Sitting
Long sitting, with the knees slightly flexed or straight, is the position in which a normal baby learns to establish his/her bottom and legs as his/her base of support. The child first flexes his/her trunk right forward over his/her legs, and then gradually brings his/her trunk more upright as his/her legs, and then gradually brings his/her trunk more upright once his/her base becomes more established. It is not until the child is able to rotate his/her trunk and reach freely outside his/her stable base that he/she develops a straight back, and then a lumbar lordosis, in sitting. It is at this time that the child develops the ability to stand with support and may be starting to take his/her first step, signifying that his/her body has ‘Split in two’ one half anchoring, supporting and adjusting, while the other half counter–balancing and moving. The postural education that takes place in long sitting is obviously important. This is also a position in which the hamstrings and hip adductors can be stretched. If the child is unable to sit flat on the floor without his/her pelvis rotating posteriorly, he/she can be placed so that his/her bottom is slightly raised, such as on a very low stool, telephone book, or in sitting downhill on a wedge.

Some children choose to side–sit. If they do this more easily to one side than the other, there is probably a related problem of windswept hips, and the child should be encouraged to sit symmetrically, or on the other side for part of the time. More able children will sit cross–legged (tailor–sitting) readily, less able children find it difficult. It is for some a comfortable, acceptable alternative to long sitting. The only contra–indication might be a child whose legs ‘frog’ ( hips externally rotate and abduct) excessively, when the hips might be in danger of anterior dislocation.

W–sitting (between heels) has long been frowned upon by therapists. This is due to its possible reinforcement of the flexed, adducted and internally rotated position of the hips. It may contribute also to tibial torsion and foot deformity. However, for many cerebral palsied children it is an easily assumed and stable position for play, and such children must already have the necessary range of motion at the hip joints. Probably the major worry is when a child is placed into the position, or adopts it himself, but has great difficult getting out of it and is there for a prolonged period.

If the child sits on the floor for prolonged periods in a position felt to be detrimental and there is not an acceptable, floor–level alternative, it might be best to promote chair–sitting. For children able to sit on a chair–freely without falling, consideration must be given to

• The stability of the chair.
• Its height–the child’s feet should reach the floor, or a foot platform.
• The height of the work surface. If the child’s bottom tends to slide about, and he/she is otherwise stable, a mat placed under his/her bottom might be sufficient to anchor it.

Standing
Hip deformity is a common orthopedic problem in cerebral palsy. The correct formation of the acetabulum and femoral head and neck, which results in a stable hip, is apparently dependent upon early weight–bearing in a correct position.
Other benefits of standing include:

1. Prevention of flexion deformity at the trunk, hips and knees and equinus deformity at the ankles.
2. Development of weight–bearing surfaces of the feet.
3. A child is often more able to use his/her head, arms and hands in standing than in other positions.
4. Sensory feedback in standing is important both proprioceptively and perceptually.
5. The child benefits socially from being at the same height as his/her standing peers.
6. The cardiovascular, digestive, respiratory and excretory functions are stimulated.

In general, any cerebral palsied child who is not standing well by the age of 12–18 months should be stood regularly. The hips should be extended and slightly externally rotated and abducted. Knees should be straight and feet should be plantigrade. Care must be taken to prevent the child from standing in a windswept position, the use of asymmetrical straps to pull the pelvis and, possibly, the thorax to the middle is often effective. The upright standing position is usually preferable to ‘prone’ standing, when the entire body is angled forward and supported on a platform. This is because many children, when placed in prone standing either flex their trunks and pull down strongly with their arms, and therefore inch their way up the prone board, removing any weight from their feet, or totally hyperextend. However, a prone stander may be the best choice if

• The child is very flexed and the main aim is to straighten him/her out.
• The child has developed severe deformities and the effect of gravity in upright standing only serves to pull him/her down into his/her deformities. In this care, the main aim is straightness and amelioration of deformity, with weight–bearing a secondary aim.

If a child hyper extends when stood in upright standing, a position in which the hips are slightly flexed (5o to 10o) is often effective in overcoming this tendency. The position should be similar to that naturally adopted by a normal person when standing symmetrically and learning forward slightly on to an elbow height work surface. A child who has flexion deformities of his/her knees, or deformities of his/her feet, can be positioned in upright kneeling, usually by minor adaptation to a standing frame.

Positioning of Cerebral Palsied Child for Function
The physiotherapist is often asked by other therapists and colleagues to advise on appropriate positioning for various functional activities. For example, improved exhalation and breath control for speech can often be obtained in prone lying or standing. A position in which the child can produce a reliable, repeatable response may be required for auditory, visual or psychological testing. Positioning for the optimal use of head and eyes may be needed educationally. With the increasing use of electronic aids for communication, play, and mobility, positioning for the most appropriate means of access to switches is a frequent and important consideration. Positions for dressing should encourage maximum participation from the child. The appropriate positions will vary from child to child and according to the activities required, but it is important to convey the idea that a variety of positions should be considered.

Movement between position
The everyday handling of a child will inevitably include movement from one position to another. This is an opportune time to promote some of his/her abilities without disrupting daily life.

Rolling
The ability of the child to roll from supine to side–lying should depict his/her ability to shift weight from side to side. However, some children hyperextend their necks, arch their backs and flip themselves on to their sides, which serves only to strengthen their ability to totally extend, and should therefore be discouraged. When rolling to side–lying, the child should be encouraged to turn his/her head and tuck in his/her chin. Once the child has rolled to prone, an adult can encourage the child to turn his/her head and free his/her trapped arm by fixing his/her bottom with one hand and retracting his/her shoulder on the same side as his/her trapped arm with the other.

Lying to Sitting
When a cerebral palsied child is pulled from supine to sitting, two of his/her basic abilities should be encouraged:

• Fixing the bottom so that it does not slide, and
• Raising the head. However, many children either arch or round their backs and strongly adduct their legs. For these less able children, various means of promoting their abilities can be tried, including:
  • Supporting the child proximally and protracting the shoulder as the child is lifted.
  • Starting with the child’s head and shoulders raised by a pillow or something similar, so gravity has less effect.
  • Starting from the sitting position and working gradually down to lying. Care must be taken that fixing the neck in hyperextension, poking the chin and hunching the shoulders are not mistaken for head control. An asymmetrical child will often anchor one side of his/her bottom better than the other, and will favor coming to sitting over one side only. When brought to sitting over the other side, being unable to anchor his/her bottom, he/she will spin around. For children who cannot be brought from supine to sitting without excessive effort or abnormal, asymmetrical activity, it is often best to roll them to side–lying prior to bringing them to sitting. For more able children, the adult might encourage the child to assist with lying to sitting by pulling him/her gently up with one arm and waiting for the other arm to be used spontaneously to lean on and push.