11

Jurnal Sains Kesihatan Malaysia 14(2) 2016: 11-21DOI : http://dx.doi.org./10.17576/JSKM-2016-1402-02

Artikel Ulasan/Review Articles

Postural Control Influence on Upper Extremity Function among Children with Cerebral Palsy: A Literature Review

(Pengaruh Kawalan Postur Terhadap Kefungsian Anggota Atas di Kalangan Kanak-kanak Palsi Serebral: Ulasan Literatur)

NUR ZAIDAH ZULKAPLI, NUR ZAKIAH MOHD. SAAT & SAZLINA KAMARALZAMAN

ABSTRACT

Performance of upper extremity function and movement sequence is influenced by postural control. Motor disorders lead to deficits in postural control, which subsequently may lead to postural instability of children with cerebral palsy (CWCP). This will limit their upper extremity activity performance. Management strategies help to support and enhance the CWCP’s upper extremity function so that they may engage with the activities of daily living. The purpose of this paper is to review previous literature on the influence of postural control towards upper extremity function. Literature searches were conducted in various electronic databases, including ProQuest, Science Direct, Springer Link, Sage, Wiley Online Library, and Google Scholar using specific key terms. Search terms included children with cerebral palsy; postural control; postural adjustments; upper extremity function; reaching and sitting and from references of retrieved articles. Nineteen journal articles published between 2000 and May 2015 were found. Most search results consisted of experimental studies, while others are reviews, case studies, and cross-sectional studies. Findings show that, postural control has a major influence on upper extremity function. In conclusion, it is necessary to highlight the importance of both factors to the CWCP parents or caregivers, as understanding and awareness on this matter is still inadequate in the community. Hence, a study is needed on the awareness of the postural control influence on upper extremity function among caregivers, as well as examining the implementation of management strategies in community settings.

Keywords: Children with cerebral palsy; postural control; postural adjustments; upper extremity function; reaching

ABSTRAK

Prestasi kefungsian anggota atas dan turutan pergerakan dipengaruhi oleh kawalan postur. Kecelaruan motor akan menyebabkan kelemahan pada kawalan postur, seterusnya membawa kepada ketidakstabilan postur kanak-kanak palsi serebral. Ini akan menghadkan prestasi aktiviti anggota atas. Strategi pengurusan didapati dapat membantu menyokong dan meningkatkan kefungsian anggota atas kanak-kanak palsi serebral supaya mereka dapat melibatkan diri dengan aktiviti harian. Tujuan kajian ini adalah untuk mengulas kajian lepas mengenai pengaruh kawalan postur terhadap kefungsian anggota atas. Carian literature telah dijalankan dalam pelbagai pangkalan data elektronik termasuk ProQuest, Science Direct, Springer Link, Sage, Wiley Online Library, dan Google Scholar menggunakan istilah spesifik. Istilah carian yang dimasukkan adalah kanak-kanak palsi serebral; kawalan postur; pengubahsuaian postur; kefungsian anggota atas; mencapai dan duduk serta dari rujukan artikel yang ditemui. Sembilan belas artikel jurnal yang diterbitkan di antara tahun 2000 dan Mei 2015 telah ditemui. Kebanyakan hasil carian terdiri daripada kajian eksperimen, sementara yang lainnya terdiri daripada ulasan, kajian kes, dan kajian keratin rentas. Kesimpulannya, kawalan postur mempunyai pengaruh yang besar terhadap kefungsian anggota atas. Kepentingan kedua-dua factor tersebut perlu ditekankan kepada ibu bapa atau penjaga kanak-kanak palsi serebral kerana pemahaman dan kesedaran di kalangan masyarakat masih belum mencukupi. Oleh yang demikian, kajian terhadap kesedaran pengaruh kawalan postur terhadap kefungsian anggota atas di kalangan penjaga adalah sangat diperlukan, begitu juga kajian mengenai pelaksanaan strategi pengurusan dalam latar masyarakat.

Kata kunci: Kanak-kanak palsi serebral; kawalan postur; pengubahsuaian postur; kefungsian anggota atas; mencapai

INTRODUCTION

Cerebral palsy or CP is a non-progressive defect or lesion in the immature brain that will cause disorders of motor and postures (Chung et al. 2008; Huang et al. 2008), including

postural control (Bigongiari et al. 2011; Cheng et al. 2013; Ju et al. 2010), that limits childrens’ participation in daily living activities (Cheng et al. 2013; Huang et al. 2008). Deficiency of postural control are the cause of deficits in motor behaviour (Brogren et al. 2001; van der Heide et al.

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2004; Zadnikar & Kastrin 2011) and developmental delays in CWCP (Donker et al. 2008).

Postural control can be defined as “a mechanism of sensorimotor strategies for the regulation of posture stability” (Chung et al. 2008; Grant 1999; Hadders-Algra 2013; Shumway-Cook & Woollacott 2012). It develops differently between CWCP and typical developing (TD) children (Bigongiari et al. 2011). Besides affecting sitting position, postural control can have influence in planning movement accordingly (Chung et al. 2008).

Postural control is correlated with hand reaching performance. Adequate postural control interacts with upper extremity control to ensure successful movement of hand to the target without loss of balance (Ju et al. 2010). However, literature reviews highlighting tahe relationship between postural control and upper extremity function among CWCP have not yet been produced. Only a few studies have addressed the postural control relation and influence on upper extremity function. Awareness among caregivers on the importance of good postural control contribution in enhancing upper extremity function needs to be emphasised. Hence, the purpose of this paper is to review previous literature upon the relationship between postural control and upper extremity function in CWCP.

METHODOLOGY

SEARCH PROCEDURES

Literature searches were conducted in various electronic databases: ProQuest; Science Direct; Springer Link; Sage; Wiley Online Library; and Google Scholar using specific key terms ‘children with cerebral palsy’ AND ‘postural control’ OR ‘postural adjustments’ AND ‘upper extremity function’ OR ‘reaching’ AND ‘sitting’ and from references of retrieved articles. Only articles in English from 2000 to May of 2015 were searched. They were examined for (1) Methods of the study; (2) Purpose of study; and (3) Key findings and results of analysis.

The search yielded 95,601 articles. Forty three articles were selected based on titles and abstract. The articles were then further excluded until 19 articles due to (1) The article retrieved is not in full text (2) the participants were not children or adolescents with cerebral palsy (3) the content is not discussing about postural control and/or its relation with upper extremity function (4) Article on validation of an assessment or model of intervention (5) Article on reliability of an assessment or model of intervention. The article selection flow may be seen in Figure 1.

FIGURE 1. Article selection flow

Potentially relevant articles identifiedthrough electronic databases (n = 95,601):

• Science Direct: 96• Springer Link: 138• Sage: 4041• Wiley: 84586• Google scholar: 6740

Articles included after titles screeningand abstract for review (n = 43).

Reasons for exclusion:

i. The participants were not children or adolescents with Cerebral Palsy

ii. the content is not discussing about postural control and/or its relation with upper extremity function

iii. Article on validation of an assessment or model of intervention

iv. Article on reliability of an assessment or model of interventionIncluded articales (n = 19)

• Science Direct: 5• Springer Link: 1• Sage: 1• Wiley: 3• Google scholar: 9

Full text retrieved for furtherassessment

RESULTS

Nineteen journal articles that were published from 2000 until 2015 were found (Table 1) for authors, methods, population, purpose, key findings and results of analysis). Of these, 11 articles are experimental studies, while others are descriptive study (1 article), systematic review (1 article), review (4 articles), cross-sectional study (1 article) and case study (1 article).

THE IMPORTANCE OF POSTURAL CONTROL IN MOTOR PERFORMANCE

Three studies address on the importance of postural control in motor performance. Bigongiari et al. (2011) highlight the importance of postural control sufficiency in attaining voluntary movement performance. Batra et al. (2011) reported that the development of postural control helps in movement, stability, and motor ability in CWCP.

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TAB

LE 1

. Rev

iew

ed st

udie

s

No

A

utho

rs

M

etho

ds

Po

pula

tion,

N

Pu

rpos

e

K

ey fi

ndin

gs &

resu

lts o

f ana

lysi

s

1.

B

atra

et a

l.

Expe

rimen

tal

• Su

bjec

ts: 3

8 ch

ildre

n w

ith c

ereb

ral

To e

valu

ate

the

effe

ctiv

enes

s of i

nter

vent

ion

• Th

e tre

atm

ent o

f dyn

amic

s of p

ostu

ral c

ontro

l is m

ore

effe

ctiv

e th

an

(2

011)

pa

lsy

(CW

CP)

ba

sed

on d

ynam

ics o

f pos

tura

l con

trol

co

nven

tiona

l app

roac

h fo

r dev

elop

men

t/ m

odifi

catio

n of

pos

tura

l

•

Age

: 2-7

yea

rs

as k

ey e

lem

ent o

ver c

onve

ntio

nal a

ppro

ach

re

actio

n in

CW

CP.

• IQ

leve

l: ≤

50

in C

WC

P.

•

Dyn

amic

pos

tura

l con

trol g

roup

: 19

• C

onve

ntio

nal t

reat

men

t: 19

2.

B

igon

giar

i Ex

perim

enta

l •

Con

trol g

roup

: 12

typi

cal d

evel

opin

g To

exa

min

e po

stur

al c

ontro

l in

CW

CP

• R

esul

t sho

ws a

pos

itive

rela

tions

hip

betw

een

EMG

and

agi

ng fo

r

et

al.

(201

1)

(TD

) chi

ldre

n pe

rfor

min

g a

bila

tera

l sho

ulde

r flex

ion

to

co

ntro

l gro

up, h

owev

er th

e re

latio

nshi

p w

as n

egat

ive

for p

artic

ipan

ts

•

Expe

rimen

tal g

roup

: 12

CW

CP

gras

p a

ball

from

a si

tting

pos

ition

.

with

CP.

• Th

e re

sear

cher

sugg

este

d th

at th

e m

ain

post

ural

con

trol s

trate

gy in

ch

ildre

n is

bas

ed o

n co

rrec

tions

afte

r the

beg

inni

ng o

f the

mov

emen

t.

•

The

linea

r rel

atio

nshi

p be

twee

n EM

G a

nd a

ging

sugg

ests

the

post

ural

co

ntro

l dev

elop

men

t is a

ffect

ed b

y ce

ntra

l ner

vous

dis

ease

that

lead

to

incr

ease

in m

uscl

e co

-act

ivat

ion.

3.

B

rogr

en e

t al.

Expe

rimen

tal

• C

ontro

l gro

up: 1

0 TD

chi

ldre

n To

exp

lore

whe

ther

the

devi

ant p

ostu

ral

• TD

chi

ldre

n ex

hibi

t a d

istin

ct p

ostu

ral a

djus

tmen

ts a

dapt

atio

n to

(200

1)

•

Expe

rimen

tal g

roup

: 10

CW

CP

with

ad

just

men

ts in

chi

ldre

n w

ith sp

astic

dip

legi

a

sitti

ng p

ositi

on.

m

ild to

seve

re sp

astic

dip

legi

a is

due

to th

eir c

rouc

hed

sitti

ng p

ositi

on o

r •

The

CW

CP

had

a de

ficits

ada

ptat

iona

l cap

acity

that

is m

ore

visi

ble

• A

ge: 3

-7 y

ears

6 m

onth

s to

tally

due

to th

eir n

eura

l defi

cit.

in

the

erec

t tha

n in

the

crou

ched

pos

ition

. Hen

ce th

e cr

ouch

ed

sitti

ng p

ositi

on d

id n

ot c

ause

pos

tura

l defi

cien

cy b

ut o

ffer a

solu

tion

to

sens

ory-

mot

or p

robl

em o

f the

inst

abili

ty e

xper

ienc

ed.

• C

hild

ren

with

seve

re d

iple

gia

show

lack

of d

irect

ion

spec

ifici

ty in

th

e le

g m

uscl

es d

urin

g ba

ckw

ard

body

sway

that

poi

nts t

o a

basi

c

defic

it in

pos

tura

l con

trol.

The

child

ren

exhi

bit d

ysfu

nctio

ns in

the

pr

ecis

e tu

ning

of t

he p

ostu

ral a

djus

tmen

ts to

task

-spe

cific

con

ditio

ns.

4.

C

arlb

erg

&

Des

crip

tion

N

/A

• D

escr

iptio

n of

pat

hoph

ysio

logi

cal o

f

N/A

Had

ders

-Alg

ra

post

ural

con

trol d

urin

g si

tting

.

(2

005)

• Th

e ou

tline

of i

mpl

icat

ions

for

m

anag

emen

t and

inte

rven

tion

of C

WC

P.

5.

C

heng

et a

l. Ex

perim

enta

l •

Subj

ects

: 14

CW

CP

(div

ided

into

To

exp

lore

the

influ

ence

of l

ower

lim

b •

The

low

er li

mb

stab

iliza

tion

sign

ifica

ntly

dec

reas

ed th

e tru

nk la

tera

l

(2

013)

2

grou

ps)

stab

iliza

tion

and

penc

il de

sign

on

body

and

forw

ard

devi

atio

ns, a

nd th

e vi

sual

focu

s-ve

rtica

l ang

le.

• A

ge: 7

-17

year

s old

bi

omec

hani

cs in

CW

CP.

•

The

biax

ial p

enci

l and

the

assi

gned

grip

hei

ght d

esig

n si

gnifi

cant

ly

de

crea

sed

the

head

, sho

ulde

r, tru

nk a

nd p

elvi

c de

viat

ions

com

pare

d

with

the

regu

lar d

esig

n.

•

The

resu

lts sh

ow th

at lo

wer

lim

b po

sitio

ning

was

effe

ctiv

e in

impr

ovin

g th

e tru

nk p

ostu

re.

• A

pen

cil w

ith a

ssig

ned

grip

hei

ght o

r with

bia

xial

des

ign

coul

d

impr

ove

head

, sho

ulde

r, tru

nk a

nd p

elvi

c al

ignm

ent,

how

ever

it

didn

’t in

fluen

ce th

e m

uscl

e ex

ertio

n of

the

uppe

r ext

rem

ity.

6.

C

hung

et a

l. Sy

stem

atic

revi

ew:

N

/A

• To

revi

ew re

sear

ch o

n th

e ef

fect

of

•C

onfli

ctin

g re

sults

wer

e re

porte

d fo

r sad

dle

seat

s and

opt

imal

seat

/

(2

008)

El

ectro

nic

ad

aptiv

e se

atin

g on

sitti

ng p

ostu

re/

ba

ck a

ngle

for i

mpr

ovin

g si

tting

pos

ture

/pos

tura

l con

trol.

da

taba

se/h

and

po

stur

al c

ontro

l in

CW

CP.

•

Sign

ifica

nt im

prov

emen

ts w

ere

repo

rted

with

inse

rts, e

xter

nal

se

arch

es

• To

exa

min

e w

heth

er c

hang

es in

pos

tura

l

supp

orts

, and

mod

ular

seat

ing

syst

ems.

How

ever

, evi

denc

e

cont

rol r

elat

ed to

cha

nges

in o

ther

asp

ects

supp

ortin

g ef

fect

s of p

ostu

ral c

ontro

l on

func

tiona

l abi

litie

s was

of

func

tioni

ng.

lim

ited.

Con

tinue

d

Bab 2.indd 13 28/07/2016 09:35:09

14

TAB

LE 1

. Con

tinue

No

A

utho

rs

M

etho

ds

Po

pula

tion,

N

Pu

rpos

e

K

ey fi

ndin

gs &

resu

lts o

f ana

lysi

s

7.

D

e G

raaf

-Pet

ers

Rev

iew

N/A

•

Firs

t par

t: •

The

resu

lt sh

ows t

hat a

t an

early

pos

t-nat

al a

ge a

n in

fant

pos

sess

es

et

al.

(200

7)

Rev

iew

of t

he d

evel

opm

ent o

f pos

tura

l

skill

of d

irect

ion-

spec

ific

adju

stm

ents

. The

usa

ge o

f the

skill

is

cont

rol i

n TD

chi

ldre

n an

d in

CW

CP.

depe

nd o

n th

e ch

ild’s

age

and

the

natu

re o

f the

pos

tura

l tas

k.

•

Seco

nd p

art:

•

CW

CP

have

the

abili

ty to

gen

erat

e di

rect

ion-

spec

ific

adju

stm

ents

,

R

evie

w c

urre

nt k

now

ledg

e on

the

effe

ct o

f

but t

hey

have

a d

elay

ed d

evel

opm

ent i

n th

e ca

paci

ty to

recr

uit

in

terv

entio

n on

mus

cle

coor

dina

tion

durin

g

dire

ctio

n-sp

ecifi

c ad

just

men

ts in

task

s. C

WC

P ha

ve d

ifficu

lties

in

post

ural

dev

elop

men

t in

child

ren

with

fine-

tuni

ng o

f pos

tura

l act

ivity

.

typi

cal a

nd a

typi

cal m

otor

dev

elop

men

t. •

Inte

rven

tion

usin

g ba

lanc

e tra

inin

g w

ith a

ctiv

e tri

al a

nd e

rror

expe

rienc

e m

ay im

prov

e po

stur

al c

ontro

l in

child

ren

with

or a

t hig

h

risk

of d

evel

opm

enta

l mot

or d

isor

der.

8.

D

onke

r et a

l. Ex

perim

enta

l •

Subj

ects

: To

exa

min

e th

e st

ruct

ure

of C

entre

of P

ress

ure

• C

WC

P ha

ve la

rger

and

regu

lar a

mou

nt o

f sw

ay.

(200

8)

a.

TD

chi

ldre

n: 9

(C

OP)

traj

ecto

ries i

n C

WC

P an

d TD

chi

ldre

n.

• C

WC

P m

ight

gai

n be

nefit

from

ther

apie

s inv

olvi

ng p

ostu

ral t

asks

b.

CW

CP:

10

w

ith e

xter

nal f

unct

iona

l con

text

for p

ostu

ral c

ontro

l.

9.

H

adde

rs-A

lgra

R

evie

w

N

/A

To re

view

the

deve

lopm

ent o

f rea

chin

g an

d its

•

Aty

pica

lly d

evel

opin

g in

fant

s hav

e di

fficu

lties

in a

dapt

ing

post

ural

(201

3)

as

soci

ated

pos

tura

l con

trol d

urin

g in

fanc

y, in

adju

stm

ents

and

may

hav

e re

duct

ion

of re

perto

ire.

parti

cula

r in

supi

ne a

nd si

tting

pos

ition

s dur

ing

• M

ost r

each

ing

mov

emen

ts a

re p

erfo

rmed

dur

ing

sitti

ng in

infa

ncy.

the

first

pos

tnat

al p

erio

d.

• Th

e po

stur

al c

halle

nge

of si

tting

may

inte

rfer

e w

ith th

e de

velo

pmen

t

of re

achi

ng in

aty

pica

lly d

evel

opin

g in

fant

s.

10.

H

arbo

urne

Ex

perim

enta

l •

Subj

ects

: To

com

pare

two

inte

rven

tions

for i

mpr

ovin

g •

Alth

ough

bot

h TD

chi

ldre

n an

d C

WC

P m

ade

prog

ress

in G

ross

et a

l. (2

010)

a.

TD c

hild

ren:

15

sitti

ng p

ostu

ral c

ontro

l in

infa

nts w

ith C

P.

M

otor

Fun

ctio

n M

easu

re (G

MFM

), th

e gr

oup

with

per

cept

ual-

b.

CW

CP:

35

infa

nts t

hat h

ave

dela

yed

m

otor

inte

rven

tion

show

adv

anta

ge o

n th

e C

OP

(cen

tre-o

f-pr

essu

re)

de

velo

pmen

t & a

t ris

k fo

r CP

(they

mea

sure

s. Th

e C

OP

mea

sure

s app

ear s

ensi

tive

for a

sses

smen

t of

w

ere

divi

ded

into

2 in

terv

entio

n

infa

nt p

ostu

ral c

ontro

l and

qua

ntify

ing

inte

rven

tion

resp

onse

.

grou

ps; h

ome

prog

ram

& p

erce

ptua

l

mot

or p

rogr

am)

11.

H

arbo

urne

&

Cas

e st

udy

• 3

case

exa

mpl

es o

f: To

exp

lore

the

rela

tions

hip

of p

ostu

re a

nd

• Po

stur

e an

d ar

m fu

nctio

n is

com

plet

ely

linke

d ac

cord

ing

to p

revi

ous

Kam

m (2

015)

1.

An

infa

nt w

ith c

ereb

ral p

alsy

lear

ning

re

achi

ng a

nd a

ssum

ptio

ns fr

om th

e hi

stor

ic

re

sear

ch fi

ndin

gs.

to

sit a

nd re

ach

neur

o-m

atur

atio

nal t

hera

peut

ic a

ppro

ache

s. •

To le

arn

new

upp

er e

xtre

mity

skill

trea

tmen

ts, i

t is e

ssen

tial t

o ha

ve:

2.

A sc

hool

-age

d ch

ild w

ith

1.

Va

riabi

lity

and

prob

lem

solv

ing;

de

velo

pmen

tal c

oord

inat

ion

prob

lem

s

2.

Link

ages

bet

wee

n po

stur

e an

d up

per e

xtre

mity

use

with

eac

h

3.

A

n ad

oles

cent

with

con

geni

tal

chal

leng

e;

acqu

ired

hem

iple

gia

3.

Li

nkin

g in

tim

e th

e m

ovem

ent p

lann

ing

of p

ostu

re a

nd u

pper

extre

mity

;

4.

Con

side

ratio

n of

dev

elop

men

tal t

ime

in a

ttain

ing

a sk

ill;

5.

W

ork

acro

ss a

nd w

ithin

var

ious

pos

ture

s; a

nd

6.

Use

of e

rror

s to

build

new

stra

tegi

es

• Th

e pr

inci

ples

, exa

mpl

es, a

nd c

linic

al su

gges

tions

des

crib

ed b

y th

e

auth

ors p

rovi

de c

halle

nges

to c

urre

nt c

are

as w

ell a

s a p

latfo

rm fo

r

furth

er re

sear

ch a

nd im

prov

emen

t of i

nter

vent

ion

for t

hose

with

neur

omot

or im

pairm

ents

.

Con

tinue

d

Bab 2.indd 14 28/07/2016 09:35:09

15

TAB

LE 1

. Con

tinue

No

A

utho

rs

M

etho

ds

Po

pula

tion,

N

Pu

rpos

e

K

ey fi

ndin

gs &

resu

lts o

f ana

lysi

s

12.

Ju

et a

l. (2

010)

Ex

perim

enta

l •

Subj

ects

: To

exa

min

e:

• C

ompa

red

to T

D c

hild

ren,

CW

CP

exhi

bit s

low

er, s

kew

ed, l

ess

a.

TD c

hild

ren:

16

1.

The

effe

ct o

f tas

k co

nstra

int o

n th

e re

achi

ng

ef

ficie

nt a

nd le

ss c

oord

inat

ed p

atte

rn o

f rea

chin

g. C

WC

P ha

ve

b.

C

WC

P: 8

with

spas

tic C

P.

im

paire

d re

achi

ng p

erfo

rman

ce w

hen

reac

hing

late

rally

and

med

ially

2.

The

corr

elat

ions

be-

twee

n re

achi

ng

(m

ore

skew

ed a

nd le

ss e

ffici

ent).

pe

rfor

man

ce a

nd p

ostu

ral c

ontro

l. •

Rea

chin

g la

tera

lly &

med

ially

: inv

olve

trun

k ro

tatio

n th

at p

rodu

ces

m

ore

post

ural

cha

lleng

es c

ompa

red

to re

achi

ng a

nter

iorly

.

•

Find

ing

of th

is st

udy

high

light

the

diffe

renc

e in

the

effe

ct o

f tas

k

cons

train

t on

hand

reac

hing

per

form

ance

bet

wee

n TD

and

CW

CP

gr

oups

.

•

The

stra

ight

er a

nd m

ore

effic

ient

and

coo

rdin

ated

reac

hing

pe

rfor

man

ce c

an b

e ac

hiev

ed w

ith b

ette

r pos

tura

l con

trol c

apab

ilitie

s.

13.

Ju

et a

l. (2

012)

C

ross

sect

iona

l •

Subj

ects

: •

To e

xam

ine

the

effe

ct o

f rea

chin

g in

•

Com

pare

d to

TD

chi

ldre

n, C

WC

P ex

hibi

t mor

e cr

ooke

d an

d le

ss

stud

y a.

C

WC

P: 1

2

di

ffere

nt d

irect

ions

on

post

ural

adj

ustm

ents

effic

ient

CO

P pa

ttern

s, sp

ecifi

cally

on

med

ial o

r lat

eral

reac

hes.

b.

TD c

hild

ren:

16

in

dip

legi

c C

P.

•M

ore

post

ural

cha

lleng

es u

sual

ly d

urin

g re

achi

ng m

edia

lly o

r

•

To e

xam

ine

the

rela

tions

hip

betw

een

hand

late

rally

invo

lve

trunk

rota

tion,

com

pare

d to

reac

hing

ant

erio

rly.

re

ach

perf

orm

ance

and

pos

tura

l adj

ustm

ent.

•Th

e po

stur

al a

djus

tmen

ts p

atte

rns i

n C

WC

P w

ere

rela

ted

with

thei

r

•

To e

xam

ine

the

rela

tions

hip

betw

een

post

ural

po

stur

al c

ontro

l abi

lity

and

hand

-rea

ch sm

ooth

ness

.

cont

rol a

bilit

y an

d po

stur

al a

djus

tmen

t.

14.

Le

debt

&

Expe

rimen

tal

• Su

bjec

ts:

• To

ana

lyse

the

post

ural

ada

ptat

ion

durin

g •

Com

pare

d to

TD

chi

ldre

n, c

hild

ren

with

uni

late

ral C

ereb

ral P

alsy

Save

lsbe

rgh

a.

C

WC

P: 6

(con

geni

tal h

emip

legi

a)

un

ilate

ral a

nd b

ilate

ral r

apid

arm

mov

emen

t

limits

of s

tabi

lity

(LO

S) fo

rwar

d an

d to

war

d no

n-do

min

ant (

mor

e

(2

014)

b.

TD c

hild

ren:

6

an

d to

rela

te th

ese

post

ural

shift

s to

the

size

affe

cted

) sid

e w

ere

smal

ler t

han

in th

e TD

chi

ldre

n.

•

Age

: 5-1

1 ye

ars o

ld

of

the

base

of s

uppo

rt (B

OS)

and

to th

e •

LOS

back

war

d an

d to

war

d th

e do

min

ant (

less

affe

cted

) sid

e di

d no

t

limits

of s

uppo

rt (L

OS)

.

diffe

r bet

wee

n th

e tw

o gr

oups

.

15.

Pa

vão

et a

l. Ex

perim

enta

l •

Subj

ects

: •

To e

xam

ine

func

tiona

l per

form

ance

and

•

Parti

cipa

nt sh

ows d

efici

ts in

thei

r lev

el o

f fun

ctio

nal p

erfo

rman

ce

(2

014)

a.

CW

CP:

10

(spa

stic

hem

iple

gia

bala

nce

in C

WC

P an

d TD

chi

ldre

n.

an

d ba

lanc

e co

mpa

red

to T

D c

hild

ren

alth

ough

the

parti

cipa

nts h

ad

spas

tic d

iple

gia)

•

The

rela

tions

hip

betw

een

thes

e co

mpo

nent

s

mild

to m

oder

ate

mot

or im

pairm

ent.

b.

TD c

hild

ren:

27

and

post

ural

con

trol d

urin

g si

t-to-

stan

d •

In b

oth

grou

ps, i

mpa

irmen

ts in

pos

tura

l con

trol d

urin

g ST

S

•

Age

: 5-1

2 ye

ars o

ld

(S

TS) m

ovem

ent.

m

ovem

ent a

re c

orre

late

d to

func

tiona

l per

form

ance

.

•

The

resu

lt m

arks

the

impo

rtanc

e of

the

stru

ctur

e an

d fu

nctio

n

com

pone

nts t

o th

e ch

ildre

n’s a

ctiv

ity le

vel.

16.

St

avne

ss

Rev

iew

s

N/A

To

revi

ew e

vide

nce

on th

e m

ost a

ppro

pria

te

CW

CP

shou

ld b

e fit

ted

for w

heel

chai

rs th

at p

lace

them

in fu

nctio

nal

(200

6)

se

atin

g po

sitio

n fo

r CW

CP

in p

rom

otin

g si

tting

pos

ition

(FSP

) to

enha

nce

uppe

r ext

rem

ity fu

nctio

n, w

hich

ener

gy c

on-s

erva

tion

and

max

imiz

e up

per

incl

udes

:

ex

trem

ity fu

nctio

n.

a.

Orie

ntat

ion

in sp

ace

(0°-

15°)

b.

Hip

bel

t

c.

A

bduc

tion

Orth

osis

(AO

)

d.

Fo

otre

sts

e.

Cut

-out

tray

f. Sl

oped

-for

war

d se

at o

f 0°-

15°

g.

The

exac

t sea

t ang

le a

nd o

rient

atio

n in

spac

e w

ithin

0°-

15° r

ange

sh

ould

be

dete

rmin

ed o

n in

divi

dual

bas

is

Con

tinue

d

Bab 2.indd 15 28/07/2016 09:35:09

16

TAB

LE 1

. Con

tinue

No

A

utho

rs

M

etho

ds

Po

pula

tion,

N

Pu

rpos

e

K

ey fi

ndin

gs &

resu

lts o

f ana

lysi

s

17.

Va

n de

r Hei

de

Expe

rimen

tal

• Su

bjec

ts: 5

8 C

WC

P (p

rete

rm c

hild

ren)

To

ass

ess t

he p

ostu

ral c

ontro

l dur

ing

reac

hing

•

Mos

t CW

CP

have

inta

ct a

bas

ic le

vel o

f pos

tura

l con

trol (

dire

ctio

n

et

al.

(200

4)

1.

34

with

spas

tic h

emip

legi

a w

ith th

e do

min

ant a

rm in

pre

term

CW

CP.

spec

ifici

ty).

2.

24 w

ith b

ilate

ral s

past

ic C

P

H

owev

er th

ey e

xhib

it dy

sfun

ctio

n in

:

•

Age

: 2-1

1 ye

ars o

ld

a.

Rec

ruitm

ent o

rder

of p

ostu

ral m

uscl

es (e

xhib

it st

ereo

type

d to

p-do

wn

re

crui

tmen

t).

b.

A

bilit

y to

mod

ulat

e m

uscl

e co

ntra

ctio

n to

task

spec

ific

cond

ition

s. It

m

ay b

e se

en m

ore

in c

hild

ren

with

bila

tera

l CP

than

thos

e w

ith

Spas

tic h

emip

legi

a.

•

Deg

rees

of d

isab

ility

in d

aily

livi

ng a

ctiv

ities

hav

e re

latio

n w

ith

po

stur

al d

ysfu

nctio

n.

18.

Va

n de

r Hei

de

Rev

iew

N/A

To

ove

rvie

w th

e kn

owle

dge

avai

labl

e on

•

Prob

lem

in a

dapt

atio

n of

deg

ree

of m

uscl

e co

ntra

ctio

n m

ight

be

the

& H

adde

rs-

m

uscu

lar d

isco

ordi

natio

n un

derly

ing

post

ural

caus

e C

WC

P sh

ow e

xces

s of a

ntag

onis

tic c

o-ac

tivat

ion

durin

g

A

lgra

(200

5)

pr

oble

ms i

n C

WC

P.

di

fficu

lt ba

lanc

e ta

sks a

nd a

pre

fere

nce

for c

rani

al-c

auda

l rec

ruitm

ent

w

hen

reac

hing

com

pare

d to

TD

chi

ldre

n. T

hese

mig

ht b

e co

nsid

ered

as fu

nctio

nal s

trate

gies

to c

ompe

nsat

e fo

r the

dys

func

tiona

l cap

acity

to m

odul

ate

post

ural

act

ivity

.

19.

Va

n de

r Hei

de

Expe

rimen

tal

• Su

bjec

ts:

To in

vest

igat

e th

e re

latio

n be

twee

n C

WC

P •

Sitti

ng p

ostu

re: C

WC

P ha

ve d

iffer

ent p

ostu

res b

efor

e re

achi

ng o

nset

et a

l. (2

005)

a.

CW

CP:

po

stur

al c

ontro

l kin

emat

ics a

nd q

ualit

y of

com

pare

d to

TD

chi

ldre

n. C

WC

P sa

t with

mor

e re

clin

ed p

elvi

s tha

t

1.

Spas

tic h

emip

legi

a (S

H):

33

reac

hing

kin

emat

ics.

ha

s rel

atio

n w

ith b

ette

r qua

lity

of re

achi

ng m

otio

ns a

nd m

ore

2.

B

ilate

ral C

P (B

i-CP)

: 18

colla

psed

trun

k.

b.

TD

chi

ldre

n: 2

6

•

The

pelv

is a

nd tr

unk

diffe

rent

sitti

ng p

ostu

res w

ere

not a

ssoc

iate

d to

• A

ge: 2

-11

year

s

activ

ities

of d

aily

livi

ng fu

nctio

nal p

erfo

rman

ce.

• C

WC

P w

ith m

ore

stab

le h

ead,

trun

k an

d pe

lvis

wer

e co

rrel

ated

to

be

tter f

unct

iona

l per

form

ance

and

/or b

ette

r qua

lity

of re

achi

ng.

Bab 2.indd 16 28/07/2016 09:35:09

17

Inadequate force production (Bigongiari et al. 2011) and individual demands and environmental context (Ju et al. 2010) to maintain postural control may lead to abnormal posture (Batra et al. 2011; Chung et al. 2008), cause functional difficulties in eye-hand coordination (Batra et al. 2011; Kyvelidou 2011; McDonald et al. 2004), as well as motor development deficits (Batra et al. 2011; Brogren et al. 2001).

FACTORS THAT AFFECT POSTURAL CONTROL

There are a few factors that can affect postural control stability. Motor disorders, sensory, velocity of body sway, base of support (BOS), and attention can affect postural control. These factors are highlighted by five studies (Bigongiari et al. 2011; Carlberg & Hadders-Algra 2005; Donker et al. 2008; Kyvelidou 2011; Reilly 2005). Motor disorders condition in CWCP can lead to postural control limitations (Bigongiari et al. 2011; de Graaf-Peters et al. 2007). During functional task, CWCP usually perform with lower muscle activity (Bigongiari et al. 2011), which may cause instability of posture to conduct activities of daily living.

Besides that, changing sensory environment also contributes to the postural stability (Reilly 2005) and CWCP have deficits of the sensory system (Saavedra et al. 2010). Compared to the TD children, the spastic and ataxia types of CP rely totally on somatosensory information for postural control (Brogren et al. 2001; Reilly 2005) and experience instability when only vestibular information is available (Reilly 2005; Saavedra et al. 2010). The second level of adaptation of the direction-specific adjustments is based on the multisensory afferent input from somatosensory, visual, and vestibular systems (Hadders-Algra 2013).

Body sway level and velocity too play a role in postural stability. The stability of posture is lessened when body sway is greater and faster (Reilly 2005). The CWCP have smaller total sway path and range of Medio lateral sway compared to TD children. This causes a rigid posture with limited variation in frontal plane (Hadders-Algra 2013).

Base of support (BOS) is one of the factors that constraints the postural control. Many CWCP chose to accomplish daily living activities in sitting because more stability (higher BOS) may be gained in this position (Brogren et al. 2001; Carlberg & Hadders-Algra 2005).

Apart from this, Donker et al. (2008) stated that attention plays a major role in postural stability. An external focus of attention can enhance motor skills while internal focus can cause disruption to perform activities. This is because during external focus of attention, attention is ‘diverted’ from one owns body towards the task. Postural visual feedback can aid an increase in external focus of attention.

POSTURAL ADJUSTMENTS

Postural controls have two functional levels. The first level is generation of direction-specific adjustments whereby the dorsal muscles are activated when the body sways forward, while ventral muscles will be activated when the body sways backward (Hadders-Algra 2005; Hadders-Algra 2013). The next level is an adaptation of the direction-specific adjustments in which infants (age 6 months onwards) are capable of adapting postural activity to certain situations (de Graaf-Peters et al. 2007; Hadders-Algra 2005).

Direction-specific postural adjustments usually occur after successful grasping of infants at age 4 to 5 months (Bigongiari et al. 2011; Hadders-Algra 2005). As the infants learn to use postural adjustments they can achieve the task targets much better by time due to aging (Bigongiari et al. 2011). Hence, through different demands of hand reaching, the postural adjustments can be changed (Ju et al. 2012).

CWCP have the capabilities to generate direction-specific adjustments (Brogren et al. 2001; de Graaf-Peters et al. 2007), however they display delay development to train direction-specific in activities (de Graaf-Peters et al. 2007). Postural adjustment of CWCP shows a correlation with the combination of postural control capabilities and hand reaching performance (Ju et al. 2012). However, they suffer from a severely restricted repertoire of adjustments (Hadders-Algra 2013).

Severe CWCP with Gross Motor Function Classification System (GMFCS) Level V will display total deficits in direction-specific postural adjustments and are ‘non-sitting’ children (Brogren et al. 2001; Carlberg & Hadders-Algra 2005; de Graaf-Peters et al. 2007). CWCP with GMFCS Level IV at hip level and Level III of young children will experience partial loss of direction-specific (Brogren et al. 2001; Carlberg & Hadders-Algra 2005). This statement is also supported by Brogren et al. (2001) in that musculoskeletal constraints contribute to postural adjustment in children with spastic diplegia.

POSTURAL CONTROL WHILST SITTING

Two studies (Ju et al. 2012; Kyvelidou 2011)stated that infants will achieve sitting independently by the age of 6 to 9 months. In order to have a stable sitting with enhance upper extremity function, infants need adequate control of trunk and pelvis, stable base of support (BOS) of lower extremity (Grant 1999; Ju et al. 2012; Kyvelidou 2011) and sufficient information from vestibular, somatosensory and visual systems inputs (Kyvelidou 2011).

Postural control has an important influence on sitting (Costigan, & Light 2010; Rodby-bousquet & Hägglund 2010) as described in three previous studies (Harbourne et al. 2010; Kyvelidou 2011; McDonald et al. 2004). Firstly, it promotes a functional sitting posture (McDonald et al. 2004) to accomplish functional tasks (Grant 1999; Harbourne et al. 2010; Ju et al. 2012; Kyvelidou 2011).

Bab 2.indd 17 28/07/2016 09:35:09

18

Furthermore, increase success of reaching in sitting position is closely related to the existence of direction specificity and good postural control (Hadders-Algra 2013).

The earliest upright posture is sitting postural control (Harbourne et al. 2010). Previous studies described how sitting in an upright position encourages respiration (Redstone 2004) and allows infants or children to improve perception, social and cognitive development (Harbourne et al. 2010; Kyvelidou 2011). However, CWCP usually have limitations to maintain balance in an upright position as having higher centre of mass and small BOS of their posture. Therefore, they may end up spending a lot of time in a sitting position(Ju et al. 2010, 2012).

The crouched sitting position is not due to a lack of postural adjustment and does not encourage postural deficits; instead, it provides a solution to sensory-motor limitations. However, such a posture can cause problems and limits the usage of upper extremity for functional tasks for CWCP (Brogren et al. 2001).

HEAD STABILITY

Good sitting and standing positions require a stabilized head and trunk together with alignment (Bigongiari et al. 2011). The onset of reaching occurs after head and upper extremity control (Ju et al. 2010). In order to achieve a stabilized head, good postural control is needed (Saavedra et al. 2010).

Head stabilization in space is an important objective of postural control (de Graaf-Peters et al. 2007) and a better stability of the head in space have correlation with complete pattern of direction specific postural adjustments (Hadders-Algra 2013). The skill of a stabilized head may be achieved through practice of new experience involving balance problem (Saavedra et al. 2010) and from trial and error (Hadders-Algra 2005). CWCP head instability while performing dynamic tasks is due to trunk muscle activation in abnormal patterns (Saavedra et al. 2010).

POSTURAL CONTROL & UPPER EXTREMITY FUNCTION: THE RELATIONSHIP

Three studies found that, postural control has crucial effects on upper extremity function, specifically on the dexterity and motor control (Chung et al. 2008; Costigan & Light 2010; Grant 1999). In order to engage in the performance of activities of daily living, upper limb function is considered as one of the important factors (Chung et al. 2008).

In addition, it has been found that postural control ability can influence reaching performance (Hadders-Algra 2013; Harbourne & Kamm 2015; Ju et al. 2012). Reaching is a task engaging extensive neural circuitries; whereby primary motor and somatosensory cortices, frontal and parietal areas play significant parts (Hadders-Algra 2013) and can be influenced by external environment such as adaptive seating (Ju et al. 2012). The arm, hand, and trunk are programmed together in a fixed temporal order during

the reaching movement to assist transporting the hand to the target in a precise way. Such a program strategy may be useful in movement coordination, but requires stable control of the trunk through a longer movement path (Carlberg & Hadders-Algra 2005).

Evidence has shown that CWCP requires extra/further trunk movement when they try to reach forward (Ju et al. 2012) and suffer from insufficient control of reaching due to less force production, coordinated movement limitations, and reduced efficiency of hand transportation towards targets (Ju et al. 2010). The CWCP will demonstrate trunk rotation, trunk side bending, and extra/further trunk forward movement to compensate for their impaired hand control during functional task (Ju et al. 2012).

Besides that, CWCP with impaired postural control have difficulty with reaching in sitting compared to a supine position (Hadders-Algra 2013).Task constraints on reaching performance (reaching speed and direction) can affect CWCP’s control strategies while performing task. Compared to TD children, CWCP demonstrated less straight reaching direction laterally and medially as they were affected by task constraint. Although CWCP show different control strategies to certain degree, they have the ability to modulate their extremities and body to accomplish activity needs successfully (Ju et al. 2010).

Poor sitting posture can disturb CWCP learning process. These children show abnormal movement and postures that may affect their handwriting. The sacrum-sitting position does not promote writing with upper extremities. It is because in this position, children need to pay a lot of attention and energy to the task of sitting and controlling upper limb movements, diverting them from handwriting activities. Hence, proper positioning is important for the upper extremities to function successfully (Cheng et al. 2013).

Poorly organized postural responses, increased muscle co-activation at individual joints and movement limitation are the effects of stronger single and agonist/antagonist muscle activations in CWCP. Strong single muscle responses are caused by lack of supra spinal modulation on tonic stretch reflex thresholds at segmental levels, spasticity, or an immature central nervous system (CNS). The delays in the development of specific neural or musculoskeletal subsystem and sensorial deficits may be a factor of balance difficulties (Bigongiari et al. 2011).

THE SOLUTION TO THESE PROBLEMS: MANAGEMENT STRATEGIES

According to Pountney& Green (2004), management strategies are continuous strategies that support a treatment. These strategies should be conducted within the child’s daily functioning and not occur as solitary daily activity (Pountney & Green 2004). Postural management programs, functional activity training, and home programs are parts of a management strategy.

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POSTURAL MANAGEMENT PROGRAM

A postural management program for CWCP may be defined as a planned approach comprising all activities and interventions which impact on an individual’s posture and function (Gough 2009). It is an essential program that assists CWCP who cannot sit independently, cannot change position, or require more support to maintain postural stability when performing a functional task. Without adequate support, a CWCP may not be able to engage in activities and may maintain postures which could lead to deformity (Pountney & Green 2004).

For CWCP who have limited postural control and poor sitting balance, proper seating and positioning is a crucial management goal (Nwaobi 1987). With the approach of positioning CWCP in a correct posture and avoiding abnormal movement, a stereotypical pattern needs to be supported by postural management equipment. Parents also need to be taught and supported to position their child appropriately (Pountney & Green 2004). Adaptive seating (Grant 1999; McDonald et al. 2004; Rahman et al. 2012) and seat surface inclination (Arakaki et al. 2012) are the example of support for CWCP proper positioning.

FUNCTIONAL ACTIVITY TRAINING

Continuous functional activity training and neuromuscular rehabilitation are compulsory to deal with CWCP postural and movement limitations. Moreover, during rehabilitation programs, multisensory stimulation activities should be applied to increase postural and motor control (Bigongiari et al. 2011). An efficient movement patterns can be formed through trial and error (Carlberg & Hadders-Algra 2005). Previous findings have shown that 20 minutes of daily movement training for two to four months facilitates reaching ability and object manipulation in preterm infants (Hadders-Algra 2013).

HOME PROGRAM

Arakaki et al. (2012) stated that patients who joined occupational therapy home program could depend on the support of their parents as part of the rehabilitation process. This program has been proven to succeed and it has been suggested that the program for upper extremity take a minimum of eight weeks, 17.5 times a month, in sessions of an average duration of 16.5 minutes (Arakaki et al. 2012).

Guidance on enhancing reaching performance including practice of balance control during daily activities should be taught to parents. Besides that, parents and caregivers are encouraged to provide situations that allow the infant experiencing the joy of reaching and grasping toys. CWCP’s families need to be informed about various methods with which infant development can be encouraged (Hadders-Algra 2013).

DISCUSSION

During the review, the paper focused on the information regarding the postural control affect towards upper extremity performance and its management. Review of the current literature concludes that there is less evidence concerning the relationships between visual, somatosensory, and vestibular systems with posture, especially during sitting.

Furthermore, there is also less evidence concerning the vision effect towards head stability during sitting position in CWCP. Head stability plays an important role in enhancing upper extremity performance. Besides that, the studies on the effects of attention on task towards postural control also show less evidence in this topic.

The papers that have been included in this study are mostly of an experimental type, while others were based on reviews and case studies, with one cross-sectional study. Most of the papers have small number of sample size and the generalization of the findings is limited.

Most of the papers have described the development of postural control and its relation with upper extremity function. One of the findings (Harbourne & Kamm 2015) showed that infants’ reaching repertoire actually starts earlier than the accomplishment of postural control. However, there are still limited findings on the relationship between postural control and seated reaching task and ability among CWCP (Ju et al. 2010).

Despite a lack of evidence on the relation between postural control and upper extremity, previous reports in the literature regarding the usage of supportive seating to improve the upper extremity function in appropriate angle or condition are well covered. This provide crucial information for occupational therapists to consult on the prescription of adaptive seating supporting upper extremity function in clients (Grant 1999).

The issues regarding postural adjustment role in postural control ability are also well discussed in the previous literature. Most journals have highlighted the role of the postural adjustment as the basic repertoire that is required to attain stability. The papers also provide information about the development of postural control that includes its component, phase and analysis.

Moreover, through these reviews, the performance of upper extremity ability, for example reaching either during sitting or standing in TD children or CWCP, can be compared. These findings are important as it provides knowledge to therapist on which best position to place the toys or object in a child’s hand or infant’s hand. This is needed to encourage combinations of lateral and bilateral hand movements (Grant 1999).

The postural management strategies also plays crucial role in assisting and maximizing the CWCP’s activity of daily living. Various strategies should enhance the children’s abilities and at the same time improve their quality of life.

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CONCLUSION

In summary, postural control has an influence on upper extremity function. This study is important to create awareness on the part of occupational therapists for parents or caregivers of CWCP as this matter may remain disregarded or unknown to them. After awareness is achieved, then the management strategies can be implemented within the community. Postural control and upper extremity function relation knowledge is essential as the core application of the management strategies. These strategies may support upper limb abilities of CWCP to complete the functional activities. From these various approaches, the CWCP upper extremity function performance can be increased, at the same time enhancing activities of daily living and subsequently improving the quality of life. Therefore, a study on the awareness of the postural control influence on upper extremity function among caregivers and the implementation of management strategies in community settings is vitally needed.

ACKNOWLEDGEMENTS

We would like to thank Universiti Kebangsaan Malaysia (KOMUNITI-2013-026) for the financial support throughout this research.

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Nur Zaidah ZulkapliSazlina KamaralzamanOccupational Therapy ProgrammeSchool of Rehabilitation SciencesFaculty of Health SciencesUniversiti Kebangsaan MalaysiaJalan Raja Muda Abdul Aziz50300 Kuala Lumpur, Malaysia

Nur ZakiahMohd SaatBiomedical Science ProgrammeSchool of Diagnostic and Applied Health SciencesFaculty of Health SciencesUniversiti Kebangsaan MalaysiaJalan Raja Muda Abdul Aziz50300 Kuala Lumpur, Malaysia

Corresponding author: Sazlina KamaralzamanEmail address: sazlina@ukm.edu.my

Received: June 2015Accepted for publication: February 2016

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