BO7 307 Armstrong - Rehab Summit•Armstrong Physical Therapy, LLC. 2 DISCLOSURES •I have no...

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To comply with professional boards/associations standards:• I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship.•Requirements for successful completion are attendance for the full session along with a completed session evaluation.•Vyne Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.

Session 307: It Takes a Team: Improving Quality of Life for Children with Neurological Impairment

Carolyn Armstrong, PT, DPT, PCS

Leading the Way in Continuing Education and Professional Development. www.Vyne.com

INTRODUCTION

• Carolyn B. Armstrong, PT, DPT, PCS• Boulder Valley School District• Armstrong Physical Therapy, LLC

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DISCLOSURES

• I have no financial relationship with any product or service mentioned in this presentation.

COURSE OBJECTIVES

• Review and discuss 12 health challenges interfering with quality of life for children, adolescents, and young adults with significant neurological impairment

• Develop customized treatment goals by the priority of your patients’ individual health challenges

• Create a collaborative multidisciplinary intervention plan that incorporates family members

THE YOUNG MAN IN THE CAFE

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OUR CLIENTS WITH SIGNIFICANT NEUROLOGICAL IMPAIRMENT (SNI)

• Cerebral palsy• Stroke• Brain malformations• Genetic abnormalities• Traumatic brain injury• Degenerative neurological conditions• Infections• Toxic injury

DEVELOPING OUR LIST OF CHALLENGES

• Health history• Nature of neurological impairment

• Structural injury, malformation• Embryonic brain, CNS development• Stroke

• Acquired injury• Trauma• Toxicity• Infectious diseases

• Genetic abnormality

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH

Activity ParticipationBody Structures and Function

Environmental Factors

Personal Factors

Health Condition Disorders or Disease

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BODY STRUCTURES AND FUNCTIONS

• Central Nervous System (CNS) damage• Damaged inhibitory neurons• Spasticity• Seizures• Impaired motor control• Impaired postural control• Impaired sensory function, integration• Loss of memory• Impaired cognitive function• Loss of speech-language abilities• Loss of neural pathways, portions of pathways• Flaccidity• Pain


• Functions of the brain – communication, speech, language• Dysphagia• Oral-motor control• Tongue movement• Swallowing• Voice production


• Cardiorespiratory systems• Decreased heart function

• Impaired regulatory systems (autonomic)• Temperature• Heart rate• Breathing

• Pulmonary function• Gastrointestinal function• Elimination

• Kidney• Bowel• Bladder

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• Musculoskeletal impairments• Skeletal deformities, remodeling

• Scoliosis• Hip dislocation

• Osteoporosis, osteopenia• Muscle, tendon, myofascial shortening• Muscle fibrosis• Loss of muscle strength and power


• Integumentary• Pressure• Rash• Drooling

• Sensory• Hearing • Vision• Paresthesia• Vestibular• Proprioceptive




Personal Factors


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ACTIVITY

• Mobility• Locomotion• Speech production• Self-care

ACTIVITY

• Changing positions• Maintaining upright posture against gravity• Walking• Propelling wheelchair• Communicating• Writing• Speaking• Eating• Brushing teeth• Clothing management

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Personal Factors


PARTICIPATION

• Conversing with friends, family• Education• Vocation, Pursuit of happiness• Entertainment, leisure• Self-determination• Advocacy• Transportation• Health care

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PARTICIPATION

• Relationship development in community (natural environments)• Age-similar peers• Educational settings (college, community college)• Recreation facilities

• Vocational participation• Identify as an employee (or volunteer) or• Identify as a consumer

• Independent living vs. assisted living• Social engagement vs. social isolation• Self-determination

SELF-DETERMINATIONTHE ARC

• People with intellectual and/or developmental disabilities have the same right to self-determination as all people and must have the freedom, authority, and support to exercise control over their lives. To this end, they must:

• In their personal lives have:• opportunities to advocate for themselves with the assurance that their desires,

interests, and preferences will be respected and honored.• opportunities to acquire and use skills and knowledge which better enable them to

exercise choice.• the right to take risks.• the right to choose their own allies.• the lead in decision-making about all aspects of their lives.• the option to self-direct their own supports and services and allocate available

resources.• the choice and support necessary to hire, train, manage, and fire their own staff.

SELF-DETERMINATION

• In their community lives have:• the right to receive the necessary support and assistance to vote.• opportunities to be supported to become active, valued members and leaders

of community boards, advisory councils, and other organizations.• opportunities to take leadership roles in setting the policy direction for the self-

determination movement.• the right to representation and meaningful involvement in policy-making at the

federal, state, and local levels.Adopted: Congress of Delegates, The Arc of the United States, 2011

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ENVIRONMENTAL FACTORS

• Environmental barriers• Support system• Socioeconomic • Location• Services• Systems and policies• Cultural norms/biases

PERSONAL FACTORS

• Psychosocial impact • Age• Gender• Appearance

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RESEARCH

REVIEW OF RESEARCH: PAIN

• Pain can have a constant presence• Hauer and Houtrow. 2017: Pain assessment and treatment in children with

significant impairment of the central nervous system• McDowell and Duffy, 2017: Pain assessment: Pediatric Pain Profile for children

with communication difficulties• Warlow 2018 “Total Pain”• Poirot 2017 Prevalance of pain in 240 non-ambulatory severe CP: 45.6%

reported pain

“TOTAL PAIN” (WARLOW AND HAIN 2018)

• An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association of the Study of Pain (IASP) 1973)

• Pain sources• Spasticity• GERD• Muscle fatigue and immobility• Constipation• Musculoskeletal: hip dislocation, scoliosis• Headache

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“TOTAL PAIN”

• Central neuropathic pain – increased nerve excitability• Autonomic dysfunction• Sensitization to pain

• Early medical intervention experiences• Hypervigilance• Dystonia and contractures

• Psychosocial and spiritual aspects of the pain experience• Spiritual: ‘how they make sense of the world and their place in it’ • Hope and trust (caregivers)

RESEARCH: SPASTICITY

• Source of pain and dysfunction• Source of contractures, muscle fiber changes• Bonouvrie et al 2016 Baclofen• Buizer 2016 SDR• Hasnat and Rice 2015 Intrathecal baclofen• Kraus et al 2017 Intrathecal baclofen• Vadilieu 2015

RESEARCH: ORTHOPEDIC IMPAIRMENT

• Source of pain, positioning difficulties• Source of functional loss• Need for orthotic intervention• Bertoncelli et al 2017 Scoliosis• Rutz 2013 Conservative treatment of spinal deformity• MacDowell and Duffy 2017 Pain report and musculoskeletal impairment• Almeida 2017 Suits

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RESEARCH: MOBILITY AND POSITIONING

• Self-mobility • Need for frequent position changes throughout the day• Transfer ability• Medical equipment• Rodby-Bisquet et al 2016 Use of power mobility vs. manual wheelchair self-

propulsionKenyon et al 2017 Power mobility• Curtis et al 2014 Sitting balance• Curtis et al 2017 Sitting balance

RESEARCH: COMMUNICATION

• Means to make needs known• Means to exchange information, feelings, aspirations• Community opportunity for information• Cultural, social appropriateness• Karlsson 2017 Eye-gaze technology• Clarke et al 2016 AAC• Van Schie 2013 Social functioning• Lipscombe et al 2016 Early communication, social functioning

SOCIAL-EMOTIONAL FUNCTION

• Belonging• Self-determination• Loneliness• Victimization• Fear • Depression• Hypervigilance• Cognitive impairment• Behavioral concerns

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IMPACT ON FAMILY

• Financial considerations Vessey et al 2017• Time devoted to medical, rehabilitation services, hospitalizations• Attention to impacted family member• Home modifications• Emotional impact

RESEARCH: INCLUSION

• Inclusion – opposite of social isolation• Significant barriers to community participation • Stanton-Chapman 2017 Inclusive playgrounds for toddlers and preschoolers• Welgarz-Ward 2018 • Lindsay 2011 Disability awareness/social CP• Odom et al 2012 Inclusion: ¼ century of research• Price 2016 Representation of characters with disabilities in library books

MEDICATION

• Seizure control• Muscle tone management• Reflux• Pain management• Vadiveli 2015 Tone management• Smith 2011 Medical management CP

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NUTRITION

• Malnutrition and feeding difficulties• Altered metabolism• Obesity or underweight• Zaragoza 2018 Bone mineral density• Tube feeding• Effects of medications

HEALTH AND WELLNESS

• Obesity• Skin integrity• Cardiorespiratory fitness• Resistance to infection• Turk 2009 Health, mortality, wellness in adults with CP• Fortuna 2018 Health conditions, functional status, health care utilization in

adults with CP• Keawutan 2017 Sedentary behavior in DP

REVIEW OF RESEARCH: LIFE SPAN

• Individuals with significant neurological impairment have shorter life spans• Increased health complications• Holmes 2013 Life expectancy CP• Hutton 2006 Severe CP

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RESEARCH: QUALITY OF LIFE

• Focus of medical or rehabilitation intervention often misses QoL• Environmental factors play a significant part in improvement of QoL• Colver 2016 QOL CP• Jiang et al 2016 Young adults

CASE EXAMPLE: CLIENT 1

• Primary medical diagnosis• Secondary diagnoses, symptoms• Impairments of body structures and functions• Activity limitations• Participation restrictions• Environmental factors• Personal Factors

ICF MODEL



Personal Factors


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CLIENT 1

• 15-year-old male with diagnosis of cerebral palsy• Lives at home with parents, one sister• Attends public high school• Uses manual wheelchair, mostly caregiver-assisted• Communication impairment• Speech available• Walks with gait trainer• Needs assistance with all mobility, transfers• Wears bilateral ankle-foot orthoses• Needs assistance with all ADL

CLIENT 1IMPAIRMENT OF STRUCTURES AND

FUNCTIONS• Cerebral palsy

• Non-progressive• Spasticity• Joint contractures• Skeletal deformities• Cognitive impairment• Language impairment• Visual impairment• Hip joint limitation

CLIENT 1: ACTIVITY LIMITATIONS

• Dependent in: • Position changes• Transfers• Mobility• Locomotion/Travel

• Sitting balance: standby assistance• Standing balance: moderate to maximal physical assistance• Travel with wheelchair: moderate physical assistance• Travel with gait trainer: minimal physical assistance

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CLIENT 1: ACTIVITY LIMITATIONS• Activities of Daily Living (ADL)

• Maximal physical assistance• Hygiene (bathing, toileting)• Dressing• Transfers

• Moderate physical assistance• Tooth brushing• Food preparation• Environmental control devices

• Minimal physical assistance• Eating with fork or spoon

• Independent• Finger feeding• Drinking from water bottle, cup, carton with straw

ACTIVITY LIMITATIONS

• ADL• Maximal physical assistance

• Reading• Writing• Typing

• Moderate physical assistance• Turning book pages

• Minimal physical assistance• Switch operation for electrical devices

CLIENT 1

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GAIT TRAINING

BALANCE

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BALANCE, TRANSFERS

THERAPEUTIC EXERCISE

CLIENT 1 – BODY STRUCTURES AND FUNCTIONS

• Identifying challenges• Body structures and functions

• Postural control in wheelchair• High muscle tone lower extremities• Contractures of knee flexors, hip adductors• Cortical visual impairment• Incontinent

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CLIENT 1 ACTIVITY LIMITATIONS• Activity limitations

• Walking – uses gait trainer• Transfers require maximal physical assistance• Sitting (bench, toilet, chair)• Wheelchair propulsion• Conversation• Communicating needs• Eating, drinking• Dressing• Oral hygiene• Writing, typing, drawing• Tool, utensil use• Switch operation – environmental control

CLIENT 1: PARTICIPATION RESTRICTIONS

• Education - Restricted• Physical access• Self-care in school• Travel• Written communication (writing or computer use)• Spoken communication (expressive and receptive)• Endurance

• Pre-vocational - Restricted• Wheelchair positioning• Impaired motor function

• Leisure – Restricted• Mobility

CLIENT 1 – DEVELOPING A FUNCTIONAL PROFILE

• Functional profile• Clearly identify needs

• Start with client/family priorities• Identify what interventions have worked in the past

• Pinpoint achievable changes• Write goals with short-term objectives

• Include client-centered language• Self-determination

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CLIENT 1 TOP-DOWN, BOTTOM-UP

• Start with participation• Client-centered• Family concerns• Self-determination

• Activities• Body structures and function

CLIENT/FAMILY GOALS

• Being with other people• Participating in listening, playing music• Community activity

• Volunteer work• Shopping• Recreation

• Make needs known• Stay healthy

CLIENT 1: SCHOOL GOALS• Student will travel 500 feet or more using his wheelchair or gait trainer

• Student will deliver attendance to office• Student will travel between classes• Student will participate in PE class

• Student will transfer with moderate physical assistance using standing pivot transfer• Student will use standing pivot transfer from wheelchair to toilet with moderate

physical assistance• Student will transfer to and from a bench during school assemblies with moderate

physical assistance• Student will participate in instrumental music class

• Student will play harmonica during small group activity with verbal prompting• Student will use switch, strike tambourine, drum, or triangle, and activate keyboard

during small group music activity

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CLIENT 1GOALS• Student will use verbal greetings to initiate conversation with teachers and peers

• Student will use a verbal phrase when entering a room• Student will introduce himself• Student will ask one question in a conversation with a peer

• Student will feed himself during school lunch in cafeteria with assistance for set up and clean up

• Student will use spoon, cup, and fingers to eat a meal• Student will participate in cleaning his mouth and the table after his meal

• Student will choose between two activities presented verbally or with picture choices

• Student will indicate his need to use the rest room• Student will communicate verbally to use the rest room• Student will use picture cards or sign to communicate need to use the rest room

YOUR CLIENT

• List medical diagnoses• List secondary diagnoses• List participation restrictions

• Based on age• Family, cultural values

• Activity limitations• Impairments of body structures and functions• List client/family priorities• Formulate 3 goals

CLIENT 2: BACKGROUND

• Student moved to district from institution in Asia• Unable to walk• Crawled for mobility• Diagnosis of CP, Deafness, Blindness• Self-injurious behaviors• No means of communication• Dependent in all ADL including feeding

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CLIENT 2 ASSESSMENT INFORMATION

• Independent sitting balance on floor• Independent crawling• Maximal physical assistance needed to transfer• Uninterested in toys, learning materials• Attended to visual stimulus – lights, contrasting colors• Did not respond to sound• Stood momentarily with maximal physical assistance• No expressive communication• Tantrums, head-banging

ICF MODEL



Personal Factors


CLIENT 2 PARTICIPATION

• Education Restricted – Why?• Sensory deficits• Mobility limitations• Need for significant supports

• Independent living in home – Restricted• Maximal physical assistance needed for all ADL and mobility

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CLIENT 2 ACTIVITY

• Mobility – Limited – Why?• Delayed motor development• Impaired vision and hearing• Reduced muscle strength• Impaired standing balance

• ADL - Limited• Eating• Hygiene• Hand use for play, learning, exploring

• Communication – Limited• Non speaking• No signing

CLIENT 2 BODY STRUCTURES AND FUNCTION

• Low muscle strength• Blindness• Deafness• Cognitive impairment affecting speech/language development• Some interest in people• Interest in light sources

CLIENT 2 GOALS• Increase mobility

• Standing and walking• Transfers

• Increase communication• Signing• Object schedule

• Reduce injurious behaviors• Increase interest in objects

• Cause and effect devices, toys• Learning materials

• Improve ADL• Self-feeding• Hygiene• Dressing

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CLIENT 2: COLLABORATIVE TEAM• Client and family• Physical therapist• Occupational therapist• Teacher for visually impaired• Teacher for hearing impaired• Special education teacher• Speech-language pathologist• Assistive technology team• Behavior specialist• Support staff• General education teachers• Medical staff, audiologists, ophthalmologists, dentists

COLLABORATION• Team evaluation, needs identification, goals• Collaboration meeting of client, family, all service providers• Create team document

• Google doc• Record school schedule• Record home schedule• Determine practice schedule• Assign responsibilities

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NEEDS

• Standby assistance for all mobility, safety• Behavior plan

• Staff educated in consequence/reward program• Safe environment

• Communication support• Signing• Object schedule

• Assistance with self-care• Learning plan

• Orientation and mobility• Executive functioning• Scaffolding of learning experiences

Goal What Where When Who - Lead WhoAttend to table activity for 15 minutes

Choice making,Operation of light box, switch operation of environmental control devices

Intensive learning center

During intensive learning time

Teacher Paraeducators, OT, TVI, THI, Teacher

Reduce dropping during mobility

Navigate environment, reach destination without stopping using objectschedule

Travel between classes, special assignments, to and from bus, lunch

Transitions Physical therapist, psychologist

Paraeducators, PT, Teacher

Increase sign vocabulary

“Stop”, “Go”, “Eat”, “Drink”, “Bathroom”, “Done”, “Stand up”

Throughout day when appropriate

Throughout day as needed

Teacher of Visually Impaired

TVI, THI, Teachers Paraeducators, peers

Take off coat Independently take off coat

Locker First period OT OT, Teacher, Paraeducator

Participate ininstrumental music class

Remain in music class for 20 minutes, listen and participate

Instrumental music class

Third period SLP Paraeducators, PT, SLP

CLIENT 2 OUTCOMES• Body structures and functions

• Increased strength• Improved standing balance

• Activities• Walking• Transfers• Exploring environment• Signing• Use of object schedule• Eating• Light box • Switches for environmental control, learning• Walking up stairs on playground structure• Swinging on swing• Sitting on toilet• Washing hands

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CLIENT 2 OUTCOMES

• Participation• Music class• Recess• Lunch• Walks• Family outings

YOUR CLIENT

• List team members• List intervention strategies based on goals• List where, what, when, who for intervention

CLIENT 3

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CLIENT 3

• Strong communication skills• Attention problems• Limited mobility• Impaired postural and motor control• Social-emotional concerns

Time Monday Tuesday Wednesday Thursday Friday8:00-9:00 Breakfast Breakfast Breakfast Breakfast Breakfast9:00-10:00 am Reading Reading Reading Reading Reading10:00-11:00 Music PE Art Music PE11:00012:00 Math Math Math Math Math12:00-12:30 Lunch Lunch Lunch Lunch Lunch12:30-1:00 pm Recess Physical Ther Recess Recess Recess1:00-1:30 Speech

TherapyOccupational Therapy

Speech Therapy

1:30-2:00 Science Science Science Science Science2:00-3:00 Social Studies Social Studies Social Studies Social Studies Social Studies3:00-3:30 Special Ed Special Ed Special Ed Special Ed Special Ed

Goal What Where/When Who How oftenWheelchair mobility Independent 30 feet In classroom during

transitionsC. Armstrong PTMolly, Para

5 times daily

Walk with gait trainer Standby assist 100 feet 3 times

In PE C. Armstrong PTKristen, Para

2 times per week

Use of new vocabulary Use new words in conversation

Throughout the school day

MK, SLP, Para Daily

Follow multi-step directions with concept words (before, after, under) independently

Follows all steps in accurate sequence

Any time directions are given

SLP, Para, Teacher

Use both hands together for opening containers, cutting w/scissors

Standby to minimal physical assistance to complete

Lunch, classroomwhen preparing for activity

OT, Para, Teacher Daily during activity

Indicate leaving for restroom

Raise hand, make sign, leave room

During classroom time Teacher, Para Daily as needed

Log into computer Independently During computer activities, classroom

Teacher, Para Daily

Tummy time Lay 15 minutes on wedge

Before lunch in ILC Teacher, Para Daily

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CLIENT 4

INSTRUCTIONS

Positioning

• Place J on his tummy with a pillow under his tummy and a blanket roll under his feet

• Place J’s IPad with his favorite video in front of him to encourage head lifting

CLIENT 5

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Schedule Activity Team Member Lead Team Members1st ILC, Hygiene, Snack in Cafeteria

Put cup down on table, transfer skills on mat table, walking

Physical Therapist PT, Paras, Teacher

2nd Choir Walk into choir, walk out (leave wheelchair outside) sit, Posture control in wheelchair, Attending to a peer for a few minutes


3rd PE Start toilet transfers before PE, Wheelchair skills, Posture control, walking, connect picture schedule to activities and next activity, add photos of cafeteria, wheelchair, bench from “Student point of view”, yes/no questions, and choices, work on one-person assistance during walking; ball passing activity with peer mentor


INSTRUCTIONAL VIDEOS

Schedule Activity Team Member Lead Team Members4th Lunch and Long Break, Down time or go Outside, Nap time if needed

Peer engagement, Travel around the room or outside, wheelchair propulsion outdoors, make requests (e.g. picture of wiggles, must request first), practice using door opening switch at front door

Occupational Therapist OT, Paras

5th ILC (Thursday) Spools in bowls, “Give me the …” followed by wiggles, hold switch, sitting on chair, sitting on edge of mat table, Ukulele

Occupational Therapist OT, Paras

6th ILC, Speech Ukulele, more practice putting spools in bowl, switch use, bathroom break, colors -2 color cards or matching color cards to colored paper, wheelchair self-propulsion to bus, turn chair around for lift, practice wheeling over thresholds

Speech-Language Pathologist

SLP, Paras

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INSTRUCTIONALVIDEOS

INSTRUCTIONAL VIDEO

ONGOING TEAM COLLABORATION

• Google Doc• Back and forth notebook• Email• Training• Daily notes

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CLIENT 7

• Teenager about to enter high school• High verbal skills• Advocate for people with disabilities• Collaboration team includes

• School, home health, and outpatient clinic physical therapists• School, outpatient clinic occupational therapists• School, private psychologists• Extended family

Monday Tuesday Wednesday Thursday Friday

Home health PTTransfers, mobility, ADL

Gymnastics class after school

Clinic OT, PT after school

YMCA Parent Night Out Program

School: Walking with crutches with para, exercises during PE

School: walking with crutches with para, exercises during PE




School: Lunch with peers

Lunch with peers Lunch with peers Lunch with peers Lunch with peers

School OT ADL, Executive function, daily program update

School PT Exercise, walking, transfers, balance, daily program update

Social skills group with school SLP and psychologist

Daily exercises at home, knee immobilizers, ADL activities





THE LIFELONG CONTINUUM

• Prevention• Program modification for age-appropriateness• Access to resources• Advocacy• Family Life Coach• Aspirations

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YOUR CLIENT

• What could have been done at a younger age to improve current quality of life?

• Does intensity/frequency of intervention change over time? Why?

• What’s missing in your client’s life that would improve quality of life?

• What is the biggest barrier to happiness, comfort, self-determination?

SELF-DETERMINATION(THE ARC)

• People with intellectual and/or developmental disabilities have the same right to self-determination as all people and must have the freedom, authority, and support to exercise control over their lives. To this end, they must:

• In their personal lives have:• opportunities to advocate for themselves with the assurance that their desires,

interests, and preferences will be respected and honored.• opportunities to acquire and use skills and knowledge which better enable them to

exercise choice.• the right to take risks.• the right to choose their own allies.• the lead in decision-making about all aspects of their lives.• the option to self-direct their own supports and services and allocate available

resources.• the choice and support necessary to hire, train, manage, and fire their own staff.

SELF-DETERMINATION

• In their community lives have:• the right to receive the necessary support and assistance to vote.• opportunities to be supported to become active, valued members and leaders

of community boards, advisory councils, and other organizations.• opportunities to take leadership roles in setting the policy direction for the self-

determination movement.• the right to representation and meaningful involvement in policy-making at the

federal, state, and local levels.Adopted: Congress of Delegates, The Arc of the United States, 2011

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BEYOND SELF-DETERMINATION

• Dreams and aspirations• Creativity• Comfort• Circles of friends• Advocacy

IN SUMMARY

• Children with significant neurological impairment have• Participation restrictions• Activity limitations• Impairment of body structures and functions

• Client and family experience needs based on these factors• The intervention team can provide a client/family-centered program which

• Develops and prioritizes goals that increase participation and self-determination• Coordinates the team and client in intervention strategies• Monitors progress and adjusts program to changing needs• Provides communication between service providers• Evaluates effectiveness of interventions and streamlines redundancy

• Clients have equal rights to high quality of life, self-determination

REFERENCES• Almeida KM, Fonseca ST, Figueiredo PRP, Aquino AA, Mancini MC. Effects of intervention

with therapeutic suits (clothing) on impairments and functional limitations of children with cerebral palsy: a systematic review. Braz J Phys Ther, 2017; 21(5):307-320.

• Adegbove D, Sterr A, Lin J-P, Owen TJ. Theory of mind, emotional and social functioning, and motor severity in children and adolescents with dystonic cerebral palsy. European J Paediat neurol 2017,21:549 e556.

• Bertoncelli CM, Solla F, Loughenbury PR, Tsirikos AI, DomBertoncelli D, Rampal V. Risk factors for developing scoliosis in cerebral palsy: a cross-sectional descriptive study. J Child Neurol. 2017 32(7) 657-662.

• Bonouvrie L, Becher J, Soudant D, Buizer A, Van Ouwerkerk WJ, Vles G, Vermeulen RJ. The effect of intrathecal baclofen on activities of daily life in children and young adults with cerebral palsy and progressive neurological disorders. OffJ Eur Neurol Soc, 2016 (20)538-544.

• Boxum, AG Development of the quality of reaching in infants with cerebral palsy: a kinematic study. Dev Med Child Neurol, 2017; 59(11):1164-1173

• Buizer AI, van Schie PEM, Bolster EAM, van Ouwerkerk WJ, Strijers RL, van der Pol LA, Stadhouder A, Becher JG, Vermeulen RJ. Effect of selective dorsal rhizotomy on daily care and comfort in non-walking children and adolescents with severe cerebral palsy. Official J Eur Neurol Society, 2016 (21) 350-357.

• Clarke M, Price K, Griffiths T. Augmentative and alternative communication for children with cerebral palsy. Paed Child Health, 2016; 26(9): 373-377.

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REFERENCES• Coleman A, Weir K, Ware RS, Boyd RN. Relationship between communication skills and

gross motor function in preschool-aged children with cerebral palsy. Arch of Phys Med and Rehabil. 2013;94: 2210-7.

• Colver A. Outcomes for people with cerebral palsy: outcomes and quality of life. Symposium: Cerebral Palsy, Paediatrics and Child Health, 2016.:383-386.

• Curtis DJ, Woollacott M, Bencke J, Bloch Lauridsen H, Saavedra S, Bandholm T,Sonne-Holm S. The functional effect of segmental trunk and head control training in moderate-to-severe cerebral palsy: A randomized controlled trial. Dev Neurorehabil, 2017

• Curtis DJ, Butler P, Saavedra S, Benke J, Kallemose T, Sonneholm S, Woollacott M. The central role of trunk control in the gross motor function of children with cerebral palsy: a retrospective cross-sectional study. Dev Med Child Neurol, 2014 Nov.310-311.

• Erasmus CE, Van Hulst K, Rotteveel LJ, Jongerius PH, Van Den Hoogen FJ, Roeleveld N, Rotteveel JJ. Drooling in cerebral palsy: hypersalivation or dysfunctional oral motor control? Dev Med Child Neurol. 2009 Jun;51(6):454-9.

• Fortuna RJ, Holub A, Turk MA, Maccarello J, Davidson PW. Health conditions, functional status and health care utilization in adults with cerebral palsy. Family Practice 2018, May.1-10.

• Hasnat MJ, Rice JE. Intrathecal baclofen for treating spasticity in children with cerebral palsy. Cochrane Database of Systematic Reviews 2015, Issue 11. Art.No.: CD004552.

REFERENCES• Hauer J, Houtrow AJ. Pain assessment and treatment in children with significant

impairment of the central nervous system. Pediatrics. 2017Jun;139(6)20071002.• Holmes L, Joshi A, Lorenz Z, Miller F, Dabney K, Connor J, Karatas AF. Pediatric Cerebral

Palsy life expectancy: has survival improved over time? Pediat Therapeut 2013, 3:1.• Hutton JL, Pharoah POD. Life expectancy in severe cerebral palsy. Arch Dis Child. 2006

Mar; 91(3): 254–258.• Jiang B, Walston H, Reid SM, Davis E, Reddinough D. Quality of life in young adults with

cerebral palsy. Disability and Health Journal. October 2016, 9(4);673-681• Karlsson P, Allsop A, Dee-Price B-J, Wallen M. Eye-gaze control technology for children,

adolescents, and adults with cerebral palsy with significant physical disability: findings from a systematic review. Developmental Rehabilitation, 2017: 1-9.

• Keawutan P, Bell KL, Offedal S, Ware RS, Stevenson RD, Davies PSW, Boyd RN.Longitudinal physical activity and sedentary behaviour in preschool‐aged children with cerebral palsy across all functional levels. Dev Med Child Neurol. 2017; 59(8):852-857

• Kenyon LK, Farris JP, Gallagher C, Hammond L, Webster LM, Aldrich NJ. Power mobility training for young children with multiple, severe impairments: a case series. Phys Occup Ther Pediatr. 2017 Feb;37(1):19-34.

REFERENCES• Kraus T, Gegenleitner K, Svehlik M, Novak M, Steinwender G, Singer G. Long-term therapy

with intrathecal baclofen improves quality of life in children with severe spastic cerebral palsy. Official J of Euro Paed Neurol Society, Jan 2017.

• Lindsay S, MacPherson AC. Strategies for improving disability awareness and social inclusion of children and young people with cerebral palsy. Child: Care, Health, and Development, 2011;38(6) 809-816.

• Lipscombe B, Boyd RN, Coleman A, Fahey M, Rawicki B, Whittingham K. Does early communication mediate the relationship between motor ability and social function in children with cerebral palsy? Res in Dev Disabil. 2016; 53-54: 279–286

• McDowell BC, Duffy C, Pain report and musculoskeletal impairment in young people with severe forms of cerebral palsy: A population-based series. Res in Dev Disabil, 2017 (1)277-284.

• Monbaliu E, DeCock P, Maillieux L, Dan B, Feys H. The relationship of dystonia and choreoathetosis with activity, participation, and quality of life in children and youth with dyskinetic cerebral palsy. Eur J Paed Neurol, 2017 (21):327-335.

• Odom SL, Buysse V, Soukakou E. Inclusion for young children with disabilities: a quarter century of research perspectives. Journal of Early Intervention, 2012

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REFERENCES• Poirot I, Laudy V, Rabilloud M, Roche S, Ginhoux T, Kassai B, Vuillerot C. Prevalence of

pain in 240 non-ambulatory children with severe cerebral palsy. Ann Phys Rehibil Med, 2017

• Price CL, Ostrosky MM, Mouzourou C. Exploring representations of characters with disabilities in library books. Early Childhood Education J, 2016 44: 563-572.

• Rodby-Bousquet E, Paleg G, Casey J, Wizert A, Livingstone R. Physical Risk factors influencing wheeled mobility in children with cerebral palsy: a cross-sectional study. BMCPediatrics 2016 (16):165.

• Rutz E, Brunner R. Management of spinal deformity in cerebral palsy: conservative treatment. J Child Orthop,2013 (7):415–418

• Smith M, Kurian MA. Medical management of cerebral palsy. Symposium: Cerebral Palsy, Paediatr Child Health, 2016

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