Management Approaches for Spasticity in Children with Cerebral Palsy

A Critical Analysis

Dr Amitesh Narayan MPT PhD

Professor in Physiotherapy

Neuro-Sensory Developmental Unit

Department of Physiotherapy

Kasturba Medical College Mangalore

Can We Identify

the Diagnostic

Differences in

These Two

Children

POLIO CEREBRAL PALSY

POLIOMYELITIS Success of Salk amp Sabin vaccine

POLIO - disappeared as major cause disability

and so

Entire resources (manpower and finances) directed for other clients with neurophysiologic disorders ie

Cerebral Palsy etc

This led to-

Physicians and therapists started treating Cerebral Palsy from an ORTHOPEDISTS

PERSPECTIVE with surgery bracing and muscle re-education

So the Question arises are

bull Can the treatment concept will be same when etiologies has the differences

Poliomyelitis where

Anterior Horn Cells

are the site of the

lesions

Cerebral Palsy-

Where pathologies

lies in the Central

Nervous System

Abnormal Posturing in 2 Different Neonates of same age

High Risk Neonate20 Days Old

Abnormal Posturing

Normal Child24 days Old

Postural symmetryAre they Spastic

What You Think of These Neonates

Do they Develop the Muscle Tightness as a result of

SPASTICITY

in their neonatal Age ONLY

To Understand the effect of Spasticity on Skeletal

Muscles of UL LL and Trunk

We must understand about the

Transmission of Musculoskeletal Forces in active Typically developing

or a child with CEREBRAL PALSYTypically Developing Child

Child with Cerebral Palsy

Forces generated during CONTRACTION OR PASSIVE ELONGATION are

predominantly transmitted

a to bones via tendons and aponeuroses (MYOTENDINOUS PATHWAY) and

b through surrounding CONNECTIVE TISSUES (MYOFASCIAL PATHWAY)

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

Can We Identify

the Diagnostic

Differences in

These Two

Children

POLIO CEREBRAL PALSY

POLIOMYELITIS Success of Salk amp Sabin vaccine

POLIO - disappeared as major cause disability

and so

Entire resources (manpower and finances) directed for other clients with neurophysiologic disorders ie

Cerebral Palsy etc

This led to-

Physicians and therapists started treating Cerebral Palsy from an ORTHOPEDISTS

PERSPECTIVE with surgery bracing and muscle re-education

So the Question arises are

bull Can the treatment concept will be same when etiologies has the differences

Poliomyelitis where

Anterior Horn Cells

are the site of the

lesions

Cerebral Palsy-

Where pathologies

lies in the Central

Nervous System

Abnormal Posturing in 2 Different Neonates of same age

High Risk Neonate20 Days Old

Abnormal Posturing

Normal Child24 days Old

Postural symmetryAre they Spastic

What You Think of These Neonates

Do they Develop the Muscle Tightness as a result of

SPASTICITY

in their neonatal Age ONLY

To Understand the effect of Spasticity on Skeletal

Muscles of UL LL and Trunk

We must understand about the

Transmission of Musculoskeletal Forces in active Typically developing

or a child with CEREBRAL PALSYTypically Developing Child

Child with Cerebral Palsy

Forces generated during CONTRACTION OR PASSIVE ELONGATION are

predominantly transmitted

a to bones via tendons and aponeuroses (MYOTENDINOUS PATHWAY) and

b through surrounding CONNECTIVE TISSUES (MYOFASCIAL PATHWAY)

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

POLIOMYELITIS Success of Salk amp Sabin vaccine

POLIO - disappeared as major cause disability

and so

Entire resources (manpower and finances) directed for other clients with neurophysiologic disorders ie

Cerebral Palsy etc

This led to-

Physicians and therapists started treating Cerebral Palsy from an ORTHOPEDISTS

PERSPECTIVE with surgery bracing and muscle re-education

So the Question arises are

bull Can the treatment concept will be same when etiologies has the differences

Poliomyelitis where

Anterior Horn Cells

are the site of the

lesions

Cerebral Palsy-

Where pathologies

lies in the Central

Nervous System

Abnormal Posturing in 2 Different Neonates of same age

High Risk Neonate20 Days Old

Abnormal Posturing

Normal Child24 days Old

Postural symmetryAre they Spastic

What You Think of These Neonates

Do they Develop the Muscle Tightness as a result of

SPASTICITY

in their neonatal Age ONLY

To Understand the effect of Spasticity on Skeletal

Muscles of UL LL and Trunk

We must understand about the

Transmission of Musculoskeletal Forces in active Typically developing

or a child with CEREBRAL PALSYTypically Developing Child

Child with Cerebral Palsy

Forces generated during CONTRACTION OR PASSIVE ELONGATION are

predominantly transmitted

a to bones via tendons and aponeuroses (MYOTENDINOUS PATHWAY) and

b through surrounding CONNECTIVE TISSUES (MYOFASCIAL PATHWAY)

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

So the Question arises are

bull Can the treatment concept will be same when etiologies has the differences

Poliomyelitis where

Anterior Horn Cells

are the site of the

lesions

Cerebral Palsy-

Where pathologies

lies in the Central

Nervous System

Abnormal Posturing in 2 Different Neonates of same age

High Risk Neonate20 Days Old

Abnormal Posturing

Normal Child24 days Old

Postural symmetryAre they Spastic

What You Think of These Neonates

Do they Develop the Muscle Tightness as a result of

SPASTICITY

in their neonatal Age ONLY

To Understand the effect of Spasticity on Skeletal

Muscles of UL LL and Trunk

We must understand about the

Transmission of Musculoskeletal Forces in active Typically developing

or a child with CEREBRAL PALSYTypically Developing Child

Child with Cerebral Palsy

Forces generated during CONTRACTION OR PASSIVE ELONGATION are

predominantly transmitted

a to bones via tendons and aponeuroses (MYOTENDINOUS PATHWAY) and

b through surrounding CONNECTIVE TISSUES (MYOFASCIAL PATHWAY)

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

Abnormal Posturing in 2 Different Neonates of same age

High Risk Neonate20 Days Old

Abnormal Posturing

Normal Child24 days Old

Postural symmetryAre they Spastic

What You Think of These Neonates

Do they Develop the Muscle Tightness as a result of

SPASTICITY

in their neonatal Age ONLY

To Understand the effect of Spasticity on Skeletal

Muscles of UL LL and Trunk

We must understand about the

Transmission of Musculoskeletal Forces in active Typically developing

or a child with CEREBRAL PALSYTypically Developing Child

Child with Cerebral Palsy

Forces generated during CONTRACTION OR PASSIVE ELONGATION are

predominantly transmitted

a to bones via tendons and aponeuroses (MYOTENDINOUS PATHWAY) and

b through surrounding CONNECTIVE TISSUES (MYOFASCIAL PATHWAY)

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

What You Think of These Neonates

Do they Develop the Muscle Tightness as a result of

SPASTICITY

in their neonatal Age ONLY

To Understand the effect of Spasticity on Skeletal

Muscles of UL LL and Trunk

We must understand about the

Transmission of Musculoskeletal Forces in active Typically developing

or a child with CEREBRAL PALSYTypically Developing Child

Child with Cerebral Palsy

Forces generated during CONTRACTION OR PASSIVE ELONGATION are

predominantly transmitted

a to bones via tendons and aponeuroses (MYOTENDINOUS PATHWAY) and

b through surrounding CONNECTIVE TISSUES (MYOFASCIAL PATHWAY)

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

To Understand the effect of Spasticity on Skeletal

Muscles of UL LL and Trunk

We must understand about the

Transmission of Musculoskeletal Forces in active Typically developing

or a child with CEREBRAL PALSYTypically Developing Child

Child with Cerebral Palsy

Forces generated during CONTRACTION OR PASSIVE ELONGATION are

predominantly transmitted

a to bones via tendons and aponeuroses (MYOTENDINOUS PATHWAY) and

b through surrounding CONNECTIVE TISSUES (MYOFASCIAL PATHWAY)

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

We must understand about the

Transmission of Musculoskeletal Forces in active Typically developing

or a child with CEREBRAL PALSYTypically Developing Child

Child with Cerebral Palsy

Forces generated during CONTRACTION OR PASSIVE ELONGATION are

predominantly transmitted

a to bones via tendons and aponeuroses (MYOTENDINOUS PATHWAY) and

b through surrounding CONNECTIVE TISSUES (MYOFASCIAL PATHWAY)

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

Forces generated during CONTRACTION OR PASSIVE ELONGATION are

predominantly transmitted

a to bones via tendons and aponeuroses (MYOTENDINOUS PATHWAY) and

b through surrounding CONNECTIVE TISSUES (MYOFASCIAL PATHWAY)

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

SO

What Causes the Cascade of Changes in Muscles after

Neurological Insult

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

Cascade of Changes in Muscles after Neurological Insult

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

Changes in Muscle Forces and Joint Integrity

James R Gage Michael H Schwartz Steven E Koop Tom F Novacheck 2009 The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edition Clinics in developmental medicine no 180-181

These changes leads to Muscle Fiber Stiffness in Children with

Cerebral Palsy in which the role of

TITIN (Elastic component) Protein

is very Important

Any change in muscle fiber diameter

facilitates

Change in the number of TITIN Filaments that is ARRANGED IN PARALLEL Orientation

causes

Proportional change in ABSOLUTE PASSIVE STIFFNESS of the muscle fiber

Therefore Change in MUSCLE FIBER TYPE along with change in MUSCLE FIBER

SIZE in spastic muscles influences PASSIVE MUSCLE STIFFNESS

Magid amp Law 1985 Linke et al 1996

Do you know about the

Cellular Changes happens in Spastic Muscles

Cross Section of Muscle Fascicle of FCU

Pathological Signs- Presence of Central Nuclei

Thickness of Perimysium in Controls and CP

Skeletal Muscles Changes in Cerebral Palsy Children

Fewer muscle fibers

Shorter fiber length and

Longer tendon

This causes

Weak muscles due to reduced cross-sectional areas amp

Decreased excursion resulting in reduced ROM because of

short fiber lengths

Normal Muscle Spastic Muscle

Pathophysiology of Movement Disorder in

Cerebral Palsy Effect on Muscles Functioning

Release of Primitive and automatic movements

a +ve signs of CNS Dysfunction-

Abnormal Reflexive tone states and abnormal movements_ not seen inintact CNS functioning

b -ve signs of CNS Damage-

Result of direct damage to motor control areas of CNS_ causes loss ofmotor control functions

b -ve signs of CNS Damage- contd

Loss of co-contraction

Loss of reciprocal inhibition

Delayed termination of motor unit activity

Prolonged sustaining of firing of muscle activity (loss of ability to terminate this

activity)

Restricted ROM

Note many researchers find a more direct correlation of these ndashve signs of CNS dysfunction to the childrsquos skill level then +ve sign to the childrsquos

skill level

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Any change in muscle fiber diameter

facilitates

Change in the number of TITIN Filaments that is ARRANGED IN PARALLEL Orientation

causes

Proportional change in ABSOLUTE PASSIVE STIFFNESS of the muscle fiber

Therefore Change in MUSCLE FIBER TYPE along with change in MUSCLE FIBER

SIZE in spastic muscles influences PASSIVE MUSCLE STIFFNESS

Magid amp Law 1985 Linke et al 1996

Do you know about the

Cellular Changes happens in Spastic Muscles

Cross Section of Muscle Fascicle of FCU

Pathological Signs- Presence of Central Nuclei

Thickness of Perimysium in Controls and CP

Skeletal Muscles Changes in Cerebral Palsy Children

Fewer muscle fibers

Shorter fiber length and

Longer tendon

This causes

Weak muscles due to reduced cross-sectional areas amp

Decreased excursion resulting in reduced ROM because of

short fiber lengths

Normal Muscle Spastic Muscle

Pathophysiology of Movement Disorder in

Cerebral Palsy Effect on Muscles Functioning

Release of Primitive and automatic movements

a +ve signs of CNS Dysfunction-

Abnormal Reflexive tone states and abnormal movements_ not seen inintact CNS functioning

b -ve signs of CNS Damage-

Result of direct damage to motor control areas of CNS_ causes loss ofmotor control functions

b -ve signs of CNS Damage- contd

Loss of co-contraction

Loss of reciprocal inhibition

Delayed termination of motor unit activity

Prolonged sustaining of firing of muscle activity (loss of ability to terminate this

activity)

Restricted ROM

Note many researchers find a more direct correlation of these ndashve signs of CNS dysfunction to the childrsquos skill level then +ve sign to the childrsquos

skill level

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Do you know about the

Cellular Changes happens in Spastic Muscles

Cross Section of Muscle Fascicle of FCU

Pathological Signs- Presence of Central Nuclei

Thickness of Perimysium in Controls and CP

Skeletal Muscles Changes in Cerebral Palsy Children

Fewer muscle fibers

Shorter fiber length and

Longer tendon

This causes

Weak muscles due to reduced cross-sectional areas amp

Decreased excursion resulting in reduced ROM because of

short fiber lengths

Normal Muscle Spastic Muscle

Pathophysiology of Movement Disorder in

Cerebral Palsy Effect on Muscles Functioning

Release of Primitive and automatic movements

a +ve signs of CNS Dysfunction-

Abnormal Reflexive tone states and abnormal movements_ not seen inintact CNS functioning

b -ve signs of CNS Damage-

Result of direct damage to motor control areas of CNS_ causes loss ofmotor control functions

b -ve signs of CNS Damage- contd

Loss of co-contraction

Loss of reciprocal inhibition

Delayed termination of motor unit activity

Prolonged sustaining of firing of muscle activity (loss of ability to terminate this

activity)

Restricted ROM

Note many researchers find a more direct correlation of these ndashve signs of CNS dysfunction to the childrsquos skill level then +ve sign to the childrsquos

skill level

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Cross Section of Muscle Fascicle of FCU

Pathological Signs- Presence of Central Nuclei

Thickness of Perimysium in Controls and CP

Skeletal Muscles Changes in Cerebral Palsy Children

Fewer muscle fibers

Shorter fiber length and

Longer tendon

This causes

Weak muscles due to reduced cross-sectional areas amp

Decreased excursion resulting in reduced ROM because of

short fiber lengths

Normal Muscle Spastic Muscle

Pathophysiology of Movement Disorder in

Cerebral Palsy Effect on Muscles Functioning

Release of Primitive and automatic movements

a +ve signs of CNS Dysfunction-

Abnormal Reflexive tone states and abnormal movements_ not seen inintact CNS functioning

b -ve signs of CNS Damage-

Result of direct damage to motor control areas of CNS_ causes loss ofmotor control functions

b -ve signs of CNS Damage- contd

Loss of co-contraction

Loss of reciprocal inhibition

Delayed termination of motor unit activity

Prolonged sustaining of firing of muscle activity (loss of ability to terminate this

activity)

Restricted ROM

Note many researchers find a more direct correlation of these ndashve signs of CNS dysfunction to the childrsquos skill level then +ve sign to the childrsquos

skill level

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Thickness of Perimysium in Controls and CP

Skeletal Muscles Changes in Cerebral Palsy Children

Fewer muscle fibers

Shorter fiber length and

Longer tendon

This causes

Weak muscles due to reduced cross-sectional areas amp

Decreased excursion resulting in reduced ROM because of

short fiber lengths

Normal Muscle Spastic Muscle

Pathophysiology of Movement Disorder in

Cerebral Palsy Effect on Muscles Functioning

Release of Primitive and automatic movements

a +ve signs of CNS Dysfunction-

Abnormal Reflexive tone states and abnormal movements_ not seen inintact CNS functioning

b -ve signs of CNS Damage-

Result of direct damage to motor control areas of CNS_ causes loss ofmotor control functions

b -ve signs of CNS Damage- contd

Loss of co-contraction

Loss of reciprocal inhibition

Delayed termination of motor unit activity

Prolonged sustaining of firing of muscle activity (loss of ability to terminate this

activity)

Restricted ROM

Note many researchers find a more direct correlation of these ndashve signs of CNS dysfunction to the childrsquos skill level then +ve sign to the childrsquos

skill level

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Skeletal Muscles Changes in Cerebral Palsy Children

Fewer muscle fibers

Shorter fiber length and

Longer tendon

This causes

Weak muscles due to reduced cross-sectional areas amp

Decreased excursion resulting in reduced ROM because of

short fiber lengths

Normal Muscle Spastic Muscle

Pathophysiology of Movement Disorder in

Cerebral Palsy Effect on Muscles Functioning

Release of Primitive and automatic movements

a +ve signs of CNS Dysfunction-

Abnormal Reflexive tone states and abnormal movements_ not seen inintact CNS functioning

b -ve signs of CNS Damage-

Result of direct damage to motor control areas of CNS_ causes loss ofmotor control functions

b -ve signs of CNS Damage- contd

Loss of co-contraction

Loss of reciprocal inhibition

Delayed termination of motor unit activity

Prolonged sustaining of firing of muscle activity (loss of ability to terminate this

activity)

Restricted ROM

Note many researchers find a more direct correlation of these ndashve signs of CNS dysfunction to the childrsquos skill level then +ve sign to the childrsquos

skill level

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Pathophysiology of Movement Disorder in

Cerebral Palsy Effect on Muscles Functioning

Release of Primitive and automatic movements

a +ve signs of CNS Dysfunction-

Abnormal Reflexive tone states and abnormal movements_ not seen inintact CNS functioning

b -ve signs of CNS Damage-

Result of direct damage to motor control areas of CNS_ causes loss ofmotor control functions

b -ve signs of CNS Damage- contd

Loss of co-contraction

Loss of reciprocal inhibition

Delayed termination of motor unit activity

Prolonged sustaining of firing of muscle activity (loss of ability to terminate this

activity)

Restricted ROM

Note many researchers find a more direct correlation of these ndashve signs of CNS dysfunction to the childrsquos skill level then +ve sign to the childrsquos

skill level

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Release of Primitive and automatic movements

a +ve signs of CNS Dysfunction-

Abnormal Reflexive tone states and abnormal movements_ not seen inintact CNS functioning

b -ve signs of CNS Damage-

Result of direct damage to motor control areas of CNS_ causes loss ofmotor control functions

b -ve signs of CNS Damage- contd

Loss of co-contraction

Loss of reciprocal inhibition

Delayed termination of motor unit activity

Prolonged sustaining of firing of muscle activity (loss of ability to terminate this

activity)

Restricted ROM

Note many researchers find a more direct correlation of these ndashve signs of CNS dysfunction to the childrsquos skill level then +ve sign to the childrsquos

skill level

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

b -ve signs of CNS Damage- contd

Loss of co-contraction

Loss of reciprocal inhibition

Delayed termination of motor unit activity

Prolonged sustaining of firing of muscle activity (loss of ability to terminate this

activity)

Restricted ROM

Note many researchers find a more direct correlation of these ndashve signs of CNS dysfunction to the childrsquos skill level then +ve sign to the childrsquos

skill level

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

If Typically Developing children- sarcomeres are stretched maximal force production will increase whereas Opposite happens in CP- sarcomeres Muscles represented include Gracilis Semitendinosus

Soleus and FCU

Mathewson MA et al submitted and Lieber RL Frideacuten J Spasticity causes a fundamental rearrangement of muscle-joint interaction Muscle Nerve 200225(2)265ndash70 and Smith LR Lee KS Ward SR et al Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length J Physiol2011589(10)2625ndash39

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Does Musculoskeletal Operations in Children

with CP helps to Gain Motor Control and

Functional Changes successfully

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

3D ultrasound images and segmentation of muscle volume of a child with Spastic

Paresis Pre and 12 MONTHS POST- MEDIAL HAMSTRING (ST) LENGTHENING

Distal CompartmentProximal Compartment

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Findings of 3D ultrasound images Post 12 MONTHS of

MEDIAL HAMSTRING (ST) LENGTHENING in Spastic CP

bull After surgery this child showed

a Reduction of muscle volume by 26

b Decreased muscle belly length by 32 and

c Increase in tendon length by 62 bull Ref Haberfehlner H Jaspers RT Rutz E Harlaar J van der Sluijs JA Witbreuk MM et al (2018) Outcome of medial hamstring lengthening in children with

spastic paresis A biomechanical and morphological observational study PLoS ONE 13(2) e0192573 httpsdoiorg101371journalpone0192573

Impact on Muscles in CP Children following Musculoskeletal Surgeries

Reduction in Number of Sarcomeres

Muscles Wasting

Altered Sequences and Abnormal Pattern of Muscles Firing during Functional Activities

Impacting the Functional Status of a Growing Child with CP

Hence the Innovative therapeutic strategies are the

KEY for the success in

SPASTIC MUSCLES OF CHILDREN WITH CP

Focus for the Therapeutic Strategies in Children with Spasticity

1 Trunk ROM and ExtensionFlexion Rotation

Control

2 Eccentric Muscles Facilitation

Importance of Trunk Control

bull Trunk represents-over half of the body mass and has major role in bodyrsquos overall

postural control

bull In-spite of this clinical assessment and research (compared to limb movements)

on trunk is largely been ignored

bull Many clinical tests that are appropriate for assessing the extremities ie ROM

Proprioceptive testing are inappropriate when applied to trunk

Importance of Trunk Control

NEGLECT OF TRUNK

may result in misinterpretation of problems seen in UE or LE

because trunk serves as the center of control for distal movements

Trunk Control- Anatomical and Functional Significance

bull All normal Functional Activities- Depends on Trunk Control as basis of Movement

bull UE- Attached to trunk by Sternoclavicular Joint by muscles and other Soft Tissues

bull LE- Attached to trunk by Hip and Pelvic Bones

bull Posture of Trunk and Pelvic- Influences position of scapula and Clavicle which in

turn has direct muscular and biomechanical effects on all movements of UE

Trunk Control- Relation with Neck Holding

bull Similarly Inability to hold the head in midline- is a major concern in

Neurological cases

bull Inability to hold the neck in Midline- May result in retention of

STARTLE RESPONSE LONGER

bull Insufficient trunk and Neck control- affects the bodyrsquos ability to

maintain it upright against the gravity- causing child to use UE to

PROP when placed in sitting ndash making child to get stuck as they are

unable to move in or out of that position due to fear of fall

Trunk Control- Normal control in any parts ndash demands the ability to dissociate different parts of the body

bull UT- From T7 and above

bull LT- From T8 and down

eg While UT is rotating LT and Pelvis may

be laterally Flexing The point of dynamic

stability for this dissociation is T7-T8

Trunk Control- An individual must experience movement and control at higher developmental levels against gravity prior to

achieving full balance control at lower developmental level

bull When child come up against the gravity he

doesnrsquot develop balance reactions at one level

unless he is put in situations in which balance

reactions at higher levels against gravity is

required

bull At each level he needs to be working on

something higher in balance to gain full balance

control at lower level against gravity

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Hence the Innovative therapeutic strategies are the

KEY for the success in

SPASTIC MUSCLES OF CHILDREN WITH CP

Focus for the Therapeutic Strategies in Children with Spasticity

1 Trunk ROM and ExtensionFlexion Rotation

Control

2 Eccentric Muscles Facilitation

Importance of Trunk Control

bull Trunk represents-over half of the body mass and has major role in bodyrsquos overall

postural control

bull In-spite of this clinical assessment and research (compared to limb movements)

on trunk is largely been ignored

bull Many clinical tests that are appropriate for assessing the extremities ie ROM

Proprioceptive testing are inappropriate when applied to trunk

Importance of Trunk Control

NEGLECT OF TRUNK

may result in misinterpretation of problems seen in UE or LE

because trunk serves as the center of control for distal movements

Trunk Control- Anatomical and Functional Significance

bull All normal Functional Activities- Depends on Trunk Control as basis of Movement

bull UE- Attached to trunk by Sternoclavicular Joint by muscles and other Soft Tissues

bull LE- Attached to trunk by Hip and Pelvic Bones

bull Posture of Trunk and Pelvic- Influences position of scapula and Clavicle which in

turn has direct muscular and biomechanical effects on all movements of UE

Trunk Control- Relation with Neck Holding

bull Similarly Inability to hold the head in midline- is a major concern in

Neurological cases

bull Inability to hold the neck in Midline- May result in retention of

STARTLE RESPONSE LONGER

bull Insufficient trunk and Neck control- affects the bodyrsquos ability to

maintain it upright against the gravity- causing child to use UE to

PROP when placed in sitting ndash making child to get stuck as they are

unable to move in or out of that position due to fear of fall

Trunk Control- Normal control in any parts ndash demands the ability to dissociate different parts of the body

bull UT- From T7 and above

bull LT- From T8 and down

eg While UT is rotating LT and Pelvis may

be laterally Flexing The point of dynamic

stability for this dissociation is T7-T8

Trunk Control- An individual must experience movement and control at higher developmental levels against gravity prior to

achieving full balance control at lower developmental level

bull When child come up against the gravity he

doesnrsquot develop balance reactions at one level

unless he is put in situations in which balance

reactions at higher levels against gravity is

required

bull At each level he needs to be working on

something higher in balance to gain full balance

control at lower level against gravity

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Focus for the Therapeutic Strategies in Children with Spasticity

1 Trunk ROM and ExtensionFlexion Rotation

Control

2 Eccentric Muscles Facilitation

Importance of Trunk Control

bull Trunk represents-over half of the body mass and has major role in bodyrsquos overall

postural control

bull In-spite of this clinical assessment and research (compared to limb movements)

on trunk is largely been ignored

bull Many clinical tests that are appropriate for assessing the extremities ie ROM

Proprioceptive testing are inappropriate when applied to trunk

Importance of Trunk Control

NEGLECT OF TRUNK

may result in misinterpretation of problems seen in UE or LE

because trunk serves as the center of control for distal movements

Trunk Control- Anatomical and Functional Significance

bull All normal Functional Activities- Depends on Trunk Control as basis of Movement

bull UE- Attached to trunk by Sternoclavicular Joint by muscles and other Soft Tissues

bull LE- Attached to trunk by Hip and Pelvic Bones

bull Posture of Trunk and Pelvic- Influences position of scapula and Clavicle which in

turn has direct muscular and biomechanical effects on all movements of UE

Trunk Control- Relation with Neck Holding

bull Similarly Inability to hold the head in midline- is a major concern in

Neurological cases

bull Inability to hold the neck in Midline- May result in retention of

STARTLE RESPONSE LONGER

bull Insufficient trunk and Neck control- affects the bodyrsquos ability to

maintain it upright against the gravity- causing child to use UE to

PROP when placed in sitting ndash making child to get stuck as they are

unable to move in or out of that position due to fear of fall

Trunk Control- Normal control in any parts ndash demands the ability to dissociate different parts of the body

bull UT- From T7 and above

bull LT- From T8 and down

eg While UT is rotating LT and Pelvis may

be laterally Flexing The point of dynamic

stability for this dissociation is T7-T8

Trunk Control- An individual must experience movement and control at higher developmental levels against gravity prior to

achieving full balance control at lower developmental level

bull When child come up against the gravity he

doesnrsquot develop balance reactions at one level

unless he is put in situations in which balance

reactions at higher levels against gravity is

required

bull At each level he needs to be working on

something higher in balance to gain full balance

control at lower level against gravity

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Importance of Trunk Control

bull Trunk represents-over half of the body mass and has major role in bodyrsquos overall

postural control

bull In-spite of this clinical assessment and research (compared to limb movements)

on trunk is largely been ignored

bull Many clinical tests that are appropriate for assessing the extremities ie ROM

Proprioceptive testing are inappropriate when applied to trunk

Importance of Trunk Control

NEGLECT OF TRUNK

may result in misinterpretation of problems seen in UE or LE

because trunk serves as the center of control for distal movements

Trunk Control- Anatomical and Functional Significance

bull All normal Functional Activities- Depends on Trunk Control as basis of Movement

bull UE- Attached to trunk by Sternoclavicular Joint by muscles and other Soft Tissues

bull LE- Attached to trunk by Hip and Pelvic Bones

bull Posture of Trunk and Pelvic- Influences position of scapula and Clavicle which in

turn has direct muscular and biomechanical effects on all movements of UE

Trunk Control- Relation with Neck Holding

bull Similarly Inability to hold the head in midline- is a major concern in

Neurological cases

bull Inability to hold the neck in Midline- May result in retention of

STARTLE RESPONSE LONGER

bull Insufficient trunk and Neck control- affects the bodyrsquos ability to

maintain it upright against the gravity- causing child to use UE to

PROP when placed in sitting ndash making child to get stuck as they are

unable to move in or out of that position due to fear of fall

Trunk Control- Normal control in any parts ndash demands the ability to dissociate different parts of the body

bull UT- From T7 and above

bull LT- From T8 and down

eg While UT is rotating LT and Pelvis may

be laterally Flexing The point of dynamic

stability for this dissociation is T7-T8

Trunk Control- An individual must experience movement and control at higher developmental levels against gravity prior to

achieving full balance control at lower developmental level

bull When child come up against the gravity he

doesnrsquot develop balance reactions at one level

unless he is put in situations in which balance

reactions at higher levels against gravity is

required

bull At each level he needs to be working on

something higher in balance to gain full balance

control at lower level against gravity

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Importance of Trunk Control

NEGLECT OF TRUNK

may result in misinterpretation of problems seen in UE or LE

because trunk serves as the center of control for distal movements

Trunk Control- Anatomical and Functional Significance

bull All normal Functional Activities- Depends on Trunk Control as basis of Movement

bull UE- Attached to trunk by Sternoclavicular Joint by muscles and other Soft Tissues

bull LE- Attached to trunk by Hip and Pelvic Bones

bull Posture of Trunk and Pelvic- Influences position of scapula and Clavicle which in

turn has direct muscular and biomechanical effects on all movements of UE

Trunk Control- Relation with Neck Holding

bull Similarly Inability to hold the head in midline- is a major concern in

Neurological cases

bull Inability to hold the neck in Midline- May result in retention of

STARTLE RESPONSE LONGER

bull Insufficient trunk and Neck control- affects the bodyrsquos ability to

maintain it upright against the gravity- causing child to use UE to

PROP when placed in sitting ndash making child to get stuck as they are

unable to move in or out of that position due to fear of fall

Trunk Control- Normal control in any parts ndash demands the ability to dissociate different parts of the body

bull UT- From T7 and above

bull LT- From T8 and down

eg While UT is rotating LT and Pelvis may

be laterally Flexing The point of dynamic

stability for this dissociation is T7-T8

Trunk Control- An individual must experience movement and control at higher developmental levels against gravity prior to

achieving full balance control at lower developmental level

bull When child come up against the gravity he

doesnrsquot develop balance reactions at one level

unless he is put in situations in which balance

reactions at higher levels against gravity is

required

bull At each level he needs to be working on

something higher in balance to gain full balance

control at lower level against gravity

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control- Anatomical and Functional Significance

bull All normal Functional Activities- Depends on Trunk Control as basis of Movement

bull UE- Attached to trunk by Sternoclavicular Joint by muscles and other Soft Tissues

bull LE- Attached to trunk by Hip and Pelvic Bones

bull Posture of Trunk and Pelvic- Influences position of scapula and Clavicle which in

turn has direct muscular and biomechanical effects on all movements of UE

Trunk Control- Relation with Neck Holding

bull Similarly Inability to hold the head in midline- is a major concern in

Neurological cases

bull Inability to hold the neck in Midline- May result in retention of

STARTLE RESPONSE LONGER

bull Insufficient trunk and Neck control- affects the bodyrsquos ability to

maintain it upright against the gravity- causing child to use UE to

PROP when placed in sitting ndash making child to get stuck as they are

unable to move in or out of that position due to fear of fall

Trunk Control- Normal control in any parts ndash demands the ability to dissociate different parts of the body

bull UT- From T7 and above

bull LT- From T8 and down

eg While UT is rotating LT and Pelvis may

be laterally Flexing The point of dynamic

stability for this dissociation is T7-T8

Trunk Control- An individual must experience movement and control at higher developmental levels against gravity prior to

achieving full balance control at lower developmental level

bull When child come up against the gravity he

doesnrsquot develop balance reactions at one level

unless he is put in situations in which balance

reactions at higher levels against gravity is

required

bull At each level he needs to be working on

something higher in balance to gain full balance

control at lower level against gravity

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control- Relation with Neck Holding

bull Similarly Inability to hold the head in midline- is a major concern in

Neurological cases

bull Inability to hold the neck in Midline- May result in retention of

STARTLE RESPONSE LONGER

bull Insufficient trunk and Neck control- affects the bodyrsquos ability to

maintain it upright against the gravity- causing child to use UE to

PROP when placed in sitting ndash making child to get stuck as they are

unable to move in or out of that position due to fear of fall

Trunk Control- Normal control in any parts ndash demands the ability to dissociate different parts of the body

bull UT- From T7 and above

bull LT- From T8 and down

eg While UT is rotating LT and Pelvis may

be laterally Flexing The point of dynamic

stability for this dissociation is T7-T8

Trunk Control- An individual must experience movement and control at higher developmental levels against gravity prior to

achieving full balance control at lower developmental level

bull When child come up against the gravity he

doesnrsquot develop balance reactions at one level

unless he is put in situations in which balance

reactions at higher levels against gravity is

required

bull At each level he needs to be working on

something higher in balance to gain full balance

control at lower level against gravity

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control- Normal control in any parts ndash demands the ability to dissociate different parts of the body

bull UT- From T7 and above

bull LT- From T8 and down

eg While UT is rotating LT and Pelvis may

be laterally Flexing The point of dynamic

stability for this dissociation is T7-T8

Trunk Control- An individual must experience movement and control at higher developmental levels against gravity prior to

achieving full balance control at lower developmental level

bull When child come up against the gravity he

doesnrsquot develop balance reactions at one level

unless he is put in situations in which balance

reactions at higher levels against gravity is

required

bull At each level he needs to be working on

something higher in balance to gain full balance

control at lower level against gravity

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control- An individual must experience movement and control at higher developmental levels against gravity prior to

achieving full balance control at lower developmental level

bull When child come up against the gravity he

doesnrsquot develop balance reactions at one level

unless he is put in situations in which balance

reactions at higher levels against gravity is

required

bull At each level he needs to be working on

something higher in balance to gain full balance

control at lower level against gravity

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control- Midline control is not COMPLETE without some ability to rotate

bull When the infant is gaining midline control in the

entire trunk he would have already started

working on his control in lateral and rotational

movements

EG While sitting and using hands in midline at 7

months he is already using components gained

earlier when pivoting in prone with lateral flexion

and rolling with rotation

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability

and points of control

Normal Ranges of Trunk Motion

Flexion Extension Lateral Flexion Rotation

Cervical 40 0 750 350 - 450 450 - 500

Thoracic 1050 600 200 350

Lumbar 200 50

Entire Spine 1450 1400 750 - 850 900

Source Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of controlbull Dynamic Stability

eg When a child is sitting and reaching forward for an object with his Right

hand the movement initiates at the hand and the head and UT As he

reaches forward the COG shifts and the trunk needs to counterbalance

the movement to prevent falling The reaching on the RIGHT is controlled

therefore by lateral flexion and extension on the LEFT side

If this doesnrsquot happen the child would fall in the direction towards which

he reached (RIGHT side)

Hence free function in UE and LE depends on dynamic stability within

the trunk

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control- Good postural control of trunk includes need for normal range dynamic stability and points of control

bull Points of Control Movement Initiation

Trunk flexion happens when we move down and

forward Following the initial flexion movement the

trunk extensors fire in order to grade the movement in

flexion

Most UE based functional tasks involve initiation of the

movement in hand often with UT initiating the weight shift

For the functional tasks involving gross motor skills the

initiation of weight shift occurs in the LT and Pelvis

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Areas to be Looked for in Spine Examination

bull Lateral curvature of spine

bull Truncal asymmetry

bull Uneven shoulders

bull Prominent scapula ndash uneven height

bull Rib-hump

bull uneven hips

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Pediatric Spine Examination Technique

Examination Position

1Sitting

2Standing

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Pediatric Spine Examination Techniquein Sitting

1 On Bench or

2 On Bolster

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Assessment in Children for PTObservation and Assessment of

bull Highest functional level without assistance and with assistance

bull Overall tone distribution UT Vs LT

bull Abnormal Patterns of Movement (Lack of Dissociation)

bull Information what Therapist feel under hand

bull Alignment ROM and Asymmetries

bull Balance Reactions

bull Sensation and Perception

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Assessment in Children for PT

Analysis of

bull Asymmetry of Function

bull Immobility

bull Consistent abnormal pattern of Movement

bull Influence of Tone on above factors

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Assessment in Children for PT

Summary of

bull How the above findings related to the quality of function

bull Treatment plan to achieve goal related to function

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Consistent abnormal pattern of Movement

bull Beginning with Initiation of Weight shifts- Trunk

bull Specific Movement in Trunk eg Lateral rotation and Where

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Lets Look at some of Therapeutic Strategies to

develop Eccentric Control in Trunk UL and LL

muscles for the inhibition of Spasticity and

development of active Control in Children with CP

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Spine Rotation on Bolster

Correcting the Flexion posture of

spine and as extension develops

slowly bring rotation in spine and

then using forward righting

develop active control in spine

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Spastic Triplegic CP

Extension Control with

Hip Adductor and Flexor

Inhibition while using

Forward Righting on

Therapy Ball

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Spastic Triplegic CP

Extension Rotation

with Eccentric

activation of LL

muscles

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Spastic Triplegic CP

Extension Rotation Control

with Eccentric Activation of LL

muscles while child is actively

using UL for Righting bringing

Symmetry in UL

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Change in Functional

alignment in Spastic Triplegic

CP using Bilateral Elbow

Crutches for Independent

Standing

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Spastic Triplegic CP

Using Both Hands for

Opening the Wrapper

while seated

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Self Initiated Eccentric

Activation of Iliopsoas

Hanstrings and Plantar

Flexors with Trunk

Control and UL Righting

on Physioroll

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control on Ball with Inhibition of Extension Thrust in LL

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Trunk Control with Inhibition of Knee Flexion Thrust

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Hip Extension Facilitation

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Effect of Corrective Anti-spastic Therapeutic Strategy on Body Posture in Spastic Quadriplegic CP

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Thank You

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

Any Questionshelliphellip

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009

References1 Mohr JD Management of the Trunk in Adult Hemiplegia The Bobath Concept Topics in Neurology- Lession-1 APTA Education dept 1990 APTA

2 Kapandji I The Physiology of Joints- The trunk and the Vertebral Column New York Churchill Livingstone 1974

3 Boehme R (1988) Improving upper body control An approach to assessment and treatment of tonal dysfunction Tucson AZ Therapy Skill

Builder

4 Howle JM (2004) Neuro-develompmental treatment approach Theoretical foundations and principles of clinical practice Laguna Beach CA

NDTA

5 Schoen S amp Anderson J (1993) Neurodevelopmental treatment frame of reference (pp 74- 86 pp 49- 69) In P Kramer amp J Hinojosa (Eds)

Frames of Reference for Pediatric Occupational Therapy Baltimore MD Williams amp Wilkins

6 Clinical gait analysis by Nicky Thompson Elsevier Limited copy 2007 Elsevier Ltd

7 J G Becher Pediatric Rehabilitation in Children with Cerebral Palsy General Management Classification of Motor Disorders American Academy

of Orthotists and Prosthetists 142002143-149

8 Horstmann HM Bleck EE Orthopedic Management in Cerebral Palsy 2nd Edn Mac Keith Press 2007

9 James RG Michael HS Steven EK Tom FN The Identification and Treatment of Gait Problems in Cerebral Palsy 2nd Edn Mac Keith Press 2009