POSTURAL MANAGEMENT PROGRAMS: CLINICAL RECOMMENDATIONS

BASED ON A SYSTEMATIC REVIEW OF THE EVIDENCE
SHENHOD, E., GELKOP, N. and G. PALEG

נאוה גלקופ
גב' נאוה גלקופ
פיזיותרפיסטית, עם תואר שני בפיזיותרפיה נוירו התפתחותית ודוקטורנטית בחוג לריפוי בעיסוק ובחוג לחקר הראיה.

Background/Objectives:

Postural management programs are a relatively new concept for children and adults with cerebral palsy (CP). Few studies have reported the use of postural management programs and the research-based evidence supporting this practice has been limited. Clinical practice and decision making have generally depended on expert opinion combined with individual practitioner experience and preferences. Through a systematic review of the evidence, articles on postural management programs, adaptive seating, sleeping systems and standing frames were rated and specific clinical recommendations made.

Design:

The database search included MEDLINE, CINAHL, Google Scholar, High Wire Press, PEDro, Cochrane Library, and APTAs Hooked on Evidence from January 1985 to August 2011. The search terms included :  cerebral palsy and the following; postural management program, adaptive seating, seating and mobility, stretching and range of motion, neuromuscular scoliosis, hip positioning, sleeping systems, night time positioning, and standing frames. Inclusion criteria were all studies and articles in peer reviewed journals, professional publications, conference proceedings, expert opinion and systematic reviews published from January 1985 to June 2011.  CEBM levels were assigned independently by two authors, when they disagreed the third author made the final designation.  Studies, abstracts, professional presentations and articles were included if they were available in full text, in English-Language and looked at the implications of postural management programs, adaptive and customized seating, and night time lying and sleeping positioning, and/or standing devices for children with cerebral palsy.  A study was not included if it took place in the NICU, but was included if program was provided in a long term care facility, school and/or hospital.  336 unique studies were identified from abstracts, which 120 appeared to meet the inclusion criteria and were reviewed as full text articles by all three authors.  Only 35 articles met all the inclusion criteria were included in this review.

Results:

The results were organized and reported using The International Classification of Function (ICF) framework. The studies were rated using the Center for Evidence-Based Medicine (CEBM) criteria.  The peer review journal studies mainly explored using postural management programs for improving range of motion (ROM), hip integrity and comfort/well-being.  Expert opinion suggests that postural management programs should also be used to facilitate cognitive development and communication skills, and enhance participation and activity (Gericke, 2006).   The results have been divided into three groups; postural management programs, seating and standing.
Most of the publications on postural management programs have been published by Pountney and her colleagues, from the Chailey Heritage School, UK. The studies published by this group have shown a significant reduction in hip subluxation and reconstructive surgeries in children with CP who used at least 2 positioning system components (seating, standing and/or sleeping).  Results were further enhanced if the systems were used from an early age.  Picciolini (2009) was able to establish a significant reduction in hip subluxation in two case studies (part of a bigger study with 82 children) using specific French sitting and standing postural management devices.  Hägglund (2007) reported similar results in 272 children with CP, and showed statistically significant improvements in hip location in children who followed a postural management protocol combined with spasticity management, had early and bilateral hip surgery and attended a multi-disciplinary follow up clinic.  In this program, all positioning systems were reviewed and adjusted at least every 6 months.  The remaining publications on postural management that were located and reviewed were rated as CEBM level 5, and consisted of expert opinion and clinical recommendations.
The literature described the use of seating systems to increase comfort and quality of life (Telfer, 2010), improve upper extremity function (Stavness, 2006) and   improve respiratory function and/or prevent or delay deformities (Holmes 2003).  Littleton (2011) demonstrated the positive effect of sitting and side lying on respiratory measurements (oxygen saturation, heart rate, respiratory rate, and chest wall excursion) on adults with cerebral palsy.
The publications that looked at activity and participation, concluded that pelvic alignment is essential for hand function, and recommended 0-15 degrees of anterior tilt.  (Chung, 2008, Nwaobi, 1987),  use of hip belt, abduction orthosis, footrest and a tray (Stavness, 2006).  In order to achieve upright functional seating, the authors recommended that the trunk, shoulder and head should be anterior to the ischial tuberosities (Stavness, 2006).  Kangas (2009) and Lange (2004) have stated that loading the ischial tuberosities and thigh can result in a “co-activation” position that can increase alertness and participation. Carlberg (2005) suggested that the seating system should support the trunk loosely in order to enable better hand and arm functioning,
There were very few studies on the effects of sleep systems on posture, range of motion, hip integrity or any other outcomes.  One study showed a significant decrease in percentage of hip migration after one year of sleep system use that included 20 degrees of hip abduction (Hankinson, 2002). Parents reported improvements in their children’s posture, muscle tone and sleep pattern (Goldsmith 2000) and seating position and toileting (Hankinson, 2002) with use of a sleep system.  Hill (2009) documented that children with severe CP risked respiratory compromise during sleep irrespective of positioning. The authors suggested that assessment of respiratory function is needed when determining optimal positioning for children using night-time positioning equipment.

One systematic review concluded that use of a standing device improved bone mineral density, ROM, bowel function and spasticity (Glickman, 2010).  However, a question regarding the consequences of the wide range of weight bearing loads between standers and subjects has been raised (Kecskemethy, 2008, Herman, 2007).  Standing in abduction further improved hip placement (Martinsson, 2010, Macias, year).  Incorporation of movement, oscillation and/or vibration appeared promising in improving outcomes with shorter standing times (Semler, 2008, Ahlborg, 2006).

Discussion and Conclusion: 

Children with CP classified as Gross Motor Functional Classification System (GMFCS) Levels 4 and 5 (Rosenbaum, 2007) were identified by most of the studies as most appropriate for a comprehensive (24 hour) postural program.  Children with Level 1, 2 and 3 who have demonstrated emerging hip subluxation may also benefit from a comprehensive postural management program.  The evidence based clinical recommendation in seating are that each child should have their own customized supportive seating system which incorporates the need for positioning and function.  These systems may need to be varied according to the function and needs of the individual child and situation.  The seating system should incorporate symmetry of all segments, thigh abduction, 0-15 degrees of anterior and 5 degrees of posterior seat tilt for the majority of waking hours.  Clinicians should also consider placing children in an asymmetrical positions,especially during functional tasks that require hand and head  use (Kangas, 2009).  Asymmetrical postures may also improve alertness, attention, communication and tone/dystonia (Kangas, 2009).  Children with CP  should stand for 30-120 minutes per day in 30-55 degrees of abduction with possible addition of movement, oscillation and or vibration (Martinsson, 2011, Glickman, 2010)  Each child should have a customized sleep system that incorporates 15 – 30 degrees of abduction. The addition of abduction to all types of postural management programs appeared a promising trend but empirical data were inconclusive.
Children should be seen in an experienced seating, spasticity and multidisciplinary medical clinic at least twice per year.
The postural management program must consider many child-centered personal factors including; family situation, child and family's ability to cooperate, child’s pain, child and family sleep patterns/preferences (incl. family bed), child’s hip migration percentage and scoliosis, and child’s long-term prognosis. Each child needs multiple positioning options for across the day and night, not just during the school day.  Each positioning component or device needs to afford participation in an activity as well as address body function and structures.  In addition, each positioning component or device must have the ability to offer multiple orientations.  For example, the seating system needs to be able to tilt anteriorly for playing video games, posteriorly after a seizure and upright for bus transportation.  Each system should have easily removable components so that the child can transition between resting and active postures.  For example, after a rigorous activity the child may need lateral supports and a headrest, but these should be removed when the child is working on the skill of gaining better head control.  The therapist also needs to have a method of knowing which components are weight bearing so these areas can be relieved or loaded periodically.  The child may need more than one seating/positioning device for different daytime activities and environments and to ensure variability in posture.  The child may sleep in full supine one night, partial right side-lying the next and partial left side-lying on the following night. In the future, we will include orthotic use for postural management and include specific recommendations for other joints including knee and ankle. There exists a need for empirical mechanistic evidence to guide clinical postural management programs across practice settings and with various-aged participants, particularly when considering a life-span approach to practice.

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