Longitudinal study evaluating a seating system using a sacral pad and kneeblock for children with cerebral palsy

Purpose. Adaptive seating systems using sacral pads and kneeblocks are commonly used throughout the UK with children with complex motor disorders to improve their posture and stability in sitting. We sought to evaluate how effective these systems are for a group of children with cerebral palsy.

Method. A six-visit trial was performed to examine whether this combination controls pelvic and hip positioning. Twenty-three children with cerebral palsy aged 7 – 14 years participated (11 females and 12 males). The kneeblocks (active intervention) were removed for a period in the middle of the trial. Force exerted through the kneeblock, pressure exerted on the sacral pad and postural alignment was measured for change.

Results. Statistically significant differences before and after kneeblock removal were found for force at the kneeblock, but no difference was found in pressure at the sacral pad. No statistically significant correlations between force and pressure or posture were found.

Conclusion. The results indicate that seating systems using a sacral pad and kneeblock may not improve overall posture but may improve hip position in children with cerebral palsy.     

Changes in postural alignment when using kneeblocks for children with severe motor disorders

Purpose. Children with severe motor disorders often use adaptive seating devices to improve their postural alignment with aim of helping to prevent the development of deformity. Little objective evidence exists about their effectiveness, and this study sought to measure changes in postural alignment when using/not using the active element in one adaptive seating system.

Method. A seating system that uses a sacral pad and kneeblock was examined. This seating device aims to neutralize the angular deviation of the hips and pelvis in order to give a stable base for functional sitting. Change in postural alignment was measured in 23 children with severe motor impairment (GMFCS 5) when using and when not using the kneeblock devices, immediately, and after a delay of one month.

Results. We found that the removal or replacement of kneeblocks effected hip abduction and rotation on one side only, but no other immediate effect on joint angles and overall body posture.

Conclusions. The postural management of children with neurological conditions requires further objective outcome measurement on which to base clinical practice, and improvement of posture is one of a number of factors which should be considered when providing adaptive seating to this group of children.     

Management of seating posture of children with cerebral palsy by using thoracic-lumbar-sacral orthosis with non-rigid SIDO frame

Purpose. To investigate the effects of a special seating device: Thoracic-lumbar-sacral orthosis with non-rigid SIDO® frame (TLSO-SIDO®) in non-ambulant children with cerebral palsy.

Method. A prospective study with matched pairs (the same subject pre- and post-intervention) was carried out. A comparison of the lateral view of thoracic-lumbar spine X-ray before and after TLSO-SIDO® application was made. The assessment of changes in daily activities, posture was recorded by questionnaires. A total of 47 children with cerebral palsy at a mean age of 53.2 months ± 30.1 SD were involved in the study; 15 (35.71%) of the 42 children showed significant problems in feeding at the beginning of the study period, they were identified as a special subgroup with feeding difficulties.

Results. The mean pre-TLSO-SIDO® thoracic kyphosis was 53.7 ± 16.2 in Cobb angle, while the post-TLSO-SIDO® thoracic kyphosis was 47.2 ± 12.1. The lumbar lordosis was 21.3 ± 13 and in the TLSO-SIDO® 17.8 ± 11.9. The majority of the children have shown improvement in the feeding items and in posture (trunk, head and extremities). The overall satisfaction of the parents with the TLSO-SIDO® was very good, namely 3.972 ± 0.796 on the 5-point analogue scale. We did not find a direct correlation with the improvement in the separate items and the overall satisfaction.

Conclusion. It is extremely difficult to measure the effect of the postural management on the development of children with cerebral palsy. According to the results of the study, regular application of the TLSO-SIDO® in children with spastic cerebral palsy had a beneficial effect on feeding problems and on posture.     

Responsiveness of evaluative measures for children with cerebral palsy: the Gross Motor Function Measure and the Pediatric Evaluation of Disability Inventory

Purpose. The aim of this study is to describe responsiveness of the Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI) in a group of children with cerebral palsy (CP).

Method. The subjects were 55 children with cerebral palsy aged 2 to 7 years (mean 4.6 years). We described the responsiveness of the GMFM and PEDI for all children (n = 55), for children younger than 4 years of age (n = 22) and those older or equal to 4 years (n = 33).

Two frames of references for determining responsiveness were used: change over time and external criterion. Responsiveness was calculated with help of the Effect Size (ES), Standardised Response Mean (SRM) and Spearman rank order correlations of change on both the PEDI and GMFM, with change in motor functioning according to the parents as external criterion.

Results. The PEDI has ES and SRM values higher than 0.8. The GMFM has ES and SRM values higher than 0.5. For all dimensions of the PEDI and for almost all dimensions of the GMFM, the ESs and SRMs of the younger group are higher than those of the older group. The ES and the SRM of the GMFM increase with the complexity of the task. When looking at the correlations of the PEDI and GMFM change scores with the opinion of parents, the results are less unequivocal.

Conclusions. Both the GMFM and the PEDI are responsive for change in motor ability over time in children with CP, the most in children younger than 4 years of age.     

Therapeutic effects of electrical stimulation on manual function of children with cerebral palsy: evaluation of two cases

Purpose. To investigate changes in hand function associated with electrical stimulation for children with hemiplegic cerebral palsy.

Method. An ABCA single-subject design, replicated in two children, was used in this study. Each baseline (phase A) lasted 4 weeks. Intervention consisted of electrical stimulation of wrist extensors (phase B) and of wrist extensors and flexors (phase C) for 15 minutes three times a week. Intervention phases also lasted 4 weeks. Active wrist extension range of movement and three timed manual tasks were tested two times a week every week. Data analysis included the Celeration Line and Two Standard Deviation Band methods in addition to visual analysis.

Results. Significant performance gains were observed for both children, especially in phase C, when both extensors and flexors were stimulated. After intervention withdrawal, significant performance decreases were observed on most analysed variables.

Conclusions. The observed performance changes seem to be associated with the presence of intervention and suggest that electrical stimulation can be a useful adjunct to improve hand function of children with cerebral palsy.     

The effect of hinged ankle-foot orthosis on gait and energy expenditure in spastic hemiplegic cerebral palsy

Purpose. To assess the effectiveness of a hinged ankle-foot orthoses on gait impairments and energy expenditure in children with hemiplegic cerebral palsy (CP) whom orthoses were indicated to control equines.

Method. Eleven children (seven males, four females) who had a diagnosis of hemiplegic cerebral palsy were included in the study. Each child underwent gait analysis and energy consumption studies with and without ankle-foot orthosis (AFO). The AFOs were all custom-made for the individual child and had plantarflexion stop at 0° with no dorsoflexion stop. The Vicon 512 Motion analysis system was used for gait analysis. Walking energy expenditure measurements were done with breath by breath method using an open-circuit indirect calorimeter (Vmax 29c, Sensormedics, USA). All tests were carried out on the same day with enough resting period.

Results. AFO application, as compared with the barefoot condition improved walking speed, stride length and single support time. Double support time was decreased significantly with AFOs and no change in cadance. Ankle dorsiflexion at initial contact, midstance and midswing showed significiant increase. Knee flexion at initial contact was decreased and no significant change in maximum knee extension at stance and maximum knee flexion at swing was obtained. The oxygen consumption was significantly reduced during AFO walking.

Conclusion. The hinged AFO is useful in controlling dynamic equinus deformity and reducing the energy expenditure of gait in children with hemiplegic spastic cerebral palsy.     

Evaluation of biofeedback seat insert for improving active sitting posture in children with cerebral palsy. A clinical report

Biofeedback devices have been used successfully to improve head control and symmetrical standing in children with cerebral palsy. This clinical report describes a biofeedback seat insert developed to improve erect sitting posture in children with cerebral palsy who have inadequate trunk control. The seat insert is easily placed against the back of any seating device. A momentary-contact pressure switch on the seat insert is activated when the child exerts pressure on it by extending his trunk. The pressure switch then activates a videocassette recorder or can be adapted to activate a television or radio. Five children with spastic cerebral palsy participated in this evaluation of the biofeedback seat insert. The results of this evaluation show that the children used the biofeedback seat insert effectively to actively improve their sitting posture by voluntarily extending their trunk against the pressure switch. The biofeedback seat insert offers physical therapists a valuable therapeutic training tool to encourage carry-over of improved sitting posture away from the clinical setting for children with cerebral palsy.     

Key factors in the development of lower limb co-ordination: implications for the acquisition of walking in children with cerebral palsy

Purpose: This paper explores differences in walking development between normal children and those with cerebral palsy and discusses their clinical implications.

Method: A literature review (MEDLINE, RECAL) of walking development in normal children and those with cerebral palsy, including the use of walking aids.

Results: Normal neonates display reflexive stepping, at 8 months supported walking and then independent walking emerge at about 12 months. Transition from the wide-based, high stepping gait to narrower base, heel-toe gait with arm swing occurs within 6 months of walking. Gait is mature by 7 years. Children with cerebral palsy have delayed walking. Prognostic factors include retained reflexes, age of head control and of independent sitting. They retain kinematic and muscle activation patterns seen in supported walking. Older children show co-contraction patterns and lose range of motion at leg joints. Walking aids have been studied for energy consumption, but only independent walking patterns are described. Treadmills and partial weight relief have been used for walking training.

Conclusions: Children with cerebral palsy fail to achieve the transition from supported stepping to mature gait patterns. Assessment tools to identify gait maturity need to be developed so that treatment that promotes transitions can be promoted and effectively monitored.