Positioning the Child with Cerebral Palsy

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Posture and Posture Control

Posture is the attitude assumed by body either when the body is stationary or when it is moving. The continuous adaptations of the body posture necessary for the execution of functional activities are generated by complex interactions of musculoskeletal and neuronal systems and are defined as postural control. Postural control requires achieving normal developmental milestones and includes the maturing of postural reactions (righting, protective and equilibrium reactions), the integration of primitive reflexes (Asymmetrical Tonic Neck Reflex, Symmetrical Tonic  Neck Reflex, Tonic Labyrinthine Reflex), as well as normal muscle tone, normal postural tone and intentional voluntary movements  

Normal muscle and postural tone are essentials for dynamic postural control, which in turn is the fundamental prerequisite for movement control. Altered postural tone (hypertone, low tone or fluctuating tone), common in children with Cerebral Palsy, affects their ability to organize and control voluntary movements effectively, producing abnormal patterns that compromise their performance during daily live activities and increase the risk of secondary complications such as contractures and deformities, pressure sores, briefing difficulties, swallowing impairments, pain etc. 

Goal of Positioning

Children with Cerebral Palsy need external postural support in different positions (positioning) with the aim of enabling them to experience and develop more normal ways of moving and prevent secondary complications. Based on clinical and research evidence, it is widely accepted and common practice for the general goals of seating and positioning to include:   

• Normalizing tone or decreasing its abnormal influence on the body   
• Maintaining skeletal alignment 
• Preventing or accommodating skeletal deformity 
• Providing a stable base of support to promote function 
• Promoting increased tolerance of the desired position   
• Promoting comfort and relaxation 
• Facilitating normal movement patterns or controlling abnormal movement patterns   
• Managing pressure or preventing the development of pressure sores 
• Decreasing fatigue 
• Enhancing autonomic nervous system function (cardiac, digestive and respiratory function)   
• Facilitating maximum function with minimum pathology 

Moreover,  adequate positioning facilitate eye contact, child communication and social interaction.

General Principles of Good Positioning

Good positioning includes some basic general principles:   

1. Symmetry and alignment should be respected as much as possible in all positions 
2. The child should feel comfortable. At first the child might not like a new position but if he continues to show discomfort probably he requires some more preparation before placing him in the position (loosen the stiffness and normalize the tone) and/or some position adjustments, even if this means compromising partially the ideal position. Parents should be discouraged in forcing the child in a position if the child feels uncomfortable. 
3. The child should be stable but not stuck. The position should enable the child to experience more normal pattern of movements. For example good proximal stability of the trunk in sitting promotes selective movements of the upper limbs for playing, writing, eating etc. 4 
4. The positions should be varied and changed frequently. Positioning should be changed often to avoid pressure areas, to prevent stiffness and contractures and to allow the child to experience movement in different positions.

It is very important to remember that CP children may manifest with a variety of different clinical features, for example children with spastic quadriplegia can show global pattern of extension or global pattern of flexion or asymmetric postures, therefore the general principles mentioned above should be adjusted to the specific positions useful to modify/improve the child’s pattern of posture and movement. 

For example, if the child is habitually in an abnormally straight or extended position in lying (global pattern of extension Fig. 1) it may be helpful to put him into a more bent or more flexed, symmetrical position. This might help such a child to look at and use two hands for a task at a table placed in front.

Recent Related Research (from Pubmed)

References

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