To perform external rotation of the legs is a challenging movement for children with cerebral palsy. During the 1990s, a research study was conducted where electromyography measurements were performed on a girl with cerebral palsy spastic diplegia. The study investigated her gait pattern both with and without the use of a derotational orthosis, an orthosis that positions the foot in external rotation while allowing free movement. Ingrid Odeén and Karin Harms Ringdahl, prominent figures in Swedish physiotherapy, supervised this work and encouraged publication, although for various reasons, it did not materialize.
The study, now available for reading, has been revised from typed text and includes copies of electromyography curves. Despite many changes since then, it is significant to note that external rotation had an overall impact on the movement pattern. After using the orthosis for 30 minutes, the child regained normal activity in the calf muscle (gastrocnemius) as well as in the hip abductors. It’s clear that further research and, above all, efforts are needed to teach children with cerebral palsy how to perform external rotation. By transitioning from walking on tiptoe and crossing legs, children are given the opportunity to walk with their entire foot and activate the correct muscle groups. A deeper understanding of how external rotation affects spastic gait is necessary for future interventions.
The Sitting shell provides the conditions for learning head control and sitting balance. Many children have learned to sit through the use of the sitting shell. Children who previously sat leaning forward with their hands propped on the floor could suddenly lift their hands off the ground without falling. Other children who had sat leaning backward in spastic movement patterns found calmness and control in the sitting shell. The child gained an understanding of the goal of balance – to sit upright. To learn balance while sitting, the child needs to release hand support and adopt a stable ‘pillar,’ which the sitting aid helps the child with. If the child is leaning backward, it’s not possible to teach balance. Therefore, it’s important to have expectations and create opportunities for the child to practice sitting balance in an upright position where the center of gravity falls perfectly along the vertical axis. When the child receives assistance with the stable aspect of sitting and simultaneously moves their arms and head, balance is trained and strengthened. For those who initially have neck and/or chin support, gradually easing off the supports allowed the child to eventually learn to sit independently. In a link below, you will find background, purpose, information about research, and also manufacturing instructions.
Conceptual Confusion
When the sitting shell was first created, there were no other products with the same name. Today, products that are reclined and passive, referred to as seating aids, are manufactured. This emphasizes the importance of precision when specifying the product to be produced at an orthopedic workshop.
Practical
The seating aid is functional – the child can sit on the floor, in the bathtub, on the grass, or in a sled. If you remove the rear support, the child can sit on a chair (with the assurance that someone is sitting beside, of course). The child sits on their own bottom, and the seating aid is easy to carry along. The picture below shows one of the first seating aids, further down you can see a relatively newly made seating aid with a distinct built-in arch in the lower back, providing a clear improvement in posture.
Principles of the sitting shell.
“Sitting shell with lumbar support – excellent!”
The groin straps attach to the sides of the seating aid, preventing the child from sliding forward.
If you are interested in seating aids, you can contact your nearest orthopedic workshop. If you, as an orthopedic engineer, caregiver, or parent, want more information about seating aids, the purpose of seating aids, and also instructions on how they are made, you can click here to access manufacturiing instructions. If you want to read a study on children’s balance with and without seating aids, you canfind it here.
Below is a picture of what is sometimes confused with the sitting shell. “There is a BIG difference between a Sitting shell and the image below.” In the picture below, the child’s center of gravity is behind the hip joints, and the child sits reclined and PASSIVE in a resting position. The child is not sitting on their own bottom, and the seat is heavy and difficult to use in various ways. “When you and I sit upright, we engage the postural muscles in the back and neck They don’t tire out, allowing us to sit for extended periods. The child is not allowed to do this in this type of seat. Here, the child needs to perform a ‘sit-up’ if they want to achieve an upright position. It is important to believe in the child and provide the opportunity for the child to learn to sit with the center of gravity in a perfect position – not too far back.
Here, the center of gravity shifts too far back, resulting in passive sitting without active learning.
Now available! Web-based training on Children’s Sitting Development – from passive to active sitting is completed and serves as a “golden standard” for the upcoming course on how children with neurological injuries learn to sit. You can find the link to the course here.
The web course on normal sitting development serves as the basis for the next training on how to teach children with disabilities to sit. Learn to Move aims to convey expectations of development opportunities based on knowledge derived from research and experience. Web course two on sitting with disabilities is expected to be completed in the fall of 2024 and will focus on learning to sit with both low and high muscle tone.
Children with neurological challenges can learn to solve tasks such as balance and motor skills in the same way as typically developing children. The motor development is the “answer key,” but there are many ways to get there, and the child needs support to pay attention to their body and understand the goal of training and learning. It is exciting and interesting to break down motor skills into small details to find the right task to start with.
The research that Learn to Move has been involved in primarily focuses on sitting in children with cerebral palsy and also around the orthopedic aid “sitting shell.”
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Children and adolescents with cerebral palsy have good opportunities to learn body control while sitting. If they are given the opportunity to sit just like us, with good pelvic position, straight back, straight neck, eyes in horizontal position, and with the center of gravity of the upper body in front of the hips, then children over time can learn good postural control and hand use. .Children may need good hip belts, dynamic leg separators, and a seat that provides conditions for a good pelvic position, i.e., a neutral or slightly forward-tipped pelvis, but not a backward-tipped pelvis. The seat should be flat or forward-tilted, not backward-tilted. How children with cerebral palsy learn to sit in a functional sitting position is described in the thesis “On factors of importance for sitting in children with cerebral palsy” by Ulla Myhr, presented in Gothenburg in 1994. The research followed a total of 80 children in Norrbotten and Uppsala, who were filmed and followed for five years. The five-year follow-up was presented at the World Congress of Physiotherapy in Washington DC in 1995 and showed that children who were given a good sitting position developed positively and improved, while those who continued to sit in positions that contributed to increased spasticity experienced increased problems such as hip dislocation and scoliosis.
Here’s the dramatic change in control one minute into the video – when the child is provided with conditions to sit upright by having the upper body above the support surface, instead of behind the hips. You can watch the video a bit further down on the page.
For those interested in learning more about functional sitting, here are two articles to download.
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