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Gözaçan Karabulut D, Numanoğlu Akbaş A. Validity and reliability of the Sitting Assessment Scale in cerebral palsy. J Eval Clin Pract 2024; 30:670-677. [PMID: 38588276 DOI: 10.1111/jep.13992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 04/10/2024]
Abstract
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.
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Affiliation(s)
- Demet Gözaçan Karabulut
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Gaziantep Islam Science and Technology University, Gaziantep, Turkey
| | - Ayşe Numanoğlu Akbaş
- Department of Physical Therapy and Rehabilitation, Health Sciences Faculty, Sivas Cumhuriyet University, Sivas, Turkey
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Acharya BD, Karki A, Prasertsukdee S, Reed D, Rawal L, Baniya PL, Boyd RN. Effect of Adaptive Seating Systems on Postural Control and Activity Performance: A Systematic Review. Pediatr Phys Ther 2023; 35:397-410. [PMID: 37747975 DOI: 10.1097/pep.0000000000001042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
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.
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Affiliation(s)
- Bishnu Dutta Acharya
- Department of Physical Therapy (Mr Acharya), Karnali Academy of Health Sciences, Jumla, Nepal; Community-Based Rehabilitation (Ms Karki) International Nepal Fellowship, Mugu, Nepal; Faculty of Physical Therapy (Dr Prasertsukdee), Mahidol University, Salaya, Thailand; School of Medical Sciences (Dr Reed), Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia; School of Health, Medical and Applied Sciences (Dr Rawal), Central Queensland University, Sydney, Australia; Nepal Health Research Council (Ms Baniya), Kathmandu, Nepal; Queensland Cerebral Palsy and Rehabilitation Research Centre (Dr Boyd), Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Ilharreborde B, de Saint Etienne A, Presedo A, Simon AL. Spinal sagittal alignment and head control in patients with cerebral palsy. J Child Orthop 2020; 14:17-23. [PMID: 32165977 PMCID: PMC7043126 DOI: 10.1302/1863-2548.14.190160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Spinal sagittal alignment restoration has been associated with improved functional outcomes and with reduced complications rates. Several limitations exist for radiological analysis in cerebral palsy (CP) patients. The goal of this study was to summarize the existing literature and report the important considerations to evaluate in a CP patient undergoing spinal surgery. METHODS A retrospective radiological analysis was performed, including non-ambulant CP children with progressive scoliosis. Full-spine sitting radiographs performed pre-and postoperatively were required to measure spino-pelvic sagittal parameters. RESULT A total of 23 non-ambulating CP patients were included, mean age 16.0 years (standard error of the mean 0.5). Two distinct groups of patients were identified. Group 1 (61%) were patients with less trunk control (lumbar lordosis (LL) < 50°), retroverted and vertical pelvis (mean sacral slope (SS) 11.4° and pelvic tilt (PT) 38.1°) and anterior imbalance (mean sagittal vertical axis (SVA) 5.9 cm) and Group 2 (39%) were patients with better trunk control (LL > 60°, anteverted and horizontal pelvis (mean SS 49.3°, PT 9.7°) and posterior imbalance (mean SVA 5.8 cm). Postoperative measures showed significant impact of surgery with a PT reduction of 19° (p = 0.007), a mean SS increase of 15° (p = 0.04) and a LL gained of 10° (p = 0.2). CONCLUSION Sagittal spino-pelvic alignment in non-ambulating CP patients remains difficult to assess. The current literature is poor but our radiological study was able to define two distinct groups among Gross Motor Function Classification System (GMFCS) level V patients, based on the quality of their trunk control. All possible factors that may influence head and trunk posture should be systematically considered and optimized. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | | | - Ana Presedo
- Department of Pediatric Orthopaedics, Paris Diderot University, France
| | - Anne-Laure Simon
- Department of Pediatric Orthopaedics, Paris Diderot University, France,Correspondence should be sent to Anne Laure Simon, Department of Pediatric Orthopaedics, Robert Debré Hospital, AP-HP, Paris Diderot University, 48 Bd Sérurier, 75019 Paris, France. E-mail:
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Angsupaisal M, Dijkstra LJ, la Bastide-van Gemert S, van Hoorn JF, Burger K, Maathuis CGB, Hadders-Algra M. Effects of forward tilted seating and foot-support on postural adjustments in children with spastic cerebral palsy: An EMG-study. Eur J Paediatr Neurol 2019; 23:723-732. [PMID: 31420131 DOI: 10.1016/j.ejpn.2019.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/19/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Mattana Angsupaisal
- University of Groningen, University Medical Center Groningen, Department of Paediatrics - Division of Developmental Neurology, Groningen, the Netherlands
| | - Linze-Jaap Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Paediatrics - Division of Developmental Neurology, Groningen, the Netherlands
| | - Sacha la Bastide-van Gemert
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, the Netherlands
| | - Jessika F van Hoorn
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center for Rehabilitation, Groningen, the Netherlands
| | - Karine Burger
- Vogellanden Rehabilitation Center, Zwolle, the Netherlands
| | - Carel G B Maathuis
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center for Rehabilitation, Groningen, the Netherlands
| | - Mijna Hadders-Algra
- University of Groningen, University Medical Center Groningen, Department of Paediatrics - Division of Developmental Neurology, Groningen, the Netherlands.
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Giray E, Karadag-Saygi E, Ozsoy T, Gungor S, Kayhan O. 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. Disabil Rehabil 2018; 42:410-418. [PMID: 30293457 DOI: 10.1080/09638288.2018.1501098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Esra Giray
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Evrim Karadag-Saygi
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Tugba Ozsoy
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Sabiha Gungor
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Onder Kayhan
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
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Pedicle Subtraction Osteotomy Versus Multiple Posterior Column Osteotomies in Severe and Rigid Neuromuscular Scoliosis. Spine (Phila Pa 1976) 2018; 43:E905-E910. [PMID: 29293162 DOI: 10.1097/brs.0000000000002538] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE The aim of this study is to compare the safety and efficacy of the apical pedicle subtraction osteotomy (PSO) technique with multiple posterior column osteotomies (PCOs) in nonambulatory patients with severe, rigid neuromuscular scoliosis. SUMMARY OF BACKGROUND DATA Neuromuscular scoliosis frequently causes intolerance to sitting due to pelvic obliquity, trunk decompensation, and associated back and rib impingement pain which diminish the patient's functional capacity. In the case of rigid curves, spinal osteotomy techniques are occasionally required for effective correction. METHODS We retrospectively reviewed our patients with severe and rigid neuromuscular scoliosis with associated pelvic obliquity who were treated with posterior instrumented fusion extending to pelvis with more than 1-year postoperative follow-up. We compared radiological and clinical results of PSO and multiple PCO techniques in severe rigid neuromuscular scoliosis with pelvic obliquity of more than 15° in traction radiograph under general anesthesia. Hospital records were also reviewed for operative time, intraoperative blood loss, amount of blood transfusion, duration of hospital stay, and complications. RESULTS There were 12 patients in the PSO group and 10 patients in the PCO group. There was no significant difference between groups in terms of major curve magnitude, sagittal parameters or pelvic obliquity. Although not statistically significant, PSO technique did trend toward better scoliosis correction (post-op Cobb angle 56.1° vs. 66.7° [P = 0.415]). PSO technique provided a significantly better correction in pelvic obliquity (59% vs. 84%) (P = 0.001). There was no significant difference in average intraoperative blood loss, transfusion, and operative times including anesthesia time, hospital stay, or complications. CONCLUSION PSO may be an option in correction of severe and rigid neuromuscular scoliosis. It provides better correction of pelvic obliquity without increasing operative time, need for transfusion, or duration of hospitalization as compared to multiple apical PCO technique. Traction radiograph under general anesthesia is a valuable tool in surgical decision making. LEVEL OF EVIDENCE 4.
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Does stabilizing input pressure orthosis vest, lycra-based compression orthosis, improve trunk posture and prevent hip lateralization in children with cerebral palsy? Turk J Phys Med Rehabil 2017; 64:100-107. [PMID: 31453498 DOI: 10.5606/tftrd.2018.1332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 07/21/2017] [Indexed: 11/21/2022] Open
Abstract
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.
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Sahinoğlu D, Coskun G, Bek N. Effects of different seating equipment on postural control and upper extremity function in children with cerebral palsy. Prosthet Orthot Int 2017; 41:85-94. [PMID: 27025243 DOI: 10.1177/0309364616637490] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Dilek Sahinoğlu
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
| | - Gürsoy Coskun
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
| | - Nilgün Bek
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
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McDonald R, Surtees R, Wirz S. The International Classification of Functioning, Disability and Health provides a Model for Adaptive Seating Interventions for Children with Cerebral Palsy. Br J Occup Ther 2016. [DOI: 10.1177/030802260406700703] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Bañas BB, Gorgon EJR. Clinimetric properties of sitting balance measures for children with cerebral palsy: a systematic review. Phys Occup Ther Pediatr 2014; 34:313-34. [PMID: 24490854 DOI: 10.3109/01942638.2014.881952] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Saether R, Helbostad JL, Riphagen II, Vik T. Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review. Dev Med Child Neurol 2013; 55:988-99. [PMID: 23679987 DOI: 10.1111/dmcn.12162] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2013] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Rannei Saether
- Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Paediatrics, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Effgen SK, McEwen IR. Review of selected physical therapy interventions for school age children with disabilities. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/174328808x309287] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Field D, Livingstone R. Clinical tools that measure sitting posture, seated postural control or functional abilities in children with motor impairments: a systematic review. Clin Rehabil 2013; 27:994-1004. [PMID: 23858526 DOI: 10.1177/0269215513488122] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Debra Field
- 1Sunny Hill Health Centre for Children, Canada
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Braccialli LMP, Sankako AN, Braccialli AC, Oliveira FT, Lucareli PRG. The influence of the flexibility of the chair seat on pressure peak and distribution of the contact area in individuals with cerebral palsy during the execution of a task. Disabil Rehabil Assist Technol 2011; 6:331-7. [DOI: 10.3109/17483107.2010.529632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Costigan FA, Light J. Functional Seating for School-Age Children With Cerebral Palsy: An Evidence-Based Tutorial. Lang Speech Hear Serv Sch 2011; 42:223-36. [DOI: 10.1044/0161-1461(2010/10-0001)] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
| | - Janice Light
- The Pennsylvania State University, University Park
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ŞŞimşşek TT, Türkücüoğğlu B, Çokal N, Üstünbaşş G, ŞŞimşşek İİE. The effects of Kinesio® taping on sitting posture, functional independence and gross motor function in children with cerebral palsy. Disabil Rehabil 2011; 33:2058-63. [DOI: 10.3109/09638288.2011.560331] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Costigan FA, Light J. Effect of Seated Position on Upper-Extremity Access to Augmentative Communication for Children With Cerebral Palsy: Preliminary Investigation. Am J Occup Ther 2010; 64:596-604. [DOI: 10.5014/ajot.2010.09013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- F. Aileen Costigan
- F. Aileen Costigan, MSc-OT, is Doctoral Candidate, Department of Communication Sciences and Disorders, 308 Ford Building, The Pennsylvania State University, University Park, PA 16802;
| | - Janice Light
- Janice Light, PhD, is Distinguished Professor, Department of Communication Sciences, The Pennsylvania State University, University Park
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Rodby-Bousquet E, Hägglund G. Sitting and standing performance in a total population of children with cerebral palsy: a cross-sectional study. BMC Musculoskelet Disord 2010; 11:131. [PMID: 20573201 PMCID: PMC2908562 DOI: 10.1186/1471-2474-11-131] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 06/23/2010] [Indexed: 11/12/2022] Open
Abstract
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.
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Wright C, Casey J, Porter-Armstrong A. Establishing best practice in seating assessment for children with physical disabilities using qualitative methodologies. Disabil Rehabil Assist Technol 2009; 5:34-47. [DOI: 10.3109/17483100903137154] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Cherng RJ, Lin HC, Ju YH, Ho CS. Effect of seat surface inclination on postural stability and forward reaching efficiency in children with spastic cerebral palsy. RESEARCH IN DEVELOPMENTAL DISABILITIES 2009; 30:1420-1427. [PMID: 19647395 DOI: 10.1016/j.ridd.2009.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Accepted: 07/05/2009] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- Rong-Ju Cherng
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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21
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Mcnamara L, Casey J. Seat inclinations affect the function of children with cerebral palsy: A review of the effect of different seat inclines. Disabil Rehabil Assist Technol 2009; 2:309-18. [DOI: 10.1080/17483100701661314] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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22
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Radell U, Tillberg E, Mattsson E, Åmark P. Postnatal cerebral infection leading to hemiplegic cerebral palsy: Functional limitations and disability of 13 children in Sweden. Disabil Rehabil 2009; 30:1910-9. [DOI: 10.1080/09638280701673641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Lancioni GE, O'Reilly MF, Singh NN, Oliva D, Scalini L, Vigo CM, Groeneweg J. Microswitch clusters to enhance adaptive responses and head control: A programme extension for three children with multiple disabilities. Disabil Rehabil 2009; 27:637-41. [PMID: 16019874 DOI: 10.1080/09638280500030472] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE We assessed the possibility of extending adaptive responding and head control in three children with multiple disabilities through the use of microswitch clusters. METHOD The children had previously learned to perform an adaptive hand response and to control head position during that response. They were now taught one or two new adaptive responses (foot lifting, leg touching, or vocalization) and to combine such responses with appropriate head position. Microswitch clusters served to ensure that an adaptive response was followed by positive stimulation only if it was combined with appropriate head position. RESULTS The results were positive with the children learning the new adaptive responses and combining them with appropriate head position. This performance was maintained during two- or three-month post-intervention checks. During these checks, the children were also successful in using the old adaptive hand response with appropriate head position. CONCLUSIONS The use of microswitch clusters was effective to extend the level of adaptive responding and enhance appropriate head position during this responding. This outcome, which indicates a successful technical replication and procedural extension of previous work in the area, has positive practical implications for educational and occupational programmes for children with multiple disabilities.
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Affiliation(s)
- G E Lancioni
- Department of Psychology, University of Bari, Italy.
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Oliva D, Gatti M, Manfredi F, Megna G, La Martire ML, Tota A, Smaldone A, Groeneweg J. A microswitch-cluster program to foster adaptive responses and head control in students with multiple disabilities: replication and validation assessment. RESEARCH IN DEVELOPMENTAL DISABILITIES 2008; 29:373-84. [PMID: 17681451 DOI: 10.1016/j.ridd.2007.06.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Accepted: 06/28/2007] [Indexed: 05/16/2023]
Abstract
A program relying on microswitch clusters (i.e., combinations of microswitches) and preferred stimuli was recently developed to foster adaptive responses and head control in persons with multiple disabilities. In the last version of this program, preferred stimuli (a) are scheduled for adaptive responses occurring in combination with head control (i.e., head upright) and (b) last through the scheduled time only if head control is maintained for that time. The first of the present two studies was aimed at replicating this program with three new participants with multiple disabilities adding to the three reported by Lancioni et al. [Lancioni, G. E., Singh, N. N., O'Reilly, M. F., Sigafoos, J., Didden, R., Oliva, D., et al. (2007). Fostering adaptive responses and head control in students with multiple disabilities through a microswitch-based program: Follow-up assessment and program revision. Research in Developmental Disabilities, 28, 187-196]. The second of the two studies served to carry out an expert validation of the program's effects on head control and general physical condition with the three participants of Study I as well as the three participants involved in the Lancioni et al. study mentioned above. The expert raters were 72 new physiotherapists and 72 experienced physiotherapists. The results of Study I supported previous data and indicated that the program was effective in helping the participants increase the frequency of adaptive responses in combination with head control and the length of such control. The results of Study II showed that the raters found the effects of the new program more positive than those of other intervention conditions and also considered such program a useful complement to formal motor rehabilitation programs.
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Seat load characteristics in children with neuromuscular and syndrome-related scoliosis: effects of pathology and treatment. J Pediatr Orthop B 2008; 17:139-44. [PMID: 18391813 DOI: 10.1097/bpb.0b013e3282fde471] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The amount of correction from spine deformity surgery that is required to avoid asymmetric and unbalanced sitting is not known, and methods sensitive enough to document moderate changes in pressure distribution over time are few, as the commonly used methods are qualitative or semiquantitative. The aim was to analyse seating pressure distribution with a pressure sensor mat system in patients with nonidiopathic scoliosis and to compare the pressure distribution with that in able-bodied controls. The aim was also to apply the method in a surgically treated scoliosis group before and after the spine fusion. Peak pressure, contact area of the entire and the maximum pressure surface, and three measures of asymmetry were calculated. Patients had higher peak pressure and more asymmetric loading than controls. Significant difference was indicated in contact area. After the spine fusion, all asymmetry indices improved. The method fulfilled clinical needs to detect the differences from normal controls as well as the surgery-dependent changes.
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Effectiveness of adaptive seating on sitting posture and postural control in children with cerebral palsy. Pediatr Phys Ther 2008; 20:303-17. [PMID: 19011521 DOI: 10.1097/pep.0b013e31818b7bdd] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Gisel E. Interventions and outcomes for children with dysphagia. ACTA ACUST UNITED AC 2008; 14:165-73. [DOI: 10.1002/ddrr.21] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Wiens GA, Pitetti KP. A method to measure reaching capacity of children with neuromuscular disorders. Pediatr Phys Ther 2006; 18:226-8. [PMID: 16912643 DOI: 10.1097/01.pep.0000232448.75039.c7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Butler PB. A preliminary report on the effectiveness of trunk targeting in achieving independent sitting balance in children with cerebral palsy. Clin Rehabil 1998; 12:281-93. [PMID: 9744664 DOI: 10.1191/026921598667577442] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- P B Butler
- The Movement Centre at The Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, Shropshire, UK
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Pain H, Pascoe J, Gore S, McLellan DL. Multi-adjustable chairs for children with disabilities. J Med Eng Technol 1996; 20:151-6. [PMID: 8934406 DOI: 10.3109/03091909609008395] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There is a growing demand that severely disabled children should be offered a normal-looking, comfortable alternative to highly supportive wheelchair seating to facilitate relaxation and social integration. An evaluation of five chairs, funded by Medical Devices Agency, an executive agency of the Department of Health, was undertaken with potential and actual users of these chairs to investigate the chairs' function with respect to the child's posture, and what features were effective. Twenty-nine children tried five chairs for up to 30 min in each; and a postal survey received 100 responses. The chairs seem to meet many users' postural needs (78% of postal survey; 31-72% of short-term evaluation depending on chair); the chairs' adjustability and availability of special features are important in meeting the needs of this user group; evidence of poor design and its implications are discussed.
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Affiliation(s)
- H Pain
- Disability Equipment Assessment Centre, Southampton General Hospital, UK
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