An overview of systematic reviews of adaptive seating interventions for children with cerebral palsy: where do we go from here?

Understanding the use and benefits of assistive devices among young children with cerebral palsy and their families in Norway: a cross-sectional population-based registry study

PURPOSE

Assistive technology intervention has become an important strategy in enhancing function in young children with cerebral palsy. This study aimed to provide an in-depth knowledge of the use of assistive devices by describing their purposes, the environments in which they are used, frequency of use and perceived benefits from the caregiver's perspective.

MATERIAL AND METHODS

This is a cross-sectional population-based study using data from national cerebral palsy registers in Norway. Of a total of 202 children, 130 participated (mean age 49.9 months, SD 14.0 months).

RESULTS

The 130 children and their families used a median of 2.5 assistive devices (range 0-12) to support positioning, mobility, self-care and training, stimulation and play. Devices most commonly had one or two main purposes and were used both at home and in kindergarten/school. The usage rate varied from less than twice a week to several times a day. The majority of parents reported significant benefits for caregiving and/or the child's functioning. Total use increased in accordance with the level of the child's gross motor limitations and was associated with restrictions imposed by housing concerns.

CONCLUSIONS

The frequent use of a wide range of devices, and the intended and perceived benefits, demonstrates that early provision of assistive devices can be an effective function-enhancing strategy in young children with cerebral palsy. However, the findings also indicate that factors others than the child's motor abilities must be considered when integrating the use of devices into the child's daily routines and activities.

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.

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

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

Turkish validity and reliability of the level of sitting scale in children with cerebral palsy

BACKGROUND

The Level of Sitting Scale (LSS) is a valid and reliable classification index that categorizes sitting ability. The aim of this study is to establish the Turkish validity and reliability of the LSS in children with cerebral palsy (CP).

METHODS

In total, 165 children (75 girls and 90 boys) between the ages of 4 and 18 years who were diagnosed with CP were included in the study. All children were evaluated by two independent physiotherapists for the interrater reliability analysis of the LSS and were reevaluated 1 week later by the same physiotherapist for the intrarater reliability analysis. The Gross Motor Function Classification System (GMFCS) was used for validity analysis.

RESULTS

The intrarater reliability analyses of the LSS showed an intraclass correlation coefficient of 0.999 (ICC 95% CI [0.999-1]),and the interrater reliability analyses showed an intraclass correlation coefficient of 0.998 (ICC 95% CI [0.998-0.999]). A statistically significant, negative, and strong correlation was found between the GMFCS and the LSS (p < 0.001, r = -0.770).

DISCUSSION

The Turkish version of the LSS in children with CP is a valid and reliable scale. The Turkish LSS can be used by researchersand clinicians in research and to determine the sitting level of children with CP.

Prevalence of the need for adaptive seating systems among children with cerebral palsy in Egypt

BACKGROUND

An adaptive seating system is a basic rehabilitation need for children and youth with cerebral palsy (CP) as it supports the structure and function of the musculoskeletal system and can positively affect their activities and participation. Despite the importance of adaptive seating systems, there is limited access to such systems in low-income countries.

OBJECTIVES

To determine the percentage of children and youth between 4 and 18 years of age with CP in Egypt whose activity level and sitting ability suggest the need for an adaptive seating system.

STUDY DESIGN

Observational cross-sectional study.

METHODS

One hundred ninety-three participants were included after fulfilling the criteria of the Surveillance of Cerebral Palsy of Europe. Their level of activity was assessed by a physical therapist using the Gross Motor Function Classification System (GMFCS), and their sitting ability was evaluated using the Level of Sitting Scale (LSS). Participants were considered to require an adaptive seating system if they scored GMFCS level IV or V and LSS level 1-5 concurrently.

RESULTS

Approximately 44% of the study participants were classified as GMFCS level IV or V and LSS level 1-5, suggesting that they were in need of an adaptive seating system.

CONCLUSIONS

There is a large percentage of children and youth with CP in Egypt who need an adaptive seating system to be integrated into their rehabilitation.

Evidence-informed clinical perspectives on postural management for hip health in children and adults with non-ambulant cerebral palsy

Postural management is a multi-disciplinary approach incorporating a comprehensive schedule of daily and night-time positions, equipment and physical activity to help maintain or improve body structures and function and increase activity and participation. Postural management may play a role in preventing contracture, deformity, pain, and asymmetry. This article provides an overview of the evidence supporting use of postural management to positively influence hip health in individuals with cerebral palsy, functioning as Gross Motor Classification System (GMFCS) levels IV or V. Sitting or lying without changing position for more than 8 hours, unsupported supine lying and asymmetrical or windswept postures are associated with pain and hip subluxation/dislocation. Although high-quality experimental research is still limited by many factors, there is limited evidence of harm, and most individuals at GMFCS IV or V require positioning supports to enable participation and function and ease caregiving. Clinical recommendations combining research and clinical opinion support the early use of comfortable positioning routines and/or equipment to reduce time spent in sustained asymmetrical or potentially harmful sitting and lying positions. Supported standing, active weightbearing and stepping are recommended to promote active movement and position change when possible, depending on individual, family and caregiver routines and preferences.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Evidence Based Position Paper on Physical and Rehabilitation Medicine professional practice for persons with cerebral palsy

INTRODUCTION

Cerebral palsy (CP) is a group of the most common developmental disorders affecting movement and posture of the body, causing activity limitations and participation restrictions. The motor disorders of persons with CP are often accompanied by disturbances of sensation, cognition, communication and perception. The symptoms of CP are very diverse and persons with CP are usually presented with a mixed type of symptoms. The non-progressive disturbances can be attributed to disorders that were developed during pregnancy, birth and/or infant stage.

AIM

The aim of this study was to improve Physical and Rehabilitation Medicine physician´s professional practice for persons with cerebral palsy in order to improve their functionality, social and community integration, and to reduce activity limitations and/or participation restrictions.

MATERIAL AND METHODS

A systematic review of the literature including an eighteen-year period and consensus procedure by means of a Delphi process was performed and involved the delegates of all European countries represented in the Union of European Medical Specialists Physical and Rehabilitation Medicine (UEMS PRM) Section.

RESULTS

As the result of a Consensus Delphi procedure process 74 recommendations are presented together with the systematic literature review.

CONCLUSIONS

The PRM physician´s role for persons with cerebral palsy is to lead and coordinate the multiprofessional team, working in an interdisciplinary way. They should propose and manage the complex but individual PRM programme developed in conjunction with other health professionals, medical specialists and importantly in agreement with the patient, their family and care giver. This should be, according to the specific medical diagnosis to improve patients´ health, functioning, social and education status, considering all impairments, comorbidities and complications, activity limitations and participation restrictions.

Evaluation of the multidimensional effects of adaptive seating interventions for young children with non-ambulatory cerebral palsy

PURPOSE

To investigate the short-term effectiveness of the first adaptive seating system received by children with non-ambulatory cerebral palsy (CP) who are classified as level IV or V according to the Gross Motor Function Classification System.

MATERIALS AND METHODS

A trained clinical assessor examined 20 children with non-ambulatory CP (mean age: 4.5 years) for their trunk control ability in static, active, and reactive tasks using the Segmental Assessment of Trunk Control. Their primary caregivers were also interviewed about their child's activity and participation using the Paediatric Evaluation of Disability Inventory Computer - Adaptive Test in daily activity and social/cognitive domains and Family Impact of Assistive Technology Scale for Adaptive Seating in child and family functioning domains. Data for each measure were collected 3 times: at baseline (pre-intervention) and then 6 weeks and 3 months after children received their first adaptive seating system.

RESULTS AND CONCLUSION

The static and active trunk control scores between baseline and 6 weeks, and baseline and 3 months significantly improved. Daily activity scaled scores significantly improved between baseline and 3 months, and 6 weeks and 3 months. Significant, large gains in child and family functioning overall were detected between baseline and 6 weeks, and baseline and 3 months. These findings provide emerging evidence of multidimensional effects associated with the introduction of a first adaptive seating system into the lives of young children with non-ambulatory CPIMPLICATIONS FOR REHABILITATIONThe introduction of an adaptive seating system into the wheelchair of children with non-ambulatory cerebral palsy may be associated with short-term gains in body function, activities, participation and aspects of the child's environment.

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

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

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.

Best seating condition in children with spastic cerebral palsy: One type does not fit all

BACKGROUND

The effect of forward-tilting of the seat surface and foot-support in children with spastic cerebral palsy (CP) is debated.

AIM

To assess the effect of forward-tilting of the seat surface and foot-support in children with CP on kinematic head stability and reaching.

METHODS

Nineteen children functioning at Gross Motor Function Classification System levels I-III participated [range 6-12y; ten unilateral spastic CP (US-CP) and nine bilateral spastic CP (BS-CP)]. Kinematic data were recorded of head sway and reaching with the dominant arm in four sitting conditions: a horizontal and a 15° forward (FW) tilted seat surface, each with and without foot-support.

RESULTS

Seating condition did not affect head stability during reaching, but did affect kinematic reaching quality. The major reaching parameters, i.e., the proportion of reaches with one movement unit (MU) and the size of the transport MU, were not affected by foot-support. Forward-tilting had a positive effect on these parameters in children with US-CP, whereas the horizontal condition had this effect in children with BS-CP.

IMPLICATIONS

A 15° forward-tilted seating and foot-support do not affect head stability. Reaching in children with US-CP profits from forward-tilting; in children with BS-CP forward-tilting worsens reaching - effects that are independent of foot-support.

Validity and Responsiveness of the Trunk Impairment Scale and Trunk Control Measurement Scale in Young Individuals with Cerebral Palsy

AIM

This study examines construct validity and responsiveness of the Trunk Impairment Scale (TIS) and Trunk Control Measurement Scale (TCMS) in individuals with cerebral palsy (CP).

METHODS

Twenty-six individuals with CP (nine males), 8-29 years (mean age 17.6) with gross motor function corresponding to GMFCS I-IV, participated in three weeks of intensive and varied physical training at a health sports center. Trunk control was assessed with the TIS (includes three subscales) and TCMS (includes three subscales), and gross motor function with the Gross Motor Function Measure 66 item set (GMFM-66-IS), before and after the training period. The GMFM-66-IS was used as a comparison measure.

RESULTS

The median score of the TCMS subscale dynamic sitting balance, reaching (DSB-R), increased from 6 to 7 (range: 1-10; p = .031), and there was a median change of 3 points in GMFM-66-IS score (p = .036). There were no significant changes in the TIS. The correlations (Spearman's rho), between the TIS, TCMS, and the GMFM-66-IS (pre-scores), ranged between 0.57 and 0.75 (p< .003). Correlations between change scores (pre- and post-scores) were low, and not statistically significant. However, the TCMS DSB-R change score correlated significantly with hours spent on "trunk-targeted training" like paddling/rowing (rho = 0.66; p = .003) and horseback riding (rho = 0.54; p = .011).

CONCLUSIONS

Our results support construct validity of the TIS and TCMS in young individuals with CP, whereas responsiveness could not be documented. However, the correlations between the TCMS DSB-R change score and hours spent on ''trunk-targeted training'' suggest that this subscale may have the potential to be used in intervention studies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring the functional impact of adaptive seating on the lives of individual children and their families: a collective case study

PURPOSE

This study examined parent-reported change in the functional performance of four school-aged children with wheeled mobility needs who had used a new adaptive seating system for 6 weeks.

METHODS

The collective case study involved four mothers whose children, ages 6-9 years, received a new adaptive seating system for a manual wheelchair or stroller. Mothers completed the Family Impact of Assistive Technology Scale for Adaptive Seating (FIATS-AS) at the time their child received a new seating system, and then after 6 weeks of daily use. Other questionnaires, health records, and semi-structured interviews provided additional data about the seating interventions and their functional effects on individual children and their families.

RESULTS

The FIATS-AS detected overall functional gain in one family, and both gains and losses in 2-7 dimensions for all families. Functional status and change scores showed consistency with measures of seating intervention satisfaction, global functional change, and home participation. Interview themes also suggested consistency with change scores, but provided a deeper understanding of important factors that influenced adaptive seating outcomes.

CONCLUSION

This study supports the need to explore further the complexity, temporality and meaningfulness of adaptive seating outcomes in individual children and their families. Implications for Rehabilitation Assistive technology practitioners need to adopt practical measurement strategies that consider the complexity, temporality, and meaningfulness of outcomes to make evidence-informed decisions about how to improve adaptive seating services and interventions. Health measurement scales that measure adaptive seating outcomes for service applications must have adequate levels of reliability and validity, as well as demonstrate responsive to important change over time for individual children and their families. Needs-specific measurement scales provide a promising avenue for understanding functional outcomes for individual children and youth who use adaptive seating systems.

Lessons learned from studying the functional impact of adaptive seating interventions for children with cerebral palsy

Little empirical evidence exists about the effectiveness of assistive technology interventions for children with cerebral palsy (CP) to inform clinical practice. This article reviews what we know about the functional impact of adaptive seating interventions - a common assistive technology type recommended for children with CP. A contemporary assistive technology outcomes framework is considered as a way to model the temporality and measure the effects of seating interventions and moderating cofactors. Three research studies are profiled to illustrate different research methods, measurement approaches, and follow-up periods to learn about adaptive seating outcomes. Recommendations for future research include the adoption of common measurement indicators, consideration of quality assessment criteria, and the use of varied methodologies to generate new knowledge about functional outcomes. It is suggested that the proposed strategies will lead to new understandings, clinical applications, and ultimately improvements in the everyday lives of children with CP and their families.

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.

Effects of seat surface inclination on respiration and speech production in children with spastic cerebral palsy

Background

Respiratory and speech problems are commonly observed in children with cerebral palsy (CP). The purpose of this study was to identify if inclination of seat surface could influence respiratory ability and speech production in children with spastic diplegic CP.

Methods

Sixteen children with spastic diplegic CP, ages 6 to 12 years old, participated in this study. The subjects’ respiratory ability (forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), peak expiratory flow (PEF), and maximum phonation time (MPT)) were measured in three sitting conditions: a seat surface inclined 0°, anterior 15°, and posterior 15°.

Results

FVC was significantly different across three inclinations of seat surface, F(2, 45) = 3.81, P = 0.03. In particular, the subjects’ FVC at a seat surface inclined anterior 15° was significantly greater than at a seat surface inclined posterior 15° (P < 0.05). However, FEV1, PEF, and MPT were not significantly affected by seat surface inclination (P > 0.05).

Conclusions

The results suggest that anterior inclination of seat surface may provide a positive effect on respiratory function in children with spastic diplegic CP.

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.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Reliability and validity of the Trunk Impairment Scale in children and adolescents with cerebral palsy

Standardized clinical tools are useful for treatment planning and evaluation, however clinical tools to assess quality in trunk movements in children with cerebral palsy (CP) are sparse. We have recently reported good intra- and inter-observer reliability of the Trunk Impairment Scale (TIS) in 5-12 year old children with CP. The aim of this study was to assess reliability in adolescents (13-19 years old), and to assess the construct validity in children and adolescents in the whole age spectrum from 5 to 19 years. Video recordings of 17 children with CP with Gross Motor Function Classification (GMFCS) level I-IV were analyzed by three observers on two occasions. For construct validity the TIS was compared with Gross Motor Function Measure (GMFM), in 37 children with GMFCS levels I-IV. Intraclass correlation coefficients varied between 0.82 and 0.98, and 86% of the kappa values varied between 0.61 and 1.00, suggesting high inter- and intra-observer reliability. The smallest detectable difference (SDD) of the TIS (scale range 0-23) varied between 2.55 and 3.82 for intra- and 4.07-8.23 for inter-observer observations. The high inter-observer SDD was partly due to consistently lower TIS scores by one observer. The correlation between the TIS total score and the dimension scores of the GMFM was high (Spearman's rho: 0.80-0.87), while decreasing GMFCS levels were associated with increasing total TIS score; both findings indicating good construct validity of the TIS. This study suggests that the TIS is a reliable and valid measure of trunk control for both children and adolescents with cerebral palsy.