The Effect of Positioning for Children with Cerebral Palsy on Upper-Extremity Function: A Review of the Evidence

Carrie Stavness

ABSTRACT. Context. Controversy exists about the most appropriate seating position for children with cerebral palsy (CP) to promote energy conservation and maximize upper-extremity function. Evidence Acquisition. Sixteen journal articles published after 1980 were identified by searching allied health, medical, and occupational and physical therapy data bases and evidence-based medicine reviews using specific key terms (positioning, wheelchair, postural control, posture, adaptive seating devices, patient positioning, cerebral palsy, movement disorders, upper extremity, reaching, grasping, and occupational therapy) and reviewing bibliographies of retrieved articles. Evidence Synthesis. The majority of the evidence supports the positive effects of a neutral to slightly forward orientation (whole chair tilted) on upper-extremity function. Only one study did not demonstrate
Carrie Stavness is Research Assistant for CanChild in the area of transition to adulthood for youth with disabilities and an Occupational Therapist at Hamilton Health Sciences in the Complex Medicine Rehabilitation Unit. She is a 2004 graduate of the MS Program in Occupational Therapy at McMaster University. She received an Honours Bachelor of Science in Kinesiology from the University of Waterloo in 1995. Address correspondence to: Carrie Stavness (E-mail: cstavness@cogeco.ca). The author would like to acknowledge Jackie Bosch who is an Assistant Clinical Professor at McMaster University and a Research Associate at the Population Health Research Institute for her extensive support, encouragement, and input throughout the completion of this review paper. This review paper began as a second-year occupational therapy student project at McMaster University where one of the requirements was to critically appraise and present the evidence on a controversial topic Physical & Occupational Therapy in Pediatrics, Vol. 26(3) 2006 Available online at http://potp.haworthpress.com 2006 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J006v26n03_04

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such effects. Of the supporting studies, one suggested the addition of an abduction orthrosis (AO), one recommended the entire functional sitting position (FSP) package (this orientation plus a hip-belt, footrests, AO, and cutout tray), and one established the long-term effects of the FSP. One less rigorous study opposed the addition of an AO. With the exception of one study, most of the evidence states that seat angle does not affect functional abilities. However, some of these studies contain faulty methodology and/or their results demonstrate clinical significance. Conclusion. Evidence supports that children with CP should be fitted for wheelchairs that place them in a FSP, which includes; orientation in space of 0-15, a hip-belt, an AO, footrests, and a cutout tray, with the addition of a sloped forward seat of 0-15, to improve upper-extremity function. The exact seat angle and orientation in space within the 0-15 range should be determined on an individual basis. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www. HaworthPress.com> 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Cerebral palsy, seating, functional abilities

INTRODUCTION Cerebral palsy (CP) is characterized by impaired voluntary movement, such as spasticity and ataxia and involuntary movements, both resulting from prenatal malformation and perinatal or postnatal damage to the central nervous system (Case-Smith, 2001; Levih, 1982). As such, it is a non-progressive disease (Levih, 1982). Its prevalence has remained stable (1.4-2.4 cases per 1000 births) over the last 30 years. Advances in medicine have reduced complications during birth; however, these positive impacts have been offset by the increased survival rate of premature, low birth weight infants (Case-Smith, 2001). In the United States, approximately 8,000 infants and 1,200-1,500 preschool children are diagnosed with CP every year (United Cerebral Palsy Research and Educational Foundation, 2001). Children with CP usually experience spasticity of the upper and lower limbs, hypotonus of the trunk, and persisting tonic reflexes. Typically their shoulders and arms are flexed, their legs are extended with tight hamstrings, their pelvis is tilted backwards, their knees are extended, their hips are adducted and internally rotated, and their feet are plantar flexed (Myhr & Wendt, 1990, 1993). Because of the lower extremity ex-

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tension pattern, children with CP sit on their sacrums rather than ischial tuberosities (Reid, 1996). To avoid falling backwards, they move their centre of gravity forward by flexing their spinal column (Reid, 1996) and, because their trunk muscles have low tone, gravity pulls them into extreme forward flexion (Myhr & Wendt, 1991; Stewart & McQuilton, 1987). Often children with CP lack righting and equilibrium reactions and cannot return themselves to an upright position (Myhr & Wendt, 1991). Usually children with CP are reclined in their chairs and secured with supports and straps to counter this adaptive positioning (Myhr & Wendt, 1990, 1991, 1993; Nwaobi, 1987; Stewart & McQuilton, 1987). Myhr and Wendt (1991) and Myhr, Wendt, Norrlin, and Radell (1995) determined that the majority of their subjects in studies that examined the current seating practices for children with CP (19 of 23; 7 of 10) were in a reclined position. In this position, children must overcome gravity to raise their head and arms to see their environment and to reach and grasp objects (Myhr & Wendt, 1990). Further, an asymmetrical tonic neck reflex may result if their head touches the head support as they try to raise and turn their head (Myhr & Wendt, 1991). The children find these efforts exhausting and overwhelming, leaving little energy for functional activities (Miedaner & Finuf, 1993; Myhr & Wendt, 1990; Stewart & McQuilton, 1987). Further, this position does not promote coordinated hand-eye movements (Myhr & Wendt, 1990). Children are often left in these reclined positions because they appear comfortable and relaxed; however, this does not promote the performance of functional activities, such as reaching and grasping to operate a communication device (Nwaobi, 1987). Although data indicate that a reclined position is not functionally optimal for children with CP who require seating, controversy exists about the most appropriate seating position. Therefore, the following review focuses on determining the most appropriate sitting position for children with CP to promote energy conservation and optimal functional abilities. REVIEW OF METHODOLOGY Search Criteria Key search terms included positioning, wheelchair, postural control, posture, adaptive seating devices, patient positioning, cerebral palsy, movement disorders, upper extremity, reaching, grasping, and occupational therapy. Published journal articles involving experimental trials or

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qualitative measures of positioning children with CP to improve upperextremity function, specifically reaching and grasping were reviewed. Aricles were excluded if they were purely descriptive, did not involve children with CP, included surgery as part of their intervention, explored only one individual case, did not study upper-extremity function, and were published before 1980 (articles prior to this date reflected practice that is substantially different from current practice). Search Methods First, Morris (McMaster University library catalogue) was searched to obtain a description of cerebral palsy. Second, Cumulative Index to Nursing and Allied Health (CINAHL), Allied and Complimentary Medicine (AMED), HealthStar, Pubmed, and MEDLINE were searched to secure data from allied and medical health professionals. Third, Excerpta Medica Database (EMBASE) was consulted to gain an international perspective regarding positioning of children with CP. Fourth, evidence-based medicine reviews (Cochrane Database of Systemic Reviews; Database of Abstracts of Reviews of Effects; American College of Physicians Journal Club; and Cochrane Central Register of Controlled Trials) and occupational and physical therapy evidence data bases (OTseeker and PEDro) were accessed to identify systematic reviews and quality ratings for existing evidence of the most appropriate seating positions for children with CP. Finally, a bibliographical review was completed to obtain any other relevant articles. RESULTS The literature review identified 16 articles that met inclusion/exclusion criteria. Each will be discussed below. All studies included subjects with spastic cerebral palsy, specifically diplegia, tetraplegia, and/ or quadriplegia. Seven of these studies also included subjects with athetoid cerebral palsy (Colbert, Doyle, & Webb, 1986; Miedaner & Finuf, 1993; Nwaobi, 1987; Seeger, Caudrey, & OMara,1984), dystonic syndrome (Myhr & Wendt, 1991), dystonic tetroplegia (Myhr & Wendt, 1993), and multiple handicaps (hypotonicity, mixed tone, and mental retardation) (Hulme, Gallacher, Walsh, Niesen, & Waldron,1987). All articles addressed how the alignment of the pelvis affected upper-extremity function: Four studies examined the effects of a neutral pelvis on on upper-extremity function (Colbert et al., 1996; Hulme et al., 1987;

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Miedaner & Finuf, 1993; Noronha, Bundy, & Groll, 1989) (see Table 1); two studies examined whether an anteriorly tilted pelvis achieved through a functional sitting position (FSP) improved upper extremity function (Myhr & Wendt, 1991; Myhr et al., 1995) (see Table 2); five studies examined the effect of seat angle on upper-extremity function (McClenaghan, Thombs, & Milner, 1992; McPherson et al., 1991; Nwaobi, Hobson, & Trefler, 1986; Reid, 1996; Seeger et al., 1984) (see Table 3); and five studies evaluated the effect of body orientation (whole chair tilted 15 to 30) on upper extremity function (Milner et al., 1991; Myhr & Wendt, 1993; Nwaobi, 1987; Pope, Bowes, & Booth, 1994) (see Table 4). Two of the previously mentioned studies as well as one other addressed whether an abduction orthosis (AO) (Myhr & Wendt, 1993; Ekblom & Myhr, 2002) or a tray (Myhr & Wendt, 1991) affected upper extremity function (see Table 5). DISCUSSION Neutral Pelvis Positioning A majority of the studies are consistent regarding the positive effect of neutral positioning on functional abilities. Only one study (Noronha et al., 1989) did not show such an effect. In this study, total scores revealed no difference between neutral (supported in standing frame) and posterior pelvic (unsupported sitting) positioning in reaching and grasping ability and subtest scores revealed mixed results, that is, subjects with neutral pelvic positioning took a shorter time to feed themselves, but a longer time to grasp small objects. These findings may have been due to an inappropriate outcome measure as the distance to the tabletop was less for sitting then for standing. As such, subjects could support their elbows and forearms on the tabletop, while seated to reach and grasp cards, checkers, and small, light, and heavy objects and, thus, may have augmented posterior pelvic positioning data. As simulated feeding is more of an up/down movement, external upper-extremity support would not be beneficial and, perhaps, the true effect of neutral pelvic positioning could be seen in this subtest. As only one of the studies used an experimental design, further experimental studies are needed to confirm that neutral positioning has a positive effect on functional abilities. However, the consistent positive effects on upper-extremity function with no evidence to suggest harm supports a neutral pelvic position.

44 TABLE 1. Effect of Neutral Pelvis Positioning on Function

Purpose Evaluate relationship between unsupported sitting versus fitted with wheelchair and reaching/grasping Children with mild to severe CP (n = 12) Cognitive tests with reach/grasp items Randomized cross over design Group A = Fitted to Unsupported Group B = Fitted to Unsupported Sample Measures Research Design Results Evaluate whether ASDsa improved head control, sitting posture, visual tracking, reaching, and grasping Children with CP and multiple handicaps (n = 19) who require seating Direct observation and using a scoring system developed and validated by the authors Longitudinal before and after Study the longterm effects of the DESEMOb on upper extremity function Children with CP with severe motor impairments (n = 12) Questionnaire completed by childrens parents, therapists, and equipment designers Before and After

Reference

Miedaner and Finuf, 1993

Hulme et al., 1997

Colbert et al., 1986

Significant improvement in reach/grasp when seated in fitted wheelchair (Group A: M = 1.5, SD 2.07; Group B: M = 5.2, SD 4.02; t = 3.61; p 0.05) Significant difference between original seating position and ASDs for sitting posture (F = 34.7; df = 1, 20; p 0.01), head control (F = 9.7; df = 1, 20; p 0.01), and grasping (F = 8.4; df = 1, 20; p 0.01) No significant difference for visual tracking and reaching Clinical meaningfulness as 37% more subjects completed reaching tasks at final evaluation Improved upper extremity function (8/10 children brought hands to midline and operated a joystick at final evaluation) Unable to obtain two final questionnaires

Noronha et al. (1989)

Children with CP Determine whether a prone stander c (n = 10) versus a normal chair improved reaching and grasping abilities

Overall time (in seconds) to turn cards, manipulate small, light, and heavy objects, complete simulated feeding task, and place checkers

Randomized, Cross Over, Repeated Measure Design

Mean total scores: no significant difference between groups (sitting: 79.32, 67.04; standing: 79.72, 64.03; F = 0.03; p = 0.87) Mean individual scores: significant difference between groups for feeding (sitting: 28.35, standing: 21.02; T = 11; p 0.0004) and reaching/handling small objects (sitting: 11.54, standing: 18.45; T = 55; p 0.03)

Note. ASDs = Adaptive Sitting Devices. aASDs maintain hips, knees, and ankles in an optimal position (90) and head in midline. bDESEMO is a custom-molded seating system which provides a neutral pelvis position. cA prone stander supports the pelvis in a neutral position and prevents the pelvis from rotating posteriorly.

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46 TABLE 2. Effect of Anterior Pelvic Tilt on Function

Purpose Children and Compare head, trunk, adolescents with and foot control, and CP and dystonic arm and hand function syndrome between FSPa, original sitting position, (N = 23) and experimental positions (tray and/or AO) Cross-sectional Survey SASb to rank subjects as they reached out to grasp, hold and release a familiar toy Sample Measures Research Design Results Examined the longChildren with slight term effects of the FSPa to severe CP on head, trunk, and foot (n = 10) control and arm and hand function SASb to rank subjects as they leaned forward to touch, manipulate, and release familiar objects and toys Before and After

Reference

Myhr and Wendt, 1991

Myhr et al., 1995

Significant difference between FSPa total mean score and those of all other positions (FSPa: 14; original: 8; original plus tray: 9, FSPa minus tray and AO: 11; original plus AO: 8; FSPa minus table: 12; p 0.001) Clinical meaningfulness since a one point change on scale indicates a large functional gainc Significant differences between baseline and both post FSPa and five year follow-up total scores (110, 132, and 145; p 0.001) Two subjects who did not continue to use the FSPa demonstrated a significant decline in total score (19, 31, and 17; p 0.001)

Note. FSP = functional sitting position; AOs = abduction orthosis; SAS = Sitting Assessment Scale. a A FSP includes orientation in space of 0-15 degrees, a hip belt, an abduction orthosis, footrests, and a cutout tray. bSAS is a four-point rating scale designed and validated by authors to evaluate head, trunk and foot control and arm and hand function before and after seating interventions. cThe following is an example of one sub-scale of the SAS: 1 = Unable to control arms by will; 2 = Uses arms for support, but easily loses control; stretches arms toward objects but in uncontrolled movements; 3 = Uses one arm for support and stretches other toward objects intentionally; 4 = Use one or both arms for support, stretches arms toward objects intentionally or uses arms for functional movements.

TABLE 3. Effect of Seat Angle on Function

Purpose Children and adoles- Time and accuracy to complete upper cents with mild to motor tasks moderate CP (n = 10) Prospective Case Control Study Sample Measures Research Design Results Seat angle does not affect upper extremity motor performance

Reference

McClenaghan et al., 1992

McPherson et al., 1991 Adolescents with mild to moderate CP (n = 10)

Study the relationship between seat angle (0, 5, and 5) and functional use of upper extremity Determine whether seat angle (0,15, and 15) altered upper extremity function No. of movement segments to complete reaching task Quasi-Experimental Design with random assignment to position and repeated measures

Reid, 1996

Evaluate upper extremity movement control using the saddle seat (15) versus a flat bench (0)

Children with mild to moderate cerebral palsy

Time and path length to reach a target

Experimental Cross Over Design

No significant difference in quality of arm movements due to position (H = 1.57, p 0 .05) Clinical meaningfulness as subjects positioned with seat angle of 0 and 15 reached targets in 14 less movements No significant effects were detected (p = 0.17 to 0.89) Clinical meaningfulness as 4/6 subjects reduced reaching path length by 4 to 22 centimeters and 5/6 subjects reduced time to touch a target by 0.05 to 0.18 seconds

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48 TABLE 3 (continued)
Purpose Investigate the effect Children and adoleson hand function of cents with mild to moderate CP (n = 9) variations in seat angle (0,10, 20, and 30) Evaluate the effect of Children with CP seat angle (50, 70, (n = 10) 90, and 110) on upper extremity function Time (in seconds) to touch a trigger switch Time and accuracy to use a joystick to match targets Sample Measures Research Design Results Increasing seat angle has no affect on hand function Prospective Case Control Study with random assignment to positions and carry-over effects controlled for Single Case Design with random assignment to positions Significant improvement in upper extremity performance with seat angle of 90 (1.06) and that achieved in all other positions, 50, 70, and 110, (1.52, 1.52, & 1.48; p 0.05)

Reference

Seeger et al., 1984

Nwaobi et al., 1986

Note. In all studies, the angle between seat and back was altered. 0 seat angle = 90 of hip-flexion.

TABLE 4. Effect of Body Orientation on Function

Purpose Children with CP (n = 8) Time to reach a target and response efficiencya Prospective Case Control Study Sample Measures Research Design Results

Reference

Milner et al., 1991

Pope et al., 1994

Evaluate the short and long-term effects of an anterior tipped chair-seat (10) versus normal chair on upper extremity function Determine whether the SAMb improved function Children with CP (n = 10) Time to manipulate blocks and complete an obstacle course operating a power wheelchair Obtained subjective reports from parents and teachers

Nwaobi, 1987

Measure upper extremity Children with CP function in (n = 13) four different seating orientations (0, 15, 15, and 30)

Time (in seconds) to activate a switch

No significant improvements in more neutral positions Significant improvements in response efficiency Longitudinal Study No improvements in performance in timed block tasks Improved ability to operate a power wheelchair (6/9 subjects) and complete feeding and computer activities (subjective data) Repeated Measures Significant differences Cross-Sectional Study between neutral with random position and all other assignment to positions (F = 63.2; p positions 0.05; 0 means = 38, 32.8; 15 means = 48.6, 44; 15 means = 47.6, 44.2; 30 means = 54.5, 53) and between both of the 15 positions and the 30 reclined position (p 0 .05)

Note. In all studies the whole chair was tilted in space with no change in seat and back angle. SAM = Seating and Mobility Device

aResponse efficiency is the number of movements it takes to reach a target. bThe SAM supports the trunk and pelvis in an anterior position.

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PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS TABLE 5. Effect of External Devices on Function

Reference Purpose Myhr & Wendt, 1993

Sample

Measures

Monitor leg EMG Children and adolescents activity and the effects of an AO with CP and in different body dystonic tetraplegia orientations (n = 8) (0 AO; 10 AO; 0; 10; 10 AO)

Ekblom & Myhr, 2002

Monitor leg EMG activity and the effects of a FSPa with versus without an AO

Children with CP (n = 4; one outlier excluded)

Significantly lower EMG activity in neutral and forward positions with AOs (0 AO; 10 AO) than in neutral and reclined positions without AOs (0; 10) and reclined position with AO (10 AO); p 0 .04 EMG activity Prospective No significant Case Control difference in and SASb EMG activity or as subjects Study upper extremity reached for function a toy and grasped and moved it

Research Design EMG activity Prospective as subjects Case Control reached for Study a toy and grasped and moved it

Results

Note. FSP = functional sitting position; AOs = abduction orthosis; SAS = Sitting Assessment Scale a A FSP includes orientation in space of 0 to 15 degrees, a hip belt, an abduction orthosis, footrests, and a cutout tray. bSAS is a four-point rating scale designed and validated by authors to evaluate head, trunk and foot control and arm and hand function before and after seating interventions.

Anterior Pelvic Tilt The findings from both studies were consistent regarding the shortterm positive effects of a FSP on functional abilities. Evidence also exists to support that children with CP benefit most with the entire FSP package rather than some components, that is, minus tray and/or AO. In the longitudinal study (Myhr et al., 1995), researchers did not account for maturation and co-intervention and did not establish a true control group. Consequently, further rigorous experimental studies need to be completed to determine the long-term effects of a FSP on functional abilities. However, the current literature supports the positive immediate effects of a FSP on the upper-extremity function for children with CP. Seat Angle Only one study recognized the positive effects of a neutral to slightly forward seat angle on functional abilities. All other studies identified

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that seat angle does not affect functional abilities. However, some of these studies contain faulty methodology and/or their results did not demonstrate statistical significance but did demonstrate clinical significance. In the Reid study (1996), statistical significance may not have been reached because of its small sample size as a post hoc analysis revealed it was grossly under powered. It did, however, along with one other study (McPherson et al., 1991) demonstrate clinical significance since a forward seat angle reduced the number of arm movements or path length required to access a target and, thus, reduced the amount of effort required. Even though further studies need to be completed with larger sample sizes, evidence supports the positive effects of a neutral to slightly forward seat angle on functional abilities. Body Orientation The two identified studies were consistent in their findings that a neutral position or slightly forward orientation (whole chair is tilted) has short- and long-term positive effects on reaching and grasping efficiency. There is some less rigorous evidence to support that this position also improves reaching and grasping speed. External Devices One study supports the positive effects of a neutral to slightly forward orientation with the addition of an AO. Authors suggested that these positions decreased the amount of energy required to contract lower extremity musculature to stabilize the body and possibly increase upper-extremity function. This finding is supported by the information obtained in the FSP study for anterior pelvic positioning (Myhr & Wendt, 1991). One study opposed the benefits of the addition of an AO; however, its data was based on a very small sample size and, thus, generalizations cannot be made. Consequently, evidence supports a neutral to slightly forward orientation to improve children with CPs upper-extremity function. CONCLUSION Evidence supports that an upright position versus a reclined position improves a child with CPs upper-extremity function like reaching and pressing to operate a communication device. Children with CP should be fitted for wheelchairs that place them in a FSP, which includes an orientation in space of 0-15, a hip-belt, an abduction orthosis, footrests,

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and a cutout tray, with the addition of a sloped forward seat of 0-15. The exact seat angle and orientation in space within the 0-15 range should be determined on an individual basis. Therapists should ensure that the line of gravity of the childs trunk, shoulders, and head are anterior to his/her ischial tuberosities. In a more upright position, children would not have to waste precious energy to fight against gravity and stabilize their trunk. They can use this saved energy to complete tasks, such as accessing a communication device. DIRECTIONS FOR FUTURE RESEARCH Evidence is consistent that children with CP should be fitted for wheelchairs that place them in a FSP with an anterior slopped seat of 0-15 to improve functional abilities. However, this conclusion is based on only a few experimental designs, a plethora of less rigorous studies, and outdated information (only one recent study exists (Ekblom & Myhr, 2002) suggesting that therapists are just accepting standard practice without questioning it. Therefore, it is imperative that the findings of this review be verified through a more rigorous research design, such as a randomized controlled trail comparing the experimental position with that of standard practice. Furthermore, all studies reviewed varied regarding severity of CP (mild to severe). Thus, subjects also need to be stratified according to a classification system. REFERENCES
Case-Smith, J. (Ed.) (2001). Occupational therapy for children (4th ed.). St. Louis, MO: Mosby. Colbert, A., Doyle, K., & Webb, W. (1986). DESEMO seats for young children with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 67, 484-486. Ekbolm, B., & Myhr, U. (2002). Effects of the hip abduction orthosis on muscle activity inchildren with cerebral palsy. Physiotherapy Theory and Practice, 18, 55-63. Hulme, J., Gallacher, K., Walsh, J., Niesen, S., & Waldron, D. (1987). Behavioral and postural changes observed with use of adaptive seating by clients with multiple handicaps.Physical Therapy, 67, 1060-1067. Levih, S. (Ed.). (1982). Treatment of cerebral palsy and motor delay (2nd Ed.). St Louis, MD: Blackwell Publications. McClenaghan, B., Thombs, L., & Milner, M. (1992). Effects of seat surface inclination on postural stability and function of the upper extremities of children with cerebral palsy. Development Medicine and Child Neurology, 34, 40-48. McPherson, J., Schild, R., Spaulding, S., Barsamian, P., Transon, C., & White, S. (1991). Analysis of upper extremity movement in four sitting positions: A compari-

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son of persons with and without cerebral palsy. The American Journal of Occupational Therapy, 45, 124-129. Miedaner, J., & Finuf, L. (1993). Effects of adaptive positioning on psychological test scores for preschool children with cerebral palsy. Pediatric Physical Therapy, 23, 177-182. Milner, M., Lotto, W., Koheil, R., Sochaniwskyj, A., Bablich, K., & Reid, D. (1991). Functional and clinical evaluation of the short and long term effects of anteriorly tipped seating in children with cerebral palsy. Journal of Rehabilitation Research & Development, 28, 469-470. Myhr, U., & Wendt, L. von (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, 63, 65-76. Myhr, U., & Wendt, L. von (1991). Improvement of functional sitting position for children with cerebral palsy. Developmental Medicine and Child Neurology, 33, 246-256. Myhr, U., & Wendt, L. von (1993). Influence of different sitting positions and abduction orthoses on leg muscle activity in children with cerebral palsy. Developmental Medicine and Child Neurology, 35, 870-880. Myhr, U., Wendt, L. von, Norrlin, S., & Radell, U. (1995). Five-year follow-up of functionaling position in children with cerebral palsy. Developmental Medicine and Child Neurology, 37, 587-596. Noronha, J., Bundy, A., & Groll, J. (1989). The effect of positioning on the hand function of boys with cerebral palsy. The American Journal of Occupational Therapy, 43, 507-512. Nwaobi, O. (1987). Seating orientations and supper extremity function in children with cerebral palsy. Physical Therapy, 67, 1209-1212. Nwaobi, O., Hobson, D., & Trefler, E. (1986). Hip angle and upper-extremity movement time of children with cerebral palsy. Developmental Medicine and Child Neurology, 28, Suppl 53: 24. Pope, P., Bowes, C., & Booth, E. (1994). Postural control in sitting the SAM system: Evaluation of the use over three years. Developmental Medicine & Child Neurology, 36, 241-252. Reid, D. (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. Seeger, B., Caudrey, D., & OMara, N. (1984). Hand function in cerebral palsy: The effect of hip flexion angle. Medicine and Child Neurology, 26, 601-606. Stewart, P., & McQuilton, G. (1987). Straddle seating for the cerebral palsied child. British Journal of Occupational Therapy, 50, 136-138. United Cerebral Palsy Research and Educational Foundation. (2001, October). Cerebral PalsyFacts and figures. Retrieved January 29, 2005, from http://www.ucp. org/ucp_generaldoc.cfm/1/9/37/37-37/447.