Effect of Adaptive Seating Devices on the Activity Performance of Children With Cerebral Palsy

Article Outline

• Abstract
• Methods
  • Participants
  • Intervention
  • Outcome Measures
    • Canadian Occupational Performance Measure.11
    • Home activity log interview
  • Data Collection
  • Data Analysis
• Results
  • Canadian Occupational Performance Measure Results
  • Home Activity Log Results
    • Theme 1: adaptive seating can have an enabling influence on child
    • Theme 2: caregivers and family find adaptive seating useful
    • Theme 3: the adaptive seating devices did not meet every family's needs
  • Descriptive Results
• Discussion
  • Study Limitations
  • Implications for Clinical Practice and Research
• Conclusions
• Acknowledgments
• Appendix 1. Home Activity Log Interview
• References
• Copyright

Abstract 

Rigby PJ, Ryan SE, Campbell KA. Effect of adaptive seating devices on the activity performance of children with cerebral palsy.

Objective

To evaluate the short-term impact of 2 adaptive seating devices on the activity performance and satisfaction with performance of children with cerebral palsy (CP), as observed by their parents.

Design

Baseline-intervention-baseline study.

Setting

Homes of participating families.

Participants

Parents and their children (N=30), mean age of 4 years 6 months, with Gross Motor Function Classification System levels III and IV CP participated.

Interventions

Two special purpose seating devices: one for sitting support on the floor or on a chair, the other for postural control on a toilet.

Main Outcome Measures

Changes in activity performance and satisfaction were measured through parent ratings on the Canadian Occupational Performance Measure. We interviewed parents biweekly using the Home Activity Log to describe and explain their child's activity performance during the 3 study phases.

Results

Parents identified 139 activity performance issues (4.6 a child): 58.3% in self-care, 34.5% in play, and 7.2% in socialization and quiet recreation. We used paired t tests to demonstrate significantly improved performance and satisfaction with self-care and play activities when the children used the adaptive seating devices during the 6-week intervention phase. Three themes arose from the analysis of comments made by parents during Home Activity Log interviews: adaptive seating can have an enabling influence on the child, caregivers and family find adaptive seating useful, and the adaptive seating devices did not meet every family's needs.

Conclusions

Parents reported that their young children with CP were more able to engage in self-care and play activities when using specific adaptive seating devices in their home. Parents indicated that their child's activity performance decreased after the seating devices were removed from their homes.

Key Words: Activities of daily living, Disabled children, Rehabilitation, Treatment outcome

List of Abbreviations: CP, cerebral palsy, COPM, Canadian Occupational Performance Measure, FIATS, Family Impact of Assistive Technology Scale, GMFCS, Gross Motor Function Classification System

CEREBRAL PALSY IS A nonprogressive lesion of the immature brain that results in impairment of movement and postural control, and is the most common physical disability in childhood.¹ Many young children with CP cannot sit without support.², ³ Thus, physical and occupational therapists routinely prescribe adaptive seating devices for them to promote their function and improve their developmental capabilities.¹, ², ³, ⁴

A number of studies have evaluated sitting posture and various features of adaptive seating devices for children with CP, and 3 authors have reviewed this literature.², ³, ⁵ Roxborough² found that postural control, pulmonary function, and psychologic skills improved with some adaptive seating interventions. However, she found little evidence for the effect of seating on self-care. Harris and Roxborough⁵ concluded that seating interventions that stabilized the pelvis and increased the seating base of support optimized postural control. The review by Stavness³ examined how sitting affected upper extremity function. She found that upper extremity function was better when children sat in an upright versus a reclined position, with a neutral to slightly forward orientation of the seat.

Harris and Roxborough⁵ recommended that future studies should examine the impact of adaptive seating on children's functional abilities in their daily life. This is important because a primary goal for therapists who prescribe adaptive seating is to provide the child with CP with a safe, stable seated posture from which the child can engage in controlled upper extremity movements to enable the child to engage actively in many daily activities, including play and self-care.³, ⁶ Furthermore, contemporary models of rehabilitation and family-centered services recommend that rehabilitation practice and research should address the activity performance and participation of children with CP within family life as outcomes of interest.⁷, ⁸, ⁹

Despite widespread clinical use, little is known about the effect of seating technologies on the activity performance of young children with CP at home. To address this gap in knowledge, we conducted a study to examine the impact of 2 seating devices on important, parent-identified activity performance issues at home. We asked the question, “Do special purpose seating devices used in the home improve the activity performance of young children with GMFCS levels III and IV CP¹⁰ as measured by the COPM?”¹¹

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Methods 

The present study was part of a larger project that examined the measurement properties of the FIATS.¹² We received ethical clearance from the Research Ethics Board of Bloorview Research Institute.

We used a within-subject A1-B-A2 design to study the influence of postural control devices for seating on children's activity performance in daily life within their homes. The first baseline period (A1) lasted for 3 weeks, followed by a 6-week seating intervention period (B), then another 3-week return to baseline period (A2), as shown in figure 1. This design eliminates between-subject effects by using parents and their children as their own controls. While a crossover protocol would have been a stronger design, this design was chosen for the larger measurement study.

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• Figure 1. 

  Research design schedule. Abbreviation: HAL, home activity log.

The baseline period of 3 weeks was considered a sufficient length to demonstrate stable functional behaviors.^13(p186) Based on our previous experience, an intervention period of 6 weeks provided adequate time for the children and their families to adjust to using the seating technologies and to establish regular activity routines.¹⁴

Participants 

Thirty parents and their young children (mean age, 4y, 6mo; range, 2y, 6mo–6y, 7mo), who were clients of 3 children's rehabilitation centers in south-central Ontario, Canada, agreed to participate in this study. All parents provided informed consent for themselves and their children. Eligible families included children who had a primary diagnosis of CP with a functional status defined by GMFCS level III or IV.¹⁰ This functional level meant that each child had some ability to move around on the floor (eg, by rolling or creeping) but had difficulty in maintaining floor sitting, or required trunk support to maximize hand function when sitting on a chair.¹⁰ We found that our sample size exceeded the number of participants needed for a power of 80% and α equal to .05 (2-sided) when we examined data from a comparable within-subjects study wherein the COPM was used to evaluate performance differences with and without an adaptive seating intervention.¹⁴ Details on recruitment procedures can be found in an earlier publication.¹⁵

While we recruited children who did not use special purpose seating devices for floor sitting, chair sitting, or toileting, most participants did use some form of assistive technology in the home at the time of enrollment in the study. All children either used a wheelchair or a stroller in their home. Parents also reported that they positioned their children by using an assortment of pillows, or the help of family members, or by using modified juvenile seating systems such as a highchair or a car seat. Some families also used homemade devices such as modified potty seats and corner seats to provide seating support.

Intervention 

In the study, we supplied the Flip2Sit^a activity seat for floor sitting and table-level activities, and the Aquanaut^a toileting system for toileting and grooming in the bathroom. Both devices are intended to provide sitting support for children with CP who have postural instability. Clinicians and parents have reported that both devices provide appropriate postural support in sitting to help young children with CP participate in a variety of important home activities.¹⁶, ¹⁷ We also provided families with a simple, self-standing bed tray,^b so children could play on an elevated surface while they sat in the activity seat at floor level.

Outcome Measures 

The COPM is a criterion-referenced outcome measure that has demonstrated responsiveness to change over time,¹⁴, ¹⁸, ¹⁹ and has been found useful for evaluating the effectiveness of assistive technologies.¹⁴, ²⁰, ²¹ It has been successfully used with parents for the evaluation of children's occupational performance problems or issues as identified by the child's parents,²² and to evaluate the effect of adaptive seating devices for children with CP.¹⁴ The reliability and validity of the COPM are well documented.¹¹, ¹⁸ A change of 2 or more points on the performance or satisfaction with performance scales on the COPM is considered a clinically important change.¹¹

We chose the COPM because it is administered through a semistructured interview, and it allowed us to ask each parent to identify up to 5 important problems that their child was experiencing in the areas of self-care, play, and leisure within their daily life at home.¹⁸ In order to evaluate the impact of the seating devices, we adapted the COPM questions and asked the parents to focus on activities that the child required seated postural control to do, and which were difficult for the child to do. Consequently, we identified these as activity performance issues rather than occupational performance issues, because parents had targeted specific aspects or steps of the occupation that their child had difficulty doing.

We developed the home activity log interview (appendix 1) for this study to monitor, biweekly, the parent's perspectives about their child's activity performance over the 12-week study. Parents were asked to describe any changes that they observed in their child's daily behaviors and activity performance in the 3 categories of self-care, play, and quiet recreation/leisure. They were also asked how the seating devices influenced the activity performance of their child during the intervention phase. We collected these perspectives from parents to help us interpret the COPM change scores.

Data Collection 

One of 2 experienced occupational therapists (who had 12 and 20 years experience with children with physical disabilities, respectively) visited each parent and child in their homes at selected times to administer the outcome measures. The COPM was administered 4 times in total: during weeks 1 and 3 (the beginning and end of the baseline period), during week 9 (at the end of the 6-week intervention period), and during week 12 (at the end of the second baseline period), as shown in figure 1. It was impossible to blind the occupational therapists because of the nature of this intervention.

On each administration, the parent used the 10-point COPM scales to rate their child's performance and satisfaction with their child's performance on each of the activity performance issues that they had identified during the baseline COPM interview during week 1. On the performance rating scale, a 1 meant that the child was not able to do the activity, whereas a rating of 10 meant that the child was able to do the activity extremely well. On the satisfaction scale, a rating of 1 meant that the parent was not satisfied at all with the child's performance, whereas a rating of 10 meant that the parent was extremely satisfied with the child's performance of that activity.

The study therapist administered the home activity log every other week either through a phone interview or in person during the home visit. The study therapist used the home activity log as a guide to interview parents and record changes in the child's activity performance, and any changes in family routines over the previous week. The therapist recorded the parents' comments during the interview.

The therapist delivered and set up the study devices for each family at the end of the first baseline phase. Parents were shown how to use the devices with their child and were given precautions and safety instructions. Parents were also given the device owner's manuals and were asked to read them to ensure they understood how to use the devices. Families used the study devices for 6 weeks, and the therapist retrieved the devices at the end of the intervention phase, at the end of week 9. Once the measures were administered a final time, the research therapist offered the 2 devices to parents free of charge to show our appreciation of their participation in our study.

Data Analysis 

The COPM data were aggregated, as others have done,¹⁹, ²³, ²⁴ into 3 categories: self-care, play, and socialization/quiet recreation. Parametric statistics were used as recommended in the COPM manual,¹¹ and based on examination of the distribution of our results. We used paired t tests to compare mean scores between weeks 3 and 9, and between weeks 9 and 12. We used a type I error rate of α equal to .05 (2-sided) with Bonferroni correction for multiple testing for the performance and satisfaction t tests. With 16 tests, this led to a statistical significance defined as a P value less than .003 for any of the t tests.

We collated the home activity log data from 6 data collection points and then conducted a thematic analysis through an iterative process of sorting the data into common themes. We integrated the interpretation of home activity log and COPM results using the “follow a thread” strategy described by Moran-Ellis et al,²⁵ which involved an iterative examination of common threads across both datasets. This process helped us to explain and further understand the families' experiences with the seating interventions and their COPM ratings.

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Results 

Canadian Occupational Performance Measure Results 

The 30 participating parents (29 mothers, 1 father) each identified 3 to 5 activity performance issues for their children. We then organized the 139 activity performance issues (average of 4.6 activity performance issues a family) into the 3 categories. All 30 parents identified activity performance issues in self-care (58.3% of the activity performance issues), while 27 parents identified that their children had challenges playing (34.5% of the activity performance issues), and only 6 parents identified activity performance issues in socialization and quiet recreation (7.2% of the activity performance issues). Figure 2 provides examples of activity performance issues reported by parents in each category.

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• Figure 2. 

  Categories and examples of activity performance issues identified on COPM.

The aggregate mean scores for each COPM category and the total are shown in table 1. The mean scores shown for weeks 3, 9, and 12 are from the baseline, intervention, and return to baseline (or postintervention) phases (A1, B, A2). The performance scores on the COPM increased by an average of 4.6 (on a 10-point scale) during the intervention phases, while the satisfaction scores on the COPM increased by an average of 4.9. The results of paired t tests, mean differences, and the 95% confidence intervals around the differences (see table 1) confirm that the effect of the seating intervention on parent ratings of the children's activity performance resulted in significant changes in performance and satisfaction scores between the intervention phase and 2 baseline phases overall and within the self-care and play activity performance issues categories. The t test results were not significant for the socialization and quiet recreation performance and satisfaction scores when comparing week 3 to 9 and week 9 to 12. Parents rated their children's performance of most of the activities and their satisfaction with their child's performance as much greater when the children used the study devices than during the baseline and postintervention weeks, when their children did not use the devices.

Table 1. Paired Comparisons of Canadian Occupational Performance Measure Total and Category Scores

Activity Performance	Mean Scores				Mean Change (99% CI) P
Categories	Week 1	Week 3	Week 9	Week 12	Weeks 3–9	Weeks 9–12
Self-care
Performance	2.37	2.13	7.48	2.14	5.38 (3.80 to 6.96) P<0.000⁎	−5.34 (−6.98 to −3.71) P<0.000⁎
Satisfaction	2.67	2.23	8.07	2.21	5.79 (4.08 to 7.51) P<0.000⁎	−5.86 (−7.69 to −4.03) P<0.000⁎
Play/school
Performance	2.35	2.10	6.21	2.50	4.11 (2.21 to 6.00) P<0.000⁎	−3.71 (−5.62 to −1.81) P<0.000⁎
Satisfaction	2.57	2.18	6.57	2.15	4.39 (2.28 to 6.50) P<0.000⁎	−4.17 (−6.39 to −1.97) P<0.000⁎
Social/quiet recreation
Performance	2.00	2.83	6.33	2.83	3.50 (3.23 to 10.23) P=0.076	−3.50 (−9.27 to −2.27) P=0.058
Satisfaction	2.50	3.33	7.17	2.50	3.83 (3.11 to 10.77) P=0.090	−4.67 (−10.80 to −1.46) P=0.028
Overall mean score
Performance	2.31	2.22	6.83	2.33	4.61 (3.14 to 6.09) P<0.000⁎	−4.50 (−6.01 to −2.99) P<0.000⁎
Satisfaction	2.60	2.35	7.27	2.36	4.92 (3.39 to 6.45) P<0.000⁎	−4.92 (−6.66 to −3.18) P<0.000⁎

NOTE. The CIs are around the differences used in the paired t tests.

Abbreviation: CI, confidence interval.

Home Activity Log Results 

Three themes arose from the thematic analysis of sorted data. The findings largely reflect the parents' views about the impact of the study devices, because there were 2 additional questions asked during the intervention phase.

Most parents reported positive benefits from using the adaptive seating devices, including that their child was sitting better, was doing more, was more engaged, and was doing the activities identified on the COPM for longer periods when using the adaptive seats during the intervention phase. Several parents reported that their child's skills improved, while others reported that their children were happier and more eager to sit and do activities and were now able to engage in face-to-face social interactions, resulting in more socialization with members of the family and with friends. After the devices were removed at the end of the intervention phase, several parents reported that their children became more passive, or were less interested and less engaged, while other parents described their child as less social and less interactive.

During the intervention phase, parents found the seating devices convenient and easy to use, and many reported that their child needed less caregiver help. Nearly one quarter of the parents described how their child was able to now join the family for meals, games, and social interactions. The comments made by 1 mother reflected how several parents felt about being able to sit facing their child, when using the study devices, rather than holding their child from behind. She noted that she had more eye contact and more communication when she played with her child. She felt she understood his wants and needs faster because she could see his face.

Parents also commented favorably about the portability of the activity seat, saying they used it on various chairs within their home, such as kitchen or computer chairs; they took the seat with them when visiting family and friends in their homes, and they used it successfully at restaurants. For example, 1 parent noted that they took the activity seat everywhere, including restaurants, and thought it was great. For some of those who used the activity seat for quiet recreation, they described feeling safer leaving their child to watch television or listen to music.

A few families reported little to no change in how their child completed the activities identified on the COPM during the intervention phase. The most common complaints were that the activity seat did not provide enough support or that it lacked the stability their child needed on the floor. These parents reported that they supervised their child more closely when using the activity seat. A few parents said that their child complained about the straps on the activity seat and did not like to be constrained, preferring instead to be mobile.

Descriptive Results 

A descriptive analysis of the parent interviews showed that 26 children used the activity seat and 24 children used the toileting system over the entire intervention period. The toilet seat was used primarily for self-care, including toileting, grooming, and brushing teeth, whereas the activity seat was used for play, mealtime, and social or leisure activities. The activity seat was used on the floor or on a variety of chairs, including kitchen/dining room/office chairs, couches, and restaurant chairs. For families who did not use both study devices, their principal reasons were that 1 or both devices did not provide sufficient postural support for their child and/or the child rejected the device.

When offered the devices at the end of the study, 25 families (83%) kept at least 1 device, while 19 (63%) families kept both devices. Four families (13%) kept the activity seat and returned the toilet seat, while 2 families kept the toilet seat and returned the activity seat. Five families (17%) returned both devices.

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Discussion 

Our COPM results indicate that statistically and clinically significant improvements in activity performance and performance satisfaction were achieved when the children used adaptive seating devices in their homes for specific self-care and play activities. These findings were supported by the views expressed by their parents during the home activity log interviews.

When the study devices were removed from their homes during the postintervention phase, the children's activity performance and parents' satisfaction with their child's performance returned to baseline levels on the COPM, and parents described their children's loss of abilities on the home activity log. The magnitude and precision of the change scores overall, and on the self-care, and playing activities on the COPM suggest that the removal of these devices had a negative effect that was both statistically significant and meaningful to parents.

It is also important to note that the mean performance scores for self-care and play were less than 3 points on the 10-point scale at weeks 3 and 12, which demonstrates that the children were not able to do the activities very well without the seating devices, whereas they were able to do the activities quite well with a self-care mean score of 7.48 and play mean score of 6.21 when they used the seating devices, as measured in week 9. Our study provides preliminary evidence that adaptive seating interventions can be used successfully to help children with GMFCS level III or IV CP attain a supported sitting posture, which enabled them to perform a variety of childhood activities more successfully within their daily life at home.

Although the point estimates of the true difference scores between the intervention and baseline phases for performance and satisfaction were greater than 2 for the category of quiet recreation and socialization, which is considered a clinically significant change,¹¹ our corrected confidence limits were too large to infer a statistical effect. We do not believe that we lost significance by using a parametric versus a nonparametric approach to examine the differences in scores. The loss of precision in this estimate occurred because parents reported only 10 activity performance issues overall. Consequently, we could not conclude that the study devices made a significant difference to COPM performance and satisfaction scores for this category.

The activity performance issues identified by the parents demonstrate that parents focused on very specific functional challenges within the child's daily life, many of which directly involved sitting, and others that were greatly influenced by the child's ability to sit. For example, most of the self-care and play activities involved manual manipulation of materials such as toys and feeding and grooming utensils. The seating interventions appear to have enabled most children to gain a stable, supported sitting posture, from which they could use their hands to engage in various activities.

While we cannot make inferences about the impact of the seating devices on hand function, our findings do support the clinical assumption that achieving a stable seated posture from a seating intervention has an enabling effect on a child's hand function.⁴ Our results build on the findings from studies reviewed by Roxborough² and Stavness,³ which demonstrated how specific seating interventions improve postural control and upper extremity function.

Our results are also consistent with an earlier study, not included in the review by Stavness,³ that examined the clinical assumption that a stable pelvis leads to improved hand function. Reid et al¹⁴ used the COPM to evaluate the impact of a wheelchair-mounted rigid pelvic stabilizer on bimanual task performance for 6 school-age children with CP, using a within-subject A1-B-A2 design over 11 weeks. They found that participants and their parents agreed that the child's bimanual task performance was better when the postural control device was used to stabilize the child's pelvis, compared with a lap belt. Satisfaction ratings were also higher during the intervention phase.

Our home activity log findings provide context and explanation for the COPM outcomes. During the home activity log interviews, parents described the changes in how some activities were performed over the 3 phases of the study. It was evident that for many families, the child was not doing some activities or was doing those activities very differently prior to the introduction of the seating intervention. Then, during the intervention phase, the child became accustomed to being able to do an activity, and both children and their parents wanted to continue that activity after the study device was removed.

For example, many children were using diapers rather than a toilet prior to the introduction of the toileting device. Some families reported that their children were somewhat successful in using the toilet while positioned on the toileting device. During the postintervention phase, some parents expected their children to continue to do that occupation (eg, toileting) using the method adopted during the intervention phase. However, without the study device, parents then had to hold their child instead. The absence of the device made it more difficult to perform this activity because the way in which the child was supported on the toilet was different. This was reflected in the lower performance and satisfaction scores on the COPM at the end of the final phase.

These findings lead to speculation that, given a longer intervention phase, the children could be exposed to and given more opportunity to engage in activities that were previously not accessible to them because of their inability to sit independently. Because the activity seat is multipurpose, portable, and easy to set up and use, several families reported using it in a variety of ways during the intervention phase. For example, some families took the activity seat to restaurants or relatives' homes for meals, while others used it outdoors for play. Future research could be designed to explore the impact of this and other seating devices over longer periods than we used in our study. Lenker and Paquet²⁶ propose that the impact of assistive technology is a predictor of future use of that technology. Based on their arguments, we would expect that the children and families from our study would continue to find the seating devices useful over time, particularly if families find the benefits and the ease of use outweigh any shortcomings in the technology itself.

While our results were largely positive, a few families found that 1 or both seats did not help their child. Although our research therapists evaluated the appropriateness of the devices for the children, the parent or child rejected the devices part way through the intervention phase. Neither level of acuity on the GMFCS nor age was a factor here. Further, some families had limited space available in their home (eg, lived in a small apartment or had a crowded home), and they could not easily store the device when it was not in use by the child.

Study Limitations 

Our study has several limitations. The baseline-intervention-baseline design is more vulnerable to measurement error (bias) than a randomized controlled trial or a crossover design. Bias may have been inadvertently introduced into the parent interviews because the research therapists were aware of the study objectives. Parents were not aware of the study objectives; however, they may have made their own assumptions, which could have influenced them to respond in ways to make it appear that the impact of the devices was greater than it actually was. However, our results are consistent with the findings of our broader study, in which we used the FIATS and the Impact on Family Scale to measure the impact of the study devices on the lives of children and their families.¹⁵

Implications for Clinical Practice and Research 

The findings from our study may not generalize to children with differing physical disabilities or those who live in different geographic regions, because our respondents were parents of children with CP who lived within or close to a large city.

Two important implications for clinical practice and future assistive technology research arise from our study. First, during recruitment for the study, we learned that there were many children who were not using adaptive seating devices in their homes. We suspect that this may be a result of several factors: many therapists in our region provide services primarily to children in schools, and may not be mandated to assess or make recommendations regarding a child's home environment; families may not be aware of the adaptive seating options available to them for their home; alternative ad hoc approaches were being used by families (eg, using an assortment of pillows to provide the child with postural support on the floor); and financial support for special types of assistive technology, such as our study devices, is not available from traditional government sources. This finding also raises questions about how aware therapists are of seating technologies that could be used to support functional outcomes for children in their homes.

Secondly, we found the COPM to be a very useful and responsive outcome measure for detecting families' perceptions of meaningful change in their child's activity performance when examining the impact of adaptive seating interventions. These clinically meaningful results are consistent with the findings of our study using the FIATS as a primary outcome measure of the impact of the devices on child and family life¹⁵ and with previous studies in which the COPM was used to demonstrate the effectiveness of assistive technology devices on children's activity performance and on their parents' level of satisfaction with this performance.¹⁴, ²¹ The COPM also enables the clinician prescribing adaptive seating interventions to use a family-centered perspective⁹ because parents and/or children evaluate self-identified occupational or activity performance issues that matter to them. Our experiences with the COPM add to the growing interest in the benefits of using individualized outcome measures, such as the COPM, in assistive technology research.²⁷, ²⁸

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Conclusions 

Parents reported that their young children with CP were more able to engage in self-care and play activities when they used the study seating devices in their homes during the intervention phase. Parents were also more satisfied with their child's activity performance when the study devices were used, and described the enabling influence provided by the study devices, and how the devices helped in their interactions with and care of their child. A few parents, however, felt the study devices were not well suited to their child's needs. Our study findings reinforce the need to remind rehabilitation technology practitioners to be mindful of the match between the goals and circumstances of individual children with CP and their families, and the opportunities for functional gains afforded by adaptive seating devices.

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Acknowledgments 

We thank the participating families for their time and commitment to the research for this project. We also thank Darlene Hubley, BSc, OTReg(ON), Betty Chan, MSc, OTReg(ON), Barbara Fishbein-Germon, MSW, RSW, and Joan Walker, who provided research support and advice during the development and execution of our study, and our colleagues at Bloorview Kids Rehab, Toronto, Erinoak Kids Centre for Treatment and Development, Mississauga, and Grandview Children's Centre, Oshawa, ON, Canada, who helped recruit families.

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Appendix 1. Home Activity Log Interview 

Activity Performance Areas	Activity: In the past week, please tell me how…
Play	…your child played while seated at home. For example, did s/he actively play more or less with friends/family members, change how s/he did tabletop or floor level activities such as coloring, or change how s/he played with objects such as toys or games?
Self-care	…your child participated in self-care while seated at home. For example, did s/he actively participate more or less during activities such as getting dressed, brushing teeth, or using the toilet?
Leisure	…your child participated in leisure while seated at home. For example, did s/he actively participate more or less in recreational activities such as singing, listening to music or watching television?
Were there any changes in your family routines or caregiver routines that changed your child's activities at home over the past 2 weeks? (eg, holidays, visitors, special events, illness…)
Intervention Phase Only
Please tell me how using Aquanaut influenced how you, your child, and other family members did activities in the bathroom over the past 2 weeks.
Please tell me how using Flip2Sit influenced how you, your child and other family members did activities over the past 2 weeks.

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• a Otto Bock HealthCare Canada Limited, 5045 South Service Rd, Suite #201, Burlington, ON, Canada, L7L 5Y7.
• b Inter IKEA Systems B.V., Olof Palmestraat 1, NL-2616 LN Delft, The Netherlands.