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CHARTER 20 spasticity management usually’ rely on input from Cerebral Palsy physical therapists. The therapist’s influence is not SANDRA J. ONLNEY, BSc restricted (P&OT), Med, PhDcenter and treatment to the medical MARILYNJ. WRIGHT, BSCPT NATURE AND CHARACTERISTICS OF CEREBRAL PALSY Classification, Etiology and Pathophysiology Progress in Primary Prevention Impairment Determinants of Prognosis or Outcome EXAMINATION, INTERVENTION Infancy EVALUATIAB, AND Cerebral palsy’ (CP) is the neurologic condition most frequently encountered by pediatric physical therapists. Jr is a permanent but not unchanging neurodevelopmental impairment caused by a non progressive defect or lesion in single or multiple locations in the immature brain. The defect or lesion can occur in utero or during or shortly after birth and produces motor impairment and possible sensory deficits that are usually evident in early infancy (Scherzer & Tscharnuter, 1990). CP involves one or more limbs and frequently the trunk. It causes disturbances of voluntary motor function and produces a variety of symptoms. Nevertheless, CP is itself an artificial concept, comprising several causes and clinical syndromes that have been lumped together because of a commonality of management. The impaired control and coordination of voluntary muscles is accompanied by mental retardation or learning disabilities in 50 to 75% of children and by disorders of speech (25%), auditory impairments (25%), seizure disorders (25-35%), or abnormalities of vision (40-50%) (Batshaw. & Perret, 1992; Schanzenbacher, 1989). Social and family problems may occur secondary to the presence of primary deficits. In few conditions do therapists play such a central role or have as much potential to influence the outcome of children’s lives. Their interventions have not only immediate but also lifelong effects, and can be efficient and cost-effective. Treatment of children is specialized: therapists provide services that will help them reach their full potential in their homes and communities. Furthermore, decisions a bout many medical interventions such as orthopedic surgery and Preschool Period School-Age and Adolescent Period Transition to Adulthood RESEARCH NEED GLOBAL ISSUES PROFESSIONAL ISSUES CADE HISTORIES gymnasium, but frequently includes consultation regarding the child’s functioning in settings within the home, school, recreation, and community environments. Good therapy not only helps the child with CP but also can have a positive influence on the child’s family and caregivers. In summary, parents of children with disabilities want services that provide general and specific information about their child, provide coordinated and comprehensive care, and are provided by’ respectful and supportive professionals (King et al., 1998). The pediatric physical therapist is ideally’ suited to fill these roles. This chapter discusses the background of cerebral palsy the classification, etiology, and pathophysiology; prevention; associated impairments; and determinants of outcomes. Physical therapy examination, evaluation, and intervention that are related to each age between infancy and adulthood are discussed. The chapter concludes with two case histories. NATURE AND CHARACTERISTICS OF CEREBRAL PALSY Classification, Etiology, and Pathophysiology CP has been classified in a number of ways. A classification based on the area of the body exhibiting impairment yields the designations of monoplegia (one limb), diplegia (lower limbs), hemiplegia (upper and lower limbs on one side of the body), and quadriplegia (all limbs). Another classification, based on the most obvious movement abnormality resulting from common brain lesions, yields spastic, dyskinetic, and ataxic types. The spastic type, in which the muscles are perceived as excessively stiff and taut, especially during attempted movement, results from involvement of the motor cortex or white matter projections to and from cortical sensorimotot areas of the brain. Involvement of the basal ganglia is reflected in dyskinesia or athetosis and sometimes in intermittent muscular tension of the extremities or trunk and involuntary movement patterns. A cerebellar lesion produces ataxia, or general instability of movement. A hypotonic classification, not known to be related to a particular lesion, is characterized by diminished resting muscle tone and decreased ability to generate voluntary muscle force. Symptoms of spasticity and dyskinesia may both be present in a child, with the type of CP referred to as mixed. The degree of severity of CP varies greatly, and the designations mild, moderate, and severe are often applied within types. The Gross Motor Disability Classification System is a five-level, age categorized system that places children with CP into categories of severity that represent clinically meaningful distinctions in motor function (Palisano et al., 1997). Although the proportions of the various subtypes of CP vary with the reporting source, a series from Sweden noted that hemiplegia accounted for 36.4%; diplegia, 41.5%; quadriplegia. 7.3%; dyskinesia or athetosis, 10%; and ataxic forms, 5% (Hagberg et al., 1989a). CP is a condition with multiple causes leading to damage within the central nervous system. Although the causes are not completely understood, certain prenatal, perihatal, and postnatal factors have been associated with CP (Torfs et al., 1990). There is general agreement that the majority of cases of CP in term infants are due to prenatal or unknown causes, whereas in the vast majority of preterm infants the lesion causing CP develops during the perinatal period. Preterm birth, although not believed to be causative, is associated with up to 33% of all cases, including more than 50% of diplegia (Pharoah et aL, 1990), 25% of hemiplegia (Uvebrandt, 1988), and 5% of quadriplegia (Edebol-Tysk, 1989). Prenatal malnutrItion, intrinsic developmental problems of the fetus, poor maternal prenatal condition, and maternal infection are also associated with CP (Menkes, 1990). Intracranial hemorrhage, especially among premature infants, is a wellestablished causal factor. Neonatal asphyxia is a significant perinatal event, but only a small minority of cases result from such events (Nelson & Ellenberg, 1986). Infection in the perinacal period is also important. The effects of hvperbilirubinemia and other blood incompatibilities frequently resulting in athetoid CP are a concern, particularly in developing countries. The statistics from developing countries are in sharp contrast to those of developed countries. Studies have suggested that up to 63%. of cases in the former have preventable causes associated with shortage of care personnel and inadequate financing for effective services (Karumuna & Mgone, 1990; Nottidge & Okogbo, 1991). The dramatic decrease in perinatal mortality in developed countries during the 1980s, largely a result of improved survival rates for low birth weight infants, has given rise to the fear of increased numbers of children with neurodevelopmental impairments. In fact, there was a steady-state incidence of CP of about 2.5 per 1000 live births until about the mid-1950s (Little, 1958), which was followed by a decrease in incidence to about 1.5 per 1000 for about 15 years. Since then, the incidence has increased to near mid-1950s Levels, if Swedish statistics are typical (Hagberg et al., 1989b). The change in this trend mainly reflects changes in the live birth rate of preterm infants, especially in those with spastic diplegia. A study conducted between 1982 and 1994 of a cohort of 2076 consecutively born infants with birth weights of 500 to 1500 g (O’Shea et al., 1998) concluded that the increasing survival of very low birth weight infants has not resulted in an increased prevalence of cerebral palsy among survivors. The risk of CP increases sharply with decreasing birth weight (Atkinson & Stanley, 1983; Hagberg et al., 1989a; Pharoah et al., 1987) and has been reported to be as much as 40 times higher in infants weighing less than 1000 g (Hagberg et al., 1989b). The increased risk of CP in preterm infants must be put in perspective, however. Reports of longterm outcome of extremely premature infants, that is, infants born between 24 and 28 weeks of gestational age, suggest about a 75% survival hte, with more than 50% of those who survive free of major neurodevelopmental impairments, about 25% with major impairments, and about 11% with CP (Msall et al., 1991). Autopsies of infants have revealed three types of neuropathic lesions (Weinstein & Tharp, 1989): neuropathy resulting from hemorrhage below the lining of the ventricles (subependymal), encephalopathy caused by anoxia or hypoxia, and neuropathy resulting from malformations of the central nervous system. Most subependymal hemorrhages occur in infants of less than 28 weeks of gestational age and those with low birth weight. Intraventricular hemorrhages, present in up to 46% of infants weighing less than 1500 g (Papile et al., 1978), are thought to develop secondary to lesions of ischemic origin. In most cases, blood ruptures into the lateral ventricle and the ensuing connective tissue blocks the cerebrospinal fluid flow, frequently resulting in hydrocephaLus. Anoxic or hypoxic encephalopathy results in gray matter and white matter lesions. Gray matter lesions are diffusely present throughout the cortex, basal ganglia and thalamus, brainstem, and spinal cord, whereas lesions in the white matter are frequently in the periventricular zone. Periventricular atrophy has been identified as the most common abnormality found in preterm infants who developed hemiplegic CP, occurring in 50% of cases (Wiklund et al., 199 lb). It is unclear, however, whether the lesions occur before, during, or after birth. Although periventricular atrophy is a bilateral lesion thought to be responsible for most cases of preterm spastic diplegia, it has also been reported as an asymmetric or unilateral lesion or one with bilateral lesions expressing only unilateral clinical symptoms (Wiklund et al.. 199 lb). Malformations of the central nervous system may generate hemorrhagic and anoxic lesions. Many factors may be responsible, including drug ingestion, radiation, and infection by viruses such as herpes simplex and rubella. Attempts to relate cerebral lesions to the extent of disability have had only limited success. With respect to the side of expression, in the small percentage of children with hemiplegia with bilateral morphologic findings, subtle physical abnormalities were sometimes seen on the nonhemiplegic side (Wiklund & Uvebrant, 199la). Results suggest the existence of a continuum between hemiplegia and diplegià resulting from periventricular lesions. Magnetic resonance imaging showed that, of several measures, only the amount of white matter correlated with the severity of disability (Yokochi et al., 1991). In children with hemiplegia, no significant correlations between size of lesion and severity of impairment have been found, although trends toward the association of less impairment with smaller lesions have been reported (Molteni et al., 1987; Wiklund & Uvebrant, 199 la). Quadriplegia has been associated with brainsrm and basal nuclei damage in addition to cortical and subcortical lesions (Wilson et aL., 1982). Further discussion of the causes of the various types of CP can be found in works by Menkes (1990) and Weinstein and Tharp (1989). Progress in Primary Prevention The primary way to reduce the incidence of CP is through good socioeconomic health of the population coupled with maternal education. The role of poverty and low socioeconomic status in the prevalence of CP (Dowding & Barry, 1990) and in determining the need for special educational resources (Msall et al., 1991) has frequently been overlooked, yet there is empirical evidence of its importance. Certain maternal prepregnancy and pregnancy-related risk factors are associated with delivery of a child with a disability (Holst et al., 1989). Studies have suggested that improved intrapartum diagnosis of risk factors, prevention of asphyxia, and medical treatment of children with low Apgar scores would reduce the incidence of disabilities, as would intervention to prevent premature rupture of membranes. However reasonable these hypotheses may seem, no studies are known to have tested them. The role of the obstetrician in preventing CP before birth occurs is limited (Weinstein & Tharp, 1989). Attention is directed toward developing effective prevention of and intervention for premature delivery, fetal distress, neonatal asphyxia, and mechanical birth trauma. Methods of inhibiting labor have met with much success, although the effects on incidence of CP remain unclear. Methods of antepartum fetal evaluation, including sonographic measurement, electronic fetal monitoring, fetal pH monitoring, and intrauterine pressure monitoring, have provided the obstetrician with powerful tools for assessing the need for active intervention id the labor process. Delivery procedures using high forceps and certain presentations of breech deliveries that were found to be associated with increased perinatal morbidity have dramatically decreased in favor of cesarean section. This is partly due to the increased safety of cesarean birth for both the mother and the fetus. Impairment Early detection of CP facilitates optimal management by the family and the health care and educational community. Complicating the picture is the instability of diagnosis; CP is reported to disappear over time in many low birth weight infants (Kitchen et al., 1987). In a study designed to determine the accuracy of diagnosis of CP at 2 years of age (Kitchen et al., 1987), only 55% of those so diagnosed at age 2 were deemed to have CP at age 5, but the diagnosis of those with moderate or severe involvement did not change. Only 1% of children not diagnosed at age 2 were identified at age 5 to have CP. Of those children in whom the diagnosis was no longer accurate at age 5, most had minor neurologic abnormalities and left-hand preference, but their psychologic test scores were no different from those of children who had n’ever been diagnosed as having CP. Tests of neurologic status, motor function, primitive reflexes, and posture have been assessed for their ability to identify CP (Burns et al., 1989). Although assessments performed at age 1 month failed to identify several of the infants who later showed CP, assessments made at 4 months of age resulted in some overidentification. At 8 months of age, the presence of three or more abnormal signs was highly predictive of CP, and the authors concluded that all but the mildest cases of CP can be identified by that age. Formal tests have varying abilities to detect motor abnormalities (Harris, 1989). The sensitivity of the Movement Assessment of Infants (MAI) has been calculated to be 73.5% in a high-risk population (Harris, 1987). When compared with the Bayley motor scale (Bayley, 1993), the MAI identified more than 3 times as many children with diplegia at 4 months of age, more than 2 times as many children with hemiplegia, and about 1.5 times as many children with quadriplegia (Harris, 1989). In children at 1 year corrected age, however, the Bayley motor scale demonstrated sensitivities of 100% for both spastic diplegia and quadriplegia and 75% for spastic hemiplegia. Furthermore, the MM has a lower rate. of specificity than does the Bayley motor scale; that is, a greatez percentage of children with normal outcomes are identified as being at risk. Physical Therapy-Related impairments Impairments in CP are problems with the neuromuscular and skeletal systems that are either an immediate result of the existing pathophysiologic process or an indirect consequence that has developed over time. Impairments can be classified, somewhat artificially, into single-system impairments and multisystem impairmcnts. SINGLE-SYSTEM IMPAIRMENTS Single-system impairrhents are expressed in the muscular system and the skeletal system, eventhough the pathophysiologic damage occurred in the, central nervous system. Primary impairments such as insufficient force generation, spasticity, abnormal extensibility, and exaggerated or hyperactive reflexes are evident in the muscular system; malalignments such as femoral anteversion and femoral and tibial torsion (Cusick & Stuberg, 1992) are secondary impairments evident in the skeletal system. CP is characterized by insufficient force generation by affected muscle groups, which is consistent with low levels of electromyographic (EMG) activity and decreased moment of force output (Berger et al., 1982). When an activity leads to an active contraction, this impairment may be expressed as a deficiency in power (Olney et al., 1990), or when considered over time, in work. The term strength may refer to any of these measurable factors. Strength measurement in neurologic conditions is problematic, but when measured, strength has frequently been intimately linked with functional capabilities such as speed of walking (Bohannon, 1989). The clinical term tone is used to describe the impairments of spasticity and abnormal extensibility. A sensation of abnormally high tone may be caused by spasticity, a velocity-dependent overactivity that is proportional to the imposed velocity of limb movement. Spasticity is especially evident in children with clonus but is frequently mistaken for problems of extensibility. Supraspinal and interneuronal mechanisms appear to be responsible for spasticity, with increased “gain” in the muscle spindles and increased excitation of Ia afferents having been ruled out as a cause of spasticity (Young, 1994). There is experimental evidence for three pathophysiologic mechanisms: reduced reciprocal inhibition of antagonist motor neuron pools by Ia afferents, decreased presynaptic inhibition of Ia afferents, and decreased nonreciprocal inhibition by lb afferents. There is considerable evidence indicating that reciprocal inhibition is reduced in cerebral palsy (Hallett & Alvarez, 1983; Leonard et al., 1991). Adding to this effect are recent elegant studies using transcranial magnetic cerebral stimulation that have provided evidence of simultaneous activation of antagonistic muscle groups through abnormal alpha motor neuron innervation (Brouwer & Ashby, 1991). The role of decreased presynaptic inhibition of Ia afferents in spasticity has been deduced from experiments showing that vibration-induced inhibition of the H-reflex is much less in spastic than in normal muscles, a phenomenon that has been shown to be mediated by a presynaptic mechanism in animal models. Finally, nonreciprocal inhibition has been reported to be reduced and even replaced by facilitation in persons exhibiting spasticity with sustained hypertonia (Young, 1994), which suggests that there may be afurther mechanism responsible for abnormal alpha motor neuron excitability. The sense of abnormally high tone can also result from hypoextensibility of the muscle because of abnormal mechanical characteristics. Comparing healthy children with children with CP, Berger and colleagues (1982) found that the EMG activity of leg muscles in nearly all children with CP was reduced in affected limbs and that there were no indications of pathologic reflex effects on muscle activity. A force transducer on the tendo Achilles measured tension that was disproportionate to muscle activity and could best be attributed to mechanical changes in the muscle rather than to increased stretch reflexes from spasticity. These muscles were also seen to be abnormally stiff that is, they produced more force for a given length change than did muscles in non-disabled children (Tardieu et al., 1982). The most accurate term for this impairment is hypoextensibility. The muscle offers resistance to passive stretching at a shorter length than that expected in a normal muscle. In addition, if greater than normal amounts of force are required to produce a change in length, the muscle is said to have increased stiffness. This is represented as the passive tension curve for CP (pCP) in Figure 20-lA, in contrast to the normal passive tension curve (p,N) in Figure 20-iD, when one moves the ankle from a position of plantar flexion to one of dorsiflexion. When a clinician finds that it is not possible to manually stretch the muscle through a normal range using reasonable amounts of manual force, the muscle group is deemed to have a contraçtur e, represented in Figure 20-2 as “Contracture,” the difference between the joint angle at which this extreme resistance is encountered in the CP muscle and that of the normal muscle. Figure 20-1 shows hypothetical active forcelength characteristics of spastic plantar flexors (a,CP; see Fig. 20-1B) and normal plantar flexors (a,N; see Fig. 20-1E), that is, the force generated by the contractile elements of the muscle over the range of muscle lengths from a shortened position (plantar flexed) to a longer position (dorsiflexed). Note that the maximal force is lower for the CP muscle and also that the peak force occurs at a more plantarflexed position in the CP muscle than in the normal muscle. The sum of the combined effects of active force output and passive stiffness for the CP muscle is shown as total tension curve CP, and the corresponding curve for the normal muscle is shown as total tension curve N (see Fig. 20-2). The complexity of the representation in Figure 20-2 underlines the difficulty faced by a physical therapist or physician in correctly assessing the cause of increased tone through clinical methods such as passive manipulation of the limb and clinical assessment of muscle strength. If a muscle complex has become overlengthened, which is usually a secondary impairment resulting from repeated mechanical stretch, it is termed hyperextensible. The overlengthened muscle complex may also have decreased forcegenerating capabilities. Few studies of the histology and morphology of spastic muscle have been reported, but they have shown that differences are present when spastic muscle is compared with normal muscle (Romanini et al., 1989). The slowly contracting fibers of the spastic adductor muscles demonstrate hypertrophy, whereas the fast fibers show atrophy. Surprisingly, there has be’m no evidence of increase in endomysial or perimysial connective tissue at any age of child, regardless of the clinical picture. The authors concluded that joint restrictions are attributable to the atrophy of muscle fibers, which makes the muscle less elastic and extensible, and possibly to an increase of fibrous tissue in the periarticular structures, although the latter was not verified. There are no universally accepted methods of measuring spasticity (Katz & Rvmer, 1989), although techniques include measurement of forces in response to standard passive stretches (tonic) or standard hammer stimuli (phasic), Hoffmann’s reflex recording (Jones & Mullev, 1982), and measurement of responses to sinusoidal cycling or ramp stretches (Lin et al., 1994; Price et al., 1991). The modified Ashworth scale, though commonly used in clinical situations, is really an undifferentiated measure of spasticity and extensibility. It has been shown to be reliable in adults with neurolngic conditions, although reliability has not been established for children (Bohannon & Smith, 1987). MULTISYSTEM IMPAIRMENTS In the second group of impairments are three multisystem impairments expressed in. the neuromuscular system: poor selective control of muscle activity, poor regulation of activity in muscle groups in anticipation of postural changes and body movement (referred to as anticipatory regulation), and decreased ability to learn unique movements. In CP there is poor selective control of muscle activity. Normal movement is characterized by orderly phasing in and out of muscle activation, coactivation of muscles with similar biomechanical functions, and limited coactivation of antagonists during phasic or free movement. In CP there is abundant evidence of inappropriate sequencing (Nashner et al., 1983) and coactivation of svner~ists and antagonists (Knutsson & Martensson, 1980). ' FIGURE 20-1. Representation of force capabilities of ankle plantar flexor muscle at different joint angles in normal muscle (N) and spastic muscle (CP). A. Resistance to passive stretch of spastic muscle (p,CP) increasing with more dorsiflexion. B, The force of active contraction (a/ZP) varying with the joint angle, l denoting resting length. C, The sum of the passive and active effects in spastic muscle. D, Resistance to passive stretch in normal muscle (p,N). F, Force of active contraction in normal muscle (a,N). F, The total tension curve comprising the sum of the passive and active effects in normal muscle. Note that 1) the slope (i.e., the stiffness) of p,CP in A is greater for the spastic muscle than for the normal muscles (p,N) in D; 2) the maximal active force achieved by the spastic muscle (a,CP) in B is less than the maximal active force of normal muscle (a,N) in F; and 3) the maximal active force for spastic muscle (a,CP) shown in B occurs at a more plantar-flexed position than that of the normal muscle (a,N) shown in F. The reasons for poor selective control of muscle activity are unknown. Failure of the normal recipro Cal relationship of activity between agonist and antagonist muscles during voluntary movements has been observed (Berger et aL, 1982; Hallett & Alvarez, 1983; Leonard et al., 1990), but whether segmental-or supraspinal mechanisms or both are involved is unclear. Although Berbrayer and Ashby (1990) clearly demonstrated the presence of reciprocal inhibition in CP, it is not possible to exclude the possibility that other spinal mechanisms may’ be impaired (Harrison, 1988). Direct evidence for a supraspinal origin is scant; however, researchers have concluded that in CP, the corticospinal projections are directed equally to the motoneurons of agonist and antagonist muscles of the ankle (Brouwer & Ashby, 1991). Reflex overflow to antagonist muscles in children with CP (Leonard et al., 1991) has been attributed either to exuberant motoneuronal projections or to exuberant projections that extend to motoneurons innervating muscles other than the one being stimulated. From these studies, it appears certain that the neuronal “wiring” in CP is not normal. Poor anticipatory regulation of muscle sequencing when postural correction is attempted has been reported by Nashner and colleagues (1983). In healthy individuals, changes in posture are preceded by preparatory muscle contractions that stabilize the body. In people with CP, the contraction that is needed to produce stability is frequently interrupted by destabilizing synergistic or antagonistic muscle activity. FIGURE 20-2. Complete representation of forces capabilities of ankle plantar flexor muscle at different joint angle in normal muscle (N) and spastic muscle (CP) shown in Figure 20-1. a, CP = Force of active contraction of spastic muscle, 10, CP = resting length of spatic muscle, 10, N = resting length of normal muscle, an,N = force of active cobtraction of normal muscle, p, CP = resistence to passive stretch of spastic muscle, p,N = resistance to passsiva stretch of normal muscle. There is some evidence that motor memory in children with CP is frequently impaired (Lesny et al., 1990). This finding is important in considering strategies for teaching movement, but it has received little attention to date. Assessment of multisystem impairments usually involves measurement of a closely associated variable or number of variables and frequently involves different dimensions of the disabling process. Examination of the impairments of poor selective control of muscle activity, poor anticipatory regulation of muscle groups, and decreased ability to learn unique movements includes use of measures of balance, coordination, and motor control. Most are not in general clinical use. Two approaches to assessing balance are available: one is to disturb the supporting surface in a variety of ways (Nashner et al., 1983); the other is to perturb the subject or environment (Patla et al., 1989). In each case, kinematic, kinetic, and EMG responses are measured. Coordination has been documented with EMG records, which makes it possible to detect differences from normal records in timing of muscle activity onset and duration, in sequencing of agonists, and in cocontraction of antagonists. Gait has been the most commonly observed activity used to examine specific impairments of CP (Perry et al., 1976), and the potential for its wide clinical application has increased with the advent of fast and efficient computer systems. Determinants of Prognosis or Outcome. About 90% of children with CP in developed countries survive to adulthood (Evans et al., 1990). Strauss and Shavelle (1998) found that the key predictors of a reduced life expectancy were lack of mobility and feeding difficulties. Survival of high functioning adults was found to be close to that of the general population, but predictions of lifetime functional outcomes in CP are limited. A California study (Anonymous, 1991) reported that only 12 to 17% of people with CP registered with developmental services were competitively employed. Positive prognostic factors for employment included mild physical involvement, good family support, vocatioaal training, and having good employment contacts. Mental retardation, seizures, and wheelchair dependency were factors reducing the likelihood of living independently. Senft and colleagues (1990) reported that more than 60% of registrants in a neuromuscular disability program were dependent on aging parents. In a review of the literature, Bleck (1987) included the following positive predictors of independence and employment of a person with CP: regular schooling, completion of secondary schooling, independence in mobility with the ability to travel beyond the home, good hand skills, living in a small rather than a large community, and having a diagnosis of spasticity rather than one of involuntary movements. Preliminary studies of life satisfaction suggest more positive outcomes, but few studies have included this important variable (Wacker et al., 1983). Certain factors assist in predicting the ambulation potential of children with CP. Children with the hemiplegic type of CP usually have a good prognosis for ambulation, whereas the prognosis is less favorable for those with rigid or hypotonic types of CP (Crothers & Paine, 1988). Persistent tonic neck reflexes are associated with decreased likelihood of walking (Crothers & Paine, 1988). Some studies have reported that a remarkably large percentage of children who are able to sit independently by age 24 months eventually walk (Crothers & Paine, 1988) and that nearly all children with CP who ev~mtually walk do so before 8 years of age (Bleck, 1975). Watt and colleagues (1989), examining all survivors of neonatal intensive care, have reported that nearly all who sat by 24 months of age walked 15 meters or more with or without assistive devices or orthos~s by age 8 years. Independent sitting by 24 months remains the best predictor of am: bulation, despite inclusion of neonatal variables, clinical types, primitive reflexes, and reactions (Watt et al., 1989). EXAMINATION, EVALUATION, AND INTERVENTION At all ages, the physical therapy examination of the child with CP will focus on the identification of disabilities, functional limitations, and impairments. In addition, physical therapy examination is used to measure change resulting from intervention at all levels of the disabling process and provide feedback to clients. Physical therapists integrate information from the many aspects of their examination and evaluation with prognostic knowledge to predict the optimal level of improvement that can be expected. They then develop a plan of care that includes long-term and short-term goals and outcomes, specific interventions, and duration and frequency of intervention required to reach the goals and outcomes. From infancy to adulthood, physical therapy goals for clients with CP should focus on the prevention of disability by minimizing the effects of functional limitations and impairments, preventing or limiting secondary impairments, maximizing the gross motor functions allowed by the organic deficits, and helping the child compensate for functions when necessary. Achieving these goals involves the promotion and maintenance of musculoskeletal integrity, the prevention of secondary impairment and deformity, the enhancement of optimal postures and movement to promote functional independence, and optimal levels of fitness. The presence of impairments, such as low levels of force generation, spasticity, abnormal extensibility, and disturbed reflexes, can result in abnormal weight bearing and malalignment, which can, in turn, affect the orthopedic development of the spine and the extremities. The application of correct forces is required for optimal skeletal modeling before the skeleton ossifies (LeVeau & Bernhardt, 1984), although the research reported to date has offered little specific guidance. Of particular concern is the effect of increased hip flexion and adduction on acetabular development and hip joint stability. Neck and trunk asymmetry can result in torticollis or spinal deformities. At all ages, children with hypoextensibility and spasticity are prone to developing contractures. Although patt2rns of tightness vary, commonly at risk for contractures are the shoulder adductors; the elbow, wrist, and finger flexors; the hip flexors and adductors; the knee flexors; and the ankle plantar flexors (Massagli, 1991). Furthermore, the physical therapist attempts to prevent environmental deprivation that could increase existing disabilities and attempts to provide support, guidance, and education for the child, the family, and the community. Goals are individualized for the particular child and family. They should be determined in collaboration with the family and based on the needs, expectations, and values of the whole family (Rosenbaum et aL, 1998). Goal and outcome attainment should be regularly reassessed so that the therapy plan is adapted to reflect changes in the child’s progress and the family’s needs. An important component of therapy programs is education of the child and family about the disability to enable them to become capable of advocating and baking responsibility for their future. The involvement of other health care professionals in the treatment of the infant with CP depends on the child’s needs and the practices of the institution where the program occurs. Some facilities may have professionals from several disciplines working with the family, whereas at others it may be thought better to have a primary therapist initially, bringing in others for assessment or treatment as necessary. Regardless of practice approach, parents value coordination of care and consistency of service providers. Increasing emphasis on the costs of provision of services and managed care have led some institutions to develop critical paths. This is a difficult task for CP due to the diversity of presentation and the chronic nature of the condition. An example of an outline of care for CP is the document Cerebral PalsyCritical Elements of Care which was developed by the Washington State Department of Health (1997). Infancy The life role of an infant is to grow and develop in response to being loved and nurtured by parents and caregivers in a home environment. Despite being dependent in most aspects of life, infants interact with, and develop an understanding of, the people in their lives, their surroundings, and’ themselves. From the time of birth, a child with CP may not experience the normal activities associated with infancy. As a result, the parents of an infant with CP may not receive the positive feedback of a normal nurturing experience and the satisfaction of observing the development of motor and social skills, that is the normal rewards of caring for an infant. The parents must cope with the impact of the diagnosis and the grieving process that accompanies the awareness that their expectations of having a normal child will not be realized. They may be overwhelmed with the uncertainty that the future holds for them, their child, and their family. Many parents are also concerned with the immediate issues of providing basic infant care and are apprehensive about incorporating the specialized care necessary for their child’s optimal development. Movement is ~n important component in the learning and interactive processes of infancy. In infants who have CP, the nature and extent of their impairments affect their potential to develop and learn through movement. This may result in functional limitations in the development of gross motor skills and may affect their ability to interact with their parents, themselves, and their environment. Physical Therapy Evaluation Examination and Infant examination provides a baseline for the monitoring of improvement or deterioration, growth, maturation, and treatment effects. Therapists must determine the history, living environment, and social supports of an infant and the knowledge level and concerns of the family. Examination of impairment involves qualitative and, when possible, quantitative evaluation of the single system and multisystem impairments. Observation of active range of motion (ROM) provides indirect assessment of the forcegenerating ability of muscle groups and some information about muscle extensibility. Determination of the passive ROM, using a slow, maintained stretch in a position that promotes relaxation, assesses muscle group extensibility and provides information about joints, such as the presence of dislocation. Normal maturational changes in joint range and alignment must be considered in evaluating the significance of measures. Passive movement performed with greater velocity is used to assess spasticity and the sensitivity of the stretch reflex. Spasticity can be documented descriptively on the basis of resistance to movement and observations of spontaneous active movement and posturing. The severity of spasticity-whether it is mild, moderate, or severe-its distribution over the body and limbs, and its variations under different conditions should be noted. Frequently, there are variations in spasticity associated with positioning and the infant’s effort and behavior. The modified Ashworth scale (Bohannon & Smith, 1987) or the muscle tone section of the MAI can be used (Chandler et al., 1980). The presence or persistence of primitive reflexes and the development of the postural reactions of equilibrium, righting, and protective extension are assessed to determine their influence on selective control and anticipatory regulation of muscle group activity. The effects these reflexes and postural reactions have on positioning, handling, and the facilitation or inhibition of functional movement also need to be evaluated (Bly, 1991). The primitive reflex and the automatic reaction sections of the MAI (Chandler et al., 1980) are appropriate to use when evaluating infants with CP. Selective control and anticipatory regulation of muscle groups are assessed in the context of functional evaluation: for the infant, this is indicated by the assessment of gross motor skills. Standardized tests used by physical therapists when assessing infant movement include the MAI (Chandler & Harris, 1985), the Gross Motor Function Measure (Russell et al., 1989), the Peabody Developmental Motor Scales (Palisano etal., 1995), the Bayley Scales of Infant Development (Bayley, 1993), the Test of Infant Motor Performance (Murney & Campbell, 1998), and the Alberta Infant Motor Scale (Piper & Darrah, 1994). Various elements of movements and posture combine to produce functional gross motor skills. These include the ability to align one part of the body on another: to bear weight through different parts of the body; to shift weight; to move against gravity; to assume, maintain, and move into and out of different positions; and to perform graded, isolated, and variable movements with an appropriate degree of effort. When examining functional motor skills, proficiency in incorporating these elements into the achievement of purposeful and efficient movement must be evaluated. Specific assessments of seating, feeding (Evans Morris & Dunn Klein. 1987), or respiratory problems may be necessary for infants with problems in these areas. Growth is often affected in children with CP; therefore, anthropometric measures, including head circumference, weight, and length, should be documented. Growth may influence, or be influenced by, feeding, exercise, and energy efficiency (Campbell et al., 1989). Other factors to be considered during assessment include the influence of an infant’s temperament and behavior on performance; sensory, social, communication, and cognitive abilities; and support from the environment. Physical Therapy Goals, Outcomes, and Intervention Physical therapy in infancy is focused on educating the family, facilitating caregiving, and promoting optimal sensorimotor experiences and skills. Intervention must address current and potential problems. Early intervention for children with CP has been advocated to help infants organize potential abilities in the most normal way for them, although there is no definitive support for its efficacy (Barry, 1996; Campbell, 1990). FAMILY EDUCATION The foremost set of goals at all ages is to educate families about CP, to provide support in their acceptance of their child’s problems, and to be of assistance when parents make decisions about managing both their own and their child’s lives. Infancy is an important time to foster collaborative goal-setting and programming strategies with the parents and promote ongoing communication between families and service providers. These skills empower them to make decisions, solve problems, and set priorities, as well as to become effective advocates for their children and themselves. Although it is recognized that parents know their children best, at this stage, the parents’ goals may be overly optimistic and hopeful. Therapists must be realistic about the prognosis and the efficacy of physical therapy while remaining hopeful and providing options for intervention. They can break down overall goals into objectives that are meaningful, obtainable, sequential, observable, and measurable (Kolobe, 1992). HANDLING AND CARE Abnormal postures and movements resulting from impairments can make an infant difficult to handle and potition. These difficulties can affect an infant’s interaction with the environment, reaction to caregiving activities, and development of gross motor skills. Therefore, a second physical therapy goal is to promote the parents’ skill, ease, and confidence in handling and caring for their infant. These skills alleviate unnecessary stress for parents and child and also help reduce the influence of the impairments, thereby preventing unnecessary secondary impairments and limitations. Parents are taught positioning, carrying, feeding, and dressing techniques that promote symmetry, limit abnormal posturing and movement, and facilitate functional motor activity. The principles guiding these methods are 1) to use a variety of movements and postures to promote sensory variety, 2) to frequently include positions that promote the full lengthening of spastic or hypoextensible muscles, and 3) to use positions that promote functional voluntary movement of limbs. FACILITATING OPTIMAL SENSORIMOTOR DEVELOPMENT A third physical therapy goal in infancy is to facilitate optimal sensorimotor experiences and skills, thereby reducing functional limitations and disabilities. Therapy should focus on the development of wellaligned postural stability coupled with smooth mobility to allow the emergence of motor skills such as reaching, rolling, sitting, cu~w1ing, transitional movements, standing, and prewalking skills. These skills promote the development of spatial perception, body awareness, and mobility to facilitate play, social interaction, and exploration of the environment. Movements that include trunk rotation, dissociation of body segments, weight shifting, weight bearing, and isolated movements should be incorporated into gross motor exercises and activitie. These movement components, if experienced with proper alignment, can give the sensory feedback of normal movement patterns and activities. Good sources for the handling and treatment of infants and children of other ages include the works of Finnie (1997), Jaeger (1987, 1989), Scherzer and Tscharnuter (1990), and Wilson (1991). A practical reference for parents is Children with Cerebral Palsy (Geralis, 1991). Careful instruction of the family in specific techniques and activities, ongoing reinforcement, encouragement, and support are essential. Clearly written, illustrated, and updated home programs can be beneficial. Computer-generated programs or videotaping can be used to produce personalized, effective, and efficient information regarding activities, positioning, and exercises. The normal motor developmental sequence may assist in guiding the progression of motor activities, although research indicates that motor milestones and their components develop in overlapping sequences, with spurts of development interspersed with some plateaus and even regressions (Atwater, 1991). The child with CP does not always proceed along the normal developmental sequence, and therapy becomes more functionally oriented within the scope of the child’s physical capabilities (Blv, 1991). The stage at which this happens depends on the severity of the impairments; in some children, it may occur early in life. Activities or equipment may be used to allow attainment of functional skills when impairments otherwise prevent the development of certain skills. For example, the sitting position promotes visual attending, upper extremity use, and social interaction. Infants with CP may be unable to sit independently, may sit statically only with precarious balance, or may not even be able to be seated in commercially available infant equipment. Customized seating or adaptations to regular infant seats may be necessary to allow function in other areas of development to progress. Infants with limited upper extremity movement may be unable to bring their hands or toys to their mouths to provide normal oral-motor sensory input. In these cases, mouthing activities should be incorporated into therapy. Toys may need to be adapted to facilitate developmental activities. The care of an infant exhibiting asymmetry, extensor posturing, and shoulder retraction illustrates these approaches. Such an infant should be carried, seated, and fed in a symmetric position that does not allow axial hyperextension and keeps the hips and knees flexed. Positioning of or playing with the upper extremities to allow the infant to see his or her hands, practice midline play, reach for his or her feet, or suck on fingers can promote sensorimotor awareness. Active movements, such as the handling of toys that require two hands and that encourage the infant to develop flexor control and symmetry, are incorporated into daily activities. These activities facilitate the use of the neck and trunk muscles, promoting anterior and posterior control. The introduction of lateral control is the next step in achieving functional head and trunk control. In some severely affected children, slight gains in head control may be a goal, whereas in minimally affected children a fairly normal progression of motor development is expected, even without intervention. These therapeutic interventions should not limit infants’ spontaneous desires to move and play and explore their environments because even very young children need to be able to assert themselves and manipulate their world (Campbell, 1997). Some physical therapists may adhere to specific treatment philosophies, although differing treatment approaches often have underlying similarities. Two approaches used with infants are neurodevelopmental treatment (NDT) and the Vojta approach. NDT has been widely used throughout North America and other parts of the world as a basis for the treatment of infants with CP. NDT is based on the theory that inhibiting or modifying impairments of spasticity and abnormal reflex patterns can improve movement. For infants, handling techniques encourage active movement, and thus they experience normal movement sensations. The ultimate aim of the treatment is the acquisition of functioiial movements that permit children the greatest degree of independence possible to prepare them for as normal an adolescence and adult life as can he achieved (Bobath & Bobath, 1984). The Vojta approach, a European-based practice, uses proprioceptive information from the trunk and extremities to activate the central nervous system and guide it toward normal motor ontogenesis by eliciting appropriate movement patterns (Vojta, 1984). ROLE OF OTHER DISCIPLINES Occupational therapists may be involved in upper extremity function, particularly as it relates to play. In addition, speech and language pathologists may be necessary if there are oral-motor problems interfering with feeding or early language development. Community infant development workers may be involved in home-based programs. Social workers may help the parents through the grieving process, explain programs, and direct them to appropriate resources. Likewise it may be helpful to join parent support groups or meet with parents who have been through similar experiences. Preschool Period During the preschool years, locomotor, cognitive. communication, fine motor, selfcare, and social abilities develop to promote functional independence in children. The process is a dynamic one in which all these areas constantly interact with one another. The child’s environment remains oriented toward the parents, family, and home ci ring this period, but he or she begins to interact with the outside world. Child care centers, babysitters, nursery schools, and playmates thus become part of a preschooler’s world. For children with CP, the limitations in motor functioning may create disabilities in learning, socialization, and attainment of independence (Butler, 1991). Concerns of the parents include the impact of impaired performance on all areas of development : for example, their child’s ability to participate in and become integrated into normal preschool activities. the development of cognition and language, and the longterm effect of disabilities on future life and independence. During these years, the child’s attainable level of motor skills can be predicted with a greater degree of accuracy, as the influences of motor impairments on functioning become apparent. A major area of concern for physical therapists is the child’s ability to achieve independent mobility. In addition, skills in overall gross motor development continue to be a focus of physical therapy to minimize disabilities, such as the inability to learn and perform the selfcare skills of toileting, dressing, grooming, and feeding, and the limitations in play, communication, social skills, and problem-solving behavior. Physical Therapy Evaluation Examination and Assessment of disability assumes a primary focus, but it is important to determine the role of function arid impairment in the production of disability. Tests should be administered at regular intervals to document change that is due to treatment and/or maturation. Within the dimension of impairment, direct testing of the forcegenerating ability of muscle groups is not always appropriate because spasticity, abnormal extensibility, hyperactive reflexes, and poor selective control affect the assessment. In such cases, muscle strength should continue to be considered in a functional context. Observing activities such as moving between sitting and standing positions or ascending and descending stairs assess both concentric and eccentric power. Endurance should be evaluated by observing the ability to walk ageappropriate distances or propel a wheelchair a comparable span. During these years, quantitative measures of joint ROM and skeletal alignment, including the rotational and torsional alignment of the pelvis and lower extremities (Cusick & Stuberg, 1992; see Chapter 15), should be documented using consistent and standardized procedures. Variations of 10 to 150 occur in intrarater goniometric measurement in children with CP (Stuberg er al., 1988), and caution must be used to avoid misinterpreting small changes. Noting the point at which initial resistance is met with passive range of motion is clinically relevant but difficult to accurately measure clinically. Evaluation of function and disability are frequently included in the same assessments. The Gross Motor Function Measure (Russell et al., 1989) and the Peabody Developmental Motor Scales (Palisano et al., 1995) can continue to be used to monitor the child’s motor progress. When assessing motor skills, the use of equipment to achieve an activity should be taken into consideration. For example, the use of orthoses in ambulation may substantially affect walking abilities. Function and disability assessment should also include mobility and transfers, communication, social function, bowel and bladder control, self-care and the degree of reliance on caregivers, adaptive equipment, and environmental modifications in the performance of activities of daily living (ADL). The Pediatric Evaluation of Disability Inventory (Reid et al., 1993) assesses many of these functional skills in young children. The Functional Independence Measure for Children (WeeFIM), a pediatric version of the Functional Independence Measure (Msall et aL, 1990), measures disability as quantified by burden of care. Other measures of ADL (Gowland et al., 1991) such as the Vineland Adaptive Behavior Scales (Sparrow et al., 1984) can be used. The Canadian Occupational Performance Measure (Law et aL, 1990) can be used to ensure that goals are relevant to the family and to measure outcomes. Goal Attainment Scaling can be used to evaluate whether specific individualized treatment goals or outcomes have been met, but this form of assessment cannot replace standardized measures, particularly for research (Palisano, 1993). Disability measures also include attempts to assesr health-related quality of life. These measures take into account age, specific disability, and the factors and values believed to be important by health care professionals, parents, and children themselves (Rosenbaum et al., 1990). Asseisments specific to certain activities or equipment may be indicated. These include evaluations of postural stability (Westcott et al., 1997), augmentative communication, mobility, and gait (Olney et et al., 1990). Gait assessment measures ambulatory function, and if kinetic and EMG analyses are included, certain impairments are also evaluated (Fig. 20-3). The ROM of the hips, knees, and ankles in each phase of gait can be observed using a videotape. Particular attention should be paid to the propulsive movement of ankle plantar flexion during push-off and to the concurrent hip flexion. These two events are responsible for much of the forward movement of the body and are indirect measures of force generation of muscle groups. EMG recordings during walking show the general level of activation of each muscle group, the degree of cocontraction. and the selectivity and degree of sequencing of muscle-group activity-all indicators of impairment. Upper extremity activities such as reaching (Kluzik et al., 1990) haVe also been studied using videotaping and other sensing systems. When assessing children in this age group. it is necessary to be aware of the effects of attention. cooperation, and the children’s reaction to being assessed on the evaluation process. Parents or other caregivers can provide information on whether a child’s performance is characteristic of his or her abilities. Evaluation must take place at regular intervals to ensure that goals are still appropriate and therapy intervention is being appropriately directed. Physical Therapy Goals, Outcomes, and Intervention The impact and extent of the child’s impairments become more established during the preschool years. Treatment focused specifically on reducing impairments and preventing secondary effects of impairment provides a backdrop for interventions aimed at higher levels of the disabling process to prevent isolation from the typical experiences of early childhood and family life. Optimal postural alignment and movements of the body that are conducive to musculoskeletal development, neurophvsioiogic control, and function, through exercise, positioning. and equipment, are the aims of many interventions. In many cases, physical therapy goals ma serve as the building blocks for global interdisciplinary goals in communication, play, social interaction, and self-care activities. Therapists must be willing to respect the priorities of families and other professionals when determining goals, because it may not be possible to work on all areas at once. They must also be sure that treatment is cQnducive to the goals chosen and is motivating and fun for the child. Figure 20-30 Cinild taking part in gait analysis electromyography shows patterns of muscle activities and aind indentification of the presence of cocontraction of muscle groups. Markers at joints allow computer calculation of joint movements , force platforms embedded in floor permit measurement of individual muscle group contributions to the work of walking. (Courtest of Human Motion Laboratory School of Rehabilitation Therapy at Queen’s University, Kingston, Ontarion) REDUCING PRIMARY IMPAIRMENT AND PREVENTING SECONDARY IMPAIRMENT INGREASING FORGE GENERATION. Treatment to improve force generation of muscles in this age group is achieved through performing activities that create increased demands for production of both concentric and eccentric muscie force. Such act~vtt1es include transitional movements, ball gx’mnastlcs. games, and practice of functional skills such as using stairs (Stern & Steidle, 1994) SPASTICITY. Several options are available for the management of spasticity. Interventions have been directed toward decreasing the impairment ot spasticity with the goals of prevention of secondary impairment, comfort and ease of positioning. and improved functional movement. Decreasing spasticity during the preschool years allows muscle lengthening and growth (Boyd & Graham, 1997; Rang, 1990) and may delay or eliminate the need for orthopedic surgery. Two interventions most appropriate for the preschool ages are selective dorsal rhizotomies and botulinum toxin A injections. These interventions are used if spasticity is interfering with function and conversely are not used if a child appears to be dependent on spasticity for function. Ideal candidates have fair to good trunk control and selective muscle control; good cognitive abilities, motivation, and parental support that are conducive to intensive postoperative therapy programs; and no fixed contractures or deformity. Severely affected patients, such as children with spastic quadriplegia, may be appropriate candidates; however, in these cases the goals are improved positioning, care, and comfort (McDonald, 1991). Selective dorsal rhizotomy is a surgical procedure in which the dorsal nerve rootlets supplying the lower extremity muscles are selectively cut. Prospective randomized controlled clinical trials have found spasticity to be substantially reduced. Function, as measured by the Gross Motor Performance Measure, has been shown to be improved in children who have received rhizotomies compared with those receiving equivalent physical therapy in some (Steinbok et al., 1997; Wright et al., 1998) but not in another (McLaughlin et al., 1998). Gait analysis in children who have had rhizotomies has shown improved sagittal motion at the hip, knee, and ankle; however, abnormalities in patterns of muscle activation have persisted (Giuliani, 1991). This is attributed to continuing problems with motor control, which prohibit the proper sequencing of muscle action. Some gait improvements have been found to remain 10 years after surgery (Subramanian et al., 1998). Other positive effects that have been noted include improved oral-motor control, increased voice volume and endurance, improved temperament and concentration, improved bowel and bladder control, and improvement in growth parameters (McDonald, 1991). Injections of small quantities of botulinum toxin A into muscles can prevent the presynaptic release of acetylcholine at the nerve-muscle junction. The effect peaks at 2 weeks and may last for 1 to 4 months. The drug is expensive but is often covered by insurance. Targeted muscles are those in which spasticity interferes with function and those that are most prone to developing contractures. These include the calf muscles, hamstrings, hip flexors, and adductors. Upper extremity muscles have also been successfully injected. Botox injections can also be used as a diagnostic measure before orthopedic or rhizotomy surgery or as an analgesic agent to reduce pain and spasm postoperatively (Boyd & Graham, 1997). Injections in children with a dynamic component to calf equinus were successful in improving passive dorsiflexion, which may allow more opportunity for an increase in muscle length. The results were comparable with but longer lasting than those of a control group that received serial casting and also demonstrated fewer side effects (Corry et al., 1998). Therapy focusing on functional outcomes, but also emphasizing muscle strengthening, is necessary after the spasticity intervention for optimal effectiveness, because the children’s muscles are “weakened” without their spasticity (Fig. 20-4). HYPOEXTENSIBILITY. Various approaches are used to maintain muscle extensibility and joint mobility. Some therapists use manual stretching programs. The usefulness of these passive maneuvers is difficult to assess because active exercises, positioning programs, and equipment are usually used simultaneously. Research on the effectiveness of manual stretching on extensibility is inconclusive (Miedaner & Renander, 1987). Tremblav and colleagues (1990) found that a prolonged stretch of 30 minutes to the plantar flexors of children with CP reduced the impairment of spasticity and improved the voluntary activation of the plantar flexors but not the dorsiflexors. The effect lasted for as long as 35 minutes. In a parallel study, the stretching session did not produce a functional improvement in gait (Richards et al., 1991). The effects of prolonged stretching programs have been studied (Tardieu et al., 1988), and it was found that contractures were prevented if the plan-tar flexor muscles were stretched beyond a minimum threshold length for at least 6 hours during daily activity. The threshold length was the length at which the muscle began to resist a stretch. The data prompting this statement are suggestive rather than conclusive, however. Lespargot and colleagues (1994) found that physiotherapy and a moderate stretch imposed for 6 hours daily prevented muscle-body contracture but did not prevent shortening of the tendon. CASTING AND ORTHOSES. Plaster or fiberglass casting has been used as an economical method of providing stretch and is commonly used in serial casting to lengthen hypoextensible calf muscles. Casting for a 3-week period was shown to be effective if the hypoextensibility was due to imbalance between the triceps surae and dorsiflexor muscles but not if the primary impairment was lack of appropriate muscle growth in response to bone growth (Tardieu et al., 1982). Serial casting has also been used for calf muscle and other muscle groups, such as the hamstrings and elbow flexors. FIGURE 20-4. Exercises after rhizotomy are frequently directed toward increasing force generation of etensor muscles. Lower extremity orthoses are used to reduce impairment, prevent secondary impairment, and facilitate function. The specific goals are prevention of contracture and deformity, provision of optimal joint alignment, provision of selective motion restriction, protection of weak muscles, control of tone and tonusrelated deviations, enhancement of function, and postoperative protection of tissues (Cusick, 1990). Ricks and Eilert (1993) found that although casts and orthoses improved ambulation and preambulation skills, x-ray’s did not show significant changes in the bony alignment of the foot and ankle during weight bearing. Many variations of ankle-foot orthoses (AFOs) are available, depending on the biomechanical and functional needs of the individual child (Knutsson & Clark, 1991). Solid AFOs are used if restriction of ankle movement is desired. Children who would benefit from freedom of movement at the joint can use hinged AFOs. Hinged AFOs frequently prevent plantar flexion but permit dorsiflexion, which allows stretching of the plantar flexor muscle group during walking. Hinged AFOs have been found to promote a more normal and efficient gait pattern than do rigid orthotics (Carmick, 1995; Middleton et aL, 1988). Hainsworth and colleagues (1997) found that that the range of movement and gait deteriorated during the short periods without AFOs when compared with periods during which the AEOs were worn. Foot orthoses, or supramalleolar orthoses, may be used for children with pronation who do not require the ankle stabilization of an AFO (Knutsson & Clark, 1991). Supramalleolar orthoses, however, may not improve ankle motion in the sagittal plane (Carlsun et al., 1997). Another variant is the posterior leaf spring orthosis, which is intended to prevent excessive equinus while mechanically augmenting push-off. A kinetic gait analysis of 31 children found that it reduced equinus in swing, permitted ankle dorsiflexion in stance, absorbed more energy during midstance, but reduced the desirable power-generating capabilities at push-off (Oonpuu et al., 1996). Bivalved casts or therapist-fabricated splints have been used in place of AFOs as a less expensive alternative for children who are growing quickly, do not have access to funding, or require a period of evaluation. The bivalved casts, popular during the 1980s, incorporate design features such as toe extension support, which is purported to inhibit abnormal tone or reflex activity. Although clinicians have claimed that the splints reduce abnormal tone, improve positioning, and reduce unwanted reflexes, research has not substantiated the claims (Carlson, 1984). Orthoses have also been used during sleep to prevent the secondary impairment of hypoextensibility, or contracture. Baumann and Zumstein (1985) found that the use of double-shell foot orthoses as night splints from age 3 years to the end of the skeletal growth period prevented calf muscle contractures from developing and made the need for surgery rare. Other materials such as Lycra (Blair et al., 1995), neoprene, and tape have been used for splinting to assist children biomechanically and facilitate function. Caution must be taken concerning the skin tolerance of these materials. ORTHOPEDIC SURGERY Orthopedic surgery in preschoolers is usually performed to prevent secondary impairment by limiting the effects, but not the causes, of hypoextensibility and spasticity. For example, the lengthening of hypoextensible or spastic hip adductors (or both) may be performed to prevent subluxation or dislocation of the hip joint. Sometimes, however, surgery such as tendo Achillis lengthening is delayed because of the tendency for recurrence necessitating repeated surgery (Tardieu et al., 1982). Ideally, surgery is deferred until age 6 to 8 years, when multilevel corrections can be performed if necessary (DeLuca, 1996). Massagli (1991) has emphasized that musculoskeletal surgery does not alter the neurologically driven patterns of muscle activity, although lengthening, releasing, or transferring a muscle can alter its influence. Decreased force production is often a complication. Orthopedic surgery is sometimes combined with neurectomy if tonic activity of the muscle is present as a result of spasticity or other neurologic causes. A full discussion of the role of orthopedic surgery in CP can be found in the work of Rang (1990). Physical therapists play important roles in surgical decision making. They are also involved in the care of the child who is immobilized and in providing postoperative therapy (Harryman, 1992), particularly because decreased force production is a significant complication of surgery. Frequently forgotten is the importance of transporting children safely in motor vehicles when they are in casts, an activity for which various devices are available (Bull et al., 1989). POSITIONING. Alignment of the body as a whole is important. Children should have a variety of posit tions in which they can optimally function, travel, and sleep. Varying the positions of children who are limited in movement also helps prevent the secondary impairments of positional contractures and deformity, as well as skin breakdown (Healy et al., 1997). Decreased ability to change body position during sleep can cause disrupted rest for children with CP (Kctagal et al., 1994). Position changes can also contribute to pulmonary health. Severely involved children are at risk for chest complications because of chest wall biomechanics, feeding difficulties, immobility, and poor coughing abilities. Adaptive seating has also been shown to improve pulmonary functioning (Nwaobi & Smith, 1986). For the preschooler, sitting, standing, lying, and a position suitable for playing on the floor are important. When prescribing seating systems, it is necessary to be aware of not only the child’s comfort and functional abilities but also the caregivers’ concerns and needs and the child’s environment. Seating inserts can be used in a variety of situations and with equipment such as strollers and wheelchairs, which are often needed to enable parents to transport their child easily. Specific suggestions are included in Chapter 24. Approved car seats and restraints are necessary for safe and comfortable vehicular transportation (Shaw, 1987). Positioning in standing is thought to reduce or prevent secondary impairments by maintaining lower extremity muscle extensibility, maintaining or increasing bone mineral density, and promoting optimal musculoskeletal development (Stuberg, 1992), including acetabular development. A study of bone mineralization in children with hemiplegic CP concluded that bone cize and density decrease with increasing neurologic involvement, and weight bearing may slightly lessen the effect (Lin & Henderson, 1996). Optimally, standing involves movement and activity to provide intermittent loading and muscle strain. Standing programs are often started at 1 year of age if children are not able to bear their weight effectively on their own. Stuberg (1992) recommended positioning instanding for 45 minutes two or three times a day to control lower extremity flexor contractures, and for 60 minutes four or five times per week to facilitate bone development, but notes that there is no definite evidence to support these guidelines. Maintenance of the child’s ability to bear full weight through the-legs reduces the need to be lifted by caregivers. TREATMENT LIMITATIONS OF FUNCTIONAL Physical therapy for treatment of functional limitations is often intensive during the preschool years. The frequendy of treatment varies, depending on the resources available, complementary programming, client goals, parental needs and desires, and the child’s -response to treatment. Optimal treatment frequency is unknown, but periods of increased frequencies have shown improvements in attainment of specific treatment goals at levels that were maintained when frequency decreased, provided the skills were incorporated into daily functional activities. Bower and McLellan (1992) found that bursts of intensive physiotherapy directed at achievable specific measurable goals accelerated the acquisition of motor skills compared with conventional physical therapy. Therapy should be challenging and meaningful to the child and progress to integrating the skills learned into functional and cognitively directed skills for carryover. Movement tasks should be goal oriented and interesting to maintain motivation and arousal. For example. kicking a soccer ball may be a more functional and motivating method of developing balance skills than practicing standing on one foot. ChIldren with CP are able to perform concrete perceptuomotor tasks much more readily than abstract ones, even if the same movements are involved (van der Weel et al., 1991), because more information is available from the environment to direct the task. Motor control and motor-learning principles (see Chapter 6) can be used to develop treatment strategies for reducing functional limitations. Feedback is important in the process of learning skilled movement. Feedback through the child’s sensory receptors provides intrinsic information, whereas extrinsic feedback through various forms of biofeedback provides information from external sources. Knowledge of results contributes information about movement outcome, and knowledge of performance supplies feedback about the nature of the movement (Poole, 1991). Peedforward mechanisms must also be considered, because there is a cognitive component to movement skills. In some instances, cognitive strategies may be able to compensate for some of the inherent motor limitations. Many children with CP do not have normal cognition and behavior, and activities must be adapted accordingly. If a child is unable to learn, training using memorization of solutions may be necessary, although limited transfer to novel situations will occur (Higgins, 1991). If behavioral factors are negatively affecting treatment, a behavioral approach using appropriate motivators may encourage children to work on certain skills (Horton & Taylor, 1989). Improvements in functional movement of the preschool-age child are made by reducing the effects of the multisystem impairments of selective control, anticipatory regulation, and learning of unique movements. Although there is a growing literature on motor learning (see Chapter 6), on motor control in skill acquisition (see Chapter 2), and on the biomechanics of movement, the profession is still far from being able to provide optimal strategies for treatment that are known to be effective (Fetters, 1991). The therapist who treats children with CP should modify approaches as research produces new insights in the areas of motor learning and motor control. FEEDING, DROOLING, AND TOILETING. Some children with CP, particularly those who are severely affected, may have oral-motor problems, such as poor mouth closure, retraction or thrusting of the tongue, poor tongue movements, and poor coordination in swallowing, which can make speech and feeding difficult. Feeding problems can be aggravated by other problems such as impaired self-feeding and difficulties in expressing hunger or food preferences that may result in inadequate nutritional intake and poor growth (Gisel & Patrick, 1988; Reilly & Skuse, 1992). Gastroesophageal reflux and aspiration also occur in children with severe CP. Oral-motor programs, proper positioning, and parent education and support are important issues to address (Evans Morris & Dunn Klein, 1987). In extreme cases, gastrostomy and antireflux procedures may be necessary to improve growth and enhance the quality of life for the child and the family (Rempel et al., 1988). Drooling, a significant problem in about 10% of children with CP, can cause social embarrassment and affect the quality of social integration (Blasco et al., 1992). It can result from dysfunctional oral-motor activity, oral sensory problems or inefficient and infrequent swallowing. Management may include waiting for further neurologic maturation, feeding and oral stimulation programs, behavior modification programs, medications, or surgery. Failure to develop an appropriate toileting routine during the preschool years can result in an ongoing disability, because incontinence can provoke negative reactions from caregivers and peers. Expectations of toileting in children with CP should be similar to those for children of comparable cognitive abilities, and therapists should encourage training at a comparable age and recommend appropriate adaptive equipment as necessary (Shaw, 1990). MOBILITY Ambulation is a major concern of physical therapists during these years. Emphasis in treatment is initially on prewalking skills, such as attaining effective and well-aligned weight bearing, promoting dissociation and weight shifting, and improving balance. Ambulatory aids, such as walkers and crutches, may be used, either temporarily while the child is progressing to more advanced gait skills or as long-term aids for independent mobility. The use of posterior walkers has been found to encourage a more upright posture during gait and to promote better gait characteristics than does the use of anterior walkers (Fig. 20-5) (Logan et al., 1990). Children in this age group are becoming aware of the concept of achievement, and although ambulation is a coveted skill, it should not become an allconsuming goal, particularly if it may not be attainable. When interviewing adults with significant impairment, Kibele (1989) found that they remembered walking as the most important goal set for them by their parents and therapists. This resulted in feelings of failure from an early age and also in a loss of faith in rehabilitation professionals. The provision of alternative means to allow children functional, independent mobility when ambulation is impossible or inefficient is recommended. Sometimes this need is met with an adapted tricycle (Fig. 20-6) or manual wheelchair; other children require one of a wide variety of power mobility devices available (Jones, 1990) and may need special controls (Fig. 20-7). These enable children with CP to explore their environment and achieve a sense of independence and competence. Power mobility may also promote the development of initiative (Butler, 1991) and the acquisition of spatial concepts. The lack of selfpropelled locomotion can result in apathy, withdrawal, passivity, and dependent behavior that can persist into later life (Butler, 1991). indication of the implications of power mobility on housing and transportation needs. For more information, see Chapter 24. PLAY Play, the primary productive activity for children, should be intrinsically motivating and pleasurable. The benefits of play include the children’s discovering the effects they can have on objects and people in their environment; developing social skills; and promoting the development of perceptual, conceptual, intellectual, and language skills. Limitations in the play of children with physical disabilities may affect their experiential learning derived from play and result in decreased independence, motivation, imagination, creativity, assertiveness, social skills, and selfesteem (Blanche, 1997; Missiuna & Pollock, 1991). Therapy should provide and demonstrate play opportunities (Fig. 20-8). Appropriate toys and play methods should be suggested to parents and caregivers. If children are physically unable to play with regular toys, a variety of adaptations, such as switch accessing, can make their toys usable (Langley, 1990). Environmental control equipment also can be introduced to preschoolers. FIGURE 20-5. Child using a posterior walker, reported to promote upright posture and higher walking speeds than an anterior walker If power mobility is being considered, fine motor control, cognitive abilities, behavior, environment. visual and auditory abilities, and financial resources must all be taken into account. Children with motor limitations have become safely and effectively mobile in power wheelchairs at as young as 17 months of age (Butler, 1991). Parents may initially be hesitant about introducing power mobility to young children, fearing that it signifies giving up on walking. Power mobility does not preclude ambulationoriented therapy but provides the child with a method of moving about independently in the meantime. For children who will continue to be wholly dependent on power mobility for independence, it provides mobility at an appropriate age and gives the families an FIGURE 20-6 An Adapted tricycle may meet a child need for mobility. INTERVENTION APPROACHES FIGURE 20-7 Single – swoith scanning computer controller for power wheelchair permith indenoendent mobility for children with limited motor control. Developed at Hugh MacMillan Rehabilitation Centre, Toronto, Ontario It is important that children are not overprotected in their attempts to play. Parents should be encouraged to let their children enjoy typical play actisis such as rolling down hills and getting dirtx’ in the ttttid. Therapists must ensure that therapy and home programs promote, rather than interfere with, the novtmtl play experiences parents have with their children. Figure 20-8 Therapeutic exercise programs can include highly motivaTING PLAY ACTIVITIES. Thorowing a basketball may be more motivating than trunk extension exercises. NOT is a treatment approach that is used with the age group and that continues to evolve with advances in the field (Bly, 1991). Research studies on the effectiveness of NDT are available but controver~ sial and reflect the difficulty in conducting clinical research (lThiisano, 1991). However, NDT strategies incorporated into treatment have been shown to improve control of functional movements (Kluzik et al.. 1990). Strategies such as practice may need to be integrated into NDT for optimal im2rovement in specific skills (Jonsdottir or al., 1997). Conductive Education (CE), an approach originated by Andras Peto in Hungary, is based on the theory that the difficulties of the child with motor dvsfu n tion are problems of learning. The goal of treatment is the ability to function independently in the world without aids, an important objective in Hungary, where schools are not adapted for children with disabilities. Participants are selected for their abilify to learn, which may make some children ir~eligible for the program. They are usually treated in group settings that provide the incentive of competition and allow more time in therapy than does individual treatment. Functional goals are broken down into small steps. Children initiate the activities on their own, with direct conscious action aided by mental preparation (Bairstow et al., 1991). Research on CE is limited; however, a study by Reddihough and colleagues (1997) found that children in a CE program made progress similar to that of children involved in neurodevelopmental programs. Knowledge of a variety of theoretic models, not necessarily pediatric in origin, can help form a therapist’s approach to treating children with cerebral palsy. Cart and Shepherd’s task-related movement science-based approach (Shepherd, 1995), the motor control theories of Shumway-Cook and Woollacott (1995), and the dynamic systems theory (Darrah & Bartlett, 1995) can be integrated into physical therapy interventions for children with CP. The family-centered service philosophy of service provision can be applied to all treatment approaches. It is difficult to compare the effectiveness of different approaches because there are also discrepancies in parameters such as frequency, skill level of individual therapists, compliance of families, and age and abilities of the patients. In a study comparing four treatment approaches, Bower and colleagues (1996) found that parents were most pleased with therapy when they requested the services, when they were present during treatment, and when targeted goals were met. They concluded that the most appropriate approach for a child would be one that would meet the needs of the particular child. Parents of children with CP often consider alternative therapies that may not be accepted by some professionals and are usually expensive. If families choose to take an approach other than the one offered by the therapist, it is necessary to respect their choice. Reasons for seeking alternatives include a desire for more therapy, dissatisfaction with present therapy, and belief that their child could do better (Milo-Manson et al., 1997). Therapists should not react defensively but should provide impartial information about the therapies in question. FAMILY INVOLVEMENT The importance of providing family-centered setvice continues. Planning of interventions should take into account the child within the context of the family. Therapists should be sensitive to the family’s stresses, dynamics, child-rearing practices, coping mechanisms, privacy, values, and cultural variations. Therapists should be flexible in their approach and programming (Kolobe, 1992). Special efforts must be made to deal with the effects of a child with CP on the siblings (Powell & Ogle, 1985). Family involvement is crucial for integrating treatment into everyday life. Home programs are important for optimal results from therapy programs because strengthening, extensibility, and motor learning often require more input than can be provided by limited treatment resources. It is necessary to find a balance between providing parents with home programs that make them an integral part of their child’s therapy and burdening them with activities they cannot realistically be expected to carry out. Obstacles may includ&constraints on time, energy, skills, or resources or negative effects on the parent-child relationship. Hinojosa and Anderson (1991) found that although mothers of preschoolers with CP did not carry out specific home programs designed by therapists, they did activities that could be integrated into their daily routines and interactions and that were not stressful for the child or the caregiver. Siblings can be included in home programs. Craft and colleagues (1990) studied a group of children with CP whose siblings had been educated about the condition and ways in which they could encourage their brother or sister to be more independent. As a result of this, the children with CP showed increases in ROM and in functional independence. ROLE OF OTHER DISCIPLINES Occupational therapists work closely with the children at this age to develop independence in activities such as dressing, feeding, toileting, and playing. Speech and language pathologists continue to develop efficient methods of communication in children with CP. Psychologists assess cognitive skills and advise on the interaction of intellectual abilities with the other areas of development. Social workers and behavior therapists continue to provide ongoing support to the families, because the stresses involved in parenting a child with a disability persist (Sternisha et aL, 1992). Team assessment and intervention are imperative for addressing issues such as feeding problems, augmentative communication, and transition to school. School-Age and Adolescent Period During the school-age and adolescent years, children typically become more involved in school and community life while remaining dependent on their families and living in their parental homes. They refine and augment the basic functional skills they have learned and develop life skills that will enable them to cope effectively with the demands of daily living and, it is hoped, independent adult life. These can be difficult years for children with CP. They become more aware of the reality, extent, and impact of their disabilities on themselves and their families. As they strive to contend with the normal stresses of growing up, particularly those of adolescence, they must also cope with being different, acknowledge the potential obstacles to attaining independence, and work to overcome them. Parents remain anxious about how their childs disabilities will affect their participation in educational environments and in social situations. They may worry about their child’s future as an adult (Hallum, 1995). While continuing to be naturally attentive, they have to avoid being overprotective and begin to allow their child to take risks and become independent in the outside world. In some cases, there may be financial concerns regarding the need for special equipment, transportation, and home renovations. Parents of children who are dependent in ADL and transfers may suffer from physical stresses, such as back problems. Typical disabilities encountered during these years include a lack of independent mobility, poor endurance in performing routine activities, and continued difficulty and slowness with self-care and hygiene skills at a time when privacy is becoming in- creasingly important. Adolescents may also not have the opportunity to develop socially and sexually and may lack the ability to acquire age-appropriate levels of independence from the family. Societal barriers may reduce access to community and school facilities, thus limiting opportunities for participation in social, cultural, and athletic activities. Physkal Therapy Evaluation Examination and Assessment of impairments that could interfere with function, or lead to further secondary impairment, such as scoliosis, continues to he important. Children in this age group may be able to participate in measurement of force production using dynamometry. Assessment of gross motor function is appropriate, because children are often making gross motor progress during their school years. They may also change as a result of interventions such as surgery, the use of orthoses, and periods of intensive therapy. The development of the Gross Motor Performance Measure (Boyce et al., 1995) may help in detecting the fine increments of motor skill gains that are characteristic of children who are severely affected. For children with mild degrees of involvement, the Bruininks-Oseretsky Test of Motor Proficiency (Bruininks, 1978) may be useful in measuring specific components of higher levels of motor function. Tools such as the School Function Assessment may be used in educational settings (Coster et al., 1994). Gait analysis continues to be helpful in assessing ambulatory children, particularly when decisions about surgery are being made (Lee et al., 1992), although this opinion is not held by all (Abel, 1995). Endurance and efficiency of movement become increasingly important during these years as the children venture into the community on their own or with their peers. Mechanical energy costs can be assessed with motion analysis equipment (Olney’ et al., 1987). In the clinical setting, physiologic measures such as the physiologic cost index for activities such as ambulation can give energy cost estimates (Butler, 1991; Mossberg et al., 1990) or assist in selecting assistive devices (Rose et al., 1985). In a laboratory setting, ergometer assessment can analyze other aspects of endurance (Parker et al., 1992). An important consideration in maximizing endurance for daily activities is the effect of excessive weight gain, because it can compromise optimal function and efficiency. Privacy of individuals at all ages should be respected, but it is particularly important during these years when children are becoming more aware of their bodies and their sexuality. Children should be appropriately dressed when attending therapy sessions and clinics, particularly if they are being seen by unfamiliar people or are being photographed or videotaped. If it is necessary for children to remove their clothing, their permission should be asked and a reason given for doing so. It is important to include the clients in conversations that involve them and not to converse only with caregivers or other professional staff. Physical Therapy Goals, Outcomes, and Interventions As goals become oriented toward the child’s or adolescent’s lifestyle, emphasis is on maintaining or improving the level of function while considering the stresses of growth, maturation, and increastna demands in life skills and participation in communitiy activities. Although the pathophysiologic impairment of CP is nonprogressive, there are changes related to the stresses of increasing size, accumulative physical overuse, and a more competitive lifestyle. For example, as children advance to higher grades in school, there may be longer distances to walk between classes. Contractures may rapidly develop during periods when boEes are growing faster than muscles (Tardieu et al., 1982). Secondary orthopedic and functional problems must be anticipated and avoided. The maintenance of muscle extensibility and force generation, joint integrity, and fitness is important in preventing secondary impairments that can result from the stresses of aging. This age group also needs to develop problem-solving strategies to overcome environmental and societal barriers to become as independent and active as possible in home, school, recreational, social, and community life. In many cases, adolescents can and should be involved in setting goals and determining programming. It is important during these years to encourage them to take responsibility for their own health, care, and decision making so that they are prepared to assume these responsibilities in adulthood (Fox et al., 1992). It is also important to look ahead and set goals that are appropriate for their later life situations and independence. Therapists should strive to foster selfesteem and assertiveness in children and adolescents by emphasizing their abilities, finding areas and activities in which they can excel, and helping them to acknowledge their difficulties with a view toward identifying appropriate compensations and use of attendant care. In the case of children with severe (multiple) disorder, goals are oriented toward minimizing impairments to facilitate caregiving and comfort. REDUCING PRIMARY IMPAIRMENT AND PREVENTING SECONDARY IMPAIRMENT The impairment of deficient muscle force generation that may result in functional limitations and disabilities is important to address in this age group. Damiano and coworkers (1995) used ankle weights in a 6-week progressive resistive strengthening program for the quadriceps in 14 children with spastic diplegia. Stride length increased, and knee flexion at initial contact decreased. An 8-week isokinetic strengthening program for mildly affected adolescents effected strength, gains of 12 to 30% in knee extensors and flexors but no increase in spasticitv (MacPhail & Kramer, 1995). Nine of the seventeen subjects showed improvements in the standing and walking, running, and jumping dimensions of the Gross Motor Function Measure. Using free weights in a home program supervised by’ a family member, Damiano and Abel 1998) reported average strength gains of 69% when the two weakest muscle groups were trained in children with spastic diplegia or hemiplegia. The gains were associated with positive functional outcomes, although, as with the MacPhail and Kramer study, it is not clear whether increasing strength alters gait efficiency. Various methods of electrical stimulation have been used as an adjunct to the treatment of CP to reduce spasticity, to increase force production and extensibility, and to improve function activities such as gait (Stanger & Bertoti, 1997). This treatment adjunct is particularly useful in postoperative muscle training and strengthening. Protocols should be individualized for patients following careful analysis of movement, and application should be closely monitored. It was once thought that individuals had no control of their spasticity. Subjects with CP, however, have been able to reduce their responsiveness to a stretch reflex stimulus imposed during a lower limb activity (O’Dwyer et al., 1994). These findings encourage further exploration of the possibilities of reducing spastic responses. Pharmacologic intervention can be used to control the impairment of spasticity. The use of oral medications has been poorlystudied, but medication may be appropriate for some children (Pranzatelli, 1996). Children must be carefully assessed for appropriateness and monitored closely for side effects. Baclofen, a synthetic agonist of aminobutyric acid, has an inhibitory effect on the presynaptic excitatory neurotransmitter release. It has been shown to reduce spasticity in individuals with CP (Campbell et al., 1995). If taken orally, doses high enough to give the proper concentration in the cerebrospinal fluid can cause side effects such as drowsiness. To circumvent this problem, baclofen is most effective if given intrathecally by’ a continuous infusion pump implanted in the abdomen that releases the drug at a slow, constant rate into the subarachnoid space. The use of intrathecal baclofen has been postulated to reduce the need for orthopedic surgery (Gerszten et al., 1998). Biofeedback is a useful tool in addressing single-system and multisystem impairments during these years (Fig. 20-9) because by this time children have usually developed abstract thinking and sufficient cognitive ability to use it optimally. Positive results have been reported, but carryover is often limited, generalization to real-life situations is not readily demonstrated, and treat~rient is time consuming (James, 1992). Toner and colleagues (1998) found that a program of biofeedback improved active range of motion and strength and motor control in dorsiflexion in a group of children with CP. The secondary impairment ofjoint or muscle contracture may occur in this age group, particularly in the more severely affected patients. This can be a result of chronic muscle imbalance, abnormal posturing, or static positioning. Casting may be used to increase the range of joint movement by lengthening muscles or tendons or both with nc associated loss in strength (Brouwer et al., 1998; Cusick, 1990; O’Dwyer et al., 1989; Tardieu et al., 1982). Interventions of botulinum toxin A and casting may complement each other in children with spasticity and contractures. Anderson and colleagues (1988) found that soft splints made of polyurethane foam were effective in reducing severe knee flexor contractures; this may be an attractive alternative for low-income families. Orthopedic surgery continues to be used to reduce, the effects of primary and secondary impairment on mobilirv, posture, cosmesis, and hygiene and to prevent further secondary impairment. Possible surgical procedures include muscle lengthenings or transfers, tenotomies, neurectomies, osteotomies. and fusions. Surgery may improve posture and gait, but outcomes can be unpredictable because muscle weakness often results. As children get older, they should be active participants in surgical decision making that may he influenced by their interests, priorities. and concerns about interruptions in their lives as result of hospitalizations, immobilizations, and recovery periods. The secondary impairment of joint hypomobility resulting from capsular or ligamentous tightness can be treated with manual therapy techniques (Brooks-Scott, 1995). Joint mobilizations may be used to regain joint mobility, particularly after immobilization. Therapists must ascertain whether joint structures are causing movement restriction and must also be aware of the contraindications and precautions relevant to using mobilizations in growing and neurologically involved patients (Harris & Lundgren, 1991). Spasticity, abnormal extensibility of muscles, muscular imbalance, and decreased force generation can resulr in scoliosis, which, in turn, can affect positioning and respiratory status. Spinal deformity can be a particularly difficult problem in the severely affected patient. Rigid orthoses can result in skin breakdown arid patient intolerance; by contrast, the use of a soft orthosis has been found to be beneficial in the management of scoliosis in patients with CP (Letts et al, 1992). In some-ases, surgical intervention may be necessary (see Chapter 10). wheelchair or a power scooter, as they become larger and need to travel greater distances to meet their social and educational objectives. Ambulant children with cerebral palsy are less active than their peers (van den Berg-Emons et al., 1995). Availability of power mobility should not preclude activity to the point of decreased musculoskeletal integrity or physical fitness. Mobility devices may require modifications, such as ramps to buildings or washroom renovations, for accessibility’. Dnve r training offers the freedom to travel independen:Iy. For those unable to drive, instruction in the use of public or special transportation should be provided. The functional limitation of low endnrance levels, frequently related to inefficiency of movement, has been identified in children with CP. Rose and colleagues (1990) found chat energy expenditure indices based on oxygen uptake and heart rate measured at a given walking speed were 3 times higher in children with CP than in normal control children. Findings that were similar, but based on mechanical energy analyses, were reported for children with hemiplegia (Olney et al., 1987). Rose and colleagues (1985) also found that children who were ambulatory with wheeled walkers or quadruped canes had high physiologic wotkloads when walking for 5 minutes, suggesting that it is impractical for such children to walk long distances. Orthoses may also influence energy expenditure. Mossberg and colleagues (1990) showed that the use of AFOs significantly reduced the energy demands of walking in children with spastic diplegia. FIGURE 20-9. Biofeedback is a useful teatment tool when precise objectives can be indentified MOBILITY AND ENDURANCE Many compensatory strategies can be implemented to promote function and circumvei~t disability during the school years. The continued use of po’ver mobility devices is important for independent mobility. Often children who are able to walk independently need an alternative form of mobility, such as a manual FIGURE 20-10 Computer-based communication system with keyboard on computer screen and head pointer acting as controller. Developed at Hugh MacMillan Rehabilitation Centre, Toront, Ontario SCHOOL AND COMMUNITY Many children are involved in school based programs, particularly with continuing application of the Education for All Handicapped Children Act in 1975 in the United States (Poirier et al., 1988) and the Charter of Rights and Freedoms in Canada in 1982 (Poirier et al., 1988). In most jurisdictions, the educational program must be implemented in the least restrictive environment for that child, and “the child. mainstreamed to the fullest possible extent” (Clune & Van Pelt, 1985). Facilities and resources such as support personnel, equipment for accessibilityi, and computer-based systems (Fig. 20-10) are necessary to meet the physical needs of children in the school system. Therapists working with school personnel may instruct assistanrs and teachers in positioning, lifting, and transferring the children; carrying out exercise programs; and adapting and developing physical education programs (Wilcox, 1988). Therapists may also be involved in accessibility, transportation, evacuation, and other safety issues. Therapists working in school settings must be sensitive to the physical and scheduling constraints of the educational environment and be willing to compromise to meet the educational priorities of the students. Therapy may range from consultation and monitoring for students who are thought to have reached their maximal level of functioning, to active therapy for children who have specific treatment goals. When children are primarily seen through the educational system, effort must be made to keep the family involved in all aspects of care and treatment. See Chapter 32 for further information on this subject based on experiences in the United States. In addition to educating school staff about children with CP, therapists can help educate the other children in the classroom. Knowledge ahout, and positive interactions with, people with disabilities can create positive attitudes, particularly when children are between 7 and 9 years of age, because their attitudes about people with disabilities are flexible at this age (Morrison & Ursprung, 1987). It is important for children with disabilities to be involved in community and recreational activities that provide social as well as therapeutic opportunities. Many adapted or integrated sports activities are suitable for people with CP, including horseback riding (MacKinnon et al., 1995), swimming, skiing, sailing, canoeing, camping, kayaking, fishing, bun-gee jumping, yoga, and tai chi. Adapted games can provide athletic competition and participation in team experiences and can facilitate the social aspects of sports (Jones, 1988). All athletes are at risk for sports-related injuries, but relatively minor injuries can incapacitate people with CP. They should be encouraged to be responsible for their bodies during sports activities by following appropriate conditioning, warm-up, and cool-down routines; following comprehensive injury prevention programs, which include strengthening, flexibility, and aerobic and anaerobic training activities; and using appropriate protective and orthotic equipment. Injuries should be treated promptly. The knee is the most frequently injured body part in athletes with CP. Shoulders, hands, and ankles are also vulnerable (Ferrara et al., 1992). For more information, see Chapter 17. During these years, children learn about their bodies, their sexuality, and appropriate interactions with other people. Children and adults with disabilities have an increased risk of suffering abuse, including sexual abuse, which can result in physical, social, emotional, and behavioral consequences (Hallum, 1995; Sobsey & Doe, 1991). Many of the perpetrators have relationships with the victims that are similar to those commonly found among nondisabled victims; however, some abusers have relationships specifically related to the victim’s disability. These people can be personal care, attendants, transportation providers, residential care staffi and other disabled individuals. Abuse is a serious matter that must be guarded against at all times. Physical therapists must know how to detect the signs of abuse, be sensitive and receptive to clients who may choose to confide in them, and know the proper procedures to follow if they suspect abuse. They must work with other professionals to promote assertiveness and positive self-esteem in their clients. All professionals involved with patients who have CP must educate them in being streetwise. Their physical and sometimes cognitive limitations can make them particularly vulnerable to crime. Children and adolescents with disabilities should be taught to avoid threatening situations. They should be warned about carrying valuables (large sums of money or important medications) with them, particularly in a purse that attracts attention and is easy to grab) such as one slung over a wheelchair handle. Attendance at self-defense courses should be encouraged; some that are specifically designed for people with disabilities are becoming available. Health care professionals must realize that although parents have been coping with their children’s needs for a number of years, parent education is still important: their children and their needs are constantly changing. Continued attention to education in lifting and transferring is necessary to prevent injury to caregivers as their children grow larger and heavier and they themselves are aging. the family, and the health care team to provide comprehensive planning to ease the transition to adulthood. ROLE OF OTHER DISCIPLINES Occupational therapists may be involved in promoting independence in ADL. Multidisciplinary lifeskills training may be offered to focus on self-care, community living, and interpersonal relationships. Prevocational training and related activities, such as money management and employment searching, may be necessary. Psychologists or social workers may be involved in social and sexual counseling. Transition to Adulthood The life role of an adult is to be an independently functioning and self-sufficient individual who has a satisfying social and emotional life and is a contributing member of society. The natural environment for adults is living independently in the community, alone or with others, with employment to support them. The extent to which people with CP can realize these goals depends on factors such as level oficognition, available resources and support, and independence in self-care activities and mobility. Many adults with CP continue to live with their families, in group homes, or in institutions, and a small proportion of them are employed. In Finland, a study of young adults who had been followed since childhood revealed that 31% of those older than 19 years were competitively employed, but an additional 21% who were judged to be employable were unemployed (Sillanpaa et al., 1982). Finding employment can be particularly difficult when there is considerable unemployment in the able-bodied population. At a time when most parents are experiencing freedom from caregiving responsibilities, many parents of children with CP continue to have these obligations and have to cope with many anxieties (Hallum, 1995). Their concerns focus on how their child can function as an independent adult, how they can continue to care for their child as they themselves age, and who will care for the child when they are unable to do so. They, and their child, may also be coping with a decrease in the numbei of relatively organized and available programs that were available for the younger child. Physical therapy involvement continues to address all levels of the disabling process; however, there is an emphasis on working together with the individual, Physical Therapy Evaluation Examination and Although there is a continuing need to assess impairment, adult assessments focus on functicn and disability, particularly on the level of independent functioning. A variety of functional disability scales, such as the Barthel Index, have been developed for adults in general rather than for adults with a particular disability (Mahoney & Barthel, 1965). These measure performance in various self-care, independence. and mobility functions (Spector, 1990). Physical Therapy Goals, Outcomes, and Interventions The major goal during this period of transition is to maximize the client’s capabilities to achieve optimal independence and happiness as an adult. Ideally, the medical, therapeutic, and educational goals of childhood have had this as a long-term goal in earlier intervention. In a study of adults with CP health in terms of acute illnesses was not a problem, but 76% had multiple musculoskeletal problems, and many nonambulatory adults had urinary complaints. Equipment and therapy needs were poorly met (Murphy et al., 1995). In many situations, professionals, the client, and the family are dealing with external environmental forces that make it difficult for a person to overcome disabilities. REDUCING PRIMARY IMPAIRMENT AND PREVENTING SECONDARY IMPAIRMENT Although there is a focus on overall disability, therapists must still be cognizant of the impact of impairment on function. Adults with CP must deal with the normal effects of aging in addition to their existing impairments (Overeynder & Turk, 1998). Insufficient force generation and hypoextensibility can still respond to therapy. Although secondary impairments such as contracture may appear to be static, there can still b3 deteriorarion, so momtoring and treatment, if necessary, should be available. If significant deformity occurs, aggressive salvage surgery may be necessary for comfort and ease of care. One example is proximal femoral resection if a hip is painful or if hip mobility is limited to the extent that sitting and perineal care are affected; however, this surgery has a high complication rate (Perlmutter, 1993). Of particular importance is the prevention of overuse syndromes, joint degeneration, progression of contractures, osteoporosis, poor endurance, and pathologic fractures. Cervical and back pain, nerve entrapment syndromes, or tendinitis can occur as a result of excessive and repetitive physical stresses (Bergman, 1994; Murphy et al., 1995). Such injuries should be treated with orthopedic therapy techniques, as they would be in the general population. Preventive treatment to minimize the long-term effects of the neuromuscular dysfunction may be beneficial. This may include use of additional mobility aids or devices, orthoses, or surgery. Changes to the adult’s environment may be necessary to maintain optimal independence (Overeynder & Turk, 1998). LIFE SKILLS Ongoing involvement in fitness and recreational activities should be planned. This will provide social opportunities, as well as maintain or improve cardiovascular fitness, weight control, and integrity of joints and muscles; help prevent osteoporosis; and generally promote the optimal health that contributes to independent functioning. Fitness clubs, swimming, wheelchair aerobics. and adapted sports are options. Endurance continues to be an important concern. Fernandez and Pitetti (1993) found that the values for physical work capacity of ambulatory adults with CP were significantly lower than normal values and concluded that adults with CP would possibly experience fatigue before completing a normal workday. However, physical work capacity and workrelated activities improved with training. Technology is providing adults with CP many options that were not previously available. These include computers for communication, artificial speech devices, environmental control devices, and mobility devices. For more information, see Chapter 24. Society is becoming more conscious of the rights and needs of the disabled (Bickenbach, 1993). Human rights legislation now exists to accommodate people with disabilities and to prevent discrimination against them in areas such as employment, accessibiLty, the legal system, and education. Government programs and services are available to people with disabilities. Theaters, restaurants, libraries, museums, government buildings, educational facilities, shopping areas, parks, campground facilities, and parking lots are becoming accessible, where possible, through the provision of ramps, appropriate washroom facilities, and other modifications. Air and rail travel is also becoming more accessible to people with special mobility needs, and there are now travel organizations that cater to people with disabilities. In some situations, funding for assistive devices, living allowances, and housing and tax exemptions help prevent undue hardship. Therapists should be aware of the facilities available to the disabled and the political policies and issues concerning the disabled and should advocate their advancement. TRANSITION PLANNING Ideally, the planning for the transition to adult services and lifestyle takes place before the actual major life changes. Areas to be addressed when planning for the transition include the following: vocational training or postsecondary educational placement, which may range from higher education to supported work models; living arrangements (independent, with family, institutional, or other supportive care); leisure and recreation (religious groups, community programs, and recreational centers); personal management, including birth control; social skills; and household management. The continuation of professional health services must also be dealt with (Fox et. al. 1992). This includes the provision of therapy when needed, medical consultation, primary care, and equipment needs and maintenance. Financial planning and education about budgeting, tax and other governmental benefits, advocacy and legal services, guardianship, conservatorship, wills, and trusts must be addressed (Hallum, 1995). RESEARCH NEEDS Research in CP is urgently needed. The selection of treatment for an individual with CP requires predictive information about the effects of interventions, if any, on the pathophysiology, impairments, functional limitations, and disabilities of the person throughout the life span, yet even descriptive information is limited. To take a simple example, to decide whether orthoses are appropriate for a particular child, we should know whether the impairment of hypoextensibility is preventable by orthoses, as some studies suggest (Tardieu et al., 1988), and, if so, under what conditions. Furthermore, we should know if force generation capability is changed with orthotic wear, how force output changes with growth, and what conditions favor successful longterm outcomes. The multisystem impairments of poor selective control of muscles, poor anticipatory regulation of movement, and decreased ability to learn unique movements have received little attention. We need better information about the relationships between measures at each level of the disabling process. This will facilitate specificity of treatment. There is a need for research that predicts long-term outcomes. Finally, there are needs for specific and sensitive measurements of all dimensions of the disabling process to be developed within a focused research program. GLOBAL ISSUES The treatment of children with CP varies throughout the world. Physical therapists use many different approaches and combinations of approaches, depending on the facilities available, the child’s and the family’s needs, the therapisty is training and background, and the diversity of client values, beliefs, and priorities. Many of the treatments and technologies discussed are practiced in developed countries, where services, although variable in their extent, quality, and funding, are available and accessible. However, much of the world’s population lives in underserviced areas, particularly in developing nations or in remote areas of developed nations. Often, many of the principles and equipment ideas developed elsewhere can be adapted to the various situations (Werner, 1987). Using indigenous materials to fabricate effective and affordable equipment, recycling used equipment, and training local personnel or fostering exchange programs can help provide resources to underserviced areas. It is important to be sensitive to local customs, cultures, and environmental situations when adapting programs for different settings. Often, the direct application of a certain method is impractical or inappropriate because of economic, geographic, or cultural differences. There is an increasing emphasis on corñmunity-based rehabilitation, which promotes interventions that are practical and functional for the particular settings, lifestyles, and cultures. PROFESSIONAL ISSUES Therapists who care for children (vith CP must realize that the work can be physically demanding. They must practice appropriate lifting and handing precautions and should maintain a suitable level of fitness if they are actively treating patients. Working with children and their families can also be emotionally stressful. Therapists may often be challenged with ethical issues, unrealistic expectations and demands, limited resources, and the pressures of dealing with families during the grieving period and other times of crisis. Therapists need to concentrate on what is positive and realize that they cannot control all the variables in their patients’ conditions and lives. Professionals must acknowledge their own needs and reactions and feel comfortable in seeking assistance and support from others. This chapter concludes with two case histories that illustrate some of the management principles discussed in this chapter. CASE HISTORY JAMIE Jamie is an 8-year-old boy with spastic diplegia and microcephaly. After a pregnancy complicated by preeclamptic toxemia, labor began at 37 weeks of gestation, and an emergency cesarean section became necessary when fetal distress occurred. Treatment was begun in the hospital. On returning home with their child, the parents performed routine stretches daily, and a therapist visited every other week. A mothers’ support group met every 2 weeks, which provided general information and guidance, as well as support. When Jamie was about 1.5 years of age, the family moved to a town in another province where coordinated services were provided. jamie took part in physical therapy, occupational therapy, and speech therapy and was assessed routinely by the psychologic services. When he began attending day care, he received services from the same therapists, and the parents, teachers, and therapists worked together on his treatment. When Jamie was 3.5 years old, the impairment of K poextensibility of the hamstrings and heel cords was present. Functionally, he was able to walk independently, although he fatigued easily. Toewalking was common and accompanied by slight knee flexion and adduction and internal rotation of the hips. His right limb showed more impairment than his left. Bivalved short leg casts were worn for 2hours three times a day, the goal being to prevent further hypoextensibility of the ankle plantar flexors. At age 4.5 years, jamie’s gait was examined in the Motion Analysis Laboratory at the School of Rehabilitation Therapy at Queen’s University in Kingston, Ontario. He walked at an average of 0.71 m/s, compared with-the normal value for his age of about 1.00 in/s (Sutherland et al., 1980). joint excursions were reduced (Fig. 20-11). He walked with marked plantar flex~on of the right foot and with slight flexion and reduced excursion of both knees, and he had reduced power generation of the ankle plantar flexors on both sides (A2-PF, Fig. 20-12), which was evidence of low force-generating capability, hypoextensibility, or both. He was compensating for these deficiencies with larger than normal pull-off by hip flexors on the left side (H3-F, Fig. 20-12). The family engaged jamie in an electrostimulation program from an outside clinic in which the quadriceps and ankle dorsiflexors were stimulated overnight at a level below that required to produce muscle contraction. During the next few months, while electrostimulation and weekly therapy were continued but the use of casts was not, jam ie’s ankle plantar flexors became much more hypoextensible. The use of bivalved casts was reintroduced, and the previous range was regained rapidly. Clinical examination when jamie was 5.5 years old revealed that his hip adductors, knee flexors, and ankle plantar flexors were more hypoextensible; functionally, he was \.‘alking on his toes with reduced excursions of his ankles. Although a number of surgical alternatives were considered, including rhizotomy, the family decided on a lengthening of the right heel cord. The goals of gait reeducation were toward attaining initial contact with the heel and an extended knee and achieving effective push-off with the ankle plantar flexors. His electrica stimulator was used in treatment postoperatively to strengthen the ankle dorsiflexors and the surgically weakened plantar flexors. Other treatment goals and activities included climbing and descending stairs with one foot per stair and stepping off a stair or curb without hand support. Because jamie had a keen interest in sports, movement components such as weight shifting, balancing, and eye-hand-foot coordination and skills such as running, starting and stopping, changing direction, and throwing were incorporated into sports activities such as baseball, coccer, and badminton. The improvement noted at a 6month postsurgical gait analysis (see Fig. 20-11) was more marked on the right side, but several improvements were noted on the left. On the right side, initial contact was made with the heel, and ankle dorsiflexion during late stance reached about 150. The knees on both sides were more extended at initial contact and extended more in late stance than was the case before surgery. The push-off power of the right ankle was greater after surgery (A2-PF, Fig. 20-1 2) than before surgery, and right hip power was more effective (H1-E, hip extensors in early stance; H3-F, hip flexors at pull-off; Fig. 20-12). Average walking velocity was 0.82 m/s.jamie was able to join the community soccer league the following summer. Jamie attends school in a regular classroom, although he has some cognitive limitations. He is visited by a familiar therapist from the treatment center every 2 or 3 weeks and attends speech therapy weekly. The main problem the parents have encountered within the school system is a practice of inflexibly classifying the children according to their chronologic age only. Although jamie is cognitively young and physically small for his age, there has been considerable reluctance to permit him to join younger groups, even for sports. Outside of school, jamie takes part in a nj.imber of athletic activities. He is interested in team sports, and the family has been pleased with the efforts of coaches and managers to include him in organized teams. Update: 5 years later Jamie is now a happy and likeable 13-year-old about to face the challenges of adolescence. He is completing his last year of school at the intermediate level and will be entering a public high school next year. The family is very happy with his education to date, and is trying to help him prepare for the challenges of a large school in which the children are expected to be independent. His cognitive impairments are more limiting than his physical situation. Still small for his age, he has not been able to continue in team sports. His greatest joy is karate, which he attends 3 days a week. He expects to receive his violet belt soon. This activity has helped him with selfdiscipline, balance, and coordination. jamie attends physical therapy about every 3 weeks, where he concentrates on stretching and functional activities that are complementary to his karate practice. About once a year, the hypoextensibility of his left calf group is treated with about 3 weeks of serial casting. FIGURE 20-11. Plots of joint angles from gait analysis of one stride for Jamic, shown presurgically and postsurgically and with normal values (dotted line). Each plot represents one stride beginning and ending with initial contact of the foot on the floor. Plotted upward (positively) are hip flexion, knee flexion, and ankle dorsiflexion. Note limited knee extension on both sides, extreme limitation of ankle dorsiflexion on the right, and normalization of postsurgical values. FIGURE 20-12. Plots ofjoint power from gait analysis of one stride forJamie, shown presurgically and postsurgically and with normal values (dotted line). Each plot represents one stride beginning and ending with initial contact of the foot on the floor. Plotted upward (positively) are muscle power generations (concentric contractions), and downward (negatively) are muscle power absorptions (eccentric contractions). Plots ofJamie’s right side show low force generation of right hip extensors in early stance (H1-E), of hip flexors at pull-off (H3-F), and Gf ankle plantar flexors (A2-PF) presurgically, and increases in all of these after surgery. Plots of Jamie’s left side show compensatory increase in H3-F (pull-off of hip flexors) presurgically, and normalization after surgery. CASE HISTORY NICOLE Nicole has moderate to sev ore spastic diplegia. She was born at 29.5 weeks of gestation after placental separation. She weighed 1300 g and had an Apgar score of 8 at 5 minutes. She was treated with ventilatior for 8 hours and then.was wearied off the ventilator onto continuous positive airway pressure, and then to oxygen. She received phototherapy for 3 days for an increased bilirubin level and was administered theophyliine for apnea. Nicole remained in the neonatal intensive care unit for 6 weeks and then went home to live with her parents and 3-year-old sister. Nicole was followed up at the screening clinic for high-risk infants. At 3 months of age corrected for prematurity, she exhibited extensor positioning of her neck and trunk and hypertonicity was emerging in her legs, but her family did not have any concerns. At 4 months of corrected age, these findings were discussed with her mother, and positioning and handling recommendations were made. At 5 months of corrected age, the diagnosis of CP was made on the basis of hypertonicity in her extremities, affecting lower extremities more than upper; strong, persisting primitive reflex activity; and delayed development of head and trunk control. An ultrasound scan at this time showed the left lateral ventricle to be slightly enlarged and the right lateral ventricle to be at the upper limits of normal in size. The periventricular brain parenchyma appeared normal. Management by a developmental pediatrician, a social worker, an orthopedic surgeon, a physical therapist, and later an occupational therapist was coordinated at the local children’s treatment center. Nicole attended physical therapy sessions weekly. The basic therapy was based on NDT and encouraged active control of movement and play. Positions that reduced the influence of her extensor postuing were used to encourage active control of movements and functional skills. Bivalved casts were introduced early to maintain muscle extensibility and provide optimal alignment of her feet when she was working on standing activities. The casts also reduced some of the extensor posturing in her lower extremities, resulting in improvements in her alignment in sitting and standing and improvements in the quality of functional activities in these positions. These casts were later replaced with solid AFOs when growth slowed down, and Nicole was eager to wear regular shoes. Customized seating and a standing frame gave her a variety of positions that offered opportunities to interact with others and use her hands and provided some weight bearing with her body optimally aligned. At 2 years of age, the impairments of adductor hypcextensibility and spasticity were treated surgically with bilateral adductor muscle releases and anterior obturator neurectomies. The purpose of the surgery was to give her more functional motion at her hips and to put her hip joints in an optimal position for acetabular development; it was also intended to avoid the potential secondary impairment of hip subluxation or dislocation. During her preschool years, Nicole attended an integrated child care program with governmentsubsidized funding for children with special needs. This setting allowed for integration with able-bodied children and also gave Nicole and her family opportunities to meet other children with special needs and their families. Nicole’s physical and occupational therapists visited the center regularly to discuss Nicole’s abilities, programs, handling, and equipment. Her resource teacher was invaluable in coordinating care, supporting the family, and adapting or acquiring equipment. When Nicole was 5 years of age, she was progressing slowly in her gross and fine motor skills. However, spasticity in her lower extremities that was clinically apparent was affecting her ability to maintain well-aligned postural stability, and she could not move easily using optimal patterns of movement. These restrictions resulted in functional limitations in sitting, standing, transitional movements, fine motor activities, and ADL and limited her potential for independence. Ambulation was not functional, but she could move about independently in a power chair and had some limited mobility in a manual wheelchair. The prominence of spasticity and the generally good forcegenerating capabilities of her musculature prompted the decision to have a selective dorsal rhizotomy. After the rhizotomy, Nicole’s lower extremity tone was greatly reduced, and Nicole participated in daily inpatient physical therapy and occupational therapy sessions for 8 weeks postoperatively and then had sessions twice a week for the next year (Figs. 2013 and 20-14). A Gross Motor Function Measure evaluation was done preoperatively and 1 year after the surgery. Her scores im~oved from 88 to 96% in lying and rolling; from 78 to 87% in sitting; from 19 to 57% in crawling and kneeling; from 13 to 32% in standing (with AFOs); and from 7 to 10% in walking, running, and jumping (with AFOs). She had been able to walk 10 m at 0.04 m/s preoperatively but could walk 30 m at 0.15 m/s at her 1-year follow-up. Although these findings indicated that there had been improvements in her gait, the distance and velocity of her walking were still much below age norms and did not result in functional ambulation. She had improved isolated muscle control, which was demonstrated by improved active ROM of her quadriceps, dorsiflexors, and plantar flexors. Her passive ROM improved in her hips, knees, and ankles, particularly in motions involving the hamstring muscles. Nicole continues to have decreased muscle force production, particularly in her hip and knee extensor muscles (Fig. 20-15). FIGURE 20-13 Mother and therapist Nocole, encouragaing force generation of trunk and hip extensors FIGURE 20-14. Nicole, wearing ankle-foot arthoses, doing exercises at school FIGURE 20-15. Despite many improvement after posterior rhizotomy, Nicole still shows diminished forcegenerating ability hip and knee muscles. Nicole showed improvements in her self-care skills, particularly in dressing her lower extremities, because she was able to move one leg independently of the other. On a modified Klein-Bell test of ADL, she achieved 9/33 before surgery and 1 9/33 when tested 1 year later. She was able to function better with her hands in activities such as opening jars, printing, and propelling her manual wheelchair. The improvements were believed to be the result of better trunk control and co-contraction in the shoulder musculature rather than of changes in the intrinsic muscles of her hands, motor planning, or visuoperceptual skills-areas that continue to be problems for Nicole. The Beery Developmental Test of visuomotor integration score was at an age equivalency of 4.1 both preoperatively and postoperatively. Nicole now attended her neighborhood school. Transportation was provided by the school board in a school bus with a wheelchair lift so that she could travel to school with her peers. The educational system also provided a full-time educational assistant to help Nicole with transfers, toileting, schoolwork, and exercise and sports programs. She played with her friends on the playground at lunch and recess in her power chair. She used a typewriter to increase the speed at which she could put information down on paper. Nicole’s family has worked with medical. educational, governmental, and community organizations to gain access to services and programs that provide her with normal childhood experiences and minimize disabilities. Nicole has been involved with horseback riding, swimming programs, and adapted games. She rides in her family’s boat using a Tumble Form seat, goes on an annual vacation to Florida, and traveled to England to be a flower girl at her aunt’s wedding. She attends her peers’ birthday parties, where her friends or their parents help her as necessary. She has modeled in fashion shows in her wheelchair. Nicole has attended the community day camp, Brownies, and the Easter Seals family camp in the summer. Resources her family has found useful include the Easter Seals Society; the Ontario government’s As~istive Devices Program; parent support groups; and the Community and Social Services Respite Care Program, which provides funds for students to work with Nicole-arid provide parent relief. The Canadian railroad, VIA Rail, which allows wheelchair escorts to ride free and offers reduced rates for Nicole, is useful for traveling to out-of-town appointments. Nicole and her family face barriers. The family home is in the country and has a gravel driveway. The house is not wheelchair accessible because there are stairs into the house, stairs inside, and narrow doorways. Thick carpeting makes manual wheelchair pushing and walker maneuvering difficult. When Nicole visits friends, their homes have similar obstacles. Renovations have been made to the school washroom, and equipment has been provided, but the entrance doors are too heavy to open, playground equipment is inaccessible, and classroom door handles are difficult to turn. There is no public wheelchair transportation in their township community. Although obstacles are becoming less common as society becomes more aware of accommodations necessary for people with disabilities, barriers such as buildings without ramps, inadequate parking, and inaccessible washrooms still exist. Nicole’s parents have found regular family conferences invaluable in helping to facilitate effective family and school involvement in therapy programs. In these conferences, all the team members meet to discuss short- and long-term goals. Agendas and minutes clarify the objectives of the meetings and document the decisions that are made. Such conferences help empower parents and allow them to become effective advocates for their children. They also reinforce the philosophy of teamwork and partnership with the therapists and the treatment center. Nicole’s parents have found Craig Shield’s book Strategies: A Practical Guide for Dealing with Professionals and Human Service Systems to be helpful (Shields, 1987).They believe that home visits designed to deal with issues of daily routines, integrate treatment goals into home life, and involve all family members are important. Similarly, school visits are important. Nicole’s parents believe that it is particularly important not to withhold any information from the family. They also emphasize the need for feedback and encouragement to the family, especially to the primary caregiver. Update: 5 years later Nicole is now a warm and friendly 13-yearold who will be entering high school next year. Her parents have worked closely with teachers and administrators of the school, where she has a half-day educational attendant who helps with her schoolwork and gives personal assistance. Her above average knowledge of computer functions allows her to develop more efficient ways of completing her school assignments and communicating with others. Nicole uses a taxi fitted for wheelchair transport when she travels by herself to school and to the shopping mall. She uses a power wheelchair in most places other than her own home, where she uses a manual wheelchair. For recreation, Nicole swims at a local pool, and, in the summer, attends a camp. Like many teenagers, she uses a chat line on the Internet, and she speaks with her friends on the telephone. Because Nicole had received some professional services (notably the dorsal rhizotomy) from a nearby city, it was difft cult for the family to obtain a consensus of prognostic information that would help them make decisions about their home and lifestyle. Nicole’s mother arranged a telephone conference between all of the relevant professionals in the two cities and Nicole and herself which she felt was the single most important event in the past several years. As a result, Nicole’s family has built an addition to their home, which makes the downstairs fully accessible. It also has a large deck that allows Nicole to go outdoors on her own and gives a second entrance to the house. The driveway is paved to enable her to reach her taxi or bus. She needs one-person assistance with transfers, toileting, and dressing, but she showers and washes her own hair independently using a commode chair in a wheel-in shower. Nicole eats independently. Nicole is seen by a physical therapist working in the school system about once a month, and she attends a teen group for girls organized by the professionals of the Child Development Centre. Stressing life skills, the meetings also provide opportunities for the teens to discuss items of mutual interest. Her mother thinks physical therapy may be needed to maintain the range of moton in her hamstrings, which is needed for upright standing during transfers. Nicole’s parents are very active advocates for changes that will provide people with disabilities with a full range of life’s opportunities. They believe parents must be prepared to play centrr!, responsible leadership roles within groups and agencies that can assist in these endeavors. ACKNOWLEDGMENTS Acknowledgments are extended to the Child Development Centre of the Hotel Dieu Hospital, Kingston, Ontario; the Motion Analysis Laboratory at the School of Rehabilitation Therapy at Queen’s University, Kingston, Ontario; the BloorviewMacMillan Rehabilitation Centre, Toronto, On tario, for assistance in providing data and photographs; and to the parents of Jamie and Nicole for their support of and contributions to the case histories. Recommended Resources Barry, MJ. Physical therapy interventions for patients with movement disorders due to cerebral palsy. Journal of Child Neurology, 11(suppl 1):S51-S60, 1996. Campbell, SK. Therapy programs for children that last a lifetime. Physical and Occupational Therapy in Pediatrics, 17(1):1-15, 1997. Geralis, E (Ed.). Children with Cerebral Palsy. Rockville, MD: Woodbine House, 1991. Available from Ingram, 1125 Heilquaker Boulevard, Leverane,TN 37086-1986. Gcwland, C, King, G, King, 5, Law, M, Letts, L, MacKinnon, L, Rosenbaum, P, & Russell, D. Review of Selected Measures in Neurodevelopmental Rehabilitation. Research Report 91-2, Neurodevelopmental Clinical Research Unit, Chedoke-McMaster Hospitals, 1991. Available from Chedoke-McMaster Hospitals, P0 Box 2000, Station A, Hamilton, Ontario, Canada, L8N 3Z5. Jaeger, DL. Transferring and Lifting Children and Adolescents: Home Instruction Sheets. Tucson. AZ: Therapy Skill Builders, 1989. Available from Therapy Skill Builders, 555 Academic Court, San Antonio, TX, 78204-2498. Jaeger, L. Home Program Instruction Sheets for Infants and Young Children. Tucson, AZ: Therapy Skill Builders, 1987. Available from Therapy Skill Builders. 555 Academic Court, San Antonio, TX, 78204-2498. Law, M, King, G, MacKinnon. E. Russell, D, Murphy, C, Harley, P, & Bosch, E. All About Outcomes: A Program to Help You Organize Your Thinking About Otmzrne Measures (CD-ROM). Thoroughfare, NJ: Slack, Inc. Lollar, DJ (Ed.). Preventing Ss:ondarv Conditions Associated with Spina Biflda or Cerebral Pals:. Washington, DC: Spina Bifida Association of America, 1994. 54-64. \X’ashington State Department of Health. Cerebral Palsy— Critical Elements of Care. Seattle, \XA: Washington State Department of Health, 1997. Phone: 206-51 ‘-2462. Wilcox, C. Hey, What About Me! Activities for Disabled Children. Toronto: Doubleday Canada, 1988. Available from Doubleday, 105 Bond Street. Toronto. Ontario, Canada, MSB 1Y3. WEB SITES American Academy for Cerebra. Palss and Developmental Medicine: http://aacpdm.org/ United Cerebral Palsy’: http:// www.ucpa.org/ Ontario Federation for Cerebral Palsy :http://www.ofcp.on.ca/ References Abel, MF. Gait laboratory analvs:s for pre-operative decision making in spastic cerebral palsy: Is it all that it is cracked up to be? (Letter; Comment). Journal of Pec9a:ric Orthopedics, 15:698-700, 1995. Anderson,JP, Snow, B, Dorey’. St Kabo,JM. Efficacy’ of soft splints in reducing severe knee-flexicr contractures. Developmental Medicine and Child Neurology. 39:502508, 1988. Anonymous. Residential arrancaments for adults with cerebral palsy— California, 1988. Nlorbiciio; & Nlortalitv \Xeeklv Report, 40(1): 16-18, 1991. Atkinson, 5, & Stanley. FJ. Spas: diplegia among children of low and normal birthweight. Develoomental Medicine and Child Neurology, 25:693-708, 1983. Atwater, SW. Should the norma. motor developmental sequence be used as a theoretical model :r pediatric physical therapy? In Lister, MJ (Ed.), Contemporary Maoagement of Motor Control Problems: Proceedings of the II STE2 Conference. Alexandria, VA: Foundsnon for Physical Therapy. I 991. pp. 89-93. Bairstow, P, Cochrane, R, & Rusk, I. Selection of children with cerebral palsy for conductive education and the characteristics of children judged suitable and unsuitable. Developmental Medicine and Child Neurology, 33:984992, 1991. Barry’, MJ. Physical therapy interver.dons for patients with movement disorders due to cerebral palsy. Journal of Child Neurology, 11(suppl !):S5l-S60, 1996. Batshaw, MI, & Perret, YM. Children with Disabilities: A Medical Primer, 3rd ed. Toronto: Paul H. Brookes, 1992. Baumann, JU, & Zumstein, M. Experience with a plastic ankle-foot orthosis for prevention of muscle contracture. Developmental Medicine and Child Neurology, 27:83, 1985. Bayley, N. Bayley II. San Antonio: Psychological Corporation, 1993. Berbrayer, D, & Ashby, P. Reciprocal inhibition in cerebral palsy. Neurology, 40:653-656, 1990. Berger, W, Quintern,J, & Deitz, V. Pathophysiology of gait in children with cerebral palsy. Electroencephalography and Clinical Neurophysiology, 53:538-548, 1982. Bergman, JS. Protecting the mobility of the aging person with spina bifida or cerebral palsy. In Lollar, DJ (Ed.), Preventing Secondary Conditions Associated with Spina Biflda or Cerebral Palsy. Washington, DC: Spina Bifsda Association of America, 1994, pp. 54-64. Bickenbach, J. Physical Disability and Social Policy. Toronto: University of Toronto Press, 1993. Blair, E, Ballantyne,J, Horsman, 5, & Chauvel, P. A study of a dynamic proximal stability splint in the management of children with cerebral palsy. Developmental Medicine and Child Neurology, 37:544-554, 1995. Blanche, El. Doing with—Not doing to: Play and the child with cerebral palsy. In Parham, LD, & Fazio. LS (Eds.), Play in Occupational Therapy for Children. St. Louis: Nloshv, 1997, pp. 202-2 18. Blasco, PA, Allaire, JH, and participants of the Consortium on Drooling. Drooling in the developmentally disabled: Management practices and recommendations. Developmental Medicine and Child Neurology, 34:849862, 1992. Bleck, BE. Locomotor prognosis in cerebral palsy. Developmental Medicine and Child Neurology. 17:18-25, 1975. Bleck, BE. Orthopedic Management in Cerebral Pals.’. Philadelphia:JB Lippincott, 1987. Bly, L. A historical and current view of the basis of NDT. Pediatric Physical Therapy, 3:13 1—135, 1991. Bobath, K, & Bobath, B. The neuro-devebopmental treatment. In Scrutton, D (Ed.), Mdnagement of the Motor Disorders of Children with Cerebral Palsy. Clinics in Developmental Medicine (No. 90). Philadelphia:JB Lippincott, 1984. pr. 6-18. Bohannon, RW, Is the measurement of muscle strength appropriate in patients with brain lesions? Physical Therapy, 69:225—236, 1989. Bohannon, RW, & Smith, MB. Interrater reliability of a modified Ashworth scale of muscle spastici tv. Physical Therapy’, 67:206-207, 1987. Bower, E, & McLellan, DL. Effect of increased exposure to physiotherspy on skill acquisition of children with cerebral palsy’. Developmental Medicine and Child Neurolo~v. 34:25-39. l992~ Bower, E, McLellan, DL, Arney, J, & Campbell, Ml. A randomised controlled trial of different intensities of physiotherapy and different goal-setting procedures in 44 children with cerebral palsy. Developmental Medicine and Child Neurology. 38:226-237, 1996. Boyce, W, Gowland, C, Rosenbaum, P. Lane, M, Pleas. N, Goldsmith, C, Russell, D, Wright, V, Zdrobov. S. & Harding, D. The Gross Motor Performance Measure: Validity and responsiveness of a measure of quality of movement. Ph~’sical Therapy’, 75:603-613, 1995. Boyd, R, & Graham, HK. Botulinum toxin A in the management of children with cerebral palsy: Indications and outcome. European Journal of Neurology, 4(suppl 2):S15-S22, 1997. Brooks-Scott, S. Mobilization for the Neurological>: Involved Child. Tuscon, AZ: Therapy Skill Builders. 1995. Brouwer, B, St Ashby, P. Altered corticospinal projections to lower limb motoneurons in subjects with cerebral palsy’. Brain, 114:1395-1407, 1991. Brouwer. B, \Vheeldon, RK, Stradiotto-Parker, N, & Allum, J, Reflex excitabilit’.’ and isometric force production in cerebral palsy: The effect of serial casting. Developmental Medicine and Child Neurology, 40:168-175, 1998. Bruininks, RH. Bruininks-Oseretsky Test of Motor Proficiency: Examiners Manual. Circle Pines, MN: American Guidance Service, 1978. Bull, Mj. Weber, KL, DeRosa, GP, & Bruner Stroup, K. Transporting children in body casts. Journal of Pediatric Orthopedics, 9:280-284. 1989. Burns, YR, 0Callaghan, M, & Tudehope, DI. Early identification of cerebral palsy in high risk infants. Australian Paediatric Journal, 25:215-219. 1989. Butler, C. Augmentative mobility: Why do it? Physical Medicine and Rehabilitation Clinics of North America, 2(4):801-8 15, 1991. Campbell, 810 Introduction to the special issue. Pediatric Physical Therapy 2123-125 1990. Campbell, SK. Therapy programs for children that last a lifetime. Physical and Occupational Therapy in Pediatrics, 17(1):1-15, 1997. Campbell. 5K. Almeida, GL, Penn, RD, & Corcos, DM. The effects of intrathecailv administered baclofen in patients with spasticity. Physical Therapy, 75:352-362, 1995. Campbell, 8K. Wilhelm, U St Slaton, DS. Anthropometric characteristics of young children with cerebral palsy. Pediatric Physical Therapy’. 1:105-108, 1989. Carlson, SJ. A neurophysiological analysis of inhibitive casting. Physical arid Occupational Therapy in Prdiatrics, 4(4):31-42, 1984. Carlson. WE, Vaughan, CL, Damiano, DL, St Abel, ME. Orthotic management of gait in spastic diplegia. American Journal of Physical Medicine and Rehabilitation, 76:219-224, 1997. Carmick. J. Managing equinus in a child with cerebral palsy: Merits of hinged ankle-foot orthosis. Developmental Medicine and Child Neurology. 37:1006-1019, 1995. Chandler, L, St Harris, S. Movement assessment of infants. Workshop Presentation, Northeastern District of the Section on Pediatrics of the American Physical Therapy Association, Amherst, MA. Cited in Campbell. SK. Assessment of the child with CNS dysfunction. In Rothstein. JM (Ed.), Measurement in Physical Therapy. New York: Churchill Livingstone, 1985. Chandler, CS. Andrew, MS, St Swanson, MW. Movement Assessment of Infants: A Manual. Rolling Bay, WA: Infant Movement Research, 1980. Ciune, \VH, & Van Pelt, MH. A political method of evaluating the Education for All Handicapped Children Act of 1975. Law and Contemporary Problems, 48(1):762, 1985. Corry, IS, Cosgrove, AP, Duff~i, CM, McNeill, 5, Taylor, TC, St Graham, HK. Botulinum toxin A compared with stretching casts in the treatment of spastic equinus: A randomised prospective trial. Journal of Pediatric Orthopedics, 18:304-3 11, 1998. Coster, \VJ, Deeney, TA, Haltiwanger, JT, St Haley, SM. School Function Assessment. Boston University, 1994. Craft, MJ, Lakin, JA, Oppliger, RA, Clancy, GM, St Vanderlinden, DW. Siblings as change agents for promoting the functional status of children with cerebral palsy. Developmental Medicine and Child Neurology, 32:1049-1057, 1990. (lhothers, B, St Paine, RS. The Natural History of Cerebral Palsy (2nd ed.). Philadelphia: Lippincott, 1988. Cusick, BD. Progressive Casting and Splinting for Lower Extremity Deformities in Children with Neuromotor Dysfunction. Tucson, AZ: Therapy Skill Builders, 1990. Cusick, BD, St Stuberg, WA. Assessment of lower extremity alignment in the transverse plane: Implications for management of children with neuromotor dysfunction. Physical Therapy, 72:3-15, 1992. Damiano, DL, St Abel, MF, Functional outcomes of strength training in spastic cerebral palsy. Archives of Physical Medicine and RThabilitation, 79:119-125, 1998. Damiano, DL, Kelly, CE, St Vaughn, CL. Effects of quadriceps femoris muscle strengthening on crouch gait in children with spastic diplegia. Physical Therapy, 75:658-671, 1995. Darrah. J, St Bartlett, D. Dvn amic systems theory and management of children with cerebral palsy: Unresolved issues. Infants and Young Children, 8:52-59, 1995. DeLuca. PA. The musculoskeletal management of children with cerebral palsy. Pediatric Clinics of North America, 43:1135-1150, 1996. Dowding, VM, St Barry, C. Cerebral palsy: Social class differences in prevalence in relation to birthweight and severity of disability. Journal of Epidemiolog’. and Community Health, 44:191-195, 1990. Edebol-Tysk, K. Epidemiology of spastic tetraplegic cerebral palsy in Sweden. I: Impairments and disabilities. Neuropediatrics, 20:41— 45.1989. Evans, PM, Evans, SJ\XJ, St Aiberrnan, E. Cerebral palsy: Why we must plan for survival. Archives of Disease in Childhood, 65:1329-1333, 1990. Evans Morris, 5, St Dunn Klein, M. Pre-feeding Skills: A Comprehensive Resource for Feeding Development. San Antonio, TX: Therapy Skill Builders, 1987. Fernandez, JE, St Pitetti, 10-I. Training of ambulatory individuals with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 74:468-472, 1993. Ferrara, MS, Buckley. WE. McCann. BC, Limhird, TJ, Powell, JW, St Robl, R. The injury experience of competitive athlete with a disability: Pre~ention implications. Medicine and Science in Sports and Exercise, 24:184-188. 1992. Fetters. C. Measurement and treatment in cerebral palsy: An argument for a new approach. Physical Therapy, 71:244247, 1991. Finnie. NR Handling the Young Cerebral Palsied Child at Home, 3rd ed. Oxford: Buttern-ortl-.-Heinemann. 1997. Fox, AM, Gillett, JM, St Goldberg, B. Adults with cerebral palsy: Who provides medical care? Annals of the Royal College of Physicians and Surgeons of Canada 25:206209, 1992. Geralis, E (Ed.). Children wuh Cerebral Palsy. Rockville, MD: Woodbine House, 1991. Gerszten, PC. Albright, AL. St Johnstone, GF. Intrathecal baclofen infusion and subsequent orthopedic surgery in patients with spastic cerebral palsy.Journai of Neurosurgery. 88:1009-1013, 1998. Gisel, EG, St Patrick. J. Identification of children with cerebral palsy unable to maintain a normal nutritional state. Lancet, 1:283-286, 1988. Giulia.ni, CA. Dorsal rhizotomy for children with cerebral palsy: Support for concepts of motor control. Physical Therapy, 71 :248-259, 1991. Gowland, C, King, G, King, 5, Law, M, Letts, C, MacKinnon, C, Rosenbaum, P, St Russell, D. Review of Selected Measures in Neurodevelopmental Rehabilitation. Research Report 91-2, Neurodevelopmental Clinical Research Unit, Chedoke-McMaster Hospitals, 1991. Hagberg, B, Hagberg, G, Olow, I, St vonWendt, C. The changing panorama of cerebral palsy in Sweden. V. The birth year period 1979-82. Acta Paediatrica Scandinavica, 78:283-W0, 1989a. Hagberg, B, Hagberg, G, St Zetterstrom, R. Decreasing perinatal mortality-Increase in cerebral palsy morbidity? ~kota Paediatrica gcandinavica, 78:664-670, 1989b. Hainsworth, F, Harrison, MJ, Sheldon, TA, St Roussunis, SHP. Preliminary evaluation of ankle orthoses in the management of children with cerebra! palsy. Developmental Medicine and Child Neurology, 39:243247, 1997. Hallett, M, St Alvarez, N. At~cmpted rapid elbow flexion movements in patients with athetosis. Journal of Neurology, Neurosurgery and Psychiatry, 46:745-750, 1983. Hallum, A. Disabilin- and the transition to adulthood: Issues for the disabled child, the famiir-, and the pediatrician. Current ProLlems in Pediatrics, 25:12—50, 1995. Harris, SR Early detection of cerebral palsy: Sensitivity and specificity of two motor assessment tools. Journal of Perinatology, 7:11-15, 1987. Harris, SR Early diagnosis of spastic diplegia, spastic hemiplegia, and quadriplegia. AmericanJournal of Diseases of Children, 143:1356-1360, 1989. Harris, SR, St Lundgren, BD. Joint mobilization for children with central nervous system disorders: Indications and precautions. Physical Therapy, 71:890-896, 1991. Harrison, A. Spastic cerebral palsy: Possible spinal interneuronal contributions. Developmental Medicine and Child Neurology, 30: 769-780, 1988. Harryman, SE. Lower-extremity surgery for children with cerebral palsy’: Physical therapy management. Physical Therapy, 72:16-24, 1992. Healy, A, Ramsey, C, St Sexsemith, E. Postural support systems: Their fabrication and functionat use. Developmental Medicine and Child Neurology, 39:706710, 1997. Higgins, S. Motor skill acquisition. Physical Therapy, 71:123-139, 1991. Hinojosa, J, St Anderson, J. Mothers’ perceptions of home treatment programs for their preschool children with cerebral palsy. The American Journal of Occupational Therapy, 45:273-279, 1991. Holst, K, Andersen, E, Philip,J, St Henningsen, I. Antenatal and perinatal conditions correlated to handicap among 4year-old children. AmericanJournal of Perinatology, 6:258-267, 1989. Horton, SV, St Taylor, DC. The use of behavior therapy and physical therapy to promote independent ambulation in a preschooler with mental retardation and cerebra! palsy. Research in Developmental Disabilities, 10(4):363-375, 1989. Jaeger, DL. Transferring and Lifting Children and Adolescents: Home Instruction Sheets. San Antonio, TX: Therapy Ski Builders, 1989. Jaeger, C. Home Program Instruction Sheets for Infants and Young Children. San Antonio, TX: Therapy Skill Builders. 1987. James, R. Biofeedback treatment for cerebral palsy r children and adolescents: A review. Pediatric Exercise Science. 20:198~212, 1992. Jones, CK. In search of power for the pediatric client. Physical and Occupational Therapy in Pediatrics, 10(2):47-68. 1990. Jones, EW, St Mulley, GP. The measurement of spast:citv. In Rose PC (Ed.), Advances in Stroke Therapy. New York: Raven Press, 1982. Jones, JA (Ed.). Training Guide to Cerebral Palsy’ Sports. Champaign. IL: Human Kinetics, 1988. Jonsdottir, J, Fetters, C, St Kluzik, J. Effects of phvstcal therapy on postural control in children with cerebral pals~. Pediatric Physical Therapy, 9:68-75, 1997. Karumuna, JMS, St Mgone, CS. Cerebral palsy’ in Oar es Salaam. Central African Journal of Medicine, 36( 1):8-10. 1990. Katz, RT, St Rymer, WZ. Spastic hypertonia: Mechamsms and measurement. Archives of Physical Medicine and Rehabilitation, 70: 144-155, 1989. Kibele, A. Occupational therapy’s role in improving tale quality of life for persons with cerebral palsy. American Journal rfOccupationsi Therapy’, 43:371-377, 1989. King, 0, Law, M, King, 8, St Rosenbaum, P. Parents’ and service providers’ perceptions of the familv-centredness of children’s rehabili:anon services. Physical and Occupational Theraz; in Pediatrics. 18:21-40, 1998. Kitchen, WH, Ford, GW, Rickards, AL, Lissenden. JY. St Ryan, MM. Children of birth weight <1000 g: Changing outcome between aces 2 and 5 vears.Journal of Pediatrics, 110:283-288. 1987. Kluzik, J, Fetters, C, St Coryell, J. Quantification of control: A prelim:nary study of effects of neurodevelopmental treatment on reacr.ing in children with spastic cerebral palsy. Physical Therapy, 70:65- 78, 1990. Knutsson, CM, St Clark, DE. Orthotic devices for ambulation in citYdren with cerebral palsy and myelomeningocele. Physical Therapy. 71:947-960, 1991. Knutsson. CM, St Martensson, A. Dynamic motor caPacity in spas: paresis and its relation to prime mover dysfuncuon, spastic reflexes and antagonist co-activation. Scandinavian Icurnal of Rehabilitation Medicine, 12:93106, 1980. Kolobe, TI-IA. Working with families of children with disabilities. Pediatric Physical Therapy, 4:57-63, 1992. Kotagal, S, Gibbons, VP, St Stith, JA. Sleep abnormalities in patients with severe cerebral palsy. Developmental Medicine and Child Neurology, 36:304-311, 1994. Langley, MB. A developmental approach to the use of toys for facilitation of environmental control. Physical and Occupational Therapy in Pediatrics, 10(2):69-9 1, 1990. Law, M, Baptiste, 5, McColl, MA, Opzoomer, A, Polatajko, H, St Pollock, N. The Canadian Occupational Performance Measure: An outcome measure for occupational therapy. Canadian Journal of Occupational Therapy, 57:82-87, 1990. Lee, EH, Gob, JCH, St Bose, K. Value of gait analysis in the assessment of surgery in cerebral palsy. Archives of Physical Medicine and Rehabilitation, 73:642-646, 1992. Leonard, CT, Hirschfeld, H, Moritani, T, St Forssberg, H. Myotatic reflex development in normal children and children with cerebral palsy. Experimental Neurology, 111:379-382, 1991. Leonard, CT, Moritani, T, Hirschfeld, H, St Forssberg, H. Deficits in reciprocal inhibition of children with cerebral palsy as revealed by H reflex testing. Developmental Medicine and Child Neurology, 32:974-984, 1990. Lesny, I, Nachtmann, M, Stehlik, A, Tomankova, A, St Zajidkova, J. Disorders of memory of motor sequences in cerebral palsied children. Brain and Development, 12:339-341, 1990. Cespargot, A, Renaudin, E, Khouri, N, St Robert, M. Extensibility of hip adductors in children with cerebral palsy. Developmental Medicine and Child Neurology, 36:980-988, 1994. Cetts, M, Rathbone, D. Yamashita, T, Nichol, B, St Keeler, A. Soft Boston orthosis in management of neuromuscular scoliosis: A preliminary report. Journal of Pediatric Orthopedics, 12:470-474, 1992. LeVeau, BF, St Bernhardt, DB. Developmental biomechanics: Effects of forces on the growth, development and maintenance of the human body. Physical Therapy, 64:1874-1882, 1984. Cm, JP, Brown, JK, St Brotherstone, R. Assessment of spasticity in hemiplegic cerebral palsy. II. Distal lower-limb reflex excitability and function. Developmental Medicine and Child Neurology, 36: 290-303, 1994. Cm, PP St Henderson, RC. Bone mineralization in the affected extremities of children with spastic hemiplegia. Developmental Medicine and Child Neurology. 38:782786, 1996. Little, WJ. On the influence of abnormal parturition, difficult labours, premature births and asphyxia neonatorum on the mental and physical condition of the child especially in relation to deformities. Transactions of the Obstetrical Society of London 1862. Cerebral Palsy Bulletin, 1:5-34, 1958. Logan C, Byers-Hinkley’, K, St Ciccone, CD. Anterior versus posterior walkers: A gait analysis study-. Developmental Medicine and Child Neurology, 32:10441048, 1990. MacKinnon, JR, Nob, 5, Lariviere, J, MacPhail, A, Allan, Dli, St Laliberte, D. A study- of therapeutic effects of horseback riding for children with cerebral palsy’. Phy’sical and Occupational Therapy in Pediatrics, 15(l):17—34, 1995. MacPhail, HEA, St Kramer, JF. Effect of isokinetic strengthtraining on functional ability and walking efficiency in adolescents with cerebral palsy. Developmental Medicine and Child Neurology, 37:763-775, 1995. Mahoney, Fl, St Barthel, DW. Functional evaluation: The Barthel Index. Maryland Medical Journal. 14:61-65, 1965. Massagli, TL. Spasticitv and its management in children. Physical Medicine and Rehabilitation Ciinics of North America, 2:867-889, 1991. McDonald, CM. Selective dorsal rhizotomy: A critical review. Physical Medicine and Rehabilitation Clinics of North America, 2:891-915, 1991. McLaughlin, JF, Bjornson, 10-. Astley, SI, Graubert, C, Hays, RM, Roberts, TS, Price, R, St Temkin, N. Selective dorsal rhizotomy: Efficacy and safety in an investigator-masked randomized clinical trial. Developmental Med:cine and Child Neurology, 40:220-232, 1998. Menkes, JH. Textbook of Child Neurology, 4th ed. Philadelphia: Lea St Febiger, 1990. Middleton, EA. Hurley, ORB. - Mcllwain, JS. The role of rigid and hinged polypropylene ankle-foot orthoses in the management of cerebral palsy: A case study. Prosthetics and Orthotics International, 12:129-135, 1988. Miedaner, JA, St Renander, J. The effectiveness of classroom passive stretching programs for increasing or maintaining passive range of motion in non-ambulatory children: An evaluation of frequency. Physical and Occupational Therapy in Pediatrics. 7(3):35-43, 1987. Milo-Manson, 0, Rosenbaum. P St Steele, C. Alternative therapies: Prevalence and pattern of use in pediatric rehabilitation. Developmental Medicine and Child Neurology, 39(suppl 75):19, 1997. Missiuna, C, St Pollock, N. Pla;’ deprivation in children with physical disabilities: The roles of the occupational therapist in preventing secondary disability. American Journal of Occupational Therapy, 45:882-888, 1991. Molteni, B, Oleari, 0, Fedrizzi. E, St Bracchi, M. Relation between CT patterns, clinical findings and etiology in children born at term, affected by congenital hemmaresis. Neuropediatrics, 18:75—80, 1987. Morrison, JM, St Ursprung, AW~ Children’s attitudes toward people with disabilities: A review of the literature. Journal of Rehabilitation, 53(1):45-49, 1987. Mossberg, KA, Cinton, KA, St Friske, K. Ankle-foot orthoses: Effect on energy expenditure of gait in spastic diplegic children. Archives of Physical Medicine and Rehabilitation, 71:490-494, 1990. Msall, ME, Buck, GM, Rogers. BT, Merke, D, Catanzaro, NC, St Zorn, WA. Risk factors for major neurodevelopmental impairments and need for special education resources in extremely premature infants. Journal of Pediatrics. 119:606—614, 1991. Msall, ME, Roseberg. 5, D:Guadio, 1KM, Braun, SC, Duffy, C, St Granger, CV. Pilot test for the WeeFIM for children with motor impairments (Abstract). Developmental Medicine and Child Neurology, 32(9, suppl 62):41. 1990. Murney, ME, St Campbell, SK. The ecological relevance of the Test of MotOr Performance elicited scale items. Physical Therapy, 78:479-489, 1998. Murphy, KP, Molnar, GE, St Lankasky, K. Medical and functional status of adults with cerebral palsy. Developmental Medicine and Child Neurology, 37:10751084, 1995. Nashner, C, Shumway-Cooke, A, St Mann, 0. Stance posture control in select groups of children with cerebal palsy: Deficits in sensory organization and muscular coordination. Experimental Brain Research, 49:393-409, 1983. Nelson, KB, St Ellenberg,J. Antecedcnts of cerebral palsy. Multivariate analysis of risk. New England Journal of Medicine, 315:81-86, 1986. Nottidge, VD, St Okogbo, ME. Cerebral palsy in Ibadan, Nigeria. Developmental Medicine and Child Neurology, 33:241-245, 1991. Nwaobi, OM, St Smith, PD. Effect of adaptive seating on pulmonary function o~children with cerebral palsy. Developmental Medicine and Child Neurology, 28:351354, 1986. O’Dwyer, NJ, Neiison, PD, St Nash, J. Mechanisms of muscle growth related to muscle contracture in cerebral palsy. Developmental Medicine and Child Neurology, 31:543-552, 1989. O’Dwyer, N, Neilson, P, St Nash, J. Reduction of spasticity in cerebral palsy using feedback of the tonic stretch reflex: A controlled study. Developmental Medicine and Child Neurology, 36:770-786, 1994. Olney, SJ, Costigan, PA, St Hedden, DM. Mcchanical energy patterns in gait of cerebral palsied children. Physical Therapy, 67:1348-1354, 1987. Olney, SJ, MacPhasl, HEA, Hedden, DM, St Boyce, WF. Work and power in hemiplegic cerebral palsy gait. Physical Therapy, 70:431438, 1990. Oonpuu, 5, Bell, KJ, Davis, RB, St DeCuca, PA. An evaluation of the posterior leaf spring orthosi.s using joint kinematics and kinetics. Journal cf Pediatric Orthopedics, 16:378-384, 1996. O’Shea, TM. Preisser, JS, Klinèpeter. KL, St Dillard, RG. Trend,s in mortalirv and cerebral palsy’ in a geographically based cohort of very low hirthweight neonates born between 1982 to 1994. Pediatrics 101u42647, 1998. Overeynder. iC, St Turk, MA. Cerebral palsy- and aging: A framework for promoting the health of older persons with cerebral palsy. Topics in Geriatric Rehabilitation. 13(3):l9-24, 1998. Palisano, K. Research on the effectiveness of neurodevelopmental treatmenr. Pediatric Physical Therapy, 3:143-148, 1991. Palisano, K. Validity of goal attainment scaling in infants with motor delays. Physical Therapy, 73:65 1-660, 1993. Palisano, R, Kolobe, T, St Hales-. S. Validity of the Peabody Developmental Gross Motor Scale as an evaluative measure of infants receivin~ phy’sical therapy’. Physical Therapy, 75:939-95 1, 1995. Palisano, R, Rosenbaum, P Walter, 5, Russell, D, Wood, E, St Galuppi, B. Dcvelc’pment and reliability’ of a system to classif5s gross motor function in children with cerebral palsy’. Developmental Medicine and Child Neurology, 39:214-223, 1997. Papile, C, Burstein.J, Burstein, K. St Koffler, H. Incidence and evolution of subependymal and intraventricular hemorrhage: A study of infants with hirthweight of less than 1500 gins. Journal of Pediatrics, 92:520~534, 1978. Parker, DF, .iirriere, C, Hebestreit, H. St Bar-Or, 0. Anaerobic endurance ann peak muscle power in children with spastic cerebral palsy. American Journal of Diseases of Children, 146:1069-1073, 1992. Patla, AE, Winter, DA, Frank, JS, Walt.JS, St Prasad, S. Identification of age-related changes in the balance control system. Proceedings of the APTA Forum on Balance. Nashville, TN: American Physical Therapy Association, 1989. Perlmutter, MN, Sny’der, M, Miller. F, St Bisbal, R. Proximal femoral resection for older children with spastic hip disease. Developmental Medicine and Child Neurology, 57:525-53 1, 1993. Perry, J, HorYer, NI, ,A.ntonelli. D, Plut, J, Lewis, 0, St Greenberg, K. Electromvography before and after surgery for hip deformity’ in children with cerebral pals~. Journal of Bone and Joint Surgery (American). 58:20 1-208, 1976. Pharoah, POD. Cooke, T, Cooke, RWI, St Rosenbloom, C. Birthweight specific trends in cerebral palsy. Archives of Disease in Childhood, 65:602-606, 1990. Pharoah, POD, Cooke, T, Rosenbloom, C, St Cooke, RWI. Trends in birth prevalence of cerebral palsy. Archives of Disease in Childhood, 62:379-384, 1987. Piper, MC, St Darrah, J. Motor Assessment of the Developing Infant. Philadelphia: \VB Saunders, 1994. Poirier, D, Goguen, C, St Leslie, P. Educational Rights of Exceptional Children. Toronto: Carswell, 1988. Poole, JL. Application of motor learning principles in occupational therapy. American Journal of Occupational Therapy, 45:531-537, 1991. Powell, TH, St Ogle, PA. Brothers and Sisters—A Special Part of Exceptional Families. Baltimore: Paul H. Brookes, 1985. Pranzatelli, MR Oral pharmacology for the movement disorders of cerebral palsy. Journal of Child Neurology, 11(suppl 1):S13-S22. 1996. Price, K, Bjornson, 10-, Lehmann, JF, McLaughlin, JF, St Hays, KM. Quantitative measurement of spasticity in children with cerebral palsy. Developmental Medicine and Child Neurology, 33585-595, 1991. Rang, M. Cerebral palsy. In Morrissy, RI (Ed.), Covell and Winter’s Paediats-ic Orthopedics, 3rd ed. Philadelphia JD Lippincott, 1990, pp.465-506. Reddihough. D, King J, Coleman, 0, St Catanese, I. Efficacy of programs based on conductive education for young children with cerebral palsy. Developmental Medicine and Child Neurology, 39(suppl 75):20, 1997. Reid, DI, Boschen, K, St Wright, V. Critique of the Pediatric Evaluation of Disability Inventory (PEDI). Physical and Occupational Therapy in Pediatrics, 13(4):57-87, 1993. Reilly, 5, St Skuse, D. Characteristics and management of feeding problems of young chiidren with cerebral pals~. Developmental Medicine and Child Neurology, 34:379388, 1992. Rempel, GR, Colwell, SO, St Nelson, RP. Growth in children with cerebral palsy fed via gastrostomy. Pediatrics, 82:857-862, 1988. Richards, CL, Malouin, F, St Dumas, F. Effects of a single session of prolonged stretch on muscle activations during gait in spastic cerebral palsy. Scandinavian Journal of Rehabilitation Medicine, 23:103—111, 1991. Ricks, NR, St Eilert, RE. Effects of inhibitory casts and orthoses on bony alignment of foot and ankle during weight-bearing in children with spasricity. Developmental Medicine and Child Ncurology, 35:1 1-16, 1993. Rornanini, C, Villani, C, Meloni, C, St Calvisi, V. Histological and morphological aspects of muscle in infantile cerebral palsy. Italian Journal of Orthopaedics and Traumatology, 15:87-93, 1989. Rose, J, Gamble, JO, Burgos, A, Medeiros, J, St Ha.skell, WC. Energy expenditure index of walking for normal children and for children with cerebral palsy. Developmental Medicine and Child Neurology, 32:333340, 1990. Rose, J, Medeiros, JM, St Parker, K. Energy cost index as an estimate of energy’ expenditure of cerebral-palsied children during assisted ambulation. Developmental Medicine and Child Neurology, 27: 485-490, 1985. Rosenbauin, P Cadman, D, St Kirpalani, H. Pediatrics: Assessing quality’ of life. In Spilker, B (Ed.), Quality of Life Assessment in Clinical Trials. New York: Raven Press, 1990, pp.205-215. Rosenbaum, P. King, 5, Law, M, King, G, St Evans. I. Family-centred service: A conceptual framework and research review. Physical Therapy’ and Occupational Therapy’ in Pediatrics. 18(1): 1-20, 1998. Russell, D. Rosenbaum, P Cadman, D, Gowland. C. Hardy, 5, StJarvis, S. The Gross Motor Function Nleasure: A means to evaluate the effects of physical therapy’. Developmental Medicine and Child Neurology, 31:341352, 1989. Schanzenbacher, KE. Diagnostic problems in pediatrics. In Pratt, PN, St Allen, AS (Eds.), Occupational Therapy for Children. Toronto: Mosby’, 1989, p. 97. Scherzer, AL, St Tscharnuter, I. Early Diagnosis and Therapy in Cerebral Palss’: A Primer on Infant Developmental Problems, 2nd ed. New York: Marcel Dekker, 1990. Senft, KE, Pueschel, SM, Robison, NA, St Kiesslin~. CS. Level of function of young adults with cerebral palsy’. Physical and Occupational Therapy in Pediatrics, 1O(1):19-25, 1990. Shaw, 0. Vehicular transport safety’ for the child with disabilities. American Journal of Occupational Therapy, 41:35-42,1987. Shaw, J. Continence in cerebral palsy. Health Visitor, 63:30 1-302, 1990. Shepherd, RB. Training motor control and optimizing motor learning. In Shepherd, RB (Ed.), Physiotherapy in Paediatrics, 3rd ed. Oxford: Butterworth-Heinemann, 1995. Shields, CV. Strategies: A Practical Guide for Dealin~ u-ith Professionals and Human Service Systems. Richmond Hill. Ontario: Human Services Press, 1987. Shumway-Cook, A, St Woolacott, M. Motor Control: Theory’ and Practical Applications. Baltimore: Williams St Wilkins. 1995. Sillanpaa, NI, Piekkala, P St Pisirici, H. The young adult with cerebral palsy’ and his chances of employment. International Journal of Rehabilitation Research, 5:467476, 1982. Sobsey’, D, St Doe, I. Patterns of sexual abuse and assault. Sexuality’ and Disability, 9:243-259, 1991. Sparrow, SS, Balla, DA, St Ciccetti, DV. Vineland Adaptive Behavior Scales (Survey Form). Circle Pines, MN: American Guidance Sets’ice, 1984. Spector, RC. Functional Disability Scales. In Spilker. B (Ed.), Quality of Life Assessments in Clinical Trials. New York: Raven Press, 1990, pp. 115-129. Stanger, M, St Bertoti, D (Eds.), An overview of electrical stimulation for the pediatric population. Pediatric Physical Therapy, 9(3): 95-143, 1997. Steinbok, P, Reiner, AM, Beauchamp, K, Armstrong, RW, St Cochrane, - DD. A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegi c cerebral palsy. Developmental Medicine and Child Neurology, 39:178184, 1997. Stern, C, St Steidle, K. Pediatric Strengthening Program Reproducible Exercises. Tuscon, AZ: Therapy Skill Builders, 1994. Sternisha, C, Cays, M, St Campbell, C. Stress responses in families with handicapped children: An annotated bibliography. Physical and Occupational Therapy in Pediatrics, 12(1):89-103, 1992. Strauss, D, St Shavelle, K. Life expectancy of adults with cerebral palsy. Developmental Medicine and Child Neurology, 40:369-375, 1998. Stuberg, WA. Considerations related to weight-bearing programs in children with developmental disabilities. Physical Therapy, 72:3540, 1992. Stuberg, WA, Fuchs, RH, St Miedaner, JA. Reliability of goniometric measurements of children with cerebral palsy. Developmental Medicine and Child Neurology, 30:657-666, 1988. Subramanian, J, Vaughan, CC, Peter, JC, St Arens, U. Gait before and 10 years after rhizotomy in children with cerebral palsy spasticity. Journal of Neurosurgery. 88:1014-1019, 1998. Sutherland, DH, Olshen, K, Cooper, C, St Woo, SY. The development of mature gait. Journal of Bone and Joint Surgery (American), 62: 336-353, 1980. Tardieu, C, Huet de Ia Tour, E, Bret, MD, St Tardieu, 0. Muscle hvpoextensibility in children with cerebral palsy: I. Clinical and experimental observations. Archives of Physical Medicine and Rehabilitation, 63:97-102, 1982. Tardieu, C, Lespargot, A, Tabary, C. St Bret, MD. For how long must the soleus muscle be stretched each day to prevent contracture? Developmental Medicine and Child Neurology, 30:3-10, 1988. Tardieu, 0, Tardieu, C, Colbeau-Justin, P St Cespargot, A. Muscle h~’poextensibility in children with cerebral palsy: II. Therapeutic implications. Archives of Physical Medicine and Rehabilitation, 63: 103-107, 1982. Toner, LV, Cook, K, St Elder. GCB. Improved ankle function in children with cerebral palsy after computer assisted motor learning. Developmental Medicine and Child Neurology’, 40:829-835, 1998. Torfs. CP, van den Berg, B1. St Oechsli, FW. Prenatal and perinatal factors in the etiology’ 0f cerebral palsy. Journal of Pediatrics, 116:615—619, 1990. Tremblay’, F, Malouin, F, Richards. CC, St Dumas, F. Effects of prolonged muscle stretch on reflex and voluntaty’ muscle activations in children with spasric cerebral palsy. Scandinavian Journal of Rehabilitation Mcdicine. 22:171-180, 1990. Uvebrandt, P. Hemiplegic cerebral palsy. Aetiology’ and outcome. Acts Paediatrica Scandinavica Supplement, 345:5-100, 1988. van den Berg-Emons, HJG, Saris, \VHM, de Barbanson, DC, Westerterp, KR, St can Bank, N’lA. Daily’ physical activity’ of schoolchildren with spastic diplegia and of health control subjects. Journal of Pediatrics, 127:578584, 1995. van der Weel, FR, van der Nicer, ALH, St Lee, DN. Effect of task on movement control in cerebral palsy: Implications for assessment and therapy. Developmental Medicine and Child Neurology, 33: 419-426, 1991. Vojta. V. The basic elements of treatment according to Vojta. In Scrutton, D (Ed.), Management of the Motor Disorders of Children with Cerebral Palsy. Philadelphia: JB Lippincott, 1984, pp. 75-85. Wacker, OP Harper, DC, Powell, \~, St Healy, A. Life outcomes and satisfaction ratings of n-.ultiha.ndicapped adults. Developmental Medicine and Child Neurology. 25:625-63 1, 1983. Washington State Department of Health. Cerebral Palsy— Critical Elements of Care. Seattle. ‘VA: Washington State Department of Health, 1997. Watt, JM, Robertson, CM?. St Grace, MGA. Early prognosis for ambulation of neonatal intensive care survivors with cerebral palsy. Developmental Medicine and Child Neurology, 31:766-773, 1989. Weinstein, SC, St Tharp, BR. Etiology and timing of static encephalopathies of childhood (cerebral palsy). In Stevenson, OK, St Sunshine, P (Eds.), Fetal ail Neonatal Brain Injury. Toronto: BC Decker, 1989. Werner, 0. Disabled Vmlla~ ildren A Guide for Community Health Workers, Rehabilitatm” Workers and Families. Palo Alto, CA: F-iesperian Foundation 987 Westcott, SC, Paxhowes, C-Richardson, PK. Evaluation of postural stability in children: C ent theoies and assessment. Physical Therapy, 77:629-643, Is Wiklund, CM, St Uvebran Heinmplegic cerebral palsy: Correlation between CT inorpholc and clinical findings. Developmental Medicine and Child Ne ology 33 5 12-523. 199 la. Wiklund, CM, Uvebrant, P Flodmark 0. Computed tomography as aim adjunct iii etidlo~mi anaIv~ms of hemipiegic cerebral palsy’. I: Children born preterm \europedmatricS, 22:50—56, 199 lb. Wilcox, C. Hey, What About Me! Activities for Disabled Children. Toronto: Doubleday Canada, 1988. Wilson, ER, Mitts, 5, St Schwartz j~ Congenital diencephalic and brain stem damage: Neuropathoiogic study of three cases. Acta Neuropa.thologica, 57:70-74, 1982. Wilson, JM. Cerebral palsy. In Campbell, S (Ed.). Pediatric Neurologic Physical Therapy, 2nd ed. New York: Churchill Civingstone, 1991, pp. 30 1-360. Wright, FV, Sheil, EMH, Drake, JM, Wedge, JH. St Naumann, S. Evaluation of selective dorsal rhizotomv for the reduction of spasticity’ in cerebral palsy: A randomized controlled trial. Developmental Medicine and Child Neurology, 40:239-247, 1998. Yokochi, K, Aiba, K, Hone, M, Inukai, K, Fujimoto, 5, Kodama, M, St Kodama, K. Magnetic resonance imaging in children with spastic diplegia: Correlation with severity of their motor and mental abnormality. Developmental Medicine and Child Neurology, 33:18-25, 1991. Young, KR. Spasticity: A review. Neurology, 44(11 suppl 9):512-520, 1994.