Improvement of functional sitting position for children with cerebral palsy

Validity and reliability of the Sitting Assessment Scale in cerebral palsy

AIM

The aim of this study was to examine the validity and reliability of the Sitting Assessment Scale (SAS) in individuals with cerebral palsy (CP).

METHODS

The study included 34 individuals with a diagnosis of spastic CP. Individuals were evaluated with the Gross Motor Function Classification System and the Manual Ability Classification System. SAS and Trunk Control Measurement Scale (TCMS) were applied to the participants. The intraclass correlation coefficient (ICC) was calculated to determine the intraobserver and interobserver reliability of the scale scored by three different physiotherapists at two different time intervals. Internal consistency was calculated with Cronbach's ⍺ coefficient. The fit between SAS and TCMS for criterion-dependent validity was evaluated using Pearson Correlation Analysis.

RESULTS

According to the GMFCS level, 79.41% of the children were mildly (Level I-II), 14.71% were moderately affected (level III), and 5.88% were severely affected (level IV). Intra > observer and interobserver reliability values of SAS were extremely high (ICCinterrater > 0.923, ICCintrarater > 0.930). It was observed that the internal consistency of SAS had high values (Cronbach ⍺test > 0.822, Cronbach ⍺retest > 0.804). For the criterion-dependent reliability; positive medium correlations found between SAS with Total TCMS Static Sitting Balance (r = 0.579, p < 0.001), with TCMS Selective Movement Control (r = 0.597, p < 0.001), with TCMS Dynamic Reaching (r = 0.609, p < 0.001), and with TCMS Total (r = 0.619, p < 0.001).

CONCLUSION

SAS was found to have high validity and reliability in children with CP. In addition, the test-retest reliability of the scale was also high. SAS is a practical tool that can be used to assess sitting balance in children with CP.

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 Relationship between Trunk Control and Upper Extremity Function in Children with Obstetric Brachial Plexus Palsy

PURPOSE

This study aimed to assess sitting skills and trunk control in children with obstetric brachial plexus palsy (OBPP) and investigate the effect of these skills on upper extremity function.

METHODS

A total of 106 children with OBPP aged 10-18 months were included in this study. Injury severity was determined with Narakas Classification. The Gross Motor Function Measurement Sitting Sub-scale was used to assess sitting skills, while the Sitting Assessment Scale was used to evaluate the trunk control. The upper extremity functions were assessed with using the Active Movement Scale and the Modified Mallet Score.

RESULTS

As the severity of injury increased, sitting skills and trunk control values decreased (p = .0001). In addition, upper extremity function decreased with the decreasing sitting skills and trunk control (p = .0001).

CONCLUSION

Rehabilitation approaches should involve approaches that aim to increase trunk control in addition to programs targeting the extremity function in children with OBPP.

Parent-delivered interventions used at home to improve eating, drinking and swallowing in children with neurodisability: the FEEDS mixed-methods study

BACKGROUND

Eating, drinking and swallowing difficulties are common in young children with neurodisability. These difficulties may lead to inadequate calorie intake, which affects a child's nutrition, growth and general physical health.

OBJECTIVE

To examine which interventions are available that can be delivered at home by parents to improve eating, drinking and swallowing in young children with neurodisability and are suitable for investigation in pragmatic trials.

DESIGN

This was a mixed-methods study that included focus groups, surveys, an update of published systematic reviews of interventions, a systematic review of measurement properties of existing tools, evidence mapping, evidence synthesis, a Delphi survey and stakeholder workshops.

SETTING

The study was carried out in NHS hospitals, community services, family homes and schools.

PARTICIPANTS

Parents of children who had neurodisability and eating, drinking and swallowing difficulties. Professionals from health and education. Young people with eating, drinking and swallowing difficulties or young people who had previously experienced eating, drinking and swallowing difficulties.

DATA SOURCES

Literature reviews; national surveys of parents and professionals; focus groups with parents, young people and professionals; and stakeholder consultation workshops.

REVIEW METHODS

An update of published systematic reviews of interventions (searched July-August 2017), a mapping review (searched October 2017) and a systematic review of measurement properties using COnsensus-based Standards for the Selection of health status Measurement INstruments (COSMIN) methodology (searched May 2018).

RESULTS

Significant limitations of the available research evidence regarding interventions and tools to measure outcomes were identified. A total of 947 people participated: 400 parents, 475 health professionals, 62 education professionals and 10 young people. The survey showed the wide range of interventions recommended by NHS health professionals, with parents and professionals reporting variability in the provision of these interventions. Parents and professionals considered 19 interventions as relevant because they modified eating, drinking and swallowing difficulties. Parents and professionals considered 10 outcomes as important to measure (including Nutrition, Growth and Health/safety); young people agreed that these were important outcomes. Stakeholder consultation workshops identified that project conclusions and recommendations made sense, were meaningful and were valued by parents and professionals. Parents and health professionals were positive about a proposed Focus on Early Eating, Drinking and Swallowing (FEEDS) toolkit of interventions that, through shared decision-making, could be recommended by health professionals and delivered by families.

LIMITATIONS

The national surveys included large numbers of parents and professionals but, as expected, these were not representative of the UK population of parents of children with eating, drinking and swallowing difficulties. Owing to the limitations of research evidence, pragmatic decisions were made about interventions that might be included in future research and outcomes that might be measured. For instance, the reviews of research found only weak or poor evidence to support the effectiveness of interventions. The review of outcome measures found only limited low-level evidence about their psychometric properties.

CONCLUSIONS

Opportunities and challenges for conducting clinical trials of the effectiveness of the FEEDS toolkit of interventions are described. Parents and professionals thought that implementation of the toolkit as part of usual NHS practice was appropriate. However, this would first require the toolkit to be operationalised through development as a complex intervention, taking account of constituent interventions, delivery strategies, implementation and manualisation. Subsequently, an evaluation of its clinical effectiveness and cost-effectiveness could be undertaken using appropriate research methods.

FUTURE WORK

Initial steps include FEEDS toolkit development and evaluation of its use in clinical practice, and identification of the most robust methods to measure valued outcomes, such as Nutrition and Growth.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10454425.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 22. See the NIHR Journals Library website for further project information.

Influência dos diferentes assentos no alinhamento postural: rede adaptada para paralisia cerebral

RESUMO A rede de tecido é uma opção para o sentar na região norte do Brasil. No entanto, sua estrutura flexível pode causar instabilidade postural nos indivíduos com paralisia cerebral (PC), limitando sua independência. Assim, criou-se a rede adaptada, com inserção de sistema assento/encosto, buscando posicionamento sentado com alinhamento postural adequado. O objetivo deste estudo foi verificar o alinhamento de tronco e membros inferiores (MMII) de indivíduos com PC nas condições: rede adaptada, rede sem adaptação e banco, comparando-os com indivíduos-controle, sem alterações neurológicas. Seis indivíduos com PC (GPC) e seis típicos (GC), de 8 a 14 anos, foram avaliados na postura sentada nas condições: rede adaptada, banco e rede sem suporte de assento/encosto. Por meio da análise cinemática foram avaliados ângulos de tronco, pelve e membros inferiores na postura estática por 5 segundos. Houve aplicação de parte do questionário Quebec B-Quest com os responsáveis. Resultados: houve semelhança dos ângulos de MMII, pelve e tronco nas três condições. Quebec B-Quest: maior satisfação quanto às dimensões do produto e menor quanto ao conforto e à segurança. A rede adaptada pode ser considerada opção de sentar por curtos períodos de tempo, pois promoveu adequado alinhamento postural em indivíduos com PC.

Effects of forward tilted seating and foot-support on postural adjustments in children with spastic cerebral palsy: An EMG-study

OBJECTIVE

To evaluate the effect of 15° forward (FW) seat inclination and foot-support in children with cerebral palsy (CP) on postural adjustments during reaching.

DESIGN

Observational study repeated-measures design; step two of two-step-project.

SETTING

Laboratory unit within University Hospital and two special education schools.

PARTICIPANTS

19 children (ten unilateral spastic CP (US-CP); nine bilateral spastic CP (BS-CP); Gross Motor Function Classification System levels I-III; 6-12 years old). Participants were able to take part for one one-hour session.

INTERVENTION

Reaching while sitting in four seating conditions (FW or horizontal seat; with or without foot-support) applied in randomized order.

OUTCOME MEASURES

Simultaneously, surface electromyography (EMG) of neck, trunk and arm muscles and kinematics of head and reaching arm (step one of two-step-project) were recorded. Primary outcome parameters were the ability to modulate EMG-amplitudes at baseline and during reaching (phasic muscle activity). Other EMG-parameters were direction-specificity (1st control level), and 2nd level of control parameters: recruitment order, and anticipatory postural activity. Motor behaviour measures: ability to modulate EMG-amplitudes to kinematic characteristics of reaching and head stability.

RESULTS

Only foot-support was associated with increased tonic background EMG-amplitudes and decreased phasic EMG-amplitudes of the trunk extensors in children with US-CP and BS-CP (mixed-models analyses; p-values <0.01). The foot-support effect was also associated with better kinematics of reaching (Spearman's Rho; p-values <0.01).

CONCLUSION

In terms of postural adjustments during forward reaching, foot-support enhanced the children's capacity to modulate trunk extensor activity, which was associated with improved reaching quality. FW-tilting did not affect postural muscle activity.

A pilot investigation of anterior tilt use among power wheelchair users

PURPOSE

To examine the influence of use of the anterior tilt-in-space power seat function on performance of functional activities, physical health, and user satisfaction on among power wheelchair users.

MATERIALS AND METHODS

Ten full-time power wheelchair users with a seat elevator on their current chair participated in a mixed-methods, repeated measures study. At Visit 1 participants completed the Wheelchair Outcome Measure, Functional Mobility Assessment, Wheelchair Users Shoulder Pain Index, Fatigue Severity Scale, and the Spinal Cord Injury Secondary Conditions Scale. Physical assessments were performed to examine transfer quality (transfer assessment instrument), functional reach, activities of daily living (performance assessment of self-care skills), seated balance (function in sitting test), spasticity, respiratory function, and speech production. Approximately 3 days later (Visit 2), participants were trained on use and provided a power wheelchair with anterior tilt to trial for two weeks. After two weeks (Visit 3), the Visit 1 protocol was repeated and a semistructured interview conducted.

RESULTS

Participants lived with disabilities of cerebral palsy, spinal muscular atrophy and multiple sclerosis. With use of anterior tilt, significant improvements were seen among safety of meal preparation, p = 0.033, d_z = 0.91 and functional reach in the vertical direction, p = 0.000, d_z = 2.62. Subjectively, participants found anterior tilt helpful in performance of reaching tasks in but found the safety equipment restrictive.

CONCLUSION

Preliminary results indicate that use of the anterior tilt may help to improve performance of functional activities. Additional research is needed to examine the long-term influence of the technology.Implications for rehabilitationThe anterior tilt seat function changes the seat angle orientation in relation to the ground in the sagittal plane and angles the seat forward. As a result, the individual using the assistive technology is positioned in a semistanding position.Preliminary results of this study indicate that with use of anterior tilt, safety of meal preparation and functional reach in the vertical direction significantly improved. Subjectively, participants found anterior tilt helpful in performance of reaching tasks but found the safety equipment restrictive.Additional research is needed to examine the long-term influence of anterior tilt on functional activities, physical health and user satisfaction on among a large and diverse group of power wheelchair users.

The effects of vest type dynamic elastomeric fabric orthosis on sitting balance and gross manual dexterity in children with cerebral palsy: a single-blinded randomised controlled study

Purpose: To evaluate the effects of vest type dynamic elastomeric fabric orthosis on posture and balance during sitting and gross manual dexterity and to compare the efficacy of daily wearing time of 2 h versus 6 h.Method: Twenty-four children with cerebral palsy (CP) aged 3-9 years with GMFCS levels III and IV were randomised to either of three groups: (i) a control group who received only conventional exercise therapy, (ii) dynamic elastomeric fabric orthosis 2 h group who wore the orthosis for 2 h during therapy and dynamic elastomeric fabric orthosis 6 h group who wore the orthosis for 4 h in addition to the 2 h of wear along with therapy during hospital inpatient stay for 2 weeks. Children continued to use dynamic elastomeric fabric orthosis during the post-discharge period. The primary outcome measure was the Sitting Assessment Scale. The secondary outcome measurements were the sitting dimension of Gross Motor Function Measure, Box and Block Test and Parent Satisfaction Survey. Assessments were made before treatment, at post-treatment, at 1-month post-treatment, and at 3-months post-treatment. Sitting Assessment Scale and Box and Block Test were also assessed when immediately after wearing the orthosis. This trial is registered with Clinicaltrials.gov, under number NCT03191552.Results: All groups showed similar improvements except the control group which showed less improvement in Sitting Assessment Scale scores compared to the dynamic elastomeric fabric orthosis groups. Dynamic elastomeric fabric orthosis groups showed greater improvements compared to the control group in the Sitting Assessment Scale but not in the sitting dimension of Gross Motor Function Measure and Box and Block Test at post-treatment, at 1-month post-treatment and at 3-months post-treatment. When the dynamic elastomeric fabric orthosis groups (2 h versus 6 h) were compared, there were no significant differences in any of the assessments. The Sitting Assessment Scale and Box and Block Test scores also improved immediately after the patients put on the orthosis. At 1-month post-treatment, parents of children in the control group reported less satisfaction than parents of the children in dynamic elastomeric fabric orthosis groups.Conclusions: Dynamic elastomeric fabric orthosis vest has an immediate effect on the sitting balance and gross manual dexterity. It also provides improvements in posture and balance during sitting. Wearing dynamic elastomeric fabric orthosis vest for 2 h during therapy is as much effective as wearing it for 6 h in children with CP in addition to therapy to improve sitting balance.Implications for rehabilitationDynamic elastomeric fabric orthosis vest provides improvements in sitting balance when used in addition to conventional therapy in children with cerebral palsy.Wearing dynamic elastomeric fabric orthosis for 2 h and wearing dynamic elastomeric fabric orthosis vest for 6 h resulted in similar clinical outcomes.Dynamic elastomeric fabric orthosis vest has an immediate effect on sitting balance and gross manual dexterity in children with cerebral palsy.

Children with moderate to severe cerebral palsy may not benefit from stochastic vibration when developing independent sitting

PURPOSE

Determine sitting postural control changes for children with cerebral palsy (CP), using a perceptual-motor intervention and the same intervention plus stochastic vibration through the sitting surface.

METHODS

Two groups of children with moderate or severe CP participated in the 12 week interventions. The primary outcome measure was center of pressure data from which linear and nonlinear variables were extracted and the gross motor function measure (GMFM).

RESULTS

There were no significant main effects of intervention or time or an interaction. Both treatment groups increased the Lyapunov exponent values in the medial-lateral direction three months after the start of treatment as well as their GMFM scores in comparison with baseline.

CONCLUSIONS

The stochastic vibration did not seem to advance the development of sitting postural control in children between the ages of 2 and 6 years. However, perceptual-motor intervention was found beneficial in advancing sitting behavior.

Does stabilizing input pressure orthosis vest, lycra-based compression orthosis, improve trunk posture and prevent hip lateralization in children with cerebral palsy?

Objectives

This study aims to investigate whether the use of a lycra-based compression orthosis known as stabilizing input pressure orthosis (SPIO) vest improves trunk posture and hip lateralization in children with cerebral palsy (CP) and to compare the effects of two- and six-hours daily wear of the orthosis.

Patients and methods

Between December 2013 and July 2015, a total of 24 children with CP (5 boys, 19 girls; mean age 61.1 months; range 35 to 105 months) with impaired trunk control were included in this single-blind, randomized-controlled study. All were randomized to either of the three groups as the control group (received only conventional exercise therapy), the SPIO 2-hour group (worn orthosis two hours during therapy), and the SPIO 6-hour group (worn orthosis four hours in addition to two hours of wear during therapy). The Sitting Assessment Scale (SAS), Cobb angle, kyphotic angle, and Migration Index were used to evaluate the trunk posture and hip lateralization before treatment and at six months after treatment.

Results

The SAS scores improved compared to baseline in all groups. The Cobb angle and kyphotic angle showed a significant decrease at six months after treatment only in the SPIO groups, while intra-group analysis of the Migration Index did not show a statistically significant difference. Changes in the radiographic assessments were similar among the groups, except for the kyphotic angles. The kyphotic angle showed less change in the control group. Comparison of the SPIO groups showed no significant differences in terms of the variables assessed.

Conclusion

The SPIO vest improves the kyphotic posture, but not scoliosis and hip lateralization in children with CP with impaired trunk control when used in combination with the conventional therapy. Using the SPIO vest for two and six hours also yields similar outcomes.

Effects of different seating equipment on postural control and upper extremity function in children with cerebral palsy

BACKGROUND

Adaptive seating supports for cerebral palsy are recommended to develop and maintain optimum posture, and functional use of upper extremities.

OBJECTIVES

To compare the effectiveness of different seating adaptations regarding postural alignment and related functions and to investigate the effects of these seating adaptations on different motor levels.

STUDY DESIGN

Prospective study.

METHODS

A total of 20 children with spastic cerebral palsy (Gross Motor Function Classification System 3-5) were included. Postural control and function (Seated Postural Control Measure, Sitting Assessment Scale) were measured in three different systems: standard chair, adjustable seating system and custom-made orthosis.

RESULTS

In results of all participants ungrouped, there was a significant difference in most parameters of both measurement tools in favor of custom-made orthosis and adjustable seating system when compared to standard chair ( p < 0.0017). There was a difference among interventions in most of the Seated Postural Control Measure results in Level 4 when subjects were grouped according to Gross Motor Function Classification System levels. A difference was observed between standard chair and adjustable seating system in foot control, arm control, and total Sitting Assessment Scale scores; and between standard chair and custom-made orthosis in trunk control, arm control, and total Sitting Assessment Scale score in Level 4. There was no difference in adjustable seating system and custom-made orthosis in Sitting Assessment Scale in this group of children ( p < 0.017).

CONCLUSION

Although custom-made orthosis fabrication is time consuming, it is still recommended since it is custom made, easy to use, and low-cost. On the other hand, the adjustable seating system can be modified according to a patient's height and weight. Clinical relevance It was found that Gross Motor Function Classification System Level 4 children benefitted most from the seating support systems. It was presented that standard chair is sufficient in providing postural alignment. Both custom-made orthosis and adjustable seating system have pros and cons and the best solution for each will be dependent on a number of factors.

The International Classification of Functioning, Disability and Health provides a Model for Adaptive Seating Interventions for Children with Cerebral Palsy

Children with severe types of cerebral palsy use adaptive seating systems to encourage function and assist in delaying the development of deformity. These systems are often assessed for and provided by occupational therapists. However, there has been no unifying policy or theoretical basis on which these systems are provided and research evidence is lacking, with studies tending to be small and non-controlled.

The International Classification of Functioning, Disability and Health (World Health Organisation 2001a,b) aims to establish a common language for clinical practice as well as research, while bringing together the opposing social and medical models of health care delivery. This paper suggests that the ICF model is an ideal theoretical basis for adaptive seating system assessment and provision, given that these systems often conflict between the medical model of reducing or delaying impairment of body functions and structures and the social model of children and families accessing life and environmental situations through mobility and seating equipment.

The paper considers all the domains of the ICF with regard to the current literature. It concludes that using the model in the context of providing adaptive seating gives occupational therapists both a powerful tool for communicating with children and families as well as managers and a basis for evaluating practice.

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

PURPOSE

To test the effects of segmental trunk support on seated postural and reaching control in children with cerebral palsy.

METHODS

Seventeen children (age range 2-15 y, Gross Motor Function Classification System levels III-V) were classified with the Segmental Assessment of Trunk Control into mild (complete trunk control/lower lumbar deficits), moderate (thoracic/upper lumbar deficits), and severe (cervical/upper thoracic deficits). Postural and arm kinematics were measured while reaching with trunk support at axillae, mid-ribs, or pelvis.

RESULTS

Children in the mild group did not display changes in posture or reaching across conditions. The moderately involved group showed decrements in postural and reaching performance with pelvic compared with higher supports (P < .01). Children in the severe group were unable to maintain posture with pelvic support and showed postural deficiencies with mid-ribs compared with axillae support (P < .01).

CONCLUSIONS

Children with cerebral palsy and trunk dysfunction demonstrate improved motor performance when the external assistance matches their intrinsic level of trunk control.

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.

Segmental Contributions to Trunk Control in Children With Moderate-to-Severe Cerebral Palsy

OBJECTIVE

To examine postural constraints in children with moderate-to-severe cerebral palsy (CP) using a segmental approach.

DESIGN

Quasi-experimental repeated-measures study; case series.

SETTING

Motor control research laboratory.

PARTICIPANTS

Children (N=15; age range, 4-16y) with moderate (Gross Motor Function Classification System [GMFCS] IV; n=8; 4 boys) or severe (GMFCS V) (n=7; 4 boys) CP.

INTERVENTIONS

Each child participated in 3 data collection sessions. During each session, we evaluated postural control for sitting using kinematics and clinical assessments.

MAIN OUTCOME MEASURES

Kinematic data were used to document head alignment and stabilization with external support at 4 levels (axillae, midrib, waist, hip). Two clinical assessments, the Segmental Assessment of Trunk Control and behavioral assessment for stage of trunk control, were also used to compare results for children with CP to previous longitudinal data from typically developing (TD) infants (3-9mo of age).

RESULTS

Children with GMFCS V had difficulty aligning and stabilizing their head along the medial-lateral and anterior-posterior axes. External support improved postural control for children with GMFCS V but not for those classified as GMFCS IV, who had opposite responses to support compared with TD infants.

CONCLUSIONS

Children with GMFCS V have limited trunk control but respond to support similarly to young TD infants, suggesting delayed postural control. Response to external support for children with GMFCS IV suggests a unique strategy for trunk control not observed in typical infants. Overall a segmental approach offers new insights into development of trunk control in children with moderate-to-severe CP.

Early intervention to improve hand function in hemiplegic cerebral palsy

Children with hemiplegic cerebral palsy often have marked hand involvement with excessive thumb adduction and flexion and limited active wrist extension from infancy. Post-lesional aberrant plasticity can lead to progressive abnormalities of the developing motor system. Disturbances of somatosensory and visual function and developmental disregard contribute to difficulties with hand use. Progressive soft tissue and bony changes may occur, leading to contractures, which further limit function in a vicious cycle. Early intervention might help to break this cycle, however, the precise nature and appropriateness of the intervention must be carefully considered. Traditional approaches to the hemiplegic upper limb include medications and botulinum toxin injections to manage abnormalities of tone, and surgical interventions. Therapist input, including provision of orthoses, remains a mainstay although many therapies have not been well evaluated. There has been a recent increase in interventions for the hemiplegic upper limb, mostly aimed outside the period of infancy. These include trials of constraint-induced movement therapy (CIMT) and bimanual therapy as well as the use of virtual reality and robot-assisted therapy. In future, non-invasive brain stimulation may be combined with therapy. Interventions under investigation in the infant age group include modified CIMT and action observation therapy. A further approach which may be suited to the infant with thumb-in-palm deformity, but which requires evaluation, is the use of elastic taping. Enhanced cutaneous feedback through mechanical stimulation to the skin provided by the tape during movement has been postulated to modulate ongoing muscle activity. If effective, this would represent a low-cost, safe, widely applicable early intervention.

Seat surface inclination may affect postural stability during Boccia ball throwing in children with cerebral palsy

The aim of the study was to examine how seat surface inclination affects Boccia ball throwing movement and postural stability among children with cerebral palsy (CP). Twelve children with bilateral spastic CP (3 with gross motor function classification system Level I, 5 with Level II, and 4 with Level III) participated in this study. All participants underwent pediatric reach tests and ball throwing performance analyses while seated on 15° anterior- or posterior-inclined, and horizontal surfaces. An electromagnetic motion analysis system was synchronized with a force plate to assess throwing motion and postural stability. The results of the pediatric reach test (p = 0.026), the amplitude of elbow movement (p = 0.036), peak vertical ground reaction force (PVGRF) (p < 0.001), and movement range of the center of pressure (COP) (p < 0.020) were significantly affected by seat inclination during throwing. Post hoc comparisons showed that anterior inclination allowed greater amplitude of elbow movement and PVGRF, and less COP movement range compared with the other inclines. Posterior inclination yielded less reaching distance and PVGRF, and greater COP movement range compared with the other inclines. The anterior-inclined seat yielded superior postural stability for throwing Boccia balls among children with bilateral spastic CP, whereas the posterior-inclined seat caused difficulty.

Clinimetric properties of sitting balance measures for children with cerebral palsy: a systematic review

Assessment of sitting balance in children and youth with cerebral palsy (CP) is critical in order to design appropriate interventions to enhance activities and participation. This systematic review synthesized research evidence on the reliability, validity, responsiveness to change, and clinical utility of sitting balance measures for children and youth with CP. A two-tiered search in August 2012 using nine peer-reviewed electronic databases yielded nine articles with relevant information on seven clinical measures. Four of seven clinical measures: the Pediatric Reach Test (PRT), Sitting Assessment for Children with Neuromotor Dysfunction (SACND), Segmental Assessment of Trunk Control (SATCo), and Trunk Control Measurement Scale (TCMS), demonstrate acceptable overall applicability (at least one study supporting clinical utility, reliability, and validity) and are thus recommended for use in practice. Ongoing research on responsiveness to change, however, is warranted to support validity for outcomes measurement.

Seating

INTRODUCTION

Patients with neuromuscular disorders are not able to adapt their sitting posture continuously. Seating devices, like seating orthoses, braces, seating shells, and custom-made cushions for wheelchairs, however may improve their quality of life by stabilizing their pelvis and trunk. Sitting should be regarded as a dynamic process regulated by motor reactions of trunk and pelvic muscles due to endogenic and exogenic influences.

METHODS

Prerequisites for the indication of high-quality and cost effective seating devices are guidelines for planning and fitting which consider both pathomorphologic mechanisms and the patient's personality. In order to avoid functional problems and pain caused by an insufficient seating device it is necessary to pay attention to the exact indication, time, and combination of technical options. Planning within a seating clinic needs teamwork. Primarily the goal of treatment is defined; it depends on the functional deficit, on the daily living activities of the patient, and on the social environmental factors. Secondly, fitting of the devices follows defined treatment guidelines.

CONCLUSION

By examination of the sensor and musculoskeletal system, it is possible to classify the patient's sitting or seating ability for simplifying indication: three groups of ACTIVE sitters who are able to change position of trunk and pelvis actively are differentiated from three groups of PASSIVE sitters who have to be seated.

Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review

We aimed to review tools used to assess balance in clinical practice in children and adults with cerebral palsy (CP), to describe their content and measurement properties and to evaluate the quality of the studies that have examined these properties. CINAHL, Embase, and PubMed/MEDLINE were searched. The COnsensus-based Standards for selection of health Measurement INstruments (COSMIN) was used to assess the 'quality of studies' and the Terwee criteria were used to assess the 'result of studies'. Twenty-two clinical balance tools were identified from 35 papers. The content and focus of the tools varied significantly. There was moderate or limited levels of evidence for most of the measurement properties of the tools; the strongest level of evidence was found for the Trunk Control Measurement Scale and the Level of Sitting Scale, in the category 'maintain balance', the Timed Up and Go and the Segmental Assessment of Trunk Control in the categories 'achieve balance' and 'restore balance' respectively. Information on responsiveness was scarce. Further studies providing better evidence for reliability and responsiveness for clinical balance tools are needed. In the meantime, results of studies evaluating effects of treatment of balance in individuals with CP should be interpreted with caution.

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.

Effect of Seated Position on Upper-Extremity Access to Augmentative Communication for Children With Cerebral Palsy: Preliminary Investigation

OBJECTIVE. Our goal in this study was to determine the effect of seated position on upper-extremity access to augmentative communication for a child with cerebral palsy.

METHOD. A single-subject ABAB design was used with one 5-yr-old participant. We compared accuracy and speed of selection of targets on a speech-generating device in the participant’s typical position and in an intervention position. The intervention position conformed to current clinical conventions and research on promoting upper-extremity movement. The intervention position was achieved through simple modifications to the participant’s typical seating.

RESULTS. Accuracy of target selection was moderately improved in the intervention position compared with the typical position.

CONCLUSION. Results provide preliminary empirical evidence of the positive effects of functional seating on access to augmentative communication for children with cerebral palsy. Further research is required to confirm the positive effect of the intervention position across other people who use augmentative communication.

Sitting and standing performance in a total population of children with cerebral palsy: a cross-sectional study

Background

Knowledge of sitting and standing performance in a total population of children with cerebral palsy (CP) is of interest for health care planning and for prediction of future ability in the individual child. In 1994, a register and a health care programme for children with CP in southern Sweden was initiated. In the programme information on how the child usually sits, stands, stands up and sits down, together with use of support or assistive devices, is recorded annually.

Methods

A cross-sectional study was performed, analysing the most recent report of all children with CP born 1990-2005 and living in southern Sweden during 2008. All 562 children (326 boys, 236 girls) aged 3-18 years were included in the study. The degree of independence, use of support or assistive devices to sit, stand, stand up and sit down was analysed in relation to the Gross Motor Function Classification System (GMFCS), CP subtype and age.

Result

A majority of the children used standard chairs (57%), could stand independently (62%) and could stand up (62%) and sit down (63%) without external support. Adaptive seating was used by 42%, external support to stand was used by 31%, to stand up by 19%, and to sit down by 18%. The use of adaptive seating and assistive devices increased with GMFCS levels (p < 0.001) and there was a difference between CP subtypes (p < 0.001). The use of support was more frequent in preschool children aged 3-6 (p < 0.001).

Conclusion

About 60% of children with CP, aged 3-18, use standard chairs, stand, stand up, and sit down without external support. Adding those using adaptive seating and external support, 99% of the children could sit, 96% could stand and 81% could stand up from a sitting position and 81% could sit down from a standing position. The GMFCS classification system is a good predictor of sitting and standing performance.

Effect of seat surface inclination on postural stability and forward reaching efficiency in children with spastic cerebral palsy

The purpose of this study was to examine the effect of seat surface inclination on postural stability and forward reaching efficiency in 10 children with spastic cerebral palsy (CP) and 16 typically developing (TD) children. The children performed a static sitting and a forward reaching task while sitting on a height- and inclination-adjustable stool at flat, three anterior-inclined, and three posterior-inclined positions. Postural stability was expressed as normalized (with body weight) peak vertical ground reaction force, center of pressure displacement in the anterior/posterior directions (COP_AP), in the medial/lateral directions (COP_ML), and sway ratio (COP_AP/COP_ML). Reaching efficiency was expressed as reaction time and movement time of arm reaching forward to a target. The results showed that seat inclination affected children's postural stability and the effects were comparable for CP and TD children in all measures except for COP_ML. Children with CP presented much larger COP_ML than TD children at the posterior-inclined positions relative to the flat and the anterior-inclined positions. Seat inclination affected reaching efficiency for both groups of children equally. Efficiency was better at the anterior positions than the posterior positions. Anterior-inclined positions improved postural stability and reaching efficiency. Posterior positions posed greater postural challenge and the challenge was tougher for children with CP.

Tilted seat position for non-ambulant individuals with neurological and neuromuscular impairment: a systematic review

Objective: To determine the effects of tilt-in-space seating on outcomes for people with neurological or neuromuscular impairment who cannot walk.

Data sources: Search through electronic databases (MEDLINE, Embase, CINAHL, AMED). Discussions with researchers who are active in field.

Review methods: Selection criteria included interventional studies that investigated the effects of seat tilt on outcome or observational studies that identified outcomes for those who had used tilt-in-space seating in populations with neurological or neuromuscular impairments. Two reviewers independently selected trials for inclusion, assessed quality and extracted data.

Results: Nineteen studies were identified which fulfilled the selection criteria. Seventeen of these were essentially before–after studies investigating the immediate effects of tilting the seating. All studies looked at populations with neurological impairment, and most were on children with cerebral palsy (n = 8) or adults with spinal cord injury (n = 8).

Reviewer's conclusion: Posterior tilt can reduce pressures at the interface under the pelvis.

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.

Effect of seat surface inclination on postural control during reaching in preterm children with cerebral palsy

BACKGROUND AND PURPOSE

Because it is debatable whether seat surface inclination improves motor function in children with cerebral palsy (CP), the effect of seat surface tilting on postural control and quality of reaching was studied.

SUBJECTS

The subjects were 58 children with CP aged 2 to 11 years (34 with unilateral spastic CP, 24 with bilateral spastic CP).

METHODS

During the task of reaching movements, surface electromyographic and kinematic data were recorded for posture and reaching with the dominant arm in 3 sitting conditions: horizontal seat surface, seat surface tilted forward 15 degrees, and seat surface tilted backward 15 degrees.

RESULTS

In the children with unilateral spastic CP, forward tilting improved postural efficiency and quality of reaching. In the children with bilateral spastic CP, both forward and backward tilting of the seat surface was associated with more postural instability and did not affect the quality of reaching.

DISCUSSION AND CONCLUSION

The results suggest that, in terms of postural control and quality of reaching, children with unilateral spastic CP benefit from a forward-tilted position and children with bilateral spastic CP benefit from a horizontal sitting position.

The effects of therapeutic taping on gross motor function in children with cerebral palsy

PURPOSE

Therapeutic taping to address dysfunctional sitting control in children with cerebral palsy (CP) was investigated in this study.

METHODS

Eighteen children with quadriplegic CP, Gross Motor Function Classification System for Cerebral Palsy levels IV (n = 9) and V (n = 9) participated in the 12-week program. Subjects were assigned randomly to one of two groups: therapeutic taping + physical therapy or physical therapy only. Therapeutic taping was applied for periods of up to 72 hours over the paraspinal region. The effects were assessed with the Gross Motor Function Measure (GMFM-88) at baseline, six weeks, and 12 weeks. A factorial analysis of variance was used to examine group differences over time.

RESULTS

No significant differences were found for the GMFM-88 scores between groups over time.

CONCLUSION

Therapeutic taping does not evoke a positive functional change in the seated postural control of children with quadriplegic cerebral palsy. Subjective observation, however, suggested that one child with athetosis benefited from therapeutic taping over the paraspinal region.

A method to measure reaching capacity of children with neuromuscular disorders

PROBLEM

The measurement of quantitative changes in upper-extremity skills has been limited by the lack of objective standardized measures and, therefore, reaching tasks have been subjectively defined.

SOLUTION

A frame made from PVC tubing was constructed to assist in measuring the parameters of vertical, horizontal, and cross midline functional reach of children with neuromuscular disorders, and a measurement protocol was adopted for obtaining the measures of reach.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Suggestions for assuring consistency in measurements and further exploration of the number of sessions required to determine a child's best reaching effort are put forth.

Buggy-to-wheelchair progression for children with cerebral palsy: Parents’ and therapists’ opinions

Some children with cerebral palsy (CP) are transported in buggies until they master the skills of ambulation. Many never learn to walk and progress from a buggy to a wheelchair as a means of maximizing their independence and improving their motor and functional skills. Therapists and parents often hold conflicting views as to why a child may not be progressed to a wheelchair from a buggy.

A study was undertaken to explore the opinions of health professionals and parents concerning this problem. A questionnaire for each cohort (therapists n=17; parents n=28) was constructed containing 10 identical but general questions. Results obtained were analysed individually for each cohort and then compared to see if there was any concordance between them. Both groups believed the main factors preventing change were: transport problems making wheelchair travel difficult; inadequate housing; poorer manoeuvrability of the wheelchair compared with the buggy; and a lack of information about progressing to a wheelchair. Statistical analysis showed no correlation between how parents and therapists responded. A multilingual handbook for therapists and parents needs to be produced detailing the pros and cons of buggy-to-wheelchair progression.

Therapeutic positioning, wheelchair seating, and pulmonary function of children with cerebral palsy: a research synthesis

This review analyzed research literature concerning pulmonary function and positioning of persons with cerebral palsy (CP) who lack trunk control. The search reviewed literature published from 1966 through March 2003. Twenty-eight references located by electronic database search were analyzed using Moody's Research Analysis Tool. All reflected either a physiologic or therapy-based model involving function in activities of daily living, but no health outcomes. One reference applied a nursing model to care of developmentally disabled persons, including those with CP. Existing research gaps include the need for human subjects, larger sample sizes, measurement of influence of gravity on body position, greater precision in describing independent variables of positioning, and participation by children with disabilities. This paper proposes a conceptual model using Orem's self-care theory upon which to base nursing interventions, including therapeutic positioning of persons with CP who lack trunk control. Future nursing research should explore health outcomes of various properties of wheelchair positioning.

Clinical evaluation of seating in persons with complete thoracic spinal cord injury

STUDY DESIGN

Consecutive male patients studied with photographic measurement of a combination of clinical methods.

OBJECTIVES

To describe seating in individuals with complete thoracic spinal cord injury (SCI) by using a combination of clinical methods.

SETTING

Spinalis SCI unit, Stockholm, Sweden.

METHODS

Wheelchair specifications were documented. Measurements of posture from photographs in 30 male subjects with complete thoracic SCI, sitting in a relaxed and an upright position on a standardized surface and in a wheelchair were calculated. A comparison was made between positions and seating surfaces. An examiner's classification of lower trunk position in wheelchair was compared to subjects' evaluations. SCI subjects reported sitting support, satisfaction, and wishes for improvement.

RESULTS

Most SCI subjects used similar wheelchair specifications. None of the backrests were custom designed. Relatively small differences were found between the relaxed and upright position in the wheelchair regarding measurements of posture and according to the examiner's classification of the lower trunk position. Only 13/30 SCI subjects were sitting with the lower trunk centered relative to the backrest in the upright position. The examiner's classification and the subjects' evaluation of asymmetric sitting were not always in agreement. Only 12/30 SCI subjects were satisfied with their way of sitting.

CONCLUSION

Current wheelchair specifications and adjustments seem to inhibit a postural correction towards upright sitting and fail to provide sufficient lateral support. Findings indicate an inability for SCI subjects to vary their sitting position in a wheelchair to a large extent. Both an examiner's classification and subjects' evaluation of asymmetric sitting are necessary to obtain a sufficient knowledge base for subsequent adjustment. By using methods regarding different aspects of seating, a more comprehensive view of seating was achieved. The combination of clinical methods seems to be useful in order to describe seating in individuals with complete thoracic SCI.

A comparison between parents?? and therapists?? views of their child??s individual seating systems

Children with cerebral palsy are often prescribed adaptive seating systems for use in their wheelchairs for the purposes of improving posture and to help prevent the development of long-term deformity. However, clinical experience indicates that parents and the therapists who advocate the use of these systems do not always agree about the wheelchairs. This study discusses the development of questionnaires for both parents and therapists to measure differences in their opinions about the wheelchairs. The questions were developed through clinical experience, validation was through interviews to discuss topics important to the participants, and repeated application of the questionnaire ensured consistency. The reliability of the questions appears satisfactory and the interview responses demonstrate that the questions selected are important to both groups of stakeholders. However, it was found that parental concerns over their children's seating systems concentrated on functional and day-to-day management issues, whereas therapist concerns focused on technical issues and postural management. Both groups of stakeholders agreed that the questionnaires would be a useful precursor to attending a seating clinic appointment, as it could aid communication between the parent and provider and improve the efficiency and satisfaction of such an appointment. It appears the questionnaire has potential as an outcome measurement tool.

Differences in seated postural control in children with spastic cerebral palsy and children who are typically developing

OBJECTIVE

To quantitatively evaluate the difference of posture control in sitting position between children with spastic cerebral palsy and normal subjects.

DESIGN

Twenty children with spastic cerebral palsy who could sit independently and 20 age- and sex-matched normal children were enrolled. The Chatteex Balance System was used to evaluate static and dynamic posture control as the subjects were sitting on a bench. The sway distance in sagittal and lateral directions, sway ratio, and sway index in both the static and dynamic sitting positions were recorded by the Chatteex Balance System.

RESULTS

There was a significantly lower static and dynamic sway ratio and a greater static sway index and dynamic lateral sway distance in the study group. The dynamic sway index in the study group was greater than the index in the control group, although it did not reach statistical significance.

CONCLUSIONS

Children with diplegic cerebral palsy did perform significantly worse in sitting posture control compared with normal subjects of similar chronological age. The sway index and sway ratio proved to be the objective and sensitive indicators that can be used to distinguish children with cerebral palsy from normal peer groups.

Management of upper limb dysfunction in children with cerebral palsy: a systematic review

Effective use of the upper limb can impact on educational outcomes, participation in activities of daily living and vocational options for many children with cerebral palsy (CP). This article presents the results of a systematic review of the literature on the management of upper limb dysfunction in children with CP. The range of management options includes therapies such as physiotherapy, occupational therapy, neurodevelopmental therapy and conductive education; peripheral splinting and casting; focal or generalized pharmacotherapy; and surgery to improve upper limb function or correct deformity. A literature search identified 60 papers, of which four were randomized controlled trials and 44 were prospective studies with objective outcome measures. Principal studies undertaken for each type of treatment and the efficacy of the different types of treatment were critically evaluated. In addition, the current level of evidence for each study was evaluated according to Sackett's (1989) model and ICIDH-2 classification. A close examination of two relatively new treatments for upper limb spasticity, constraint induced movement therapy and botulinum toxin type A (BTX-A) was conducted with reference to more extensive data on the efficacy of BTX-A in the lower limb.

Effects of static and dynamic shoulder rotator exercises in women with rheumatoid arthritis: a randomised comparison of impairment, disability, handicap, and health

The aim was to compare static and dynamic shoulder rotator endurance training in a group of women with mild rheumatoid arthritis and to see whether such training could influence impairment, disability, and handicap. The effects on general health were also studied. Patients were randomly assigned to a static (n = 17) (average age 59, median disease duration 7) or a dynamic training group (n = 20) (average age 56, median disease duration 10.5). Measurements were taken at the start, 10 weeks later when the training period was finished, and after a further 10 weeks. After the training both groups had fewer swollen joints in the upper extremity and less shoulder-arm pain. The dynamic group patients also improved according to the physical and overall dimensions of the Sickness Impact Profile. As impairment and aspects of disability and handicap were influenced by training but not by the patients' opinions regarding perceived disease activity and health, these relationships must be studied further.

A preliminary report on the effectiveness of trunk targeting in achieving independent sitting balance in children with cerebral palsy

OBJECTIVE

To assess the potential of Targeted Training in initiating or accelerating improved movement control of the trunk and hip joints in children with cerebral palsy so that independent sitting balance without specialized seating could be achieved.

DESIGN

Six single case studies.

SETTING

Assessment and review were undertaken in a specialized centre with intervention in the subjects' home or school.

SUBJECTS

Children between the ages of two years five months and seven years five months (mean four years seven months) with an established diagnosis of cerebral palsy. None had independent sitting balance at the start of the study.

INTERVENTION

Targeted Training using specialized equipment was directed at the appropriate few joints of the trunk as determined by initial testing and progressed when control at those joints had become automatic. The equipment provided support and challenged control learning. Periods of no intervention and placebo intervention, when the equipment was inappropriately set up, were also used. Two of the children ceased their traditional physiotherapy input while Targeted Training or placebo training took place.

MAIN OUTCOME MEASURE

A new test was devised and validated to determine the most caudal extent of control of the vertical posture. In addition, a functional test of independent sitting balance was defined.

RESULTS

All six children showed an increase in movement control and all gained independent sitting balance within 12-25 weeks (mean 16 weeks). This was irrespective of the continuation or cessation of traditional physiotherapy.

CONCLUSION

These preliminary findings suggest that Targeted Training may be an effective means of promoting movement control and functional ability. Confirmation of these findings by other investigators would be of value.

Postural control in sitting children with cerebral palsy

Children with cerebral palsy (CP) display postural problems, largely interfering with daily life activities. Clarification of neural mechanisms controlling posture in these children could serve as a base for more successful intervention. Studies on postural adjustments following horizontal forward and backward displacements of a movable platform in ten school-age children with spastic diplegia and non-disabled controls revealed that sitting CP children, like standing CP children, show direction specific postural adjustments, indicating that the basic pattern of muscle coordination in these conditions is conserved. Dysfunctions are especially present in the modulation of the response pattern of ventral muscles during forward translations. They consist of: (1) a stereotyped and non-variable activation of all ventral muscles; (2) an abnormal top-down muscle recruitment; and (3) an excessive degree of antagonistic co-activation. The altered patterns of muscle coordination could be the result of two interacting mechanisms, the primary deficit due to the early brain damage and a compensation due to the postural instability. Especially the latter dysfunction furnishes opportunities for therapeutic help.

Quantifying the effects of interventions for movement disorders resulting from cerebral palsy

The purpose of this article is to review a variety of tests and measures that are useful in documenting and quantifying the outcomes of intervention for persons with cerebral palsy. The topics included are (1) a discussion of the need for meaningful outcome measures, (2) a model of the disabling process for classifying measures used to assess several different dimensions of disablement, and (3) a review of selected tests and measures categorized according to the model described.