postural control influence on upper extremity function ......batra et al. experimental • subjects:...
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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: [email protected]
Received: June 2015Accepted for publication: February 2016
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