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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 Jul 30, 2007

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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  z  Posture z  z  Any modifications to seating devices with the purpose of improving sitting posture and/or postural control in mobility-impaired individuals1 A position of the limbs or the body as a whole2,3  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  z  Incidence z  z  A broad term used to describe a group of nonprogressive disorders of posture and movement4 1 in 500 children in Canada5  Causes z z  Multi-factorial Attributed to factors during fetal or infant brain development4  Cerebral Palsy z  Clinical features z z z z  z  Decreased muscle strength Abnormal muscle tone Inability to maintain postural control Abnormal sensation, cognition, communication and/or behaviour  Classification z z z  Severity Motor disorder Secondary motor impairments  Interventions z Postural  control interventions  Balance training protocols/devices z Ankle foot orthoses z Neurodevelopmental treatment z Whole-body LycraⓇ garments z Adaptive seating z  Previous Reviews z Roxborough6 z  (1995) – 8 studies  3 positive results pulmonary function z active trunk extension z performance on the Bayley Mental Scale z  z Harris z  and Roxborough7 (2005) – 12 studies  7 positive results for postural outcomes  ICF Model z Why  is the ICF important for the field of  CP? Promotes a holistic approach to treatment z Educates family about the importance of relating function with socialization z  Research Questions Primary Question z What  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 z What  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 peerreviewed 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. 2. 3. 4. 5. 6.  MEDLINE CINAHL EMBASE PUBMED Database of Reviews of Effectiveness (DARE) The Physiotherapy Evidence Database (PEDro)  7. 8. 9. 10. 11. 12.  OT Seeker Cochrane Controlled Trials Register Cochrane Database of Systematic Reviews Web of Science Dissertation abstracts Education Resources Information Centre (ERIC)  Search Strategy Key Terms z Child z Children z Cerebral palsy z Adaptive seating z Assistive device z Orthoses z Positioning z Seating  z z z z z z z z  Wheelchair Chair Infant equipment Posture Body posture Postural control Postural dysfunction Sitting posture  Search Strategy Grey Literature z z  Reference lists Contacting experts in the field  Hand search (1995-2005) z z z  Journal of Pediatric Orthopedics Pediatric Physical Therapy 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  z  AACPDM Quality Assessment Scale  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 I  Systematic review of randomized controlled trials (RCTs) Large RCT (with narrow confidence intervals) (n > 100)  II  Smaller RCTs (with wider confidence intervals) (n < 100) Systematic reviews of cohort studies “Outcomes research” Cohort studies (concurrent control group) Systematic reviews of case control studies  III IV  V  Case series Cohort study without concurrent control group Case-control study Expert opinion Case study or report Bench research Expert opinion based on theory or physiologic research Common sense/anecdotes  Level of Evidence AACPDM Level of Evidence for Single Subject Design I  N-of-1 randomized controlled trial  II  ABABA design Alternating treatments design Multiple baseline designs (concurrent or nonconcurrent; across subjects, settings, or behaviours)  III  ABA design  IV  AB design (with replication on > subject)  V  AB design (with 1 subject only)  Flow Chart Potentially relevant citations identified through electronic and hand searches (n = 468)  TITLE SCREENING  Citations excluded after title screening (n = 325)  Abstracts retrieved for review (n = 143)  ABSTRACT SCREENING Studies excluded after abstract screening (n = 126)  Full articles retrieved for review (n = 19)  FULL TEXT REVIEW Studies excluded after full text review (n = 6) Qualitative reviews (n=2) Upper limb function (n=1) Adult CP subjects (n=1) No data for extraction (n=2)  Relevant studies included in systematic review (n = 13)  OVERALL RESULTS  Study Characteristics  10 group designs Research Design  1 single subject design 2 case studies  Methodological  0 to 7 (median: 4)  Quality Level of Evidence  II to V (median: IV)  Participant Characteristics No. Subjects Age Motor Impairments Motor Disorders Severity of CP  2 to 23 (total: 152) 12 mos to 20.8 yrs Diplegia (n=7), triplegia (n=2), tetrapelgia (n=6) Spastic (n=12), dystonia (n=2), athetosis(n=2) Mild, moderate, severe  Interventions z z z z z  Saddle seats (n=3) Seat/backrest inclinations (n=4) Seat inserts (n=2) External supports (n=1) Modular seating system (n=4)  Outcomes Outcomes  Studies  ICF Model  Sitting posture  6  Body structure  Sitting postural control Upper limb function Mobility  11 4  Body structure and function Activity  1  Activity  Performance of ADLs Social skills  1  Activity  2  Participation  STUDY RESULTS & DISCUSSION  Overview z  Body Structure and Function z  Interventions: z z z z z  z  A) Saddle Seating B) Seat/Backrest Positional Angles C) Seat Inserts D) External Supports E) Modular Seating Systems  Activity and Participation z  Outcomes: z z z  A) Upper Extremity Function B) Mobility C) Social Skills & ADLs  Grades of Recommendations  A Level 1 studies B Level 2 or 3 studies C Level 4 studies D Level 5 studies  Body Structure & Function  Sitting Posture & Postural Control  Saddle Position z Saddle-shaped  seat  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 z  Saddle Position  Pope et al.8 (1994)  Saddle Position z  Pope et al.8 (1994) z  Description: z  z  Findings: z  z  Level IV evidence; 4/7 quality variable results - no to little improvement in sitting posture and postural control  Major limitations: z z z  Small sample size (n=9) Lack of control of confounding variables eg. Environment Poor adherence to intervention  Saddle Position z  Reid9 (1996) z  Description: z  z  Findings: z  z  z  Level IV evidence; 4/7 quality Significant decrease in abnormal postural responses = improved sitting postural control Significant increase in spinal extension = improved sitting posture  Major limitations: z z  Did not control for postural cueing Did not operationally define mild and moderate CP  Saddle Position z Stewart z  Description: z  z  Level V evidence; 0/7 quality  Findings: z  z  & McQuilton10 (1987)  Qualitative observation showed improved sitting postural control  Major limitations: No reports of inter or intrarater reiability z Lack of details re: methods and intervention z  Saddle Position Author  Level of evidence  Quality Results  Pope8  IV  4  Variable  Reid9  IV  4  Improved  Stewart10  V  0  Improved  Saddle Position z Overall  recommendations:  Grade C: mixed evidence z Grade D: one study lends support z  Positional Angles 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 z  Sochaniwskyj11 (1991) z  Description: z  z  Level III; 3/7 quality  Findings: z  10° anterior tilt: z  z  15° anterior tilt: z z  z  significantly increased back extension significantly decreased sitting postural control greatest EMG activity of erector spinae muscles  Major limitations: z z  Non-equivalent control group Poor construct validity  Positional Angles z  McClenaghan et al.12 (1992) z  Description: z  z  Findings: z  z  z  Level III; 5/7 quality Quiet sitting: 5° posterior tilt improved lower limb stability; 5° anterior tilt decreased head stability Active sitting: no differences  Major limitations: z z  High inter-subject variability No interrater reliability reported  Positional Angles z Miedaner13 z  Description: z  z  Level III; 2/7 quality  Findings: z  z  (1990)  20º forward tilted bench improved trunk extension in sitting  Major limitations: z  No interrater reliability reported  Positional Angles z  Nwaobi14 (1983) z  Description: z  z  Findings: z  z  Level V; 4/7 quality Lowest EMG muscle activity when back rest at 90º and seat inclined at 0º  Major limitations: z  Only looked at low back extensors  z  Only recorded EMG muscle activity for 60 seconds  Positional Angles Author  Level of Quality Results evidence  Sochaniwskyj11  III  3  Improved with 10º anterior tilt  McClenaghan12  III  5  Improved with 5º posterior tilt  Miedaner13  II  2  Improved with anterior tilt  Nwaobi14  V  4  Improved with neutral position  Positional Angles z Overall  recommendations:  Grade B: mixed: two studies supported anterior tilt; one study supported posterior tilt z Grade D: one study supported neutral position z  Seat Inserts z  Added to a child’s adaptive seating device to improve postural control Contoured foam seating (CFS) z Biofeedback z  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 z  Small convenience sample (n=2) Clinician who made CFS had 12 years of experience  Seat Inserts z Bertoti16 z  (1988)  Description: Level IV; 3/7 quality z Biofeedback seat insert z  z  Findings: z  z  Subjective report of improved sitting posture  Major limitations: Subjects were children with “normal intelligence” z ?? Amount of use needed to optimize gains, feasibility of compliance, long term effects z  Seat Inserts Author  Level of Quality Results evidence  Washington15 II  7  Improved  Bertoti16  3  Improved  IV  Seat Inserts z Overall  recommendations:  Grade B: one study supports use of CFS z Grade C: one study supports use of biofeedback z  External Supports 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 z Holmes z  et al.17 (2003)  QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture.  Description: Level IV; 5/7 quality z 3-point lateral supports system z  z  Findings: z  z  Significantly improved scoliosis = improved sitting posture  Major limitations: only measured in 2-D, but scoliosis is 3-D z ?? Long term effects, adherence z  External Supports z Overall z  recommendations:  Grade C: one study supports 3 point lateral support force system  Modular Seating Systems z Combination  of positional adjustments  and orthoses z Allows for a functional sitting position  Modular Seating Systems z “Maxit”  or “Real” Chair  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 z  Modular Seating Systems z  Myhr & von Wendt18 (1990) z  Description: z z  z  Findings: z  z  Level V; 2/7 quality Modular seating system longest duration of head control & least number of pathological movements = improved postural control  Major limitations z z z  Small sample size (n=2) Not standardized intervention Poor construct validity  Modular Seating Systems z  Myhr & von Wendt19 (1991) z  Description: z z  z  Findings: z  z  Level IV; 6/7 quality “Maxit” or “Real” Chair Significantly improved overall sitting postural control  Major limitations: z z  z  Non standardized intervention Sitting Assessment Scale – no reports of validity or reliability Use of Spearman correlation coefficient  Modular Seating Systems z  Myhr et al.20 (1995) z  Description: z z  z  Findings: z  z  z  Level IV; 6/7 quality 5 yr follow-up study 8 of 10 children: z maintained functional sitting position z significant improvement in sitting postural control 2 children: z deteriorated and trunk control worsened  Major limitations: z  Same methods a/a, thus limitations are similar  Modular Seating Systems z Ther z  Adapt Posture Chair  Consists of adjustable: Seat height z Kneepads z Lumbar support z  z  Used to obtain a stabilized sitting posture  Modular Seating Systems z Miedaner13 z  Description: z  z  Level III; 2/7 quality  Findings: z  z  (1990)  Ther Adapt Posture Chair improved trunk extension in sitting  Major limitations: z  Intervention was not specified and standardized  Modular Seating Systems Author  Level of Quality evidence V 2  Improved  Myhr (1991)19  IV  6  Improved  Myhr (1995)20  IV  6  Improved  Miedaner  II  2  Improved  Myhr (1990)18  Results  Modular Seating Systems z Overall  recommendations:  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 z  Activity and Participation Upper limb function, Mobility, Social Skills and Performance of ADLs  Upper Limb Function z Saddle z  seat (Pope et al.8, Reid9)  No significant impact on improving: fine motor z dexterity z upper limb function z  Upper Limb Function z  Seat Positional Angles (McClenaghan et al.12) z  5º anterior tilt: z  z  5º posterior tilt: z  z  significant increase in thumb-press performance Reduction in linear tapping performance  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  Mobility z Saddle z  Overall increase in mobility  z Overall z  seat (Pope et al.8)  recommendations  More research is needed to examine the activity component of the ICF  Social Skills & Performance of ADLs z CFS z  (Washington et al.15)  Subjective reports of improved: social interactions z functional independence z feeding ability z functional performance z  Social Skills & Performance of ADLs z Overall z  recommendations  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):46572.  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.  Background: ICF Model z  Definition of ICF Components (ref): z z z z z z  Body Functions: physiological and psychological functions of body systems Body Structures: anatomical parts of the body such as organs, limbs and their components Activity: the execution of a task or action by an individual. Participation: involvement in a life situation. Environmental Factors: physical, social, cultural, institutional or attitudinal in nature Personal Factors: Gender, age, education and lifestyle  Results Outcomes Outcomes Measures Sitting posture  Subjective reports Trunk, hip, and knee ROM Spinous process angle measurements  Sitting postural control  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  Results Outcomes Outcomes  Measures  Upper limb function  Visual observation Performance in fine motor and dexterity tasks  Mobility  5 point scale  Social skills and performance of ADLs  Subjective reports  


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