9. 10.
11.
12.
13.
14. 15.
cerebral palsy and typically developing children. Dev Neurorehabil. 2007;10(3):249-260. Chen J, Woollacott MH. Lower extremity kinetics for balance control in children with cerebral palsy. J Mot Behav. 2007;39(4):306-316. Suzuki N, Mita K, Watakabe M, Akataki K, Okagawa T, Kimizuka M. Strain on the gastrocnemii and hamstrings affecting standing balance on an inclined plane in spastic cerebral palsy. A study using a geometric model. Bull Hosp Jt Dis. 1998;57(4):208-215. Bartonek A, Lidbeck CM, Pettersson R, Weidenhielm EB, Eriksson M, Gutierrez-Farewik E. Influence of heel lifts during standing in children with motor disorders. Gait Posture. 2011;34(3):426-431. Naslund A, Tamm M, Ericsson AK, von Wendt L. Dynamic ankle-foot orthoses as a part of treatment in children with spastic diplegia— parents’ perceptions. Physiother Res Int. 2003;8(2):59-68. American Academy of Orthopedic Surgeons. Joint Motion; Method of Measuring and Recording. Edinburgh, London, Melbourne, and New York: Churchill Livingstone; 1988. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987;67(2):206-207. ˜ Davis R, Ounpuu S, Tyburski D, Gage JR. A gait analysis data collection and reduction technique. Hum Mov Sci. 1991;10:575-587.
16. Ross SA, Engsberg JR. Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy. Arch Phys Med Rehabil. 2007;88(9):1114-1120. 17. Eek MN, Beckung E. Walking ability is related to muscle strength in children with cerebral palsy. Gait Posture. 2008;28(3):366-371. 18. Thompson N, Stebbins J, Seniorou M, Newham D. Muscle strength and walking ability in diplegic cerebral palsy: implications for assessment and management. Gait Posture. 2011;33(3):321-325. 19. Moreau NG, Li L, Geaghan JP, Damiano DL. Fatigue resistance during a voluntary performance task is associated with lower levels of mobility in cerebral palsy. Arch Phys Med Rehabil. 2008;89(10):20112016. 20. Berthoz A. The Brain’s Sense of Movement. Cambridge, MA: Harvard University Press; 2000. 21. Alboresi A, Belmonti V, Ferrari A, Ferrari A. Dysperceptive forms. In: Ferrari A, Cioni G, eds. The Spastic Forms of Cerebral Palsy: A Guide to the Assessment of Adaptive Functions. Milano, Italy: Springer; 2010:273-290. 22. Rosenbaum PL, Walter SD, Hanna SE, et al. Prognosis for gross motor function in cerebral palsy: creation of motor development curves. JAMA. 2002;288(11):1357-1363.
CLINICAL BOTTOM LINE Commentary on “Postural Orientation During Standing in Children With Bilateral Cerebral Palsy”
“How could I apply this information?” As physical therapists, we know that multiple systems interact to determine a child’s functional ability. Assessment of standing posture is an important component in the evaluation of children with cerebral palsy (CP). The authors confirmed classic clinical findings that children with bilateral CP tend to stand in a “crouched” posture. All of the children with bilateral CP in this study stood with less hip and knee extension than was passively available, and these findings were more pronounced in the children who required upper extremity support to stand. This evidence can be used when evaluating children with CP to help interpret the influence of range of motion (ROM), and what should be considered a typical posture for this patient population. The authors’ findings indicate that standing posture cannot be predicted by ROM measurements alone. Therapists should be cognizant of other factors that contribute to standing alignment—for example, perceptual information or strength. “What should I be mindful about when applying this information?” Although the authors assume that muscle weakness and fatigue in the lower extremities contributed to the standing alignment in the children with CP; strength was not formally assessed. If surface electromyography was included in the assessment, the authors would be able to analyze and compare which muscle groups were firing during quiet stance in each group of children. In the sample of children with CP, many of them had multiple orthopedic surgeries and 2 had prior selective dorsal rhizotomies, which can confound range of motion data and make the group too heterogeneous to compare. Taking into consideration the large age range of the sample and effect of maturation on bony alignment, stratifying the groups by age or surgical intervention may be valuable for future studies. Questions for Discussion:
r How can you integrate these findings to a patient you are currently treating? r Would you assess your patients with their braces on as the authors do, or without? Discuss the benefits of each.
r What are your thoughts about the asymmetrical standing alignment that was found? Which group had more asymmetries and why do you think this is?
Jill Ordorica, PT, DPT, PCS Laura Rohnert, PT, PCS Children’s Hospital Los Angeles Los Angeles, California The authors declare no conflicts of interest. DOI: 10.1097/PEP.0000000000000026 Pediatric Physical Therapy
Standing Posture in Children With CP
229
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
11.
12.
13.
14. 15.
cerebral palsy and typically developing children. Dev Neurorehabil. 2007;10(3):249-260. Chen J, Woollacott MH. Lower extremity kinetics for balance control in children with cerebral palsy. J Mot Behav. 2007;39(4):306-316. Suzuki N, Mita K, Watakabe M, Akataki K, Okagawa T, Kimizuka M. Strain on the gastrocnemii and hamstrings affecting standing balance on an inclined plane in spastic cerebral palsy. A study using a geometric model. Bull Hosp Jt Dis. 1998;57(4):208-215. Bartonek A, Lidbeck CM, Pettersson R, Weidenhielm EB, Eriksson M, Gutierrez-Farewik E. Influence of heel lifts during standing in children with motor disorders. Gait Posture. 2011;34(3):426-431. Naslund A, Tamm M, Ericsson AK, von Wendt L. Dynamic ankle-foot orthoses as a part of treatment in children with spastic diplegia— parents’ perceptions. Physiother Res Int. 2003;8(2):59-68. American Academy of Orthopedic Surgeons. Joint Motion; Method of Measuring and Recording. Edinburgh, London, Melbourne, and New York: Churchill Livingstone; 1988. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987;67(2):206-207. ˜ Davis R, Ounpuu S, Tyburski D, Gage JR. A gait analysis data collection and reduction technique. Hum Mov Sci. 1991;10:575-587.
16. Ross SA, Engsberg JR. Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy. Arch Phys Med Rehabil. 2007;88(9):1114-1120. 17. Eek MN, Beckung E. Walking ability is related to muscle strength in children with cerebral palsy. Gait Posture. 2008;28(3):366-371. 18. Thompson N, Stebbins J, Seniorou M, Newham D. Muscle strength and walking ability in diplegic cerebral palsy: implications for assessment and management. Gait Posture. 2011;33(3):321-325. 19. Moreau NG, Li L, Geaghan JP, Damiano DL. Fatigue resistance during a voluntary performance task is associated with lower levels of mobility in cerebral palsy. Arch Phys Med Rehabil. 2008;89(10):20112016. 20. Berthoz A. The Brain’s Sense of Movement. Cambridge, MA: Harvard University Press; 2000. 21. Alboresi A, Belmonti V, Ferrari A, Ferrari A. Dysperceptive forms. In: Ferrari A, Cioni G, eds. The Spastic Forms of Cerebral Palsy: A Guide to the Assessment of Adaptive Functions. Milano, Italy: Springer; 2010:273-290. 22. Rosenbaum PL, Walter SD, Hanna SE, et al. Prognosis for gross motor function in cerebral palsy: creation of motor development curves. JAMA. 2002;288(11):1357-1363.
CLINICAL BOTTOM LINE Commentary on “Postural Orientation During Standing in Children With Bilateral Cerebral Palsy”
“How could I apply this information?” As physical therapists, we know that multiple systems interact to determine a child’s functional ability. Assessment of standing posture is an important component in the evaluation of children with cerebral palsy (CP). The authors confirmed classic clinical findings that children with bilateral CP tend to stand in a “crouched” posture. All of the children with bilateral CP in this study stood with less hip and knee extension than was passively available, and these findings were more pronounced in the children who required upper extremity support to stand. This evidence can be used when evaluating children with CP to help interpret the influence of range of motion (ROM), and what should be considered a typical posture for this patient population. The authors’ findings indicate that standing posture cannot be predicted by ROM measurements alone. Therapists should be cognizant of other factors that contribute to standing alignment—for example, perceptual information or strength. “What should I be mindful about when applying this information?” Although the authors assume that muscle weakness and fatigue in the lower extremities contributed to the standing alignment in the children with CP; strength was not formally assessed. If surface electromyography was included in the assessment, the authors would be able to analyze and compare which muscle groups were firing during quiet stance in each group of children. In the sample of children with CP, many of them had multiple orthopedic surgeries and 2 had prior selective dorsal rhizotomies, which can confound range of motion data and make the group too heterogeneous to compare. Taking into consideration the large age range of the sample and effect of maturation on bony alignment, stratifying the groups by age or surgical intervention may be valuable for future studies. Questions for Discussion:
r How can you integrate these findings to a patient you are currently treating? r Would you assess your patients with their braces on as the authors do, or without? Discuss the benefits of each.
r What are your thoughts about the asymmetrical standing alignment that was found? Which group had more asymmetries and why do you think this is?
Jill Ordorica, PT, DPT, PCS Laura Rohnert, PT, PCS Children’s Hospital Los Angeles Los Angeles, California The authors declare no conflicts of interest. DOI: 10.1097/PEP.0000000000000026 Pediatric Physical Therapy
Standing Posture in Children With CP
229
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
