Patty C. Coker-Bolt * Pea Motor control Functional electrical Hemiplegia stimulation Quadriplegia Gaming technology Botulinum toxin Physical agent modalities ‘therapy Rehabilitation robotics ‘complementary and alternative medicine Flexible and rigid taping ‘Adaptive recreation, GUIDING QUESTIONS 1, What are clinical characteristics associated with the different types of cerebral palsy (classification and distribution in body)? 2, How do the primary and secondary impairments associated with cerebral palsy contribute to functional limitations? 3. How are current theories of motor control applied to interventions for children with cerebral palsy? 4, How does impaired muscle tone influence activity and participation in children diagnosed with cerebral palsy? 5. How are rehabilitative and compensatory approaches applied in comprehensive services for children with cerebral palsy? ‘The term cerebral paly (CP) describes a group of developmen tal motor disorders arising ftom a nonprogressve lesion of shsorder of the brain’ Associated damage to one of mote areas ff the brain may lead to paralysis, spasticity, of abnormal contzol of movement or posture, Although the injury to the brain is considered static, the pattern of motor impairment changes over time, often affecting development in all daily ‘occupations of childhood." The motor disorders associated with cerebral palsy can be accompanied by disturbances of sensation, cognition, communication, and perception and by a seizure disorder." The lesion or damage in the brain may cause impairment in muscle activity in all of part of the body, Cere- bral palsy typically affects the development of sensory, percep- ‘wal, and motor areas ofthe central nervous evstem, As axes the child has diffculry incegesting the information hat the bain aceds to correctly plan and direct movements in the enuak Neuromotor: Cerebral Palsy Teressa Garcia. * Erin Naber sand extremities that are wsed in everyday interactions with the environment. The muscles are activated in uncoordinated and incficient ways and ate unable to work together to create smooth, effective motion." Prevalence and Etiology of Cerebral Palsy CCercbral palsy isthe most prevalent cause of persistent motor dysfunction in children, with a prevalence of one in 500 births to thice ia 1000 bisths "The prevalence of cercbral palsy has remained stable since the 1950s, although prenatal and perinatal care as improved dramatically over the last 4 decades" Socctal comts for persons dingnosed with CP are sbstantial, and estimates of total lifetime expenditazes ate estimated as bigh as $11.5 billion” Average netime expen- diraze per child could exceed $900,000 above ordinary costs of tssing scild." ‘The diagnosis of CP i approximately 1.5 times more common in males and is higher among non-Hispanic Atcan “American children and chiliren ffom low to middle income families.” According tothe United Cerebral Palsy (UCP) four dation, approximately 800,000 claldsen and adults in che United States ive with one oF more symptoms of cerebral palsy. The origin of bain injury may occur during the prena- tal, petinatal, of postnatal period, but evidence suggests thst 70% to 80% is prenatal in origin The nervous system damage that causes CP can occur before or ding birth of before «child's second year, the time when myelination ofthe child's sensory and motor tacts and cental nervous system, (CNS) seacnres occurs rapidly: eis increasingly apparent that CP can result fom the imter- action of miliple factors, snd in many ease, 9 single cause cannot be idented.* Prenatal maternal infection, premature bith, low birth weight, and multiple pregnancies have been sssociated with cerebral pai.” Prenatal factors may snelade genetic abnormalities or maternal heals Fctors such assess, ‘malnutrition, exposure to damaging. drugs, and pregnancy induced hypertension. Some gestational conditions of the smother, such as diabetes, may cause perinatal rks to the devel- loping infant; prematarity and low birth weight signiicanly increase an infants chance of acquiring. cerebral paly diag nosis Medical problems asociated with premature birth may arms am ‘Quadriplegic: ll four extremities 24% Hemiplegi one-sided invelvement, arm > leg ty Double hemiplegie both sides; one greater than othe, ams > legs 24%, ‘Choreoathetoid han Dystonie het Ataxic am Mixed (percentages included above)cuarrer 28 Neuromotor: Cerebral Palsy 797 CET) ‘Ben isa 9-month-old infant referred for occupational therapy services because of developmental delay. His mother is con- ‘ered that he is “not moving like his older brother was st this age.” Ar 9 months, he recently learned to sit indepen- dently but has dificulty rolling because of “tightness” in the left arm and leg. The occupational therapist completed 2 thorough evaluation including formal snd informal asess- ‘ment of body structure and function and developmental sills. She administered the Grasping and Visual Motor Integration subscales of the Peabody Developmental Motor Scaler-2 (PDMS.2) and the Alberta Infint Motor Scales (AIMS). On cach of the assessments, Ben scored below average when ‘compared with typical age peers, He did not reach and grasp ‘with his left arm and did not bring both hands to midline to play. He did not use both hands to hold a sippy cup and his mother seported dificulty putting on shirts and pants because of tightness in Ben's left arm and le During the occupational therapist's clinical observation of Ben's movement. during ply, she noticed that he eabibited Knted conteol of lett am. and leg movement when transitioning out of sing, collie, lor reaching for objects, He did aot use hit lef ama for protec. tive reactions forward of sideways. She also aoticed that hie yes were not aligned and his left eye appeared (0 dai laterally. ‘After her evaluation, the occupational therapist discussed the revue of er evaluation with the referring peditric ne: rologist. The neurologist ordered a magnetic zesonance ‘enaging (MAX) test to identify posible central nervous sytem lesion). The results of the MRE revealed that Ben bas a lesion affecting the night primary motor cortex and interal capri, and the neurologist conimed a diagnosis of spastic leit hemiplegi cerebral paly lesion inthe Iain, Because the lesion occurs in immature brain structures, the progression of the child’s motor development ‘may appear to change, causing secondary impairments (see Box 28-3). Normal nervous system maturation shifts control of ‘voluntary movement to cortical brsia areas. The child who bss CP exhibits some changes in movement ability that result fom the expected progression of motor development skills, but these changes tend to be delayed relative ro age and often Show snuck less variety than those seen ia the sypicaly developing. child, See Case Study 28-1 ‘Children with CP devslop secondary impairments in systems fr organs over time because of the elfects of one oF more of the primary impairments.’ These secondary impairments may become just as debilitating as che primary impairments “Although che initial basin injury is wachaneing, the results o the secondary impairments are not static and change over time swath body growth and aitempts to move against gravigy“!* ‘When playing or in fitnctional sctvitie, children with CP move in appical pattems that may become repetitive and fixed. The repetition of the atypical movement patterns prevents children ‘with CP trom gaining full voluntary contro oftheir movements and can lead to diminished strength and musculoskeletal prob- Jems, The combination of impaited muscle co-activation and the use of reflexively controlled postures may lead to future contractures in the muscle, tendon, and ligamentous tissues, causing the tissues to become permanently shortened. Sof tissue changes can lead to contractures and possibly bone defor~ mites; they can also cause spinal and joint misalignment. In addition to the risk for joint contractures and deformities and spinal or joint misalignment, children with CP are at risk for skin breakdown and decreased bone density. Ciaildten in ‘wheelchairs, who maintain sitting or ving for extended periods for who cannot independently shift their weight, risk skin break- down, Children who are most vulnerable may sit with their body weight pressure on body prominences for prolonged time ‘periods. Children in wheelchairs also experience decreased time standing or ambulsting, negatively indhuencing the strength of the individual's bones. Children diagnosed with CP may have decreased bone mineral density and are vulnerable to patho- logic fractures.” Oceupational therapy practitioners provide opportunities for children with CP to maintain upright posi sions and bear weight in a variety of positions. This can be accomplished by providing children with adapted seating, such as specialized seats, prone or supine standers, and toys chat promote weight bearing (¢.g, scooter). Children with CP may experience additional problems such at scinures and other medical conditions not dteety related to the child's movement disorder, When postural nauscles are ‘weak, breathing can be compromised. Abnormal posture and weak muscle setivity may compromise cardiac and respiratory functions and prevent these systems from working efficiently ‘The resulting low endurance and fatigue can infleence the culd's capacity for activity. The occupational therapy pracitio- net monitors cach child’s physical endurance and plane thera- peutic goals to increase strength and endurance Cognition and Language Because CP is caused by a focal brain lesion, language and cognition may or may not be affected, depending om which areas of the brain are affected (e.g., fontal lobe, temporal lobe), Lesions afecting the frontal lobe may affect the child’s cognitive abilities, including artention, organization, problem solving, inhibition, and judgment, Lesions affecting both the primary motor and temporal lobes may affect language and speech development. Because speech requites complex move- ments of oral/facial structure and requires control of breathing, chaildren and adult diagnosed with CP may have various prob- lems with speech and language. These potential problems nelide decreated speech prodvction, poor articulation, and decreased speech intelligibility. Dysarthria isthe term sed 0 describe a disorder of speech production secondary to decreased muscle coordination, paralysis, or weakness In addition to specch production disorders, children who have cercbral palsy may have changes in the quality of their voice resulting fom decreased strength oF control of respira- tory and postural muscles. Because CD has the potential to abet areas of the brain outside of the motor system, children who have CP can have decreased expressive and receptive Janguage skills. This means they have diffculyy processing language-hased information or producing responses. All of798 — section IV Areas of Pediatric Occupational Therapy Services OT “Antoine is an 8-year-old boy with a history of a seizure dis- ‘order and athetoid cerebral palsy, He uses a power wheelchair for all mobility and an augmentative communication device for communication, He attends elementary school, where he is placed in an age-appropriate classroom with accom ‘modations snd related services, including physical therspy, ‘occupational therapy, speech-language therapy, and assistive technology. Antoine's continuous body movements rake it dificult for him to complete fine motor tasks, including. Accessing hie communication device to communicate with hie tcacher and fricads. He gets frustrated when he knows the answer toa question but cannot communicate itt his teacher and classmates in a timely manner, Hie has difficulty with fine ‘motor tasks and it cakes additional time for him to complete clasework, Antoine's therapy team discovers that a head stick helps to improve his access to his communication device and that using his head, versus his hand, i a faster and more efficient ‘way for him to access his communication device and a word [processing program on the computer. The occupational ther spirt worked with his art teacher to fisten a holder for tools stich as a paintbrush to his head stick. Now Antoine is able to creatively express himself through variety of medis, including paint and pastels, which do not require a lot of [pressure when drawing, Antoine also seems to have improved. success in using the device when he grasps the armrest of his ‘wheelchair, s0 his occupational therapist tres mounting a bar fon his tray for him to push into to improve his trunk stability these potential impaisments can have a significant impact on ‘he child’ participation in age-appropriate activities with peers, ‘oaderstanding of and response to directions, making his ox her sceds known, and managing his or her own care. A child's cognitive and linguistic sll level is considered when develop- ing goals and potential outcomes (Case Study 28-2) Sensory Functions hhldren with CP may have visual or sensory impairments ‘Visual impairments such as blindness, uncoordinated eye move ments, and eye muscle weaknese affect as many a 50% of children who have CP. Chalden who have more severe CP are more likely to have visual impairment.” Regardless of the fane- sional level ofa child, vision should always be taken into con- sideration during fine motor task, play, and activities of daily living completion, Vision plays an important role in tring of grasp and release, manipulating objects, orienting materials, making eye contact, and finding needed items. Children with ‘inaal impairments may use postural adaptations, such as a head, Lilt oF changes to the angle of gaze, to compensate for visual deficits, These deficits may be oculomotor in nature, meaning their eye muscles do not move smoothly or in syne or may. move involuntarily. The term strabismus refers to the eyes not being aligned because of muscle imbalance. Functionally, sra- bismus may cause difiulty wath attending to visual ask, The child may have decreased convergence or divergence, decreased depth perception, or double vision, Other terms describing misalignment of the eyes include cxouropia (one eye drifs temporally), esotropia (one eye drifts nasally), hypertropia (one «ye daifts upward), and hypotropia (one eye drifts downward). Novtagmus refers to the eves constantly moving in a repetitive snd uncontrolled way. Functional issues associated with mys tagmus include reduced acuity, dificult fixating on a target to ‘maintain balance, reduced target accuracy when reaching or grasping, compensatory head movements, or posturing t0 com- ‘pensate for visual defi, In addition to oculomotor impairments, children may have deficits in the way the brain processes visual information. ‘Without proper processing, a child may not understand the spatial relationships among objects, be missing part ofthe visual field, or not identisy partially hidden item, suc as his ot her coat in a closet. ‘Auditory reception and processing deficits have an impact fon 25% of individuals with CP.” Heaving loss with both con- ductive hearing lose and sensorineural hearing impairments may occur if child hae been affected by a congenital nervous system infection. Both vision and heating should be tested regularly fr chil dren with CP. Children with CP may have difficulty processing tactile and proprioceptive information (c.g, fingertip force regulation suring object manipulation).”" Children with CP may also demonstrate tactile hypersensitivites (€.g., overreacting 0 touch, textures, and changes in head position), causing some children to become viibly upset when handled or moved by cothers. When childzen have multiple sensory processing prob- Jems, they may have difficulty understanding and responding to the social and physical clements of their environments, Oral tactile sensitivity may be associated with abnormal oral move- ment patterns, Children may have aversion to certain food textures, causing disorganized oral motor control and problems coordinating, chewing, sucking, and swallowing. Those with severe problems in this azea may be surgically Sted with a percutaneous endoscopic gastrostomy (PEG) tube for feeding. Occupational therapy practitioners must consider a child’s sensory limitations and strengths when setting intervention goals. The practitioner considers which sensory experiences are Likely to improve occupational performance. linia! obscrvation of the child's occupational performance provides the occupational practitioner with data on factors lnfluencing the child's muscle tone, reflex activity, gross and fine motor sll, sensory systems, cognition, perception, and piychosocial development. Clinical asscstment dats create a * of the child's functioning and indicate his or her strengths and weaknesses. Observation of a child completing simple taske sch as putting on a sbitt, transitioning from acHarrer 28 Neuromotor: Cerebral Palsy 799 TABLE 28-2 Selected Upper Limb Assessments for Body Structure, Function, and Activity for Children with Cerebral Palsy Assessment Age Domain and Activities Melbourne Assessment of 5-15 years Assessment of impairment and activity limitations in the upper extremity. Examiner Unilateral Upper Limb administers 16 items that involve reach, grasp, release, and manipulation. Each Funetion (MuuL)*= iter is scored according to specific criteria to rate quality of ange of motion, accuracy, fluency, and dexterity, yielding a maximum possible raw score of 122. Quality of Upper Extremity 2-13 years Acriterion-referenced observational assessment measuring 34 items in four domains ‘Skis Test (QUEST) (dissociated movement, gasp, weight bearing, and protective extension). Scores ‘rom each domain are summed and converted to a percentage core. Jebson Taylor Test of Hand 6-17 years A clinical evaluation of speed and dexterity of upper limb tasks. The seven timed Function (TTHE)” TABLE 28-3 ‘subtests vary in complexity and use everyday objects to assess how a child uses grasp and release in dally tasks. Selected Participation and Quality of Life Measures for Children with Cerebral Palsy ‘Outcome Measure Age Domains and Relevant Items Cerebral Palsy Quality of Life 4-12 years 66 items (CP QOL—Child”™ Parent report: 4, Social well-being and acceptance Child report 2. Participation and physical health 9-12 years, 3. Functioning 4. Emotional wellbeing 5 Pain and impact of disability 5. Access to services 7, Family SelF-report: 53 items Cerebral Palsy Quality of Life 12.48 years 22 items (CP QOL}—Teen”™ Child report Well-being and participation Communication and physical health School well-being Social well-being, ‘Access to services Family health Feelings about functioning chair to the floor, opening containers, or playing with age- appropriate toys helps the occupational therapist identify arypi- cal postures and movements that may be limiting functional abilities. Early identification and intervention of atypical pos ‘ures may minimize the use of compensatory and dysfunctional movements, Which could lead to secondary impairments and decteased functional abilities for children with CP. During sherspy sessions, the occupational therapist facilitates mature and typical movement patterns to promote progress in typical developmental milestones Thorough assessment dats are essential when working as part ofa service delivery team. Selection of assessment measures ay be based on several factors, including the child’s age, setting (e.g, home health, schoo! system, commusity}, and the caregiver's and child's specific concetns about functional liita- tions, Table 28-2 provides information on specific lasifiation systems and assessments commonly used for children diagnosed with CP. Two assessments are designed specially to measure gualty of lie and overall participation in children with (Table 28-3), Functional classifeation systems include the ‘Gross Motor Function Classification System (GMECS) and the ‘Manual Ability Classification System for Children with Cerebral Palsy (MACS) (Tables 28-4 and 28-5), ‘The occupational therapy practitioner uses assessment infor mation, including patent concems and priorities, o Formslate goals that match the child’s needs, developmental performance, and potential outcomes. Examples include increasing a child's ability to participate in a dasssoom writing activity and teaching family members adaptive techniques so th can bathe or feed a child with greater ease, Goals for the ado- lescent might adders accessing public transportation ot learn- ing ways to perform homemaking shills. See Box 28-1 for sample goals Occupational Therapy Interventions The occupational therapy practitioner plans and implements interventions to promote faction and independence in chile dren with CP. Practitioners may work one-on-one with the00 section IV Areas of Pediatric Occupational Therapy Services TABLE 28-4 Gross Motor Function Classification System Level Level | Walks without limitations. Performs gross motor skills like running and jumping but speed, balance, and coordination may be impaired Level Walks with limitations. This includes on uneven surface, inclines, stairs, long distances, or in crowds of confined spaces Level Ill Walks using a hand-held mobility device. Walks on even surfaces, indoors and outdoors with an asitive device. ‘children may use manual wheelchair for long distances Level IV Self-mobilty with limitations. Child may use powered mobility or require assitance from a caregiver. May walk short stances with a mobility device but relies primarily on wheeled mobility. Level V_ Transported in a manual wheelchair. Child has no means of independent mobility and relies on caregiver forall ‘transportation needs From Patsano R, Rosenbaum, P, Walle, S, Ruse, D, Wood, & Galupp, 8, 1987). Development and relabilty of a system to casly gross Ita uncon ehisen wth cerebral pel. Devlopmental edn &'Chid Neurology 38 714-208. "9 TABLE 28-5 _ Manual Ability Classification System Level _ Description of Functional Abilities Levell Handles objects easily and successfully. At most times, handles objects with both hands. The child may have limitations In the ease of performing manal tasks requiring speed and accuracy. However, any limitations in manual abilities do nat restrict independance in daily activities. Level ll Handles most objects but with somewhat reduced quality andor speed of achievement. The child may avoid certain ‘activities or the activity will be achieved with some difficulty. The child develops ways of performing some manwal activities that do not usualy restrict independence in daily activities Handles objects with difficulty; needs help to prepare and/or modify activities. The child’ performance is slow and achieved with limited success regarding quality and quantity. The child cannot perform certain activities and his or her degree of independence is related to the supportiveness of the environmental context. Activities are performed independently if they have been set up or adapted. Handles a limited selection of easily managed objects in adapted situations. The child performs parts of activities with ‘effort and with limited success. Requires continuous suppert and assistance andlor adapted equipment, for even partial achievement of the activity Does not handle objects and has severely limited ability to perform even simple actions. Requires total assistance. Level I Level lv Level v From Eliasson, A.C, Krumlinde Sundhol, L,Rosblad, 8, Beckung Amer M, Ohrvall,A. Met al. (2006). The Manual Ability Classification System (MACS) for children with cerebral palsy Scale development and evidence of validity and reliability. Developmental Medicine and Child Neurology, 48, 549-554 child, lead groups of children with similar goals, or take a BOX 28-4 Sample Occupational Therapy Goals P P Py consultative role in assisting caregivers with problem-solving Selfcare Gill wi don pullover shir wih minimal Sapte tools and seatepes to encourage the Cy indepen sibtance, 100% tal ence They can work With children ina very of tne, ‘Child will use adaptive spoon to eat soft solid including school, home, and the community. A recent compre- foods with modified independence. ‘hensive review of interventions used with children with CP” Fay __Gildwl sow improved postural control to‘ he following interventions to be supported by creat ‘engage in 15-minute play activity while boten o ‘s a 4 ‘ipm he > s rue in Tomine pnyecivy whe | hon, coms indoced movement tea, Reina pa oes fod gostdieced terpy, and bamaaval waning These ine terest ‘eos, as wel a an overview of sonal interventions tha Secupasonalthrapss may select to adress the neon Recreation Gil will swcestulyparicpate onan funds for chien with CP ae promided in Us secon. The eee ety tse of specie pracice models ghlghed fae sped peur pe parents tort Fine metor Child will wiite fist raw from meioty with Adaptive Equipment Training hho errors, 80% of tials, Child will isolate right index finger to successfully access games on iPad, 4 out of 5 trate Avvaticty of adaptive devices aad equipment can assist a child with CP to complete activites of daly living (ADL), instru- mental actiitis of daily living (IADLS), play, and educational tasks, These devices serve to modify of conttol some of thecuarrer 28 Neuromotor: Cerebral Palsy 801 (case stupy 28-3 Brian is an L1-yearold boy who was born at 35 weeks’ szcstation by emergency cesarean section. He was had global developmental delays with bypotonia and was diagnosed with ‘quadriplegic cerebral palsy and neurodevelopmental disability He quickly becomes fatigued during seléfeeding, and requires ssritance with spoon feeding to obtain adequate nutrition, His mother reports that she often feeds him at home so he is able to eat much more quickly, She reposts that he is easly distracted when eating, ‘During an occupational therapy assessment, Brian grasped 4 toddler spooa with large handle ae well as 4 bent-bandled spoon with large handle, He switched hand dominance, but performed best when using his left hand, Hle required moder- ate to maximum assistance to scoop thick foods from a scoop bow! and minimal assist to wansport foods to his mouth without spilling Brian required repeated tactile and verbal cues 0 close his lips around the spoon and use his top lip to clea the spoon. He prefers to “dump” food into his mouth. He exlabited rongue thrust movements to move food laterally and poste- Hlorly for swallowing. No coughing or choking was observed. Brian used a straw to drink thin liquide from a juice box, Dut he had difficulty creating a tight scal with his lps and lost small amounts of liquid when drinking, The occupational therapist suggested an adapted straw witha larger opening to make it easier for him to drink. Brian made gains in his ability to clear the spoon with his top lip whea he was given assistance to stabilize his lower jaw and verbal cues to use is top lip o clear the spoon, He made improvements ia his ability to move food from the bowl to ‘bis mouth without spilling, See Chapter 14 for additional information on feeding interventions. degrees of ficedom required for children to engage in daily activites, The occupational therapist aclects a device eat matches the ebild’s motor needs while simultaneously consider- ing his or her sensory functioning (including vision, auditory, and sensation), the environment in which it will be used, and the child's position when using it (standing, sting, or in his fr her wheelchair or bed). Other considerations are the chil for family’s ability to transport the adaptive equipment, the set up nceded to use it, and the ease of cleaning the device. ‘The occupational therapist may work with interdisciplinary team members when determining the child’s needs. For example when selecting a communication device for a child swath quadriplegic CP and cortical visual impairment, an occu ptional therapist may work with « low vision therapist and speech-language pathologist to select the most appropriate device and determine the most eflcient way to aecess the device and the optimal position to mount the device for ease of visual scanning, The occupational therapist may recommend adaptive vutensils during mealtime to compensate for limited grasping patterns or nonskid material (o control the child’ plate on the tabletop, Dressing tasks can also be moditied to optimize the ciaild’s safety, efficiency, and independence, ‘A large zipper pull on jeans or pants may be recommended for s child with diplegic CP and limited fine motor coordina- sion (Case Stuy 28-3), The occupational therapist practitioner should become familar witha diverse group of assistive devices 10 that equipment recommendations consider all occupational performance concerns and the family’s financial resources. Its also common for occupational therapists to fbricate assistive devices from common household materials or splinting materi als (Case Study 28-4; Figare 28.1) Casting, Orthotics, and Splinting Splinsing or casting can be used to improve hand function, prevent joint contracture, improve hygiene, of relieve pai in 4 specific joint, Splining may also be used eo reduce unsafe Dochaviors in a child with selGinjutiows behaviors, Splints and orthotics can support the atm in a functional posi tion to improve performance in activities of daily ling (see Chapter 29). Serial static splints and casts are designed to Tengthen tissues and correct deformity through application of ageatle forces sustained for extended periods of time with the goal of reducing tightness or spasticity in a selected muscle soup. Splinte are remolded and cast replaced st intervals that allowed for the muscle tise to respond to the lengthened position, The biomechanical effects of splinting and casting relate to changes inthe length of muscle and connective tsses, ‘which can reverse the effects that oceur when a muscle ie main= tained in a shortened position, Splinting to lengthen tight aad contracted msscles in children with CP is best if applied con- tinuously for periods greater than 6 hows”? Casting has add sional biomechanical and neurophysiologic effects, although the exact newrophysiologic effects of casting on spasticity are not well defised at this time. Ie is theorized that inhibition fof muscle contractions allowing lengthening of muscle tissue results from decreased cutaneous sensory input from muscle receptors during the petiod of immobiliztion, The effects of neutral warmth and circumferential contact also ate believed to contaibute to modification of spasticity (Figure 28-2)."* Splints can also be used to meet the goals of the child oF parent, For example, a splint may he fabricated to isolate a cluld’s index finger to access a touch screen device or com- ‘munication system, Splints have been used to compensste for hand deformities preventing the ability to grasp cating oF ‘writing utensils, Splints may’ also be used to aid in the ability to drive a power wheelchair such ae a wrist support that allows 4 child to access the joystick control. Temporary splints are also fabricated by therapists to prevent movement from the hhand to the mouth when childeen exhibit set-injutious behay= tors or attempt to pull out feeding cubes, intravenous lines, for tracheostomy tubing. A systematic review of splint use in childeem with CP reported that splinting when combined ‘with an active therapy program” can have positive etleets on, fanction. The use of splinting alone without use of other com- plementary interventions docs not have evidence of efficacy ‘When an occupational therapist detcemince that a child would benefic from wearing an orthosis or cast, he or she needs to educate parents as to che purpose and goals for the orthosis, provide instructions for donning, doffing, and cleaning, and802 section IV _ Areas of Pediatric Occupational Therapy Services aes Nathan isa 14-year-old boy with spastic quadriplegic cerebral palsy and normal cognition, He uses a power wheelchair. His posture is poor and he has impaired righting equilibrium and protective responses, He requies a chest strap and lateral sup- ports on his wheelchair co asst with postural alignment and ‘upright seating in his char. His dynamic unsupported siting balance is poor and his static sitting balance on the edge of | his bed is fair bu zequires close supervision, Fine motor skills axe significantly impaired with limited ip strength; islet hhand is more affected than his right. Nathan has not received ‘occupational therapy services since he was 10 years old whess hhc and his family decided to take a break fiom services and cxplore adaptive recreational activities and aquatic therapy. ‘Recently (at 14) he requested to return to services to become zmore independent in sel-eare, Tis family also recently pur- chased a computer tablet for him and he is interested in finding applications that will help him control his environ- rent, Av his initial evaluation the occupational therapist con- dlueted the Canadian Occupational Performance Measure (COPM)" with Nathan. He identified his most important ‘occupational performance problems as dofling his shocs, ‘completing simple meal preparation, curing on his bedroom lights, and completing written work for school assignments During the evaluation the occupational therapist determined that his power wheelchair was the safest place for him to «complete ADL since it offered him the best postural support Occupational Therapy Goals 1. While sitting with «rank supported and using adapted ‘equipment, Nathan will successfilly dof shoes within 1 ‘minute 2. Nathan will follow four-step instnuctions 10 prepare a simple meal with intermittent verbal cucing by the Uherapist. 3. Using a tablet programmed for environmental contro! placed on his power wheelchair, Nathan will successfully ‘hum lights on in rooms at home, 100% of tials 4. Nathan will dictate all appropriate school reports using adaptive word processing program with supervision and set up only Over the course of his 12-week admission, the occupa- tional therapist tied and evaluated various adaptive eguip- rent training, To inerease independence in lower extremity dressing, Nathan atempred to use a yeacher and long-handled shoe hom with good success. By the end of the 12 weeks, ‘Nathan successfully unstrapped his foot supports, untied hie shoes, and, using a long-handled shoe horn, doffed them, He continued to requite assistance with doling his ankle foot ‘orthoses (AFOs) but was making progress toward indepen: dence with the stategics and adaptive equipment provided by his therapist ‘To address simple meal preparation activities, the oveupa- sional therapist suggested use of an adapted cutting, board shat secured food and use of a rocker knife. Positioning his chair to the side of the counter to retrieve materials with his stronger arm war also beneficial, With a consult from sn assis tive technology specialist Nathan and the occupational thera: pist explored tablet applications for environmental control, snd forind one that controlled the lights, his television, and is DVD player. The occupational therapist fabricated a mount with a Loc-Line modular hose system that allowed him to easily reposition his computer tablet or push it ont of| the way when not in use, The assistive technology specialist also recommended text-to-speech software and agreed that the most effective position for him to dictate school reports ‘was in his chair, where he had the bese breath support, Nath ‘worked with the occupational therapist to learn how to use the software and his speech-language pathologist war con- sulted for strategies to improve hie articulation, At the end of the 12 weeks the occupational therapist reassessed his prog: ress through structured observation and re-administered the COPM, Nathan reported improved performance and sstsfic sion with his performance on all the performance goals identi fied at admission, with the greatest change noted on meal preparation tasks, Because of his progress the occupational therapist reduced visits to one-time monthly consultative ses sions for the next 6 months determine an optinal wearing schedule that fits the family's Constraint-Induced Movement Therapy Constraint-induced movement therapy (CIMT) is an evidence- based intervention for children with hemiplegia that targets the functional use of the child's affected upper extremity through engagement in intensive practice, shaping and grading of ta- acted movements, and restricting use of the wnaficcted, stron- ser upper extremity. Children with hemiplegia often. show ‘developmental disregard”; that is, they lear to ignore the involved arm because it is ineffcicnt. Therefore ute of the involved arm is negatively reinforced despite the function that ray be available, The goal of CIMT is to reverse this effect. Constrsint-induced movement therapy developed out of basic experimental pychology research by Edward ‘Taub and his colleagues on sensory contributions fo motor learning in pri- mates." Constraintinduced movement therapy was initially used in the rehabilitation of patients post stroke and then developed as an intervention for children. Miutip case reports, cohort studies, and randomized conteol tials have reported the cffectivenese of thie intervention technique.!7™"" Current implementation of CIMT vanics, bus all progr bhave three essential features: (1) some method of constraint of sse of the unimpaired upper extremity; (2) intensive, repetitive practice of motor activities, for up to 6 hours per day, for 20 4 weeks; and (3) shaping of more complex, functional motor acts by identifying the component movements of a targeted task and rewarding actions successive approximations to the task, The lterarute reports a vatiery of constraining vices and wearing schedules, including mitts, casts, splintsNeuromotor: Cerebral Palsy 803 FIGURE 28-1. Example of a pre-fabricated wrist and thumb support with thermoplastic insert for a child with hemiplegia. FIGURE 28-2 An example of sensory exploration during modified CIMT. and slings. Use of constraining devices may be intermittent and they may be removed at certain times of the day or ater massed practice trials are completed, or they may be applied continu- ously, allowing for practice and generalization of skills through- cout the child’: day for a set period of Constrsintinduced movement therapy can be defined as either a signature CIMT oF modified CIMT (m-CIMT). signature CIMT approach hae ‘five essential components, (Photos courtesy of Kennedy Krieger Institute) including (1) constraint of the unaffected upper limb, (2) 3 high dosage of repetitive ask practice (3 to 6 houts of therapy per day over several consecutive days), (3) the use of shaping techniques, (4) therapy provided in natural setting, and (5) 4 transition of post-CIMT program to maintain gains acquired during CIMT program." A typical signature approach provides massed practice and shaping of more mature motor movement at least 2 consecutive weeks (14 to 21 days, dosage equal 10 42 to 128 hows) by a professional with an understanding of rehabilitation techniques to improve motor function (C3se Seudy 28-5) “Modified constraint-induced movement therapy (m2-CIMT) is defined as constraint of the stronger or less affected upper mb combined with less than 3 hours per day of therapy. Most of the five essential clements of the signature approach are provided, but with modifications, including variation in where the therapy is provided (c.g, clinic oF camp versus individual ent at home) o a varation in the dosage of therapy (¢.8., less concentrated, may be more distributed over several days oF weeks)." Massed practice may be provided by a professional With training in CIMT, but not necessarily an occupational or physical therapist" (patent, dayeare Worker, eamp coun selor). Unlike occupational therapists in adule settings, pedi therapists wsing CIMT embed repetitive task practice in daily fenetional and play activities (Figures 28-3 and 28-4)" Research questions remain about appropriate dosage, optimal age for teatment inication, and optimal repeat inrervention intervals”804 Areas of Pediatric Occupational Therapy Services Constraint-Induced Movement Therap: Logan is a 314-year-old boy with hemiplegic cerebral palsy Until he was 3 years old he received home-based services through an eazly intervention program. When he tumed 3, hhe began outpatient occupational therapy services once & week, Logan's goals included increased arm strength such that he mainthins a quadruped position for a minute, fall arm extension to push his arm through his shirt sleeve, and pulling up his pants with both hands, Another goal rs with his right hand and carry toys with both is 0 grasp hand, Logan will show improved upper extremity strength to phy in a quadruped position for up to 10 minutes with rho physical cue required from the therapist logan Logan will be able to push both arms through sleeves of long sleeve shire with minimal assistance from therapist or caregiver, 100% of wal ‘Logan wil pull pants up from knees to waist after toileting with minimal assitance from therapist of categiver, 80% of tal. Logan participated in a constraintinduced movement therapy program at an outpatient clinic, Logan attended program for 3 hours a day and wore a continuous cast on his unaffected, stronger arm. Activities that are motivating such. ss carrying a bucket loaded with balls and picking up cats snd patting them on a race tack are done at high level of repet ion, Imaginary play activities, such as pushing his afected. sem through dress-up clothes, help him generalize these new skills to play and ADL. tatks FIGURE 28-4 Two examples of kinesiology tape to improve thumb abduction needed for grasp and release. (Photos courtesy of Patty Coker-Bolt)cuarrer 28 Neuromotor: Cerebral Palsy 805 eae ‘vais 17-year-old girl with hemiplegic cerebral palsy alfect ing her lefts, Ava is learning to drive and has worked with 4 driver rchabilitation specialise to adapt her mini-van, Ax ‘uaining, progressed, Ava reported that she had diffcalry ‘opening the car door with her left hand when holding. her backpack or her textbooks in her right hand, The occupa: tonal therapist developed a strengthening program for Ava's left hand grip and an electrical stimslation program for hee left wrist extensors. Ava's electrical stimulation device was pre-programmed with the help of the therapist. During the intervention session, Ava took a photo with her camera phone of electrode placement on her let forearm. During occupa- somal therapy, Ava demonstrated placing the pads in a correct location and collaborates with the occupational therapist to develop list of activities to complete during electrical stimu lation, which was 4 days per week for 20 minutes at home. ‘Activities include playing games on a touch screen tablet positioned on a vertical surface, waxing her car, ors positions Jn prone, and writing on a vertical surface Physical Agent Modalities ‘Various modalities target increasing muscle length and strength, ng spasticity in children with CP to improve a chil’: in play, ADLs, IADIs, and academics, These intet- ‘vention modalities include electrical stimulation and hot/cold therspy. Heat maybe used in conjunction with a stretching program to improve muscle length and reduce pain. Electrical stimulation can be sed (0 strengthen antagonist onasces, re-educare muscles, target pain reduction, improve coordina. sion, increase range of motion, and reduce spasticity (Case Study 28-6).°* Blecueal stimulation is most effective when vosed with a Functional activity, seh as combing hair wher stimulating the biceps or releasing toys into a container while simulating waist extensors, Use of neuromuscular clectsical stimulation when applied with intensity cam improve upper limb range of motion and strcngth, especially when paired with dynamic splinting,” Occupational therapy practitioners should defer to their state regulatory boards regarding guidelines for application and training requirements for using physical agent modalities (PAMs). Some states may require a physician pre- scription before administration, Risk for burns is an important consideration, and conttaindications such as cancer applv. Prac- sitionere should complete advanced training in physical agent modality application before using RAMS, Therapeutic Taping and Strapping “Two types of therapeutic tape are used in rehabilitation, Thera- pists use rigid sape to limit movement around a joint oF to protect a joint during functional movement, while fiexible, clastic hincrileyy tape is used to facta improved movement patterns.” Kinesiology tape is applied directly to a child's skin and works by increasing stimulation to evtancous mechanorecep- tors that filtate muscle contraction or inhibition (Figure 28.5), The elastic properties of the tape ean also be used (0 reposition joints to a more appropriate alignment. Four major fanctions of kinesiology tape are co (1) support a weakened muscle, (2) improve circulation, (3) reduce pain, and (4) improve joint alignment.” Published evidence to support oF refute the use of taping interventions is minimal at best and is often reported in small case studies oF cohort studies without controls” A recent ease study reported significant improve- rents on sit-torstand performance of a child with CP after application of elastic tape to lower extremity muscles.” Another FIGURE 28-5 A screen shot of robotic device software report by Footer" examining rig raping techniques found no improvements in postural control in sample of 18 childten with quadtiplegic CP. Because of potential skin sensitivities in children, i is always important before taping a full joint, co apply small “test” stip to the child's skin to check for nega- tive reactions to the propertics ofthe tape. Advanced taining in kinesiology and rigid taping applications i available through continuing education courses Positioning, Handling, and Neurodevelopmental Treatment Occupational therapy practitioners often employ ncurodevel- ‘opmental treatment (NDT) techniques of therapeutic position- ing and handling to assist culdren with CP to optimize their independence with functional tasks. Occupational therapists determine the safest and most efficient positioning and haa- dling techniques to facilitate completion of ADIs and TADLs. ‘They recommend and select wheelchaiss, standers, activity chaize, commode or bath chaits, and side-yers to aid in com pleting play and ADL. tasks, The occupational therapist maker recommendations for positioning, seating, and mobility in col- Jaboration with interdisciplinary ream members from rehabilta- sion engineering, speech-language pathology, and physical sherspy depending o the complexity of the child and his or baer needs. For example, an occupational therapist may stiggeat a reclined bath chair with a seat belt co support a child wich quadriplegic CP and poor head control during bathing. A806 section IV _ Areas of Pediatric Occupational Therapy Services school therapist may suggest a slant bosed and foot support {0 improve posture during writing tasks for a child with hemiplegic CP. In addition to positioning in preparation for tasks, thers- peutic handling can affect a child's tone throughout the body to assist with eficient muscle activation for movement, As a preparatory technique, handling techniques such as imposed rotstional movement patterns, slow rocking, and bouncing ‘Aciltate or inhibit the child's muscle one and enbsance arousal level, Often children with CP have poor body awareness and a limited ability to anticipate postural changes required for move- ‘ment oF anticipatory control.” Facilitated weight bearing and weight shifting can build strength, improve co-contrsction, aad improve postural symmetry and alignment in children with CP. For example, an occupational therapist working with a chil ‘who tends t0 move in an extensor pattern may facilitate sus tained flexion of the trunk and slow tnunk rotation in sitting snd knee lesion in quadmuped in preparation for sitting in a cir for mealtime ‘A practitioner may also train a parent to complete these activities wath the child before dressing. Ifthe child has high tone and his or her muscles are sti, positioning and handling ‘echniques may filtate movements required for dressing and sclf-eare tasks, Improved passive knee flexion reduces the burden of care on the caregiver while donning a child's pants. Evidence to support thie intervention is mixed as recent studies have not been able to isolate the effect of treatment to this intervention,” Neurodevelopmental treatment research shows conflicting findings and results ate dificult to interpret because cscatchers ased a variety of ontcome measures, Lew studies were randomized; and samples included participants with a Wide range of functional abilities” Community Recreation Cire and teens with dsabilitic are at sik for limited pare ‘eipation in reerational an lente activities, snd youths with physical disables experience two to theee times the actvicy lbmitations that ate experienced by children with other chronic conditions.” In addition, chile with diabilities are more resticted in ther participation compared with their peers ‘These leize activities tend to be limited; they attend fewer social engagements and spend ls ine in quit secrestion than their typically developing peer." Children with disabilities tend to be involved with moze informal versus formal recre- stion activities and participate less in physical snd sil-based activities” Occupational therapy practitioners can assist hil tron with CP in accessing adaptive recreation options. Chile dren's recreation snd leisure parucipation can be divided into formal actives (e-, sractred activities with res and often 2 leader) and informal activities (e.g, chik-inivated, unstruc- tured activites.” Occupational dherapsts ean assist in identiy- ing prefered formal and informal Icirure and. recreational activities for children with CP snd also ean assist in the modi fieation of specific etivities to meet the need ofthe eld both For example, an occupational therapist may suggest the wie of tee stand for a child with hemiplegia to participate om a softball team with his of her pects or may provide a universal elf to allow a cbild to participate in playing a video game ax home. Occupational therapists may also guide fimiles to appropriate community organizations that provide recreational activities for children with disabilities, Complementary and Alternative Medicine ‘The National Center for Complementary and Alternative Med leine defines complementary and alternative medicine (CAM) se "s group of diverse medical and health care systems, prac: tices, and products that are not generally considered part of conventional medicine."”* Conventional medicine is practiced by holders of MD. (medical doctor) or D.O, (Doctor of Osteopathic Medicine) degrees and by their allied health professionals such as physical therapists, psychologists, and registered murscs. Over the past several years, the use of CAM approaches, including yora, has become more popular. ‘According <0 the 2007 National Health Interview Survey, ‘which gathered information on CAM use among more than, 9000 children aged 17 and under, nearly 12% of the children bad used some form of CAM during the past 12 months. The top five most commonly used forms of CAM therapy included natural products, chiropractic and osteopathy, yoga, and homeopathic teatments, Msjncmer and colleagues" reported ‘hat 25% ofthe 166 adolescents with CP surveyed in their study currently use of bad used some form of CAM. The most Popular of these was massage. Some occupational therapy, practitioners with taining in these methods of advance certi- cations may ase CAM to help childeen with CP engage in leisure activities to improve overall quality of life, Ultimately ‘occupational therapists are responsible for the safety of their patients and use their clinical judgment and the best available cvidence to determine use of these intervention techniques to complement service delivery,’ Complementary and alternative medicine approaches commonly used by occupational thera- pists include guided imagery, myofascial release, yogs, and seditation.” Robotics and Commercially Available Gaming Systems Robotics is an emerging technology to enhance motor and cognitive performance in children diagnosed with CP. These devices typically employ robotic arms, joysticks, oF otler con- twollers to measure the patieat's performance on the targeted movement. Early studies demonstrate that children using robotic devices in therapy sessions aze motivated and make postive gains *** Rehabilivasion roborcs i the use of robotic vices to restore oF improve function for a person with a dis- ably. Robotics can be part of prosthetic, used as an asitive device for some functional sk, or used therspeuticaly to achieve a high level of repetition of movement patterns. Thera- pesttic robotics may be used to achieve massed practice during ‘therapy program, Because most devices have settings that progress and challenge movement patterns and strength, the ‘occupational therapist can sslect the level of challenge most appropriate for the child Robotic devices range from large stationary devices with both gross and fine motor components to glove-based systems with small sensors (see Figures 28.6 and 28-7 for examples of different devices). Most robotic devices are connected to a computer so that the child can receive feedback from the game graphics on a screen of monitor (see Figure 28-6). Figure 28-7A.C, Examples of adaptive cuff and Coban grip adaptation on commercially available gaming technology. (Photo courtesy of Kennedy Krieger Institute.) ie ‘A, Armeo® Spring Exoskeleton with integrated spring mechanism. (Photo A courtesy of Hocoma, Ag, Volketswil, Switzerland) B-D, Handtutor™ by Medi- touch. (Photo courtesy of Meditouch, Netanya, irael_)808 section IV _ Areas of Pediatric Occupational Therapy Services (+ eee Aiden is a 7-year-old boy with diplegic cerebral palsy. He walks with Loftrand crutches and is working on simple snack taking and lower body dressing siting on the ede of hs be ‘His family has a Wii gaming system at home, Although he hs some trouble Keeping up with bis brother ding oxtdoor play, they are evenly matched when playing thee panes at home. His occupational therapist develops adaptations to the Wit and makes it part of his home exercise program, With these adaptations, the Wii oflers Aiden a recreational activity ‘hat also promotes arm and hand coordination and strength (ee Figure 28-7), Chloe is a 10-year-old giel with spastic quadriplegic cerebral palsy and cognitive delay, Chloe has limited finger exten- fon and significant wnst flexion contracture, Her mother reported that she recently had difficulty thoroughly washing Chloe's hands, especially her left palm, A stretching home program was trialed for 6 weeks with no changes in Chloe's functional ability to open her hand. After discussing interven- tion options with the physiatrist and occupational therapist, Chloe's mother agreed to botwinum neurotoxin injections to Chloe's thenat eminence and wrist flexors in conjunction (+ ae) with serial splinting for 2 hours during the day and all ni splint wear for the next 12 weeks, Two weeks afer the injec- tion her mother noticed a significant change in the muscle tone of her left hand, Her hand wae more relaxed, making it easier for her mother to open her and for hygiene casks and to don her splints. In addition to splinting, the ther apist recommended activities to encourage hand opening, sich a movement to songs that required hand opening, releasing a ball into a container, and tossing a ball to her service dog, shows adaptations that allow children with limited hand fune- tion to use a robot arm or access gaming technology. Research fon the effectiveness of robotics for children with CP is limited. ‘One ssudy reported that use of robotic tesining with children with hemiplegia demonstrated improved range of motion and coordination of the upper limb.” Gaming technology refers to the use of commercially avail able video game systems in the clinical environment in ways shat are integrated with planned therapy. In recent years, 2 umber of gaming devices that require gross motor activity to successfully operate have become commercially available and ate quickly being incorporated into clinical rehabilitation pro- grams. Research on use of these devices in rehabilitation is limited to case reports. In one report, an adolescent with spastic diplegin showed positive changes in mobility, postural contxol, and visual perception after using the Nintendo Wi for 11 ses sions (see Case Study 28-7) ‘Use of robotics and gaming technology showld be selected with caution, When choosing a device or gaming system, 30 ‘occupational therapist considers multiple factors. The child's age and cognitive ability suggest his or her capacity 0 follow shrections and play games astociated with the device. The size of the child’s arm and hand may prohibit his or her use of a robotic device that was created for adult tse, Baseline level of ‘motor function helps determine the level of additional support tr adaptations a device may requite for the participant to hold she device. Vieal perceptual capacities may pose a challenge oF add additional frustration to game play. Games with high con- trast or solid backgrounds may be easier for the child (0 se. During intervention, occupational therapists monitor for com- ppensatory movements that could cause repetitive use injuries sind provide breaks at regular intervals. The occupational thers- pit is responsible for monitoring mule fatigue snd providing the appropriate challenge based on the child's performance. Robotics, virual reality, and commercially available gaming systems may complement an occupational therapy plan of care because they motivate the child and provide additional oppor- tunities for masied practice Medical Based Interventions Physicians may prescribe pharmaceutics, recommend surgeris, ‘or apply specific medical interventions for childgen and youth ‘with CP. Medical interventions are often used in conjunction, ‘wath occupational therapy to maximize the effect. Children, ‘with spasticity may benefit from medications that reduce muscle tone, Baclofen is a medication that may be dosed orally of injected into a pump that delivers the medication diectly into the cerebrospinal fad, Baclofen reduces muscle tone through- lout the person's body, Botulinum neurotoxin, commonly called Botox, is a more specific approach to reducing tone, with injections delivered shrectly to a epastic muscle, ‘The injection of the toxin causes paralysis of the sargeted muscle by blocking. acetylcholine release, which is necessary for muscle activation and contrac- tion. Botulinum injections typically take a week to demon- strate an effect that lasts for 3 to 4 months." A child is rcstricted in the number of injections he or she can seccive each year, Risks include the medication “bleeding” into other muscle groups, especially ia ateas ike the band and thumb in which children’s muscle bellies ate small, Injections can be paired with serial casting or splinting to maximize gains in range of motion. Evidence for the use ofthese injections is limited, and, as with ‘any’ interventions, this technique is often paired with other reclniques, making it difficult to eonchade thatthe treatment effect is only from the injections (Case Srady 28-8) Over time and with growth, children with moderate to severe spasticity may eaperieace increasing muscle and tendon tightness, contractures, joint dislocation (particularly ac hips), and other joint problems. Orthopedic surgeries can help ¢0 ameliorate these issues when more conservatave treatment such se eplinting ie not cfcctive. Surgerice include tendon transfers,