examines the relationship between segmental trunk control and gross motor performance in low birth weight (LBW) infants.

METHODS

A total of 42 LBW infants and 43 normal birth weight (NBW) infants aged 3-9 months were sampled for this cross-sectional study. All infants were evaluated one time by the Segmental Assessment Trunk Control (SATCo) and the Alberta Infant Motor Scale (AIMS).

RESULTS

Statistically high and significant correlations were found between gross motor performance and segmental trunk control in all sample populations (r = 0.835; p = .001). No statistically significant difference was found regarding the segmental trunk control between the groups (p = .119). The LBW infants with atypical motor development had poorer trunk control than the LBW infants with typical development (f = 5.480; p = .001).

CONCLUSION

Our results show that LBW infants with atypical motor development had poorer trunk control than LBW infants with typical motor development. It was found that the segmental trunk controls of LBW infants were 0.398 times lower than in NBW infants.

The effects of postural control and upper extremity functional capacity on functional Independence in preschool-age children with spastic cerebral palsy: a path model

PURPOSE

To investigate the effects of postural control and upper extremity functional capacity on functional independence and identify whether quality of upper extremity skills mediates the effects of postural control on functional independence in preschool-age children with spastic cerebral palsy (CP).

METHODS

106 children with CP -mean age 43.4 ± 11.3 (24-71 months)- were included in this cross-sectional study. Postural control, upper extremity functional capacity, and functional independence in activities of daily living were evaluated using the Early Clinical Assessment of Balance (ECAB), Quality of Upper Extremity Skills Test (QUEST), and the Functional Independence Measure of Children (WeeFIM), respectively. A path model was used to evaluate the total, direct, and indirect effects.

RESULTS

According to the path model, ECAB (direct effect; r = 0.391, p < 0.01, indirect effect; r = 0.398) and QUEST (direct effect; r = 0.493, p < 0.01) had an impact on WeeFIM. In addition, QUEST had mediating effects on the relationship between ECAB and WeeFIM. The path model explained 71% of the variation in functional independence of the participants.

CONCLUSION

In the management of CP in preschool-age children, the focus should be on improving not only upper extremity capacity but also postural control to help improve functional independence in activities of daily living.

Motor control and skill acquisition in pediatric physical therapy: an enactive proposal

Theories of motor control and skill acquisition strongly influence and guide various fields of clinical practice. In last decades, changes in theoretical frameworks related to the conceptualization of brain plasticity, functional structures within the child, and environment have led to a revision of therapy approaches progressing from therapist-driven to child-initiated approaches. Even though theoretical frameworks and clinical practice are closely linked to the child's body, the profession has paid less attention to theories concerning the body's role and status in interpersonal relationships when fostering motor control and skill acquisition in children. In this theoretical paper we discuss the theoretical frameworks of motor control and skill acquisition that currently guide clinical practice. Through highlighting valuable contributions of these theories, we explore theoretical and practical benefits pediatric physical therapy can acquire by taking an enactive approach as a means to bring the child as a subject into focus. We rely on enactive concepts of embodiment, autonomy, and participatory sense-making in our exploration to provide an extended understanding of motor control and skill acquisition shaping our beliefs about what counts in therapeutic encounters in pediatric physical therapy.

Improving Trunk Postural Control Facilitates Walking in Children With Cerebral Palsy: A Pilot Study

OBJECTIVE

The aim of this study is to determine the effects of bilateral trunk support during walking on trunk and leg kinematics and neuromuscular responses in children with cerebral palsy.

DESIGN

Fourteen children with spastic cerebral palsy (Gross Motor Function Classification System level I to III) participated in this study. Children walked on a treadmill under four different conditions, that is, without support (Baseline), with bilateral support applied to the upper trunk (upper trunk support), the lower trunk (lower trunk support), and combined upper and lower trunk (combined trunk support). The trunk and leg kinematics and muscle activity were recorded.

RESULTS

Providing bilateral support to the trunk had a significant impact on the displacement of the pelvis and trunk ( P < 0.003) during walking. Children's weaker leg showed greater step length ( P = 0.032) and step height ( P = 0.012) in combined trunk support compared with baseline and greater step length in upper trunk support ( P = 0.02) and combined trunk support ( P = 0.022) compared with lower trunk support. Changes in soleus electromyographic activity during stance phase of gait mirrored the changes in step length across all conditions.

CONCLUSIONS

Providing bilateral upper or combined upper and lower trunk support during walking may induce improvements in gait performance, which may be due to improved pelvis kinematics. Improving trunk postural control may facilitate walking in children with cerebral palsy.

Study protocol for a randomised controlled trial to determine the efficacy of an intensive seated postural intervention delivered with robotic and rigid trunk support systems

INTRODUCTION

Children with cerebral palsy (CP) classified as gross motor function classification system (GMFCS) levels III-IV demonstrate impaired sitting and reaching control abilities that hamper their overall functional performance. Yet, efficacious interventions for improving sitting-related activities are scarce. We recently designed a motor learning-based intervention delivered with a robotic Trunk-Support-Trainer (TruST-intervention), in which we apply force field technology to individualise sitting balance support. We propose a randomised controlled trial to test the efficacy of the motor intervention delivered with robotic TruST compared with a static trunk support system.

METHODS AND ANALYSIS

We will recruit 82 participants with CP, GMFCS III-IV, and aged 6-17 years. Randomisation using concealed allocation to either the TruST-support or static trunk-support intervention will be conducted using opaque-sealed envelopes prepared by someone unrelated to the study. We will apply an intention-to-treat protocol. The interventions will consist of 2 hours/sessions, 3/week, for 4 weeks. Participants will start both interventions with pelvic strapping. In the TruST-intervention, postural task progression will be implemented by a progressive increase of the force field boundaries and then by removing the pelvic straps. In the static trunk support-intervention, we will progressively lower the trunk support and remove pelvic strapping. Outcomes will be assessed at baseline, training midpoint, 1-week postintervention, and 3-month follow-up. Primary outcomes will include the modified functional reach test, a kinematic evaluation of sitting workspace, and the Box and Block test. Secondary outcomes will include The Segmental Assessment of Trunk Control test, Seated Postural & Reaching Control test, Gross Motor Function Measure-Item Set, Canadian Occupational Performance Outcome, The Participation and Environment Measure and Youth, and postural and reaching kinematics.

ETHICS AND DISSEMINATION

The study was approved by the Columbia University Institutional Review Board (AAAS7804). This study is funded by the National Institutes of Health (1R01HD101903-01) and is registered at clinicaltrials.gov.

TRIAL REGISTRATION NUMBER

NCT04897347; clinicaltrials.gov.

Identifying Postural Instability in Children with Cerebral Palsy Using a Predictive Model: A Longitudinal Multicenter Study

Insufficient postural control and trunk instability are serious concerns in children with cerebral palsy (CP). We implemented a predictive model to identify factors associated with postural impairments such as spastic or hypotonic truncal tone (TT) in children with CP. We conducted a longitudinal, double-blinded, multicenter, descriptive study of 102 teenagers with CP with cognitive impairment and severe motor disorders with and without truncal tone impairments treated in two specialized hospitals (60 inpatients and 42 outpatients; 60 males, mean age 16.5 ± 1.2 years, range 12 to 18 yrs). Clinical and functional data were collected between 2006 and 2021. TT-PredictMed, a multiple logistic regression prediction model, was developed to identify factors associated with hypotonic or spastic TT following the guidelines of "Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis". Predictors of hypotonic TT were hip dysplasia (p = 0.01), type of etiology (postnatal > perinatal > prenatal causes; p = 0.05), male gender, and poor manual (p = 0.01) and gross motor function (p = 0.05). Predictors of spastic TT were neuromuscular scoliosis (p = 0.03), type of etiology (prenatal > perinatal > postnatal causes; p < 0.001), spasticity (quadri/triplegia > diplegia > hemiplegia; p = 0.05), presence of dystonia (p = 0.001), and epilepsy (refractory > controlled, p = 0.009). The predictive model's average accuracy, sensitivity, and specificity reached 82%. The model's accuracy aligns with recent studies on applying machine learning models in the clinical field.

Opportunities for learning and social interaction in infant sitting: Effects of sitting support, sitting skill, and gross motor delay

The development of independent sitting changes everyday opportunities for learning and has cascading effects on cognitive and language development. Prior to independent sitting, infants experience the sitting position with physical support from caregivers. Why does supported sitting not provide the same input for learning that is experienced in independent sitting? This question is especially relevant for infants with gross motor delay, who require support in sitting for many months after typically developing infants sit independently. We observed infants with typical development (n = 34, ages 4-7 months) and infants with gross motor delay (n = 128, ages 7-16 months) in early stages of sitting development, and their caregivers, in a dyadic play observation. We predicted that infants who required caregiver support for sitting would spend more time facing away from the caregiver and less time contacting objects than infants who could sit independently. We also predicted that caregivers of supported sitters would spend less time contacting objects because their hands would be full supporting their infants. Our first two hypotheses were confirmed; however, caregivers spent surprisingly little time using both hands to provide support, and caregivers of supported sitters spent more time contacting objects than caregivers of independent sitters. Similar patterns were seen in the group of typically developing infants and the infants with motor delay. Our findings suggest that independent sitting and supported sitting provide qualitatively distinct experiences with different implications for social interaction and learning opportunities. HIGHLIGHTS: During seated free play, supported sitters spent more time facing away from their caregivers and less time handling objects than independent sitters. Caregivers who spent more time supporting infants with both hands spent less time handling objects; however, caregivers mostly supported infants with one or no hands. A continuous measure of sitting skill did not uniquely contribute to these behaviors beyond the effect of binary sitting support (supported vs. independent sitter). The pattern of results was similar for typically developing infants and infants with gross motor delay, despite differences in age.

Quantifying States and Transitions of Emerging Postural Control for Children Not Yet Able to Sit Independently

Objective, quantitative postural data is limited for individuals who are non-ambulatory, especially for those who have not yet developed trunk control for sitting. There are no gold standard measurements to monitor the emergence of upright trunk control. Quantification of intermediate levels of postural control is critically needed to improve research and intervention for these individuals. Accelerometers and video were used to record postural alignment and stability for eight children with severe cerebral palsy aged 2 to 13 years, under two conditions, seated on a bench with only pelvic support and with additional thoracic support. This study developed an algorithm to classify vertical alignment and states of upright control; Stable, Wobble, Collapse, Rise and Fall from accelerometer data. Next, a Markov chain model was created to calculate a normative score for postural state and transition for each participant with each level of support. This tool allowed quantification of behaviors previously not captured in adult-based postural sway measures. Histogram and video recordings were used to confirm the output of the algorithm. Together, this tool revealed that providing external support allowed all participants: (1) to increase their time spent in the Stable state, and (2) to reduce the frequency of transitions between states. Furthermore, all participants except one showed improved state and transition scores when given external support.

What Is the Relationship between Trunk Control Function and Arm Coordination in Adults with Severe-to-Moderate Quadriplegic Cerebral Palsy?

Adults with tetraparesis cerebral palsy (i.e., wheelchair users) tend to experience more accelerated ageing, resulting in physical deterioration that increases the impact of the disability, leading to a loss of mobility that interferes with people's daily activities and participation in the community. The aim of this work is to study the relationship between trunk control and the function of the less-affected arm in this population. For this purpose, 41 para-athletes were invited to participate in this study, performing five tests to assess upper limb coordination, two tests to assess manual dexterity [i.e., Box and Block Test (BBT) and Box and Ball Test (BBLT)] and three tests to assess intra-limb coordination in different planes. Trunk control was assessed in both static and dynamic sitting conditions. The results show moderate correlations between static postural control and manual dexterity tests in the BBT (r = -0.553; p = 0.002) and BBLT (r = -0.537; p = 0.004). Large correlations were also found between static postural control and intra-limb tasks in horizontal (r = 0.769; p = 0.001) and vertical movements (r = 0.739; p = 0.009). Better static trunk control is related to a better upper limb function in the sagittal plane. Considerations and implications are explained in the manuscript.

Vojta Therapy Affects Trunk Control and Postural Sway in Children with Central Hypotonia: A Randomized Controlled Trial

(1) Background: Decreased trunk stability is accompanied by delay in motor development in children with central hypotonia. We investigated the effect of Vojta therapy on trunk control in the sitting position in children with central hypotonia. (2) Methods: In 20 children with central hypotonia, Vojta therapy was applied to the experimental group (n = 10) and general physical therapy to the control group (n = 10). The intervention was applied for 30 min per session, three times a week, for a total of six weeks. We assessed abdominal muscle thickness, trunk control (segmental assessment of trunk control), trunk angle and trunk sway in a sitting position, and gross motor function measure-88. (3) Results: In the experimental group, the thicknesses of internal oblique and transversus abdominis were significantly increased (p < 0.05). The segmental assessment of trunk control score was significantly increased (p < 0.05), and the trunk sway significantly decreased (p < 0.05). Gross motor function measure-88 was significantly increased (p < 0.05). (4) Conclusions: Vojta therapy can be suggested as an effective intervention method for improving trunk control and gross motor function in children with central hypotonia.

Objective measurement of sitting - Application in children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) and a severe motor impairment, have limited ability to perform volitional movements due to spasticity, involuntary postures and movements and reduced ability to maintain antigravity head and trunk control. A stable sitting position is a prerequisite for participation in daily life, but there is a lack of objective measurement methods for this population.

RESEARCH QUESTION

Is it feasible to measure a stable sitting position with pressure mapping and 2D motion analysis, and can it detect differences to a) a reference group, b) between subgroups of CP and c) before and after treatment with intrathecal baclofen (ITB)?

METHODS

Pressure mapping, and a 2D motion analysis system, were used to capture movements of centre of pressure (CoP), and movements of head, hand and leg, sitting on a bench for 90 s. Twenty-two children with dyskinetic or bilateral spastic CP, GMFCS III-V, mean age 9.0, and 30 children with typical development (TD) mean age 10.7, were recruited between 2010 and 2019. Seventeen children were treated with ITB. Parents were interviewed regarding aspect of sitting. Non-parametric methods were used for statistical analysis.

RESULTS

Differences in CoP and kinematics were detected with more movements in children with CP compared to children with TD (p < 0.001). There were more movements in children with dyskinetic CP compared to children with bilateral spastic CP as captured with the pressure mapping system (CoP distance p = .005 and Anterio-Posterior sway p = .014). After treatment with ITB, involuntary movements had decreased (CoP p = 0.006-0.035, kinematics p = 0.002-0.020). Parents reported improvement in sitting. The two measurement systems showed consistent results (rho 0.500-0.771, p = <0.001-0.049).

SIGNIFICANCE

It was feasible to objectively measure sitting position in children with a moderate-to-severe motor impairment with differences to a reference group and after an intervention. CoP and head movements were the variables that were easiest to capture.

Relationship between Trunk Position Sense and Trunk Control in Children with Spastic Cerebral Palsy: A Cross-Sectional Study

METHODS

In this study, 24 children with spastic CP aged between 8 and 15 years were recruited. They were classified based on their functional performance using Gross Motor Function Classification System (GMFCS). Trunk control and trunk position sense were assessed using the trunk control measurement scale (TCMS) and digital goniometer, respectively. The correlation between these variables was tested using Spearman's correlation coefficient.

RESULTS

Significant negative correlation was found between trunk position sense and TCMS score. Similarly, a significant moderate correlation was found between trunk position sense and GMFCS. A strong negative correlation was also found between GMFCS and TCMS.

CONCLUSION

Children with spastic CP with better trunk position sense had better trunk control. Similarly, children with higher functional performance had better trunk control and lesser error in trunk position sense. The current findings imply the relevance of proprioceptive training of the trunk for enhancing trunk motor control in children with spastic CP.

Impact of Upper Extremity Impairment and Trunk Control on Self-Care Independence in Children With Upper Motor Neuron Lesions

OBJECTIVE

The purpose of this study was to evaluate the relative importance of different approaches to measure upper extremity selective voluntary motor control (SVMC), spasticity, strength, and trunk control for explaining self-care independence in children affected by upper motor neuron lesions.

METHODS

Thirty-one patients (mean [SD] age = 12.5 [3.2] years) with mild to moderate arm function impairments participated in this observational study. Self-care independence was evaluated with the Functional Independence Measure for children (WeeFIM). Upper extremity SVMC was quantified with the Selective Control of the Upper Extremity Scale (SCUES), a similarity index (SISCUES) calculated from simultaneously recorded surface electromyography muscle activity patterns, and an accuracy and involuntary movement score derived from an inertial-measurement-unit-based assessgame. The Trunk Control Measurement Scale was applied and upper extremity spasticity (Modified Ashworth Scale) and strength (dynamometry) were assessed. To determine the relative importance of these factors for self-care independence, 3 regression models were created: 1 included only upper extremity SVMC measures, 1 included upper extremity and trunk SVMC measures (overall SVMC model), and 1 included all measures (final self-care model).

RESULTS

In the upper extremity SVMC model (total variance explained 52.5%), the assessgame (30.7%) and SCUES (16.5%) were more important than the SISCUES (4.5%). In the overall SVMC model (75.0%), trunk SVMC (39.0%) was followed by the assessgame (21.1%), SCUES (11.0%), and SISCUES (4.5%). In the final self-care model (82.1%), trunk control explained 43.2%, upper extremity SVMC explained 23.1%, spasticity explained 12.3%, and strength explained 2.3%.

CONCLUSION

Although upper extremity SVMC explains a substantial portion of self-care independence, overall trunk control was even more important. Whether training trunk control and SVMC can translate to improved self-care independence should be the subject of future research.

IMPACT

This study highlights the importance of trunk control and selective voluntary motor control for self-care independence in children with upper motor neuron lesions.

Self-Feeding Kinematics in an Ecological Setting: Typically Developing Children and Children With Cerebral Palsy

Assessment of self-feeding kinematics is seldom performed in an ecological setting. In preparation for development of an instrumented spoon for measurement of self-feeding in children with cerebral palsy (CP), the current work aimed to evaluate upper extremity kinematics of self-feeding in young children with typical development (TD) and a small, age-matched group of children with CP in a familiar setting, while eating with a spoon.

METHODS

Sixty-five TD participants and six children diagnosed with spastic CP, aged 3-9 years, fed themselves while feeding was measured using miniature three-dimensional motion capture sensors (trakStar). Kinematic variables associated with different phases of self-feeding cycle (movement time, curvature, time to peak velocity and smoothness) were compared across age-groups in the TD sample and between TD children and those with CP.

RESULTS

Significant between-age group differences were identified in movement times, time to peak velocity and curvature. Children with CP demonstrated slower, less smooth self-feeding movements, potentially related to activity limitations.

CONCLUSIONS

The identified kinematic variables form a basis for implementation of self-feeding performance assessment in children of different ages, including those with CP, which can be deployed via an instrumented spoon.

Head support in wheelchairs (scoping review): state-of-the-art and beyond

BACKGROUND

Many wheelchair users experience disabilities in stabilising and positioning of the head. For these users, adequate head support is required. Although several types of head supports are available, further development of these systems is needed to improve functionality and quality of life, especially for the group of severely challenged users. For this group, user needs have not been clearly established. In this article, we provide an overview of the state-of-the-art in wheelchair mounted head supports and associated scientific evidence in order to identify requirements for the next generation of head support systems.

MATERIALS AND METHODS

A scoping review was performed including scientific literature (PubMed/Scopus), patents (Espacenet/Google Scholar) and commercial information. Types of head support and important system characteristics for future head support systems were proposed from consultations with wheelchair users (n = 3), occupational therapists (n = 3) and an expert panel.

RESULTS

Forty scientific papers, 90 patents and 80 descriptions of commercial devices were included in the scoping review. The identified head support systems were categorised per head support type. Only limited scientific clinical evidence with respect to the effectiveness of existing head support systems was found. From the user and expert consultations, a need was identified for personalised head support systems that intuitively combine changes in sitting and head position with continuous optimal support of the head to accommodate severely challenged users.

CONCLUSIONS

This study presents the state-of-the-art in head support systems. Additionally, several important system characteristics are introduced that provide guidance for the development and improvement of head supports.Implications for rehabilitationEspecially for the group of severely challenged wheelchair users, current head support systems require further development to improve their users' quality of life.The desired system characteristics which are discussed in this review are an important step in the definition of requirements for the next generation of head supports.

Postural mechanisms in moderate-to-severe cerebral palsy

People with moderate-to-severe cerebral palsy (CP) have the greatest need for postural control research yet are usually excluded from research due to deficits in sitting ability. We use a support system that allows us to quantify and model postural mechanisms in nonambulatory children with CP. A continuous external bench tilt stimulus was used to evoke trunk postural responses in seven sitting children with CP (ages 2.5 to 13 yr) in several test sessions. Eight healthy adults were also included. Postural sway was analyzed with root mean square (RMS) sway and RMS sway velocity, along with frequency response functions (FRF, gain and phase) and coherence functions across two different stimulus amplitudes. A feedback model (including sensorimotor noise, passive, reflexive, and sensory integration mechanisms) was developed to hypothesize how postural control mechanisms are organized and function. Experimental results showed large RMS sway, FRF gains, and variability compared with adults. Modeling suggested that many subjects with CP adopted "simple" control with major contributions from a passive and reflexive mechanism and only a small contribution from active sensory integration. In contrast, mature trunk postural control includes major contributions from sensory integration and sensory reweighting. Relative to their body size, subjects with CP showed significantly lower damping, three to five times larger corrective torque, and much higher sensorimotor noise compared with the healthy mature system. Results are the first characterization of trunk postural responses and the first attempt at system identification in moderate-to-severe CP, an important step toward developing and evaluating more targeted interventions.NEW & NOTEWORTHY Cerebral palsy (CP) is the most common cause of motor disability in children. People with moderate-to-severe CP are typically nonambulatory and have major impairments in trunk postural control. We present the first systems identification study to investigate postural responses to external stimulus in this population and hypothesize at how the atypical postural control system functions with use of a feedback model. People with moderate-to-severe CP may use a simple control system with significant sensorimotor noise.

Influence of Chest and Diaphragm Manual Therapy on the Spirometry Parameters in Patients with Cerebral Palsy: A Pilot Study

Objective

To evaluate the influence of manual therapy of the chest and diaphragm on the spirometry parameters in patients with cerebral palsy (CP).

Method

The study was carried out on 20 youths with CP. All participated in 6 sessions (3 sham and 3 actual), with measurements of spirometry at baseline, postsham therapies 1 and 3, before actual therapy, and postactual therapy sessions 1 and 3. Two manual techniques were included: soft tissue mobilization of the chest and the diaphragm.

Results

After the first actual therapy, there was a significant (p < 0.01) improvement in forced vital capacity (FVC) by 0.23 L (8% of the average predicted value) and forced expiratory volume in one second (FEV₁) by 0.18 L (7% of the average predicted value) as compared to results before the therapy. Change in FVC parameter was clinically significant, whereas change in FEV₁ was not clinically significant. After sham therapy, there was no improvement in spirometry parameters as compared to baseline results.

Conclusion

Single-time manual therapy of the chest and diaphragm has a positive effect on FVC and FEV₁.

Promoting Functional and Independent Sitting in Children With Cerebral Palsy Using the Robotic Trunk Support Trainer

Seated postural abilities are critical to functional independence and participation in children with cerebral palsy, Gross Motor Functional Classification System (GMFCS) levels III-IV. In this proof-of-concept study, we investigated the feasibility of a motor learning-based seated postural training with a robotic Trunk-Support-Trainer (TruST) in a longitudinal single-subject-design (13y, GMFCS IV), and its potential effectiveness in a group of 3 children (6-14y, GMFCS III-IV). TruST is a motorized-cable driven belt placed on the child's trunk to exert active-assistive forces when the trunk moves beyond stability limits. TruST-intervention addresses postural-task progression by tailoring the assistive-force fields to the child's sitting balance to train trunk control during independent short-sitting posture. TruST-intervention consisted of 2 training blocks of six 2hour-sessions per block (3 sessions per week). Pelvic strapping was required in the 1^st block to prevent falls. As primary outcomes, we used the modified functional reach test, gross motor function measure-item set (GMFM-IS), Box & Blocks, and postural kinematics. After TruST-intervention children did not require pelvic strapping to prevent a fall, improved trunk stability during reaching (baseline = 5.49cm, 1week post-training = 16.38cm, 3mos follow-up = 14.63cm, ) and increased their sitting workspace (baseline = 127.55cm², 1week post-training, = 409.92cm², 3mos follow-up = 270.03cm², ). Three children also improved in the GMFM-IS. In summary, our novel robotic TruST-intervention is feasible and can effectively maximize functional independent sitting in children with CP GMFCS III-IV.

The Seated Postural & Reaching Control Test in Cerebral Palsy: A Validation Study

Aim: Children with moderate-severe cerebral palsy (CP) show postural control deficits that affect their daily activities, like reaching. The Seated Postural and Reaching Control test (SP&R-co) was developed to address the need for clinical measures that objectively identify dimensions of postural imbalance and corresponding reaching limitations in children with CP.Methods: SP&R-co documentation was designed for test validity and rater training. Rater and internal consistency were examined using Cronbach's α. Reference SP&R-co score sheets of children and rater's scores were used for absolute item-by-item, average inter-rater, and intra-rater reliability. Motor classification systems and performance tests were used for construct and concurrent validity.Results: The SP&R-co scoring showed acceptable-good consistency (α = 0.76-0.84). Interrelatedness of SP&R-co items was good-excellent (α = 0.82-0.97). The raters demonstrated fair, good, and excellent item-by-item reliability (ICC = 0.41-0.92). Inter-rater and intra-rater reliability of SP&R-co dimensions were good-excellent (ICC = 0.68-0.86 and ICC = 0.64-0.95, respectively). Construct and concurrent validity showed moderate-excellent correlations (r = 0.49-0.88).Conclusions: Results provide evidence that the SP&R-co is a reliable and valid test for therapists to objectively examine and quantify seated postural and reaching control in children with CP.

Trunk involvement in performing upper extremity activities while seated in neurological patients with a flaccid trunk - A review

BACKGROUND

Trunk control is essential during seated activities. The trunk interacts with the upper extremities (UE) and head by being part of a kinematic chain and by providing a stable basis. When trunk control becomes impaired, it may have consequences for the execution of UE tasks.

AIM

To review trunk involvement in body movement and stability when performing seated activities and its relation with UE and head movements in neurological patients with a flaccid trunk, with a focus on childhood and development with age.

METHODS AND PROCEDURES

A search using PubMed was conducted and 32 out of 188 potentially eligible articles were included.

OUTCOMES AND RESULTS

Patients with a flaccid trunk (e.g. with spinal cord injury or cerebral palsy) tend to involve the trunk earlier while reaching than healthy persons. Different balance strategies are observed in different types of patients, like using the contralateral arm as counterweight, eliminating degrees of freedom, or reducing movement speed.

CONCLUSIONS AND IMPLICATIONS

The key role of the trunk in performing activities should be kept in mind when developing interventions to improve seated task performance in neurological patients with a flaccid trunk.

Parent handling of typical infants varies segmentally across development of postural control

Although trunk muscles extend across multiple vertebral joints, recent motor control studies have shown that a top-down progression of trunk control in typical infants occurs incrementally, one segment at a time, until independent sitting. The current study merges this surprising developmental pattern with parent behavior by exploring the relationship between how parents hold their infant and the segmental level for which the infant exhibits postural control. We measured trunk control of 60 infants (1-8 months) via the segmental assessment of trunk control. Spontaneous parental hold and variability was recorded during repeated sitting and standing conditions. Parent hold correlated with infant level of control in both sitting and standing, providing evidence for a positive interaction between parent behavior and segmental trunk development.

The Impact of Segmental Trunk Support on Posture and Reaching While Sitting in Healthy Adults

The authors investigated postural and arm control in seated reaches while providing trunk support at midribs and pelvic levels in adults. Kinematics and electromyography of the arm and ipsiliateral and contralateral paraspinal muscles were examined before and during reaching. Kinematics remained constant across conditions, but changes were observed in neuromuscular control. With midribs support, the ipsilateral cervical muscle showed either increased anticipatory activity or earlier compensatory muscle responses, suggesting its major role in head stabilization. The baseline activity of bilateral lumbar muscles was enhanced with midribs support, whereas with pelvic support, the activation frequency of paraspinal muscles increased during reaching. The results suggest that segmental trunk support in healthy adults modulates ipsilateral or contralateral paraspinal activity while overall kinematic outputs remain invariant.

Effect of Biomechanical Constraints on Neural Control of Head Stability in Children With Moderate to Severe Cerebral Palsy

BACKGROUND

External support has been viewed as an important biomechanical constraint for children with deficits in postural control. Nonlinear analysis of head stability may be helpful to confirm benefits of interaction between external trunk support and level of trunk control.

OBJECTIVE

The purpose of this study was to compare the effect of biomechanical constraints (trunk support) on neural control of head stability during development of trunk control.

DESIGN

This was a quasi-experimental repeated-measures study.

METHODS

Data from 15 children (4-16 years of age) with moderate (Gross Motor Function Classification System [GMFCS] IV; n=8 [4 boys, 4 girls]) or severe (GMFCS V; n=7 [4 boys, 3 girls]) cerebral palsy (CP) were compared with previous longitudinal data from infants with typical development (TD) (3-9 months of age). Kinematic data were used to document head sway with external support at 4 levels (axillae, midrib, waist, and hip). Complexity, predictability, and active degrees of freedom for both anterior-posterior and medial-lateral directions were assessed.

RESULTS

Irrespective of level of support, CP groups had lower complexity, increased predictability, and greater degrees of freedom. The effect of support differed based on the child's segmental level of control. The GMFCS V and youngest TD groups demonstrated better head control, with increased complexity and decreased predictability, with higher levels of support. The GMFCS IV group had the opposite effect, showing decreased predictability and increased complexity and degrees of freedom with lower levels of support.

LIMITATIONS

Infants with typical development and children with CP were compared based on similar segmental levels of trunk control; however, it is acknowledged that the groups differed for age, cognitive level, and motor experience.

CONCLUSIONS

The effect of external support varied depending on the child's level of control and diagnostic status. Children with GMFCS V and young infants with TD had better outcomes with external support, but external support was not enough to completely correct for the influence of CP. Children with GMFCS IV performed worse, with increased predictability and decreased complexity, when support was at the axillae or midribs, suggesting that too much support can interfere with postural sway quality.