The effect of positioning for children with cerebral palsy on upper-extremity function: a review of the evidence.

CONTEXT Controversy exists about the most appropriate seating position for children with cerebral palsy (CP) to promote energy conservation and maximize upper-extremity function. EVIDENCE ACQUISITION Sixteen journal articles published after 1980 were identified by searching allied health, medical, and occupational and physical therapy data bases and evidence-based medicine reviews using specific key terms (positioning, wheelchair, postural control, posture, adaptive seating devices, patient positioning, cerebral palsy, movement disorders, upper extremity, reaching, grasping, and occupational therapy) and reviewing bibliographies of retrieved articles. EVIDENCE SYNTHESIS The majority of the evidence supports the positive effects of a neutral to slightly forward orientation (whole chair tilted) on upper-extremity function. Only one study did not demonstrate such effects. Of the supporting studies, one suggested the addition of an abduction orthrosis (AO), one recommended the entire functional sitting position (FSP) package (this orientation plus a hip-belt, footrests, AO, and cutout tray), and one established the long-term effects of the FSP. One less rigorous study opposed the addition of an AO. With the exception of one study, most of the evidence states that seat angle does not affect functional abilities. However, some of these studies contain faulty methodology and/or their results demonstrate clinical significance. CONCLUSION Evidence supports that children with CP should be fitted for wheelchairs that place them in a FSP, which includes; orientation in space of 0 degrees -15 degrees, a hip-belt, an AO, footrests, and a cutout tray, with the addition of a sloped forward seat of 0 degrees -15 degrees, to improve upper-extremity function. The exact seat angle and orientation in space within the 0 degrees -15 degrees range should be determined on an individual basis.