Evaluating the Adult with Cerebral Palsy for ... - Physical Therapy

Evaluating the Adult with Cerebral Palsy for
Specialized Adaptive Seating
LYNDA HOLLETT HUNDERTMARK
Physical therapists may not expect to have a pronounced effect on the neurodevelopmental
function of the cerebral palsied adult because the neuroplasticity
of the child is no longer present in the adult. Adapting the environment to such
an adult, therefore, becomes of utmost importance. The wheelchair may be the
most important structure of the environment for cerebral palsied adults. I present
methods for assessing the severely involved adult client and evaluating adaptations
of the wheelchair for therapeutic seating. The anterior and posterior tilt of
the pelvis and the vertical angle of the backrest are emphasized in achieving
therapeutic seating for the severely multiply handicapped adult.
Key Words: Adult, Cerebral palsy, Wheelchair.
Adaptive seating for severely disabled cerebral palsied children
has been a subject of increasing concern in recent years.
The literature, however, has rarely addressed the needs of
adults with cerebral palsy. As physical therapists, we have
often focused our attention on mobile and changing children
with cerebral palsy. Many severely multiply handicapped
adults, however, also require the knowledge and skills of
physical therapists to adapt the environment to individual
needs. Adaptive seating may be the most important device
available for any client who cannot be comfortably, safely,
and functionally seated in a commercially available wheelchair.
The adaptive wheelchair should be "therapeutically" designed
to improve the overall function of the client. Goals
may include providing increased mobility for the client or
improving the client's posture, muscle tone, or ability to eat,
digest, and breathe properly. Interaction with the environment
from the upright position may also enhance psychosocial
and cognitive development of the client.
In my experience, most adult clients requiring highly specialized
seating have severe extensor spasticity. Nearly all these
clients have severe scoliosis with vertebral rotation, and many
retain early developmental reflexes (tonic labyrinthine reflex
and tonic neck reflexes) that impair or prevent normal functioning.
With rare exceptions, adult clients have moderate or
severe contractures that are often permanently fixed. These
problems often preclude seating in commercial wheelchairs
without extensive adaptations.
The therapeutic success of the adapted seat depends on the
accuracy and comprehensiveness of the initial seating assessment.
Sitting posture, tone, reflex patterns, and musculoskeletal
limitations must be accurately assessed in the upright
position. The appearance of symmetrical posture is often
deceptive when the trunk, pelvis, hip, and knees are not
carefully observed with clothing removed. The purpose of this
Ms. Hundertmark was Program Coordinator for Physical Therapy, Wassaic
Developmental Center, Wassaic, NY, at the time this article was written. She
is now a consultant and educator in the field of adaptive equipment and
developmental disabilities in private practice, R.D. 2, Clove Valley Rd, La-
Grangeville, NY 12540 (USA).
This article was submitted March 16, 1984; was with the author for revision
14 weeks; and was accepted August 16, 1984.
article is to suggest a method for assessing severely multiply
handicapped adults for adaptive seating. I discuss observations
of changes of tone, reflexes, and normal reactions as seating
positions are altered. I explain the "fitting chair" and assessment
of the orientation of the client in relation to gravity in
the chair. Finally, I present problems inherent in wedging the
wheelchair seat and reclining the seat insert to overcome
extensor spasticity.
ASSESSMENT
The therapist working with children may assess changes of
postural tone and reflexes as they are carried, moved in the
lap of the therapist, and placed in different positions. Children
may often be hypotonic rather than spastic, are also more
mobile, and will almost certainly change during the growing
process. 1 Adults, on the other hand, are frequently more fixed
in their movement patterns. They may have learned to use
abnormal reflexes functionally or to "fix" with spasticity
against a backrest or calf panel for stability. Only a careful
and precise assessment of the client can determine how the
client may gain or lose function with various adaptations.
The client should be evaluated in the sitting position over
the side of a mat table. Beginning at the pelvis, 24 particular
attention must be paid to anterior and posterior tilt and to
lateral symmetry because restriction in any direction will
cause changes throughout the body. For the very involved
client, the therapist may assume a position behind the client,
knees astride the client, and hands on the pelvic crests. An
assistant may stabilize the client's feet and knees at or as near
90 degrees as possible with the thighs evenly supported on the
mat. With this high degree of support and control at the
pelvis, the therapist slowly shifts the client's weight laterally,
forward, and backward. The therapist may need to use her
own body to shift the client's entire trunk forward from the
pelvis, sometimes rotating the client's trunk to encourage
relaxation. The therapist must accurately assess the position
of the superior iliac spines as the trunk is moved to assure
that apparent movement of the pelvis is not in fact occurring
in the back. The therapist should note if reflexes or abnormal
Volume 65 / Number 2, February 1985 209
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