This thesis outlines the successful development of an objective measurement . system to assist in the prescription of seating to non-ambulant children with CP at risk of developing scoliosis. Non-ambulant children with CP are at high risk of developing severe spinal deformities that can lower the standard of life and life expectancy. Postural support is an important aspect of clinical care however the process of seating prescription is wholly subjective. During this study appropriate stakeholder groups were fully integrated in the development of a system specification utilising a user centred design approach. An initial seating system was developed to provide comparable seating posture within a surface topography spinal imaging system and a spinal X-ray. A clinical investigation was carried out using this system, results from 18 non-ambulant children with CP identified surface topography to be an acceptable alternative to potentially harmful spinal X-rays for moderate spinal curves. Following the initial clinical study stakeholders were re-engaged and an improved system to assess further key parameters of seating was developed. The Seating Measurement System (SMS) was developed to measure spinal curvature and back shape, force distribution through the torso, pressure distribution through the seat and upper limb function. A feasibility study was successfully carried out involving 4 able bodied children and 6 children with CP. Results from this study identified some similar measures or seating trends between these groups. One child with CP is presented as a case study. Results identified that improved postural support may reduce high muscular tone and (identified though parental feedback) improve arm function. Results from this study were used with an osteo-ligamentous finite element model of the spine and rib cage to simulate the non-surgical correction of scoliosis. This study identified that patient specific simulations may be powerful tools to assist in the prescription of optimum seating. However, to be fully utilised in neuromuscular scoliosis models must consider asymmetrical muscular loading

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Background. Adaptive seating systems are used with children with cerebral palsy to promote function and independence and to prevent the development of deformity. A seating system that uses a sacral pad and kneeblock to control the pelvis was investigated. Methods A mixed methodology design was employed. Acceptability was addressed through the development and administration of matching questionnaires to the parents and therapists of the children participating in the project. Effectiveness was investigated by measuring pressure at the sacral pad, force exerted through a kneeblock, seated postural alignment and seated function; during a case controlled trial, where children were seen 6 times over a period of 6 months. Children removed their kneeblocks for a period of one month between visits 3 and 4. The force, pressure and postural alignment data were statistically analysed. Theoretical biomechanical analyses were also performed. Results Questionnaire results showed important differences between parents and therapists views of the seating systems. Therapists concentrated on postural management, whilst parents were concerned with day-to-day management of the child. There were few statistically significant differences over the 6-visit trial for force, pressure or postural alignment. There were no statistically significant correlations between force measured at the kneeblocks and pressure exerted through a sacral pad, nor between force and postural alignment. Statistically significant effects on hip abduction and hip rotation were found on removal of kneeblocks. Finally, individual biornechanical analysis illustrated positive effects for hip abduction for some children, but a tendency to increase deformity in half of the children. Conclusions Adaptive seating systems that use a kneeblock and sacral pad may achieve hip rotation and abduction for children with cerebral palsy. However, no other improvements in posture were seen, and biomechanical analysis showed an increase in tendency of the children to develop secondary deformity.

Children with cerebral palsy and powerful whole body extensor spasms find sitting in a rigid seat uncomfortable and sometimes painful due to the large forces they apply to their constraints. They are usually unable to speak and communication is difficult. The spasms affect every aspect of their lives. This thesis describes the genesis of a new functional dynamic seat for children with severe whole body extensor spasms, and the novel method used to design it. This novel seat technology is known as ‘Whole Body Dynamic Seating’. The thesis describes the clinical need this seat addresses, and the design and technology context in which this research takes place. The user evaluation, observation, measurement, analysis and reasoning that led to a successful seat design are described in detail. Children with cerebral palsy sometimes have whole body spasms that mean they cannot be seated in conventional static seating that positions a child in a fixed posture. For this research the children were classified as functioning at Chailey Sitting Ability Level 1 and Gross Motor Functional Classification System Level V. Such children spend much of their time being held by a person, or lying on a mat, bed or pad. This results in difficulty with social engagement and physical functioning, particularly in school. This research created a seat that such children could sit in, providing a comfortable and functional seat for use in a home or school classroom environment. This seat was designed with the direct and essential involvement of disabled children, their parents, therapists, teachers and carers. The work is part of a larger programme of research into seating and support technology that will enhance a child’s ability to gain functional movement and communication skills that can be employed to enable the child’s free self expression and social participation. The research investigated means of supporting children with whole body extensor spasms through a progressive iterative method utilizing direct user evaluation of a series of prototypes incrementing in complexity and fidelity towards a fully functional physical seat. An iterative method was used to design, build and evaluate three dynamic seats. This method incorporated two new approaches to prototyping developed for the research programme in response to difficulties encountered in designing dynamic systems for children with highly complex neuromotor disability. Soft and Semi-soft prototyping and evaluation methods provided essential feedback on dynamic seating concepts that guided proposed solutions, without requiring costly and time-consuming manufacture. Video was used to create a record of the children’s movements and responses for subsequent analysis. Instrumentation was built into the seats to enable direct objective measurement of the reaction forces and seat movement caused by extensor spasms. This thesis presents several unique features created through this research programme: 1. Independent and virtually hinged anatomical dynamic thigh supports; 2. Independent anatomical dynamic foot supports; 3. A virtually hinged dynamic back support; 4. An anatomical dynamic head support concept. The final Whole Body Dynamic Seat was child-centred in its functionality and aesthetic design, and was favourably commented upon by parents, children and school staff. Use of the new dynamic seating by three children (including one from a previous work programme) showed that children with severe whole body extensor spasms can be seated comfortably. The children also demonstrated gains in physical and social function as a result of using the dynamic seats. The two fully independent dynamic seats made advances in comfort over static seating for children with whole body extensor spasms. One of the children especially liked the seat and resisted being put back into his usual seating. An adult with severe cerebral palsy and extensor spasms evaluated a dynamic foot support concept and reported very significant reductions in spasticity and pain, and gains in physical function. The Whole Body Dynamic Seats showed gains in postural symmetry and in hand and head function over the usual static seats when used by the children with spasms. These gains were reported by staff during long term evaluations and measured specifically during the final evaluation. Two children learned to control the movement of seats in which they were sat, and were able to control their posture and use that control to carry out functions such as switch pressing. Such learning through the use of dynamic seating by children with severe dystonic cerebral palsy and whole body extensor spasms has not previously been documented. The seats did not just affect the children - school staff were affected too. School staff working around the children in the dynamic seats were observed to be more inclusive towards the children, and to expect more interaction from them. The ability of the children to move altered staff expectations of their ability to participate and communicate. This new seating has improved the quality of life of the children that use it. Future implementation of this technology in commercially produced seating offers the possibility of similar gains to many more severely disabled children who are currently less comfortable and less functional than they need to be.

Children with cerebral palsy suffer from primary abnormalities that affect their ability to control movement of body segments. There is evidence that the core (trunk and pelvis) of the body activates prior to the periphery (extremities) during human movement, and so improvement in controlling the core first, then the periphery, could lead to carrying out activities of daily living more effectively. Virtual rehabilitation is developing as a method for the training and assessment of movement function, with evidence suggesting games controlled by the periphery can lead to improvements in activities of daily living, but virtual rehabilitation on the core is scarce. Study One (feasibility study) assessed the changes in gait in response to a six week virtual reality intervention training the core in children with cerebral palsy diplegia (n = 5), using a laboratory based virtual reality system. Improvement in selective motor control of the core occurred after VR training, represented by increased VR game performance (maximum settled speed). Participants showed that single plane trunk movement was better controlled than cross plane trunk movement, trunk rotation was better controlled than trunk tilt, and the trunk was controlled better than the pelvis. Changes in game performance did not transfer to improvements in gait as measured using the Gait Deviation Index. Study Two used a portable virtual reality system in primary schools to train the core and periphery in children with cerebral palsy. A randomised, cross-over design on children with cerebral palsy (n = 8) found that VR game performance improved after receiving VR training, represented by an increase in maximum settled speed and a reduction in variation of pass distance. Single plane movement of the trunk was better controlled than cross plane movement during each assessment, ankle control was better than knee control at each assessment, and control of peripheral segments was better than control of core segments. There were no significant differences in performance of the sit -to-stand movement in response to core training (one week) followed by peripheral training (one week), or when training order was reversed. Overall, Study One and Study Two found no improvements in activities of daily living. Low levels of exposure to virtual reality training, inappropriate outcome measures, in addition to low sample sizes, may have reduced the effect on performance of activities of daily living. Study Two demonstrated that portable virtual reality training is feasible in schools, and can be provided on a daily basis to children with movement difficulties. Overall, the findings provide an important insight into virtual reality training aimed at improving control of the core and periphery in children with cerebral palsy.

The aim of this study was to investigate factors that influence the burden of caregiving on the caregivers of children with cerebral palsy (CP) in Windhoek, Namibia. Ethical approval was obtained from researcher’s university and Namibia Ministry of Health and Social Services ethics committee. A quantitative, non-experimental, descriptive and cross-sectional design in the form of a survey was used. Total population sampling technique was used to draw 91 respondents drawn from the patient register at the two public hospitals in Windhoek. A questionnaire adapted from the Zarit Burden Interview (ZBI) was used to collect data. Data which was obtained was complete and the researcher paid consistent attention to the data collection process. The results showed the following characteristics to be significantly related to increased burden among caregivers; living in the same household as a child with cerebral palsy, marital status, knowledge and understanding of cerebral palsy, ethnic group and caregiver having previously been treated for a physical ailment. It was recommended that the social grant and housing policies be reviewed, and support groups for caregivers and community awareness on cerebral palsy be introduced. / Health Studies / M. P. H. (Public Health)