Вы находитесь на странице: 1из 54

The Fundamental Principles of Seating and Positioning in Children and Young People with Physical Disabilities

Laura Neville BSc (Hons) Occupational Therapy Student University of Ulster

Supervised by:

Mrs Jackie Quigg (School of Health Sciences UU)

Dr Alison Porter Armstrong (Health and Rehabilitation Sciences Research Institute UU)

Commissioned by James Leckey Design Limited

Summer 2005

Project Background

James Leckey Design Limited (Northern Ireland) is a company specialising in equipment design, manufacture and provision for children with physical disabilities. As part of a 2 ½ year project, involving the University of Ulster (with Mrs Jackie Quigg and Dr Alison Porter Armstrong) to research the clinical effectiveness of one of their product ranges, the company commissioned three BSc (Hons) Occupational Therapy students (Laura Neville, Linda McNamara and Glenda Alexander) to conduct critical reviews of the literature in three designated areas:

1)

Fundamental Principles of Seating and Positioning in Children and

People with Physical Disabilities. (Laura Neville)

Young

2) Postural Management: Components of Specialised Seating Equipment. (Linda McNamara)

3) Early Intervention and the Effects of Adaptive Seating on Function. (Glenda Alexander)

The critical reviews undertaken were completed between June and August 2005 and conducted as part of a steering group comprising of: Mr James Leckey (James Leckey Design Limited); Mr Noel McQuaid (Technical Director, James Leckey Design Limited), Mrs Clare Wright (Research Occupational Therapist, James Leckey Design Limited), Mrs Jackie Quigg (UU) and Dr Alison Porter Armstrong (UU), with formal supervision provided on a weekly basis. This is the first of three critical reviews commissioned by James Leckey Design reviewing and critically appraising the literature regarding the fundamental principles of seating and positioning in children and young people with physical disabilities.

Acknowledgements

I would like to thank Mrs Jackie Quigg and Dr Alison Porter Armstrong for their continued support, direction and guidance in regarding completion of this review. Thanks also to James, Noel and Clare for providing the opportunity to engage in this project and thank you to Linda and Glenda for your constant support and encouragement and making the completion of this review possible.

Index of Contents

Page

Introduction

3

Methods

4

The relationship between posture, movement, stability and function

4

Normal posture

6

The action of sitting

6

Neutral sitting posture

7

The 90-90-90 position how functional?

8

Functional Sitting Position

9

Factors affecting positioning

13

Primitive reflex activity

13

Structural asymmetries

15

Abnormal muscle tone

18

Childhood conditions

20

Cerebral Palsy

20

Congenital hip deformity/Developmental Dysplasia

23

Rett Syndrome

24

Duchenne Muscular Dystrophy

25

Spina Bifida

26

Conclusion

27

References

28

Appendices

35

Principles of Seating and Positioning

Introduction

The prescription of appropriate seating equipment for children and young people with physical disabilities is important, in order to provide an optimal seated position from which they may engage in functional activities. Research has evidenced the benefits of adaptive seating to include improved postural alignment (Miedaner 1990; Myhr and von Wendt 1991), development of motor skills (Green and Nelham 1991), helping the prevention of fixed deformity (Pountney et al 2002) and facilitation of upper extremity function (Myhr and von Wendt 1991; Myhr et al 1995, van der Heide 2003). It is imperative that health professionals prescribing and engineers designing seating equipment are well informed regarding the fundamental seating principles that dictate the sitting postures of children and young people and the impact they have on long term health and function.

Traditional emphasis regarding positioning is placed on achieving an upright symmetrical posture utilising the 90-90-90 flexion at the hips, knees and ankles position (Green and Nelham 1991; Ham et al 1998; Erhardt and Merril 1998, Hong 2002). Although an important posture to achieve, this upright position is suggested as non-functional (Engström 2002) and difficult to maintain over time (Howe and Oldham 2001), resulting in adoption of compensatory postures which may lead to long term deformity and further deterioration when appropriate external support is unavailable. Seating solutions may require reaching a balance between an upright anatomical symmetrical posture and ability to function (Ham et al 1998; Pope 2002).

The focus of this research was to review and critically appraise the literature regarding the fundamental principles of seating and positioning used with children and young people with physical disabilities. The report uses evidence from published studies, and expert opinion to identify seating and positioning principles used with children and young people with disabilities, the benefits of optimal positioning and problems which may incur as a result of incorrect positioning. An overview of normal and abnormal postures is discussed from biomechanical and neurophysiological viewpoints. Common childhood neuromotor and neuromuscular conditions are considered with respect to clinical manifestations and resultant positioning problems which health professionals and engineers must consider when prescribing / designing seating interventions to promote long term health and functional independence.

Methods

A literature search was conducted using the following electronic data bases; AMED (Allied and Complimentary Medicine), ASSIA (Applied Social Sciences Index and Abstracts), BIDS, British Nursing Index, CINHAL (Cumulative Index of Nursing and Allied Health Literature), Embase, ISI Web of Science, MEDLINE, OTDbase, Pubmed, Proquest, Psychinfo and Zetoc. Criteria for considering relevant literature for review required all articles to be in the English language, and published between January 1990 up to and including May 2005. On occasions, earlier dated key papers were included for relevance. Tables 1-7 (appendix 1) identify the key words utilised in the search strategy with respect to the data bases searched. Electronic database searching was supplemented with hand searches, citation searches of reference lists, conference proceedings and retrieving relevant literature from published textbooks. The McMaster critical review forms (Law et al 2002) were used as a guideline for critiquing relevant studies attained.

The relationship between posture, movement, stability and function

Posture may be defined as, the position of one or many body segments in relation to one another and their orientation in space (Ham et al, p26). Body segments are referred to as the head, thorax, pelvis, lower limbs and feet, whilst the body linkages are considered as the spinal joints, hips, knees, ankle and shoulder joints (Pope 2002). When considering posture, one should not consider it as static, but as an active and dynamic process which underpins movement and function (Hong 2005). Normally, our postures continuously shift and change position to facilitate movement to engage in functional activities. Pope (2002) identifies that posture is a prerequisite for movement. Howe and Oldham (2001) also highlight that posture and movement are inextricably linked, referring to posture as a temporary arrested movement, which is in a constant state of change. From a neurodevelopmental perspective Nichols (2001) suggests that the development of postural control and acquisition of motor milestones are intrinsically linked. Ham et al (1998) support this assumption highlighting that there is constant neuromotor activity being used to maintain body balance and posture. Engström (2002) further suggests that biological and physiological influences affect body position and posture. This is also in addition to the somatosensory, vestibular and musculoskeletal systems (Nichols 2001).

For functional movement to occur in sitting, literature suggests that stability of proximal body parts (pelvis, spine and shoulders) is a prerequisite for distal control (Green and Nelham 1991; Herman and Lange 1999). For example, pelvic stability is required for the spine so that the neck is free to move; shoulder girdle stability is required to stabilise the arm for fine motor and hand control. Washington et al (2002) however suggests that there is limited published research to support this hypothesis

suggesting that the relationship between proximal stability and distal control is not necessarily one of cause and effect. This is supported by Case-Smith et al (1989) who identified weak correlations between proximal control and hand function in typically developing children as assessed by the Posture and Fine Motor Assessment of Infants (Case-Smith 1987). However evidence suggests that clinicians and therapeutic seating do utilise the principle of achieving pelvic stabilisation to maximise distal control for function in children with neuromotor dysfunction. This is illustrated in the literature by the use of anterior pelvic stabilization devices in seating interventions (Reid and Rigby 1996; Reid 1996, Rigby et al 2001) and by promoting anterior pelvic tilt via the use of the functional sitting position in children with cerebral palsy (Myhr and von Wendt 1990, 1991; Myhr et al 1995. Children with neuromotor and neuromuscular dysfunction will require external support from seating systems to accommodate for compromised postural control and postural deficits. Based on clinical and empirical evidence, it is accepted that the general goals of seating and positioning include the following, and will be considered in the context of this review:

1) Normalise tone or decrease abnormal influence on the body. 2) Maintain skeletal alignment. 3) Prevent, accommodate or correct skeletal deformity. 4) Provide stable base of support to promote function. 5) Promote increased tolerance of desired position 6) Promote comfort and relaxation. 7) Facilitate normal movement patterns or control abnormal movement patterns. 8) Manage pressure or prevent the development of pressure sores. 9) Decrease fatigue 10) Enhance autonomic nervous system function (cardiac, digestive and respiratory function) 11) Facilitate maximum function with minimum pathology.

(Jones and Gray 2005).

Seating and Positioning: Principles and Practice

Normal Posture

Following a review of the literature, it is difficult to define what constititutes normal posture. This is because each person is unique regarding their physiological profile and continually engages in a number of postural variations which may be attributed to fatigue and emotional state (Howe and Oldham 2001). From a biomechanical viewpoint, good posture is dependent on the balance of the skeleton and symmetrical alignment of body segments. Engström (2002) states that those who balance their body in accordance with mechanical rules for human body systems (laws of physics) tend to be more erect. From a neurophysiological and developmental perspective, normal posture is also dependant on the development of normal postural control which is described as the control of the body s position in space in order to obtain stability and orientation (Brogren et al 1998) and is influenced by the neuromotor, somatosensory, vestibular and musculoskeletal systems (Nichols 2001). Postural control requires achieving normal developmental milestones and includes the development of postural reactions (righting, protective and equilibrium reactions), developmental integration of primitive reflexes (asymmetrical tonic neck reflex, symmetrical tonic neck reflex, tonic labyrinthe reflex), normal muscle tone, normal postural tone and intentional voluntary movements (Wandel 2000).

The action of sitting

It is also useful to understand the interface between the standing and seated posture. Turner (2001) suggests the action of sitting results in flexion of the thoracic spine, flexion of the lower extremities, and backwards rotation of the pelvis towards the rear of the seat. Pelvic rotation in turn dictates the compensatory curves of the spine, which in turn dictates the position of the remaining body segments (Harms 1990). The pelvis is then placed on the seat against the backrest. The trunk extends, moving towards the backrest. The upper part of the pelvis is in contact with the lower part of the backrest, thus achieving pelvic stability, with the person now sitting in an upright neutral position.

Neutral sitting posture

Sitting skills emerge in a normally developing child approximately between 7 and 9 months and requires the child to maintain postural control of the head, trunk and extremities against the pull of gravitational forces (Wandel 2000). The majority of the literature refers to the 90-90-90 position as the normal upright neutral seated posture and considers the head, trunk and extremity positions in relation to each other. Assuming that one is sitting on a flat, right angled chair in a static or neutral position, the upright symmetrical position is characterised by extension of the trunk, the pelvis in anterior tilt, thighs slightly abducted, parallel and horizontal and the iliac crests aligned and level in the lateral plane (Ham et al 1998). The hips, knees and ankles are placed at ninety degrees of flexion, the feet are in plantar grade or 0° degrees flexion (Green and Nelham 1991) and the head is positioned in midline and maintained in the vertical plane (Erhardt and Merril 1998). The head position in relation to the spine is important as it has a direct effect on posture. Loss of head control can therefore affect body position (Ham et al 1998). When the pelvis is in anterior tilt, the centre of gravity falls anterior to the ischial tuberosities (Ham et al 1998) hence the base of support is provided through the ischial tuberosities and the upper thighs (Howe and Oldham 2001). Depending on the chair design, weight will be transferred through the back rest, and the arm rests to the floor through the feet (Pynt et al 2001). The goal of upright positioning is therefore to promote symmetry and alignment of the body segments and linkages (Ham et al 1998). The sitting position is more relaxing than the standing posture, provides a greater support surface and allows relaxation of the muscles of the lower extremities (Howe and Oldham 2001). However, there is greater potential for pelvic instability in sitting compared to standing due to the hip joint position, the anatomical shape of the ischial tuberosities (Reid and Rigby 1996) and the tendency for the pelvis to rotate backwards (Engström

2002).

In the seated posture, it is desirable that as much contact is made with the chair s support surface in order to provide maximum stability to facilitate function (Green and Nelham 1991), with the goal of seating being able to achieve a stable base of support surface to allow function (Jones and Gray 2005). However in right angled seating, it is difficult to achieve and often results in a person acquiring a slumped posture to compensate for fatigue and discomfort. Combined with the effects of constant activation of the erector spinae muscles, a person will gain relief from excessive muscle activity by sacral sitting, resulting in posterior rotation of the pelvis, accentuation of thoracic kyphosis and cervical lordosis, loss of lumbar lordosis of the spine (Pynt et al 2001) and increased risk of tissue trauma in the sacral area (Han et al 1998). A further goal of seating is to prevent or decrease the occurrence of pressure sore development (Jones and Gray 2005). Conflicting opinion exists regarding the causation of posterior pelvic tilt. Some authors postulate that the tendency for the pelvis to rotate posteriorly may be due to tension in the hamstrings and gluteal muscles which promotes flexion of the lumbar spine hence inducing posterior rotation of the pelvis. (Mayall and Desharnais 1995; Trefler and Taylor 1991; Pynt et al 2001; Effgen 2005). Contrary to opinion Engström (2003) attributes the tendency of thoracic spine collapse (flexion) as influencing the backward rotation of the pelvis and suggests that seating interventions should aim to improve thoracic extension to block

flexion of the spine. Engström (2002) suggests that backward inclination induces flexion of the thoracic spine whereas a forward inclined seated position promotes thoracic extension. A study conducted by Miedaner (1990) investigating the effects of sitting positions on trunk extension for children with motor impairment supports this assumption. Miedaner concluded that anterior sitting (20° and 30° inclined) compared to level bench or floor sitting increased trunk extension, as measured by the modified Schoeber Measurement of Spinal Extension (AAOS 1975). Using a randomized complete block design a significance level of p=0.001 demonstrated a true mean difference between the different sitting positions, however small sample size limits the generalisability of this finding.

The 90-90-90 Position How Useful?

The 90-90-90 position may be regarded as an ideal seated position from an ergonomic perspective (Engström 2001). From an anatomical view point the goal is to achieve maximum orthopaedic symmetry between left and right sides of the body via a neutral pelvis to avoid obliquity, rotation and posterior pelvic tilt (Lange 2001). Advantages of this position depicted in the literature include minimisation of orthopaedic deformity (Ham et al 1998) and promotion of proximal stability which in turn promotes distal control (Lange 2001). One of the goals of seating is to promoted relaxation and comfort (Jones and Gray 2005). Kangas (2002) suggests the 90-90-90 position can passively and temporarily reduce tone when considered as a resting position. Two studies identified support for this assumption.

Nwaobi et al (1983) conducted a study using electromyography (EMG) to investigate the activity of extensor muscles of the lumbar spine in children with cerebral palsy in different seating positions. Seat surface inclinations of 0° and 15° combined with backrest inclinations of 75°, 90°, 105° and 120° provided the testing conditions. Results concluded that electrical activity was least when seat surface elevation was 0° and backrest inclination was 90°. Caution is advised in generalising results as testing positions were based on EMG activity recording 60 seconds of sitting in each position and on a small sample of eleven subjects. A subsequent study conducted by Nwaobi (1986) regarding the effects of body awareness in space on tonic muscle activity of patients with cerebral palsy concluded that muscle activity was lower in the upright position (90-90-90) than the reclined position (30° from vertical plane), with statistically significant results obtained for back extensors and hip adductors (p=0.05). One of the goals of seating is to promote increased tolerance in the desired position (Jones and Gray 2005). Findings from this study suggest that extensor tone is increased in the reclined position.

Literature also identifies that the 90-90-90 position is difficult to maintain over time (Ham et al 1998; Howe and Oldham 2001) and may impede function (Engström 2002). One study however concluded that the upright position was more functional in comparison with anterior and posterior sitting positions. Nwaobi (1987) investigated seat orientation of upper extremity function in thirteen children with cerebral palsy (spastic and athetoid) and concluded that arm movements were significantly faster

when positioned in 90-90-90 compared to anterior (15°) and posterior (15° and 30°) orientations. The authors attribute this outcome to either improved control of or decreased abnormal neuromuscular activity in the upright position. The authors also consider loss of horizontal eye contact and greater effort required to counteract gravitational effects in the posterior orientation as impeding upper extremity function (Nwaobi 1987). Other studies identified compare the upright neutral position to alternative sitting positions e.g. inclined/reclined seat base, inclined/reclined back rest, and their relationship to function. Findings from studies examining the effects of seat inclination on upper extremity function are mixed. Some authors (Mhyr and von Wendt 1990, 1991, Myhr et al 1995) concluded that anterior sitting in the functional sitting position improved upper extremity function in children with neuromotor dysfunction. Other research studies report no effects on upper extremity function with regard to seat inclination (McClenaghan et al 1992) and no effects regarding anterior tipped seating on respiratory function in children (Reid and Sochaniwskyj 1991). These studies will be reviewed in the next section.

Several authors advocate the idea of bypassing the 90-90-90 position. Kangas (2002) argues that for functional performance, movement and tone are required, but the 90-90-90 position prevents functional performance as it is essentially a resting position and too restrictive. Minkel (2001) postulates that the goal of adapted seating should extend beyond achieving perfect symmetry, but should focus on providing external support, at the angles needed by an individual to achieve an upright, stable and functional position. It is recognised that ideology based on expert opinion and experience provides important information which may be added to a growing evidence base however caution must be exemplified when using anecdotal evidence to justify practice. Shimizu et al (1994) acknowledges that deviation from the optimal upright position is often required to accommodate for fixed deformities and abnormal postural tone, yet basic positioning principles should be maintained. This is to provide equal distribution of weight, for support, stability and comfort. It may be derived that the 90°/90°/90° position is a useful baseline position to achieve to promote symmetry with further seating adaptations / components being utilised to facilitate function.

Functional Sitting Position

A major goal in seating is to provide and stable base of support to promote function and to enhance autonomic nervous system function (Jones and Gray 2005). Pain et al (2003) suggests that alternative sitting positions to 90-90-90 are being proposed and include forward inclination to permit engagement in functional tasks and backwards recline for relaxation. Findings from studies regarding the effects of seat inclination on function and/or postural control are conflicting. Studies identified for review, focus on the cerebral palsy population and/or typically developing children. Several authors suggest that forward inclination promotes improved upper

extremity function (Myhr and von Wendt 1991, Myhr et al 1995; Reid 1996); trunk extension (Miedaner 1990) and improved postural efficiency (van der Heide 2003, Myhr and von Wendt 1990, 1991). Other research studies report no effects of anterior tipped seating on respiratory function (Nwaobi and Smith 1986, Reid and Sochaniwskyj 1991, Redstone 2004); upper extremity function (McPherson et al 1991; McClenaghan et al 1992) and postural stability (McClenaghan et al 1992).

Myhr and von Wendt (1991) conducted a study to find a functional sitting position for children with cerebral palsy. Twenty-three children were photographed and video filmed in six different sitting positions, including the functional sitting position (FSP). The FSP required the pelvis to be anteriorly tilted, with the upper body anterior to the fulcrum at the ischial tuberosities to allow an upright posture. Symmetrical weight bearing through the ischial tuberosities was achieved via fixation of hip belt at 45° angle and use of abduction orthoses. Results suggested that the functional sitting position in comparison to the children s original sitting position minimised pathological reflexes, improved postural control and improved upper extremity function when children sat in forwards inclination (mean 8°, range 0° to 15°), with a firm back rest supporting the pelvis and supported by a cut out level table to eliminate lateral sway imbalance. Results support previous preliminary findings investigating the FSP and its impact on reduction of spasticity and enhancement of postural control (Myhr and von Wendt 1990), although seat inclination alone showed no identifiable effects, it is subjectively suggested that anterior tilting may stretch the hamstring muscles when the pelvis is rotated forward hence reducing spasticity. This is assuming the feet are secured and fixed and the lower extremities are not permitted to flex under the thighs, however the authors do not provide a specific description regarding the exact positioning of the feet. A five year follow up study investigating ten children with cerebral palsy (Myhr et al 1995) concluded that the FSP contributed to significant improvement (p> 0.05) in head, trunk and foot control and upper extremity function in eight of the ten children as assessed by the Sitting Assessment Scale (Myhr and von Wendt 1991).

A study conducted by Reid (1996) utilising a repeated measures experimental cross over design compared the effects of level or flat benched seating versus saddle- benched seating (15° anterior tilt) on postural control and reaching motions of six children with cerebral palsy assessed by the Sitting Assessment for Children with Neuromotor Dysfunction (Reid 1995). Small sample size rendered insufficient power analysis to detect statistically significance differences, however group results and single subject data analysis suggest that saddle sitting may potentially improve postural and reaching movements.

An investigation regarding the development of postural adjustments during reaching in twenty-nine typically developing children, and ten adults (van der Heide

et al 2003) suggested that forward tilted seating (15° seat surface inclined) was a more efficient position for postural efficiency compared to horizontal (0°) and backwards

tilted (15° seat surface reclined) sitting positions.

original hypothesis postulated by the authors, who hypothesised that backward sitting

would have been the most efficient position as it would passively counterbalance the forward body sway induced by reaching movements. Sitting positions were studied via surface Electromyograms (EMG) and kinematics, therefore quantifying results.

Findings were contrary to the

Miedaner (1990) investigated the effects of sitting positions on trunk extension in fifteen children with motor impairment (cerebral palsy) using the modified Schober Measurement for Spinal Extension. As previously discussed, results suggested that the anterior sitting (20° and 30° inclined) tend to increase trunk extension compared to level bench or floor sitting. Subjective observations suggest that upper extremity function is not compromised despite increased muscle activity required to maintain trunk extension when the seat is tilted forward. Further EMG analysis of spinal muscle activity regarding trunk extension would objectify results.

Contrary to these findings other authors conclude that seat inclination has no discernable effects. McClenaghan et al (1992) investigated the effects of seat surface inclination on postural stability and function of the upper extremities of children with cerebral palsy. Twenty children (ten non-impaired; ten mild cerebral palsy) were included in the study, with seat surface inclinations depicted as 0° horizontal, 5° anterior tilt, and 5° posterior tilt, with seat to back inclination maintained at 90°. Previous authors (Myhr and von Wendt 1990, 1991; Miedaner 1990; Myhr et al 1995; Reid 1996; van der Heide 2003) used seat surface inclinations of greater than 5° (range 8°- 30°); however McClenaghan justifies 5° inclination by stating that greater tilting is difficult to tolerate for an extended period with this assumption based on pilot investigations. Previous research has shown that lumbar spine muscle activity increases when the seat is tilted forward (Nwaobi 1987).

McClenaghan et al (1992) concluded that significant between-group differences were observed on most dependent measures (p>0.05) however, suggested that anterior tilt seating in cerebral palsied children may actually disturb postural stability, without improving performance of the upper extremities and suggested posterior tilt as a more efficient position during periods of upper extremity function. Although only applicable to the adult cerebral palsy population, McPherson et al (1990) also concluded that no significant differences could be attributed to seat inclinations regarding upper extremity movement. Hadders et al (1999) when conducting a study to investigate the development of postural adjustments in reaching in infants in children with cerebral palsy also favoured the reclined position (semi- recline at 45°) as opposed to lying in supine, long leg sitting and upright sitting). McClenaghan (1992) also argues that the use of a table in Myhr and von Wendt (1991) study may result in weight bearing on the support surface, which in turn actually impedes the use of the upper extremities for function. This would hinder the carrying out of bilateral activities.

Similar findings have been reported regarding the effects of seat inclination on respiratory function. Redstone (2004) investigated the respiratory patterns in upright and semi-reclined seating positions in ten preschool children with cerebral palsy and ten typically developing children. No significant differences could be attributed to seat position alone. Reid and Sochaniwskyj (1991) conducted a study to investigate the effects of anterior tipped seating on respiratory function of normal children and children with cerebral palsy. Twelve subjects (six normal; six cerebral palsy) were compared in level (0°) and anterior tipped (10° seat surface inclined) seating, with respiratory function measured by respitrace transducers. No significant differences in respiratory function could be attributed to seat inclination alone either in the normal or cerebral palsy groups, however it is recognised that a larger sample size may have

yielded greater power analysis to detect statistical significance. Nwaobi and Smith (1986) in an earlier study investigated the effect of adaptive seating on pulmonary function of eight children with spastic cerebral palsy, and concluded that pulmonary function was more efficient when children were positioned in adaptive seating in the upright (90-90-90) position.

Continued disparity in the literature exists regarding the direction of seat inclination for improved function and postural control. Studies reviewed used small sample sizes, lacked power analysis, and used various seat inclination values and different assessment times in seated positions and short periods of data analysis therefore making comparisons difficult. Additionally some studies do not refer to cerebral palsy as a heterogeneous group. Selection bias was also evident in some studies therefore questioning the reliability of the findings. Future research should utilise larger sample sizes and to aid power estimates so that results may be generalisable to the sample population.

FACTORS AFFECTING POSITIONING

Children with neuromotor / neuromuscular dysfunction will have compromised postural control. This section discusses postural problems and how they can affect positioning and possible seating solutions that accommodate or prevent further deviation from normal posture; however consideration regarding the effectiveness of seating components and their functional use are beyond the scope of this report. The problems depicted in the literature include a) retention of primitive reflexes; b) presence of structural asymmetries c) abnormalities of muscle tone.

a) Primitive Reflex Activity

ÿ Asymmetrical Tonic Neck Reflex

ÿ Symmetrical Tonic Neck Reflex

ÿ Tonic Labyrinthine Reflex

ÿ Positive Supporting Reaction

ÿ Moro Reflex

Asymmetrical Tonic Neck Reflex (ATNR)

According to Ham et al (1998) ATNR is elicited when the head is turned to one side. The reflex is characterised by increased extensor tone on the side to which the head is turned and increased flexor tone on the opposite side. This reflex is usually integrated between 4-6 months (Lowman 2000). According to Hong (2005) the continued presence of ATNR after 4-5 months is considered abnormal and interferes with rolling, bilateral integration, reaching and grasping activities. Due to the tendency of children to use one hand, continued repetitive movements may lead to the development of scoliosis (Ham et al 1998). Extensor postures (Levitt 2004), soft tissue balance and asymmetries in muscle tone may also lead to secondary deformities including subluxed hips and, contractures mainly affecting the hip flexors and adductors (Hong 2005).

Symmetrical Tonic Neck Reflex (STNR)

STNR is elicited when the head is flexed or extended (Lowman 2000). According to Ham et al (1998) when the head is flexed, the upper extremities flex and the lower extremities extend. When the head extends, the upper extremities extend and the lower extremities are pulled into flexion. This reflex is normally integrated

between 4-6 months.

(Lowman 2000) and upper limb function (Ham et al 1998.)

Retention of STNR interferes with reciprocal creeping, walking

Tonic Labyrinthine Reflex (TLR)

TLR is elicited when in supine or being moved into flexion or extension (Lowman 2000). In supine or with the head extended, there is increased extension throughout the body. In prone or when the head is forward of the upright position, there is an increase in flexion throughout the body (Ham et al 1998). This reflex is usually integrated between 4-6 months. Retention of TLR interferes with side turning, rolling, and lying to sitting ability and creeping (Lowman 2000).

Positive Supporting Reaction

The positive supporting reaction is elicited when infants are supported under the shoulders and held upright with feet flat on the floor (Ham et al 1998) Proprioceptive stimuli via the feet induce extension of the lower extremities and plantar flexion of the feet (Lowman 2000). This response is usually integrated between 1-2 months and disappears when the child learns to weight bear through feet and stand independently (Ham et al 1998). Retention of this response will interfere with walking patterns and may lead to walking on toes (Lowman 2000). In addition, Ham et al (1998) suggest that proprioceptive stimuli applied to the intrinsic muscles of the feet when pushing down on foot rests can also elicit an extensor thrust, which can lead to sacral sitting and the development of extension contractures of the hip.

Moro Reflex

Ham et al (1998) suggest the Moro reflex is elicited when the head extends backwards, which results in an extension pattern of the body, with the arms extended, abducted and externally rotated followed by a flexion posture. This reflex is normally integrated between 4-6 months and if retained, interferes with head control, sitting equilibrium and protective reactions (Lowman 2000), all of which are needed for postural control.

Seating Interventions

Goals of seating include normalising tone or decreasing abnormal influences on the body and to facilitate normal movement or pathological activity (Jones and Gray 2005). Although Wright-Ott and Egilson (2001) suggest that tilt in space may provide a child with hypotonia (low muscle tone) with greater tolerance for upright sitting, other authors suggest that tilt in space and/or reclined sitting may

increase pathological reflexes (Nwaobi et al 1983; Nwaobi 1986; Myhr and von Wendt 1990, 1991, Mhyr 1994; Engström 2002).

As previously discussed, Nwaobi (1986) concluded that children with cerebral palsy have better postural control in the upright rather than the reclined or tilted position. In testing conditions Nwaobi (1986) found that increased extensor tone resulting from TLR was elicited by the position of the head in the reclined position, adding that loss of horizontal eye contact resulted in a greater effort to overcome gravity and consequently increased tone. This study also highlighted that asymmetry of muscle activity in back extensors and prolonged seating in the reclined position may contribute to development of a scoliosis. Ham et al (1998) also suggest that tilting of a seat and reclining the backrest can affect eye contact, as well as upper extremity function and spinal posture. Tilting may therefore reduce functional ability to participate or interact with others and the environment.

Similarly Myhr and von Wendt (1990) in their pilot study concluded that the backward tilted position was the most inefficient position to reduce spasticity and enhance postural control. Pathological reflex activity increased considerably in the tilted position. Twenty-two ATNR movements were recorded in the tilted position compared to one ATNR when in the functional sitting position. Myhr and von Wendt (1991) support these findings when investigating the functional sitting position in children with cerebral palsy. Findings suggest that pathological movements were significantly reduced (p=0.001) in the functional sitting position compared to backward tilting. Herman and Lange (1999) suggest that the head should be kept close to mid line to avoid active neck rotation which may elicit an ATNR.

Levitt (2004) suggests that therapists prevent extensor patterns and subsequently chair sliding by using tilt in space with hips flexed between 95° and 110°, although adds that it is not a suitable position for those displaying the Moro response, head and trunk thrust in semi lying or increased athetosis. Engström (2002) postulates that a constant tilt in space position may contribute to development of extensor patterns in the cerebral palsy population and suggests that the trunk s position in space may change the extensor pattern. Engström suggests that an individual contoured seating unit which is forward tipped may be beneficial and highlights that dynamic seating systems may be beneficial as they enable a change of position between upright and rest.

b) Structural Asymmetries

ÿ Spinal deformity (lordosis, scoliosis, kyphosis)

ÿ Pelvic Tilt

ÿ Windswept deformity / Hip dislocation

Spinal deformity:

Lordosis

Lordosis may be defined as an anteroposterior curve of the lumbar spine in which the concavity is directed posteriorly (Rodgers et al 2001). In normal posture the lumbar spine should be slightly hollow or lordosed, however muscle imbalance may result in excessive lengthening and weakening of the abdominal and gluteal muscles and tightening of the iliopsoas and spinal erector muscles which results in the pelvis being tilted anteriorly and further increasing the curvature of the lumbar spine. This results in a lordotic posture (Howe and Oldham 2001). Lordosis may be secondary to other spinal deformities, anterior pelvic tilt, hip flexion contractures and is also associated with muscular dystrophy. Treatment usually centres on managing underlying problems and includes stretching tight hip flexors, strengthening abdominal muscles and in severe cases bracing may be required (Rodgers et al 2001).

Scoliosis

Scoliosis is a lateral curvature of the lumbar and/or thoracic spine often accompanied by axial rotation of the vertical bodies (Howe and Oldham 2001). The Scoliosis Research Society defines scoliosis as a lateral curvature exceeding 10° using the Cobb method (Scoliosis Research Society 2002). According to Rodgers et al (2001) curves of less than 20° are mild, curves over 40° result in permanent deformity and curves of 65° and over may result in compromised cardiopulmonary function. The development of scoliosis has been associated with asymmetrical muscle tone (Young et al 1998), retention of primitive reflexes (Ham et al 1998), poor postural tone, hip contractures (Rodgers et al 2001) and compensatory postures resulting from leg length discrepancy or abnormal pelvic tilt (lateral tilt, obliquity and rotation) (Howe and Oldham 2001), and increased interface pressure when sitting (Shoham et al 2004). Scoliosis occurring in combination with pelvic obliquity and hip deformity is usually convex to the side opposite the dislocated hip and pelvic obliquity (Gudjonsdottir and Stemmons Mercer 1997). It is recognised that scoliosis is generally progressive and can contribute to a number of secondary health problems such as positional pain, respiratory compromise, pressure sores and loss of function (Holmes et al 2003). Scoliosis may be described as fixed or structural meaning that there is permanent deformity which cannot be altered by posture, with the vertebral bodies rotating towards the convexity of the curve and the spinal processes towards the concavity of the curve (Howe and Olham 2001). In extreme cases, surgical intervention may be considered. A flexible scoliosis may be passively or actively corrected via non-surgical intervention including spinal jackets and specialised seating (Holmes et al 2003).

The literature suggests that management of scoliosis is achieved via a three point force system to the sides of the body. Ham et al (1998) suggests the use of lateral supports, which involves forces acting from anterior to posterior at the pelvis, anterior to posterior at the shoulders and posterior to anterior at the apex of the kyphotic (flexible) spine. A study conducted by Holmes et al (2003) investigating the effects of special seating on lateral spinal curvature in the non-ambulant spastic cerebral palsy population supports this assumption. Holmes et al (2003) concluded that significant static correction of the scoliotic spine can be achieved by a three point force arrangement of lateral pads to the sides of the body.

Shoham et al (2004) investigated the influence of seat adjustment and a thoraco-lumbar-sacral orthosis (TLSO) on the distribution of body seat pressure in fifteen children with scoliosis and pelvic obliquity. Seat adjustments included either the use of either elevation of the lower side of the pelvis or a wedge insertion beneath the raised pelvis. Results concluded that the TLSO significantly reduced the spinal curvature and interface sitting pressure (p<0.05), however seat adjustment had no significant effect on pressure distribution.

Kyphosis

Kyphosis is characterised by an increased posterior curvature ( C- shaped ) of the thoracic spine (Howe and Oldham 2001). The kyphosed posture is apparent during sacral sitting, with the pelvis posteriorly tilted and the thoracic spine in flexion (Ham et al 1998). Ham et al (1998) further add that a sling back seat and back support can accentuate kyphosis. The development of kyphosis may be associated with poor posture, weak erector spinae muscles (required for trunk extension), compensation to hip deformity (Howe and Oldham 2001), and also occurs in children with cerebral palsy who demonstrate extensor spasticity in the lower extremities due to tight hamstrings (Ham et al 1998). Head position is then affected, resulting in forward flexion or head drop. In order to compensate for head dropping, the individual will hyperextend their neck in order to visually interact with the environment, however this will compromise respiratory and swallowing function (Herman and Lange 1999). Engström (2002) suggests additional problems include neck pain, flexion contractures of the trunk muscles, restricted arm movement and increased abdominal pressure.

Several authors (Trefler and Taylor 1991; Ham et al 1998; Engström 2002; Levitt 2004) suggest tilt in space or opening the seat to backrest angle to accommodate or support a kyphosis. Engström (2002) suggests the seating unit should be contoured for equal pressure distribution and the backrest is reclined, although does not an angle at which recline should occur. Trefler and Taylor (1991) also suggest the use of a custom contoured back support with a flexible anterior harness, adding that individuals with a 30° or greater scoliosis may require reclined seating to accommodate or correct the curve. Tilt in space may also be considered as it may reduce the effects of gravity acting on the upper body, with the weight of the body being taken through the backrest (Ham et al 1998, Pope 2002). However, the advantages of tilting must be considered against the loss of function.

Pelvic Tilt

Posterior pelvic tilt is a major problem in seating as it compromises pelvic stability (Engström 2002). Problems associated with posterior pelvic tilt include flattening of lumbar curve, accentuation of thoracic kyphosis (Pynt et al 2001) sacral sitting, and increased risk of pressure sore development at sacral / coccygeal area (Ham et al 1998). Causation of posterior of pelvic tilt is attributed to the tension in

the hamstrings (Mayall and Desharnais 1995; Trefler and Taylor 1991; Ham et al 1998; Pynt et al 2001) or by flexion of the thoracic spine (Engström 2002). Effgen (2005) suggests when a child has tight hamstring muscles, footrests must angle under the seat to accommodate for tightness and allow the pelvis to remain stabilised. Seating solutions utilize anterior pelvic stabilisation devices to maintain the pelvis in anterior tilt to prevent backward rotation (Reid and Rigby 1996). Approaches used include ramped cushions (15° inclined) in conjunction with a pelvic belt, sacral pad, knee blocks and foot support (Green and Nelham 1991). Straddle seating (Reid 1996), firm back rests and use of an anterior superior iliac spine padded bar acting on the ischial tuberosities (Ham et al 1998), and anterior tipped seating combined with use of hip belt and abduction orthosis (Myhr and von Wendt 1990, 1991, Mhyr et al 1995) are other methods used to achieve pelvic stabilisation.

Windswept Deformity

Windswept hip deformity is an abduction contracture of one hip resulting in an adduction contracture of the contralateral hip and may be associated with pelvic obliquity and secondary scoliosis (Young et al 1998). Pelvic obliquity results in pelvic rotation in the transverse plane and pelvic tilt in the saggital plane (Gujonsdottir and Mercer 1997). Aetiology of windswept deformity is unknown; however contributing factors include acetabular dysplasia, femoral anteversion, spasticity, retention of ATNR (Reese et al 1990), muscle imbalance and hip contractures (Young et al 1998). Seating interventions may utilise a knee block system to help correct windswept hips (Levitt 2004). According to Ham et al (1998), the knee blocks should be adjusted so that a force is applied anterior to posterior, via the abducted femur, to the pelvis on the side that is rotated anteriorly. This is in addition to the use of lateral supports and a sacral pad to help de-rotate the pelvis. Trefler and Taylor (1991) suggest positioning in abduction may discourage the tendencies of adduction of both hips via the use of a pommel. Structural deformity of the hip joint is a major problem in seating. Developmental Dysplasia or Congenital Hip Dislocation will be explored in greater depth in the childhood diseases section of the report.

c) Abnormal Muscle Tone

Normal muscle tone refers to the ability of muscles to maintain the correct amount of tension and elasticity during movements (Wandal 2000) and may be defined as resistance to passive elongation or stretch (Harris 1991). Abnormalities of muscle include hypotonicity, hypertonicity or fluctuating tone (Hong 2002) and have been associated with deficits in postural control (Nichols 2001). Hypotonia is

characterised by decreased muscle tone and results in muscles appearing lax and floppy (Kohlmeyer 1998) with functional movement and muscle endurance compromised (Reed 2001). Decreased muscle tone can contribute to the development of kyphosis or lordosis with increased hip flexion, lower limb contractures (Ham et al 1998), joint immobility, instability and subluxation due to large range of movement (Hong 2002), weakness, hyperextended knees and valgus or flat feet (Levitt 2004). Hypertonicity or spasticity is characterised by increased tension or contraction in the muscles (Ham et al 1998). Increased muscle tone may also contribute to scoliosis, muscle contractures, extensor/flexion synergies (Ham et al 1998), clonus, hyperreflexia (exaggerated stretch reflex) patterns (Reed 2001) and persistent primitive reflexes (Erhardt and Merill 1998). Hong (2002) highlights that hypotonicity and hypertoncity often present simultaneously. This is illustrated in the cerebral palsy population whereby the child may exhibit a hypotonus trunk, rendering trunk extension difficult, yet present with hypertonicity of the extremities (Westcott and Goulet 2005).

Research has highlighted that spasticity is decreased when the hips are flexed (Nwaobi et al 1983). Nwaobi et al (1983) also found that in addition to the influence of hip flexion, orientation of the body contributed to controlling extensor muscle tone. As previously discussed, this study concluded that spasticity in the lumbar area was lower in the upright position (90°/90°/90°), compared to a backward tilted position. Nwaobi (1986) also concluded that tonic muscle activity of the back extensor and hip adductor muscles were significantly lower (p=0.05) in the upright position compared to recline. Myhr and von Wendt (1990) suggest that stretching spastic hamstring muscles can only be achieved by rotating the pelvis anteriorly, with a straight back. Research has evidenced enhanced postural control via the use of the functional sitting position which puts the pelvis into anterior tilt (Myhr and von Wendt 1990, 1991; Myhr et al 1995, van der Heide 2003).

Based on expert opinion, Herman and Lange (1999) suggest that knee flexion past 90° and ankles in dorsiflexion with slight eversion may reduce extensor spasticity. Empirical evidence suggests that dynamic seating components may also accommodate and reduce tone and enhance function (Cooper et al 2001). This evidence suggests that accommodating abnormal movement and gently returning the limb to normal alignment is more beneficial than blocking the movement. Some authors suggest that tilt in space may be required if the child has hypotonus in order to counteract the effects of gravity (Wright-Ott and Egilson 2001; Ham et al 1998; Pope 2002) yet highlight that advantages of tilt in space must be considered against loss of function.

CHILDHOOD CONDITIONS

ÿ Cerebral Palsy

ÿ Congenital Hip Deformity / Developmental Dysplasia

ÿ Rett Syndrome

ÿ Duchenne Muscular Dystrophy

ÿ Spina Bifida

Cerebral Palsy

According to Rodgers et al (2001), Cerebral palsy may defined as a non- progressive abnormality of the developing brain that results in neurological, motor and postural deficits in the developing child. Perceptual, cognitive, sensory and psychosocial dysfunction may also co-exist with this disorder (Ham et al 1998). Classification of cerebral palsy may be according to topographical distribution (monoplegia; diplegia; hemiplegia; paraplegia; tetraplgia or quadriplegia), quality of tone (hypotonia or spasticity; hypertonia; athetosis; ataxia), degree of involvement (mild; moderate or severe) and locality of the brain lesion (Westcott and Goulet 2005). It is reported that the incidence rate of cerebral palsy is approximately 2:1000 live births (ref) and may be attributable to pre-natal, perinatal and post-natal factors (Erdhardt and Merril 1998). Reed (2001) describes four main groups of cerebral palsy syndromes:

Spastic This type displays increased muscle tone resulting from an upper motor neuron lesion, ranges from mild to severe and is categorised according to the part of the body affected. Erdhardt and Merril (1998) state that spasticity is also accompanied with persistent primitive reflexes, clonus and hyperreflexia and results in difficulty with gross and fine motor control.

Athetoid / Dyskinetic This results from basal ganglia dysfunction and is characterised by slow, jerky, writhing involuntary movements which may affect the extremities (athetosis) or proximal parts of the trunk and limbs (dyskinesis). Athetosis or fluctuating tone results in tone rapidly shifting from normal or hypertonic to hypotonic or low tone (Wandall 2000). It is suggested that athetoid movements are exasberated by emotional disturbance (Ham et al 1998; Reid 2001; Westcott and Goulet 2005) and decreased by prone lying, fatigue or increased concentration (Ham et al 1998).

Ataxic This results from cerebellar dysfunction and is characterised by weakness, incoordination, intention tremor, unsteady wide based gait, difficulty coordinating fine motor skills (Reed 2001) and difficulty maintaining stable alignment of the head, trunk, shoulders and pelvis Wandall (2000). According to Ham et al (1998) a child with ataxic cerebral palsy is at greater risk of developing scoliosis than those with spastic diplegia or hemiplegic cerebral palsy.

Clinical Manifestations

In addition to motor impairment, a multitude of clinical problems co-exist with cerebral palsy and include cognitive and learning disabilities (Ham et al 1998); sensory deficits including hyperresponsivity or hyporesponsivity (Erhardt and Merril 1998) proprioceptive, visual and vestibular dysfunction (Westcott and Goulet 2005); epilepsy (Hare et al 1998); hydrocephalus (McDonald et al 2004); behavioural disturbances (Ham et al 1998); oral motor dysfunction due to retention of primitive reflex activity affecting eating and swallowing ability (Erdhardt and Merril 1998); gastro-oesophageal reflux and speech and language difficulties (McDonald et al 2004). This report focuses on the musculoskeletal impairments of body segments associated with cerebral palsy.

SPINE

Literature suggests that children with cerebral palsy are likely to develop spinal deformity (scoliosis, thoracic kyphosis and lordosis) with the highest incidence occurring in individuals with spastic quadriplegia (Gudjonsdottir and Stemmons Mercer 1997). Research has evidenced that there is a correlation between tight hamstrings and hypolordosis in children with cerebral palsy (McCarthy and Betz 2000). Additional contributing factors to spinal deformity include decreased stability and asymmetrical posture (Westcott and Goulet 2005), primitive reflex activity (Ham et al 1998), atypical muscle imbalance, tone and weight bearing (Gudjonsdottir and Stemmons Mercer 1997), leg length discrepancy and pelvic obliquity (Howe and Oldham 2001). Consequences of spinal deformity include decreased range of movement, positional pain, and functional limitations.

PELVIS

According to Lowes and Orlin (2005) pelvic abnormalities in cerebral palsy include obliquity, posterior and anterior rotation. The relationship between tight hamstrings and hypolordosis may also contribute to the posterior rotation of the pelvis.

HIP

Hip displacement (dislocation or subluxation) is a major disability in cerebral palsy and can cause difficulties in sitting, positioning (Hankinson and Morton 2002), ambulation and perineal hygiene (Scrutton et al 2001). According to McDonald et al 2004) hip displacement is measured by the migration of the head of femur away from the acetabulum, with hip subluxation exceeding 33% migration and hip dislocation exceeding 80% migration. Aetiology is unknown however; contributing factors include persistence of ATNR, acetabular dysplasia, hypertonicity, hip contractures, decreased ambulation and muscle imbalance. Research evidence suggests that children with tonal asymmetry and severe spasticity appear to be at increased risk of dislocation, with a windswept deformity on the opposite side (Young et al 1998).

Pountney et al (2001) support this assumption by stating that imbalance in muscle strength and length around the hip leads to dysplasia and subsequent hip subluxation. Gudjonsdottir and Stemmons (1997) suggest that an important predictor in hip stability is the age at which a child is able to pull to stand. Cornell (1995) reported that less than 2% of children who are able to pull to stand before the age of three years have hip subluxation or dislocation. Hip dislocation, pelvic obliquity and scoliosis are related problems in cerebral palsy (Gudjonsdottir and Stemmons Mercer 1997), with Letts et al (1984) reporting that dislocation occurs first, followed by obliquity, then scoliosis. Research has evidenced that postural management interventions have an important role in preventing dysplasia of the hip in children with cerebral palsy (Pountney et al 2001). A retrospective study of 59 children with bilateral cerebral palsy concluded that children using all Chailey Adjustable Postural Support Systems (CAPS) maintained significantly more hip integrity (p<0.05) compared with other groups.

FOOT / ANKLE

Lowes and Orlin (2005) suggest that impairments of the foot and ankle include reduced dorsiflexion resulting from shortened gastrocnemius, plantar flexion during weight bearing resulting from hypertonicity and ankle instability and the acquisition of a flat foot position due to breakdown of the arch of the foot resulting from decreased weight bearing ability.

Seating and Postural Implications

Children with cerebral palsy will have difficulty with stationary postures, transitionary movements and functional mobility (Westcott and Goulet 2005). Literature suggests that appropriate seating should aim to normalise tone, inhibit reflex activity, prevent deformity, promote optimal function, maintain postural alignment, maintain tissue integrity and maximise stability (Mhyr and von Wendt 1990; Healey et al 1997; Ham et al 1998) with McDonald et al (2004) suggesting that the provision of adaptive equipment to children with cerebral palsy should be individualised based on functional and contextual factors. Disparity in the literature exists regarding the optimal sitting position for a child with cerebral palsy. Some authors advocate the upright posture (Nwaobi et al 1983; Nwaobi 1986, 1987; Green and Nelham 1991). Others are in favour of straddled (Reid 1996) and forward inclined seating (Myhr and von Wendt 1990, 1991; Miedaner 1990; Myhr et al 1995; van der Heide 2003) and there are those that advocate a reclined posture (McClenaghan et al 1992; Hadders et al 1999) to enhance postural control. It is recognised that some of these studies do not refer to cerebral palsy as a heterogeneous group. Please refer to previous sections reviewing these studies.

Congenital Hip Deformity / Developmental Dysplasia

Developmental dysplasia is a condition of pathological hip instability characterised by dislocation or subluxation of the femoral head from the acetabulum (Lowes and Orlin 2005) with incidence being reported at 2:1000 live births (Cox and Kernohan 1998). Rodgers et al (1998) attributes the cause of developmental dysplasia to both environmental (birth complications) and genetic factors. Ham et al (1998) support this assumption stating that developmental dysplasia may be due to hormonal joint laxity, genetically determined joint laxity and delivery in the breech position. Limited hip abduction and asymmetry are manifestations of this condition, with typical neonates displaying 75° and 90° abduction in each hip (Lowes and Orlin 2005). This condition is also characterised by poor hip socket development, poor weight bearing surface and leg length discrepancy if the femur is subluxed from the acetabulum (Lowes and Orlin 2005). Early diagnosis is imperative as this condition is treatable in the early stage, however long term permanent damage will incur if left untreated of if late diagnosis occurs (Cox and Kernohan 1998, Rodgers et al 1998, Lowes and Orlin 2005). Treatment usually comprises of orthopaedic surgery and splinting (Cox 1995). Positioning problems include reduced abduction and flexion at the hip joint, leg length discrepancy, (Lowes and Orin 2005) and if not corrected early, delayed walking and abnormal gait patterns will be evident (Ham et al 1998). Two studies identified discuss the seating and mobility issues encountered by children with developmental dysplasia.

Cox (1995) used a survey method with parents of 11 children who either had undergone or were undergoing treatment for late diagnosed developmental dysplasia. Results highlighted that there was insufficient equipment able to accommodate children in plaster and splints and there was a need to develop seating products, with emphasis placed on mobility. Small sample size and a response rate of 48% limit the generalisability of these findings. Cox et al (1998) further researched seating and mobility in a subsequent study, again utilising a survey method. To identify problems, a survey of 113 affected families in England and Northern Ireland was conducted. Results identified problems in areas of mobility, which creates emotional and social difficulties in family routines. Regarding mobility, it was found that due to the child s loss of mobility, parents resorted to lifting and carrying the child more frequently, which became problematic as the child increased in age and size. Seating equipment in the home often had to be adapted and improvised to accommodate the size of the splint, therefore compromising safety. Lack of mobility and seating problems were found to restrict the child s movement and restricted parental activity. The authors (Cox et al 1998) suggest problems could be improved in this population by provision of special devices that would allow mobility in the car, in a pushchair and provide seating in the home environment. Caution must be applied when generalising results as finding are based on a 38% response rate.

Rett Syndrome

Rett Syndrome is a rare neurodevelopmental disorder which predominantly affects females (Cass et al 2003). It is characterised by progressive loss of intellectual functioning, loss of fine and gross motor skills, loss of purposeful hand movements and development of stereotypical hand movements such as hand wringing, washing and clapping (Parker 2000; Reed 2001), difficulty or inability ambulating (Parker 2000) and marked changes in emotional development and behaviour (Ham et al 1998). Research has evidenced the prevalence of fractures as 20.9% amongst this population (McDonald et al 2002). Rett syndrome is also classified as a pervasive developmental disorder as it also characterised by severe and complex impaired social interaction, communication and behaviour (Rodgers et al 1998) According to Parker (2000) normal development occurs between the first 6-18 months of life, after which regression appears to occur. Clinical manifestations also include muscle atrophy, increased spasticity and seizures (Ham et al 1998), hypotonia, ataxia, and trunk rocking (Effgen 2005).

Scoliosis is the primary orthopaedic complication of Rett syndrome with onset associated with stereotypical arm and hand movements, slowing down of righting and equilibrium reactions, age (McClure et al 1998) alterations in muscle tone, spasticity, and muscle incoordination (Harrison and Webb 1990). Research has evidenced that there is a significant relationship between the prevalence of Rett syndrome scoliosis and orthopaedic risk factors. McClure et al (1998) concluded that rett scoliosis may be due orthopaedic asymmetries rather than a neurological form of scoliosis, with age, abnormal upper body positioning, and non-ambulation as significant predictors of scoliosis. Cass et al (2003) also suggest that early asymmetry of the pelvis as well as shoulder protraction and elevation may be a precursor to fixed deformity. Clinical implications therefore would be to promote bilateral symmetrical muscular balance through proper sitting and lying positions (McClure et al 1998). Ham et al (1998) suggest that in the early stages, weight bearing should be encouraged to help minimise and delay the onset of deformity, as well as the use of spinal jackets. Ham et al (1998) also suggest that soft moulded seats with supports at the backrest are recommended.

Duchenne Muscular Dystrophy

Duchenne Muscular Dystrophy (DMD) is a genetic disorder characterised by progressive proximal muscle weakness (Reed 2001). This disorder only affects boys, with few surviving beyond 20-30 years old and mortality as a consequence of cardiopulmonary compromise (Ham et al 1998). In DMD, muscles break down and are replaced with fat and scar tissue, (pseudo hypertrophy) resulting in the muscles appearing bulky, with the calf muscles looking unusually large (Parker 2000). Impairment of muscle is affected proximally to distally ( Lowes and Orlin 2005) with Rodgers at al (1998) suggesting involvement begins in the proximal musculature of the pelvis, proceeding to the shoulder girdle and subsequently to the distal muscle groups. Thompson et al (1998) add that muscle involvement is bilateral and symmetrical. To compensate for muscle weakness, the child may resort to using the upper extremities to assist knee extension by using his hands to walk up from floor to standing (Gower s sign) (Ham et al 1998; Lowes and Orlin 2005). In addition hyperextension or lordosis of the lumbar spine may be apparent as a compensatory posture in order to maintain an upright position and head in midline (Ham et al 1998). Early signs of DMD are evident when the child displays increased plantar flexion by walking on their toes at approximately 1 year old (Parker 2000). Brown (2002) suggests that loss of ambulation may occur between 8-11 years, with Lord et al (1990) reporting wheelchair dependence at 6-15 years. As muscle weakness progresses, flexion contractures (Reed 2001) and scoliosis (Lowes and Orlin 2005) will occur. Research highlights that pain is related to spinal deformity (Lui et al 2003). Brown (2002) highlights that pelvic obliquity will coincide with scoliosis resulting in difficulty in sitting due to unequal weight distribution over the ischial tuberosities.

Bakker et al (2000) suggest that correct positioning and stretching may delay the development of contractures and spinal deformity. Parker (2000) also highlights good body alignment is imperative especially with older children for efficient respiratory function as many may be reliant on ventilators to assist breathing. Due to the progression of DMD, the child s postural needs will continually change; hence seating interventions must be able to accommodate change. Intervention may also be complex as proximal stabilisation is one of the first functions to diminish in DMD, therefore external stabilisation with adaptive seating is required (Clark et al 2004). Intervention involves the use of knee-ankle-foot orthoses (Ham et al 1998; Thompson et al 1998; Rodger et al 1998; Lowes and Orlin 2005) however a recent systematic review suggested that although the use of knee ankle foot othoses can prolong assisted walking and standing, it is uncertain whether they can prolong functional walking (Bakker et al 2000). Ham et al (1998) also highlight that the success of seating systems is variable as it cannot prevent the onset of scoliosis in this population. Initially a light-weight self-propelling chair may be required, progressing onto a powered wheelchair. Clark et al (2004) suggest common clinical practice regarding seating is to level the pelvis, with a firm seat base, align the trunk with lateral supports to facilitate head alignment and support the elbows and forearms on a tray or with arm supports. Ham et al (1998) highlight that reclining or tilting the seating system may reduce the load on the spine, however may be contraindicated by the child adopting an exaggerated lordosed position of the lumbar spine to maintain upright balance and the head in midline. According to Clark et al (2004) limited research exists regarding

the effects of postural support in seating on health and function of young people with neuromuscular disorders.

Clark et al (2004) conducted a prospective two-period randomised crossover study to measure the effects of postural support in seating on posture, respiration and upper limb function for young people with neuromuscular disorders. Nineteen participants aged 6-22 years old, with a diagnosis of DMD (n=15) or Freidreich s Ataxia (n=4) were assessed in wheelchair seating and in adaptive seating via a standard protocol. Sitting posture, respiration and upper limb function was compared when sitting in a standard wheelchair and in adaptive seating. Results concluded that there were no significant differences in respiratory function and no overall improvement in upper limb function when compared in the two seating systems, however suggested that adaptive seating can improve the posture of this client group by changing body alignment of young people in the chair. Small sample size and difficulty with accurate postural measurements in the clinical setting limit the generalisability of these findings. The proposed protocol used in the study has not yet been tested for reliability and validity.

Spina Bifida

Spina bifida, is described as a congenital defect of the vertebral arches in the spinal column (Rodgers et al 1998) whereby the neural tube fails to unite therefore exposing a gap over which the skin is defective (Ham et al 1998). Parker (2000) highlights three spina bifida classifications and includes spina bifida occulta (minor defect not obvious at the skin surface), meningocele (protruding sac containing meninges) and myelomeningocele (protruding sac containing meninges and spinal cord). It is suggested that the cause of spina bifida results from genetic and environmental factors (Reed 2001; Rodgers et al 1998). Numerous clinical manifestations are apparent with spina bifida and include the following: fine motor and hand skill delay (Reed 2001), hydrocephalus (Pountney and McCarthy 1998), impaired or loss of sensation, paralysis, vasomotor dysfunction (Westcott and Goulet 2005), perceptual dysfunction (visual, auditory, propriceptive, tactile , kinaesthetic and hypo- or hyperresponsitivity), learning disability (Reed 2001), pressure sores (Vaisbuch 2000) and psychosocial problems (Pountney and McCarthy 1998). Evidence also suggests that children with spina bifida frequently report clinically significant yet under recognised and untreated pain (Clancy et al 2005).

Neurological dysfunction will also contribute to the onset of orthopaedic problems posing problems for seating and positioning, with the level of the lesion determining functional ability. Spinal deformities associated with spina bifida include scoliosis, kyphosis or kyphoscoliosis (Reed 2001), with deformity being present at birth or occurring as the child develops (Pountney and McCarthy 1998). Retention of primitive reflexes, abnormal muscle tone, limited range of movement in the extremities, poor postural control of trunk, poor coordination and presence of hip

dislocation / subluxation (Reed 2001) and flexion contractures of knees and ankle (Pountney and McCarthy 1998) are factors which must be considered regarding seating intervention. Ham et al (1998) suggest that seating objectives with this population are to provide a stable base of support, maintain alignment of the spine, relieve discomfort over pressure areas, encourage cardiopulmonary function and improve independence.

One study identified investigated the effect on interface pressure distribution in a group of children with complete paraplegia due to myelomeningocele and a group of aged matched controls in different sitting positions (Vaisbuch et al 2000). This study concluded that the lean forward position (hips flexed to 45°) produced the largest reduction in interface pressure, however the authors acknowledge the children felt apprehensive in this posture. The tilt position also reduced interface pressure, with the authors suggesting that tilting is used to relieve pressure during periods of non functional activity. No other studies were identified regarding seating principles with this population.

Conclusion

Following a review of the literature, it is concluded that positioning principles are based on empirical and evidence and expert opinion regarding children and young people with neuromotor and neuromuscular disabilities. The majority of research conducted reflects the impact of seating and positioning with the cerebral palsy population. Continued disparity in the literature, small sample sizes and short periods of data collection limit the generalisability of the findings, although are important in terms of clinical significance. Limited research exists regarding children with neuromuscular conditions. It is recognised that appropriate positioning in children with physical disabilities is important to facilitate engagement in functional activity and enable participation with the environment (Jones and Gray 2005). Research has evidenced that proper positioning can improve upper extremity function (Mhyr and von Wendt 1991, Mhyr et al 1995), postural alignment (Washington et al 2002), and prevent the development of deformity (Pountney et al 2002). Children and young people who lack postural control and are unable to maintain appropriate postures therefore will require external support from seating systems. The goal of intervention hence is to provide adaptive seating to create a functional seated position to maintain health and function as part of a postural management approach.

References

Bakker JPJ, de Groot IJM, Beckerman H, de Jong BA & Lankhorst GJ (2000) The effects of knee-ankle-foot orthoses in the treatment of duchenne muscular dystrophy:

review of the literature. Clinical Rehabilitation, 14, 343-359.

Brogren E, Hadders-Algra M & Foressberg H (1998) Postural control in sitting children with cerebral palsy. Neuroscience and Behavioural Reviews, 22, 591-596.

Brown G (2002) Muscular dystrophy. In A Turner, M Foster & E Johnson E (Ed). Occupational Therapy and Physical Dysfunction, Principles, Skills and Practice. London: Churchill Livingstone.

Case-Smith J, Fisher AG & Bauer D (1989) An analysis of the relationship between

American Journal of Occupational Therapy, 43, 657-

662.

proximal and distal control.

Cass H, Reilly S, Owen L, Wisbeach A, Weekes L, Slonims V, Wigram T & Charman (2003) Findings from a multidisciplinary clinical case series of females with rett syndrome. Developmental Medicine and Child Neurology, 45, 325-337.

Clancy CA, McGrath PJ, Oddson BE (2005) Pain in children and adolescents with spina bifida. Developmental Medicine and Child Neurology, 47, 27-34.

Clark J, Michael S & Morrow M (2004) Wheelchair postural support for young people with progressive neuromuscular disorders. International Journal of Therapy and Rehabilitation, 11, 365-371.

Cooper D, Dilabio RT, Broughton G & Brown D (2001) Dynamic seating components for the reduction of spastic activity and enhancement of function. Seventeenth International Seating Symposium, February 22-24.

Cornell MS (1995) The hip in cerebral palsy. Developmental Medicine and Child Neurology, 37, 3-18.

Cox SL & Kernohan WG (1998) They cannot sit properly or move around: seating and mobility during the treatment for developmental dysplasia of the hip in children. Pediatric Rehabilitation, 2, 129-134.

Cox SL (1995) Problems of seating and mobility encountered by children with developmental dysplasia of the hip. Clinical Rehabilitation, 9, 190-197.

Engström B (2002) Ergonomic Seating A True Challenge Wheelchair Seating and Mobility Principles. Sweden: Posturalis Books.

Erdhardt RP, Merril SC (1998) Neurological dysfunction in children. In ME Neistadt, EB Crepeau (Ed) Willard and Spackman s Occupational Therapy. London:

Lippincott Williams & Wilkins.

Green EM, Nelham R (1991) Development of sitting ability, assessment of children with a neuromotor handicap and prescription of appropriate seating systems. Prosthetics and Orthotics International, 15, 203-216.

Gudjonsdottir B, Stemmons Mercer V (1997) Hip and spine in children with cerebral palsy: musculoskeletal development and clinical implications. Pediatric Physical Therapy, 9, 179-185.

Hadders AM, van der Fits IBM, Stremmalaar GF & Touwen BCI (1999) Development of postural adjustment in reaching in reaching in infants with cerebral palsy. Developmental Medicine and Child Neurology, 41, 766-776.

Ham R, Aldersea P & Porter D (1998) Wheelchair Users and Postural Seating A Clinical Approach. London: Churchill Livingstone.

Hankinson J, Morton RE (2002) Use of a lying hip adduction system in children with bilateral cerebral palsy: a pilot study. Developmental Medicine and Child Neurology, 44, 177-180

Hare N, Durham S, Green E (1998) The cerebral palsies and motor learning disorders. In M Stokes (Ed) Neurological Physiotherapy. London: Mosby.

Harms M (1990) Effect of wheelchair design on posture and comfort of users. Physiotherapy, 76, 266-271.

Harris SR (1991) Movement analysis: an aid to early diagnosis of cerebral palsy. Physiotherapy, 71, 215-221.

Harrison DJ & Webb PJ (1990) Scoliosis in rett syndrome, natural history and treatment. Brain and Development, 12, 154-156.

Healy A, Ramsey C, Sexsmith E (1997) Postural support systems: their fabrication and function use. Developmental Medicine and Child Neurology, 39, 706-710.

Holmes KJ, Michael SM, Thorpe SL & Solomonidis SE (2003) Management of scoliosis for the non-ambulant spastic cerebral palsy population a biomechanical study. Clinical Biomechanics, 18, 480-487.

Hong C (2005) Assessment for and provision of positioning equipment for children

with motor impairments.

International Journal of Therapy and Rehabilitation, 12,

126-131.

Hong C (2002) Positioning for children with learning disabilities. Therapy and Rehabilitation, 9, 443-446.

British Journal of

Howe T & Oldham J (2001) Posture and balance. In M Trew & Everett T (Ed) Human Movement An Introductory Text. London: Churchill Livingstone.

Jones M & Gray S (2005) Assistive technology: positioning and mobility.

Effgen (Ed)

Davis Company.

In SK

Philadelphia: FA

Meeting the Physical Therapy Needs of Children.

Kangas KM (2002) Seating for task performance; creating seating systems that allow weight-bearing, pelvic stability and mobility. Rehab Management: The Interdisciplinary Journal of Rehabilitation, (15), 54-56, 74.

Karlson A, Norrlin S, Silander HC, Dahl M & Lanshammar H (2000) Amplitude and frequency analysis of force plate data in sitting children with and without myelomeningocele. Clinical Biomechanics, 15, 541-545.

Kohlmeyer K (1998) Evaluation of sensory and neuromuscular performance components. In ME Neistadt, EB Crepeau (Ed) Willard and Spackman s Occupational Therapy. London: Lippincott Williams & Wilkins.

Lange ML (2000) Focus on . Dynamic seating. Occupational Therapy Practice (5),

21-22.

Lange ML (2001) Focus on .Positioning philosophies. Occupational Therapy Practice, 6, 15-16.

Law M, Stewart D, Letts L, Pollock N, Bosch J & Westmorland M (1998) Critical review form for quantitative studies. Retrieved from:

http://www.fhs.mcmaster.ca/rehab/ebp [accessed 1st July 2005].

Levitt S (2004) Treatment of Cerebral Palsy and Motor Delay. Publishing.

Oxford: Blackwell

Liao SF, Yang TF, Hsu TC, Chan RC & Wei TS (2003) Differences in seated postural control in children with spastic cerebral palsy and children who are typically developing. American Journal of Physical Medicine and Rehabilitation, 82, 622-626.

Lord J, Behrman B, Varzos N, Cooper D, Lieberman JS & Fowler WM. Scoliosis associated with duchenne muscular dystrophy. Archives of Physical Medicine and Rehabilitation, 71, 13-17.

Lowes LP & Orlin MN (2005) Musculoskeletal system: considerations and interventions for specific pediatric pathologies. In SK Effgen (Ed) Meeting the Physical Therapy Needs of Children. Philadelphia: FA Davis Company.

Lowman DK (2000) Development of occupational performance components. In J Solomon (Ed) Pediatric Skills for Occupational Therapy Assistants. London: Mosby.

Lui M, Mineo K, Hanayama K, Fujiwar T & Chino N (2003) Practical problems and management of seating through the clinical stages of duchenne muscular dystrophy. Archives of Physical Medicine and Rehabilitation, 84, 818-824.

Mayall JK & Desharnais G (1995) Positioning in a Wheelchair A Guide for Professional Caregivers of the Disabled Adult. Thorofare NJ: SLACK Incorporated.

McCarthy JJ and Betz RR (2000) The relationship between tight hamstrings and lumbar hypolordosis in children with cerebral palsy. Spine, 25, 211-213.

McClenaghan BA, Thombs L & Milner M (1992) Effects of seat-surface inclination on postural stability and function of the upper extremities of children with cerebral palsy. Developmental Medicine and Child Neurology, 34, 40-48.

McClure MK, Battaglia C & McClure RJ (1998) The relationship of cumulative motor asymmetries to scoliosis in rett syndrome. The American Journal of Occupational Therapy, 52, 196-204.

McDonald GG, Kinali M, Mercuri E, Muntonio F, Roper H, Jardine P, Jones dh & Pike MG (2002) Fracture prevalence in duchenne muscular dystophy. Developmental Medicine and Child Neurology, 44, 695-698.

McDonald R, Surtees R & Wirz S (2004) The international classification of

functioning. Disability and health provided a model for adaptive seating interventions for children with cerebral palsy. British Journal of Occupational Therapy, 67, 293-

302.

McPherson JJ, Schild R, Spaulding SJ, Barsamian P, Transon C & White SC (1991) Analysis of upper extremity movement in four sitting positions: a comparison of persons with and without cerebral palsy. American Journal of Occupational Therapy, 45, 123-129.

Miedaner JA (1990) The effects of sitting positions on trunk extension for children with motor impairment. Pediatric Physical Therapy, 2, 11-14.

Minkel JL (2001) Long term rehab: Sitting outside of the box: clinicians need to let go of the 90/90/90 seating rule to explore more effacious alternatives. Rehab Management The Interdisciplinary Journal of Rehabilitation, 14, 50-51, 82.

Myhr U & von Wendt L (1990) Reducing spasticity and enhancing postural control for the creation of a functional sitting position in children with cerebral palsy: a pilot study. Physiotherapy Theory and Practice, 6, 65-76.

Myhr U, von Wendt L (1991) Improvement of functional sitting position for children with cerebral palsy. Developmental Medicine and Child Neurology, 33, 246-256.

Myhr U, von Wendt L, Norrlin S & Radell U (1995) Five year follow-up of functional sitting position in children with cerebral palsy. Developmental Medicine and Child Neurology, 37, 587-596.

Nichols DS (2002) Development of postural control. In J Case-smith (Ed) Occupational Therapy for Children. London: Mosby.

Nwaobi OM (1986) Effects of body orientation in space on tonic muscle activity of

patients with cerebral palsy.

44.

Developmental Medicine and Child Neurology, 28, 41-

Nwaobi OM, Brubacker CE, Cusick B & Sussman MD (1983) Electromyographic investigation of extensor activity in cerebral-palsied children in different seating positions. Developmental Medicine and Child Neurology, 25, 175-183.

Nwaobi OM (1987) Sitting orientations and upper extremity function in children with cerebral palsy. Physical Therapy, 67, 1209-1213.

Pain H, McLellan L & Gore S (2003) Choosing Assistive Devices A Guide For Users and Professionals. London: Jessica Kinsley Publishers.

Parker GE (2000) Other common pediatric disorders. In JW Solomon (Ed) Pediatric Skills for Occupational Therapy Assistants. London: Mosby.

Pope PM (2002) Posture management and special seating. In Edwards S (Ed) Neurological Physiotherapy. London: Churchill Livingstone.

Pountney TE, Mandy A, Green E & Gard P (2002) Management of hip dislocation with postural management. Child: Care, Health and Development, 28, 179-185.

Pountney TE & McCarthy (1998) Neural tube defects: spina bifida and hydrocephalus. In M Stokes (Ed) Neurological Physiotherapy. London: Mosby.

Pountney TE, Mulcahy CM, Clarke SM, Green EM (2001) The Chailey Approach to Postural Management. Active Design.

Pynt J, Higgs J & Mackey M (2001) Seeking the optimal posture of the seated lumbar spine. Physiotherapy Theory and Practice, 17, 5-21.

Reed KL (2001) A Quick Reference to Publishers

Occupational

Therapy.

USA: Aspen

Reese ME, Msall ME & D Amanto C (1990) The influence of asymmetric primitive reflexes and tone on orthopedic deformity of children with cerebral palsy. (abstract) Developmental Medicine and Child Neurology, 32, 43.

Reid DT (1996) The effects of the saddle seat on seated postural control and upper extremity movement in children with cerebral palsy. Developmental Medicine and Child Neurology, 38, 805-815.

Reid DT & Rigby P (1996) Development of improved anterior pelvic stabilisation devices for children with cerebral palsy. Physical and Occupational Therapy in Pediatrics, 16, 91-96.

Reid DT, Sochaniwskyj A & Milner M (1991) An investigation of postural sway in sitting of normal children and children with neurological disorders. Physical and Occupational Therapy in Pediatrics, 11, 19-35.

Reid DT (1995) Development and preliminary validation of an instrument to assess quality of sitting of children with neuromotor dysfunction. Physical and Occupational Therapy in Pediatrics, 15, 53-81.

Reid DT & Sochaniwsky A (1991) Effects of anterior-tipped seating on respiratory function of normal children and children with cerebral palsy. International Journal of Rehabilitation Research, 14, 203-212.

Rigby P, Reid D, Schoger S, & Ryan S (2001) Effects of a wheelchair mounted rigid pelvic stabiliser on care giver assistance for children with cerebral palsy. Assistive Technology, 13, 2-11.

Rodgers SL, Gordon CT, Schazenbacher KE & Case-Smith (2001) Common diagnosis in pediatric occupational therapy practice. In J Case-Smith (Ed) Occupational Therapy for Children. London: Mosby.

Scoliosis Research Society (2002) Retrieved from: http://www.srs [accessed 5 th July

2005].

Scrutton D, Baird G, & Smeeton N (2001) Hip dysplasia in bilateral cerebral palsy and natural history in children aged 18 months to 5 years. Developmental Medicine and Child Neurology, 43, 586-600.

Shimizu ME, Tanaka S, Takamagari H, Honda K, Shimizu H & Nakamura S (1994) Optimal positioning for an adult athetoid cerebral palsy patient in a wheelchair. Hiroshoma Journal of Medical Science, 43, 69-72.

Shoham Y, Meyer S, Katz-Leurer M & Weiss PLT (2004) The influence of seat adjustment and a thoraco-lmbar-sacral orthosis on the distribution of body seat pressure in children with scoliosis and pelvic obliquity. Disability and Rehabilitation, 26, 21-26.

Thompson N, Fahal I & Edwards RHT (1998 ) Muscle disorders in childhood. In M Stokes (Ed) Neurological Physiotherapy. London: Mosby.

Trefler E & Taylor SJ (1991) Prescription and positioning: evaluating the physically

disabled individual for wheelchair seating. 15, 217-224.

Prosthetics and Orthotics International,

Turner C (2001) Posture and seating for wheelchair users: an introduction. British Journal of Therapy and Rehabilitation, 8, 24-28.

Tyldesley B & Grieve J (2002) Muscles, Nerves & Movement in Human Occupation. Oxford: Blackwell Science.

Van der Heide JC, Otten B, van Eykern LA, Hadders-Algra M (2003) Development of postural adjustments during reaching in sitting children. Exp Brain Research, 151,

32-45.

Vaisbuch N, Meyer S, Weiss PL (2000) Effect of seated posture on interface pressure in children who are able bodied and who have myelomeningocele. Disability and Rehabilitation, 22, 749-755.

Washington K, Deitz JC, White OR & Scwartz IS (2002) The effects of a contoured foam seat on postural alignment and upper-extremity function in infants with neuromotor impairment. Physical Therapy, 82, 1064-1076.

Wandel JA (2000) Positioning and handling. In JW Solomon (Ed) Pediatric Skills for Occupational Therapy Assistants. London: Mosby.

Wandel JA (2000) Cerebral palsy. In JW Solomon (Ed) Pediatric Skills for Occupational Therapy Assistants. London: Mosby.

Westcott SL & Goulet CG (2005) Neuromuscular system: structures, functions, diagnosis, and evaluation. In SK Effgen (Ed) Meeting the Physical Therapy Needs of Children. Philadelphia: FA Davis Company.

Wright-Ott C, Egilson S (2001) In J Case-Smith (Ed) Occupational Therapy for Children. London: Mosby.

Yang TC, Chan RC, Wong TT, Bair WN, Kao CC, Chuang TY & Hsu TC (1996) Quantitative measurement of improvement in sitting balance in children with spastic cerebral palsy after selective rhizotomy. American Journal of Physical Medicine and Rehabilitation, 75, 348-352.

Young NL, Wright JG, Lam TP, Rajaratnam K, Stephens D & Wedge JH (1998) Windswept hip deformity in spastic quadriplegic cerebral palsy. Pediatric Physical Therapy, 10, 94-100.

APPENDIX 1

The following tables indicate data bases searched and key words utilized regarding specific themes.

TABLE 1: Seating

Data Base

Key Words

CINAHL

exp seating/ AND Child

 

exp equipment design AND child

 

exp seating/ AND child

 

dynamic seating

BIDS

seating

Pubmed

seating

 

seating principles

 

seating and positioning

Proquest

adaptive seating

 

seating

 

seat$ AND children AND position

Embase

exp seat/ AND child

 

dynamic seating

AMED

exp seating/ AND child

 

exp equipment design/ AND exp seating AND child

 

dynamic seating

Medline (Ovid)

dynamic seating

 

seating and positioning

OTDbase

seating

ASSIA

positioning and seating

Psychinfo

seating

British Nursing Index

seating

 

Seat$

Zetoc

seating

 

pe*diatric seating

ISI Web of Science

seating

TABLE 2: Positioning / Posture

Data Base

Key Words

CINAHL

patient positioning

BIDS

posture

 

positioning

Pubmed

seating and posture

Proquest

seating and positioning

Embase

positioning

AMED

exp positioning/

 

patient positioning AND exp pelvis/

Medline (Ovid)

seating and positioning

OTDbase

positioning

ASSIA

seating and positioning

Psychinfo

positioning

British Nursing Index

patient positioning

Zetoc

seating and positioning

ISI Web of Science

seating and positioning

 

seating and posture

 

positioning and posture

TABLE 3: Cerebral Palsy

Data Base

Key Words

CINAHL

exp cerebral palsy/ AND posture/ AND child

BIDS

cerebral palsy

Pubmed

cerebral palsy and seating

Proquest

cerebral palsy and positioning

 

cerebral palsy and seating

 

spastic cerebral palsy and posture

 

spastic cerebral palsy and position

Embase

exp cerebral palsy/ AND child

 

exp cerebral palsy/ AND posture/ AND child

AMED

exp cerebral palsy/ AND seating

Medline (Ovid)

cerebral palsy and seating

OTDbase

cerebral palsy

ASSIA

cerebral palsy and positioning

 

cerebral palsy and posture

Psychinfo

cerebral palsy and posture

British Nursing Index

Exp cerebral palsy/ AND seating

Zetoc

cerebral palsy and seating

ISI Web of Science

Cerebral palsy

 

cerebral palsy and positioning

 

cerebral palsy and posture

TABLE 4: Duchenne Muscular Dystrophy

Data Base

Key Words

CINAHL

exp duchenne muscular dystrophy/ AND child

BIDS

muscular dystrophy

Pubmed

duchenne muscular dystrophy and seating

 

duchenne muscular dystrophy and posture

Proquest

exp duchenne muscular dystrophy/ AND exp child/

Embase

duchenne muscular dystrophy/ AND exp child/

AMED

duchenne muscular dystrophy

Medline (Ovid)

duchenne muscular dystrophy and seating

OTDbase

duchenne muscular dystrophy

ASSIA

duchenne muscular dystrophy

 

duchenne muscular dystrophy AND posture

Psychinfo

duchenne muscular dystrophy

British Nursing Index

duchenne muscular dystrophy

Zetoc

duchenne muscular dystrophy and seating

 

duchenne muscular dystrophy and child

 

duchenne muscular dystrophy and posture

ISI Web of Science

Duchenne muscular dystrophy

TABLE 5: Congenital Hip Deformity / Developmental Dysplasia

Data Base

Key Words

CINAHL

exp hip deformity congenital/ AND child

BIDS

congenital hip deformity

 

developmental dysplasia

Pubmed

congenital hip deformity and seating

 

congenital hip deformity and posture

Proquest

developmental dysplasia

Embase

exp hip dislocation congenital/

Medline (Ovid)

Congenital hip deformity AND child AND hip dislocation

AMED

exp hip dislocation congenital/

OTDbase

developmental dysplasia

ASSIA

developmental dysplasia

Psychinfo

developmental dysplasia

British Nursing Index

exp congenital abnormality/ AND exp developmental dysplasia/

Zetoc

congenital hip

 

developmental dysplasia

 

developmental dysplasia and seating

 

developmental dysplasia and child

ISI Web of Science

developmental dysplasia

TABLE 6: Rett Syndrome

Data Base

Key Words

CINAHL

rett syndrome

BIDS

rett syndrome

Pubmed

rett syndrome and posture

Proquest

rett syndrome and posture

Embase

exp rett syndrome/ AND exp child

AMED

exp rett syndrome/ AND exp child

Medline (Ovid)

rett syndrome and child

 

rett syndrome and posture

 

rett syndrome and posture

 

rett syndrome and child development

OTDbase

rett syndrome

ASSIA

rett syndrome

Psychinfo

rett syndrome

British Nursing Index

rett syndrome

Zetoc

rett syndrome

ISI Web of Science

rett syndrome

TABLE 7: Spina Bifida

Data Base

Key Words

CINHAL

spina bifida and seating

 

spina bifida and positioning

BIDS

spina bifida

Pubmed

spina bifida and seating

 

spina bifida and posture

Proquest

spina bifida and seating

AMED

exp child/ AND exp abnormalities/ AND exp spina bifida/

 

exp child/ AND exp meningomyelocele

Medline (Ovid)

spina bifida and posture

 

spina bifida and children

OTDbase

spina bifida

ASSIA

spina bifida and posture and seating

Psychinfo

spina bifida and children

British Nursing Index

spina bifida and seating

Zetoc

spina bifida and seating

 

spina bifida and posture

 

spina bifida

ISI Web of Science

spina bifida and child

 

spina bifida and posture

 

spina bifida and seating

Results and Conclusions

Results suggest in normal children, there is a significant but weak correlation between proximal control and the development of distal skill, suggesting that [proximal-distal principle may not be an appropriate postulate on which to base treatment / intervention. Significant relationship to support a functional relationship between proximal and distal motor functions.

Previously reported trends in presentation confirmed:

poor growth, fixed deformity and scoliosis in adulthood. mobility in adolescence, follwed by decline in adulthood. High dependency level. Limited cognition/communication skills. Slight improvement in ANS function in adulthood. Feeding difficulties into middle childhood, reachinf a

Findings confirm

that Rett Syndrome is not degenerative and suggests that intervention and support

to maintain and increase motor skills, daily living skills and cognitive and communication is

plateau.

Methodology

Posture and fine motor control were measured by the PFMAI, with testing conducted by J Case-Smith and 4 undergraduate students trained in PFMAI administration. Posture observed by the infants ability to independently sustain movement against gravity when in prone and supine. (postural reactions encouraged by attracting infants attention to developmentally appropriate toys. Fine motor skills assessed by eliciting various grasping and hand positions by presenting children with 3 objects. Infants position ed in semi recline. Four minutes of testing allocate d for reach and manipulation of each object

All participants seen in multidisciplinary tertiary health clinic (paediatrician, PT, SLT. OT and music therapist). Assessment areas included:

oralmotor skills, feeding problems, growth, breathing problems , pos tural abnormalities and joint deformities, epilepsy, stereotypies and hand movements, self-care, and cognitive and communication skills. Areas assessed by parental/carer reports, direct observation, multidisciplinary examination, clinical reports, video taped assessment sessions and assessment tools e.g. Schedule for Oral Motor Assessment.

Participants

normal infants (2-6 months:

mean 4.4 months) from day care

facility tested as measured by

the PFMAI.

 

participants ( 2yeras 1 month

44 years 10 months) with a

confirmed diagnosis of rett

syndrome seen between 1993

and 2000.

n= 76 (classic rett syndrome)

n=11 (atypical presentation of

disorder)

60

87

Study Design

Cas-series design

Case-Series design

Purpose

To investigate the relationship between proximal and distal motor control using the Postural

 

Fine Motor Assessment Scale for Infants (PFMAI)

To gather systematic data from a multidisciplinary clinical assessment case load of females with rett syndrome, to allow clinical manifestations of the disorder to be statistically validated in order to discuss implications regarding management of the condition and directions for future research.

 

Author / Date / Title

Case-Smith J, Fisher AG & Bauer

(1989).

An Analysis of the Relationship

between Proximal and Distal Motor

Control.

Cass H, Reilly, Owen L, Wisbeach

Weekes L, Wigram T &

Charman T (2003).

 

Findings from a multidisciplinary

clinical case series of females with

rett syndrome.

 

D

A,

Results and Conclusions

56% reported experiencing pain once a week or more often; Pain occurred more frequently in the head, neck, back, abdomen, shoulders, legs and hands. 43 49 with hydrocephalus reported headaches. 15 19 without hydrocehalus reported headaches Children reporting intense pain, also report frequency and pain locations. Parenta most reliable st reporting locality of children s pain. Findings conclude children with soina bifida report clinically significant, under recognised & untreated pain.

Results suggest there is a deficiency in equipment available to cope with and manage children in plaster, including products to help in seating. Special emphais is placed on mobility.

This pilot study confirmed need for future focused research to provide products suggested.

Methodology

Data collected via parental report questionnaires (The Pediatric Pain Questionnaire) and child report questionnaire (Visual Analogue Scale) and, from t medical records to investigate ain intensity, location, frequency and duration.

Measures administrated by one of two trained Masters level volunteer in separate area from clinic to ensure independent rating.

24 questionnaires distributed, of which 11 were returned (48.8% response rate).

Questionnaires either distributed by post or through parental support groups and were completed by parents.

Participants

n= 68 children with spina bifida (30 males, 38 females) Mean age 12 years 8 months (range 8-19 years). n=59 (myelomeningocele) n= 6 lipomyelomeningocele n= 3 lipomeningocele. n= 49 shunted hydrocephalus n=26 ambulated full time Children able to communicate in English and had no significant cognitive limitations. Recruited from regional children s centre.

Parents (mean age 43 years 4 months) For comparison purposes sample divided into 2 groups

Parents of 11 children (2 boys; 9 girls) who were either undergoing or had undergone treatment for late diagnosed DDH, were surveyed by questionnaire.

 

Study Design

Prospective study.

Questionnaire (pilot study) (semi structured and open)

3 questionnaires sent to patient s in Northern Ireland; 2 in the republic of Ireland; and 6 in Engalnd.

Questions generated from analysis of the literature and information obtained from detailed semi-structured interviews with surgeons and staff involved in treatment.

Questionnaire focuses on seating and mobility problems.

Purpose

1) To investigate the nature and prevalence of pain in children and adolescents with spina bifida.

2) To compare children s and parents paediatric pain ratings to determine whether or not concordance exists between the two.

To confirm the clinical suspicion that significant problems are encountered by children and their care -givers in coping the treatment of splinting resulting from late diagnoses developmental dysplasia of the hip (DDH).

 

Author / Date / Title

Clancy CA, McGrath PJ & Oddson BE (2005).

Pain in adolescents with spina bifida.

Problems of seating and mobility encountered by children with developmental dysplasia of the hip.

Cox SL & Mollan RAB (1995)

 

Results and Conclusions

Reslults suggested that parents idenfied social, emotional and physical problems. Problems included size and shape of splint, transporting ans seating problems and disruption of family routines.

Such problems may be alleviated by provision of specialised devices that would permit mobility by car, in a pushchair and provide seating in the home.

developed spastic

hemiplegia

1developed spastic

tetraplegia

developed spastic

tetraplegia with athetosis.

Results suggest basic

orientation of postural

adjustments of childr en

developing spastic CP was

intact, with main problems

being ability to modulate

postural adjustment to task

specific constraints. The

child with spastic athetosis

showed distinct abnormalities

in basic organisation of

postural adjustments.

Reaching movements were

favoured in semi recline as

opposed to upright, supine

and long leg sitting

5

1

Methodology

Questionnaire developed based on the activitied of daily iving that were established for families with children between 3 months and 3 years old.

10 questionnaires distributed in England; 3 obtained via interview with parents in childrens ward in hpspital in N. Ireland: 100 distributed to those undergoing or had undergone treatment at the hospital.

Reaching movements were assessed via simultaneous recording of video data and surface EMG of arm, neck, trunk and leg muscles during reaching in various positions (lying supine, semi -recline (45°), upright and long leg sitting).

 

Participants

113 affected families surveyed

38 questionnaires returned (3 4% response rate.

7 children (age range 4-18 months). 3 boys; 4 girls

 

Study Design

Questionnaire (semi structured and open)

Longitudinal

Purpose

To identify problems related to the treatment (splintage) of DDH in order of priority in families of hildren with DDH.

Physical, emotional and social problems are the focus of the report.

To analyse the early development of postural adjustments accompanying reaching movements in children with cerebral palsy.

 

Author / Date / Title

Cox SL & Kernohan WG (1998 ) .

They cannot sit properly or move around: seating and mobility during treatment for developmental dysplasia of the hip in children.

Hadders-Algra M, van der Fits IBM, Stremmelaar EF & Touwen BCC (1999).

 

Development of postural adjustments during reac hing in infants with cerebral palsy.

 

Results and Conclusions

Significant static correction

the spine (scoliotic) may achieved via an

arrangement of lateral pads

a seating system applying

3-point force system to the

sides of the body.

 

statistical significant

correlation was obtained

(p<0.01) between the sitting

lumbar curve and the

popliteal angle. This

correlation was less when

standing.

Study concludes that there is

correlation between tight

hamstrings and decreasing

lumbar lordosis, esp ecially in

the seated postion in children

with cerebral palsy.

of

be

on

a

A

a

Methodology

Shape of spine measured (spinous process angle in an assessment chair (CAPS II). Exerted forcs on chair measured by electrical transducers attached to lateral support pads and seat base. Measurements were taken in 3 alternative arrangements: 1) unsupported upper body 2) two lateral pads at the same height 3) body supported by 3-point force system.

The Cobb method was used to measure lumbar and thoracic kyphosis. Standing and sitiing lateral spine films were obtained.

 

The popliteal angle was measured to assess hamstring tightness.

 

Participants

subjects with spastic cerebral

9 boys: 7 girls

Man age: 14.7 years (range 6.5 -

 

Inclusion criteria reuired

subjects to be non-ambulant,

have a scoliosis and require

special seating within their

wheelchair,.

participants

Mean age: 9.4 years old

 

16

palsy

20.8).

21

Study Design

Prospective study: matched pairs design

 

Retrospective clinical and radiographic review.

 

Purpose

To investigate the effects of special seating on lateral spinal curvature in the non - ambulant spastic cerebral palsy population with scoliosis.

 

To assess the influence of tight hamstrings on the saggital alignment of the thoracic and lumbar spine in children with cerebral palsy.

 

Author / Date / Year

Holmes KJ, Michhael SM & Thorpe

(2003).

Management of scoliosis with special seating for the non -ambulant spastic cerebral palsy population a biomechanical study.

 

McCarthy JJ & Betz RR (2000)

The relationship between tight hamstrings and lumbar hypolordosis in children with cerebral palsy.

 

Results and Conclusions

Significant between group differences were observed on most dependent measures. No significant difference a could be attributed to seat inclination, however authors suggest anterior tilt may disturb postural stability, without improving upper extremity function

 

significant relationship was

found between the prevalence

rett syndrome scoliosis and

orthopaedic risk factors. The

findings suggest a treatme nt

approach focusing on

balancing bilateral muscle

 

A

of

pull.

Methodology

Seat surface inclinations of 0°, 5° (anterior tilt), 5° posterior tilt) with seat to backrest angle at 90° were compared within and between groups, with leg rest position at 90° from the seat surface for all experimental conditions.

 

questionnaires were

distributed via post, 262 were

completed and returned (66%).

were suitable for statistical

analysis (57%).

 

Responses were scored

independently by two

investigators

400

228

Participants

children (10 non -impaired:

mild-moderate spastic

cerebral palsy.

Age range: 4-15 years.

CP children able to sit

independently and ambulate

with or without mobility aids.

Able to comprehend simple

instructions.

Screened for visual problems.

262 questionnaires completed by International Rett Syndrome Association families.

 

Findings based on 57% response rate.

 

20

10

Study Design

Quasi-experimental design

Questionnaire

Purpose

To investigate the inter - relationship of seat -surface inclination on postural stability and functional use of the upper extremities in children with cerebral palsy.

 

To investigate the interrelationships between rett syndrome scoliosis and symmetric, asymmetric motor pull, ambulation and advancement of age in order to provide a treatment

 

rationale for slowing the progression of a scoliosis.

Author / Date / Title

McClenagahan BA, Thombs L & Milner M (1992).

 

Effects of seat -surface inclination on postural stability and function of the upper extremities of children with cerebral palsy.

 

McClure MK, Battaglia C & McClure RJ (1997).

 

The relationship of cumulative motor asymmetries to scoliosis in rett syndrome.

 

Results and Conclusions

Quantifiable and qualitative between group differences in reaching. No significant differences could be attributed to the seating positions.

 

Significant differences observed among the five conditions. Study suggests a anterior sitting posture is the preferred position to facilitate increased trunk extension.

 

Methodology

Arm movements were compared between groups and within groups in four different positions (neutral, wheelchair, posterior tillt (15°) and anterior tilt (15°). Four conditions presented in counterbalanced order. EMG activity recoreded.

 

Each child rated on a scale of 1 - 4 to document trunk control, rated by an experienced paediatric physiotherapist.

 

Trunk extension measures by the modified Schober Measurement of Spinal Extension (1975).

Tested in 5 random positions during 30 min session (floor sitting in tailor like fashion, level sitting with hips and knees at 90°, bench sitting with bench tilted forward (20°and 30°) and sitting in a commercial chair.

Participants

subjects

12

men: 3 women with mild -

moderate spastic cerebral palsy;

men and 3 women with no

known pathological conditi on.

Age range; 18-21 years

Right hand dominant

Able to follow instructions

children

15

Age range (2-6 years)

Diagnosis of developmental

delay and/or severe hypotonic or

hypertonic cerebral palsy

(diplegia or quadriplegia).

 

3

3

Study Design

Quasi-experimental

 

Purpose

To compare arm movements of persons with and without cerebral palsy and to determine if the alteration of the seat angle of a chair affect quality of movements.

 

To identify a reliable, objective and clinically useful measure for assessing changes in trunk alignment and to evaluate which of five different seated positions was the most effective in encouraging trunk extension.

 

Author / Date / Title

McPherson JJ, Schild R, Spaulding SJ, Barasamian P, Transon C & White SC (1991).

 

Analysis of upper extremity movement in four sitting positions:

a comparison of persons with and without cerebral palsy.

 

Miedaner JA (1990).

The effects of sitting positions on trunk extension for children with motor impairment.

 

Results and Conclusion

symmetrical fixation of belt under seat, use of an abduction orthosis and placement in the FSP. This is in addition to seat inclined forwards and arms supported

Greatest reduction of spasticity gained and postural control enhanced when three factors were combined:

No discernable

effects were identified by seat

inclination alone.

Results suggest pathological movements are minimised and postural control and upper extremity function are more 3efficient in a forward tipped seat, with a firm backrest supporting pelvis, arms supported against a table and feet permitted to move backward.

 

on a table.

 

Both children filmed and photographed individually in six positions on the same occasion, including sitting in their own adapted chairs and in the proposed FSP. Testing conditions were altered by changing the seat inclination, use/non-use of abduction orthosis and with.without a table

Total time for

postural control was recorded

and pathological movements were counted.

Children were filmed and photographed in 6 positions (adapted chair; adapted chair and cut out level table in font of child,; FSP without abduction orthosis; adapted chair and abduction orthosis,;FSP without table; FSP with table and abduction orthosis). In FSP seat was forward inclined.

Head control, pathological movements, postural control were measured via observation and Sitting Assessment Scale.

Methodolgy

in front of them.

Participants

2 children with severe cerebral palsy.

Child A: 7 years old, spastic diplegia Child B: 15 years old , spastic tetraplegia.

23 children (8 female, 15 male) Age range (2-16 years)

Study Design

Pilot study (single case design)

Quasi-experimental

Purpose

To create a functional sitting position (FSP) by identifying the essential factors required to reduce spasticity as well as enhancing postural control in children with cerebral palsy.

 

To find a functional sitting position for children with cerebral palsy and to compare this position with the children s original sitting positions with various experimental positions.

 

Author / Date / Title

Myhr U & von Wendt (1990).

Reducing spasticity and enhancing postural control for the creation of a functional sitting position in children with cerebral palsy: a pilot study.

Myhr U & von Wendt (1991).

Improvement of functional sitting position for children with cerebral palsy.

Results and Conclusions

Results revealed that in positions with the backrest vertical and with the use of a hip belt, all children held their feet posterior to the knee joint axis regardless of seat inclination.

 

8 out of the 10 children assessed, who used the FSP over the five year period, showed slight but significant improvement, the remaining two children had deteriorated.

Study concludes that the FSP contributes to improved ability to use the upper extremities (hand and arm function).

Methodology

The children were filmed and photographed whilst performing standardised tasks in 5 different sitting positions (backrest vertical and seat surface inclination varying between 0° 10° forward inclined, 10° backward reclined, and also in reclined positions in with seat and backrest lean backward from the horizontal plane and vertical plane, respectively (15 °).

Ten children were filmed and

Head, trunk, foot control, arm and hand function were assessed by the Sitting Assessment Scale

photographed after the introduction of the FSP and subsequently five years later.

Participants

non-disabled children

(7 girls; 3 boys)

Mean age 6.7 years (range: 4 -9

years).

children with CP

10

10

Study Design

Case Study

Retrospective

Purpose

To determine the spontaneous positioning of the lower extremities relative to the movement axis at the knee joint, and to determine thre extent of spontaneous use of the arms for support in different sitting positions, in a group of non-disabled children.

To obtain a baseline comparison with measurements of children with cerebral palsy.

To re-assess children who

were previously introduced to and tested in the FSP five years previously.

To re-examine the reliability of the Sitting Assessment Scale.

Author / Date / Title

Myhr U (1994).

Influence of different seat and backrest inclinations on the spontaneous positioning of the extremities of non -disabled children.

   

Myhr U, von Wendt L, Norrlin S & Radell U (1995).

Five year follow-up of functional sitting position in children with cerebral palsy.

Results and Conclusions

Results of the study suggest that pulmonary function was higher in adaptive seating compared to non -adaptive seating.

Results suggest implications for speech, sitting for prolonged periods and the prevention of pulmonary hypertension.

Results highlighted that extensor activity was lowest when backrest inclination remained at 90° and the seat surface at 0° (upright sitting). Preliminary finding from study suggests that the orientation of the head /neck/body in relation to gravity may play an important role in controlling extensor activity.

Methodology

Vital capacity, forced expiratory volume in one second, and expiratory time as measure by a spirometer , of children with CP were measured in a typical sling back wheelchair and in a wheelchair with modular inserts.

Children were positioned in 90-90-90 in both seating units.

Using surface electrodes EMG activity was recorded for the lumbar extensor spinae muscles in seven different testing conditions. Seat surface inclinations of 0° and 15° combined with backrest inclinations of 75°, 90°, 105°, and 120°

Participants

8 children with spastic CP Age range: 5-12. Non-ambulant No apparent evidence of intrinsic lung disease.

 

11 children (7 boys: 4 girls) with spastic CP. Age range: 4-8 years

Study Design

Quasi-Experimental

Experimental

Purpose

To compare the effects of adaptive and non adaptive seating on pulmonary function.

 

To determine if the myoelectric activity of the extensor muscles of the lumbar spine is affected by positions of the seat surface and seat back, or by their positions relative to one another.

Author / Date / Tilte

Nwaobi OM & Smith (1986).

Effect of adaptive seating on pulmonary function of children with cerebral palsy.

Nwaobi OM, Brubaker CE, Cusick B & Sussman (1983).

Electromyographic investigation of extensor activity in cerebral -palsied children in different seating positions.

Results and Conclusions

Results demonstrated that muscle activity was affected by body orientation, with tonic muscle activity lower in the upright position with statistically significant differences for the hip adductors and back extensors. Extensor tone may increase in the reclined position.

Results conclude orientation of the body in space affects upper extremity function. The level of upper extremity performance was highest in the upright position.

 

Methodology

Surface electrodes were used to measure myoelectric activity if the low back extensors, hip adductors and ankle planta r flexor muscles in two seating positions.

 

The seating positions were 0° in vertical plane and 30° from the vertical plane. Each participant was position ed in 90-90-90 with the use of a pommel prior to testing.

The children were placed randomly in different seating orientations (30°, 15°, and 0° posterior inclination and 15°anterior inclination).

 

Participants

children (8 boys: 4 girls)

Age range: 6-18 years

Diagnosis of mild-moderate

spastic diplegia.

Fair head and trunk control

Fair to poor fine motor skills

No fixed deformity.

 

children with CP

3 athetoid CP

spastic CP

Age range: 8-16 years

Unable to ambulate

independently

Require adaptive seating for

upright positioning

Fair-poor gross upper extremity

control.

Fair head and trunk con trol

Poor fine motor skills.

12

13

10

Study Design

Experimental

Quasi-experimental

Purpose

To measure the tonic myoelectric activity of the low back extensors, hip adductors and ankle plantar flexors in two body orientations.

 

To determine if tonic activity of these muscles change in response to body orientation, and which body orientation provides the lowest level of muscle activity.

To measure the performance time of a prescribed upper extremity activity in four different seating orientations relative to the ve rtical plane to determine the effect of body orientation on voluntary motor function.

 

Author / Date / Title

Nwaobi UM (1986).

Effects of body orientation in space on tonic muscle activity of patients with cerebral palsy.

 

Nwaobi OM (1987).

Seating orientations and upper extremity function in children with cerebral palsy.

 

Results and Conclusion

The saddle seat has the potential to modify the quality of seating posture and

Saddle bench allowed improved postural control as measured by the Sitting Assessment for Children with Neuromotor Dysfunction.

reaching movements in children with cerebral palsy.

Results conclude that no significant differences in respiratory parameters were attributed to seat inclination in either the normal group or those with CP.

Results suggest however that increased tidal volume and minute ventilation may increased in anterior tipped seating, although are not statistically significant.

Methodology

The two experimental conditions were the saddle seat (15° forwards inclination) and a flat wooden bench.

Clinical assessment of seated postural control was measured by the Sitting Assessment for Children with Neuromotor Dysfunction.

Respiration parameters of tidal volume, respiration rate and minute ventilation are compared in response to two seated positions 1) flat seating 2) anterior seating (10° forward tipped). Respiratory inductance plethysmography used to record respiratory function.

Participants

6 children with mild-moderate spastic CP.

Able to sit on a flat bench without holding on. Independently mobile via use of walker or manual wheelchair.

12 children (6 non-impaired, mean age 9.7 ; 6 with spastic CP), mean age 6.0)

Children with CP able to ambulate either with or without mobility aids

Study Design

Repeated-measures experimental cross -over design.

 

Experimental

Purpose

To evaluate postural control and upper extremity movement control in children

with cerebral palsy using a saddle seat.

To investigate the effects of using an anterior inclined seat base on tidal volume, respiration rate and minute ventilation function of normal children and children with cerebral palsy.

 

Author / Date / Title

Reid DT (1996)

The effects of the saddle seat on seated postural control and upper

extremity movement in children with cerebral palsy.

Effects of anterior tipped seating on respiratory function of normal children and children with cerebral palsy.

Reid DT & Sochaniwskj (1991).

 

Results and Conclusion

Results conclude development of postural adjustment during reaching is non-linear and not finished until 11 years old. Anticipatory postural muscle activity , consistently present in adults, was basically absent between 2 -11 years. Findings suggest that the forward tilted sitting position is the most efficient regarding postural control.

Results show that tonal symmetry is related to windswept deformity alone, whereas increased age, severe spasticity, and direction of tonal asymmetry were associated with windswept deformity and hip dislocation. Prevalence rates included 52% (windswept hips), 25% (tonal asymmetry), in hip subluxation (63%) and hip surgery (63%). The side with the strongest tone was more frequently dislocated of held in fixed adduction.

Methodology

29 children and 10 adults studies via EMG and kinematics during reaching in 4 different conditions: sitting with seat surface horizontal, with and without task load, 15° forward of seat surface and 15 ° backwards tilt of seat surface

Data gathered form me dical records and physical examination (standardised)

 

Participants

healthy children, age range

young adults (mean age

23.6±2 years)

103 subjects with spastic CP

recruited from two study institutions.

 

29

2-11.

10

Study Design

Experimental

Cross-sectional study

Purpose

To investigate the development of postural adjustments accompanying

 

reaching movements in sitting children.

To determine the prevalence of windswept hip deformity and hip dislocation, and their

relationship to asymmetry of muscle tone.

Author / Date / Title

Van der Heide JC, Oten B, van Eykern LA & Hadders -Algra

(2003).

Developmental of postural adjustments during reaching in sitting children.

Young NL, Wright JG, Lam TP, Rajaratnam K, Stephens D, & Wedge JH (1998).

Windswept deformit y in spastic quadriplegic cerebral palsy.