CEREBRAL PALSY

Chapter 16UPPER EXTREMITY INTERVENTIONIN CEREBRAL PALSY: A NEURODEVELOPMENTALAPPROACH

Laura K. Vogtle

CHAPTER OUTLINE

CEREBRAL PALSY

THE NEURODEVELOPMENTAL TREATMENTAPPROACH AND PEDIATRIC THERAPY

ROLE OF PERFORMANCE COMPONENTS ONOCCUPATIONAL PERFORMANCE

THE RELATIONSHIP OF POSTURE TO UPPEREXTREMITY FUNCTION

Postural Control in Typically Developing Children

Postural Control and Anticipatory Control inChildren with Cerebral Palsy

SENSATION AND ANTICIPATORY CONTROL IN HANDFUNCTION

KINESIOLOGIC ASPECTS OF TRUNK AND ARMFUNCTION

Typical Trunk and Upper Limb Interactions

Base of Support and Upper Limb Function

BIOMECHANICAL INTERACTIONS OF THE UPPERLIMB IN CEREBRAL PALSY

Contrasts between Hypotonia and Hypertonia

TREATMENT APPROACHES: CONCEPTS OFINHIBITION AND FACILITATION

Inhibitory Techniques

Facilitation Techniques

Combining Inhibition and Facilitation

THE ASSESSMENT PROCESS

Physical Status of the Individual

TREATMENT PLANNING

THE INTERVENTION PROCESS

Neurodevelopmental Treatment and Hand Function

Efficacy of Neurodevelopmental Treatment

SUMMARY

CASE STUDY ONE: A CHILD WITH CEREBRAL PALSY

CASE STUDY TWO: A CHILD WITH LOW TONE

Therapists who treat children with developmentaldelays, movement disorders, and tone abnormalitiessuch as those seen in cerebral palsy (CP) face significantchallenges in their efforts to provide efficacious inter-ventions. Muscle tone and spasticity are impairmentsseen in CP resulting from central nervous system(CNS) damage that cannot be permanently changed bymeans other than medication and surgery. However,therapists can maintain and improve performance inchildren with CP through their interventions and theuse of assistive technology. Clinicians can influenceclient factors and modify environments that affect themanifestation of muscle tone, its power, and the degreeto which it interferes with participation in occupation,thus adding to the potential for client participation.This chapter discusses the therapeutic management of children with CP, focusing on the use of neuro-developmental treatment (NDT) as an intervention.

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344 Part III • Therapeutic Intervention

CEREBRAL PALSY

Cerebral palsy is a general term that describes a non-progressive group of posture and movement disordersdiagnosed within the first 2 to 3 years of life (Koman,Smith, & Shilt, 2004). The apparent causes of CPcome from a variety of sources, including maternalinfection, prematurity, multiple births, hypoxia asso-ciated with birth trauma, and maternal bleeding frompremature placental separation, to mention a few(Nelson & Grether, 1999). Although the insult to theCNS is believed to be static, impairments seen with CPinclude musculoskeletal concerns, muscle weakness,spasticity, vision problems, cognitive limitations, andseizures. Secondary conditions related to the variousprimary impairments continue to evolve across the lifespan and include muscle tightness and contracture,joint abnormalities such as dysplasia and dislocation,growth problems, pain, social isolation, and diminishedability to participate in the community through occu-pations such as education, work, and leisure. Evidencesuggests that loss of function seen in typical aging isaccelerated in CP, and that the secondary conditionsassociated with CP become more common and moresevere with age (Andersson & Mattsson, 2001; Cathels& Reddihough, 1993; Murphy, Molnar, & Lankasky,2000; Turk et al., 1997).

The incidence of CP over the last 20 years, currentlyestimated at 2 to 4 per 1000 children, appears to beincreasing. This change may result from many factors,including improved documentation of the diagnosis incountries around the world, improved care of prema-ture and sick infants, or other unknown factors (Nelson& Grether, 1999).

The movement disorders associated with CP includespasticity, dyskinesia or dystonia, hypotonia, and ataxia.Spasticity is the most frequently occurring disorder anda mixture of various movement disorders are common.The accepted distributions of movement impairmentinclude hemiplegia, diplegia, and quadriplegia (Dabney,Lipton, & Miller, 1997).

Although improved care has resulted in typical lifespans for persons with less significant involvement,those with severe quadriplegia and associated con-ditions may die earlier (Hutton & Pharoah, 2002;Strauss & Shavelle, 1998). Strauss, Cable, and Shavelle(1999) carried out an epidemiologic review of a largedatabase targeting causes of death in CP. Their find-ings found elevated death rates from cancer and heartdisease occurring at relatively young ages. Althoughthis study awaits replication and support from clini-cal studies, the findings are provocative to say the least.

THE NEURODEVELOPMENTALTREATMENT APPROACH ANDPEDIATRIC THERAPY

The intervention approach discussed in this chapter isthe neurodevelopmental treatment approach, or NDT,originally called the Bobath approach. This paradigmhypothesizes that abnormal tone and impairments ofmovement and posture result from lesions in the CNSand limit the development of function. Intervention isaimed at minimizing these impairments and improvingfunctional outcomes as a result of problem-solvingamong the clinician, client, and family to develop newmovement strategies and management of postural tone.The original approach was developed by Berta andKarel Bobath, a physiotherapist and physician, respec-tively, who evolved the paradigm between late 1940and 1990. Currently the instructors who teach thetechnique and the national Neurodevelopmental Treat-ment Association (NDTA) continue to expand andupdate the treatment approach.

When Mrs. Bobath first began to practice as a physi-cal therapist, therapeutic interventions for neuromus-cular diagnoses were based on the stretching andstrengthening regimens used with the impairments leftafter polio. Unhappy with the results of such treat-ments, Mrs. Bobath documented observations fromher assessment and treatment of adults with paralysisafter stroke and children with CP. Dr. Bobath sup-ported her ideas with information from the neuro-physiologic scientists of the day, including the hierarchicperspective of the CNS, the cephalad to caudal/proximalto distal nature of human development, and the con-cept that postural control evolved from primitive reflexes(Howle, 2004). The Bobaths’ early work focused onaltering muscle tone and reflexes to enable the devel-opment of more normal movements and followed thenormal developmental sequence in treatment. Theimportance of the postural reflex mechanism was high-lighted and primitive reflexes were seen as a first step inthe development of higher-level, skilled movements.The persistence of these reflexes in conditions such asCP originally was believed to block more skilled move-ment, hence the concept of reflex-inhibiting postures(RIPs), which were used to facilitate higher levelmovements (Bobath, 1955).

Over time, Mrs. Bobath’s approach changed as shedocumented her observations about the results of hertreatment. Although the concept of reflex inhibition,even today, is seen by some as the substance of NDT,Mrs. Bobath actually discarded this focus by 1964,moving on to the idea of “handling” or moving the

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child so as to generate active movement responses. Thetreatment approach continued to focus on develop-ment of movement skills based on the normal devel-opmental sequence until the lack of carryover outsideof individual sessions became apparent. The Bobaths(1984) then acknowledged the importance of linkingtreatment to the performance of functional tasks inother settings, thus underscoring the importance ofmotor learning on the part of the client.

Motor learning is defined as

“a set of processes associated with practice or experience leadingto relatively permanent changes in the capability for producingskilled action.” (Shumway-Cook & Woollacutt, 2001, p. 27).

Shumway-Cook and Woollacutt distinguish betweenmotor learning and performance, citing changes inmotor performance as being temporary, whereaspermanent changes in skilled action result from truemotor learning. Clearly for children with CNSdysfunction to change their occupational performanceoutside of therapy intervention sessions, true motorlearning must take place. Current NDT treatmentrecognizes the importance of motor learning to skilledperformance, and the necessity of practicing client-designated activities in treatment for changes inperformance to occur.

Although the Bobaths themselves did not incor-porate motor performance into their theory, theNeurodevelopmental Treatment Association TheoryCommittee, consisting of multidisciplinary NDTinstructors in the United States, began updating thetheoretic paradigm in the early 1990s to incorporatecurrent concepts with applicability to treatment ofpersons with neurologic deficits. It was at this time thattheories such as dynamic systems theory and motorlearning were formally integrated into the theoreticbasis for the treatment approach (Howle, 2004). Oneof the challenges for clinicians is the constant need tokeep their knowledge current with changes inknowledge generated by science, a challenge theNTDA has taken seriously, as evidenced by the work ofthe NDTA Theory Committee.

ROLE OF PERFORMANCECOMPONENTS ONOCCUPATIONAL PERFORMANCE

Aspects of performance that therapists analyze whenplanning treatment for children with CP are compo-nents such as postural control, strength, muscle tone,spasticity, range of motion, and the performance of the

activity or occupation designated as the goal of inter-vention. Current studies provide a much clearer pictureof the role such impairments and movement disordershave on performance skills. For example, Gordon andDuff (1999b) studied the relationship between finger-tip force regulation in grasp, spasticity, stereognosis,two-point discrimination, manual dexterity, and per-ception of pressure sensitivity. Their work demonstrateda clear relationship among tactile perception, anticipa-tory control (activation of sensory and muscular sys-tems for a specified activity based on prior learning andexperience) (Shumway-Cook & Woollacutt, 2001) andtask performance; however, it also suggested that therole of the other impairments in performance wasdependent on the aspects of the activity being performed.They noted that spasticity appeared to affect the adjust-ment of grip to object weight and to the length of timebetween grasping and actually lifting an object, but itdid not have a relationship to anticipatory control.

The NDT approach emphasizes the importance of postural control and anticipatory postural control, both performance skills in the Occupational TherapyPractice Framework (The American OccupationalTherapy Association [AOTA], 2002), to the outcomesof therapy intervention, or areas of occupation. Thenext section of this chapter discusses postural controland its impact on upper limb function.

THE RELATIONSHIP OF POSTURETO UPPER EXTREMITY FUNCTION

One of the Bobaths’ contributions to management of neuromuscular conditions was their understandingthat spasticity was not just an individual muscle phe-nomenon, but actually affected posture and control ofupright position in space, a concept not previouslyacknowledged. The emphasis on the postural reflexmechanism as central to changes in other aspects ofmotor performance was a principal factor in the Bobathtreatment approach, which underscored their belief in the hierarchic, maturational principles of motordevelopment. The Bobaths believed that more distalskills (e.g., reach, the ability to stand) could not devel-op until postural control of head and trunk occurred,defined as the postural regulation of the body’s posi-tion in space for purposes of stability and orienta-tion (Shumway-Cook & Woollacutt, 2001). Therapiststrained in the NDT approach through the 1980sfocused on altering postural tone passively, then onfacilitating active control in the head and trunk andfinally on development of control in the upper and lower limbs. At the present time, NDT theory

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locates intervention for impairments such as posturalcontrol within the desired occupational performanceoutcome rather than as the primary treatment outcome.

POSTURAL CONTROL IN TYPICALLYDEVELOPING CHILDREN

In typically developing children, postural controlevolves from the development of antigravity move-ment, postural adjustment reactions, somatosensoryinput, and experience, and is defined as maintenance ofbody position in space (Nichols, 2001). Postural sway,a component of postural control defined as “the move-ment of the center of gravity within the base of supportin any upright position” refers to the constant move-ment of the body when upright and occurs in a devel-opmental sequence that matures around 13 years of age(Nichols, 2001, p. 275). Another aspect of posture,anticipatory postural control, defined as activation ofsensory and muscular systems for a specified activitybased on prior learning and experience, helps to pro-vide efficient adjustments of the body to support use ofthe limbs for various activities (Shumway-Cook &Woollacutt, 2001).

All motor activities require some degree of posturalcontrol, although those requirements vary dependingon the activity and the environment in which it isperformed. Bertenthal and Von Hofsten (1998) relatedpostural control to hand function, specifying that pos-tural control is a necessary requirement for the devel-opment of grasp and manipulation, and integration ofvision into hand function.

This constellation of postural control componentswas not well delineated during the Bobaths’ time; how-ever, the current premise that postural control and itselements are necessary for successful motor perform-ance supports some of the Bobaths’ ideas about theinteraction of the trunk and upper limbs. For example,Bertenthal and Von Hofsten (1998) discussed theimportance of postural elements to both visual skill andupper limb performance in tasks such as reach andgrasp, noting that

“. . . reaching for distal objects is necessarily a dynamic processdemanding mutual and reciprocal processing of the relevantperceptions and actions” (p. 519).

Stapley, Pozzo, and Grishin (1998) studied theinteraction of anticipatory postural control and reach in typical subjects. Their work suggested that the use ofanticipatory postural adjustments plays a role in activa-tion of upper limb movement from a fixed base ofsupport before reach, as well as stabilizing the bodyduring reach.

POSTURAL CONTROL AND ANTICIPATORYCONTROL IN CHILDREN WITH CEREBRALPALSY

In contrast to typical children and adults, children withCP have difficulties with postural control and antici-patory postural adjustments, as evidenced in a numberof studies. Liao and co-workers (2003) found signifi-cantly worse postural control in sitting as demonstratedon parameters of static and dynamic sway indices inchildren with spastic CP when compared with typicallydeveloping children. Roncesvalles, Woollacott, andBurtner (2002) found that children with CP did notdemonstrate increased muscle response to changes inplatform perturbations, although typical children did.They hypothesized this difference in ability to demon-strate recovery of balance resulted from insufficientcontraction of agonist postural muscles.

Studies of anticipatory postural control demonstratedifferences in children with CP as well. Van der Heideand co-workers (2004) found that children with CPafter prematurity have difficulty adapting or gradingpostural adjustments to a variety of task-specific cir-cumstances. Not unexpectedly, these difficulties wereworse in children with diplegia or quadriplegia than in children with hemiplegia. A top-down sequence ofactivation of postural muscles, particularly in the neckextensors, was seen in their sample of children with CP,which varied from the muscle activation sequence seenin typical children. They noted that the gestational ageof the child was related to postural adjustment prob-lems; the shorter the gestation, the greater the impacton postural adjustment.

There are different theories about the interaction ofpostural control and sensation and the role of anticipa-tory postural control in upper limb function, includingthe Dynamic Systems Approach and Neuronal GroupSelection Theory. Howle (2004) contrasted and com-pared some of these theories as they relate to NDT.Although these theories present different perspectiveson the topic of postural control and upper limb func-tion, there is no question these elements of performanceare an important factor to be considered in movementintervention, regardless of the theoretic perspective.

SENSATION AND ANTICIPATORYCONTROL IN HAND FUNCTION

The Bobaths saw movement and sensation as complex,interdependent aspects of human performance (Howle,2004). They hypothesized that lack of movement


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control affected the ability to perceive and processsensation. Although the sequencing of sensation andmovement proposed by the Bobaths may be open toquestion, there is no argument that persons with CNSlesions do have sensory impairments that affect theirmotor performance. Problems with sensory perceptionand sensory processing affect performance in a numberof ways, including inability to detect and identifyincoming sensory information; difficulty interpretingsingle sensory or multisensory input; problems withmodulation of sensory inputs to match changes in taskand environmental demands; and inability to matchsensory information with experience, memory andspecific tasks (Eliasson, Gordon, & Forssberg, 1995;Gordon & Duff, 1999a; Gordon & Duff, 1999b;Lesny et al., 1993; Yekutiel, Jariwala, & Stretch, 1994).Impaired development of anticipatory control duringhand function also results from impaired sensation.Eliasson and Gordon (2000) described anticipatorycontrol in object manipulation as

“internal representations or sensorimotor memories of the objectgained during previous manipulatory experience” (p. 233).

Researchers have carried out extensive studies overrecent years in an attempt to isolate the role of sen-sation in prehensile and release functions in typicaladults and children (Forssberg et al., 1991; Kinoshita etal., 1992; Eliasson, Johansson, & Westling, 1992). Thisseries of studies was followed by a body of researchlooking at issues of vision, tactile sensation, spasticity,and force generation in grasp and release. Comparisonsof these parameters in grasp and release between chil-dren with CP and typical children also were performed(Duff & Gordon, 2003; Eliasson & Gordon, 2000;Eliasson et al., 2003; Gordon, Charles, & Duff, 1999;Gordon & Duff, 1999a; Gordon & Forssberg, 1995).This work has established that the grasp and release of children with CP is impaired by deficits in tactileperception and processing, difficulty with graded con-trol resulting from balanced interactions betweenmuscle agonists and antagonists, and temporal controlof movement events (Eliasson & Gordon, 2000).Temporal issues were cited again in the work of Gordonand co-workers (2003), who found that release ofobjects that varied in weight required more time inchildren with CP than in typical children, especiallywhen accuracy and speed were necessary.

This discussion underscores the notion that motorbehaviors, sensory perception, and sensory processingare inextricably linked, and that experience and prac-tice with various motor behaviors helps to buildperformance and anticipatory control in children withCP. This is true for all aspects of motor performance,

including postural control, hand function, gait, andspeech.

KINESIOLOGIC ASPECTS OFTRUNK AND ARM FUNCTION

The problems with postural control and upper limbfunction seen in children with CP affect all aspects ofoccupational performance. It is for this reason thatevaluation of posture, postural adjustments, and theirinteractions with the upper limb particularly should bepart of a therapeutic assessment, as well as the status ofbody structures.

TYPICAL TRUNK AND UPPER LIMBINTERACTIONS

The axial skeleton is the base upon which the limbs aresupported and from which they operate. The alignmentof the spine, pelvis, and ribs influences how both theupper and lower limbs rest in space and how theirmovements are used in the performance of variousactivities. Remember that many of the muscles control-ling the upper and lower limbs attach to the spine, ribcage, and pelvis, and that the shoulder girdle movesover the rib cage. The anatomical connections betweenthese musculoskeletal units are why mobility and stabil-ity of the entire trunk are so important to movement ofthe limbs (Neumann, 2002).

The pelvis provides support for the spine. Becausethe lumbar spine interacts specifically with the pelvis invirtually all movement sequences (e.g., forward flexion,extension, rotation, lateral flexion), motor or jointimpairments in one or the other structure affect move-ments in both areas. Similarly movements in any regionof the spine result in movements within the entirespine, with the degree of the resulting motion decreas-ing distally from the originating movement. Thereforedisruption of motion in one region of the spine affectsthe entire spine, and by association, the position of thehead in space (Neumann, 2002).

In children with CP, both structures and movementsof the axial skeleton often are impaired, affecting bothposture and limb function. Such limitations in the bio-mechanical interactions of the pelvis and spine areconcerns for therapy intervention in the child with CP.

The shoulder girdle is comprised of the scapulae,clavicles, sternum, and glenohumeral joints. Just aswith the spine and pelvis, dysfunction at any one jointof the complex affects movement at all of the otherjoints. The shoulder, elbow, and forearm place andsustain the wrist and hand in space for function.


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Arranging hair on the back of the head, clipping toe-nails, bathing, and dressing are all examples of activitiesthat require the hand to be moved to a distance awayfrom the body. In typical movements, certain shouldercomplex functions are aided by actions of the spine. Forinstance, rotation and flexion of the lumbar, thoracic,and cervical spine extends the range of reach for itemshigh on a shelf or under a bed.

The rotary movements of the shoulder and forearmare particularly important to skilled dexterous move-ments within and between the hands, both at and awayfrom midline. Removing post earrings, for example,requires the palms of the hands to be facing each otheron one side of the body, an action that would not be easily performed without humeral and forearmrotation.

Finally, the complexity of wrist and hand movementsis significant and remarkable for the highly comple-mentary nature of the interactions among various struc-tures. Consider playing the piano and the configurationof the wrist and fingers. During an octave stretch, thewrist may be flexed to provide additional range ofmovement in abduction and extension at the fingers.When a chord is played, the wrist is extended toprovide power, stability, and control for the flexedfingers. Knowledge of these kinds of interactions assiststhe therapist to both understand and treat limitationsin occupational performance that involve the hands.Awareness of the complex structures in the hand iscritical as well, including the carpal, metacarpal, pha-langeal joints, and arches.

BASE OF SUPPORT AND UPPERLIMB FUNCTION

Another biomechanical aspect of upper limb perform-ance is the base of support generated for upper limbfunction, basically the foundation of the head, trunk,and limbs. Shumway-Cook and Woollacutt (2001)define base of support as

“the area of the object in contact with the support surface” (p. 164).

A wide base of support, such as the feet widelyseparated in standing, provides stability for motorfunctions, whereas a narrow base of support in sittingand standing is more conducive to body mobility. Onealso needs to consider the nature of the supportingsurface; some properties of various surfaces enhancecontact with body structures, such as beanbag chairs.Age, the nature of the activity, and the environment areother factors that affect the base of support incor-porated by the individual.

In movement disorders such as CP, base of supportis affected by the movement disorder itself, structuralissues such as hip dislocation, and elements related tothe movement disorder such as limited postural con-trol. Age, task constraints, and the physical environ-ment mentioned previously should be considered whencarrying out assessments of performance in which baseof support is an issue. Interventions used to developmore skilled action in NDT are designed to take intoconsideration base of support and its impact on theindividual’s ability to perform upper limb functions.

BIOMECHANICAL INTERACTIONSOF THE UPPER LIMB INCEREBRAL PALSY

Depending on muscle tone and distribution of motorimpairment in the individual with CP, there arecommonly fluctuations in movement control that affectposition of the spine and pelvis and postural adjustmentresponses (Liao et al., 2003; Van der Heide et al.,2004). These difficulties can be increased by tightnessin the soft tissue structures of the lower limbs, such asthe hamstrings and hip flexors (Reid, 1996). Suchproblems in the axial structures influence purposefulmovements in the upper limbs of children with CP.Posterior tilt of the pelvis and flexion of the lumbarspine increase thoracic flexion and compromise actionsin the shoulder girdle and shoulder.

As discussed, changes in any aspect of shouldergirdle function influence the entire shoulder girdlecomplex (Neumann, 2002). Scapulohumeral rhythm iscommonly affected by increased thoracic flexion,causing the scapula to rotate upward sooner in theinteraction of the two structures and sometimes lim-iting the range of overhead action. Movements in thefrontal plane, such as humeral flexion and horizontaladduction, seem to be difficult for children with CP,resulting in the increased presence of humeral abduc-tion and sometimes humeral extension. External rota-tion of the humerus is affected by both increasedthoracic flexion and the resulting scapular abduction,which biomechanically aligns the humerus into aninternally rotated posture. This configuration is mostoften seen in children with spasticity; those who havedyskinesia or dystonia may seek to control extraneousmovement in their upper limbs by holding their upperlimbs against their bodies in a practice called “fixing” orstabilizing the upper limb (Nichols, 2001). This prac-tice volitionally can limit their humeral motionsinitially; however, if the practice persists, actual softtissue limitations can occur.


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Movement of the body and limbs as a unit is acharacteristic seen in CP (Hadders-Algra et al., 1999).Isolation of movement in the various segments of theupper and lower limb is missing, causing a lack of dis-association between the movement elements betweenand within each limb. For instance, the motions used in the shoulder girdle and humerus affect movementcomponents seen in the forearm and wrist. Humeralabduction and internal rotation facilitate overuse offorearm pronation and limit active supination neededfor efficient hand use, a common problem in childrenwith spastic CP. Active elbow and wrist extension isoften restricted by spasticity in the elbow and wristflexors, over time causing muscle tightness and con-tracture. The predominance of flexion at the elbow andwrist also affects the development of active intrinsicmuscle function in the hand, resulting in the use oftenodesis interaction between the wrist and fingers andthe use of extrinsic finger flexors and extensors to con-trol the digits. Types of grasp available, especially forchildren with more severe impairments, are limited tomore primitive grasp sequences and lack of both powerand precision prehensions. Deformities of the web spaceof the thumb and hypermobility in the metacarpo-phalangeal (MCP) and distal interphalangeal joints ofthe thumb are common.

These atypical interactions in the upper limb ofchildren with CP result in significant activity andoccupational limitations. Some authors hypothesizethat the movement alterations are actually an adaptivefunction rather than true movement impairments(Steenbergen, Hulstijn, & Dortmans, 2000). Whateverthe cause of the movement limitations, the manip-ulative function needed to manage such items asclothing fasteners, the ability to write, and use scissors,is often either impaired or missing. Clinicians shouldassess the child’s postural control and upper limb func-tion as a whole to design interventions that enhance allaspects of performance.

CONTRASTS BETWEEN HYPOTONIAAND HYPERTONIA

The discussion to this point has addressed posturalcontrol, anticipatory postural control, the relationshipof posture to upper limb function, and aspects ofatypical motor performance in children. Most of thediscussion has related to the child with spasticity andincreased tone. Muscle tone refers to the resistance amuscle offers when lengthened (Shumway-Cook &Woollacutt, 2001). This resistance is a result of bothneural factors (e.g., spasticity) and biomechanical fac-tors (e.g., fibrosis, atrophy, changes in contractile prop-erties of some muscle fibers).

Children with hypertonia have increased stiffness ortone in their muscles, whereas children with hypotoniahave decreased resistance to lengthening and laxity ofboth muscle and other soft tissue structures around the joints. It is not uncommon to find children withhypotonia in the trunk and hypertonia in the limbs, orthose with fluctuating tone, as well as children withgeneralized hypotonia. The intervention approaches tothese variations in muscle tone differ in that childrenwith hypotonia use end range movements (activitiescarried out by motions at the end of the available jointrange) and often have increased range of motion incontrast to the limited active and passive mobility seenwith hypertonia. Children with underlying low toneoften use stabilizing or fixing of a body part (Nichols,2001) to create stability, as well as a wide base of sup-port in upright positions to create postural stability.Body movements are characterized by straight planeactions without a rotary component and limitations instrength and endurance are common. In the upperlimb and hand, lack of graded, efficient movementsrestrict refined functions such as precision grasp, inter-digital interaction, and isolated digital control used in complex manipulative sequences. The interventionprocedures differ somewhat, although the emphasis onpostural control as a necessary element of performanceremains unchanged.

TREATMENT APPROACHES:CONCEPTS OF INHIBITION AND FACILITATION

Three concepts underscore therapeutic handling (facili-tating active movement by using a hands-on approach)in the NDT treatment approach, key points of control,inhibition, and facilitation. Key points of control refers to specific hand placement by the therapist duringhandling that allows direct influence or control overthe area and indirect control over other body structuresor functions proximal or distal to the key point. Thesesources of control are used to either inhibit or facilitatemovement sequences and postural control. Proximalkey points include the pelvis, shoulder girdle, and trunk,whereas distal key points are areas such as the elbowand ankle. Inhibition is defined as

“the reduction of specific underlying impairments that interferewith function” (Howle, 2004, p. 261).

In treatment, therapists use inhibition to limit theungraded force produced by spasticity, to balanceunequal power between antagonists and agonists, or to


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limit those movements that impair smooth coordinatedaction. Facilitation consists of

“strategies employed in therapeutic handling that make aposture or movement more likely to occur” (Howle, 2004, p.260).

It is used to activate, grade and change variousmovements, and should affect the direction, force andavailability of various movements.

Specific techniques are used for inhibition and facili-tation (Box 16-1). These are discussed next.

INHIBITORY TECHNIQUES

Inhibition is the primary tool used to manage abnormalposture and tone. Specific “hands-on” inhibitory tech-niques such as vibration, use of mobile surfaces,location, position of structures within the treatmentenvironment, and use of various sensory stimuli andspeed of movement can all be used to minimizeimpairments.

Vibration in NDT consists of placing the hand on abody area and vibrating or oscillating the locationgently and consistently. Use of mechanical vibrators isdiscouraged because of the noise and difficulty gradingthe intensity of the vibration. This technique is bestused when a more global movement or gross motoractivity is being performed so as not to interfere withperformance. It is particularly useful when managingtrunk tone for vocalization or extending the range ofmovement in the trunk or a limb. As with all inhibitorytechniques, one should withdraw the technique duringactivity performance.

Prolonged stretch through weight bearing in bothupper and lower limbs is an inhibitory technique usedto elongate soft tissue structures and minimize flexion

or extension synergies in the limbs. It can be used toincrease range of movement and decrease tone in chil-dren with spasticity, or in children with hypotonia orathetosis who have decreased range caused by fixingbody parts to limit extraneous motion.

Therapist guidance of movement has applicability for both inhibition and facilitation. For inhibition, thetherapist uses key points of control to limit ungradedforce in one muscle group while facilitating activemovement in the agonist or antagonist. It can beparticularly helpful in the case of hemiplegia, in whichasymmetries exist, or in the cases of diplegia andquadriplegia, in which symmetry of limb posture andlack of dissociation of movement is a problem. In thesecircumstances, the therapist can inhibit asymmetry bydirecting activities that are bilateral or symmetric innature, or by inhibiting symmetry of posture by usingtreatment activities that require the limbs to be usedreciprocally.

Use of mobile surfaces has both inhibitory and facili-tatory applications. Children who have increased trunkextensor tone accompanied by lower limb extensioncan be positioned on a mobile surface and the gentlerocking movements of the surface used to inhibit toneand relax the child. Over time, passively applied move-ment on a mobile surface is shifted to the facilitation ofthe child’s ability to use his or her own active motionto manage tone increases.

Inhibition through activity is when the therapistteaches the child or individual how to manage atypicalmovements or increases in stiffness through specificmovement sequences. For example, in the child whohas increased tone in the flexors of the upper limb thatlimits dressing or bathing, upper limb weight bearingagainst a wall or the floor can help inhibit the flexionposture, or bending from the waist and shaking thearms in space can help reduce the stiffness. Wheneverpossible, clients should be taught to use their ownmovement over time for health promotion andincreased participation.

FACILITATION TECHNIQUES

The use of key points of control combined with therapistguided movement plays a big role in facilitation.Remember that key points of control are body areasfrom which the therapist facilitates or inhibits move-ment. In facilitation, the goal might be to assist theclient to open a cupboard door using a more involvedupper limb while the unimpaired limb holds and thenplaces an item into the cupboard. The therapist coulduse either the shoulder or elbow as a key point ofcontrol to facilitate placement of the impaired arm on the door handle, a task that the client cannot dowithout prompts.


BOX 16-1 Specific Techniques Used forInhibition and Facilitation

INHIBITORY TECHNIQUES• Vibration• Prolonged stretch• Therapist guidance of movement• Use of mobile surfaces• Inhibition through activity

FACILITATION TECHNIQUES• Deep pressure and joint approximation• Weight bearing on both upper and lower limbs• Vestibular input• Environmental modifications• Sensory modifications• Combining inhibition and facilitation

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In this same example, tapping could be used alongthe muscle belly of the elbow extensors to activate themovement necessary to extend the arm to the doorhandle. Tapping can be used alternatively with tactilecues, which are a firm touch on the body part to indi-cate that it needs to move. Tactile cues are a lessinvasive form of facilitation, so moving back and forthbetween the two techniques is one way to withdrawinput as the client is more able to perform the desiredactivity with less assistance.

Deep pressure and joint approximation are facilitationtechniques to activate cocontraction around the joints.The use of these techniques works best on low-tonedpersons, but those with high tone often demonstrateunderlying low tone when their high tone is altered.Sequencing deep pressure and joint approximationafter tone inhibition is a common practice to facilitatebetter control and muscle activation.

Weight-bearing on both upper and lower limbs hasproperties of facilitation, as well as inhibition, depend-ing on how it is applied. Static weight-bearing, espe-cially for extended periods of time, can be achieved by“locking” or hanging on the joints. However, if weight-bearing is accompanied by weight-shifting (volitional orassisted movement of body weight) and active move-ment sequences, it can facilitate active movements invarious muscle groups. Weight-shifting refers to move-ment of body weight through momentum of a bodypart (Shumway-Cook & Woollacutt, 2001). Activeweight shift occurs in all volitional movement transi-tions and is an important therapeutic tool in personswith movement impairments resulting from neuro-muscular disorders. In the upper limb, humeral flexion,elbow extension and possible wrist and finger extensioncan be facilitated by weight-shifting over weight-bearing positions.

Vestibular input can be used to facilitate posturalcontrol. Combinations of sensory-integrative tech-niques can be incorporated, using swings or platforms(Blanche, Botticelli, & Hallway, 1995). If the child isnot capable of sitting independently or sustainingposture on such equipment, the therapist can sit on thedevice with the child in his or her lap. A more desirableoption is to incorporate meaningful activities such asdance with repeating rotary turns into the treatmentwhenever possible.

Environmental modifications include arrangement ofphysical, sensory, and even social aspects of theenvironment to facilitate action. Pediatric therapists areparticularly good at such modifications. Arranging theroom so that items are placed strategically so as toencourage active movement, use of surfaces that chal-lenge the abilities of the child, and use of materials inoccupations that are meaningful to the child are allways to facilitate skilled action and successful perform-

ance. These same kinds of modifications can apply tospecific aspects of hand function as well. For instance,using checkers instead of pennies to facilitate elementsof a precision prehension can ensure success for thechild and build the motor and sensory aspects ofactivity demands.

Sensory modifications can be helpful too. Music thatis invigorating or calming can be used, singing, use ofhigh contrast, complex or simple visual backgroundsare some ways to alter the sensory environment. Use ofsocial facilitation is another technique that has beenenhanced by inclusive practices in the classroom(Kellegrew, 1996). Peer engagement and support canserve to motivate and facilitate children in ways thatparents or therapists cannot achieve. Children’s desireto be like their peers is a powerful force in facilitatingperformance, especially in the achievement of activitiesand occupations that the child wishes to perform to bewith friends.

COMBINING INHIBITION AND FACILITATION

In almost any treatment session with children who haveCP, it is necessary to combine aspects of inhibition andfacilitation. This requires considerable skill on the partof the clinician, especially in the case of active children.By altering movements through the use of facilitationor inhibition, the clinician causes the client to changeor adapt. This requires the clinician to quickly alterhands-on input to continue to enhance the improve-ment in the child. Ultimately the goal is to be able towithdraw both kinds of techniques so that the child candemonstrate motor learning and carryover of the skillslearned in therapy.

THE ASSESSMENT PROCESS

Assessment of the child with cerebral palsy can becomplex. Multiple aspects of performance should beanalyzed, including physical and sensory status, devel-opmental status, postural control, and quality ofmovement elements. The challenge for the clinician ishow to sort through these aspects of the client to seewhich appear to be most critical to occupational per-formance. Distribution and degree of movementimpairment also can be a guide. Children with mildhemiplegia, for instance, may not need extensive physi-cal assessment but based on research findings (Gordon& Duff, 1999b) need assessment of tactile function.Developmental and occupational assessments areappropriate. A child with severe quadriplegia is morelikely to need physical status assessment (e.g., strength,range of motion, spasticity) and less likely to need a fulldevelopmental evaluation.


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Various assessments are discussed next, includingstandardized tools whenever possible.

PHYSICAL STATUS OF THE INDIVIDUAL

Range of motion and muscle strength are assessedusing standard goniometry and manual muscle testing.Argument existed for some years about whether accu-rate evaluation of strength was possible in children withmuscle tone impairments, however, the existing litera-ture on functional gain after strengthening programsmakes this a relevant area to assess (Damiano, Vaughan,& Abel, 1995; Darrah et al., 1999; Dodd, Taylor, &Damiano, 2002).

Muscle tone is assessed through the use of tools thatare somewhat subjective, including the Ashworth Scale(Bohannon & Smith, 1987). The Tardieu Scale’s use isevolving; however, it requires more time and expertiseto achieve accurate results (Mackey et al., 2004). Thesetwo scales assess increased tone but are not particularlyhelpful with hypotonia. Existing tools to measuredecreased tone directly do not exist.

Assessment of sensation is a time-consuming processthat often is not carried out in children with CP in spiteof a body of research indicating tactile discriminationdeficits in children with CP, particularly hemiplegia andquadriplegia (Duff & Gordon, 2003; Eliasson &Gordon, 2000; Eliasson, Gordon, & Forssberg, 1995;Gordon et al., 2003; Gordon, Charles, & Duff, 1999;Gordon & Duff, 1999a). Gordon and Duff (1999b)and Lesny and co-workers (1993) used a variety ofmeasures in their work that are recommended forclinical practice, including tests of two-point discrimi-nation, stereognosis, and deep pressure.

NDT emphasizes quality of movement. Existingtools that assess quality of movement are limited.Examples are the Gross Motor Performance Measure(Boyce et al., 1995; Gowland et al., 1995; Thomas etal., 2001), the Toddler and Infant Motor Evaluation(TIME) (Miller & Roid, 1993; Rahlin, Rheault, &Cech, 2003), and the Movement Assessment of Infants(Hallan et al., 1993; Harris et al., 1984).

The limitations in standardized tools that assessmovement and posture are a concern for the NDTtreatment approach because the treatment emphasis ison developing posture and movement. Researchershave options available to them, but these are too expen-sive and complex for the clinic. Nichols (2001) sug-gested using indirect observation during assessment ofmotor milestones, which is the best option available inthe clinic at present.

The success of any therapeutic intervention isdependent on the therapist’s ability to analyze aspectsof performance and change over time. When one isplanning interventions that use an NDT treatment

approach, remember that the approach addresses pos-ture and movement in the context of occupationalperformance. This means that occupational perform-ance needs to be assessed. Pediatric therapists have ahost of tools available to them in this realm, some ofwhich have a developmental or skill focus. The readershould see Asher (1996) for a complete listing.

TREATMENT PLANNING

Planning appropriate interventions and documentingoutcomes are aspects of service provision that requirecareful attention. Setting appropriate goals is thecornerstone of treatment planning. As noted in the OTPractice Framework, the occupations selected as out-comes of intervention should be meaningful andpurposeful to the client and family; and successfuloutcomes are more likely when occupations are incor-porated into daily routines (AOTA, 2002). Thesepremises hold true for NDT intervention just as theydo for other treatment approaches.

Use of activity analysis and the principle of partialparticipation are useful tools to help build specific skillsover time (Vogtle & Snell, 2004). Refer to Table 16-1in Case Study 1 for one example of activity analysis thatis useful when planning NDT intervention. Sensoryand motor elements are delineated to assist the clinicianin organizing treatment and incorporating strengths ofthe client. Partial participation, which enables clients tocomplete steps of an activity that they are able to dowith the remaining steps completed by a caregiver, canbe planned satisfactorily through the use of this kind of activity analysis (Vogtle & Snell, 2004). Breaking an activity into steps also helps the clinician evaluatetreatment outcomes in a more systematic manner.

Another aspect of treatment planning that benefitsfrom activity analysis and partial participation is theintegration of accommodations into interventions. Bybreaking an activity into steps and sorting out which of those the client can do, modifications to promotesuccessful performance can be easily identified and usedin treatment. This has the extra benefit of giving theclinician the opportunity to see if suggested modifica-tions really work before asking families and educatorsto make them.

Tables 16-2 and 16-4 in the Case Studies later in thechapter give illustrations of how a clinician could use anactivity analysis to plan treatment. The tables includecolumns for activity steps, movement components, andfacilitation techniques. Organizing treatment into thiskind of table can help the clinician develop a plan forintervention that includes aspects of facilitation andinhibition.


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THE INTERVENTION PROCESS

Once assessment is complete and goals are establishedby the family, child, and clinician, it is time to considerhow to provide treatment. The use of NDT techniquesmeans that the therapist needs to combine the clientfactors to be addressed (e.g., tone, weakness, range of motion, postural control issues) with performanceskills and activity demands of the goal while learningand practicing identified activities or occupations. Thenature of the occupation selected as a goal in con-junction with client factors dictates the degree ofpostural control integrated into the intervention.

If the goal activity is focused on hand function, thenthe level of postural control and adjustment factoredinto the session depends on the planes in which thehand function takes place and future postural controlgoals. For instance, tying shoes occurs at some distancefrom the body. Potentially there should be either morework on posture involved in this kind of activity than ifthe goal was handwriting, or the therapist shoulddevelop postural supports necessary to allow the handsto be free for the act of shoe-tying.

The base of support required by an activity duringintervention depends on the movement transitionsneeded during performance, and on the degree of bodystability required by activity demands when adjusted byclient factors. For instance, a child with significantquadriplegia may not be likely to use isolated trunkcontrol, so a wider base of support might be chosenduring hand function activities to contribute to thechild’s stability. A less involved child who is mobile andhas elements of active trunk control would be morelikely to benefit from working on a narrower base ofsupport. Base of support can be graded over time asprogress is seen. It is also important to remember if the child is in supportive seating during the day, thepractice part of sessions needs to take place in the sameconfiguration.

Base of support can affect the degree of weightshifting used in treatment. Large weight shifts obvi-ously are important to movement transitions; however,lesser degrees of weight shifting can play an importantrole in upper extremity treatment. Sitting at a table and cutting with scissors, for instance, usually incor-porates subtler weight shifts. If the child reaches foritems set back from the edge of the table, an anteriorweight shift occurs. Similarly, reaching for items off tothe side results in a lateral weight shift. Using subtleweight shifts assisted by key points of control whenworking on table top activities and development of fine motor skills can extend reach and assist with handplacement, as well as inhibiting extensor tone in thetrunk.

Weight shifts can assist in inhibition of tone andfacilitate active trunk and upper limb function. Otherfacilitation and inhibition techniques can be appliedduring treatment of hand function as well. Gentlevibration or oscillation on the trunk or limbs helps tomanage upper limb tone and use of the shoulder orelbow as key points of control facilitates active move-ments in the wrist and hand. Preparatory activitiesusing upper limb weight bearing prepare the hand formore active hand function by inhibiting tone andimproving mobility of wrist and finger flexors. Theseactivities can take place with the child in sitting orstanding, not just in quadruped, positions in whichupper limb weight bearing often takes place in typicalchildren.

NEURODEVELOPMENTAL TREATMENT ANDHAND FUNCTION

There are children in whom the primary interventionfocus needs to be within the hand. Examples arechildren with quadriplegic involvement in which themost important goal is isolated index finger function toaccess a computer or augmentative communicationdevice; a child with hemiplegic impairment who wantsto be able to hold a piece of paper in the impaired handso that cutting can be accomplished; or a young personwho wants to be able to manipulate a joystick to drivea power chair.

In these kinds of examples, direct treatment of thehand is necessary. Most of the inhibition and facilita-tion techniques described earlier can be applied directlyto the hand. Vibration or oscillation at the wrist orfrom the web space of the thumb minimizes tone in thefingers; these techniques can be used as preparationbefore performance or used during activities. Weightbearing on the hand is a well-known NDT techniquefor soft tissue stretch and tone management that isunderused in reciprocal hand interactions such as hand-to-hand clapping games with another person, in whichhand contact is extended for the purpose of stretch,deep pressure, or tone management. The degree ofwrist and finger extension involved in the activity canbe graded by the therapist depending on the desiredoutcomes and the tolerance of the child.

Key points of control in the hand include the wrist,longitudinal arch of the hand, MCP joint of the indexfinger, thenar eminence, and web space of the thumb.Obviously the use of key points of control has to becarefully managed in such a small area as the hand,which is when careful grading of activities comes intoplay. For example, when isolated control of the indexfinger is desired, the therapist may choose to use theMCP joint as a key point of control. Activities thatmight be used to facilitate sensorimotor experiences in


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this situation include pushing keys on a piano, com-puter, or toy, pressing stickers onto a surface, makingfingerprints in play dough, extending the digit forplacement, removal of a ring, and so forth. Thoseactivities that entail pressure (e.g., play dough, pressingkeys, stickers) are situations in which weight shiftsacross the pad of the digit provide alternating deeppressure inputs into the interphalangeal (IP) joints, aswell as the MCP joint, a facilitatory technique.

The mobility of the carpals and metacarpals of thehand contribute to the arch structures of the hand,wrist flexion and extension, and radial to ulnar sideinteractions within the hand. All of these elements alsoplay a role in grasp and manipulation between andwithin the hands. Hypertonic CP commonly results ina predominance of wrist and finger flexion combinedwith ulnar deviation at the wrist—resulting in ulnarprehensions. Maintaining mobility in the structures of the hand mentioned earlier while facilitating activemovement and the ability to participate in chosenoccupations are focal concerns of NDT treatment.

Although the prevailing muscle tone in the hand isincreased with generalized hypertonia, hypermobilityin the IP joints of the fingers and thumbs is common,as well as in the MCP and carpometacarpal joint of thethumb. This combination of increased mobility andfluctuating tone in the spastic hand presents challengesfor the therapist and the need to alternate strategies ofinhibition and facilitation frequently when workingwithin the hand.

Activity demands should be considered as part of treatment as well. AOTA (2002) defines thesedemands as

“. . . objects, space, social demands, sequencing or timing,required actions, and required underlying body functions andbody structure needed to carry out the activity.” (p. 624).

Specific aspects of any activity are items that shouldbe considered in treatment, and amended or modifiedwhen necessary to enable the client to have success inperforming the occupation. Nowhere is this moreimportant than when working within the hand. Forexample, it is common for therapists to choose thesmallest possible items to develop skills such as tip-to-tip prehension. Larger items offer the child bettercontrol and incorporate the same movement sequencesused in precision prehension; as skill is gained, thetherapist can then move on to include small objects intherapy.

Practicing occupations during treatment has beenemphasized in this chapter. There is a body of researchsupporting the efficacy of activity practice in childrenwith cerebral palsy (Duff & Gordon, 2003; Taub et al.,2004) and the importance of activity context on prac-tice outcomes (Volman, Wijnroks, & Vermeer, 2002).

It is critical that the therapist spend significant timehaving the client practice designated goals during thesession. The therapist can use inhibition and facilitationin this process, but needs to withdraw such assistance as the session moves on, remembering that ultimatelythe child is expected to do the task without suchassistance.

EFFICACY OF NEURODEVELOPMENTALTREATMENT

Judgment about the efficacy of therapeutic interven-tions should be based on careful examination ofpublished studies, either through systematic review ormeta-analysis. Such methods are limited by the limitedavailability of high-quality studies. Two recent system-atic reviews of NDT intervention have been carried out (Brown & Burns, 2001; Butler & Darrah, 2001).Butler and Darrah (2001) incorporated articles back to 1973, whereas Brown and Burns (2001) includedthose published since 1975. There were 21 studies inthe review by Butler and Darrah (2001) and 17 articlesin the review by Brown and Burns (2001). Bothreviews classified articles as one of five levels of evi-dence. Brown and Burns (2001) used the QualityAssessment of Randomized Clinical Trials scale createdby Jaded and co-workers (1996) to assign levels ofevidence, whereas Butler and Darrah (2001) used asystem developed by the American Academy of CerebralPalsy and Developmental Medicine (Butler & Darrah,2001). Another unique feature of their review is theirincorporation of dimensions of disability reflective of the National Center for Medical RehabilitationResearch (NCMRR) model of disablement (Shumway-Cook & Woollacutt, 2001) as one judgment ofoutcome.

Both reviews cited numerous problems in attempt-ing systematic study of NDT. Problems includedheterogeneity of the target population, lack of random-ization, inadequate blinding of subjects, a wide rangeof subject ages, use of a variety of clinical and stan-dardized outcome measures, small sample size andlimited follow-up, interventions that included othermethods besides NDT, a range of duration and inten-sity of treatments, and inconsistency of significanceacross studies. Both studies concluded that the efficacyof NDT could not be decided on the basis of thestudies reviewed, although Butler and Darrah notedthat studies published in the last 14 years had morestatistically significant results. In addition, both notedthat newer interventions based on more currenttheories of motor learning and skill development existand appear to be generating more conclusive evidence(Butler & Darrah, 2001). Butler and Darrah cited thelack of association to any of the NCMRR dimensions to which the various studies were compared. These


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same authors suggest that the use of NDT as a controlintervention in studies comparing it to another treat-ment would contribute to the body of existing evidenceabout treatment efficacy for children with CP.

Since these two systematic reviews were published,other publications about efficacy of NDT have beenpublished (Trahan & Malouin, 2002; Tsorlakis et al.,2004). Trahan and Malouin’s research was a pilot studyanalyzing the outcomes of an intermittent intensiveNDT intervention. Tsorlakis and co-workers (2004)research was a carefully designed randomized clinicaltrial comparing outcomes between two different dura-tions of NDT treatment that attempted to avoid designproblems of earlier studies. Duration of interventionhas become a focus of studies because of the devel-opment of constraint-induced therapy that providesintensive duration of therapy over a relatively shortterm (Taub et al., 2004).

SUMMARY

This chapter has described the neurodevelopmentaltreatment approach to pediatric intervention, and itshistory, evolution, and current perspective. As reiter-ated throughout the chapter, NDT is an interventionfocused on improving postural control and activemovement skills. The therapist bears the responsibilityfor integrating this kind of approach into function andpractice of function. Carryover of movement changesinto function does not occur naturally, as once pro-posed by the Bobaths. Although the efficacy of NDThas yet to be demonstrated convincingly, more recentstudies are supportive and suggest that the shift tointegration of NDT with functional outcomes hasmerit in the treatment of upper limb function in chil-dren with CP.


Seven-year-old Jodie, who had spastic CP of quadriplegicdistribution, used a head-activated switch to work on thecomputer, which meant scanning the keyboard rather thanbeing able to use direct selection of desired keys. Herschool therapists, teachers, and family wanted to explorethe possibility of hand activation of Jodie’s computeraccess switch with the eventual goal of direct selection onan alternative keyboard, which would be faster and moreproductive. Although computer use in the context of theschool environment was the initial occupational goal,success meant she would be able to access her homecomputer with less assistance than she presently required.

TASK ASSESSMENT AND GOALSActivity analysis of the process of pushing a switch (Table 16-1) and physical assessment of Jodie’s ability to push aswitch with her hand were carried out, along with anassessment of performance components, activity demands,and client factors in the OT Practice Framework (AOTA,2002) and of performance components in UniformTerminology III (AOTA, 1994). Jodie demonstrated chal-lenges in motor and process aspects of performance skills.She maintained her head in an upright position for longperiods of time and used it to move her eyes when trackingitems. Efforts at arm and hand movement affected move-ments of her head and trunk, resulting in dynamic tonechanges throughout her body manifested by increased

extension in her torso, head, and neck, and by bilateralrigid extension at the elbows and in the lower limbs. Aconsistent lean to the left was noted, a trend made worseby her attempts to use her hands. She could lift her armsactively by flexing and elevating her shoulders to about 80degrees but movement toward or away from the midlineto place her hands was difficult. There were soft tissuerestrictions in her shoulders, limiting the end range ofhumeral flexion and abduction.

Jodie’s hands were most often fisted and wrists stifflyextended. A right hand preference was noted. Jodiereached for offered items directly in front of her body butwas unable to grasp an object volitionally or bring herhands to her mouth. When a toy was placed in her hand,she would hold it indefinitely using increased flexor tonein the fingers of her hands but was unable to do anythingwith it; there was no volitional release of objects andefforts to do so resulted in head shaking in an effort torelease items from her hand. There was no isolation ofmovement between limbs or within either limb.

Jodie could place her hand on a 5″ × 7″ switch placedin front of her with difficulty, but could not consistentlydepress and release the switch to use it for computeraccess, nor could she remove her hand from the switchonce it was placed there.

The movement components she needed to activate the switch for various aspects of the activity are noted in

CASE STUDY 1

A CHILD WITH CEREBRAL PALSY

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Table 16-2. The use of these movements for activating theswitch were felt to be appropriate because Jodie’svolitional control of her elbow, wrist, and hand move-ments was minimal, and the switch could be successfullyactivated using these movements. In addition to move-ments to activate and release the switch, she needed to beable to organize and sequence these movements withenough speed to push the switch in a timely fashion whenvisually cued to do so by the scanning sequence. Thusanticipatory control in her arm (remember that antic-ipatory control was defined as activation of sensory andmuscular systems for a specified activity based on priorlearning and experience), postural control and adjustmentof her head, and active isolated movements of her rightupper limb were other aspects of performance needed for

motor control and learning so that she could initiate,sustain, and terminate movements of the shoulder insequence to perform the activity.

TREATMENT PLANThe organization of the treatment plan for Jodie isdetailed in this section and based on a school year withweekly sessions. The treatment plan incorporates bothenvironmental and client factors, as well as practice of theskill being developed during sessions and at home outsideof the therapy setting at school.

THERAPY GOALSThe goals found in Box 16-2 include long-term goals andbenchmarks as seen in an individualized educational plan(IEP) write-up. Benchmarks were chosen that support the

Table 16-1 Activity analysis of activating/deactivating a switch for computer use

Step of Visual Auditory Movement Tactile Activity Component Component Components* Component

Moves arm to Locates switch Lifts right arm toward Kinesthetic switch the switch using feedback from

humeral flexion and the limbhorizontal abduction. movingElbow extension

Places hand on Sees switch and Humeral extension Jodie feels the switch uses vision to activated to bring switch under

guide placement hand to switch her fisted of hand on switch hand

Presses switch to Sees scanning Hears click as Humeral extension is Jodie feels the activate array activate switch is activated used to push the pressure of the

when switch is switch switch on her pressed hand increase

as she pushes

Releases pressure Uses vision to Hears click as Humeral flexion is Feels absence on the switch guide her hand pressure is used to lift her hand of sensation as

lifting to release released and off the switch her hand clears switch pressure switch deactivated the switch

Moves arm and Sees hand lift off Moves arm away from Feels table rests hand on the of switch and the switch using surface under surface away targets where humeral flexion and her hand and from the switch hand is to rest horizontal adduction; arm when she

humeral extension is rests them onused to lower arm to the tablethe table surface

*Because the client has stiffly extended elbows, which become stiffer with efforts at movement, the choice made is to focus onhumeral movements to move her hand. Use of wrist flexion and extension also would be helpful; however, these movements arenot absolutely necessary to activate the switch.

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use of Jodie’s right upper extremity for single switchactivation working from her wheelchair. Although Jodiedoes have significant limitations in postural control, notethat postural elements are woven into the treatment butare not identified as long-term goals.

THERAPY ENVIRONMENTThe therapist chose to intervene with Jodie in her class-room. The first-grade classroom was broken up into areas,meaning that there were times when floor space was avail-able for therapy with Jodie out of her wheelchair. Thetherapist brought a therapy bolster to use during sessions.Being in the classroom meant that the same physical set-up of the switch and computer was available for practice ina real-life situation in which the therapist could observeJodie’s progress. Classmates were present, as was the caseduring spelling class, and could be available to provideencouragement if approved to do so by the classroomteacher.

HANDS-ON TREATMENT

The therapist used four premises upon which to base hertreatment. First, tone increases seen in Jodie when sheattempts to use her upper limbs will be altered throughthe use of work on a mobile surface (the bolster), facili-tation of forward and lateral weight shifts when reachingfor her switch, and use of periodic rapid oscillations to theupper limbs. Second, use of facilitatory tapping and active-assisted hand placement on the switch will be used to helpJodie activate shoulder movements for hand placement,switch depression, and switch release (see Table 16-2).Third, practice of the task will be used to ensure changesin motor performance, motor learning of the skill beingdeveloped, and switch activation for computer use. Fourth,tactile enhancement and reinforcement will be used toensure that Jodie knows when her hand is and is not onthe switch to help build anticipatory control mechanismsneeded for successful task accomplishment.

Table 16-2 Facilitation and inhibition techniques to be used in Jodie’s treatment

Step of Activity Movement Component Facilitation/Inhibition Techniques

Moves arm to Lifts right arm toward the Tapping under the humerus to facilitate shoulder switch switch using humeral flexion flexion and elbow extension; tapping on the

and horizontal abduction. medial border of the arm to facilitate horizontalElbow extension abduction; forward then lateral weight shift of

torso across the pelvis to facilitate arm movement in a sagittal then lateral plane

Places hand on Humeral extension activated to Sweep tap across volar surface of the humerus; switch bring hand to switch posterior weight shift of torso across the pelvis

to facilitate arm movement toward the switch

Presses switch to Humeral extension is used to Active assist from head of humerus or on the activate push the switch forearm to facilitate pressure on hand to activate

switch; lateral weight shift of torso across the pelvis to facilitate switch activation

Releases pressure on Humeral flexion is used to lift Tapping under the humerus to facilitate shoulder the switch her hand off the switch flexion and elbow extension; tapping on the

medial border of the arm to facilitate horizontal abduction; forward weight shift of torso across the pelvis to facilitate arm movement in a sagittal plane

Moves arm and rests Moves arm away from the switch Tapping under the humerus to facilitate shoulder hand on the surface using humeral flexion and flexion and elbow extension; tapping on the away from the horizontal adduction; humeral lateral border of the arm to facilitate horizontal switch extension is used to lower arm to adduction; forward then medial weight shift of

the table surface torso across the pelvis to facilitate arm movement in a sagittal then lateral plane

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TREATMENT IMPLEMENTATIONIn this section, sequencing within therapy sessions isdescribed, incorporating the physical environment, ther-apy equipment, therapeutic facilitation, and practicecomponents.Tone Management and Preparation for ActivityJodie was removed from her wheelchair for the first 15 to20 minutes of each 40-minute session. This enabled thetherapist to use weight shifts and techniques to modify thedynamic muscle tone Jodie demonstrated whenever shetried to use her upper limbs and gave her practice in use of appropriate postural components. A bolster was usedbecause it enabled the therapist to use two planes ofmotion: anterior/posterior movements and lateral move-ments. Jodie was placed on the bolster, either on the farend or straddling it, to enable the therapist to use themovement of the bolster when addressing Jodie’s muscletone during activities and to facilitate her active weightshifts while providing a wide base of support. These bol-ster motions were activated by the therapist’s use of herown lateral weight shifts and anterior or posterior bodymovements.

At the same time, rapid oscillations of Jodie’s upperlimbs were used to help loosen her stiff arms in prepa-ration for developing the active shoulder movements neededto activate the switch (Figure 16-1). At this point, thetherapist had Jodie lean onto her upper limbs positionedon the bolster to help inhibit tone and increase range inher hands as preparation for switch activation.

Forward weight shifts accompanied the upper extrem-ity weight bearing, passively accomplished at first by thetherapist leaning forward into Jodie’s torso and movingher forward. The therapist facilitated the weight shift in

this manner for the first few times, and then used decreas-ing assistance as Jodie exhibited the ability to activate aweight shift on her own.Switch ActivationThis skill was practiced first with Jodie still on the bolster.Using the bolster allowed the therapist to facilitate weightshifts and shoulder movements and inhibit hyperextension of the trunk during efforts at movement. An adjustableheight table under which the bolster was slid helped tosupport the switch. The switch position at first was putfurther back on the table than needed to require anexaggerated forward weight shift to counterbalance theextensor thrust that occurred when Jodie tried to move.Remember at this point that Jodie’s arms were resting onthe table surface at midline so she would not have to moveher shoulder high or far laterally to place her hand on theswitch. The switch surface could be enhanced with a num-ber of different materials (e.g., carpet samples, variousfabrics) to heighten differences between the table andswitch surfaces.

When Jodie was asked to activate the switch, a series of short taps under her humerus were used to activatehumeral flexion (Figure 16-2), then laterally to bring thehumerus to the switch, which was placed slightly off to theside (Figure 16-3). Active assistance in placing her handwas also used alternatively to help Jodie develop a sense ofwhat was needed to get to the switch; however, this onlyoccurred on alternate attempts rather than each time shetried to touch the switch.

BOX 16-2 Long-Term Goal andBenchmarks for Jodie

Jodie will be able to depress and release a 4 × 6computer switch attached to a computer-scanningprogram in order to participate in spelling tests withher classmates

a. Jodie will be able to lift and place her handon the switch accurately 80% of the time.

b. Jodi will be able to depress the switch toactivate a simple on-off toy or object such asa radio 90% of the time

c. Jodie will be able to depress and release theswitch to participate in a simple computergame with 80% accuracy

d. Jodie will be able to activate the switch withsufficient timing and accuracy to complete a10-word spelling test within a 30-minuteperiod of time

e. Jodie will maintain her accuracy at switchactivation through out the school day withminimal fatigue

Figure 16-1 Jodie is seated on a bolster with thetherapist behind her. The therapist supports Jodie’sarms at the elbow or slightly below, and moves themin a rapid alternating, up-and-down sequence toreduce muscle tone. The hands can be clappedagainst each other to assist. The therapist can movethe bolster side to side with her own body if needed,and can lean forward to facilitate more trunkextension on the part of the child.

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Placing her hand on the switch and activating theswitch were skills that were separated on the goal list butnot in treatment. At this early point in learning to activatethe switch, the switch was attached to a device such as aradio or fan, items that do not require a great deal ofaccuracy for successful activation. Once Jodie had herhand on the switch, a tap on either the volar surface of thehumerus or the forearm was used to facilitate activation.An assisted weight shift posteriorly helped with switchactivation as well, but it needed to be carefully carried outso that Jodie was not pulled backward. Active assistancewas used to press the switch, using the same carefulguidelines described earlier. A latch switch was used tolimit the amount of time the device is active, requiringJodie to lift her hand from the switch, then depress itagain to restart the device.

Releasing the switch was facilitated by incorporatingthe same techniques used to facilitate placing Jodie’s handon the switch only in reverse order. Release of objects is amore challenging task for children with CP, as indicated byresearch in children with hemiplegia (Eliasson & Gordon,2000; Gordon et al., 2003). Such studies have shown thatthe temporal aspect of release is a particular problem,which was the case for Jodie when releasing the switch.

SEQUENCING THE PLANThe idea was to move Jodie forward in her treatment planas expeditiously as possible. To do this, she needed to

practice outside of her therapy sessions. Ideally this wouldoccur in both home and school settings, depending on thefamily and time in the classroom. Another way to managemore practice would be to increase the frequency andduration of treatment sessions. Although this program wasdeveloped around the traditional weekly model of therapyfrequency, research has demonstrated that massed or inten-sive practice such as is used in constraint-induced para-digms and other research has better outcomes for childrenwith CP (Duff & Gordon, 2003; Taub et al., 2004).

Another critical issue was communication between thetherapist and teacher. This assisted in documenting goalsand assuring that teacher, aide, and therapist were all usingsimilar techniques and the same equipment. If progresswas not seen in a short period of time (2 to 3 weeks), thenit would be necessary to re-evaluate the plan and adjustintervention.

OUTCOMEIt was soon apparent that the switch needed to be stabi-lized on the surface; therefore a slightly inclined easelsurface with Dycem under the switch and easel were usedto provide stability. Masking tape was used on both homeand school table surfaces to mark where the easel went to be sure that the location of the switch was consistentover time.

Figure 16-2 Jodie has been asked to activate theswitch but is demonstrating delayed response time. Toassist her, the therapist sweep taps on the dorsum ofher arm, moving from the elbow back toward theshoulder. The purpose is to give tactile input so thatJodie recognizes which body part needs to be moved.

Figure 16-3 A continuation of sweep tapping isused here; however, the direction has altered. Theswitch is placed about 15 degrees off of midline andJodie needs to horizontally abduct her shoulder to hither target. While the palm of the therapist’s handremains under Jodie’s arm, the tips of her fingers areon the medial border of the arm and tap lightly to cuethe change in movement direction.

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Jodie made rapid progress at placing her hand on theswitch. Accurate depression and release of the switch voli-tionally in a timely fashion took another 2 to 3 months toachieve with frequent dialogue among teachers, therapist,and family. Jodie was motivated, which helped, and hadpersistent encouragement from her classmates. Her switchactivation accuracy initially deteriorated throughout the

day as fatigue set in, so the family limited her homepractice to weekends. At the end of 3 months, Jodie couldaccurately complete a 10-word spelling assignment usinghand-activation of her switch in 30 minutes. Fatigue wasbecoming less of a factor, so her teacher began to addshort assignments later in the day.

Two-and-a-half-year-old Lily has quadriplegic involvementwith low muscle tone and aimless movements of her limbs.She can hold her head up and sit for short periods of time(3 to 5 minutes) when placed in supported sitting butspends much of her day playing in prone or supine, orpropped in her infant seat. She can grasp objects witheither hand but does not use both hands together. Mostof her activity consists of mouthing objects and then drop-ping them after briefly holding onto them. Her motherreports her as being an irritable child who screams whennew stimuli come into the environment. The family wouldlike her to be able to play by herself for longer periods oftime and use both hands to play, to sit up longer so theycan play with her, to hold her cup and drink from it, andfor her to be less irritable. Box 16-3 contains examples ofgoals for Lily. The goals of using her hands to hold a cupwill be used for demonstration purposes. Specifically thegoal will be for Lily to sit supported in her high chair andlift her cup and drink when it is placed on a surface in frontof her. Table 16-3 shows an activity analysis of this goal,which is used to plan the intervention.

PREPARATORY ACTIVITIESThe intervention was scheduled for Lily’s usual afternoonsnack time to locate the intervention in her usual dailypattern of activities. Doing so offered demonstration timeand consistent feedback to the mother about Lily’s per-formance and gave the therapist the opportunity to re-evaluate Lily’s skills each week. Table 16-4 illustrates thesteps of the activity and the techniques to be incorporatedinto the intervention session. Because Lily was anticipat-ing the cup, she tended to be less tolerant of extensiveprefeeding activity, so preparatory work was limited to 5to 10 minutes. The therapist sat on a chair or sofa. Lily waspositioned on the therapist’s knees; she could either facethe therapist or face her mother with her back to thetherapist. Facing the therapist meant her base of supportwas wider because she was straddling the therapist’s legs;while facing her mother she was not straddling and thebase of support was narrower. Lily was supported at theshoulders and the therapist gently bounced her using

plantar flexion and return from plantar flexion of her ownfeet to provide bounces that were timed asymmetrically soas not to be predictable. Firm downward pressure wasapplied at the shoulders, with the therapist’s thumbs posi-tioned over the heads of each humerus and the fingerssupporting the scapulae (Figure 16-4). Sound productionby Lily was encouraged to activate abdominal contractionat the same time. This activity was sustained for 1 to 2minutes, and then the therapist’s hand position was shifted

CASE STUDY 2

A CHILD WITH LOW TONE

BOX 16-3 Long-Term and Short-TermGoals for Lily

1. Lily will lift the cup from the surface to hermoutha. Lily will place both hands on the cup when it

is placed on the surface in front of her.b. Lily will lift an almost empty cup off of the

surface briefly.2. Lily will hold the cup when it is placed at her

mouth to take a drink.a. Lily will place both hands on the cup while

mother provides over hand assistance.b. Lily will spontaneously place her hands on

the cup held at her mouth for a few second.c. Lily will hold an almost empty cup at her

mouth with minimal assistance from hermother.

3. Lily will put the cup back on the surface after shehas drunk from it.a. Lily will maintain her hands on the cup with

maximal assistance from her mother as hermother returns it to the surface.

b. Lily will hold the cup briefly when she isfinished drinking and then place it.

4. Lily will lift the cup to her mouth, drink from it,and return the cup to the surface.

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to Lily’s abdomen and lumbar spine. The hand on thelumbar spine was for support, whereas the hand on theabdomen was used to apply firm downward pressure tocontinue activation of the abdominals.

A movement transition to produce coactivation oftrunk extensors and flexors followed. Lily was weightshifted toward the arm of the chair with the key point ofcontrol at the pelvis. The goal here was for Lily to putboth hands onto the chair arm, producing a bilateral upperlimb weight-bearing activity (Figure 16-5). The pelvis was

maintained in a straight plane position while the trunkrotated over it, a position requiring cocontraction of abdom-inals and trunk extensors. This activity was carried outbriefly, and then Lily was facilitated to turn to face hermother with the therapist’s hands moved back to theabdominals and lumbar spine and downward pressureapplied on the abdominals to activate a forward weightshift. Her mother facilitated bilateral shoulder flexion byholding her hands out to Lily. She did not pick up herdaughter until Lily reached out with both arms. The

Table 16-3 Activity analysis of drinking from a cup with two hands in supported sitting

Visual Auditory Movement Tactile Step of Activity Component Component Components Component

Cup is placed on Sees cup Person handing Arms move toward Kinesthetic surface; child’s approaching and the cup may make the cup; possible feedback fromarms activate at set on surface statement; cup components: humeral the limb the sight of the makes sound as abduction moves to movingcup it touches the humeral adduction;

table elbows extend and hands open

Takes cup Sees the cup held Parent may make Hands grasp cup; Lily feels the at midline statement humeri are adducted, cup on her

elbows midway hands; weightbetween flexion and of the extension and liquid givesforearm midposition, proprioceptivefingers flexing feedback

Raises cup to her Sees the cup Humeral movement Feels cup mouth moving toward is flexion; elbows touch her

her face move into flexion; mouth; feels fingers flexed weight of cup

on hands andthrough shoulders

Drinks from cup May look at Humeral and elbow Feels weight others in the flexion used to lift of the cup in room the cup to pour her hands,

liquid into the mouth and liquid in the mouth and throat

Brings cup back May look at cup Hears cup when it Humeri and elbows Feels cup hitto surface and as she moves it hits the table extend the surface releases it away from her and absence

mouth of tactilefeedbackon her hands

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movement transitions described provided limitedvestibular input. More consistent use of rotary movementsduring transitions provides the kind of vestibular inputchildren achieve themselves through active movements.

ACTIVITY PRACTICE OF DRINKING FROM THE CUPLily was placed in her child-sized chair. The therapist satbehind the high chair and placed her hands on Lily’sshoulders. The thumbs were placed along the proximalaspect of the humerus and the fingers rested on theabdomen. Her mother held a half-filled cup in front ofLily but did not place it on the tray. The therapist usedpressure on the lateral border of the humeri to bring Lily’shands together and then slipped her hands up over theproximal part of her arms to help Lily clap her handsfirmly several times. Her mother then placed the cup onthe tray, tapping it to get Lily’s attention and asking her totake the cup. A subtle forward weight shift for the reachwas facilitated using the shoulders as a key point ofcontrol. Her mother cued her verbally again and thetherapist waited briefly to see if Lily reached for the cup,

then helped place her hands on it. Firm pressure on theshoulders was attempted to sustain Lily’s hands on thecup. When unsuccessful, the therapist slid her hands downover Lily’s hands (Figure 16-6). Once Lily sustained hergrasp of the cup, tapping under the proximal aspect of thearm was used to facilitate lifting. As Lily became moreproficient at grasping, the therapist moved her hands backup to the child’s shoulder to help facilitate lifting andholding of the cup at the mouth. With further progress,the therapist gradually withdrew her support, limiting thecues needed to generate Lily’s participation.

The mother could facilitate this activity from in front ofLily in a sitting position using the same key points andsequence of activity. The preparatory activities were taughtto the mother as a game to be carried out at differenttimes during the day, as well as in preparation for feeding.

OUTCOMESLily actively resisted the movement transition sequence.After attempting to use it before giving Lily her cup, thetherapist chose to discontinue this aspect of the inter-

Table 16-4 Facilitation and inhibition techniques to be used in Lily’s treatment

Step of Activity Movement Components Facilitation/Inhibition Techniques

Cup is placed on Arms move toward the cup; Deep pressure on the abdominals to facilitatesurface; child’s arms possible components: humeral trunk and humeral movements toward midline; activate at the sight abduction moves to humeral humeri as key point of control to bring hands of the cup adduction; elbows extend and together passively then as cue to do so actively;

hands open Hands clapped together to give sensory cue toopen hands and deep pressure feedback to palms of hands.

Takes cup Hands grasp cup; humeri are Anterior weight shift to assist in reaching for and adducted, elbows midway grasping the cup; hands brought to the cup and between flexion and extension deep pressure on hands over the cup used to giveand forearm midposition, fingers sensory feedback; approximation through the flexing trunk to facilitate co-contraction of abdominals

and extensors

Raises cup to her Humeral movement is flexion; Shoulders used as a key point of control tomouth elbows move into flexion; sustain hands on the cup; ulnar side fingers used

fingers flexed to tap under the arms to facilitate forward flexion;posterior weight shift used to facilitate arms to lift.

Drinks from cup Humeral and elbow flexion used Posterior weight shift to facilitate neck flexors to lift the cup to pour liquid and abdominals to hold with head and trunk into the mouth extended while drinking; shoulders continue as

key point of control for entire upper limb

Brings cup back to Humeri and elbows extend Anterior weight shift to assist in reach of arms surface and lets it to the tray; gentle vibration to facilitate fingers drop letting go of the cup.

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vention and worked on two-handed reach and grasp of thecup only. Lily was able to reach and grasp with two handssuccessfully in several weeks. Her ability to keep two handson the cup while bringing it to her mouth took anothermonth. Lily still refuses to grasp the cup on occasion whenirritable.

Figure 16-4 Lily is positioned on the therapist’sknees facing the therapist. She is supported at theshoulders and the therapist is gently bouncing her,using her own feet to provide the bounces. Firmdownward pressure is applied at the shoulders, withthe therapists’ thumbs positioned over the heads ofeach humerus and the fingers supporting thescapulae.

Figure 16-5 A movement transition to producecoactivation of trunk extensors and flexors is illustratedhere. Lily’s weight is shifted toward the arm of thechair with the therapist’s key point of control at thepelvis. The pelvis rotates slightly and one side lifts withthe weight shift while the trunk rotates over it. At thesame time, Lily moves her hand to the arm of therocking chair to support herself, producing a weight-bearing activity in conjunction with a movementtransition.

Figure 16-6 In this figure, the child is havingdifficulty sustaining her grasp on the surface of thecup. To cue her, the therapist places her hands overLily’s and applies gentle pressure over Lily’s wrists andhands to support the cup and give her sensoryfeedback about the task. As Lily becomes moreproficient, the therapist can slide her hands back upthe forearms to guide the movement while Lilymaintains her grip on the cup independently.

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REFERENCESAmerican Occupational Therapy Association (1994).

Uniform terminology for occupational therapy, 3rd ed.American Journal of Occupational Therapy,48:1047–1059.

American Occupational Therapy Association (2002).Occupational therapy practice framework: Domain andprocess. American Journal of Occupational Therapy,56:609–639.

Andersson C, Mattsson E (2001). Adults with cerebralpalsy: A survey describing problems, needs, and resources,with special emphasis on locomotion. DevelopmentalMedicine and Child Neurology, 43:76–82.

Asher I (1996). Occupational therapy assessment tools: Anannotated index, 2nd ed. Rockville, MD, AmericanOccupational Therapy Association.

Bertenthal B, Von Hofsten C (1998). Eye, head and trunkcontrol: The foundation for manual development.Neuroscience & Biobehavioral Reviews, 22(4):515–520.

Blanche E, Botticelli T, Hallway M (1995). Combiningneuro-developmental treatment and sensory integrationprinciples: An approach to pediatric therapy. San Antonio,TX, Therapy Skill Builders.

Bobath B (1955). The treatment of movement disorders ofpyramidal and extra-pyramidal origin by reflex inhibitionand by facilitation of movements. Physiotherapy,41:146–153.

Bobath B, Bobath K (1984). The neuro-developmentaltreatment. In D Scrutton, editor: Management of themotor disorders of children with cerebral palsy (pp. 6–18).Philadelphia, JB Lippincott.

Bohannon R, Smith MB (1987). Interrater reliability of amodified Ashworth scale of muscle spasticity. PhysicalTherapy, 67:206–207.

Boyce WF, Gowland C, Rosenbaum P, Lane M, Plews N,Goldsmith CH, Russell J, Wright V, Potter S, Harding D(1995). The Gross Motor Performance Measure: Validityand responsiveness of a measure of quality of movement.Physical Therapy, 75:603–613.

Brown GT, Burns SA (2001). The efficacy of neuro-developmental treatment in paediatrics: A systematicreview. British Journal of Occupational Therapy,64(5):235–244.

Butler C, Darrah J (2001). Effects of neurodevelopmentaltreatment (NDT) for cerebral palsy: An AACPDMevidence report. Developmental Medicine and ChildNeurology, 43:778–790.

Cathels B, Reddihough DS (1993). The health care ofyoung adults with cerebral palsy. The Medical Journal ofAustralia, 15:444–446.

Dabney KW, Lipton GE, Miller F (1997). Cerebral palsy.Current Opinions in Pediatrics, 9:81–88.

Damiano DL, Vaughan CL, Abel MF (1995). Muscleresponse to heavy resistance exercise in children withspastic cerebral palsy. Developmental Medicine and ChildNeurology, 37:731–740.

Darrah J, Wessel J, Nearingburg P, O’Connor M (1999).Evaluation of a community fitness program foradolescents with cerebral palsy. Pediatric Physical Therapy,11:18–23.

Dodd KJ, Taylor NF, Damiano DL (2002). A systematicreview of the effectiveness of strength-training programsfor people with cerebral palsy. Archives of PhysicalMedicine & Rehabilitation, 83:1157–1164.

Duff S, Gordon A (2003). Learning of grasp control inchildren with hemiplegic cerebral palsy. DevelopmentalMedicine and Child Neurology, 45:746–757.

Eliasson A, Gordon A (2000). Impaired force coordinationduring object release in children with hemiplegic cerebralpalsy. Developmental Medicine and Child Neurology,42:228–234.

Eliasson A, Gordon A, Forssberg H (1995). Tactile controlof isometric fingertip forces during grasping in childrenwith cerebral palsy. Developmental Medicine and ChildNeurology, 37:72–84.

Eliasson A, Johansson RS, Westling G (1992). Developmentof human precision grip. III. Integration of visual sizecues during the programming of isometric forces.Experimental Brain Research, 90:399–403.

Forssberg H, Eliasson A, Kinoshita H, Johansson RS,Westling G (1991). Development of human precisiongrip. I. Basic coordination of force. Experimental BrainResearch, 85:451–457.

Gordon A, Charles J, Duff S (1999). Fingertip forcesduring object manipulation in children with hemiplegiccerebral palsy. II. Bilateral coordination. DevelopmentalMedicine and Child Neurology, 41:176–185.

Gordon A, Duff S (1999a). Fingertip forces during objectmanipulation in children with hemiplegic cerebral palsy. I. Anticipatory scaling. Developmental Medicine and ChildNeurology, 41:166–175.

Gordon A, Duff S (1999b). Relation between clinicalmeasures and fine manipulative control in children withhemiplegic cerebral palsy. Developmental Medicine andChild Neurology, 41:586–591.

Gordon A, Lewis SR, Eliasson AC, Duff S (2003). Objectrelease under varying task constraints in children withhemiplegic cerebral palsy. Developmental Medicine andChild Neurology, 45:240–248.

Gowland B, Boyce WF, Wright V, Russell D, GoldsmithCH, Rosenbaum P (1995). Reliability of the Gross Motor Performance Measure. Physical Therapy,75:597–602.

Hadders-Algra M, van der Fits I, Stremmelaar EF, TouwenB (1999). Development of postural adjustments duringreaching in infants with CP. Developmental Medicine andChild Neurology, 41:766–776.

Hallan P, Weindling AM, Klenka H, Gregg J, RosenbloomL (1993). A comparison of three procedures to assess themotor ability of 12-month-old infants with cerebral palsy.Developmental Medicine and Child Neurology,35:602–607.

Harris SR, Haley SM, Tada WL, Swanson MW (1984).Reliability of observational measures of the MovementAssessment of Infants. Physical Therapy, 64:472–476.

Howle J (2004). Neuro-developmental treatment approach.Laguna Beach, CA, Neuro-Developmental TreatmentAssociation.

Hutton JL, Pharoah PO (2002). Effects of cognitive,motor, and sensory disabilities on survival in cerebralpalsy. Archives of Disability in Children, 86:369–375.

Jaded AR, Moore RA, Carroll D, Jenkinson C, ReynoldsJM, Gavaghan DJ, McQuay DJ (1996). Assessing thequality of reports of randomized clinical trials: Is blindingnecessary? Controlled Clinical Trials, 17:1–12.

Kellegrew D (1996). Occupational therapy in full-inclusionclassrooms: A case study from the Moorpark model.American Journal of Occupational Therapy, 50:718–724.

Kinoshita H, Eliasson A, Johansson RS, Westling G (1992).Development of human precision grip. II. Anticipatory


A03186-Ch16.qxd 6/8/05 10:24 AM Page 364

control of isometric forces targeted for object’s weight.Experimental Brain Research, 90:393–398.

Koman LA, Smith BP, Shilt JS (2004). Cerebral palsy.Lancet, 363:1619–1631.

Lesny I, Stehlik A, Tomasek J, Tomankova A, Havlicek I(1993). Sensory disorders in cerebral palsy: Two pointdiscrimination. Developmental Medicine and ChildNeurology, 35:402–405.

Liao SF, Yang TF, Hsu TC, Chan RC, Wei TS (2003).Differences in seated postural control in children withspastic cerebral palsy and children who are typicallydeveloping. American Journal of Physical Medicine andRehabilitation, 82:622–666.

Mackey AH, Walt SE, Lobb G, Stott NS (2004).Intraobserver reliability of the modified Tardieu scale inthe upper limb of children with hemiplegia.Developmental Medicine and Child Neurology,46:267–272.

Miller LJ, Roid GH (1993). Sequence comparisonmethodology for the analysis of movement patterns ininfants and toddlers with and without motor delays.American Journal of Occupational Therapy, 47:339–347.

Murphy K, Molnar G, Lankasky K (2000). Employmentand social issues in adults with cerebral palsy. Archives ofPhysical Medicine and Rehabilitation, 81:807–811.

Nelson K, Grether JK (1999). Causes of cerebral palsy.Current Opinions in Pediatrics, 11:487–491.

Neumann D (2002). Kinesiology of the musculoskeletalsystem: Foundations for physical rehabilitation. St Louis,Mosby.

Nichols DS (2001). Development of postural control. In JCase-Smith, editor: Occupational therapy for children, 4thed. (pp. 266–288). St Louis, Mosby.

Rahlin M, Rheault W, Cech D (2003). Evaluation of theprimary subtests of toddler and infant motor evaluation:Implications for clinical practice in pediatric physicaltherapy. Pediatric Physical Therapy, 15:176–183.

Reid D (1996). The effects of the saddle seat on seatedpostural control and upper-extremity movement inchildren with cerebral palsy. Developmental Medicine andChild Neurology, 36:805–815.

Roncesvalles MN, Woollacott MW, Burtner PA (2002)Neural factors underlying reduced postural adaptability inchildren with cerebral palsy. Neuroreport, 13:2407–2410.

Shumway-Cook A, Woollacutt M (2001). Motor control:Theory and practical applications, 2nd ed. Philadelphia,Lippincott Williams & Wilkins.

Stapley P, Pozzo T, Grishin A (1999). The role of

anticipatory postural adjustments during whole bodyforward reaching movements. Neuroreport, 9:395–401.

Steenbergen B, Hulstijn W, Dortmans S (2000). Constraintson grip selection in cerebral palsy: Minimizingdiscomfort. Experimental Brain Research, 134:385–397.

Strauss D, Shavelle R (1998). Life expectancy of adults withcerebral palsy. Developmental Medicine and ChildNeurology, 40:369–375.

Strauss D, Cable W, Shavelle R (1999). Causes of excessmortality in cerebral palsy. Developmental Medicine andChild Neurology, 41:580–585.

Thomas SS, Buckon CE, Phillips DS, Aiona M, Sussman M(2001). Interobserver reliability of the gross motorperformance measure: Preliminary results. DevelopmentalMedicine and Child Neurology, 36:97–102.

Taub E, Ramey SL, DeLuca S, Echols K (2004). Efficacy ofconstraint-induced movement therapy for children withcerebral palsy with asymmetric motor impairment.Pediatrics, 113(2):305–312.

Trahan J, Malouin F (2002). Intermittent intensivephysiotherapy in children with cerebral palsy: A pilotstudy. Developmental Medicine and Child Neurology,44:233–239.

Tsorlakis N, Evaggelinou C, Grouios G, Tsorbatzoudis C(2004). Effect of intensive neurodevelopmental treatmentin gross motor function of children with cerebral palsy.Developmental Medicine and Child Neurology,46:740–745.

Turk MA, Geremski CA, Rosenbaum PF, Weber RJ (1997).The health status of women with cerebral palsy. Archivesof Physical Medicine and Rehabilitation, 78:10–17.

Van der Heide J, Begeer C, Fock JM, Otten B, StremmelaarE, van Eykern L, Hadders-Algra M (2004). Posturalcontrol during reaching in preterm children with cerebralpalsy. Developmental Medicine and Child Neurology,46:253–266.

Vogtle L, Snell ME (2004). Methods for promoting basicand instrumental activities of daily living. In CChristiansen, editor: Ways of living: Self-care strategies forspecial needs, 3rd ed. (pp. 85–108). Rockville, MD, TheAmerican Occupational Therapy Association.

Volman MJ, Wijnroks A, Vermeer A (2002). Effect of taskcontext on reaching performance in children with spastichemiparesis. Clinical Rehabilitation, 16:684–692.

Yekutiel M, Jariwala M, Stretch P (1994). Sensory deficit inthe hands of children with cerebral palsy: A new look atassessment and prevalence. Developmental Medicine andChild Neurology, 36:619–624.


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