The Effect of Dynamic Elastomeric Fabric Orthoses on Upper Extremity Function of Children with Cerebral Palsy: Systematic Review of the Literature

Shana Garland, DPT.


Introduction and Purpose

The movement patterns of children with cerebral palsy are different from those of children with typical development. Cerebral palsy is defined as a group of permanent disorders of movement and posture development that causes activity limitation.1 Movement patterns can vary depending on the type (athetoid, ataxia or spastic) and severity, influencing activity limitation. Children with athetoid type of cerebral palsy exhibit poor control, lack of fixation, and tend to use extreme ranges of movement. Children with spastic type of cerebral palsy may have or develop limited joint range of motion. This lack of motion is demonstrated in a common posture of flexion at the elbow, wrist, and fingers together with internal rotation at the shoulder and pronation of the forearm resulting in impaired functional performance of the hand and arm.2 The third type of cerebral palsy is ataxic and can cause instability and rapid fluctuation in muscle tone from low to normal.3 It is important to recognize that impairments can interfere with every day activities and therapeutic intervention should focus on the child's movement goals.2

Rosenbaum and Stewart note the influence of the International Classification of Functioning, Disability and Health (ICF) upon cerebral palsy assessment and treatment.4 The ICF has helped to expand thinking beyond fixing impairments to promoting functional activity and full participation of children in life activities. Reaching and grasping are essential parts of many daily functional tasks; a motor skill that is acquired by the age of two. However, reaching and grasping are difficult for children with athetosis and ataxia, who present with decreased proximal stability at the trunk and distal stability at the wrist and hand. Reaching and grasping are difficult for children that have spastic type of cerebral palsy, because of the decreased range of joint movements that are limited by spasticity.3 The ICF defines the central aim, of all upper limb motor based interventions in children with cerebral palsy as, increasing activity "execution of a task or action by an individual" and participation "involvement in a life situation."5

Dynamic elastomeric fabric orthoses (DEFOs) are worn on the trunk or body surface as well as those worn only on the upper and lower limb. The DEFOs are made of different material ranging from lycra to deltaflex. DEFOs have been reported to enhance sensory and proprioceptive awareness, leading to enhance function; and improve grasping and feeding ability.6 This enhanced function may be a result of direct deep pressure from contact on the skin with the deep pressure receptors giving more useful information to the proprioceptive feedback system. Thus, positional limb and body awareness is improved and can give way to direct movement and specific muscle activation more precisely.7

Better proximal stability appears to be another main function of dynamic elastomeric fabric orthoses fitted to the trunk.8 The increased proximal stability is especially evident in children with athetosis, ataxia, and hypotonia. DEFOs reduce involuntary movements and improve posture for sitting, thereby increasing a child's feeding ability. A stable trunk is essential for controlled movements of the upper limb. Increased stability assisted by increased internal pressure on soft tissue structures may play a role in increased loading of joints where increased intra abdominal pressure provides improved anterior spinal stabilization.7

Unfortunately, there are conflicting views on the benefits of dynamic elastomeric fabric orthoses in upper extremity function with children that have cerebral palsy.6 Evidence regarding soft splinting is very weak, with only one crossover trial documented in 1995. The majority of the studies have been case studies or literature reviews performed up to 2010. There is a need for high quality randomized control trials to determine if dynamic elastomeric fabric orthoses improve outcomes in the area of body structure and functions, activity and participation, in children with cerebral palsy.

The purpose of this article is to update the review of literature to determine if higher quality research might clarify the scientific basis for the use of dynamic elastomeric fabric orthoses. The following question guided this review: Does evidence from high quality research support the efficacy of the DEFOs on the upper extremity function of children with cerebral palsy? For clinicians and researchers, it is important to evaluate and compare the effects of therapies and treatments, in order to make a well-founded choice for the best therapy or treatment for the patient.

Method

The methods for conducting this systematic review and for assessing the quality of evidence were based on the processes outlined by the Center of Reviews and Dissemination at the University of York.10 Studies published from 1993 to 2011 were included in the present review.

Types of Studies

Study designs included randomized control trials, crossover study, pre-experimental design, and case studies.

Types of Participants

The study population in this review included children (both boys and girls) with cerebral palsy. Studies were included in which participants' ages ranged from 15 months to 17 years of age as to include all studies with children as participants.

Types of Interventions

Inclusion criteria incorporated all studies that evaluated the effect of dynamic elastomeric fabric orthoses worn on the entire body, arm, or hand and wrist, on upper extremity function of children with cerebral palsy. Exclusion criteria eliminated studies that did not include DEFOs, children, or children without cerebral palsy.

Types of Outcome Measures

Only outcome measures related to upper extremity tasks were considered in this review including: 3D upper limb kinematics, Vicon motion analysis, upper limb and trunk kinematics across four upper limb movement tasks, questionnaires and observation from parents, patients, therapists and an orthotist, upper limb and trunk kinematics across four upper limb movement tasks, angular position and passive rotational stiffness and two assessments developed to assess hand as well as grasp and manipulation of objects. Standardized tests evaluated upper extremity impairment, motor function, and activity in society.

Data Sources

To identify all relevant studies for this review, the search strategy included bibliographic databases: PubMed, Cinahl, Cochrane Library, and PEDro. Bibliographies of retrieved articles from the bibliographic databases were also searched. This strategy involved checking the title of the articles against the inclusion criteria. Furthermore, inclusion was validated by checking the abstracts against the inclusion criteria.

Search Strategy

All relevant studies without language restriction, published between 1993 and 2011 were located for assessment against the inclusion criteria. The key words, defined from the MeSH database in Medline were cerebral palsy, lycra orthosis, soft dynamic, dynamic elastomeric fabric orthoses, upper extremity, and children. Initially, a search was performed for each key word as well as phrases. As a second step, keywords were combined in pairs, then in trios and finally a conclusive search was performed with all key words combined. The keywords lycra, cerebral palsy and children produced the most articles with a total of nine results.

Study Selection

Studies were eligible for inclusion in this review, if the following information was in the title or abstract: participants were children with cerebral palsy; intervention included suits, splints, or gloves, and any outcome measure of upper extremity function. Relevant studies were identified from the hits produced from each bibliographic database or reference list by applying the eligibility criteria. The full text version of all studies was obtained, checked once more against the inclusion criteria and then assessed for method quality.

Level of Evidence

To describe potential for bias the level of evidence of each retrieved study was assessed according to the criteria suggested by Law and Webb10 (Table 1). These criteria were chosen because it was suggested as adequate for the rehabilitation scientific literature.10

Method Quality

The method quality of the included studies was critically appraised after completing the training program and passing the accuracy test for the PEDro scale given by the George Institute for Health. The PEDro scale is an ordinal scale comprised of 11 items with each item scored present (1 point) or absent. The scale includes aspect of external, internal, and statistical validity. The PEDro Scale total is a 10 with the item "specified eligibility criteria" not scored. Higher scores represent higher method quality.11 Studies are ranked by the PEDro scale criteria in Table 2.

Data Extraction

In addition to a PEDro rating, data was extracted describing each study so that it could be compared across studies. Information that was included was general information about the study such as authors, journal and data of publication, subject demographics, study design, intervention characteristics, outcome measure characteristics and key results.

Data Synthesis

Levels of evidence were cited and key outcomes described in agreement with the international classification of functioning, disability and health (ICF). The details of each study are described chronologically by date of publication in Table 3. A Cohen d statistical analysis was used to determine the significance of the study results2, 12, 21 in regards to the ICF domain of body structure and function. The study13 stated there was no statistical evidence that dynamic elastomeric fabric orthoses improves motor function during intensive therapy, was not utilized in this assessment because the outcomes were only in the activity domain.

Results

Description of the Included Studies

The search strategy identified twenty four potentially relevant studies, published between 1993 and 2011. Nine were retrieved from databases and nineteen from the bibliography of the retrieved studies. Fourteen studies fulfilled the inclusion criteria and are considered in this review. Four studies were published in the 1990's and ten were published in the 2000's. The processes of selecting the studies for this review are detailed in Figure 1 .

Method Quality of Included Studies

Three randomized clinical trials 2, 12, 13 had a comparison group of children with cerebral palsy that did not wear a DEFOs are level I. The crossover study21 is a level II and four studies7, 14, 15, 19 are level III. Five case studies16, 17, 20, 21, 22 were level IV. One study13 scored 7, two studies2, 12 scored 5, five studies7, 14, 15, 16, 20 scored a 1, three studies17, 18, 22 scored a 2, two studies19, 21 scored a 0 and one study21 scored a 3 on the PEDro Scale. The one study13, that scored a 7 and the two studies2, 12 that scored a 5 were published in 2011. Scoring details are displayed in Table 2.

Characteristics of Participants

Across all studies, a total of 170 participants were investigated. Children with cerebral palsy classified based on motor function consisted of: 61 participants with a diagnosis of spastic, 37 participants with a diagnosis of dystonia, 16 with athetosis, 2 with choreoathetosis, 15 with ataxic, 6 with hypotonia and 6 spastic with athetoid. Children classified based on topographical distribution were 1 child with diplegia and right hemiparesis and 5 children with hemiparesis were recorded. The sample sizes ranged from 5 to 32 participants and ages range from 15 months to 17 years of age.

The severity of cerebral palsy was classified in two studies by the Gross Motor Function Classification System (GMFCS) at levels I to II.13, 14 Two studies17, 21 recorded types of cerebral palsy as well as rated the severity by the GMFCS.

Types of Interventions

Among the fourteen studies reviewed, there were different types of dynamic elastomeric fabric orthoses manufactured by different companies. Four studies investigated the effect of Second Skin2, 12, 19, 21 one for Theratog14, one for SPIO7, one for UPsuits16, four for Kendal-Camp Orthopaedic17, 18, 20, 22 one for Therasuit.13 One study15 did not identify the company that manufactured DEFOs worn by the children. Control conditions for the three randomized control studies2, 12, 21 were children not wearing the dynamic elastomeric fabric orthoses. This information is provided in Table 4.

Types of Outcomes

The International Classification of Functioning, Disability and Health (ICF) framework can be used for the classification of upper extremity outcome measures into three domains. The ICF describes human functioning into three domains (Diagram 2 ), i.e. function level (body structures and function), activity level (task execution) and participation level (involvement in life situations).5

A summary of the studies' results based on the outcomes described in terms of the ICF recommendations as well as authors, conclusions are presented in Table 3. Five studies2, 7, 12, 16, 21reported seven outcomes within the body structure and function domain and nine studies7, 12, 14, 15, 18, 19, 20, 21, 22 reported fifteen outcomes within the activity domain of the ICF. There were no outcomes reported that focused on the domain of participation.

Body Structure and Function Domain

The ICF defines body structure and function domain as body functions?that?are the physiological functions and body structures are anatomical parts of the body.5 Examples of tasks in the body structure and function domain are: reaching forward which focuses on the concept of active range of motion of the shoulder, elbow and wrist on reach, and fluency, which focuses on the smoothness of upper limb movement.23

Grip Strength. No evidence was found in an association between DEFOs and increased grip strength, which was measured with a vigrometer.21

Melbourne Assessment of Unilateral Upper Limb Function. The Melbourne assessment is used to assess the quality of unilateral upper limb motor function based on items involving reach, grasp, release and manipulation.23 Improvements were found using the DEFOs to increase fluency of movement2, yet another study found a decrease in movement with long term use.16

Two randomized control trials2, 12 and a crossover study21 reported success with individual items of the Melbourne Assessment of Unilateral Upper Limb Function for dynamic elastomeric fabric orthoses in children with cerebral palsy increasing upper extremity function. A Cohen d statistical analysis was performed and demonstrated moderate to large effect sizes in the domain of body structure and function. The upper limb movement, including quality of movement and gross motor skills Blair et al21, resulted in a moderate effect size, ES=.655 for body structure and function. A moderate effect was also found in percentage of jerk in secondary movements, normalized jerk from baseline to three months of splint wear decreased (ES =.3862 and ES=.3751 respectively).2 Furthermore, a moderate effect size was also found with regards to total range of motion for pronation with hand to mouth, total range of motion with flexion with front reach task and maximum elbow extension (ES=.5385, ES=.6528, and ES=.4865 respectively).12 A large effect size was found with hand to mouth motion of pronation and front reach task with maximum pronation (ES=.7206, and ES=.7949 respectively).2

Observation. Observational studies have shown with the use of dynamic elastomeric fabric orthoses improved active weight bearing on extended arms15 as well as improved protective extension.7 Improvement has been shown with increased wrist extension into a neutral position as well as increased range of motion of the metacarophalangeal joints.15

Quality of Upper Extremity Skills Test (QUEST). QUEST assesses quality of upper extremity function in four domains: dissociated movement, grasp, protective extension, and weight bearing.23 Two participants with showed improvement with the QUEST assessment in regards to disassociation of movement and grasp with DEFOs.17

Upper limb kinematics across four upper limb movement tasks: DEFOs in addition to goal directed therapy were demonstrated to show improvement in functional range of motion observed across the upper limb tasks. In the reach forward, task significant improvement were demonstrated in maximum elbow extension. Maximum shoulder flexion during the reach forwards task revealed a significant improvement as well as shoulder abduction in sideways reaching. Also, supination/pronation involved in hand to mouth task improved significantly.2

Upper limb kinematics. Video raters rated quality of upper limb movement and fine motor skills as having improved significantly more after addition of the DEFOs than without it.21

Activity Domain

The ICF defines activity as the "the execution of a task or action by an individual". Activity is further delineated by two qualifiers known as capacity and performance. Capacity describes an individual's ability to execute actions or tasks in an optimal environment and performance describes what an individual does in his or her current environment or the real world.5 Examples of tasks in the activity domain are: pincer grasp which focuses on the concept the ability to use a pincer grip, with the wrist in a neutral to extended position, to pick up a piece of cereal and orienting objects which focuses on how objects are oriented and positioned during task performance.23

Canadian Occupational Performance Measure (COPM). The Canadian Occupational Performance Measure (COPM) is a semistructured interview instrument in which the child or parent identifies self-care, productivity, and leisure activities that the child wants, needs, or is expected to perform and is currently having problems performing. Performance improvements noted by the parents on the COPM included greater participation in gym class, improved handwriting, buttoning, and typing with DEFOs.14

Goal attainment scale (GAS). Goal attainment scaling (GAS) is a mathematical technique for quantifying the achievement goals set, which is used in rehabilitation settings. The goal attainment scale demonstrated 15/16 participants had achieved their personal movement goals resulting in increases in movement proficiency of greater than 25% in the areas of self care, community, social and civic life, domestic life and mobility with DEFOs.12 When the use of DEFOs are combined with goal directed training, longer term splint wear can improve upper limb movement of children with cerebral palsy.12

Gross and fine motor assessment. All of the children in Edmondson et al20 study showed partial improvement in an unspecified gross and fine motor assessments with the use of DEFOs.

Gross Motor Function Measure (GMFM). The Gross Motor Function Measure (GMFM) is a standardized observational instrument designed and validated to measure change in gross motor function over time in children with cerebral palsy. No significant differences with children wearing a DEFO was demonstrated.13

Patient/caregiver attitudes, questionnaires, video recordings. One study22 noted there were less significant improvements with upper extremity function when dynamic elastomeric fabric orthoses were utilized. However, five studies7, 19, 20, 21 reported through questionnaires and patient/caregiver reports, a increase in self feeding, fine motor skills and proprioception. Two therapists documented improvement when children wore the DEFOs with upper limb movement through video recording.21

Pediatric Evaluation of Disability Inventory (PEDI). The Pediatric Evaluation of Disability Inventory (PEDI) focuses on the domains of functional skills involving self care, caregiver assistance involving self care, and functional skill mobility. No significant differences of upper extremity function was found with children wearing a DEFO.13, 18 However, one study found positive changes in one or more domains of the PEDI when utilizing a DEFO.22

Two assessments19 developed to analyzed hand use as well as grasp and manipulation of objects. The two assessments found significant improvement when children wore DEFOs and performed upper extremity tasks. Assessment A found improvement in 7/9 tasks that involved hand use when children wore the DEFO either on the upper extremity or as a bodysuit. The tasks performed were threading, pegs in a board, stack three cubes, knife and fork, unscrew a jar, unwrap a piece of sweet, and catch a bean bag. Assessment B found significant improvement with tasks that analyzed grasp and manipulation of objects when children wore DEFOs. These tasks consisted of threading, pegs in a board, stacking three cubes, knife and fork, and unscrew a jar. Improvement was documented in 4/7 tasks with children who wore DEFOs on the upper extremity, 3/7 tasks when children wore the DEFO on the upper extremity as well as a bodysuit, and 1/7 tasks when children only wore a DEFO as a bodysuit.19

General Discussion

There has been discrepancy in the literature with regards to dynamic elastomeric fabric orthoses providing improved upper extremity function in children with cerebral palsy. Past research into the efficacy of DEFOs has been compromised due to the lack of sensitivity of measures to detect clinically significant functional change.12, 18, 19 However, the underlying cause has been that most of the studies have been case studies. Studies using high quality methods are still needed to support evidence based decision regarding DEFOs for children with cerebral palsy. The large number of participants necessary for randomization into groups and the homogeneity among participants required might make it difficult to conduct a randomized control trial study on the use of DEFOs with children that have cerebral palsy.19, 21, 24 Furthermore, results from randomized control trials are typically expressed as group averages and generalizations from groups to individuals may be challenging due to the uniqueness of each patient.25

There is a place for alternative designs to randomized control trials. Alternative designs can investigate individual characteristics that are important in a population with a detailed large variety of structural and functional characteristics as in children with cerebral palsy. Researchers have proposed and implemented the use of n =1 randomized control trials known as n of 1 RCTs. With this design, subjects are assigned to an active treatment or placebo and then crossed over at random during a series of treatment intervals.26 An n-of-1 randomized control trial is similar to a single subject experimental design. An n-of-1 consists on repeated measures but, it also relies on procedures used for implementing group randomized control trials such, as the assignment of subjects to treatment conditions.27 An example of an alternative design to randomized control trial is a cross over study performed by Blair et al.21

There is a continuing need for high quality experimental studies in the area of dynamic elastomeric fabric orthoses for children with cerebral palsy. A high quality randomized control trial provides the best design to control for potential bias, thus offering the strongest evidence of cause effect inferences between interventions and outcomes. Use of the PEDro Scale in future systematic reviews would provide comparable data to identify progress in the gathering of scientific evidence on this topic. The use of the PEDro scale in the present review provided quantitative information about studies' methodological quality.11

Outcomes focused on the three domains of the ICF: body structure and function, activity and participation. The domain of body structure and function was found to have moderate to large effect sizes with a Cohen d statistical analysis. However, the participation domain was not addressed in any of the outcomes. Perhaps future studies could utilize Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) which offers a comprehensive video based look at upper extremity function across multiple ICF domains.28 The use of the ICF in future studies would provide a framework for the investigation of all the components of functioning and of the relationship among components. Furthermore, it would provide a common language to improve communication among healthcare providers, researchers, policy makers, and people with disabilities.27

Summary and implications for research and clinical practice

The results of the reviewed studies show positive effects of when the dynamic elastomeric fabric orthoses are worn by children with cerebral palsy. This positive is effect is demonstrated as a significant improvement in upper extremity function in the domain of body structure and function of the ICF. However, the quality of the methods of ten out of the fourteen studies reviewed is low (level III and IV). Future studies should consider stronger designs that can control for confounding factors such as a cross over and n of 1 RCTs. The dissemination of three research articles performing randomized control trials shows the progress in the quality of the evidence since the last published review on this topic.7 Clinicians should not only rely on their clinical experience to guide the clinical decision making process on the use of dynamic elastomeric fabric orthoses. A search of new studies that provide valid ad applicable evidence to support their clinical practice should also be emphasized.

TABLE 1

Level I Randomized clinical trials (or meta-analysis of such trials) of adequate size to ensure a low risk of incorporating false positive or false negative results
Level II Randomized clinical trials that are too small to provide level 1 evidence. These may show either positive trends that are not statistically significant or no trends and are associated with high risk of false negative results.
Level III Evidence is based on nonrandomized, controlled, or cohort studies; case-series; case-controlled or cross-sectional studies.
Level IV Evidence is based on the opinion of respected authorities or that of respected authorities or that of expert committees as indicated or guidelines.
Level V Evidence expresses the opinion of those individuals who have written and reviewed these guidelines based on their experience, knowledge of the relevant literature, and discussion with their peers.

 

TABLE 2
Level and Methodological Quality of the Evidence

 

Quality of Evidence - Sub scores at PEDro Scale

 
Authors Year of Authors Level of Publication Specified Eligibility Evidence Random Allocation of Criterion Concealed Subjects Similar Prognosis at Allocation Blinded Baseline Blinded Subjects Blinded Therapists More Than 85% Assessors Intention-to-Treat Follow-Up Between Group Statistical Analysis Point Estimates of Analysis Variability Total Score at PEDro Scale
Elliott et al2 2011 i Yes Yes No Yes No No No Yes No Yes Yes 5
Elliott et al12 2011 i Yes Yes No Yes No No No Yes No Yes Yes 5
Bailes13 2011 i Yes Yes No Yes No No Yes Yes Yes Yes Yes 7
Flanagan et al14 2009 iii Yes No No No No No No Yes No No No 1
Attard et al15 2004 iii Yes No No No No No No Yes No No No 1
Corn et al16 2003 iv Yes No No No No No No Yes No No No 1
Knox. V17 2003 iv Yes No No Yes No No No Yes No No No 2
Nicholson J et al22 2001 iv Yes No No Yes No No No Yes No No No 2
Rennie18 2000 iv Yes No No Yes No No No Yes No No No 2
Brownlee19 2000 iii Yes No No No No No No No No No No 0
Edmondson et al20 1999 iv Yes No No No No No No Yes No No No 1
Hylton N7 1997 iii Yes No No No No No No Yes No No No 1
Blair et al21 1995 iv Yes No No No No No No No No No No 0
Blair et al21 1995 ii Yes No No No No No No Yes No Yes Yes 3

 

TABLE 3
Participants, Sample Details, Methods, and Conclusions

* NA: Domain not assessed secondary to limited information

Methods

Author Year Study Design N Participants' Age Range Intervention vs. Control Condition Procedures Outcomes ICF Domain Main Results & Authors' Conclusions
Elliott et al2 2011 Randomized Control Trials 16 11.5 ± 2.2 yrs 3 months lycra arm splint wear & Control group Melbourne involving 16 upper limb tasks each assessment. 3D motion was collected using a Vicon 370 motion analysis

3D upper limb kinematics Body Structure/Function

Melbourne Assessment Body Structure/Function

Lycra arm splinting induces changes in movement, motor & fluency can be quantied & amenable to change with intervention
Elliott et al12 2011 Randomized Control Trials 16 8-15 ± 2.2yrs. Control group & 3 months lycra arm splint wear with goal directed therapy GAS administed @ 3 points. Upper limb movement of four upper limb tasks was recorded with vicon 370 motion analysis Goal attainment scale Activity
Upper limb movement kinematics across four upper limb movement tasks.
Body structure/Function
Lycra arm splint made quantificable change to attainment of movement Improved ROM for functional tasks at elbow, shoulder & thorax segment.
Bailes et al13 2011 Randomized Control Trials 20 3-8yrs. Control group with control suit & therasuit wearers for 4 and 9 weeks PEDI & GMFM administered before & after 4 & 9 weeks

GMFM: Gross Motor Function Measure Activity

PEDI: Pediatric Eval of Disability Inventory Activity

No significant difference found with children wearing Therasuit during & intensive therapy program.
No significant difference found with children wearing Therasuit during & intensive therapy program.
Flangahan14 2009 Case Studies 5 7-13rs. No control group Theratog worn 12 12 weeks, 10 to 12 hours a day. First 2 weeks, vest & shorts worn alone Baseline, 12 week, 2 & 4 month postintervention assessment performed COPM: Canadian Occupational
Performance Measure Activity
Performance not statistically significant. Exception is statisfcation after 2 months of wear. Performance reported greater participation in gym class, handwritting, buttoning and typing
Attraid et al15 2005 Literature review & 2 case studies 17 6 and 9 yrs No control group Observation of improvement in each child's progress in an unspecified time period Orthotist Observation
Body Structure/Function
Observer noted improvement with 9 yr old weight bearing on upper extremities & hold position 30 seconds. 6 yr old child showed improvement in in wrist & MCP joint extension
Corn et al16 2003 Case series 4 8-16 years No splint; Upper limb splints 6 hours a day at school for several weeks Assessed at baseline & intervention phase twice weekly for the upper limb for 14-17weeks. Melbourne Assessment Body
Function/Structure
No change in quality of uniltateral upper limb movement. Decrease in movement with longterm use.
Knox17 2003 Case series 8 3.5-18 years No control group. Garments worn>4h/d for 4 weeks. Total body and gloves (1); long sleeved vest (1); shorts (1); plus therapy Measured at baseline & 4 weeks QUEST: Quality of Upper Extremity Skills Test
Body Structure/Function
Two participants improved QUEST scores. Participant 2 & 3 improved grasping & dissociated movements. Participant 3 able to self feed while wearing the garment.
Nicholoson22 2001 Case Studies 12 2-17yr No control group Invidually tailored lycra full body garment with sleeves (6), vest with full sleeve & gloves (3) suits with at leat one glove, (3) worn 6 hrs a day for 6 weeks; plus therapy Children given 2 weeks of exposure to lycra suits for 6 hrs a day for 6 weeks with therapy during the 6 weeks

PEDI: Pediatric Eval of Disability Inventory Activity

Patient/Caregiver Questionnaire Activity

11 Children had positive change in one or more PEDI domain.
Statistically significant improvement in group score for self help domain
Less significant improvement noted with caregivers
Renne18 2000 Case Studies 8 5-11 No control group
Function assessed by PEDI
2 wk period followed by 6 hrs everyday followed by a reassessment of boNy suits extending from ankle to the neck & wrist. PEDI Pediatric Eval of Disability Inventory
Activity
There were no statistically significant changes in the PEDI
Brownlee19 2000 Pre-experimental design with a pre-test post test method 20 3 years & 8 months to 15 yrs & 17 months. No control group. Presplinting @ 3 wks with the marment &
8 wks with garment on and oOf. All tests video recorded & questionnaire used to to ass9ss individual goals.
Hand/gauntlet splint worn by hemiplegia group. Body lycra suits for quadriplegia group.
Two assessments developed.
(Assessment A) analyzed hand use and (Assessment B) analyzed grasp & manipulation of objects

Questionnaire NA: Goals are not identified

Assessment A Activity

Assessment B Activity

3 children using Upsuit & 3 using arm splint/gauntlet achieved their goals as assessed by tees questionnaire.
Assessmest A assesed improvement in 7/9 tasks with the arm splint and Upsuit users. Assessment B assessed improved in 4/7 tasks with the arm splint, 3/7 with arm splint & the Upsuit worn, and 1/7 with only the Upsuit worn.
Edmondson20 1999 Case Studies 15 2-12 years No control group. Body suit worn 6 hrs a day for 12 months. Unspecified assessment of gross & fine motor motor function. Final assessment took place one month later without the garment.

Unspecified assessment of gross and fine motor ronction.
Activity

Questionaire Activity

One child improved the most with gross motor skills & 8 chilereo improved the most with fine motor skills.
Six parents stated children improved with feeding & 12 parents viewed their children had improved with self feeding
Hlyton N7 1997 Case Studies 3 10 months to 12 years No control group. Lycra suits worn as well as participation in therapy Patient/Carer attitudes Activity
Observational discussion Body Structure/Function
Reported improved proprioceptive awareness and ability to completer complex skills
Blair et al21 1995 Crossover study 16 15 months to 14 years Control Intervention: No UP suit. Soft splinting intervention 4 wks daytime wear of lycra UP suit, 3 wk nonwear & 6 weeks of wear. Suits were worn 60 days. Children were video taped performing dynamic & static functions. Video Recordings
Two therapist rating
patients on posture & quality of movement
Activity
Grip strength
Body Structure/Function
Improved postural stability for group and upper limb movement in patients that have shoulder instability
No significaot difference in muscle strength
Blair et al21 1995 Case Study 24 4.5 to 8 years No Control group Lycra UP suits worn 6.5 hours a day,
53 days (4 weeks of wear and 3 weeks of nonwear and 6 weeks of wear)
Descriptive study via questionaires with independent observers. 2 therapists viewed all video recordings of goal assessment session first together, then indpendently. Questionaires
Activity
Positive effect on all domains which included reduction of involuntary movement, fine motor function and gross motor function of upper limbs (i.e. bringing hands to a position)

 

TABLE 4
Characteristics of Dynamic Elastomeric Fabric Orthoses

Name Second Skin Therasuit Theratogs SPIO Kendall-Camp Orthopaedic
Study Elliot et al2,12 Brownlee et al19 Blair etal21, & Corn16 Bailes13 Flagan et al14 Hylton7 Edmondson et al20, Knox17 Rennie18, Nicholson et al22
Description Consist of sections of lycra stitched together under tension with a specific direction of pull.The inherent properties of lycra create a low force that resists the hypertonic muscle facilitating the antagonist action. A system of rubber bands align the patient's body with specific pressure. provides external stabilization stabilization to the trunk which allows more fluid & coordinated movements for upper and lower extremities. Orthotic undergarment made of delta-flex. Provides a passive force to correct imbalance. Lycra material & compression ratios gives multidirectional steady stretch tension directly to the skin & indirectly to to internal soft tissue structures. It does not restrict movement. Constructed of lycra. Possiblity of adding reinforcing panels or derotation bands. Boning is not used for added stability.
Purpose The splint is designed to promote better hand and arm function by addresing postura and tonal issues impacting on the elbow by addressing either pronation-flexion or supination-extension. Utilizing the rubber bands increases postural alignment which plays a plays a crucial role in normalizing muscle tone sensory, and vestibular function. A passive force corrects imbalances/ alignment through a combination of a trunk & shorts along with a customized external strapping system. Compression provides deep pressure sensory information to the child's proprioceptive system. Improved positional limb & body awareness, core muscle & joint stabilizaiton & increased precision of muscle activation & movement. Reduces hypertonus & fluctuations in tone improving upper limb tone and movements.
Additional The first Upsuit body splin-was used to promote reach and play. The splint was designed to provide stablization of the trunk, pelvis, and shoulder girdle manufactured by second skin.        

Bon Secours Health System and American Orthotics and Prosthetics, Virginia Beach, VA

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