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Efficacy and Effectiveness of Adaptive Seating on Sitting Posture and Postural Control in Children with… Chung, Julie; Evans, Jessie; Lee, Corinna; Lee, Jessie; Rabbani-nejad, Yasha; Roxborough, Lori 2007-07-30

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Efficacy and Effectiveness of Adaptive Seating on Sitting Posture and Postural Control in Children with Cerebral Palsy Julie Chung Jessie Evans Corinna Lee Jessie Lee Yasha Rabbani Supervisors: Lori Roxborough and  Dr.Elizabeth Dean Outline of Presentation z Purpose z Definitions z Background z Research Question z Methodology z Overall Results z Study Results & Discussion z Limitations z Clinical Implications z Conclusions z Future Directions Purpose z To examine the current literature to determine the effectiveness and efficacy of adaptive seating on sitting posture and postural control in children with cerebral palsy (CP). Definitions z Adaptive seating z Any modifications to seating devices with the purpose of improving sitting posture and/or postural control in mobility-impaired individuals1 z Posture z A position of the limbs or the body as a whole2,3 z Postural control z The ability to control the body’s position in space to obtain stability and orientation2,3 BACKGROUND Cerebral Palsy z Cerebral palsy z A broad term used to describe a group of non- progressive disorders of posture and movement4 z Incidence z 1 in 500 children in Canada5 z Causes z Multi-factorial z Attributed to factors during fetal or infant brain development4 Cerebral Palsy z Clinical features z Decreased muscle strength z Abnormal muscle tone z Inability to maintain postural control z Abnormal sensation, cognition, communication and/or behaviour z Classification z Severity z Motor disorder z Secondary motor impairments Interventions z Postural control interventions z Balance training protocols/devices z Ankle foot orthoses z Neurodevelopmental treatment z Whole-body LycraⓇ garments z Adaptive seating Previous Reviews z Roxborough6 (1995) – 8 studies z 3 positive results z pulmonary function z active trunk extension z performance on the Bayley Mental Scale z Harris and Roxborough7 (2005) – 12 studies z 7 positive results for postural outcomes zWhy is the ICF important for the field of CP? z Promotes a holistic approach to treatment z Educates family about the importance of relating function with socialization ICF Model Research Questions Primary Question zWhat is the effect of adaptive seating on sitting posture and postural control in children between 0 to 20 years of age, who are non-ambulatory with varying types and severity of CP? Research Questions Secondary Question zWhat is the effect of improved sitting posture and/or postural control on participation and functional performance of activities in children with CP? METHODOLOGY Search Strategy Inclusion Criteria z (P) Children with CP between 0 and 20 years of age z (I) Adaptive seating z (C) N/A z (O) Sitting posture and/or postural control z English language articles appearing in a peer- reviewed journal (Jan 1980 – Dec 2006). Search Strategy Exclusion Criteria z (P) Children had co-morbidities z (I) Co-interventions or non-seating related adaptive devices z (O) Standing postural control z A survey, anecdote, letter, or comment Search Strategy 1. MEDLINE 2. CINAHL 3. EMBASE 4. PUBMED 5. Database of Reviews of Effectiveness (DARE) 6. The Physiotherapy Evidence Database (PEDro) 7. OT Seeker 8. Cochrane Controlled Trials Register 9. Cochrane Database of Systematic  Reviews 10. Web of Science 11. Dissertation abstracts 12. Education Resources Information Centre (ERIC) Search Strategy z Child z Children z Cerebral palsy z Adaptive seating z Assistive device z Orthoses z Positioning z Seating z Wheelchair z Chair z Infant equipment z Posture z Body posture z Postural control z Postural dysfunction z Sitting posture Key Terms Search Strategy Grey Literature z Reference lists z Contacting experts in the field Hand search (1995-2005) z Journal of Pediatric Orthopedics z Pediatric Physical Therapy z Developmental Medicine and Child Neurology Data Extraction Our data extraction form included: z Study designs z Sample size z Participant characteristics z Interventions z Outcome Measures z Results z Conclusions z Relevant notes Quality Assessment Assessment Tools z Group designs: z AACPDM Quality Assessment Scale z Single subject designs: z The Quality, Rigor, or Evaluative Criteria Description z 7-item scales z Scores are interpreted as: strong (6 or 7), moderate (4 or 5), or weak (3 or less) Level of Evidence Sackett’s Level of Evidence for Group Design Expert opinion Case study or report Bench research Expert opinion based on theory or physiologic research Common sense/anecdotes V Case series Cohort study without concurrent control group Case-control study IV Cohort studies (concurrent control group) Systematic reviews of case control studies III Smaller RCTs (with wider confidence intervals) (n < 100) Systematic reviews of cohort studies “Outcomes research” II Systematic review of randomized controlled trials (RCTs) Large RCT (with narrow confidence intervals) (n > 100) I Level of Evidence AACPDM Level of Evidence for Single Subject Design AB design (with 1 subject only) V AB design (with replication on > subject) IV ABA design III ABABA design Alternating treatments design Multiple baseline designs (concurrent or non- concurrent; across subjects, settings, or behaviours) II N-of-1 randomized controlled trial I Flow Chart Potentially relevant citations identified through electronic and hand searches (n = 468) Citations excluded after title screening (n = 325) Abstracts retrieved for review (n = 143) TITLE SCREENING Studies excluded after abstract screening (n = 126) Full articles retrieved for review (n = 19) ABSTRACT SCREENING Studies excluded after full text review (n = 6) Relevant studies included in systematic review (n = 13) FULL TEXT REVIEW Qualitative reviews (n=2) Upper limb function (n=1) Adult CP subjects (n=1) No data for extraction (n=2) OVERALL RESULTS Study Characteristics II to V (median: IV)Level of Evidence 0 to 7 (median: 4)Methodological Quality 10 group designs 1 single subject design 2 case studies Research Design Participant Characteristics No. Subjects 2 to 23 (total: 152) Age 12 mos to 20.8 yrs Motor Impairments Diplegia (n=7), triplegia (n=2), tetrapelgia (n=6) Motor Disorders Spastic (n=12), dystonia (n=2), athetosis(n=2) Severity of CP Mild, moderate, severe Interventions z Saddle seats (n=3) z Seat/backrest inclinations (n=4) z Seat inserts (n=2) z External supports (n=1) z Modular seating system (n=4) Outcomes Participation2Social skills Activity1Performance of ADLs Activity1Mobility Activity4Upper limb function Body structure and function 11Sitting postural control Body structure6Sitting posture ICF ModelStudiesOutcomes STUDY RESULTS & DISCUSSION Overview z Body Structure and Function z Interventions: z A) Saddle Seating z B) Seat/Backrest Positional Angles z C) Seat Inserts z D) External Supports z E) Modular Seating Systems z Activity and Participation z Outcomes: z A) Upper Extremity Function z B) Mobility z C) Social Skills & ADLs Grades of Recommendations Level 5 studiesD Level 4 studiesC Level 2 or 3 studiesB Level 1 studiesA Sitting Posture & Postural Control Body Structure & Function z Saddle-shaped seat z Maintains abduction and outward rotation of the hips z Incorporates a forward slope to facilitate anterior rotation of the pelvis z Encourages a midline posture z Increases dynamic and equal weight bearing through the lower extremities Saddle Position Saddle Position Pope et al.8 (1994) Saddle Position z Pope et al.8 (1994) z Description: z Level IV evidence; 4/7 quality z Findings: z variable results - no to little improvement in sitting posture and postural control z Major limitations: z Small sample size (n=9) z Lack of control of confounding variables eg. Environment z Poor adherence to intervention Saddle Position z Reid9 (1996) z Description: z Level IV evidence; 4/7 quality z Findings: z Significant decrease in abnormal postural responses = improved sitting postural control z Significant increase in spinal extension = improved sitting posture z Major limitations: z Did not control for postural cueing z Did not operationally define mild and moderate CP z Stewart & McQuilton10 (1987) z Description: z Level V evidence; 0/7 quality z Findings: z Qualitative observation showed improved sitting postural control z Major limitations: z No reports of inter or intrarater reiability z Lack of details re: methods and intervention Saddle Position Saddle Position Improved0VStewart10 Improved4IVReid9 Variable4IVPope8 ResultsQualityLevel of evidence Author Saddle Position z Overall recommendations: z Grade C: mixed evidence z Grade D: one study lends support z Anteriorly- vs. Posteriorly tipped bases? z Anteriorly tipped seat bases: z more upright and stable sitting posture z reduce kyphosis z maintain lumbar lordosis z decrease posterior pelvic rotation z shift the centre of gravity forward z Posteriorly tipped seat bases: z reduce EMG activity of hyperactive muscles z facilitates the development of functional movement in sitting Positional Angles Positional Angles z Sochaniwskyj11 (1991) z Description: z Level III; 3/7 quality z Findings: z 10° anterior tilt: z significantly increased back extension z 15° anterior tilt: z significantly decreased sitting postural control z greatest EMG activity of erector spinae muscles z Major limitations: z Non-equivalent control group z Poor construct validity z McClenaghan et al.12 (1992) z Description: z Level III; 5/7 quality z Findings: z Quiet sitting: 5° posterior tilt improved lower limb stability; 5° anterior tilt decreased head stability z Active sitting: no differences z Major limitations: z High inter-subject variability z No interrater reliability reported Positional Angles zMiedaner13 (1990) z Description: z Level III; 2/7 quality z Findings: z 20º forward tilted bench improved trunk extension in sitting z Major limitations: z No interrater reliability reported Positional Angles z Nwaobi14 (1983) z Description: z Level V; 4/7 quality z Findings: z Lowest EMG muscle activity when back rest at 90º and seat inclined at 0º z Major limitations: z Only looked at low back extensors z Only recorded EMG muscle activity for 60 seconds Positional Angles Positional Angles Improved with neutral position 4VNwaobi14 Improved with anterior tilt 2IIMiedaner13 Improved with 5º posterior tilt 5IIIMcClenaghan12 Improved with 10º anterior tilt 3IIISochaniwskyj11 ResultsQualityLevel of evidence Author Positional Angles z Overall recommendations: z Grade B: mixed: two studies supported anterior tilt; one study supported posterior tilt z Grade D: one study supported neutral position z Added to a child’s adaptive seating device to improve postural control z Contoured foam seating (CFS) z Biofeedback Seat Inserts Seat Inserts z Washington et al.15 (2002) z Description: z Level II; 7/7 quality z Contoured foam seating that is custom molded z Findings: z Significant increase in time spent in midline = improved sitting postural control z Parental report of improved postural alignment z Major limitations: z Small convenience sample (n=2) z Clinician who made CFS had 12 years of experience z Bertoti16 (1988) z Description: z Level IV; 3/7 quality z Biofeedback seat insert z Findings: z Subjective report of improved sitting posture z Major limitations: z Subjects were children with “normal intelligence” z ?? Amount of use needed to optimize gains, feasibility of compliance, long term effects Seat Inserts Seat Inserts Improved3IVBertoti16 Improved7IIWashington15 ResultsQualityLevel of evidence Author Seat Inserts z Overall recommendations: z Grade B: one study supports use of CFS z Grade C: one study supports use of biofeedback z Lateral supports arranged in a 3-point force system z 2 parallel forces opposed by a single force acting in the opposite direction External Supports External Supports z Holmes et al.17 (2003) z Description: z Level IV; 5/7 quality z 3-point lateral supports system z Findings: z Significantly improved scoliosis = improved sitting posture z Major limitations: z only measured in 2-D, but scoliosis is 3-D z ?? Long term effects, adherence QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. External Supports z Overall recommendations: z Grade C: one study supports 3 point lateral support force system z Combination of positional adjustments and orthoses z Allows for a functional sitting position Modular Seating Systems z “Maxit” or “Real” Chair z Symmetrically weight bearing on ischial tuberosities z Line of gravity of the upper body anterior to axis of rotation at the ischial tuberosities z Hips fixated with a belt under the seat z Legs separated by an abduction orthosis z Seat base either horizontal or anteriorly tipped Modular Seating Systems Modular Seating Systems z Myhr & von Wendt18 (1990) z Description: z Level V; 2/7 quality z Modular seating system z Findings: z longest duration of head control & least number of pathological movements = improved postural control z Major limitations z Small sample size (n=2) z Not standardized intervention z Poor construct validity z Myhr & von Wendt19 (1991) z Description: z Level IV; 6/7 quality z “Maxit” or “Real” Chair z Findings: z Significantly improved overall sitting postural control z Major limitations: z Non standardized intervention z Sitting Assessment Scale – no reports of validity or reliability z Use of Spearman correlation coefficient Modular Seating Systems z Myhr et al.20 (1995) z Description: z Level IV; 6/7 quality z 5 yr follow-up study z Findings: z 8 of 10 children: z maintained functional sitting position z significant improvement in sitting postural control z 2 children: z deteriorated and trunk control worsened z Major limitations: z Same methods a/a, thus limitations are similar Modular Seating Systems z Ther Adapt Posture Chair z Consists of adjustable: z Seat height z Kneepads z Lumbar support z Used to obtain a stabilized sitting posture Modular Seating Systems zMiedaner13 (1990) z Description: z Level III; 2/7 quality z Findings: z Ther Adapt Posture Chair improved trunk extension in sitting z Major limitations: z Intervention was not specified and standardized Modular Seating Systems Modular Seating Systems Author Level of evidence Quality Results Myhr (1990)18 V 2 Improved Myhr (1991)19 IV 6 Improved Myhr (1995)20 IV 6 Improved Miedaner II 2 Improved Modular Seating Systems z Overall recommendations: z Grade B: one study support the use of Ther Adapt Posture Chair z Grade C: one study lends support to use of the "Maxit” or “Real" chair; one study reported long term improvements z Grade D: one study supports a modular seating system Activity and Participation Upper limb function, Mobility, Social Skills and Performance of ADLs Upper Limb Function z Saddle seat (Pope et al.8, Reid9) z No significant impact on improving: z fine motor z dexterity z upper limb function z Seat Positional Angles (McClenaghan et al.12) z 5º anterior tilt: z significant increase in thumb-press performance z 5º posterior tilt: z Reduction in linear tapping performance z CFS (Washington et al.15) z No clear effects Upper Limb Function z Overall recommendations z More research is needed to examine the link between improved posture and postural control on increased upper limb ability Upper Limb Function Mobility z Saddle seat (Pope et al.8) z Overall increase in mobility z Overall recommendations z More research is needed to examine the activity component of the ICF Social Skills & Performance of ADLs z CFS (Washington et al.15) z Subjective reports of improved: z social interactions z functional independence z feeding ability z functional performance Social Skills & Performance of ADLs z Overall recommendations z More objective measurements are needed to capture the magnitude of change in these outcomes CLOSING REMARKS Limitations of Current Review z Heterogenous population z Difficult to compare in terms of severity, age, type of CP and motor impairment z No standardization of outcome measures z Low-level of evidence (Level II to V) z Publication bias z Lack of current research z English language Clinical Implications z Adaptive seating should be individualized to meet the needs of each child z Therapists should be patient as developing an appropriate seating device requires multiple adjustments over a series of visits z Appropriate use of adaptive seating can lead to improvements at the body structure/function, activity, and participation components of the ICF model. Conclusions z No single intervention has been shown to be more effective than others in improving sitting posture and/or postural control z Limited evidence to suggest whether improved sitting posture and/or postural control will lead to improved functional abilities z More research is needed Future Directions z Studies with stronger levels of evidence and rigorous research designs z Use of validated classification systems to describe the motor function (e.g. Gross Motor Function Classification Scale) z Standardized outcome measures for postural control z Studies that examine the link between postural control to functional skills and level of participation. Acknowledgements z Lori Roxborough z Dr. Elizabeth Dean z Dr. Susan Harris z Angela Busch z Marie Westby z Charlotte Beck z Steve Ryan z Tanja Mason z Janice Evans Thank you!   Any questions? References 1. Rehab Tools.  Assistive Technology: Resources and Links. In; 2004. 2. Massion J. Postural control systems in developmental perspective. Neurosci Biobehav Rev 1998;22(4):465- 72. 3. Stedman's Medical Dictionary. 27th ed. Baltimore, Maryland: Lippincott Williams & Wilkins; 2000. 4. Krigger KW. Cerebral palsy: an overview. Am Fam Physician 2006; 73(1)a:91-100. 5. Steultjens EM, Dekker J, Bouter LM, van de Nes JC, Lambregts BL, van den Ende CH. Occupational therapy for children with cerebral palsy: a systematic review. Clin Rehabil 2004;18(1):1-14. 6. Roxborough L. Review of the efficacy and effectiveness of adaptive seating for children with cerebral palsy. Assist Technol 1995; 7(1):17-25. 7. Harris SR, Roxborough L. Efficacy and effectiveness of physical therapy in enhancing postural control in children with cerebral palsy. Neural Plast 2005;12(2-3):229-43; discussion 263-72. 8. Pope PM, Bowes CE, Booth E. Postural control in sitting the SAM system: evaluation of the use over three years. Dev Med Child Neurol 1994;36(3):241-52. 9. Reid DT. The effects of the saddle seat on seated postural control and upper-extremity movement in children with cerebral palsy. Dev Med Child Neurol 1996;38(9):805-15. 10. Stewart P, McQuilton G. Straddle seating for the cerebral palsied child. British Journal of Occupational Therapy 1987;50(4):136-8. 11. Sochaniwskyj A, Koheil R, Bablich K, Milner M. Dynamic monitoring of sitting posture for children with spastic cerebral palsy. Clin Biomech (Bristol, Avon) 1991;6(3):161-67. References 12. McClenaghan BA, Thombs L, Milner M. Effects of seat-surface inclination on postural stability and function of the upper extremities of children with cerebral palsy. Dev Med Child Neurol 1992;34(1):40-8. 13. Miedaner J. The effects of sitting positions on trunk extension for children with motor impairment. Pediatr Phys Ther 1990;2:11-14. 14. Nwaobi OM, Brubaker CE, Cusick B, Sussman MD. Electromyographic investigation of extensor activity in cerebral-palsied children in different seating positions. Dev Med Child Neurol 1983;25(2):175-83. 15. Washington K, Deitz JC, White OR, Schwartz JS. The effects of a contoured foam seat on postural alignment and upper-extremity function in infants with neuromotor impairments. Phys Ther 2002; 82(11): 1064-76. 16. Bertoti DB, Gross AL. Evaluation of biofeedback seat insert for improving active sitting posture in children with cerebral palsy. A clinical report. Phys Ther 1988;68(7):1109-13. 17. Holmes KJ, Michael SM, Thorpe SL, Solomonidis SE. Management of scoliosis with special seating for the non-ambulant spastic cerebral palsy population--a biomechanical study. Clin Biomech (Bristol, Avon) 2003;18(6):480-7. 18. Myhr U, vonWendt L. Reducing spasticity and enhancing postural control for the creation of a functional sitting position in children with cerebral palsy: a pilot study. Physiotherapy Theory & Practice 1990; 6(2):676 19. Myhr U, von Wendt L. Improvement of functional sitting position for children with cerebral palsy. 1991 20. Myhr U, von Wendt L, Norrlin S, Radell U. Five-year follow-up of functional sitting position in children with cerebral palsy. Dev Med Child Neurol 1995;37(7):587-96. z Definition of ICF Components (ref): z Body Functions: physiological and psychological functions of body systems z Body Structures: anatomical parts of the body such as organs, limbs and their components z Activity: the execution of a task or action by an individual. z Participation: involvement in a life situation. z Environmental Factors: physical, social, cultural, institutional or attitudinal in nature z Personal Factors: Gender, age, education and lifestyle Background: ICF Model Results Outcomes Subjective reports Displacement of head, trunk,and lower limbs Number of pathological movements EMG activity of back extensors Sitting Assessment Scale Level of Sitting Ability Scale The Sitting Assessment Scale for Children with Neuromotor Dysfunction Sitting postural control Subjective reports Trunk, hip, and knee ROM Spinous process angle measurements Sitting posture MeasuresOutcomes Results Outcomes Subjective reportsSocial skills and performance of ADLs 5 point scaleMobility Visual observation Performance in fine motor and dexterity tasks Upper limb function MeasuresOutcomes


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