Anda di halaman 1dari 15

LSHSS

Tutorial

Functional Seating for School-Age


Children With Cerebral Palsy:
An Evidence-Based Tutorial
F. Aileen Costigan a and Janice Light a

Purpose: This tutorial is designed to teach speech-language


pathologists (SLPs) best practices to support functional seating
of children with cerebral palsy (CP) in the classroom and in
school-based therapy sessions. This tutorial teaches SLPs
to (a) recognize the positive effects of seating intervention,
(b) identify the characteristics of functional seating that may
produce these positive effects, and (c) realize their role in
supporting functional seating for school-age children
with CP.
Method: The research reporting positive effects of seating
intervention for school-age children with CP is presented
according to the International Classification of Functioning,
Disability and Health (World Health Organization, 2001).
Recommended guidelines for functional seating for schoolage children with CP are gleaned from the research

evidence. The specific role of the SLP in providing functional


seating for children with CP is then discussed.
Conclusion: Seating intervention may produce positive body
structure and function, activities, and participation effects for
school-age children with CP when appropriate equipment
is provided for weight bearing, the pelvis is positioned for
stability and mobility, and the body is properly aligned. SLPs
can support functional seating for school-age children with
CP by communicating with professionals with seating
expertise and by invoking and monitoring recommended
guidelines for children with basic and complex seating
needs, respectively.

hildren with cerebral palsy (CP) often experience


difficulty with speech and/or language subsequent
to cognitive, motor, and/or sensory impairments and
are therefore likely to receive school-based speech-language
pathology services (Pennington, Goldbart, & Marshall,
2004). School-age children with CP may also experience
abnormal or fluctuating muscle tone, impaired strength, and
persistent reflexes that can affect their seated position and
impair their postural control (Rogers, Gordon, Schanzenbacher,
& Case-Smith, 2001). As a result, children with CP frequently
require seating intervention in order to achieve positions
that support effective functioning in the classroom and in
school-based therapy sessions (McNamara & Casey, 2007;
Nwaobi, 1987). Seating intervention includes prescription

of specialized seating equipment (e.g., lateral supports,


adjustable seat surfaces), modifications to existing seating
surfaces (e.g., typical classroom chairs, standard wheelchairs), or deliberate physical adjustment of an individuals
position to improve his or her seated posture (Roxborough,
1995).
Traditionally, the main goal of seating intervention for
school-age children with CP has been to maintain anatomical
and physiological wellness by establishing symmetrical posture
with the assumption that improved task participation and
performance will naturally follow (Kangas, 2000; Morress,
2006). According to this anatomical approach to seating,
hereafter referred to as anatomical seating, education personnel have been encouraged to apply a number of seating
rules to achieve symmetrical posture for children with
CP in educational settings (e.g., 90 angles at the hip, knee,
and ankle joints), regardless of the childrens individual
movement abilities (Kangas, 2000; Morress, 2006). However, anatomical seating may not necessarily increase participation or performance in classroom and school-based
therapy activities for all children with CP. At this time, little
research evidence exists to suggest any facilitative connection between rigid seating rules and task participation, task

The Pennsylvania State University, University Park


Correspondence to F. Aileen Costigan: fac3@psu.edu
Editor: Marilyn Nippold
Associate Editor: Amy Weiss
Received January 11, 2010
Accepted July 29, 2010
DOI: 10.1044/0161-1461(2010/10-0001)

LANGUAGE, SPEECH,

AND

HEARING SERVICES

IN

Key Words: cerebral palsy, positioning (AAC treatment),


school-age children, functional communication

SCHOOLS Vol. 42 223236 April 2011 * American Speech-Language-Hearing Association

223

performance, or supporting abilities such as fine motor skill


in school-age children with CP (Chung et al., 2008; Kangas,
2000; Nwaobi, 1987; Stavness, 2006). Further, anatomical
seating may actually isolate children with CP from participating in classroom and school-based therapy activities by
restricting movement with strapping and supports or by forcing them to fight gravity from a reclined position (Nwaobi,
1987; Stavness, 2006).
In order to better support participation and performance
in the classroom and in school-based therapy sessions, a
functional approach to seating children with CP has emerged
(Morress, 2006). In this approach, hereafter referred to as
functional seating, the goal of seating intervention is to establish seated positions on an individual basis from which
school-age children with CP can best accomplish relevant
task goals; functional seating is therefore derived from the
abilities and goals of the individual student, the tasks that are
purposeful and meaningful to him or her, and the environments in which those tasks are completed (Kangas, 2000;
Myhr & von Wendt, 1991; Myhr, von Wendt, Norrlin, &
Radell, 1995). Functional seating for school-age children
with CP does not negate consideration of anatomical and physiological wellness. Indeed, seating that neglects anatomical
and physiological needs places school-age children with
CP at risk for muscle contractures (i.e., chronic resistance
to stretch due to muscle shortening; OToole, 1992); skin
breakdown; and anatomical deformities that can lead to pain,
decreased motivation, and suboptimal performance in academic, rehabilitation, and social tasks (Perr, 1998). Rather
than relying on seating rules, functional seating pursues a
person-centered, situation-specific balance between anatomical and task-oriented priorities through a number of general
guidelines aimed at providing comfort and stability in a
manner that also facilitates participation and performance
(Perr, 1998).
Functional seating is likely to resonate with school-based
speech-language pathologists (SLPs) because they encounter
children with all types and severities of CP who experience
a variety of seating needs (Pennington et al., 2004). By focusing on general guidelines as opposed to rigid rules, functional seating is equally appropriate for school-age children
with mild forms of CP who have basic seating needs (i.e.,
anatomical integrity, functional movement, and attention and
concentration for classroom and therapy tasks is achieved
using traditional classroom furniture; Perr, 1998) as well as
school-age children with more severe forms of CP who have
complex seating needs (i.e., anatomical integrity, functional
movement, and attention and concentration for classroom and
therapy tasks requires specialized seating equipment, schedules, or strategies; Perr, 1998). Further, an individuals seated
position can affect a variety of skill areas that are of direct
interest to school-based SLPs, including speech production,
speech intelligibility, and feeding (Hulme, Bain, Hardin,
McKinnon, & Waldron, 1989; Redstone, 2005). Schoolbased SLPs are also likely to interact with children with CP

224

LANGUAGE, SPEECH,

AND

HEARING SERVICES

IN

who require assistive technologies such as augmentative and


alternative communication (Simpson, Beukelman, & Bird,
1998). Functional seating is of particular importance to these
children because assistive technologies are often accessed
via specific motor skills (e.g., upper extremity or head movement for switch activation) that may be facilitated by seating
intervention (Mac Neela, 1987; McEwen & Lloyd, 1990).
Regardless of the intensity of childrens seating needs, the
task of defining and implementing functional seating depends
on knowledge of the positive effects that may arise from
proper seating and the recommended guidelines for seated
positions that promote these effects. Although occupational
or physical therapists typically address seating, a basic understanding of functional seating is a clinical and professional
responsibility for school-based SLPs (Mac Neela, 1987;
McEwen & Lloyd, 1990). Further, the American SpeechLanguage-Hearing Association (2002) has included knowledge of seating in the list of competencies for SLPs providing
augmentative and alternative communication services. A lack
of awareness of functional seating by school-based SLPs
can have negative ramifications; for example, children with
CP may be unsafe, uncomfortable, anxious, unable to attend
to task, unable to regulate breathing for speech, and/or unable
to perform oral or upper extremity motor tasks consistently in
class or school-based therapy activities due to compromised
stability, mobility, and respiration (Bodine & Beukelman,
1991; Costigan & Light, 2010; Hulme et al., 1989; Redstone,
2005).
Basic knowledge of functional seating will enable schoolbased SLPs to fulfill a discipline-appropriate role with respect
to seating intervention for children with CP. Within this
role, school-based SLPs should use basic knowledge of the
positive effects of functional seating and the recommended
guidelines that promote these effects to (a) communicate
effectively with professionals with seating expertise who
provide services to school-age children with CP, (b) initiate
and ensure functional seating for school-age children with CP
with basic seating needs, and (c) ensure and monitor functional seating for school-age children with CP with complex
seating needs.
This tutorial is aimed at empowering school-based SLPs
with knowledge of functional seating for children with CP
based on the available empirical evidence. The goal of the
tutorial is to provide answers to the following questions:
& What are the positive effects of functional seating for
school-age children with CP?
& What are the recommended guidelines for functional
seating that produce positive effects for children with
CP in the classroom and in school-based therapy
sessions?
& What is the role of the school-based SLP in supporting
functional seating for children with CP?
This tutorial includes a glossary of relevant terms (presented in Table 1) to clarify concepts that may be unfamiliar to

SCHOOLS Vol. 42 223236 April 2011

Table 1. Glossary of terms related to seating intervention for school-age children with cerebral palsy (CP).

Term
Abduction orthosis
Anatomical seating
Basic seating needs
Complex seating needs
Dislocation
Functional seating
Goniometric measurement
Kyphosis
Muscle contractures
Original seated position
Pelvic obliquity
Radii of sway
Rigid pelvic stabilizer
Scoliosis
Seating intervention
Subluxation

Definition
Physical support placed between the legs to limit hip adduction
Rule-based seating intervention to promote symmetrical posture
Anatomical integrity, functional movement, and attention and concentration for classroom and
therapy tasks is achieved using traditional furniture
Anatomical integrity, functional movement, and attention and concentration for classroom and
therapy tasks requires specialized seating equipment, schedules, or strategies
Complete separation of a ball and socket joint (e.g., hip or shoulder) such that the ball of one
bone is completely removed from its location in the socket of another bone
Individually driven, guideline-based seating intervention to promote task performance
Measurement of joint angles using a two-armed protractor called a goniometer
Involuntary forward flexion of the upper trunk
Chronic resistance to stretch due to muscle shortening
Seated position typically assumed before implementation of functional seating
Tilting of the pelvis, producing asymmetry between sides
Radius of the circle formed by the standard deviations of three-dimensional movement of the
C7 vertebrae
Firm physical support placed in front of the pelvis to promote neutral positioning
Involuntary lateral curvature of the spine
Theoretically driven prescription of specialized seating equipment, modifications to existing
seating surfaces, or deliberate physical adjustment of an individuals position to improve his
or her seated posture
Partial dislocation of a ball and socket joint (e.g., hip or shoulder) such that the ball of one bone
is partially removed from its location in the socket of another bone

some school-based SLPs. Terms included in the glossary are


italicized in their first appearance in the text. The tutorial is
not intended to be a comprehensive review of the literature.
Rather, it is a guide aimed at highlighting the theoretical
importance of functional seating for school-age children with
CP, introducing the recommended guidelines for functional
seating and the discipline-appropriate role of the SLP, and
acquainting the school-based SLP with the supporting research evidence regarding functional seating.

Positive Effects of Functional Seating


for School-Age Children With CP
The literature lists multiple physical, social, and functional
benefits of functional seating for school-age children with CP
relative to their original seated position (OSP; i.e., seated
position typically assumed before functional seating). These
benefits can be grouped according to the International
Classification of Functioning, Disability and Health (ICF;
World Health Organization, 2001), which is a framework
aimed at measuring health-related constructs at an individual
and societal level (McDonald, Surtees, & Wirz, 2004). The
ICF suggests that health and disability are defined by characteristics at three levels of functioning: body structure and
function (i.e., anatomical and physiological well-being of
the body), activities (i.e., the ability to complete tasks), and
participation (i.e., involvement and engagement in daily
life). The framework is congruent with functional seating as
described earlier because health and disability are considered

multifaceted constructs that are influenced not only by individual characteristics, but also by environmental, task, and
societal features.
Activities and participation effects of functional seating are
likely to directly affect functioning in the classroom and in
therapy sessions and are thus particularly relevant to schoolbased SLPs. However, an understanding of the body structure
and function effects of functional seating is also important
for school-based SLPs so they can identify the mechanisms
that support improvements in activities and participation
performance. Functional seating may (a) improve respiratory
function, (b) reduce abnormal muscle tone, (c) reduce abnormal reflexes, and (d) reduce or accommodate anatomical
deformities (McEwen & Lloyd, 1990; Morress, 2006; Perr,
1998; Stavness, 2006). These positive body structure and
function effects result in positive activities and participation
effects (McDonald et al., 2004) such as improved stability
and safety, comfort, and participation and performance in
functional activities (McEwen & Lloyd, 1990; Morress, 2006;
Perr, 1998). Body function and structure and activities and
participation effects are summarized in Table 2 and are discussed in detail in the next section, with specific reference to
the research.

Body Structure and Function Effects


Improved respiratory function. Respiratory complications
are prevalent among school-age children with CP. McCarthy
et al. (2002) found that 41% of one hundred and fifteen

Costigan & Light: Functional Seating for School-Age Children With CP

225

Table 2. Positive effects of functional seating for school-age children with CP compared to original seated position.

Positive effect

Research evidence

Body structure and function effects


Improved respiratory function
Reduced abnormal muscle tone
Reduced abnormal reflexes
Reduced risk or accommodation of
anatomical deformities
Activities and participation effects
Improved stability and safety

Improved comfort
Improved participation and performance
in functional activities

Improved vital capacity, forced expiratory volume, and expiratory time (Nwaobi &
Smith, 1986)
Reduced EMG activity of four leg muscles (Myhr & von Wendt, 1993)
Decreased pathological movements (Myhr & von Wendt, 1991)
Decreased occurrences of the asymmetric tonic neck reflex (Lee et al., 1985)
Maintained hip abduction and lateral rotation (Ekblom & Myhr, 2002)
Increased trunk extension and decreased forward flexion (Reid, 1996)
Reduced kyphotic positioning due to increased trunk extension (Miedaner, 1990)
Improved parent-perceived safety (Ryan et al., 2009)
Improved postural control and radii of sway (Reid, 1996)
Improved head, trunk, and foot control (Myhr & von Wendt, 1991; Myhr et al., 1995)
Increased duration of head and trunk control (Trefler et al., 1983)
Increased happiness (Ryan et al., 2009)
Improved relaxation (Colbert et al., 1986)
Increased activity participation, eagerness, autonomy, social interaction, and quantity
and quality of activities (Rigby et al., 2009; Ryan et al., 2009)
Improved scores on the COPM and reduced repositioning and caregiver assistance
(Reid et al., 1999; Rigby et al., 2001, 2009)
Improved accuracy of target selection on a communication device (Costigan &
Light, 2010)
Reduced reaching path and faster reaching times (Reid, 1996)
Improved control of power wheelchair and increased computer use (Pope et al., 1994)
Improved arm and hand function (Myhr & von Wendt, 1991; Myhr et al., 1995)
Improved speech (Hulme et al., 1989)
Improved feeding (Hulme et al., 1987)
Improved gross arm movements (Trefler et al., 1983)

Note. COPM = Canadian Occupational Performance Measure (Law et al., 2005).

3- to 10-year-olds with spastic CP had comorbid chronic respiratory issues that can cause pain, reduce endurance for functional activities, and impair speech production (McKearnan,
Kieckhefer, Engel, Jensen, & Labyak, 2004; Nwaobi & Smith,
1986). Functional seating has been shown to improve the
respiratory function of school-age children with CP in comparison to their OSP (Mac Neela, 1987). Nwaobi and Smith
(1986) reported 57%, 51%, and 55% increases in vital capacity,
forced expiratory volume, and expiratory time, respectively,
for 5- to 12-year-olds with spastic CP who were individually
seated in a specialized chair with adjustable seat angles as
compared to unsupported seating. Increased pulmonary function was attributed to improved control of respiratory muscles; reduced airway obstruction due to alignment of the head
and neck; and alterations in thoracic and abdominal shape,
structure, and capacities. Improved respiratory function arising from functional seating may lead to improved speech,
feeding, and endurance for functional activities in the classroom and in therapy sessions (Nwaobi & Smith, 1986; Redstone,
2004).

226

LANGUAGE, SPEECH,

AND

HEARING SERVICES

IN

Reduced abnormal muscle tone. Children with CP often


experience abnormal muscle tone, which can cause discomfort and poor voluntary control of postural structures and
the extremities (McKearnan et al., 2004; Myhr & von Wendt,
1993; Rogers et al., 2001). Common abnormalities in muscle
tone associated with CP include spasticity or hypertonia (i.e.,
increased muscle tone), hypotonia (i.e., decreased muscle
tone), or fluctuations in muscle tone (Bax, Goldstein,
Rosenbaum, Leviton, & Paneth, 2005). The empirical
research suggests that functional seating may modulate
abnormal muscle activity for school-age children with CP
as compared to OSP, particularly seated positions that look
symmetrical, relaxed, and comfortable (e.g., reclined positions) and are thus frequently used in classroom settings
(Myhr & von Wendt, 1993; Nwaobi, 1987; Stavness, 2006).
Myhr and von Wendt (1993) found that EMG activity of four
leg muscles decreased during an upper extremity task in a
specialized chair with adjustable seat angles and an abduction
orthosis as compared to OSP for 5- to 16-year-olds with spastic or dystonic CP. Normalization of muscle tone achieved

SCHOOLS Vol. 42 223236 April 2011

through functional seating may support levels of comfort,


stability, and control of posture and voluntary movements that
enable effective performance of spoken and upper extremity tasks in the classroom and in therapy sessions (Myhr &
von Wendt, 1993; Perr, 1998).
Reduced abnormal reflexes. Children with CP often
exhibit persistent reflexes such as the asymmetric tonic neck
reflex (i.e., simultaneous extension of the limbs on the side
of the body to which the head is turned and flexion of the
limbs on the opposite side) or the labyrinthine reflex (i.e.,
leg and back extension coupled with arm flexion in response
to extension of the neck) well into their school-age years
(Rogers et al., 2001). In addition to limiting functional capabilities, these reflexes can increase childrens frustration and
cause uncomfortable positioning that is difficult for children
with CP to adjust (Beckung & Hagberg, 2002; McKearnan
et al., 2004). Functional seating has been shown to inhibit
abnormal reflexes (McEwen & Lloyd, 1990; Morress, 2006;
Perr, 1998). For example, Myhr and von Wendt (1991) found
that the frequency of pathological movements (e.g., asymmetric tonic neck reflex, labyrinthine reflex) significantly decreased when 2- to 16-year-olds with varied types of CP were
placed in a specialized chair designed to promote weight
bearing and to individually adjust the line of gravity (referred
to as functional seated position or FSP by the authors) as
compared to OSP. A case study by Lee, Mahler, and Westling
(1985) also reported decreased occurrences of the asymmetric tonic neck reflex for an 11-year-old child with CP using
a foam head support that promoted midline stabilization as
compared to OSP. Inhibition of abnormal reflexes achieved
through functional seating may support increased voluntary
control of anatomical structures required for speech, feeding,
and upper extremity activities (Mac Neela, 1987; McEwen &
Lloyd, 1990; Morress, 2006).
Reduced risk or accommodation of anatomical deformities. Anatomical deformities (e.g., muscle contractures,
joint subluxation and dislocation, pelvic obliquity, kyphosis,
scoliosis) are common in school-age children with CP (Bax
et al., 2005; Ekblom & Myhr, 2002; OToole, 1992). These
deformities can cause abnormal weight bearing, limited movement, and pain (Ekblom & Myhr, 2002; McKearnan et al.,
2004; Perr, 1998). For example, approximately 22% to 45%
of children with severe CP will experience hip subluxation
and/or dislocation; and 30% to 50% of these children will
experience pain associated with these deformities (Ekblom
& Myhr, 2002; Letts, Shapiro, Mulder, & Klassen, 1984;
McKearnan et al., 2004; Root, Laplaza, Brourman, & Angel,
1995). Prevention or accommodation of such deformities is
consistently listed as a benefit of functional seating (Mac Neela,
1987; Morress, 2006; Perr, 1998). Based on goniometric measurements (Killingsworth & Pedretti, 2001), Ekblom and
Myhr (2002) reported that 3- to 8-year-olds with spastic CP
maintained abducted, laterally rotated hips while in FSP
while exhibiting adducted hips in OSP; abducted, laterally rotated hips are associated with reduced likelihood of subluxation

and dislocation (Letts et al., 1984). Reid (1996) found that


trunk extension measured by a three-dimensional motion
analysis system was significantly increased in an adapted
saddle seat as compared to a typical bench for 4- to 8-yearolds with spastic CP, with most participants also exhibiting
decreased forward trunk flexion. Miedaner (1990) reported
reduced kyphotic positioning in 2- to 6-year-olds with various
types of CP due to increased trunk extension as measured
by palpation on a modified bench and in a specialized chair
as compared to a typical bench and OSP on the floor. When
anatomical deformities are reduced or accommodated by
functional seating, school-age children with CP may be
more comfortable and may have maximized range of motion,
leading to increased ability to attend to and perform tasks in
the classroom and in therapy sessions.

Activities and Participation Effects


Improved stability and safety. Children with CP may have
difficulty achieving and maintaining balance and control of
postural structures, including the trunk, head, neck, and legs
(Brogen Carlberg & Hadders-Algra, 2005; Liao, Yang, Hsu,
Chan, & Wei, 2003). Instability and associated safety issues
that arise from limited postural control should be primary
concerns for parents and therapists of school-age children
with CP; a recent survey found that 87% of children with CP
ages 8 to 18 years were considered unstable by their parents
and/or therapists (Lacoste, Therrien, & Prince, 2009).
Functional seating may improve the stability and safety
of school-age children with CP relative to OSP by promoting increased postural control (Chung et al., 2008; Harris &
Roxborough, 2005). Several empirical studies have indicated
that scores on clinical rating scales of postural control and
safety completed by parents or therapists improve for schoolage children with CP with functional seating relative to OSP.
Ryan et al. (2009) noted dramatically improved safety as measured by a parent-completed Likert scale for children with
CP ages 2 to 7 years when specialized seating devices for
toileting and play were in place compared to when they were
absent. Reid (1996) found that childrens postural control
significantly improved on an adapted saddle seat as opposed
to a typical flat bench, as measured by a clinical rating scale
of ability to maintain the head in an upright position, control
head movements, and maintain and regain balance. Reid also
reported that most participants showed improved stability
while seated in the adapted saddle seat relative to the typical
flat bench, as indicated by reduced radii of sway. Myhr and
von Wendt (1991) found that head control improved from
a rating of none to fair, and trunk and foot control improved
from poor to fair in FSP as compared to OSP for 2- to 16-yearolds with varied types of CP. A 5-year follow-up study
reported that the participants who continued to be seated
in FSP compared to their OSP continued to demonstrate
improved head, trunk, and foot control (Myhr et al., 1995).
Trefler, Nickey, and Hobson (1983) found a statistically

Costigan & Light: Functional Seating for School-Age Children With CP

227

significant improvement in the number of hours in which


5- to 13-year-olds with CP were able to maintain head and
trunk control in a specialized seating device as compared
to OSP. With enhanced stability and safety, school-age
children with CP may be better able to attend to speech,
language, and feeding tasks and may exhibit improved performance resulting from enhanced voluntary control of their
distal anatomy (Mac Neela, 1987; Morress, 2006).
Improved comfort. School-age children with CP frequently
experience discomfort or pain subsequent to muscle tone,
structural, and respiratory issues that can affect their mood,
emotions, sleep patterns, and energy level (McKearnan
et al., 2004). A recent survey of parents by Hadden and
von Baeyer (2001) found that 67% of children with a variety
of types of CP had exhibited pain behaviors in the month
before data collection.
Functional seating is widely thought to improve comfort
in children with CP; however, empirical studies have yet
to examine changes in true measures of comfort following
functional seating for school-age children with CP (Mac Neela,
1987; McEwen & Lloyd, 1990; Morress, 2006; Perr, 1998).
Several surveys of caregivers have suggested that functional
seating may support improvements in associated constructs
for school-age children with CP over OSP. Most parents
surveyed by Ryan et al. (2009) reported in logs of home activities that their children were happier 6 weeks after implementation of specialized seating devices for toileting and
play. In addition, most parents responding to a questionnaire
by Colbert, Doyle, and Webb (1986) reported that a custommolded seating system helped their children to relax when
compared to OSP. When seated comfortably, school-age
children with CP may be best able to focus and to use available motor, cognitive, and language skills in order to participate in classroom and therapy activities (McKearnan et al.,
2004; Perr, 1998).
Improved participation and performance in functional
activities. School-age children with CP often have restricted
motor, cognitive, and social functions that limit their ability
to participate in functional activities and restrict performance
in these activities relative to their same-age peers (Beckung
& Hagberg, 2002). For example, in a recent study (Schenker,
Coster, & Parush, 2005), activities participation and performance were lower for school-age children with CP relative
to their same-age peers as measured by a therapist-completed
rating scale of school function.
Several empirical studies have investigated the effect of
functional seating on measures of participation and performance in functional activities for school-age children with
CP. Two recent studies examined the change in score on the
Canadian Occupational Performance Measure (COPM; Law
et al., 2005) following functional seating (Reid, Rigby, &
Ryan, 1999; Rigby, Ryan, & Campbell, 2009). The COPM
requires individuals to identify areas of functional performance that are meaningful and purposeful for them and to rate
both their current performance in that area and their level of

228

LANGUAGE, SPEECH,

AND

HEARING SERVICES

IN

satisfaction with that performance on a 10-point scale. Rigby


et al. (2009) found statistically significant improvements
on COPM performance and satisfaction scores for areas of
functional performance identified and rated by parents of 4- to
6-year-olds with CP when specialized seating devices for
toileting and play were in place as compared to OSP. Reid
et al. (1999) also reported higher scores on the performance
and satisfaction scales of the COPM for self-identified areas
of functional performance following the addition of a rigid
pelvic stabilizer to OSP for 8- to 12-year-olds with spastic
CP. In a related study, the need for repositioning and caregiver
assistance decreased when the rigid pelvic stabilizer was in
place (Rigby, Reid, Schoger, & Ryan, 2001). Ryan et al. (2009)
found that mean measurements on a parent-completed Likert
scale revealed improved activities participation when specialized seating devices for toileting and play were in place as
compared to when they were absent. A study by Costigan and
Light (2010) demonstrated that accuracy of target selection
on an augmentative communication device improved during
study phases in which functional seating took place to improve weight bearing, pelvic positioning, and body alignment
compared to OSP for a 5-year-old boy with hypotonic CP.
Several studies of preschool-age children with CP have
suggested that functional performance in task areas of particular interest to the SLP improve with functional seating. For
example, Hulme et al. (1989) found that the frequency of
all speech sounds, vowel sounds, and consonant sounds increased for most 1- to 3-year-olds with varied types of CP
when they used custom-designed seating devices compared
to OSP. Improvements in feeding have also been noted with
functional seating for preschool-age children with CP; Hulme,
Shaver, Acher, Mullette, and Eggert (1987) found that the
frequency of food/drink retention, sitting posture, and ability
to maintain head alignment during eating/drinking improved
significantly following implementation of custom-designed
seating devices for 1- to 4-year-olds with multiple handicaps
including CP relative to OSP.
Several authors have reported anecdotal evidence of a relationship between functional seating and participation and
performance in functional activities for school-age children
with CP. Rigby et al. (2009) analyzed home activity logs
completed by parents. Emergent themes included childrens
increased eagerness to participate in activities, increased
engagement in social interaction, and reduced caregiver assistance with functional seating in contrast to increased passivity, decreased interest and engagement in activities, and
decreased social interaction in the absence of functional seating. Most parents surveyed by Ryan et al. (2009) reported
increased quantity and/or quality of their childs activities at
home following functional seating. Several functional activities (e.g., coloring, eating dinner at the table with family)
occurred only during phases when functional seating was in
place. Further, most parents reported greater autonomy and
family interaction during phases when functional seating was
in place. A descriptive study by Pope, Bowes, and Booth

SCHOOLS Vol. 42 223236 April 2011

(1994) found that most 2- to 9-year-olds with spastic CP demonstrated improved directional control of a power wheelchair
via joystick or switch following 3 years of seating in a specialized seating device; these authors also noted subjective
reports from parents and teachers indicating improved computer use following functional seating (Pope et al., 1994).
Improved participation and performance in functional
activities are often attributed to improved coordination and
control of the upper extremity as a result of functional seating (Mac Neela, 1987; McEwen & Lloyd, 1990; Morress,
2006; Stavness, 2006). Most participants in the study by Reid
(1996) demonstrated a more direct reaching path and faster
movement times when asked to reach directly toward a target
in an adapted saddle seat as compared to OSP. Myhr and
von Wendt (1991) found that ratings of arm and hand function
improved from poor or none to fair for 2- to 16-year-olds
with varied types of CP while seated in FSP as compared to
OSP. Improved arm and hand function was maintained for
children who continued to be seated in FSP compared to OSP
during a 5-year follow-up study (Myhr et al., 1995). Trefler
et al. (1983) found statistically significant improvements in
gross arm movements (i.e., number of times a participant
could bat a ball suspended from the ceiling with an arm in
1 min) in a specialized seating device as compared to OSP for
all participants. Improved participation and performance in
functional activities achieved via functional seating may be a
key factor in supporting attainment of speech and language
goals in the classroom and in therapy sessions for school-age
children with CP (Perr, 1998; Redstone, 2004, 2005).

RECOMMENDED GUIDELINES
FOR FUNCTIONAL SEATING
There is no gold standard seated position for school-age
children with CP (Kangas, 2000; Morress, 2006). That is,
there is no evidence to suggest that a certain set of seating
rules will produce the positive body structure and function, activities, or participation effects described earlier for
every child with CP at all times. Instead, the research suggests
the following guidelines be used to produce positive effects
in an individualized manner for school-age children with
CP during classroom and school-based therapy activities:
(a) ensure equipment promotes functional weight bearing,
(b) position the pelvis for stability and mobility, and (c) pursue
proper body alignment.
Occupational and physical therapists are primarily responsible for defining and implementing appropriate seated
positions for school-age children with CP. However, SLPs
require knowledge of these guidelines in order to ensure that
children with CP are consistently well positioned in the
classroom and in school-based therapy sessions and to enable effective communication and collaboration between
professionals (Mac Neela, 1987; McEwen & Lloyd, 1990).

The recommended guidelines for functional seating are discussed in detail in the following paragraphs and are summarized in Table 3 along with the supporting evidence. Figure 1
provides visual examples of how the recommended guidelines for functional seating can be implemented with schoolage children with CP; recommended guidelines are marked on
the figure according to the labeling strategy used in Table 3.

Ensure Equipment Promotes Functional


Weight Bearing
Functional seating for classroom and school-based therapy
activities for children with CP requires seating equipment
that accommodates the individuals body weight while providing a comfortable, stable surface that supports functional
movement. The choice of equipment for functional seating
for each child with CP requires individualized attention
because the presentation of CP is heterogeneous (Bax et al.,
2005; Kangas, 2000). However, functional seats for schoolage children with CP have several common characteristics.
These include an appropriate base of support and appropriate
weight-bearing surfaces.
Base of support. Functional seating for school-age children with CP begins with an appropriate base of support
(Brogen Carlberg & Hadders-Algra, 2005; Cook & Hussey,
1995). Base of support is the two-dimensional area between
an objects contact points with the ground that accommodates
its weight (Cook & Hussey, 1995). For example, the base of
support of a typical classroom chair is the area between the four
legs where they meet the floor. Challenges to balance and
stability arise when the center of gravity of a seated individual
travels outside the base of support of the seating equipment
(Brogen Carlberg & Hadders-Algra, 2005; Cook & Hussey,
1995). An appropriate base of support will therefore be large
enough to accommodate fluctuations in the position of an
individuals center of gravity but will still enable functional
task performance by ensuring that the entire body does not
succumb to gravity (Cook & Hussey, 1995). For example,
placing the feet flat on the ground while seated in a standard
chair can enlarge the base of support of the individual seat
unit, thereby improving safety and stability while still enabling
appropriate posture for participation and performance in a
variety of functional activities.
There are currently no studies that explicitly investigate
the effect of different bases of support on the body structure
and function, activities, or participation of school-age children with CP. Further, studies that have identified positive
effects of functional seating for school-age children with CP
did not describe differences in base of support between seated
positions. However, authors often allude to the importance
of an appropriate base of support. Brogen Carlberg and
Hadders-Algra (2005), for example, stated that postural deficits and impairments in everyday function are more pronounced
in standing than in sitting for children with CP because the
base of support in the latter position best promotes stability

Costigan & Light: Functional Seating for School-Age Children With CP

229

Table 3. Recommended guidelines for functional seating.

Guideline for functional seating

Research evidence

1. Ensure equipment promotes functional


weight bearing
(a) Appropriate base of support
(b) Horizontal or forward sloped seat
(c) Vertical seat back
(d) 12 inch clearance between seat and back of knees
(e) Consistent contact between seat back and
lower back
(f ) Consistent foot support

Fastest switch use and reduced EMG activity in low back extensors, hip
adductors, and ankle flexors in horizontal seats + vertical seat backs
(Nwaobi, 1986, 1987; Nwaobi et al., 1983, 1985)
Increased trunk extension, reduced kyphotic positioning, and improved
sitting stability with forward-sloping seats (Miedaner, 1990;
Sochaniwskyj et al., 1991)
Improved production of 3-syllable utterances with vertical seat back
(Redstone, 2005)
Improved accuracy of target selection; stability; postural control; head, trunk,
foot control; control of power wheelchair via joystick/switch; computer use;
speech; respiration with seating intervention including horizontal/forward
sloped seats + vertical seat backs; seats that support buttocks through to
12 inches proximal to knee; seat backs in direct contact with lower back;
footrest in consistent contact with feet (Costigan & Light, 2010; Hulme
et al., 1989; Myhr & von Wendt, 1991, 1993; Myhr et al., 1995; Pope et al.,
1994; Redstone, 2004; Reid, 1996)

2. Position the pelvis for stability and mobility


(a) Neutral/slight anterior tilt
(b) Neutral lateral tilt and rotation

Fastest switch use in neutral pelvic tilt + horizontal seat + vertical seat back
(Nwaobi et al., 1985)
Improved accuracy of target selection; stability; postural control; head, trunk,
foot control; speech; reduced caregiver assistance with seating intervention
including neutral/anterior pelvic tilt, neutral lateral tilt, neutral rotation
(Costigan & Light, 2010; Hulme et al., 1989; Myhr & von Wendt, 1991;
Myhr et al., 1995; Reid et al., 1999; Rigby et al., 2001)

3. Pursue proper body alignment


(a) Align the trunk, neck, and head
(b) Position lower extremities to support upper body
(c) Provide external supports to upper body as needed

Reduced scoliotic deformities with three-point force system (Holmes et al., 2003)
Improved accuracy of target selection; stability; postural control; head, trunk,
and foot control; control of power wheelchair via joystick/switch; computer
use; respiratory control; speech with seating intervention including aligned
trunk, head, and neck through external supports, hip abduction, knees and
ankles flexed to 90 or slightly beyond (Costigan & Light, 2010; Hulme
et al., 1989; Myhr & von Wendt, 1991; Myhr et al., 1995; Pope et al., 1994;
Nwaobi & Smith, 1986; Reid, 1996)

without placing distinct limits on upper extremity function.


Thus, the need to establish an appropriate base of support
has been included in this tutorial due to the sound biomechanical theory that causes widespread acceptance of this guideline and to its likely fundamental role in ensuring the safety
of school-age children with CP. Readers are referred to Cook
and Hussey (1995) for an in-depth discussion.
Weight-bearing surfaces. Functional seating in the classroom and in school-based therapy sessions for children with
CP also requires appropriate weight-bearing surfaces (Perr,
1998). There are three main weight-bearing surfaces that
are relevant to functional seating: the seat (i.e., surface supporting the legs from the buttocks through the knees), the seat
back (i.e., surface supporting the back), and the surface
supporting the feet. Functional seating requires that weightbearing surfaces are present, appropriately sized, and appropriately oriented in order to (a) limit points of excess pressure
and abnormal joint posturing by evenly distributing body
weight; (b) normalize muscle tone; (c) provide stability by
accommodating the seated individuals center of gravity;
(d) allow unrestricted blood circulation; and (e) allow sufficient

230

LANGUAGE, SPEECH,

AND

HEARING SERVICES

IN

range of motion at key joints such as the hips, knees, and


ankles to address task requirements (McEwen & Lloyd, 1990).
Research that explicitly compares different weight-bearing
surfaces suggests that body structure and function improve
for school-age children with CP when seats are horizontal or
sloped forward and when seat backs are vertical (McNamara
& Casey, 2007; Stavness, 2006). Redstone (2004) recently
reported a slower rate of breathing during rest and decreased
frequency of respiratory subcycles during speech with upright as compared to reclined seat backs for 4- to 5-year-olds
with CP. Respiratory subcycles are small respiratory movements produced frequently by children with neurological
conditions that are smaller in amplitude than the main respiratory movement and may be indicative of difficulty in
controlling exhalation. Studies by Miedaner (1990) and
Sochaniwskyj, Koheil, Bablich, Milner, and Lotto (1991)
found increased trunk extension leading to reduced kyphotic
positioning on benches with forward-sloping seats compared
to flat seats for 2- to 6-year-olds with various types of CP
and 5- to 11-year-olds with spastic CP, respectively. Studies
by Nwaobi (1986) and Nwaobi, Brubaker, Cusick, and

SCHOOLS Vol. 42 223236 April 2011

Figure 1. Examples of the recommended guidelines for functional seating.

Note. This drawing is intended to provide visual examples of the recommended guidelines for functional seating and is not intended to portray
ideal seated positions for classroom activities. Recommended guidelines are marked on the figure according to the labeling strategy used in
Table 3. Copyright 2011 by F. Aileen Costigan.

Sussman (1983) found reduced EMG activity in muscles,


including the low back extensors, hip adductors, and ankle
flexors, during quiet sitting with a horizontal seat and vertical
seat back compared to backward- and forward-tilted positions
for 4- to 18-year-olds with spastic CP.
Horizontal or forward-sloping seats and vertical seat backs
have also produced positive activities and participation effects
in empirical studies of children with CP. Redstone (2005)
recently found that children with spastic CP (Mage = 4.9 years)
were better able to produce three-syllable utterances when
placed in a vertical seat back compared to a reclined seat back.
Sochaniwskyj et al. (1991) found that an individuals sitting
stability (i.e., radius of trunk movement in quiet sitting) improved in forward-sloping seats. Nwaobi (1987) compared
time to switch activation in neutral, backward-tilted, and
forward-tilted seat backs with a consistent hip flexion angle
of 90 for 8- to 16-year-olds with athetoid or spastic CP.
Performance times were lowest when the seat was horizontal
and the seat back was vertical, thereby confirming results of
an earlier study by Nwaobi, Hobson, and Trefler (1985). In
addition, several other experimental studies found no difference in the quality and efficiency of functional upper extremity
activities, including accurate joystick manipulation, functional
reaches, manipulation of small objects, typing, and drawing,
across different seat and seat back orientations for 4- through
20-year-olds with varied types of CP (McClenaghan, Thombs,
& Milner, 1992; Seeger, Caudrey, & OMara, 1984; Seeger,
Falkner, & Caudrey, 1982). These studies suggest that horizontal or forward-sloping seats coupled with vertical seat backs
are at least as effective as other seating orientations in facilitating performance of upper extremity activities.

Several studies that have reported positive effects of functional seating as compared to OSP for school-age children
with CP have described differences in weight-bearing surfaces between seated positions. Functional seating in these
studies included weight-bearing surfaces with the following
characteristics while OSP did not: seats with neutral or forwardsloping seats coupled with vertical seat backs (Costigan &
Light, 2010; Myhr & von Wendt, 1991, 1993; Myhr et al.,
1995; Pope et al., 1994; Reid, 1996); seats that support the
buttocks through to 1 to 2 inches proximal to the knee
(Costigan & Light, 2010); seat backs that are in direct physical contact with the lower back (Costigan & Light, 2010;
Hulme et al., 1989; Myhr & von Wendt, 1991; Myhr et al.,
1995); and foot rests that are in consistent physical contact
with the feet (Costigan & Light, 2010; Hulme et al., 1989;
Myhr & von Wendt, 1991; Myhr et al., 1995). In these studies,
changes in weight-bearing surfaces were part of a package
of modifications that constituted functional seating. Thus,
positive effects that resulted must be attributed to the functional seating as a whole and cannot be specifically linked
to changes in weight-bearing surfaces. Nonetheless, these
studies suggest several strategies for providing appropriate
weight-bearing surfaces that may contribute to the positive
effects of functional seating for school-age children with CP.

Position the Pelvis for Stability and Mobility


Seating equipment that promotes appropriate weight bearing may or may not be sufficient to functionally seat schoolage children with CP in the classroom and in school-based
therapy sessions. Functional seating for children with CP may

Costigan & Light: Functional Seating for School-Age Children With CP

231

also depend on the actual positioning of the individuals anatomical structures within the seating equipment. The position
of the pelvis, often considered the anatomical foundation
of seated position, is of particular importance (Kangas, 2000;
Mac Neela, 1987; McEwen & Lloyd, 1990; McNamara &
Casey, 2007). The pelvis should be positioned stably to accommodate the weight of the upper body. This is not to say
that the pelvis requires rigid restraint; rather, the pelvis requires support to capitalize on its own movement capabilities
in a stable yet dynamic manner, thereby improving postural
control, optimal handeye coordination for precision tasks,
and voluntary control of the upper extremities while limiting
the potential for structural deformities and muscle contractures (Kangas, 2000; Mac Neela, 1987; Perr, 1998; Stavness,
2006). Pelvic positioning for functional seating for schoolage children with CP is defined by appropriate pelvic tilt and
rotation.
Anteriorposterior pelvic tilt. Functional seating for children with CP in classroom and school-based therapy activities requires an appropriate angle of anteriorposterior pelvic
tilt (i.e., the ability to tilt forward or backward relative to
midline; Kangas, 2000; McEwen & Lloyd, 1990; Stavness,
2006). An appropriate angle of anteriorposterior pelvic tilt
will place the weight of the upper body well within the base
of support of the individual seat unit but in a position relative
to the pelvis that enables controlled forward and backward
pelvic movement. The pelvis can then act as a stable, comfortable base for trunk and upper extremity positioning but
can also facilitate trunk and upper extremity mobility during
functional activities through control of its own movement
capabilities (Kangas, 2000; Morress, 2006; Stavness, 2006).
The research suggests that school-age children with CP
should be seated in neutral or slight anterior pelvic tilt in order
to experience the positive effects of seating in the classroom
and therapy sessions. Neutral or anterior pelvic tilt places
the center of gravity directly over or slightly in front of the
ischial tuberosities (i.e., bony prominences at the base of the
pelvis; OToole, 1992), thereby allowing the pelvis to act as a
fulcrum for upper body movement while safely and stably
managing its weight (Cook & Hussey, 1995; Kangas, 2000;
Mac Neela, 1987; McEwen & Lloyd, 1990; Myhr & von Wendt,
1991; Perr, 1998; Stavness, 2006). Nwaobi et al. (1985) explicitly compared different angles of anteriorposterior pelvic
tilt to find that time to switch activation was the lowest in
neutral pelvic tilt coupled with a horizontal seat and a vertical
seat back. Several studies that have found positive effects of
functional seating relative to OSP for school-age children
with CP consistently included neutral or anterior pelvic tilt
whereas OSP did not (Costigan & Light, 2010; Myhr &
von Wendt, 1991; Myhr et al., 1995; Nwaobi & Smith, 1986),
thereby suggesting that neutral or anterior pelvic tilt may play
a key role in functional seating that produces positive body
structure and function, activities, and participation effects
for school-age children with CP.

232

LANGUAGE, SPEECH,

AND

HEARING SERVICES

IN

Lateral pelvic tilt and pelvic rotation. Functional seating


for children with CP in the classroom and in school-based
therapy sessions requires appropriate lateral pelvic tilt (i.e.,
ability to tilt side to side relative to midline) and pelvic
rotation (i.e., ability to rotate about midline; Cook & Hussey,
1995). Appropriate degrees of lateral pelvic tilt and pelvic
rotation place the pelvis in a position relative to the upper
body that will minimize anatomical deformities and enable
weight bearing to promote comfort, safety, and stability
(Cook & Hussey, 1995; McEwen & Lloyd, 1990).
There are no experimental studies that have explicitly
manipulated lateral pelvic tilt or pelvic rotation to determine
the effects on school-age children with CP. This is likely
because control of lateral pelvic tilt and pelvic rotation is of
more importance in mobility and locomotion than in function
while seated. No biomechanical reason has been raised to
justify a functional advantage for positioning the pelvis with
lateral tilt or rotation that deviates from neutral. Neutral lateral
pelvic tilt and neutral pelvic rotation assist in maintaining
alignment of the spinal column; this centralizes the weight of
the upper body and places it in a position from which controlled movement of the head, neck, trunk, and upper extremities can be initiated (Cook & Hussey, 1995; McEwen &
Lloyd, 1990). Despite the lack of comparative research, however, evidence does exist to suggest that functional seating
that includes neutral lateral pelvic tilt and neutral pelvic
rotation has positive effects on school-age children with CP.
Use of a rigid pelvic stabilizer aimed at promoting neutral
lateral tilt and neutral pelvic rotation had positive effects over
OSP for school-age children with CP in studies by Rigby et al.
(2001) and Reid et al. (1999). Costigan and Light (2010),
Myhr and von Wendt (1991), and Myhr et al. (1995) also
found that functional seating that ensured contact between the
back of the pelvis and the seat back, indicating neutral pelvic
rotation, produced positive effects for school-age children
with CP over other seated positions that did not necessarily
provide this support.

Pursue Proper Body Alignment


Functional seating for the classroom and for school-based
therapy sessions for children with CP pursues alignment of
the head, neck, and trunk. That is, the head, neck, and trunk
should lie roughly within the same planes, with minimal
curvature or inclination when viewed from the front and from
the side (Cook & Hussey, 1995; Kangas, 2000; McEwen
& Lloyd, 1990). Upper body alignment of this nature will
evenly distribute body weight, limit formation of anatomical
deformities, enable maximal respiratory function, and place
the body in a position from which to initiate functional upper
body and upper extremity movement (Cook & Hussey, 1995;
Mac Neela, 1987; McEwen & Lloyd, 1990; Nwaobi, 1986;
Stavness, 2006). Researchers have not deliberately placed
school-age children with CP in positions that lack upper body

SCHOOLS Vol. 42 223236 April 2011

alignment in order to compare to aligned positions; seating


that imposes a lack of upper body alignment strongly negates
biomechanical theory and thus raises ethical concerns. However, alignment of the upper body has been a component
of effective functional seating in several studies (Costigan &
Light, 2010; Reid, 1996). Alignment of the head, neck, and
truck can be achieved by strategically positioning the lower
body to effectively manage upper body weight and/or by
directly supporting the upper body itself.
Lower body positioning. Functional seating for schoolage children with CP in the classroom and in therapy sessions
requires lower body positioning that promotes upper body
alignment. Lower body positioning that promotes upper body
alignment will provide a sufficient base of support for the
seated individual, enable dynamic management of upper
body weight through motion at the knees and ankles, and
reduce the likelihood of anatomical deformities that can affect
weight bearing by maintaining joint integrity (Ekblom &
Myhr, 2002; Kangas, 2000; Letts et al., 1984; McEwen &
Lloyd, 1990; Nwaobi et al., 1983). This type of positioning
can also reduce abnormal muscle tone.
There are no experimental studies with school-age children with CP that explicitly compare the effect of different
lower body positions on alignment of the upper body while
seated. However, several studies that report positive effects
of functional seating as compared to OSP for school-age
children with CP have described differences in lower body
positioning between seated positions (Myhr & von Wendt,
1991; Myhr et al., 1995; Nwaobi & Smith, 1986; Pope et al.,
1994; Reid, 1996). These studies suggest that functional
seating that produces positive effects over OSP for school-age
children with CP includes positioning of the hips in slight
abduction with knees and ankles flexed to 90 or slightly
beyond. Experimental comparisons of different lower body
positioning strategies are required to confirm which may be
optimal.
Upper body alignment. School-age children with CP
who cannot achieve upper body alignment independently
or through strategic lower body positioning may require
explicit strategies such as external support for functional
seating. The type of external support will depend on the
typical position of the spine when viewed from the front
and from the side.
The research suggests that several external support strategies may improve upper body alignment and may thus be
components of functional seating for school-age children
with CP. A recent experimental comparison (Holmes, Michael,
Thorpe, & Solomonidis, 2003) found that a thoracic lateral
support system that applied one point of force at the site
of spinal curvature and two points of force opposite spinal
curvature reduced scoliotic deformities for 6- to 20-year-olds
with spastic CP compared to systems that provided two points
of thoracic support or pelvic support only. Two studies that
found positive effects of functional seating as compared to
OSP for school-age children with CP also included explicit

strategies to improve upper body alignment in functional


seating to visually align the head, neck, and trunk from the
front and from the side, including lateral supports and seat
back adjustment (Costigan & Light, 2010; Nwaobi & Smith,
1986). Further experimental comparisons of different external support strategies are required to isolate the best upper
body alignment approaches for school-age children with CP.

THE ROLE OF THE SLP IN FUNCTIONAL


SEATING FOR SCHOOL-AGE
CHILDREN WITH CP
Knowledge of the positive effects of functional seating
for children with CP and the recommended guidelines will
equip SLPs to (a) communicate effectively with professionals
with seating expertise who provide services to school-age
children with CP, (b) initiate and ensure functional seating for
school-age children with CP with basic seating needs, and
(c) ensure and monitor functional seating for school-age
children with CP with complex seating needs. Each of these
discipline-appropriate roles is discussed in the following
paragraphs.
SLPs who understand the positive effects of functional
seating may be motivated to communicate with professionals
with seating expertise (i.e., occupational or physical therapists) early on in the provision of services to obtain direction
on seating intervention for each individual school-age child
with CP. With the support of professionals with seating
expertise, SLPs can then ensure that equipment and strategies
that support functional seating are available and are implemented consistently throughout the provision of speech and
language services. This is important for both assessment and
intervention contexts in order to obtain a true picture of the
skills and abilities of each child with CP and to promote
optimal functioning in the classroom and in school-based
therapy sessions. For example, the articulation skills of
school-age children with CP will be best evaluated and practiced when the children are in seated positions that promote
functional respiration. In addition, SLPs with knowledge
of functional seating who communicate effectively with
professionals with seating expertise are poised to advocate for
consideration of speech and language goals when decisions
regarding functional seating are made. For example, SLPs can
support school-age children with CP who use augmentative
communication devices in the classroom by suggesting that the
equipment prescribed for functional seating should physically
accommodate these devices.
School-based SLPs who are familiar with functional
seating may also initiate and ensure implementation of the
recommended guidelines for school-age children with CP
who experience only basic seating needs and thus may not
receive services from professionals with seating expertise. By
providing verbal reminders and/or basic seating intervention

Costigan & Light: Functional Seating for School-Age Children With CP

233

(e.g., choosing appropriately sized typical furniture), SLPs


can support children with CP who experience basic seating
needs in assuming functional positions for classroom and
school-based therapy activities. However, it is important
to note that SLPs are also responsible for recognizing their
own professional boundaries in this role; professionals with
seating expertise should always be consulted if there is any
possibility that a school-age child with CP is experiencing
complex seating issues. The guidelines for functional seating
presented earlier are a useful tool for SLPs in this role; seating
intervention from an occupational or physical therapist is
required when the guidelines cannot be achieved with verbal
reminders or with basic classroom furniture.
In addition to ensuring implementation of seating intervention as recommended by professionals with seating
expertise, SLPs may also fulfill the important role of monitoring the effectiveness of equipment and seating strategies
in promoting function for school-age children with CP who
experience complex seating needs. Complex seating needs
can be dynamic and may evolve over time (Kangas, 2000;
Morress, 2006; Perr, 1998). Due to their regular interaction
with school-age children with CP in classroom and therapy
activities (Pennington et al., 2004), SLPs who are aware of
the recommended guidelines for functional seating may be
in the unique position to notice changes in seating needs
(e.g., formation of new muscle contractures or pelvic obliquities). SLPs should then communicate with involved
professionals with seating expertise or initiate new referrals
to support school-age children with CP in attaining optimal
functioning in the classroom and in school-based therapy
sessions.

Studies that compare the effect of each guideline on body


function and structure and activities performance and participation for school-age children with CP will confirm the
contribution of each to functional seating. SLPs are also
encouraged to recognize the guidelines as recommendations
rather than rules and to consider the fit between guidelines
and the individual for each child with CP; the heterogeneity
of CP requires that functional seating is individually defined
for each child. Nonetheless, the current level of evidence
provides several suggestions for SLPs to consider when
preparing school-age children with CP to participate actively
in the classroom and in school-based therapy sessions.
Although not primarily responsible for seating intervention,
SLPs can benefit from a knowledge of functional seating,
enabling them to fulfill several discipline-appropriate roles.
These include communicating effectively with professionals
with seating expertise, initiating and ensuring functional
seating for school-age children with CP with basic seating
needs, and ensuring and monitoring functional seating for
school-age children with CP with complex seating needs.

ACKNOWLEDGMENTS
Readers are referred to the Augmentative and Alternative
CommunicationRehabilitation Engineering Research Center
(AAC-RERC) Webcast entitled An Introduction to Seating and
Positioning for Individuals Who Use Assistive Technology at
http://aac-rerc.psu.edu/index.php/webcasts/show/id/9 for further
information. This work was supported in part by the SickKids
FoundationChildren and Youth Homecare Network ( http://
www.sickkidsfoundation.com) and by the Canadian Occupational
Therapy Foundation (www.cotfcanada.org).

Conclusion
The research suggests that functional seating may have
positive effects on the body structure and function of schoolage children with CP (i.e., improved respiratory function,
reduced abnormal muscle tone and reflexes, reduced risk
or accommodation of anatomical deformities) that enable
positive activities and participation effects (i.e., improved
safety and stability, comfort, and participation and performance in functional activities). SLPs are encouraged to
consider the seated position of school-age children with CP
because functional seating may support improved speech,
feeding, and general functional activity in classroom and
therapy activities.
The research also suggests several guidelines for functional seating for school-age children with CP that may enable the positive effects described above. These guidelines
include (a) providing appropriate equipment for functional
weight bearing, (b) positioning the pelvis for stability and
mobility, and (c) pursuing proper body alignment. More
experimental evidence is clearly required to confirm that the
recommended guidelines for functional seating are responsible for positive effects seen in school-age children with CP.

234

LANGUAGE, SPEECH,

AND

HEARING SERVICES

IN

REFERENCES
American Speech-Language-Hearing Association. (2002).
Augmentative and alternative communication: Knowledge
and skills for service delivery. ASHA Supplement, 22, 97106.
Bax, M., Goldstein, M., Rosenbaum, P., Leviton, A., &
Paneth, N. (2005). Proposed definition and classification of
cerebral palsy. Developmental Medicine & Child Neurology,
47, 571576.
Beckung, E., & Hagberg, G. (2002). Neuroimpairments, activity limitations, and participation restrictions in children with
cerebral palsy. Developmental Medicine & Child Neurology,
44, 309316.
Bodine, C., & Beukelman, D. (1991). Prediction of future speech
performance among potential users of AAC systems: A survey.
Augmentative & Alternative Communication, 7, 100111.
Brogen Carlberg, E., & Hadders-Algra, M. (2005). Postural
dysfunction in children with cerebral palsy: Some implications
for therapeutic guidance. Neural Plasticity, 12, 221228.
Chung, J., Evans, J., Lee, C., Lee, J., Rabbani, Y., Roxborough,
L., & Harris, S. (2008). Effectiveness of adaptive seating on

SCHOOLS Vol. 42 223236 April 2011

sitting posture and postural control in children with cerebral


palsy. Pediatric Physical Therapy, 20, 303317.
Colbert, A., Doyle, K., & Webb, W. (1986). DESEMO seats
for young children with cerebral palsy. Archives of Physical
Medicine and Rehabilitation, 67, 484486.
Cook, A., & Hussey, S. (1995). Assistive technologies: Principles
and practice. St. Louis, MO: Mosby.
Costigan, F. A., & Light, J. (2010). The effect of seated position
on access to augmentative communication for children with
cerebral palsy: Preliminary investigation. American Journal of
Occupational Therapy, 64, 596604.
Ekblom, B., & Myhr, U. (2002). Effects of the hip abduction
orthosis on muscle activity in children with cerebral palsy.
Physiotherapy Theory & Practice, 18, 5563.
Hadden, K., & von Baeyer, C. (2001). Pain in children with
cerebral palsy: Common triggers and expressive behaviors. Pain,
99, 281288.
Harris, S., & Roxborough, L. (2005). Efficacy and effectiveness
of physical therapy in enhancing postural control in children with
cerebral palsy. Neural Plasticity, 12, 229243.
Holmes, K., Michael, S., Thorpe, S., & Solomonidis, S. (2003).
Management of scoliosis with special seating for the nonambulant spastic cerebral palsy population: A biomechanical
study. Clinical Biomechanics, 18, 480487.
Hulme, J., Bain, B., Hardin, M., McKinnon, A., & Waldron, D.
(1989). The influence of adaptive device on vocalization. Journal
of Communication Disorders, 22, 137145.
Hulme, J., Shaver, J., Acher, S., Mullette, L., & Eggert, C.
(1987). Effects of adaptive seating devices on the eating and
drinking of children with multiple handicaps. American Journal
of Occupational Therapy, 41, 8189.
Kangas, K. M. (2000). The task performance position: Providing
seating for accurate access to assistive technology. Technology
Special Interest Section Quarterly, 10(3), 13.
Killingsworth, A., & Pedretti, L. (2001). Functional motion
assessment. In L. Pedretti & M. Early (Eds.), Occupational
therapy: Practice skills for physical dysfunction (pp. 279283).
St. Louis, MO: Mosby.
Lacoste, M., Therrien, M., & Prince, F. (2009). Stability of children with cerebral palsy in their wheelchair seating: Perceptions of
parents and therapists. Disability & Rehabilitation, 4, 143150.
Law, M., Baptiste, S., Carswell, A., McColl, M. A., Palatajko, H.,
& Pollock, N. (2005). Canadian Occupational Performance
Measure (4th ed.). Toronto, Ontario, Canada: CAOT Publications
ACE.
Lee, J., Mahler, T., & Westling, D. (1985). Reducing occurrences of an asymmetric tonic neck reflex. American Journal of
Mental Deficiency, 89, 617621.
Letts, M., Shapiro, L., Mulder, K., & Klassen, O. (1984). The
windblown hip syndrome in total body cerebral palsy. Journal of
Pediatric Orthopedics, 4, 5562.
Liao, S., Yang, T., Hsu, T., Chan, R., & Wei, T. (2003). Differences in seated postural control in children with spastic cerebral
palsy and children who are typically developing. American
Journal of Physical Medicine & Rehabilitation, 82, 622626.

Mac Neela, J. (1987). An overview of therapeutic positioning


for multiply-handicapped persons, including augmentative
communication users. Physical & Occupational Therapy in
Pediatrics, 7(2), 3960.
McCarthy, M., Silberstein, C., Atkins, E., Harryman, S.,
Sponseller, P., & Hadley-Miller, N. (2002). Comparing
reliability and validity of pediatric instruments for measuring
health and well-being of children with spastic cerebral palsy.
Developmental Medicine & Child Neurology, 44, 468476.
McClenaghan, B., Thombs, L., & Milner, M. (1992). Effects of
seat-surface inclination on postural stability and function of the
upper extremities of children with cerebral palsy. Developmental
Medicine & Child Neurology, 34, 4048.
McDonald, R., Surtees, R., & Wirz, S. (2004). The International
Classification of Functioning, Disability, and Health provides
a model for adaptive seating interventions for children with
cerebral palsy. British Journal of Occupational Therapy, 67,
293302.
McEwen, I., & Lloyd, L. (1990). Positioning school-aged children with cerebral palsy to use augmentative and alternative
communication. Language, Speech, and Hearing Services in
Schools, 21, 1521.
McKearnan, K., Kieckhefer, G., Engel, J., Jensen, M., &
Labyak, S. (2004). Pain in children with cerebral palsy: A
review. Journal of Neuroscience Nursing, 36, 252259.
McNamara, L., & Casey, J. (2007). Seat inclinations affect the
function of children with cerebral palsy: A review of the effect of
different seat inclines. Disability & Rehabilitation, 2, 309318.
Miedaner, J. (1990). The effects of sitting positions on trunk
extension for children with motor impairment. Pediatric Physical
Therapy, 2, 1114.
Morress, C. (2006). Bottom-up or top-down? An occupationbased approach to seating. OT Practice, 11, 1216.
Myhr, U., & von Wendt, L. (1991). Improvement of FSP for
children with cerebral palsy. Developmental Medicine & Child
Neurology, 33, 246256.
Myhr, U., & von Wendt, L. (1993). Influence of different sitting
positions and abduction orthoses on leg muscle activity in children with cerebral palsy. Developmental Medicine & Child
Neurology, 35, 871880.
Myhr, U., von Wendt, L., Norrlin, S., & Radell, U. (1995).
Five-year follow-up of FSP in children with cerebral palsy.
Developmental Medicine & Child Neurology, 37, 587596.
Nwaobi, O. (1986). Effects of body orientation in space on tonic
muscle activity of patients with cerebral palsy. Developmental
Medicine & Child Neurology, 28, 4144.
Nwaobi, O. (1987). Seating orientations and upper extremity function in children with cerebral palsy. Physical Therapy, 67(8),
12091212.
Nwaobi, O., Brubaker, C., Cusick, B., & Sussman, M. (1983).
Electromyographic investigation of extensor activity in cerebral
palsied children in different seating positions. Developmental
Medicine & Child Neurology, 25, 175183.
Nwaobi, O., Hobson, D., & Trefler, E. (1985). Hip angle and
upper extremity movement time in children with cerebral palsy. In

Costigan & Light: Functional Seating for School-Age Children With CP

235

Proceedings of the Eighth Annual Rehabilitation Engineering


Society of North America Conference (pp. 3941). Memphis, TN:
RESNA.
Nwaobi, O., & Smith, P. (1986). Effect of adaptive seating on
pulmonary function of children with cerebral palsy. Developmental Medicine & Child Neurology, 28, 351354.
OToole, M. (Ed.). (1992). Miller Keane encyclopedia and dictionary of medicine, nursing and allied health. Philadelphia,
PA: W. B. Saunders Company.
Pennington, L., Goldbart, J., & Marshall, J. (2004). Speech
and language therapy to improve the communication skills of
children with cerebral palsy. Cochrane Database of Systematic
Reviews, 3, 134.

Root, L., Laplaza, F., Brourman, S., & Angel, D. (1995).


The severely unstable hip in cerebral palsy: Treatment with
open reduction, pelvic osteotomy, and femoral osteotomy with
shortening. Journal of Bone & Joint Surgery, 77, 703712.
Roxborough, L. (1995). Review of the efficacy and effectiveness
of adaptive seating for children with cerebral palsy. Assistive
Technology, 7, 1725.
Ryan, S., Campbell, K., Rigby, P., Fishbein-Germon, B.,
Hubley, D., & Chan, B. (2009). The impact of adaptive seating
devices on the lives of young children with cerebral palsy and
their families. Archives of Physical Medicine & Rehabilitation,
90, 2733.

Perr, A. (1998). Elements of seating and wheeled mobility intervention. OT Practice, 3, 1624.

Schenker, R., Coster, W., & Parush, S. (2005). Participation and


activity performance of students with cerebral palsy within the
school environment. Disability & Rehabilitation, 27, 539552.

Pope, P., Bowes, C., & Booth, E. (1994). Postural control in


sitting the SAM system: Evaluation of use over three years.
Developmental Medicine & Child Neurology, 36, 241252.

Seeger, B., Caudrey, D., & OMara, N. (1984). Hand function in


cerebral palsy: The effect of hip flexion angle. Developmental
Medicine & Child Neurology, 26, 601606.

Redstone, F. (2004). The effect of seating position on respiratory


patterns of preschoolers with cerebral palsy. International
Journal of Rehabilitation Research, 27, 283288.

Seeger, B., Falkner, P., & Caudrey, D. (1982). Seating position


and hand function in cerebral palsy. Australian Occupational
Therapy Journal, 29, 147152.

Redstone, F. (2005). Seating position and length of utterance of


preschoolers with cerebral palsy. Perceptual & Motor Skills, 101,
961962.

Simpson, K., Beukelman, D., & Bird, A. (1998). Survey of


school speech and language service provision to school-aged
children with severe communication impairments in Nebraska.
Augmentative & Alternative Communication, 14, 212221.

Reid, D. (1996). The effects of the saddle seat on seated postural


control and upper extremity movement in children with cerebral
palsy. Developmental Medicine & Child Neurology, 38, 805815.
Reid, D., Rigby, P., & Ryan, S. (1999). Functional impact of a
rigid pelvic stabilizer on children with cerebral palsy who use
wheelchairs: Users and caregivers perceptions. Developmental
Neurorehabilitation, 3, 101118.
Rigby, P., Reid, D., Schoger, S., & Ryan, S. (2001). Effects of
wheelchair-mounted rigid pelvic stabilizer on caregiver assistance for children with cerebral palsy. Assistive Technology, 13,
211.
Rigby, P., Ryan, S., & Campbell, K. (2009). Effect of adaptive
seating devices on the activity performance of children with
cerebral palsy. Archives of Physical Medicine & Rehabilitation,
90, 13891395.

Sochaniwskyj, A., Koheil, R., Bablich, K., Milner, M., &


Lotto, W. (1991). Dynamic monitoring of sitting posture in
children with spastic cerebral palsy. Clinical Biomechanics, 6,
161167.
Stavness, C. (2006). The effect of positioning for children with
cerebral palsy on upper-extremity function: A review of the
evidence. Physical and Occupational Therapy in Pediatrics,
26(3), 3953.
Trefler, E., Nickey, J., & Hobson, D. (1983). Technology in the
education of multiply-handicapped children. American Journal
of Occupational Therapy, 37, 381387.
World Health Organization. (2001). International classification
of functioning, disability and health [Electronic version].
Retrieved from http://www.who.int /classifications/icf /en /.

Rogers, S., Gordon, C., Schanzenbacher, K., & Case-Smith, J.


(2001). Common diagnoses in pediatric occupational therapy
practice. In J. Case-Smith (Ed.), Occupational therapy for
children (pp. 136187). St. Louis, MO: Mosby.

236

LANGUAGE, SPEECH,

AND

HEARING SERVICES

IN

SCHOOLS Vol. 42 223236 April 2011

Copyright of Language, Speech & Hearing Services in Schools is the property of American Speech-LanguageHearing Association and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print, download, or email
articles for individual use.