EFFECT OF FORWARD TILT SEATING ON ARM-HAND MOBILITY IN BILATERAL SPASTIC CEREBRAL PALSY IN THAILAND

Mattana Angsupisal ¹, Jintana Paliwanich2, Wachirapon Pupanya ¹, Salakjit Pandee ¹, Wanida Sikawee ¹, Mijna Hadders-Algra3*

¹ Department of Physical Therapy, Faculty of Allied Health Sciences, Naresuan University, Pitsanuloke, Thailand 65000 2 Occupational Therapy, Physical Medicine and Rehabilitation Division, Bhudhachinaraj Hospital, Pitsanuloke, Thailand 65000 3 The institute of Developmental Neurology, Department of Pediatrics, University Medical Centre Groningen, Groningen, The

Netherlands *Corresponding author: Mijna Hadders-Algra, M.D., PhD., E-mail: m.hadders-algra@umcg.nl[Recently, article is in the procedures of corresponding author’s review and submission; (21st October 2011)] [Petty Patent Number: 6244, Issue on 26 May 2011 Product name: เกาอี้นั่งปรับองศาสะโพกแบบไมสําหรับเพิ่มการทรงตัวในทานั่งกึ่งยืนและเพิ่มการทํางานของรยางคแขนในเด็กสมองพิการ] [ผลงานตอยอด, Product name: เกาอี้นั่งปรับองศาสะโพกแบบเหล็กสําหรับเพิ่มการทรงตัวในทานั่งกึ่งยืนและเพิ่มการทํางานของรยางคแขนในเด็กสมองพิการ, เลขที่คําขอยื่นจดอนุสิทธิบัตร 1103000361 ลงวันที่ 28 มค. 54] Abstract This explorative pilot study aimed to investigate effects of forward tilt seat on arm-hand function. The adaptive seating with three wedge-inserts; 10, 20 and 30 degrees from horizontal line were invented. Five pre-school children with bilateral spastic cerebral palsy (GMFCS level varied from II to IV) participated. The child’s best degree of forward tilting out of three options was determined based on the relatively stable upright sitting and the combined center of mass anterior to the line through the ischial tuberosities contributing in weight bearing on pelvis and feet. This resulted in the application of wedge inserts of 10 degrees in two children and of 20 degrees in three children. Arm mobility was assessed three times in three weeks. Each assessment was tested in two seating conditions, 10 minutes per condition; horizontal condition (H), and forward tilt condition (FW). Conditions H and FW were applied in random order with 20-minute interval. Additional supports included a lower backrest, a pelvis strap, an abductor pad, knee locks, and a footrest. During sitting children played at arm-length reaching and were videotaped. The upper limb physicians rating scale (ULPRS) was used to explore arm-hand mobility. The repeated measure ANOVA (position x times) was used at p-value 0.05. Results showed that the average ULPRS scores were higher in condition FW (19.73±1.94 in the dominant arm and 16.53±2.21 in the non-dominant arm) compared to those in condition H (17.93±1.92 in the dominant arm and 13.8±2.52 in the non-dominant arm). The ANOVA indicated a statistically significant effect of position (p<0.05) and not of time (p > 0.05). In conclusion, forward tilting seat at 10 and 20 degrees from horizontal line increased ULPRS scores of arm-hand mobility in children with bilateral spastic CP with trunkal hypotonia. Further investigation focusing on effects of inclined seating condition with additional supports in various types of CP is needed. Key word: Spastic bilateral, Cerebral palsy, Adaptive seating, Forward tilt seat, Arm-hand mobility

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Introduction: Since early 1980s literatures have demonstrated that a promising sitting position in children with cerebral palsy (CP) provides postural alignment and stability thus resulting in better upper limb performance. There have been controversial studies related to effective seating for children with CP on their postural control and the arm-hand performance (Hadders-Algra et al, 2007; Stavness, 2006; McNamara and Casey, 2007; Chung, 2008; Reid et al, 1991; Reid, 1996; Sochaniwskyj et al, 1991; Myhr & Wendt, 1991; Myhr & Wendt, 1993; McClenaghan et al, 1992; McPherson et al, 1991). For example, Myhr and von Wendt (1991; 1993) reported the improvement of upright posture and a reduction in pathological movements which resulted in increasing arm-hand ability when children with CP were seated on a 15-degree forward tipped seat in what they termed as a Functional sitting position (FSP) whereas others claimed that seat angle did not affect upper limb motor performance (McClenaghan et al, 1992; McPherson et al, 1991; Reid, 1996).

Cerebral palsy is characterized by the impairment in the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances occurred in the developing fetal or infant brain (Bax, et al., 2005; Rosenbaum, et al., 2007). Dysfunctional postural control with poor control of trunk muscles is a primary impairment in CP (Davis et al., 2007; Rosenbaum, et al., 2007). Children with CP usually have the basic level of postural control, so called "direction specificity" or the ability to regain balance from external perturbation during sitting or standing. However, they have difficulties in the adaptation of the basic control patterns to the specifics of the situation, such as, in reaching while sitting. Especially in the group of pre-school and school-age children with spastic bilateral CP (Bi-CP), they lack this capacity entirely (Van der Heide et al. 2004). In Thailand, from clinical perspective the development of adaptive seating for CP is currently under-resourced and requiring high cost, although this is needed more evidences of research and development. We are interested in the study of children with spastic bilateral CP in preschool age as we clinically observe that these children with Bi-CP often have difficulties in control of trunk postural muscles which in turn to some extent disturbing their activity daily life such as playing while sitting. As referred to a functional sitting position (FSP) as defined by Myhr and von Wendt (1990; 1991), it is a dynamic situation and not a sitting position for rest. We hypothesize that this position, with a size's adjustment to the individual with Bi-CP who has poor control of the trunk, would challenge an adaptation of an upright trunk by naturally aligning erect lumbar spines which in turn may resulting in better upper limb performance. Thus, we developed the adaptive chair with adjustable seat angle by using a simple wedge-insert for forwardly tipping seat at 3-level angles; plus 10, 20 and 30 degrees from horizontal surface, 90 cm. in height. A special design of seat-base to lock the wedge-insert was created (Fig. 1). The purpose of this explorative pilot study was to evaluate whether clinically applied adaptive seating promotes the upper limb performance in pre-school children with bilateral spastic CP. The following question was addressed: does the forward tilt seat (FW) affect the upper limb physician rating scale (ULPRS) scores which reflects the arms, elbows and hands functional movements in pre-school children with Bi-CP, compared to their ULRRS scores in the horizontal seat position (H)?

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Methods Participants

Five children with CP aged 1 to 3.5 years (median 2.7 years) were recruited from Division of Physical Medicine and Rehabilitation at Bhudhachinaraj Hospital, Pitsanuloke, Thailand. All children had bilateral spastic CP with trunkal hypotonia and required the use of adaptive equipments in supported high sitting and standing. The Gross Motor Function Classification System (GMFCS; Palisano et al. 1997) level of five children varied from II to IV. Clinical characteristics of the children are presented in table 1. Children with severe visual impairment and difficulty in reaching and communication, and those who had GMFCS level V were excluded. Procedure

This explorative pilot study with a repeated-measures design (position x times) has been approved by the Naresuan University Research Ethics Committee. The parents signed informed consent. Each child was tested three times with a week interval and served as his/her own control.

First we determined the child’s best degree of forward tilting out of three options. The options consisted of wedges which differed in the degree of tilt of the seat surface, i.e. resulting in a forward tilt of 10, 20 or 30 degrees. Selection of the best wedge was based on the following criteria. The presence of the wedge should result in (1) stable sitting with head and trunk as upright as possible; (2) a projection of the center of mass in front of the line through the ischial tuberosities; (3) weight bearing on pelvis and feet as a result of the effect of a forward sloping seat, and of (2) (Fig. 2b). This resulted in the application of wedge inserts on the horizontal seat surface of 10 degrees in two children and of 20 degrees in three children (Table 1). The 30-degree wedge insert was not applied as its forward tipping angle made all participants unstable and slipping to the front.

Arm mobility was assessed three times with an interval of a week. During each assessment upper limb performance was tested in two seating conditions, 10 minutes per condition: (1) condition H, i.e., the condition in which the seat surface of the adaptive chair was oriented horizontally (Fig. 2a) and (2) condition FW, in which the child’s specific wedged platform was inserted in the seat-surface leading to the seat sloping of either 10 or 20 degrees forward (Fig. 2b). Conditions H and FW were applied in random order and with an interval of about 20 minutes. Both seating conditions of the children also included (1) a backrest at the lower back, (2) a pelvis strap to avoid sliding, (3) an abductor pad attached to the seat, (4) knee locks attached to the front of the seat base, and (5) a level plate of footrest without foot support/orthosis. Subject S3 was tested without pelvis-strap as he enjoyed this ‘free’ situation. The sessions were recorded on video.

In each condition the child was offered a standardized set of tasks on the basis of which the ULPRS items were evaluated (Appendix; Graham et al. 2000). The ULPRS is a semi-quantitative clinical assessment scale developed for the evaluation of change in upper extremity movement patterns in children with CP. Specific activities of the ULPRS are designed to elicit specific motor behavior. For instance, the task of opening the book refers to “active supination with elbow flexion”, and putting a cube in a cup refers to “active wrist dorsiflexion”. The examiner (PS) presented one of four attractive toys (a small cube, a story book, a cup and a small ball) at arm’s length distance of the child. The activities “open a book”, “put cubes in a cup”, “throw a ball in the midline on the table”, and “reach

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for/grasp a cube or a ball” were performed three times. In the latter reaching task the object was placed in three directions, i.e., in the midline and on the right and left side. Outcome measures:

At the end of the three week period the videos were used to assess behavior of each arm, i.e., resulting in an ULPRS score of maximally 47 points per arm per condition (Appendix). The video assessment was run in randomize order and sent to the trained selected investigator (PS). For this matter, we pooled all video recordings matched with a subject identification code (S1-S5); a seating condition code (H and FW); and time series (Wk1, Wk2, and Wk3). The display screen of the video was covered by taping one-third from the bottom to blind the video-assessor from the testing condition. Prior to the study the reliability of scoring of three raters was determined with video recordings of reaching movements of two children with CP not included in the present study. All except one rater showed good intrarater reliability (ICC = 0.88). One out of the two raters was randomly selected to carry out assessments. Data analysis

The ULPRS scores of both arms in two conditions during three testing occasions were pooled. The Mauchly’s test of normality indicated that parametric tests could be used for data analysis (p value > 0.05) (table 4a, b). To evaluate the effect of position on ULPRS scores of each arm, a two-way repeated measures ANOVA was applied using position (condition H, condition FW) x times (1st, 2nd, 3rd week). Differences which reached p<0.05, two-tailed testing were considered statistically significant.

Results The effects of both seating conditions (H and FW) on the dominant and non-dominant arm performance of the group average ULPRS scores (mean+ SD) are presented in Figure 3. The average ULPRS scores of the dominant and the non-dominant arm were both higher in condition FW than in condition H. The ANOVA indicated a statistically significant effect of position (p<0.05) and not of time (p > 0.05) (Table 2a & b). Discussion This explorative pilot study reported that the ULPRS scores in the FW condition were significantly higher in both arms compared to the H condition. With respect to the first trial on this novel adaptive seating, we have points to keep in mind that: (1) we opted to eliminate a continual process of time use on adaptive seat, i.e. we used 10-minute short time on each seating condition. This indicates the short effects of seating condition on the upper limb performance. (2) We used degrees of anterior tilting of the seat at 10 and 20 degrees. These degrees were selected from each child’s best positioning on FW condition with his/her body alignment, head and trunk stability, weight bearing on barefoot. These seat angle’s degrees are in accordance with seating literatures (Hadders-Algra et al, 2007; Myhr & Wendt, 1991; Myhr & Wendt, 1993; Sochaniwskyj et al, 1991; Nwaobi et al. 1983; Nwaobi, 1987). (3) We designed an abduction bar and a plate of footrest thus during sitting all participants took weight through barefoot with PT re-correcting foot alignment prior to the trials. This idea is in agreement with those of Myhr and colleagues (Myhr

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& Wendt, 1991; Myhr & Wendt, 1993). They called the forward tilt sitting position with necessary adjuncts for CP as “the functional sitting position, FSP”. Their findings suggested a neutral to slight inclined forward position combined with the foot plate and abduction orthosis (AO) in significantly decreasing EMG activity of leg muscles during reaching and grasping activities of children with CP. Authors explained that the effect of slightly inclined forward condition contributed to a lower demanding energy for lower-extremity function in children with CP, and possibly increased their upper limb performance. Another study opposed the benefits of additional AO to the FSP as they found no significant difference in the leg EMG activity or UE function between sitting in FSP with and without AO, however, limited numbers of subject in study (n=4) (Ekblom & Myhr 2002). One of many factors which cause the controversy of seat angle studies is the large heterogeneity in the groups studied. Hadders-Algra and colleagues found that in children with unilateral spastic CP, 15-degree anterior-tilting of the seat improved efficiency of postural sitting and quality of reaching, whereas the horizontal seat surface may well be the optimal sitting condition in children with Bi-CP (Hadders-Algra, et al., 2007; Van Der Heide, et al., 2004). The results of the current study regarding the Bi-CP group differ from those studies. We hypothesize that the difference is brought about by the present of additional foot support adjusted with individual’s leg height provided in the current study. This is in line with the suggestions of the Van der Heide et al. (2004) study. Van der Heide et al. (2004) studied the ability of children with CP to modulate postural activity during reaching movements. Interestingly, they found that only one of the four participants with severe CP who did not receive additional back or foot support could not modulate EMG amplitude whereas three out of five children who received extra support of the trunk and feet could modulate EMG activity (Van Der Heide, et al., 2004). Additionally, two of the four children who had only feet support adapted the EMG amplitude of the neck extensor muscles. These are interesting observations, which demand further exploration and systematic evaluation. CP children participated in this study We selected GMFCS Level II to IV to be inclusion criteria because in our clinic children at preschool age in these levels have some extent of difficulty in sitting balance which affect their daily activities. Van der Heide et al (2004) and Hadders-Algra et al (2007) indicated that regarding the degree of severity, the GMFCS levels play a role in functioning. Nevertheless in children with unilateral spastic CP, GMFCS levels do not reflect the severity of the condition (van der Heide et al, 2004; Hadders-Algra et al, 2007). To limit variability of ranges of types and severity in our first explorative study, we selected all children with bilateral CP and had confirmed GMFCS classification with neurological examination. Outcome measurement on upper extremity Findings support the use of the ULPRS by clinicians and researchers. In addition, analysis via video recordings in both front and side views can make a promising protocol to reveal precise changes in all movements of upper limbs (Graham HK et al, 2000; I Autti-Ramo et al, 2001). The findings of timing parameter (weeks) suggested that 3-repeated measures in this study are consistent, thus timing factor did not influence the short effect of two

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seating conditions on the characteristics of upper limb performance. We also performed repeated experiment on the second and third week with a randomized order in each participant. The strength of this study also included the video assessment with video-assessor masked to the testing condition (H and FW) and to the time series during three weeks.

Factor supporting a higher ULPRS score on forward-tip seat condition in this study possibly was associated with the more upright posture in forward inclined condition. From video observation, all children performed a higher reaching movement in the FW condition. This study lacks of evidences to confirm the adaptation of postural adjustment during sitting. A further study with sophisticated measurement, e.g. surface eletromyographic and kinematics investigation, is needed.

Limitations and future research directions There are several limitations of this pilot study that needs to be considered: (1) a small sample size, limited types of CP and their age range restrict the generalized findings, (2) a more sophisticated data measurements, such as, surface EMG activity and kinematics on involved muscles both in postural control and upper-limb motor performance should be explored in the future, (3) short-term effect in our findings could not state a completed conclusion about benefits of the forward tip seat on UE function in the Bi-CP, (4) a lack of control group of healthy children might lead to some bias of the use of this adaptive seating. A clinical implication might be that the anterior tilting seat at 10 and 20 degrees from horizontal line was satisfactory by means of the better performance of upper limb manual work in children with Bi-CP mixing with weakness of the trunk. This adaptive seating with a simple wedge inserts is easy to make, simply used for the children with CP in Thailand. Acknowledgements The study was supported by The Thailand Research Fund 2009 (IRPUS grant: I352C0101). The authors wish to thank all children with cerebral palsy and their families, Bhudhachinaraj hospital, senior OT and PT students who participated and assisted in data collection. Special thanks to Professor Dr M. Hadders-Algra, The institute of Developmental Neurology, UMCG, Netherlands for recommendation and further collaborative studies.

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References: Autti-Ramo, I.,Larsen, A.,Taimo, A. & Von Wendt, L.(2001). Management of the upper limb with botulinum type A in children with spastic type cerebral palsy and acquired brain injury: clinical implications. European Journal of Neurology, 8 (Suppl. 5), 136-144. Chung J, Evan J, Lee C, et al (2008). Effectiveness of Adaptive seating on Sitting Posture and Postural Control in Children with Cerebral Palsy. Pediatric Physical Therapy, 20, 303-317. Davis MF, Worden K, Clawson D, Meaney J, Duncan B. (2007). Confirmatory factor analysis in osteopathic medicine: fascial and spinal motion restrictions as correlates of muscle spasticity in children with cerebral palsy. Journal of American Osteopathy Association, 107226–32. Ekblom, B., & Myhr, U. (2002). Effects of hip abduction orthosis on muscle activity in children with cerebral palsy. Physiotherapy theory and practice, 18, 55-63. Graham HK, Aoki KR, Autti-Ramo I et al. (2000). Recommendations for the use of botulinum toxin type A in the management of cerebral palsy. Gait Posture, 11, 67-79. Hadders-Algra M, van der Fits IBM, Stremmelaar EF, Touwen BCL (1999). Development of postural adjustments during reaching in infants with cerebral palsy. Developmental Medicine and Child Neurology, 41, 766 – 776. Hadder-Algra M, van der Heide JC, Fock JM, et al (2007). Effect of seat surface inclination on postural control during reaching in preterm children with cerebral palsy. Physical Therapy, 87, 861-871. Mcnamara L and Casey J (2007). Seat inclinations affect the function of children with cerebral palsy: A review of the effect of different seat inclines. Disability and Rehabilitation: Assistive Technology, November; 2(6), 309 – 318. McClenaghan BA, Thombs L, Milner M. (1992). Effect of seat-surface inclination on postural stability and function of the upper extremities of children with cerebral palsy. Developmental Medicine and Child Neurology, 34, 40– 48. McPherson, J., Schild, R., Spaulding, S., Barsamian, P., Transon, C., & White, S. (1991). Analysis of upper extremity movement in four sitting positions: A comparison of persons with and without cerebral palsy. The American Journal of Occupational Therapy, 45, 124-129. Myhr, U.,&Wendt, L. von (1990). Reducing spasticity and enhancing postural control for the creation of a functional sitting position in children with cerebral palsy: A pilot study. Physiotherapy Theory and Practice, 63, 65-76. Myhr, U. & Von Wendt, L. (1991). Improvement of functional sitting positions for children with cerebral palsy. Developmental Medicine and Child Neurology, 33, 246-56. Myhr U, von Wendt L. (1993). Influence of different sitting positions and abduction orthosis on leg muscle activity in children with cerebral palsy. Developmental Medicine and Child Neurology, 3, 870- 880. Myhr, U., Wendt, L. von, Norrlin, S., & Radell, U. (1995). Five-year follow-up of functional position in children with cerebral palsy. Developmental Medicine and Child Neurology, 37, 587-596.

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Nwaobi OM, Brubaker CE, Cusick B, et al. (1983). Electromyographic investigation of extensor activity in cerebral- palsied children in different seating positions. Developmental Medicine and Child Neurology, 25, 175–183. Nwaobi OM (1987). Seating orientations and upper extremity function in children with cerebral palsy. Physical Therapy, 67, 1209–1212. Palisano, R., Rosenbaum, P., Walter, S., Russel, D., Wood, E. & Galuppi, B. (1997). Development and reliability of a system to classify gross motor function in children with cerebral palsy. Developmental Medicine and Child Neurology, 39,214-23 Reid DT, Sochaniwskyj A, Milner M. (1991).An investigation of postural sway in sitting of normal children and children with neurological disorders. Physical & Occupational Therapy in Pediatrics, 11(1), 19 – 35. Reid RT. (1996). The effects of the saddle seat on seated postural control and upper-extremity movement in children with cerebral palsy. Developmental Medicine and Child Neurology, 38, 805-815. Rosenbaum P, Paneth N, Leviton A, et al. (2007). A report: the definition and classification of cerebral palsy April 2006. Developmental Medicine and Child Neurology, Suppl. 2007, 109, 8-14. Sochaniwskyj A, Koheil R, Bablich K, Milner M, Lotto W. (1991). Dynamic monitoring of sitting posture for children with spastic cerebral palsy. Clinical Biomechanics, 6, 161 – 167. Stavness C. (2006). The Effect of Positioning for Children with Cerebral Palsy on Upper-Extremity Function: A Review of the Evidence. Physical & Occupational Therapy in Pediatrics, 26, 39-48. van der Heide JC, Begeer C, Fock JM, et al. (2004). Postural control during reaching in preterm children with cerebral palsy. Developmental Medicine and Child Neurology, 46, 253–266.

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Table 1 Clinical characteristics of participants

Variables S1 S2 S3 S4 S5 GMFCS 2 3 3 4 4 Age (yr) 1.1 1.9 2.7 3.5 4 GA (wk) 28 28 40 28 40

Wedge insert (degrees) +20 +10 +20 +20 +10

Severity of UE spasticity R>L L>R R>L L>R R>L Handedness L R L R L Weight (Kg) 15 11 15 11 14

Height (cm) 84 83 87 85 103

S= Subjects, all had bilateral spastic CP with signs of truncal hypotonia, Functional skill: S2-S5 can do floor sit independently, S1does floor sit with support of hips, GMFCS= Gross motor function classification system, UE= upper extremity, R= The Right handedness, L= The Left handedness, GA= gestational age at birth (median = 28 wk GA), median weight = 14 kg, median height = 85 cm. The dominant hand was defined as the hand with which the child preferred to use, draw or manipulate object. Table 2a: The effect of two seating condition (Horizontal vs Forward) on the dominant arm

Position (condition) Mean ULPRS scores

Mauchly’s test of sphericity

(position x times)

p-value (Position)

p-value (Times)

H condition 17.93±1.92 0.202 - - FW condition 19.73±1.94 F (1, 4) = 63.39,

p = 0.001* F (1.21, 4.83) = 0.03,

p = 0.970 Table 2b: The effect of two seating condition (Horizontal vs Forward) on the non-dominant arm

Position (condition) Mean ULPRS scores

Mauchly’s test of sphericity

(position x times)

p-value (Position)

p-value (Times)

H condition 13.80±2.52 0.934 - - FW condition 16.53±2.21 F (1, 4) = 23.06,

p = 0.009* F (1.91, 7.66) = 0.37,

p = 0.724 Table 2a & 2b: The effect of two seating condition (H = Horizontal condition vs FW = Forward tilt condition) on the dominant and non-dominant arm respectively, [p-value at 0.05, Repeated two way ANOVA (position x times). Timing parameter shows no significant difference at p >0.05.]

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Fig 1. Adaptive seating with wedgeaccessories are adductor pad at the mwith an adjustable table placed at fron Fig. 2 (a) Fig. 2 (a) show one participant seateLine of gravity (black line) is slightlyupright, weight bearing through feet w

Fig 3: The group average Upper Limbcomparison between seated on horizoMeasures ANOVA)

inserts at plus 10, 20 and 30 degree from horizontal surface to forwardly incline a seat. Other iddle of a seat, pelvis lock combined with pelvis-strap, knee blocks. This adaptive seat is applied t.

d on the horizontal seat surface and anterior to the ischial tuberosities inith more external rotation of shoulde

Physician Rating Scale (ULPRS) scntal and forward tilt seat condition (*

Fig. 2 (b)

(b) on the forward-tip surface at plus 20 degrees horizontally. both positions. Fig. 2 (b) shows better straight neck and back in rs, reaching out of arm and grasping with thumb opposition.

ores of the dominant* and non-dominant** arm of five subjects p-value = 0.001 and **p-value = 0.009, Two-way Repeated

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Appendix: Upper Limb Physicians Rating Scale (Graham et al. 2000) (in bracket: designed activity according to ULPRS parameters)

ADL = Activity daily living

Parameter (with designed activities) Definition (scores) 1. Active elbow extension (normal 180°) (reach out in midline) Score 0 = >10° reduction, 1= 0–10° reduction,

2 = No reduction 2. Active supination in extension (elbow extended, forearm supinates) *Mid-position is palm 90° to horizontal (reach out to the side ) 3. Active supination in flexion (elbow flexed 90°, forearm supinates) (open a book) 4. Active wrist dorsiflexion (forearm supported, active dorsiflexion of wrist) *Mid-position is palm level with forearm (grasp & release a cube/a ball/ put a cube in a cup)

Score 0 = None, 1= Under mid-position, 2 = To mid-position, 3 = Past mid-position

5. Wrist dorsiflexion (angle of movement) (throw a ball) Score 0 = With ulnar deviation or radial deviation , 1= Neutral 6. Finger opening (grasp & release a cube/a ball) Score 0 = Only with wrist flexion, 1= With wrist in neutral position,

2= With wrist in dorsiflexion 7. Thumb in function (grasp & release a cube/a ball) Score 0 = Within palm, 1= Pressed laterally against index finger, 2=

Partly assists in grasp, 3= Thumb-finger grasp possible, 4= Active abduction

8. Associated increase in muscle tone (clinical impression during tasks) Score 0 = In all manipulative function , 1= Only with fine motor manipulation, 2= Only with walking or running, 3= None

9. Two-handed function (transfer a cube/a ball/ put a cube in a cup/drink from cup/ throw a ball or during all tasks)

Score 0 = None, 1= Poor, no use or hidden functions, 2= Use of all functions but limited in ADL, 3= Use of all functions, not limited in ADL

Total score = 47

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