Evaluating the Adult with Cerebral Palsy for ... - Physical Therapy
Evaluating the Adult with Cerebral Palsy for ... - Physical Therapy
Evaluating the Adult with Cerebral Palsy for ... - Physical Therapy
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<strong>Evaluating</strong> <strong>the</strong> <strong>Adult</strong> <strong>with</strong> <strong>Cerebral</strong> <strong>Palsy</strong> <strong>for</strong><br />
Specialized Adaptive Seating<br />
Lynda Hollett Hundertmark<br />
PHYS THER. 1985; 65:209-212.<br />
The online version of this article, along <strong>with</strong> updated in<strong>for</strong>mation and services, can<br />
be found online at: http://ptjournal.apta.org/content/65/2/209<br />
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<strong>Evaluating</strong> <strong>the</strong> <strong>Adult</strong> <strong>with</strong> <strong>Cerebral</strong> <strong>Palsy</strong> <strong>for</strong><br />
Specialized Adaptive Seating<br />
LYNDA HOLLETT HUNDERTMARK<br />
<strong>Physical</strong> <strong>the</strong>rapists may not expect to have a pronounced effect on <strong>the</strong> neurodevelopmental<br />
function of <strong>the</strong> cerebral palsied adult because <strong>the</strong> neuroplasticity<br />
of <strong>the</strong> child is no longer present in <strong>the</strong> adult. Adapting <strong>the</strong> environment to such<br />
an adult, <strong>the</strong>re<strong>for</strong>e, becomes of utmost importance. The wheelchair may be <strong>the</strong><br />
most important structure of <strong>the</strong> environment <strong>for</strong> cerebral palsied adults. I present<br />
methods <strong>for</strong> assessing <strong>the</strong> severely involved adult client and evaluating adaptations<br />
of <strong>the</strong> wheelchair <strong>for</strong> <strong>the</strong>rapeutic seating. The anterior and posterior tilt of<br />
<strong>the</strong> pelvis and <strong>the</strong> vertical angle of <strong>the</strong> backrest are emphasized in achieving<br />
<strong>the</strong>rapeutic seating <strong>for</strong> <strong>the</strong> severely multiply handicapped adult.<br />
Key Words: <strong>Adult</strong>, <strong>Cerebral</strong> palsy, Wheelchair.<br />
Adaptive seating <strong>for</strong> severely disabled cerebral palsied children<br />
has been a subject of increasing concern in recent years.<br />
The literature, however, has rarely addressed <strong>the</strong> needs of<br />
adults <strong>with</strong> cerebral palsy. As physical <strong>the</strong>rapists, we have<br />
often focused our attention on mobile and changing children<br />
<strong>with</strong> cerebral palsy. Many severely multiply handicapped<br />
adults, however, also require <strong>the</strong> knowledge and skills of<br />
physical <strong>the</strong>rapists to adapt <strong>the</strong> environment to individual<br />
needs. Adaptive seating may be <strong>the</strong> most important device<br />
available <strong>for</strong> any client who cannot be com<strong>for</strong>tably, safely,<br />
and functionally seated in a commercially available wheelchair.<br />
The adaptive wheelchair should be "<strong>the</strong>rapeutically" designed<br />
to improve <strong>the</strong> overall function of <strong>the</strong> client. Goals<br />
may include providing increased mobility <strong>for</strong> <strong>the</strong> client or<br />
improving <strong>the</strong> client's posture, muscle tone, or ability to eat,<br />
digest, and brea<strong>the</strong> properly. Interaction <strong>with</strong> <strong>the</strong> environment<br />
from <strong>the</strong> upright position may also enhance psychosocial<br />
and cognitive development of <strong>the</strong> client.<br />
In my experience, most adult clients requiring highly specialized<br />
seating have severe extensor spasticity. Nearly all <strong>the</strong>se<br />
clients have severe scoliosis <strong>with</strong> vertebral rotation, and many<br />
retain early developmental reflexes (tonic labyrinthine reflex<br />
and tonic neck reflexes) that impair or prevent normal functioning.<br />
With rare exceptions, adult clients have moderate or<br />
severe contractures that are often permanently fixed. These<br />
problems often preclude seating in commercial wheelchairs<br />
<strong>with</strong>out extensive adaptations.<br />
The <strong>the</strong>rapeutic success of <strong>the</strong> adapted seat depends on <strong>the</strong><br />
accuracy and comprehensiveness of <strong>the</strong> initial seating assessment.<br />
Sitting posture, tone, reflex patterns, and musculoskeletal<br />
limitations must be accurately assessed in <strong>the</strong> upright<br />
position. The appearance of symmetrical posture is often<br />
deceptive when <strong>the</strong> trunk, pelvis, hip, and knees are not<br />
carefully observed <strong>with</strong> clothing removed. The purpose of this<br />
Ms. Hundertmark was Program Coordinator <strong>for</strong> <strong>Physical</strong> <strong>Therapy</strong>, Wassaic<br />
Developmental Center, Wassaic, NY, at <strong>the</strong> time this article was written. She<br />
is now a consultant and educator in <strong>the</strong> field of adaptive equipment and<br />
developmental disabilities in private practice, R.D. 2, Clove Valley Rd, La-<br />
Grangeville, NY 12540 (USA).<br />
This article was submitted March 16, 1984; was <strong>with</strong> <strong>the</strong> author <strong>for</strong> revision<br />
14 weeks; and was accepted August 16, 1984.<br />
article is to suggest a method <strong>for</strong> assessing severely multiply<br />
handicapped adults <strong>for</strong> adaptive seating. I discuss observations<br />
of changes of tone, reflexes, and normal reactions as seating<br />
positions are altered. I explain <strong>the</strong> "fitting chair" and assessment<br />
of <strong>the</strong> orientation of <strong>the</strong> client in relation to gravity in<br />
<strong>the</strong> chair. Finally, I present problems inherent in wedging <strong>the</strong><br />
wheelchair seat and reclining <strong>the</strong> seat insert to overcome<br />
extensor spasticity.<br />
ASSESSMENT<br />
The <strong>the</strong>rapist working <strong>with</strong> children may assess changes of<br />
postural tone and reflexes as <strong>the</strong>y are carried, moved in <strong>the</strong><br />
lap of <strong>the</strong> <strong>the</strong>rapist, and placed in different positions. Children<br />
may often be hypotonic ra<strong>the</strong>r than spastic, are also more<br />
mobile, and will almost certainly change during <strong>the</strong> growing<br />
process. 1 <strong>Adult</strong>s, on <strong>the</strong> o<strong>the</strong>r hand, are frequently more fixed<br />
in <strong>the</strong>ir movement patterns. They may have learned to use<br />
abnormal reflexes functionally or to "fix" <strong>with</strong> spasticity<br />
against a backrest or calf panel <strong>for</strong> stability. Only a careful<br />
and precise assessment of <strong>the</strong> client can determine how <strong>the</strong><br />
client may gain or lose function <strong>with</strong> various adaptations.<br />
The client should be evaluated in <strong>the</strong> sitting position over<br />
<strong>the</strong> side of a mat table. Beginning at <strong>the</strong> pelvis, 24 particular<br />
attention must be paid to anterior and posterior tilt and to<br />
lateral symmetry because restriction in any direction will<br />
cause changes throughout <strong>the</strong> body. For <strong>the</strong> very involved<br />
client, <strong>the</strong> <strong>the</strong>rapist may assume a position behind <strong>the</strong> client,<br />
knees astride <strong>the</strong> client, and hands on <strong>the</strong> pelvic crests. An<br />
assistant may stabilize <strong>the</strong> client's feet and knees at or as near<br />
90 degrees as possible <strong>with</strong> <strong>the</strong> thighs evenly supported on <strong>the</strong><br />
mat. With this high degree of support and control at <strong>the</strong><br />
pelvis, <strong>the</strong> <strong>the</strong>rapist slowly shifts <strong>the</strong> client's weight laterally,<br />
<strong>for</strong>ward, and backward. The <strong>the</strong>rapist may need to use her<br />
own body to shift <strong>the</strong> client's entire trunk <strong>for</strong>ward from <strong>the</strong><br />
pelvis, sometimes rotating <strong>the</strong> client's trunk to encourage<br />
relaxation. The <strong>the</strong>rapist must accurately assess <strong>the</strong> position<br />
of <strong>the</strong> superior iliac spines as <strong>the</strong> trunk is moved to assure<br />
that apparent movement of <strong>the</strong> pelvis is not in fact occurring<br />
in <strong>the</strong> back. The <strong>the</strong>rapist should note if reflexes or abnormal<br />
Volume 65 / Number 2, February 1985 209<br />
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movement patterns increase or decrease as <strong>the</strong> pelvis and<br />
trunk are moved in all planes.<br />
Lateral mobility of <strong>the</strong> pelvis must be assessed <strong>with</strong> attention<br />
to uneven distribution of <strong>the</strong> weight-bearing surface.<br />
Lateral movement may be severely restricted in <strong>the</strong> scoliotic<br />
client, and frequently one pelvic crest and <strong>the</strong> lowest rib are<br />
very near each o<strong>the</strong>r. Because <strong>the</strong> goal is to distribute <strong>the</strong><br />
client's weight as evenly as possible, changes in posture must<br />
be observed as <strong>the</strong> weight is shifted more evenly over both<br />
ischia.<br />
The <strong>the</strong>rapist should observe <strong>the</strong> impact of rightingreactions<br />
on sitting posture. As <strong>the</strong> pelvis is tilted anteriorly,<br />
righting and equilibrium reactions may result in head and<br />
trunk extension and hip and knee flexion.If <strong>the</strong> pelvis is tilted<br />
posteriorly in <strong>the</strong> presence of rightingreactions, <strong>the</strong> client will<br />
often bear weight on <strong>the</strong> sacrum and flex <strong>for</strong>ward. With <strong>the</strong><br />
neck in flexion, <strong>the</strong> head may right into extension or may<br />
remain in flexion, leaving <strong>the</strong> client looking down. Equally<br />
important, a posterior tilt in sitting may permit, and even<br />
encourage, extension of <strong>the</strong> hips, which widens <strong>the</strong> 90-degree<br />
hip angle and may <strong>the</strong>n trigger <strong>the</strong> full extensor pattern. 5<br />
Although clinicians widely recognize that <strong>the</strong> hips must maintain<br />
an angle of 90 degrees or less to prevent extensor spasticity,<br />
2, 3,6 <strong>the</strong> posterior pelvic tilt is often overlooked as a starting<br />
point of hip extension in <strong>the</strong> sitting position.<br />
Righting reactions will also influence posture if <strong>the</strong> client's<br />
back is reclined, regardless of <strong>the</strong> angle of <strong>the</strong> hips. 7 At only<br />
5 degrees of a reclined position, <strong>the</strong> client may tend to flex<br />
<strong>the</strong> head slightly <strong>for</strong>ward as we do in <strong>the</strong> seat of a car. If<br />
reclined more than 15 degrees, a client <strong>with</strong> rightingresponses<br />
may begin to curl <strong>the</strong> trunk into flexion.<br />
Changes in <strong>the</strong> lower extremities must be observed as <strong>the</strong><br />
pelvis is moved. Because <strong>the</strong> hamstrings are two-joint muscles,<br />
stabilizing below <strong>the</strong> knee <strong>with</strong> a heel or leg support of any<br />
sort in <strong>the</strong> presence of hamstring spasticity may result in<br />
undesirable hip extension and posterior pelvic tilt. The client<br />
<strong>the</strong>n may "sit on <strong>the</strong> sacrum, always slipping <strong>for</strong>ward out of<br />
<strong>the</strong>wheelchair." 5(p280)<br />
Positions of <strong>the</strong> pelvis and trunk also significantly affect<br />
head position and control. As noted above, flexion of <strong>the</strong><br />
head sometimes occurs when a seat is reclined. More often,<br />
however, contact of <strong>the</strong> back of <strong>the</strong> head <strong>with</strong> an extended<br />
backrest in a reclined or tilted position may trigger extensor<br />
spasticity. A <strong>the</strong>rapist may, <strong>the</strong>re<strong>for</strong>e, find it beneficial to<br />
avoid use of an extended backrest or head support and bring<br />
<strong>the</strong> client fully upright. The head may <strong>the</strong>n extend freely<br />
<strong>with</strong>out contributing to <strong>the</strong> full extensor pattern.<br />
Finally, <strong>the</strong> <strong>the</strong>rapist must observe <strong>the</strong> position and function<br />
of <strong>the</strong> upper extremities as <strong>the</strong> head, trunk, and pelvis<br />
are changed. As extensor tone of <strong>the</strong> trunk is reduced through<br />
positional changes, <strong>the</strong> arms may be needed to maintain<br />
stability. A tray may provide some support, but <strong>the</strong> client<br />
who must lean on <strong>the</strong> elbows to keep from slumping <strong>for</strong>ward<br />
may be free to do little else <strong>with</strong> <strong>the</strong> upper extremities. The<br />
arms may also demonstrate increase or decrease of <strong>the</strong> symmetric<br />
or asymmetric tonic neck reflexes <strong>with</strong> postural<br />
changes. The overall effect of <strong>the</strong> tonic reflexes on function<br />
should determine whe<strong>the</strong>r posture responses should be stimulated<br />
or inhibited by <strong>the</strong> adaptive unit.<br />
The position of <strong>the</strong> body in relation to gravity must also be<br />
assessed. Nwaobi et al, in a recent EMG study of low back<br />
extensor activity of spastic cerebral palsied children, suggested<br />
that "orientation of <strong>the</strong> body <strong>with</strong> respect to gravitational<br />
<strong>for</strong>ce" may be as important a factor in hyperactivity of<br />
extensors as <strong>the</strong> angle of <strong>the</strong> hip. 7(p180) Because we cannot<br />
readily assess <strong>the</strong> effect of body orientation <strong>with</strong> <strong>the</strong> hips at<br />
predetermined angles (usually 90°) while <strong>the</strong> client sits over<br />
<strong>the</strong> side of a mat, a "fitting chair" must be used <strong>for</strong> this<br />
assessment.<br />
THE FITTING CHAIR<br />
Only during a trial phase in a wheelchair can we see <strong>the</strong> in<br />
situ effects of each adjustment. Then, <strong>the</strong> goals resulting from<br />
<strong>the</strong> previous seating assessment can be applied in a "fitting<br />
chair." Whe<strong>the</strong>r a specially made fitting chair, or simply an<br />
available wheelchair is used, adjustability is <strong>the</strong> key. We must<br />
adjust width; depth; height of <strong>the</strong> footboard, armrests, and<br />
backrest; and <strong>the</strong> angle of <strong>the</strong> seat to <strong>the</strong> client's measurements<br />
and medical and <strong>the</strong>rapeutic needs. If <strong>the</strong> client is using a<br />
wheelchair, a simple seat insert of tri-wall* (triple-density<br />
cardboard) may be angled by placing "spacers" of wood, triwall,<br />
or o<strong>the</strong>r material along <strong>the</strong> front edge of <strong>the</strong> seat. The<br />
angle of <strong>the</strong> backrest may be altered in <strong>the</strong> same manner.<br />
Pieces of foam or blocks may provide all <strong>the</strong> adjustability<br />
needed in width and depth of <strong>the</strong> seat.<br />
The optimal position <strong>for</strong> seating a client is 90 degrees<br />
horizontal <strong>for</strong> <strong>the</strong> seat and 90 degrees vertical <strong>for</strong> <strong>the</strong> backrest. 2<br />
The client should be placed in <strong>the</strong> fittingchair as close to this<br />
ideal position as possible. Accommodations <strong>for</strong> a scoliosis,<br />
such as a back contour of foam or o<strong>the</strong>r material, should be<br />
included. The pelvis should be positioned in neutral in <strong>the</strong><br />
following three planes: <strong>with</strong> slight anterior tilt, equal weight<br />
bearing on <strong>the</strong> ischia, and iliac crests equally against <strong>the</strong><br />
backrest to straighten pelvis and trunk rotation if "windblown"<br />
posture is present. The <strong>the</strong>rapist may findit necessary<br />
to place <strong>the</strong> client to one side of <strong>the</strong> seat and allow <strong>the</strong> knees<br />
to drift to <strong>the</strong> opposite side to assure that <strong>the</strong> pelvis and trunk<br />
are not rotated. The corrected position may <strong>the</strong>n be maintained<br />
by <strong>the</strong> use of a wedge-shaped cushion along <strong>the</strong> abducted<br />
femur. Any o<strong>the</strong>r contractures and de<strong>for</strong>mities must<br />
also be accommodated in <strong>the</strong> fittingchair.<br />
As <strong>the</strong> angles of <strong>the</strong> seat and backrest are altered, <strong>the</strong><br />
<strong>the</strong>rapist can observe changes in <strong>the</strong> client. The seat angle<br />
may be altered by use of spacers, and a block moved behind<br />
<strong>the</strong> backrest from bottom to top will vary <strong>the</strong> trunk angles.<br />
The tilt of <strong>the</strong> entire unit may be changed by placing a wedge<br />
beneath <strong>the</strong> front casters and moving it slowly until <strong>the</strong> best<br />
angle is noted by <strong>the</strong> client's posture (Fig. 1).<br />
Remember, it is <strong>the</strong> tilt of <strong>the</strong> pelvis that influences posture<br />
and tone throughout <strong>the</strong> body. The optimal position of <strong>the</strong><br />
pelvis in sitting is slight anterior tilt. Various methods may<br />
be used during <strong>the</strong> assessment to achieve this position. Bergen<br />
and Colangelo suggested cutting out <strong>the</strong> area of <strong>the</strong> backrest<br />
that <strong>the</strong> buttocks contact so that <strong>the</strong> lower part of <strong>the</strong> pelvis<br />
extends fur<strong>the</strong>r back in <strong>the</strong> chair than <strong>the</strong> trunk. 2 Wedging<br />
<strong>the</strong> top of a back insert <strong>for</strong>ward may also tilt <strong>the</strong> pelvis and<br />
trunk anteriorly and in my clinical experience, excellent results<br />
have been attained using this method <strong>with</strong> some very<br />
spastic clients. A soft ethafoam lumbar roll, usually 2 in†<br />
thick, may work well to prevent a persistent posterior tilt in a<br />
* Tri-wall Containers, Inc, Wassaic, NY 12592.<br />
† 1 in = 2.54 cm.<br />
210 PHYSICAL THERAPY<br />
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PRACTICE<br />
limited number of clients, who often have low muscle tone<br />
ra<strong>the</strong>r than high muscle tone.<br />
Therapists should assess <strong>the</strong> foot-support system in <strong>the</strong><br />
fitting chair. Because many clients <strong>for</strong> adaptive seating have<br />
hamstring spasticity or knee flexion contractures beyond 75<br />
degrees, footrests extended in front of <strong>the</strong> casters in <strong>the</strong> usual<br />
position are not appropriate. To prevent <strong>the</strong> hamstrings from<br />
functioning as hip extensors, a foot box or leng<strong>the</strong>ned foot<br />
support may be used to allow 90 degrees or more of flexion<br />
at <strong>the</strong> knees (Fig. 2). The foot box should extend <strong>for</strong>ward<br />
beyond <strong>the</strong> reach of <strong>the</strong> heels and back under <strong>the</strong> seat as<br />
needed. Calf panels or pads should not be used <strong>with</strong> this type<br />
of foot box to avoid hamstring facilitation.<br />
When <strong>the</strong> client is seated fully upright, a tray may be<br />
suitable <strong>for</strong> support much <strong>the</strong> way we use a table or desk top.<br />
Plans <strong>for</strong> <strong>the</strong> tray should usually be determined during <strong>the</strong><br />
assessment process. The fit, height, and tilt of <strong>the</strong> tray are<br />
important in achieving <strong>the</strong> best posture and muscle tone. A<br />
tilted tray may help to maintain hands in midline and in<br />
contact <strong>with</strong> each o<strong>the</strong>r. A tray may also be essential <strong>for</strong><br />
clients whose muscle tone decreases excessively when <strong>the</strong> hips<br />
and trunk are at a 90-degree angle. The tray may be provided<br />
<strong>with</strong> a high inner rim <strong>for</strong> trunk support, or it may provide<br />
support only through <strong>the</strong> arms as <strong>the</strong> elbows rest on <strong>the</strong> tray.<br />
Fig. 1. Optimal angle of <strong>the</strong> seating unit can be determined by<br />
placing a wedge beneath front casters to observe varying angles of<br />
tilt.<br />
DISCUSSION<br />
Bergen and Colangelo noted that "a majority of clients <strong>with</strong><br />
disorders of tone show a posterior pelvic tilt when sitting"<br />
because of "overactivity of hip extensors. " 2(p5) They also noted<br />
that <strong>the</strong> posterior tilt leads to <strong>the</strong> full extension pattern. The<br />
pelvis must, <strong>the</strong>re<strong>for</strong>e, approximate as nearly as possible <strong>the</strong><br />
normal anterior tilt position in sitting. Wedging <strong>the</strong> seat<br />
invariably increases <strong>the</strong> posterior tilt in clients who lack full<br />
hip mobility. This loss of <strong>the</strong> anterior tilt is <strong>the</strong> reason that<br />
wedging of <strong>the</strong> seat has often been unsuccessful in correcting<br />
<strong>the</strong> problem of extensor spasticity in sitting.<br />
Underlying <strong>the</strong> practice of wedging is <strong>the</strong> firm belief that<br />
reducing <strong>the</strong> angle of <strong>the</strong> hips to 90 degrees or less inhibits<br />
extensor spasticity. That premise is not in question here. If<br />
<strong>the</strong> pelvis is tilted posteriorly, however, <strong>the</strong> hip angle may<br />
only appear to be 90 degrees. The true angle of <strong>the</strong> hip will<br />
often be significantly greater than 90 degrees. The true angle<br />
determines whe<strong>the</strong>r spasticity will be inhibited.<br />
The reclining position, often used <strong>with</strong> a wedged seat <strong>for</strong><br />
severely spastic clients, is successful only in a passive sense.<br />
As spasticity subsides and <strong>the</strong> client relaxes, he may sink back<br />
into <strong>the</strong> seat ra<strong>the</strong>r than extending out of <strong>the</strong> wheelchair.<br />
Moreover, extensor activity is not reduced by reclining and<br />
may actually increase. In <strong>the</strong> a<strong>for</strong>ementioned EMG study by<br />
Nwaobi et al, reclining <strong>the</strong> back as little as 15 degrees <strong>with</strong><br />
<strong>the</strong> hips maintained at 90 degrees flexion produced more low<br />
back extensor myoelectric activity than when <strong>the</strong> back was<br />
straight upright. 7 At 30 degrees of a reclined position, <strong>with</strong><br />
<strong>the</strong> hips maintained at 90 degrees, extensor tone was still<br />
higher. The results of this study suggest that reclining a client<br />
ei<strong>the</strong>r elicits <strong>the</strong> supine tonic labyrinthine reflex, or contact<br />
of <strong>the</strong> back or <strong>the</strong> head <strong>with</strong> a headrest initiates <strong>the</strong> extensor<br />
response. Nwaobi et al do not speculate on ei<strong>the</strong>r of <strong>the</strong>se<br />
reactions as possible contributing factors. 7 In ei<strong>the</strong>r event, we<br />
must be aware of <strong>the</strong> results of this study and carefully assess<br />
Fig. 2. A foot box extended back behind <strong>the</strong> uprights and under<br />
<strong>the</strong> seat prevents <strong>the</strong> hamstrings from extending <strong>the</strong> hips.<br />
<strong>the</strong> effects of reclining <strong>the</strong> backrest or tilting <strong>the</strong> insert when<br />
positioning our severely involved cerebral palsied clients.<br />
CONCLUSION<br />
Not all clients can be positioned or assessed as I have<br />
described, and so <strong>the</strong>se procedures have exceptions. Some<br />
clients may require surgical correction be<strong>for</strong>e <strong>the</strong>y can be<br />
brought to an upright position. Those <strong>with</strong> severe hydrocephalus<br />
or very low tone may be unable to bear <strong>the</strong> full weight<br />
of <strong>the</strong> head and trunk vertically. The fitting chair will reveal<br />
instances where clients have used postural reflexes or hypertonicity<br />
<strong>for</strong> function. Un<strong>for</strong>tunately, it may not be possible<br />
to provide a substitute that will allow <strong>the</strong> client as much<br />
Volume 65 / Number 2, February 1985 211<br />
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function or independence as <strong>the</strong> abnormal movements may<br />
provide. The <strong>the</strong>rapist has little alternative, in such cases, but<br />
to provide adaptations that enable <strong>the</strong> client to use <strong>the</strong>se<br />
movements as optimally as possible.<br />
Acknowledgments. I extend my appreciation to Mary Ann<br />
Delaney, whose neurodevelopmental training and discussions<br />
greatly broadened my knowledge and awareness of handling<br />
and evaluating cerebral palsied clients; and to Ed Mohler,<br />
MD, whose questions and willingness to listen led to learning<br />
and discovery. I give special thanks to Gil Recchia, Adaptive<br />
Equipment Specialist, who accepts <strong>the</strong> impossible as a challenge<br />
to his own creativity.<br />
REFERENCES<br />
1. Bobath KA: A Neurophysical Basis <strong>for</strong> <strong>the</strong> Treatment of <strong>Cerebral</strong> <strong>Palsy</strong>.<br />
Philadelphia, PA, JB Lippincott Co, 1980<br />
2. Bergen AF, Colangelo C: Positioning <strong>the</strong> Client <strong>with</strong> Central Nervous<br />
System Deficits: The Wheelchair and O<strong>the</strong>r Adapted Equipment. Valhalla,<br />
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212 PHYSICAL THERAPY<br />
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<strong>Evaluating</strong> <strong>the</strong> <strong>Adult</strong> <strong>with</strong> <strong>Cerebral</strong> <strong>Palsy</strong> <strong>for</strong><br />
Specialized Adaptive Seating<br />
Lynda Hollett Hundertmark<br />
PHYS THER. 1985; 65:209-212.<br />
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