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t
Motor SLills
* ChilJr.r.*ith
C"*.bt al P"lsy
Sirnilar Movernent DisorJ€rs
"rrJ

f'u

tb
Sieglinde Martin, M"S., P.T
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& TabIe
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of
& Contents
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Chapter 1: Developmental Delay and Cerebral palsy .......................................1

Chaptcr 2: Gross Motor Development 5

The Sequence of Gross Motol DevelopmeDt,/ 5
The Baby's Position Itfluences Motor Development / 7
The Motor Development ofthe Child wirh Cerebral palsy,u 9
Frequently Asked Quesrions / 15

Chapter 3: Obstacles to Motor Development............................. .............,.......t7

Muscle Tone,/ 17
Abnormal Movement patterns ,, 19
Refleres,/ 19
Lack ofMotor Coltrol aDd C{Drdinarion ./ 2l
Musclc Weakncss / 22
Abnornal Sensory Aw.aleness ,; 22

Chapter 4: Helping your Child Learn Motor Skitls .........................................25

Ncural Plasticit] / 2S
Motor Lcarning / 26
 Physical Therapy for Children with Cerebml Palsy / 29
The "Road to Independence" for Children with Cerebral Palsy/ 35
Frequently Asked Questions / 40

Chapter 5: Flexible Muscles and Joints 47

Possible N{usc1e Problems., 41
Possible,I.rlnt Problems ./ .+2
Daily Strctching to Prevent Muscle and Joint Problems / 44
How to Do StretchinS Exercises / 45
stretching Exercises for the Older child,/ 52
Frequently Asked Questions / 54

Chapter 6: Head-up. ......................57

The Importance of Head Conttol / 57
Meet Nina / 58
Head-Up Practice / 60
Integration of Head-Up into Daily Life / 64
Frequently Asked Questions / 66

chapter 7: Happy Baby i Back-1ying........... ..................67

Happy Baby Exercises / 68
Is Your Child Ready fot Back-lyitt* / 72
Frequently Asked Questions / 72

Chapter 8: Tummy Time...........,.............. .,,.75

Prerequisites for Tirmmy Time with Play / 76
Exercises for Ttmmy Time with Play / 76
l tEt'sNext? / 78
Big Push-ups for Sean,/ 79
Big Arm Exercises /
80
weight Bearing on "Big Arms" / 81
Frequently Asked Questions / 84

Chapter 9: Guarding Against Fa11s............ .....................87

The Boy Who Did Not Want to Touch the Floor / 88
Encoumging Protective Extension Reaction Forward / 9O
Enco[mging Protective Extension Reaction to the Sides / 92
Frequently Asked Questions / 94

Chapter l0: SiltirS Prefl)........... .....95

Meet E11i,/ 95
HelpinS rour Child to Sit.,'97
Supported Sittin8 /'97
Independenr SitlinS lrrilh Arm Supporr / 99
Sifting wlthout Arm Support/r 102
Or r,.'l\.1 r, . L, I .. 106
Variabilir! ofSitring / 108
 Sitting oD a Bench l]1 Chair,/ lOB
Moving in and our ofBeDch or Wheclchair Sitring/ 112
Frequend)' Asked Quesrions,/ l1S

Chapter 11: Gettitg Up and Crawling.,,-....... -.... L77

Meet Jennifer / 117
Up Onto Hands and Xnees / 120
Ctawling / 123
RisinS Up and Moving Down / 1,24
Doing It A11l 126
Frequertly Asked Que stions / L27

Chapter 12: Leg Exercises and Standingwith Arm Support.... ...............,729

Stimulating Leg MovemeDts / 131
l,eg Exercises / 132
Supporrin8 Your Chlld in Starding/, t3zl
Le8 Exercises lvith Weight Bearing./ 136
Your Child Stards Holding on wjrh Both Hands / 139
Helpful Bars,/ 142
Fr equentll' Askc d Quesriorls / 143

Chaptel13: Balanae ................,....145

Balance in Children with Cerebral palsy ,/ 146
Balance Training ,/ 146
Balance Tmirdng in Sifting / 147
Balance Training in Xneelhg / 150
Standi[g Balance / 152
Standing with Arm Support and Moving Irl and Out of Standing 153
/
Frequently Asked euestions / 157

Chapter 14: Standing without Arnl Support and WaIkiDg............................159

Walking \'! ith Arnl Supporl ; 160
Walking riirh a \4alkcr / 161
ImprovinS Lhc Wav Your Child Walks \,virh a Walker,/ 164
Walkjng with RedLrced SLrpporr,/ t65
Walkinguiirh CrLuches / 166
Standing r,ithour Arm Supporr./ 166
Assisted Standlng on One Leg,: l7l
Exrra StaDding'fitne for the Weakcr Leg / 172
Progrcss /ith Standjng Balirnce,/ i74
Strength anLl Quick Acrion / 174
Walkiug,/ I75
Rerdr" fbr Wa1ki.g,/ 179
Frequentlv Asked Questions,/ 180

Chapter 15: Walkingand More.........._...... ...................183

Oppor-ruDities lbr W.lkrng , 183
 Improving Balance and Coordination,/ 191
Standing on One Legl 193
The Way YouI Child Walks / 194
Frequently Asked Questions / 199

Chapter 16: Extra Strengthening and Having Fun .......................................202

StrenSlhening Excrcises,/ 202
HaviDg FLLn,/ 203

Chapter 17: Additional Interventions for Childrenwith Cerebral palsy.......209

By Lisa Bartett, DPT
Medical Managemeot / 209
Se al Casting/ 213
Neuromuscular Electrical Stimulation / 213
Lower E\rrPmiry Btacing,/ 214
I requently Asked Que stions / 217

Apperdix................ ...223
Pediatric Therapy EquiplJjrefit / 223
General Equipment and Supplies,/ 224
l-herapy Equipmenl Supplie$ / 225
Organizations ProvidinS Recrearional Oppottifiities / 226

Index
aaaaa
a
a
o
a
a
a lntroduction
a aaaaaaaoo

,l ml'er \t as bor.r oln r thr €c ,lun ths prem otllre- Tu) yourlg to brectlrc ot1 lrcr aw \
a 1Ds r

i7I\hr rpcnt her \trrile ir'reLs in arr rncubcror. Amber'.s pdrenr.s spent md4,, dn-{ious
JLr
hours dt the hospital. Thareware complications, butAmb€r sun,ived. Her parents \t,ere
happy to take her honle ot last. With tlrcil'8aod care, A tberstartedto thrive. She gained
v,eight, grew, and det eLoped itrto a cute, alert baby.
Now se yen r no, rr/rs ol4 All Lber lo.les to be helcl a il carrietl. W4rn her nr other is busy
iL Lhe kitcherl, Afiber likes to be it1 her infant.se.t f closc by ond watch her She o/so likes
lo sit in her" b4by srving ond li.rten ro ,lusic. Amber is a happy baby but herporents hove
srarted lo rroriy.rgdir. IluringAmbert lasr docaort yisir tfuephl,sicldrt had placed her on
her tltmnry. When Anlber onLy brieJly Lifted her lrcad,, he told them that her de\)elopnvrt
seented to be deLayed attd referred her for a physical therdpy e.laluntioi- Wltut would the
pllysical therapist do? Make Amber stronger? They thinkAnfier is pretq sfong dlready.
When they sLa Ll her up, rhe st,"o ng1y.lfraiglt ten.s lrcr back ctntl legs antl holds hosefup.
Alnber's parents ha|e made tlrc appotttntent as suggested, but arr skepticaL about iL-

l.uAr:isturconddhrrllyedrsoldd/tdbigforhirage-BLthedoernorlctry.rlk.Togct
oround, hc clcl/ls or walks }r,ith o Lr,olker: Stil?, his parenrs ort gldd fic hrlr [l]is tuch
llrobilial. 1'h.re x,lrs o ti,re he dlti rnuch less.
Luke had been Ltorn otr tilrle, Lyer.{hirg .l hc.lltfi,y 7lbs. H€ iod.\p.na lcss thon d day
at the /rospital heife ie rnd /rir ,1rirr/ro-r,crc blollshr hoine 6y hir hdppy fltLlLet- But fate
Lr.,os cruel. llyr; r,r,eeks 1dr.r alir lirmih x,os in d .or oc.idenl u,ilh s.rrorlr .ons€qu.rtce.s.
Lukcsustainrd o iccrd irUrrIy. A.srrbduralblecd. oJub(1ro.hnoid /rlecd, Lrnd cc,'cbru/ cdrnro
ra,erc di(gn orcd. /- ke.rpentr.n dd)'sIlt lhefuorpita1. A,rrer ,trrds, o p/r_vsiccr 1 ti crop ist begon
 XVi TEACHING A,'IOTOR SKILLs TO CHILDREN !(/ITH CEREBRAL PALSY AND SIIV]ILAR ]\'IOVEI\"TENI D]SORDERs

coming to thehouse first once a month, dndthen two times cLweekafter an eroluation
showed that Luke's motor d.erelopment was not p/ogressing os it shoLld.
Now the therapist comes to theirhouse three tifies aweeko and as before, thevlsits are
paidfor by their state's Medicaid system. Luke's pctrents feellucky bLLt stillhave complaints.
At tifies thephysicoltherapy visits interferewiththeir family Plans. AIso the therapist keeps
telling them things to do with Luke. They like to help Luke, but would rathet do it on thPi r
own term' Luke really likes his physical theraw visits afldlooks t'orward to them, but his
parentsfeel the therapist is plTying with him too muclt and does nothave him work 4s h c
should.. with all the therary they wonder, why kn't he walking?

,erek is dl, eodl'f,re yed,'.s o/.l.lnd goer lo kinde,-.grlrlen. Burhc sti11i5 lfu baby oJ the
.fdltLily. Eyeryone bre s De, ek d nd do les orer hl/il. l'V/tcn Derek leeds som cth ins. his sir ler .s
/

rrlsh to get lt. His rJ.rdJrill cdrries Airi lt,h€n they 30 oua. Ardinrurline his rronr help"" hirtt
t{) climb i/rro his sc.r I Th ere ii a ?ason f(, lh ir- ,erek hos .ertbr".ll Polsl. l3arl1 qftcr d hard
/

lo bor, he de ueloped slor.r,e, lhdn fuis sis aer.t had. His legs l/1 pd rai.u 1.1r hod dhrol's /a1r .s tfJ
Wien Derek wos n or cr.ru,ling di ld sitaing by ri.:,e mot:,rhs of ag, hisparenas be.dme
concer-ncd and lfue pediatrician referred hitll i)r a PelliaLric p]lysicol and accupatianol
Lheftipy awluat rt. E|ersince, hirpdrertls hdve a.Ikelr him lo w€eklyphlsi..rl therdplond
oc.updtiond I thcropy Jesr to, ts. l br' lx,o ,veo/. Der-ek di.so Jr.rd 9ee.h lherapy The therQpt P \
hcLte heLpetl Deteli. Thcy olso have been rtD'1,.r1r1dble ro h lsP.u-cn Ls. The-l lPIPed th.m Lnd Pr
srond Derekl\ p-obl€ is.r.sirdllorhow lo hciphim lcdrnollrhe altin.$s h. need&lao ledl'n.
Mrrli Derel is 1,olking shorl disldnccs x,irhr]Ltruppora. His plrr.71ls /lo lotlger take
hint to the clitic Jor th€rdl.y. Inrt€o4 he reccivci (rc.uPallondl rrrd lrl)'sl.al lh€rdpy ol
r.hool. lfhdla relieJllol lo hdve ao dr_.t.qhi7rl lo d ll h is .llloinlrn€nrs dnvmorel D.rekSoes
ta afLer noan kindcrgarlen. Ll t h. .narr.i:r.g dfter- his s is tc ru h.lve lel ifo I sch o.rl. DeT ek ir
tee lo play rrit/r fiir lr)-1,s, aTld his norid_isfree to rcad the paPer ot calL o Jrilltd. Afrer
v€orroIh.cticschedrr1(.r,sheenloysthisfrcedom-Bufalt€ndgdinsJIe.&elrunsure.'a.stfiis
good/if Derek? Shorrldn'tl tlo nnre t'('l-lltn? 'she rr,orrdem. She misses lhe l1'eeklycon&rca
,rith ,erek'.s rherapisas ond ahc .qLiddrL.e rhcy 8d1'a her. she do..s noryel knotl' rer€k!
schoolphlsicol theropisr well dndrqn(1.\ 1l .lflicula ro conld.l her.

Il-voLL have rhil.l like Amber. l.ukc, or Derek, vor.r Probabh call relarc to the sLo
11

ricsabor-e. Perhaps v() havebeeninformuLl that-vourchild hnsa developnentaIdd:ll.

ccr(:l)ral pals1,, or anothcr condltiotl thal (autts Llelavs, Whcther or ilot vorl'\'e bccn
given a cllagnosis fbr lour chilcl\ delavs, r'ou arc probabl,vl"ronderingifthere js anJ tling
that \''ou c:rn do to heh) him inrpr ove his motor skills. If1rcur child is rcfcrred to phl,sical
therap-\' or r(:cei \res the servicc ) ou probablv lrould like to k11o\'! a1l about the e rercises
the dlerapist does. erd ,h-v he or sh. d.res them. You we.t to better understand vlhy
the ph-ysical therapisr gi\''es )'oLL certairr rccotttnlendations. What is Lhe purpose ofthc
cxer'cjses yoLL are tokl t{).lo !vith l.oLlr child? Hor, u'ill rhe} hclP hi r?
This book tries rc l].l.lress these questiors It:
a Foclrses orl gross motor skills and on ho!\, to Leach rhur to \ar r
child with the guidanct ol ,vour phl'si( al therapisl:
a Fxpleins Lhe intent of (ommon hotne instnrctions \tLLr LheraPist
rray glve yotri
a Gives yor.r illustraled. easl- ao-f(rllol^i erercise iDsrrrctions to use
,,; 1,1,-. 6r J,,.,,t \o. r.lI r.t

l--
 lNrRoDUaTtON xvii

. Provides theoretical background information that will increase

your knowledge and confidence as you care for yorir
c1 ld or tall(
Lo r rrio. r . or olos. iona is
, epc6unlo1.
1or,
. Deepens your understanding of your own and your physical
therapist,s contdbution to yout child,s progress.

This book is ior pareDts of children with de\.elopmental delay,

cerebral palsy,
and similar movemenr disorders who are refeuecl foi physical
th"iupy. I,
howyour child rnay learn basic motor skills such as sittini, crawling,'.i"nai"i, "riluirr.
walking with yorr help and that of the physical therapistlBy
workiirg ,og",h; ""a una
coDsisteltly train iDg mis sing skills orcrucial components
ofihese skii-ls, y"ou aud the
therapist can help your child reachhis fullest poGrriai.
Many illustrated, easyhome exercises arepresented. your child,s plrysical
oroc
cupational therapis I tuay s elect the ones best for your chill
and show yuu l]o* a ur"
then. Practice these exercises first tvith the theiapist,s help and foflo*
.p".ifia
instructions the therapist provides. Afterwards, nse the exercise "ny
rou,irr"ty, oi.".u"
the small changes toward progress that mayoccur, aDd
share them with youl thera-
pist. As your child leams a new skiii, together you
and the thetapisr witt ptan ttow to
integrare ir inro yolrl chiid,s dailylife. Implementing this plan
wili be rn"rilur""r,"O.
txa rple. ol hou ro do r t- rs a re pr oviooc.
Teachers and teachirg assistants of children with cerebral palsy
and similar
rnovernentdisordersmayfilrdthisbookequallyhelpfi.Justaspar"r.rtsio,t]r"ywurrt
to urderstand their students, physical challenges and
help them to n"fri",r" J"i.t rff-
estpoteDrials. With creativity and the help ofthe schooiihysical
therapist, theynrry
find ways to adopt some ofthe hoDre instmctions for classroon
use. e. tl"
grow and_spend more time at school, they will benefit
from rhe lntegration"trila..o
oi rieir
notor skills into their classroom activities.
The book explains terms and concepts that parents or non medical
professionals
may encoLtnter Preselted in context, theoretical knowledge
educates yoriabout the in_
teot or effect ofan exercise. It provides background information
ad\.ice that will be helpful. For instance, clearly understandilg
and corrfirnr. prJ"al
why a mu."f" s"
stretched_each day or u/hy weight bearing on arms is important ""'"ari.
makes cer tain exercises
oeaningful. Following them may tircn become more satisfying and
motivating.
. _. _Treatment narratives explaj n why some tasks can be io
jifficult and shoil, how u
chltd may mffter them. These storles highlight common problems
al1d are meant ro
deepen the reader's understanding ofthem.larents need
to be a\,\rare that these are
mere examples. The problems, as well as the presented
solutions, muy o. -uy oott"
applicable to rheir child.
It is not possible to Sive specific advice for an iDdividual
.
therapist who worl* with your chiJd and knows his sh ength
child in a book_ Only the
ar-rd wealo"rr"r_fri, , rnio ,.
setofproblerns and his abilities that mayhclphLm to overcome
them_;r l..fr" p*lrl'".
to set goals, reconmend specific exercises or activities, and give
specific instructions.
fhernrorlario.rgircnIercisappJi..rDrcroaU.rild..-wircei.t r"f p,,.f1ai"i
,
rar movement drsorders. They allneedhelp lean ng
basic motor skills. Under standilg
these skills and how you can help your child acquiri
them is the empha;
Teaching anewmotorskill ro a childwith cerebral palsyor ";,il;;;,.
a serious d"r"t;;;;"-
tal delay is a slow and tedlous process. More than thirtyyears
ofexperi"rrce *i.f.lr,,
Xviii TEACHING I\4O]OR S(ILLS TO CH]LDREN wlTH CEREERAL PALSY AND SII\IILAR A,4OVEA/]ENT D]SORDERs

with children with cerebral palsy has taught me that success depends on the close
cooperation and shared expectations ofthe patent and the therapist. As the story of
Nina in the chapterHeod up shows, misunderstandings between parent and therapist
are not helpful. Working together is the key to success.It assures that your child and
his progress remains the focus of the ffeatment.
It is not easy to raise a child with cerebral palsy and it is not easy to grow up with
a disability. It is my wish ro help with both.
ooaaa
I o
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Developmental Delay
o and Cerebral Palsy
a aaaaaaaaa

Fluringthe 6rstyear ot life. some babies show a delay in motor development. Later
l/rharo.l,.rrhildrpnrhF) rolduprheirhead.p.j\wirhrhei-rand,.rollorer,.i.
up, stand, orwalk. Premature babies are more likely than otherbabies
to show such a
delay. Usually infants wirh a moror delay are referred to physical therapy.
The physical
therapists then work with the children and give theirparents home inst.u.tions.
tte
activities and exer.ises the therapists and theparents do help the children to
learn the
missing age-applopriate motor skills. Most infarts respond vetywell to this
special
help and show good progress with their development.
Some children continue to show very slow progress in spite of the help
they
receive. They will probably be labelecl, ar leasr initially, as having a developmertal
delay. Dev€lopmerral delay is a descriprive term.Itrneans thata
ciild,s cleveiopment
is slower than thar ofmosr children. Ir does not tell why the child
is developing slowty
orinwhat area ofdevelopmenthe is delayed.Ifthe childrenalso srartto siro; delrys
in other areas such as self-feeding, speech, or general responsiveness, thev mav
be
called globally delayed. cloba1 delay is also a descrjptive 1erm, which does
not tell
why a child shows this delay in several areas ofdevelcpment.
As children with more serious gross motor delay undergo more testing,
_ _ theyare
likely to be specificaliy diagnosed. Cerebral palsyis oneposJle diagrlo"i..-ih.."
nr"
otherdiagnoses, whichalso maybethe causeforthe delay. Chromoslomal
abnormali-
ties such as Down syndrome or pradel Willi syndrome, brain malformations
such as
hydrocephalus or microcephalus, or conditions such as myelination disorders
and
seizure disorders like infantile spasms are other causes for gross motot
delay.
 I
I

2 iEACH]NG AIOTOR S(ILLS TO CH]LDREN \I/ITH CEREBRAL PALSY AND SIAIILAR A,4OVEA,1ENT DJSORDERS

Cerebral Palsy
Cerebral pals-v is a disorder of rrovcment :rnd posture. It is caused br a brain injury
that occurred befbre birth, during bjrth. or durjng the first few)-ears afterbirth. Ihe
injuryhinders thebrain's abilitvto contlolthc muscles of the body properly. The brain
tclls oul-m scles hou'to move and controls the tcnsion olthe muscles. Wilhout lhe
propcr mess:l8es coming from the brain, infants r'vith cerebral p:r1s) have diffic ltlr
lcarning basic motor skills such as crau,ling. sittiDg up, or walking.
Sincc ccrebral palsy hindel s a child's developrnent and usuallv causcs pr oblcms
that persist into ad!lthood, it is clnssified as a developmeDtal disabilit1.. Er.en though
the braiD injurl that causes cercbral palsl is present at birth, ir is otien diticult for
doctors to recognize it. For this rcason, there ma), be a delay in diaSnosis.
Llow much a child's de\,elopmentis affected by cerebral palsydepends on Lhe extent
and location ofthe brain injurJ.. Differentparts ofthe br'ain influence our mo\ements i11
different ways. The damage to the brail ma-v affect sone nusc]cs morc than othen.

Ccrcbral palsy may be classified either based oll the rnuscles rhat arc most af-
fectcd or hascd on the location ofthe brain injury and the resulting movernent problcm
(Ceralis, 1998).

TYPES OF CEREBRAL PALSY

Classifications Based on Muscles Affected
Quadriplegia. This t-vpe ol cerebral palsy affecrs the rnuscles in the child's
Ihe us.lcs ofthe tr'unk, arms. and legs do notr,,orkproper11. EveDthe
r,vhole body.
rnuscles of rhe face may bc affcctcd. This may cause feeding and speech problems il
addition to gross and fine motor difficultics. Children wlth severe quadripleSia have
tillil lt e. r,r r ( rro.r r cr r irr"r ol C r,l' l.r .rrr.

Diplegia. Diplegia means that the legs are mainly affected. Often parents do
not suspect a problem until theirbabyis 7 to 9 months o1d and fails to sit. Typically,
childrenwith diplegia gain the coordination and balance required for independent
sitting more slowly and not as well as other infants. Standlng and lvalking are af
fected most. Due to spastic (tight) leg muscles, children with diplegia tend to stand
on their toes, turn their legs in, and push their knees together. Depending on the
severity ofthe cerebral palsy, some childrenwith diplegia will be able to walk short
distances with a walker, while others may progress to walking independently ir-
doors and then outdoors.

Hemiplegia. In hemiplegia, one side ofthe body is affected by cerebral palsy.

The arm is usually more affected than the leg. Frequently children with hemiplegia
are able to compensate for the one-sided disability with their unaffected arm arrd
leg. They may learn most skills almost as quickly as children without cerebral palsy
until it is time to walk. weakness, poorcoordination, and spasticityofthe affected 1eg
may delay independent walking by a year or more. Depending on the sevedty oftheir
hemiplegia, the children may have little or Iimited use oftheir affected hand.

Ee
 DEVELOPA,4EI\TAL DELAY AI..]D CEREERAL PAL5Y
3

Ctassiftcation Based on Location of Brain lnjury

pyramidai (Spastic) Cerebralpalsy. This
is themost common type ofcerebral
palsy. About B0 per.Lnt ot children u irlt:etebra I palsy
have spasticity. This means
that they have mr*cles that are tight and limit moveme,ts.
These childreD also have
invohLntary movements caused by abnormal reflexes. See
the next chapter for more
information o[ abnormai re1]exes.

Extrapyramidal cerebral palsy. About 10 percent of ch,.1ren with cerebral

palsy have this type of cerebral They have abnormally 1ow muscle toDe, which
pa Isy.
meansthatrheir uscles areweak, and theyhave diffic lty controlii ng their m!
sc1es.
These chiidren have involuntary mor-ements, which mayinclude:
a Athetosis the movements are slow and
writhing,
. Atcria_the movements are unsteady, shalq/, and lac]{ Loor dination.
a Dystonio the movemeDts are slotv, rhythmrc. and tlljsring, ol
o Chore@_the movements are ablupt, quich andjerky.
Abnormal movements are discussed in more cletail in the
next chapter.

Mixed_Type Cerebral palsy. About 10 perceff ofchildren with

cerebral palsy
have both spastic muscles and the involuntary movements characteristic
ofextrapy
rcn_ tda .prcL, _a i p.rl\\

OTHER PROBLEMS RELATED TO CEREBRAL PATSY

The brain injury ofthe child with ccrebral palsylnayalso
affect otherareas ofthe brain.
This can cau se addition a1 disabilities such as ment; I reurdation,
seizure disorder, and
vision or hea ngloss. Do not assuDe, howevet that your child with
cerebral palsy
has additional problems. Because a child,s movemenrs
are different, broadll,ass;in;
rhar other rhings are wrong does injusrice ro the child with ,,only,,
cerebr;l palsy.
Ifyour child does turn out to have other_ disabilities besides cerebrat patsy,
you
will still be able to use the straregies described in this book to help hi_ imp.ov""tris
notor skills. More.than likely, however, voll will need the assistance ofother profes-
sionals besides;: plrysical.therapisr. Depending on his age, your
childwill qualifyfor
earlyintervention or speciaI education services thatwill;robablyincludc
the services
ofan infant educator, special education Leacher, or othe; professional
who can work
with rhe physical rherapisr to develop rhe best merhods ofteachingyour
child.
aaaaa
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Gross Motor
o Development
a aaaaaaaoa

Dabies are bom completely helplessi rhey have no colltrol over their bodies. placed
lJon rherr becl.. stomech, c,r side, thcy will stay there. They have no choice. Even
though they do show some organized trovement patterfls of their head, arms, and
legs, these movements are not purposeful and are not conuolled volunta ln
This changes soon afrer birrh as rypicirlly developing inlanrs start h;lding up
their head. Thercafter, they reach, kick, roll, craw1, sit, stand. and fina11vr,valk. This
allhappenswithin approximately one year. wlich mayseemlike a long orihortperiod
of time, depending on how you look at it. For firsftlme parents, it nlayseem endlessly
long, and for occasionatty \,isiting gr.andparents, very short. AII these changes that
the irfant goes through are refefled to as gross Dotor development. Motor means
movelnent. Gross motor refers to the mot)etnents of our big rnuscles such as the
muscles of our shoulders, arms, trunk, hips, or legs. This is in conuast to fine motor
development, which refers to movernents ofthe small muscles ofthe hand, and oral
notor development, which refers to movements of the muscles ofthe face.

The Sequence of Gross Motor Development

How does gross motor'dcveloprtr]nt unjird? As a gencral guiLleline infantt; ctcquire
motor cofltrol 'tcratlial to cau(|o|,', m?clning fron top (tlk head) to bottom (tlu
hips and leSs-). Fir st. children .onlrol the musclcs ol the head. Lhen rhe shouldcr s
and arfls, next thc rrutrk. ard lasL rhc hips ard 1egs. The\. deYeloD head ro tr,r.
'fhis js good Lo r'curelnber rhen ro! obseIi,,,on, , h,l.l. nro,., ,1,
\plopmrnt. IL

j
 6 IEACHING A,IO]OR SKILTS TO CH]LDREN WTH CEREBRAL PALSY AND SIA4ILAR A,4OVEA/]ENT D]sORDERs

is the same for all developing children, inclrding children wirh developmenral
delays or cerebral palsy.
One could compare the first year ofmotor development to a symphony played
by a large orchestra. The music starts softly. Only a few instruments introduce the
theme. Soon more insuumentsjoil1 in and the sound becomes ftll. The music swells
and ebbs as different sections ofthe orchestra show their skills. There are times whell
all instruments play and it may sound lil<e a big, confusing competition. yet, at the
grand finale they alljoin together with masrerful harmony.
The symphony ofan infant's motor development starts with her head. you smile
at your baby and show her a pretty mttle. As you move it, she follows it with her eyes
and head. \4usc es oi t he necL purpo:.lu ly r u,n lter l"erd.
A few weeks later you repeatthis game. Now you notice that she is also waving
her arms. As she excitedly flai1s them about, she may bat the toy. A week or two later,
she may successfully reach for the toy. Clearly, the shoulder and arm muscles are
chimi[g in and trying to work in concert with the musc]es olthe neck.
Next, as the trunk mrscles become active, you wiil see the first controlled body
movemenr. From side lying, a rypically developing infant rolls to her back or her
stomach. when held, she not only holds up her head bur also her trunk.
How are her legs and feet doing? Yes, the infant is busily kicking her legs_ pur-
posef[lleg moyements are seen when she lifts her legs offthe floor to touch them or
to ro11 over.
By six months, halfway through the firsr year of life, a typical baby is using all
the big muscles ofherbody, but has little to show for her, efforts. She works hard to sit
up, yet topples over quickly. Struggliflgto move, she manages to circle around onher
tummy. Her muscles are notyetwell organized. Only her neckmuscles have gained
good control. She is now holding her head nicely in all positions.
During the following months, the baby nasters more important skiIls. She crawls,
pushes into sitting, and sits up ght with balance. She happily moves about, plays
r,l hile siu. n8. . no busily does so a ll dav long. W,r. a ll or r l is p.ac, ice, r he muscie. of
the shoulder and trunkbecome stronger and more coordinated over time.
Fina1ly, the le8s, too, become skilled and sttong. The babypracrices standing r.]p,
coming down, and stepping while holding onto furniture. Then, in a grand finale, all
big muscies work together in harmony. The baby takes off and walks.
From now on, mainly the component that had the late start-the hip and leg
muscles-and all balance skills will continue to improve for years to come. There is
so mrch 1nore to learn: running, jumping, hopping, skippin& stomping, galloping,
standing on one foot, bicycling, and maybe skating or skiing. Balance continues to
improve until children are twelve to fifteen years of age (Taguchi and Tada, 19BB).
Insummaay, typically deyeloping children experience a period offast gross nro
tor deyelopment from birth until roughly one year of age followed by a decacle ofslow
futher improvement and rcfinement.
Before addressing how children with cerebral palsy in particular develop, let
us pay attention to some lesser known aspects of motor development dll ng the first
months of life. It has implications for all children.

L
 GROSS ]\,IOIOR DEVELOPA,,IENT 7

The Baby's Position lnfluences Motor Development

Early motor development occurs in clusters depending on the position the infant is
placed in- Infants develop one set of skills in back-lying, another in stomach-lying,
and a third when beirg held in sitti[8, standing, or being carried. lio w the infant
is
placeilto rest or to play makes a difference. When you place youl baby on her bacl1
her side, or her stomach, you determine which muscles she will be using. This isjust
as true for babies with movement disorde$ such as cerebralpalsyas it
is for typically
developing babies.

. _Children wirh cercbralpalsyare especiallyaffected bythe position theyare piaced

in. They learn to ro11 over on their own
!qC! than other children, and som; maynever
master it. Consequently, the pareit or caretaker determines theirposition.
Knowiflg how your child,s position iofluences her gtoss motor devetoDment will
help you better understand the physical therapis I's recommendations. you will
know
better what to expect when carrying out a home program. It may help you .,sneak,,
little work sessions into your child,s daily routine.

BACK-LYING
In bdck-lyittg,
ilnfc,nts start to use the fiil5cles in hotut of their bodv called the
!9gtrylsrkt. rhese are rhe musctes rtraL tiii?nii ofi6inrsI t.nIran;;;td
r
or move the head in back-lying, the muscles jn ftont of rhe neck (the neckiflexorst
are working. lhey hold rheir head in rhe middle or I urn ir. As a baby ger. srronger
and more coordinated, she lea.ns to tuck her chin, nod her head, or lifiher head
off
the surface. You may notice your baby cra4ing her head forward in the infant or
car
seat. She wants to see everything and is using her neck flexors to do so.
Which shou der mu"cles arp wotking i1
back-lying? Again the muscles in f.ont of rhe
'hoyEg, j]bSjlS-!]-d_iL-!SIqr: -witl brin8 rhe
arms forward. Bendingboth shoulderand elbow,
the babybrings herhands to hermourh and bdngs
them together over her chest. As these muscles
get stronget she will be able to bring her arms
! 3
up with elbows straight so that she can teach afld
t 1
)
play in back-lying.
What else can babies do in backJying? They
r d kick their legs, they bring thei legs up, they rouch
their knees, and finally they b ng their legs up so
high and for so iong that they can do thef favo re
thing-play with their feet. Again, the muscles that
nrrk. rhis happcn arc iD Ironr oithe bodli The hlp
llerors bcnd rire hip and lifr lhe l.gs LLp. t t. LLr nr r mu..l.. |lhe rrLr n ( t]eru s.l help
b\' curlinii the Lrrrrrkalitrlc
Whcne..'er\.ouprr\.ourLrtiyonherbr(l(,LhcmLLsclcssherscsu,ill bemostl\.
fic':ror nrusclts- lherrfote. rh.se u,ill be,,mest,nge1..rn,lnr,,,,..oo,.l,,,eL",l..lh'e
same js trlLe uhe11\orr placu r.oLLr brb! rn ,: Lerlft,d p, \1tiolr. \fLh t\ rn
rrr rnfent
8 TEACHING A,IOTOR SKJLLS TO CHILDREN !/]TH CEREBRAL PAISY AND SIMILAR MOVEMENT DISORDERs

STOMACH-LYING
In stomach-lying, infants starl lo use tlc,nur_.ler ir fhe bo./r of tl1eir bodv coll"d
the er.tensor muscles. These are the musc-le |6.at str"Eflien Cxt""d) rhe jo, .r.
Anewborn babycurls [p on her stomach. She looks so uncomfortable with her
alms and IeSs trapped under her body and her head dowfl. The muscles at the back
ofthe neck (the neck extensors) work to I ift the head and allow it to turn to the side,
so the baby can breathe easiet
I muscles of the back (the shoulder and back extensors) stretch the body and
let the arms slide out from under it. The buttockmuscles (the hip extensors) stretch
out rlre hip and the baby rna) lifr her legs.
Every time the baby is on her tummy, these muscles are working and getting
stronSet yet she accomplishes little. She may lift her head and wave her arms while
wiggling her legs, and look like a stranded bird ready for take-offl What a great back
strengthening exercise! Try it for yourself. All of her extensor muscles are working.
It takes time for the backmuscles to work in coordination with the shoulder and
legmuscles. This happens when the baby propJherself up on her fo."ur-s, or
1,1u.".
her hands on the floor, pushes up, and straightens her elbows
(photo 2.2). Now she shifts her weight over ofle arm as she reaches
and plays with the orher While playing on her tummy she learns
to move to the side and then also forward. Last she pushes onto
hands and knees. From this position slle moyes into sitting, starts
to crawl, and finally pulls ro stand.
Whenever you put your baby on her stomach, her neck

"@.1h.y
wl!!!!!9!ljus!8s|qld_Aq!l [!j-_ ared o! cr I ime.
r1i omount of time ea* aoy r noGiiiu @nd on theit
-The
bdck, siile, or stolmalh makes a difference. Infants who spe[d
little time on their stomach have less of an opportunity to strength
en thek back muscles. Tummy time is especially important for
children with cerebral palsy because they usually have weak back
muscles. The more chances they have to train these muscles, the
bette. itwi11be.

OTHER POS'TIONS
In sirleJvin3, thcr
held LLpnghr, orr,-hrr mor,-ed lron one posirion to another. babies
ar-e stimLLlaLed to lrse the llC\or alld ertc[sor n]LLsclcs at the sarrc tin e in scquence or
rltcrnaleh'. !!hene\.er vor carrt !o1l bab1, rli:tpcr her, changr: her ciothes, or Larhe
herr, t-or affccr her .:ross nloror.le\clopnlent. As you r-oll hcr frojl si<lc to side rncllilt
herleSs,arns.orhcad.rouLrigge)lrLLsclcrcsponses.Fussijtgo|eraDdpla\ingu,ith
your babr is 8ood.
Tt rs good ti)r .he l\.pi.il \ de, el,,pr FX ( hi1cl. i n,l ir 1" 1n ,d fu1 \our
.l .1 . - r ,.i..1-,6,r |,r .-.1 .. r.r.
lying is a good pr)srtioj1 ]or habjes Lo rcst or sleep in. \\hen awrlhe, 1yin.q on
Sidr,,
Lhc sidertal\cs ir easv iar infanrs ft) hr.ing thcjr hand to th.ir mouLh Plav ith their
hands. and look ar Lhcnr. the\ .lo ror ha\:r to lift rheir arns agairsr gralitv as in
baclrl_1ing.Tnsldel]jng.abnofinalretletL\ r lrlrn .mr ln Ls.l"r,oe.r,.l.-.rlike1,,
 GRO55 I4OTOR DE\,ELOPI\4ENT 9

!-nte4l9giElh94i1d!-agq-!gqlE@ts. For these reasons, your child,s physical

therapist mayrecommend side,lying for early ur- ao.."rn"rrt. o. play activiiies.
Side lying is the position infants can move out of easily. An unintentional move-
ment and the pullof gr avity will assist them with rolling either onto the stomach
or
the back. Usually infants firsr roll out ofside lying incideDrally and later discover
how
to do it puryosefully. Theyleamtharbending or srraighrening the muscles
on rhe side
that does not touch the surface will cause the movement o;t of side-lying. For
this
reason, babies who are two moflths or older do not stay in sidelying
very long. Within
minutes ofbeing placed, rhey toll out of it.
Positioning in side,lying may be recommended for childrell with develoomen-
tal-delay or cerebra I patsy. C.p""iul ll fo. *, abl" .o p*l iiiii u,
r,,o.u:1.llirsi:h.ri "hild*n
,s
praceo ln rl1e stcte posttron. her thempist will show you ways to prop
her up so that she
willbe able to remain in the position for longer periods of time.

The,Motor Development of the Child

with Cerebral Palsy
Children with cerebral palsy acquire gross Eotor skiils in the same order as other
children. Filst rhey hold their head up, then they sit and crawl, and lasr theywalk.
"If this is true,,, you wonder, ,.why does my child do everything so differently
than other childrer?,, perhaps you have read about child development in a brochure
from the docto/s office or tr a book. There were nice pictures showing what babies
do at cetain ages. your child does not do these things.
you werc told that your child,s
development would be delayed and that she needs
more time than other children to learn basic skills. you are patient and help her
along.
Your child is growing and learning new things. But, what she does looks
different
from the pictures in the brochure. what she does may not be shown or mentioned.
Therefore, yo11 conclrlde that your child is not only developing more s]owly but
also
differently from orher children.
youl obseryation i s correct. As expiained
in Chapter 3, differences in your childt
muscle tone and in her movement patterns, as well as difficulties controlling
her
movements, affect her development of motor sldlls.
Nevertheless, it is also true that children with cerebml palsy usually develop
skillsinthe same sequence as otherchildren. fut they acquire skills more slowly ancl
theymaylearn them in bits and pieces.4lLllllllat babieit\,rricallv learn wirhin
one
month may teke the-child wjth cerebr-al palsy@ly,
and it may takc@olherelght months ,tntil .he fuliy rna.t"rs ir fh e initial
incom_
plete skill leallTilag .tnd the foltowingiiorious timila{until
full mdstery of
the skill are reasons why the motor deyelopment of childienwith cerebral paliy
appears so different.
Ler's use rhe development ofpiay and reaching in back-lying as an
example. The
baby in the brochure masrers the skill ar four months. The ciilJwith
cerebral palsy
may start to play in back-lying around the same time. She may hold
a rattle in her
had and purposefuily shake it. she may reach, butwilrnot do so in a[ directions and
may not stretch out both arms like the baby in the brochure.
,O IEACHING ]\,1OIOR 5K]LL5 IO CHILDREN wlIH CEREBRAL PALsY AND SIA,4ILAR ]\4OVE]\4ENT DISORDE]IS

With time and much practice, the child with cerebral palsy may further improve
her reaching skill. Finally, she may master it. She stretches both arms forward. But,
by then she is oo lonSer a baby who likes to play in back-lyiog. Instead she sits on her
Dad's lap and stretches both arms ou! catchitg the ball Mom rolls ro her
So even though the t)?ically developing baby and the liftle girl with cerebral palsy
do very different activities-one plays with toys dangling from the baby gym whiie
Iying on her back and the other plays ball while sitting-borh are able to straighten
their arms forward. After they haye accomplished this skill, they ate both ready to put
weight on their arms. They are ready to push onto ,,big arms,,with straight elbows,
come to hands and knees, and learn to ctawl.

ASSESSING DEVELOPMENTAL PROGRESS

With your child devcLoping so differentlr.. lvhat car vou e_rpcct her to do and
lvhcD can vou expect hcr to achicve a cerrain skill? Thjs used to bc ditllc lrtoalls\\,er.
because each child \\,jth cetebra] pa1sl, Ll$,elops uniquel]. ar hcr own pace and in her
owll \,ray. Fortunate]v. sonle gcneral guidcliDes have been dcveloped r.ccentiy:
. ALesrrorreasurc rite gross ntotorskills of chlldr.cn ith ccrebral
palsy has been developed. It is called the Gro ss Motor Functi;n
M?osi/i e (Russel, 1993). 'l'he test tclls yoLl !^rhatyour child can do
at the dme of testin g. Retes ting at regular intervals u,i I I sho\,v you r
child s progress. Thc Deurest \rcrsion of thc test gives vouvaluable
additional information (Russcl, 2002). After resrlng, the phlsical
therapistcan shor,yoLL Lhe items_vour child passcdand othcrtest
items in order of dillicrLltv for childreD with ccrebral pals\,.. The
nert skiils yolrr child may master will nlost likelybe test items oI
siurilar difficultyl-o r child has not vet passed. The printoul,vor.r
receive llsts the itens byritle. Fora clear-ulderstanding ofrhrm.
a l you, nlry ic: r r|r, pi., ,, a erpri,nal'ot .
. Acrorr MoaorF Lion rebt'al Polsvhas
been developed. lt dividcs children rr,,ith cerebral lnto five
different levels, according to rheir abiliw, and describeJ in ggneral
telnls the gross motor s of each rth and
tW6IG Yearj_9!3€9r

Table 2.1 is a reprinr olLhe (;, orsrlfr)&r.l.it,i.lrrrr CldJrlt..rti.fi -Sysl.,nr as prLblished

I.1ob fll-, \. rru , rL, o - s,.\ | l.o
Ihe Gross r\4oaor lun.tirrr Cldsrlirdalo/t .Syrtu,rl (Gi,4FCS.) ajtd rhe Groris Moao7.
lirl.ti.)n Medsurr ((;r\rFrl.4l have been Lrsed b\'{)nc research tean) to studythe gross mo-
Lor dc\rlopir]Cnr of 585 children v.,,ith cer ebral palsv alisano 2000) and by another
Leam to sloLl\' 657 childr.n 1^,ith ccrebral p;rlsl. (RoscnbalLtn 002). The researchers
,2
lound thar rh(: childrer ilt all le\ cl\ D1aL1. rh(l nlosLpr'ogress in m otor Iunction b etlve en
birth and 3 ro 4 years {)iage. B\, 7 vears of ate. m.rs. of the chjldren har reachcclrhetr
potential. The childr cD at iev.ls tV and \, tendcd ro reach their pot(:ntial eerlier rhan
children ar levels I. t1. ot IiL l he childr en at Ie\d ll continued Lo improve ar a s1oh, r ate
ior a l(nlgel trnc .han Lh! (:hildrcr irt olher lc\.e1s. Thc firsl st Ll\ (paljrirno] reports
that thcse chilclr.n pr.rgrcssed rLn.il the\ were alntorr l0 r,errs old.
 GRO55 I\4OTQR DEVELOPI\,1ENI 1
'

TABLE 2.I GROSS MOTOR FUNCTION CI-ASSIFICATTON SYSTEM

FON CEREBRAL PALSY
Robert Palisano. Peter Rosenbaum, Stephen Walter, Dianne Russell,
Ellen Wood, Barbara Galuppi

INTRODUCTION & USER INSTRU€TIONS

The Gross Motor Function Classification System for cerebral palsy is based
on self-initiated ntovementwith particLilar emphasis on sitting (truncal control)
aald walking_ When defining a 5 level Classification System, our prlmary crjte-
rion was rhat the distinctions in motor function between levels mirst be clinically
meaningful. Distinctjons between levcls ofmotor functlon are based on function
al limitarions, the need for assistive technology, including mobillty devices (such
as walkers, crutches, and canes) and wheeled mobility, and ro a much lesser
exte[t quality ofnlovement. Lev-el I_i_nclltdes children with neuromotor impair_
ments whose functional limiratrons are less rllan whar is typicillly associate<l with
cerebral palsy, and childrenwho have traditionally been diagnosed as havinq
"minimal brain dysfunctioD,, or ,,cerebral palsy of miDimal severiry.,.The disiinc
tions between Lel.els I and Ii therefore are not as pronounced as the distinctions
between the other Levels, particularly for infants less than 2 years ofage.
The focus is on determining which level best represents the child.s pres
ent abilities and limitations in motor funcrion. Emphasis is on the child,s usual
performance in home, school, and community settings. It is therefore imporrant
to classify on ordinary performance (not best capacity), and not to jncluJe j dg-
ments about prognosis. Remember the purpose is to classify a child,s present
gross motor function, not to jr.ldge quality of mo\,ement or potentlal for improve
ment. The descriptions ofthe 5leveis are broad and are flot intended to describe
all aspects of the function ofindividual children. For example. an infant with
hemipiegia who is unable to crilwl on hands and knees, brtr otherwise fits the
descriprion ofLevel I, would be classified in Level L The scale is ordinal, with no
intent that the distances between levels be considered equal or that children with
cerebral palsy are equally distributed among the 5levels. A summary ofthe dis-
tinctions between each pair of levels is provided to assist in deterntining the lel_el
that mosr closely resembles a child,s current gross motor function.
The title for each level represents rhe higllesr level of mobiliry rhat a child is
expected to achieve berween 6-12 yearc ofage. We recognize that classlfication of
motor function is dependent on age, especiallv du.ing infancy and early childhood.
Foreachlevei, therefore, separate descriptions are provided for childrell in scveral
agebands. The functional abilities and limitations for each age interval are ln_
tended to serve as guidelines, are not comprehensive, afld are notnorms_ Children
below age 2 should be considered at their corrected age ifthey wcre premarure_
An effon has beel made to emphasize children,s functionrather than theirlimi-
tations. Thus as a general pt-iflciple, the gross motor function of children who are able
ro perform rhe funcrions desc bed in any parricL ar level will probably be classified
at or above that level; in contrast the gross motor functions of childrcn who camrot
perforn the functions of a particular level will likeiy be classified below that 1eve1.

fcon/nued.n nexrpot.. )
12 CHING ]\/IOTOR SKILLS TO CHTLDREN l/rTH CEREBRAL PALSY AND SIA/]ILAR ]\4OVEA.4ENT DIsORDERS

c o ntirued Jrcm p rcr iou p ase. )

GROSS MOTOR FUNCTTON CLASSTF|CATTON SYSTEM FOn CEnEBnAL pALSy (GMFCSI

Before 2nd Birthday

Level I: infants movc ln and oua ofsitting and floor sit \\,iah bolh hands frcc
lo manipulate objects. Infenrs crau'l on hands and knees, pull to sra.Ll ind tal(cl
sleps hol.ling ()n t() flrr'niture. lnfants \yalk berureen 18 months ilnd 2 years of age
without thc nccd for any assistive ntobiliL_v de\rice.
Level II: Infants mairrain floor silrlng buL IIr:1! r]eed to sc thcil hands for
stpport to maintain balance. Inlants crecp arn thcir'stomach or cra$,1on hands
and knees. Infants mavpull to stand and tal{e steps holding on to ftLrniture.
Level III: lnfants maintain floor sitting uTher the low back is supporte.l.
Infants ro11 and creep lbrurard on thcir stomachs.
Level IV: Infants have head control hut trunk support is required for floor-
sitting. 1nl'ants can roll to supine aDd rnav ro11 ro prone.
Level V: Physiaal inpairnents linlit volllntal-y conrrol ofmovernent- lnfalLs
are unable to m:rirtaiu a Dtigravit)' head and trLlnk porirur'cs in prolte and sirting.
Infants lcq!ire adult assistance Lo roll-

Between 2nd and 4th Birthday

Level I: Children floor sit with both hands fuee to manipulate objects. Move
ments in and out offloor sitting and standing are performed without adult as
sistance. Children walk as the preferred method of mobility without the Deed for
any assistlve mobility device.
Level II: Children floor sitblu may have difficulty with balance when both
hards are free to manipulate objects. Movements in and ort ofsitting are per-
formed without aduh assistance. Children pull to stand on a stable surface. Chil-
dren crawl onhands and knees with a reciprocal pattern, cruise hotding onto furDi-
ture and walkusing an assistive nobilitydevice as preferred methods of mobility.
Level IIIi Children maintain lloor sitting often by "W-sitting" (sitting
between flexed and internally r otated hlps and loees) aDd mayrequire ad lt
assjstance to assume sittill8. Children creep on their stornach ot cranv] on hands
and knees (often without reciprocal leg movements) as their primary merhods
ofself mobility. Children may pullto stand on a stable surface and cruisc short
distances. Children may walk shofi distalces indoors using an assistive nobility
device and adult assistance for steering and t rning-
Level IV: Children floor sit when placed, but ar-e unable to nainrain align-
ment afld baiance without use oftheir hands for support. ChiidreD frequently
require adaptive equlpment for sitting and standing. Self mobi1lr1,fbr short
distances (lvithin a room) is achieved through ro11ing, creeping on stonach, or
crawling ol1 hands and knees without reciprocal leg movement-
Level V: Physical impairments restrict voluntary control ofntovement and the
ability to maintain antigra vit1, head and trunk postures- All arcas of rnotor function
are limited. Frnctional limitations in sitting and standing are not tu11y compensat-
ed for through the use of adaptive equipment aDd assistive technology- At Level V,
children have no means ofindependent mobility and are transported- Some chil
dren achieve self'nobility using a powet wheelcha with er(enslve adaptations.
 GRO55 I!4OTOR LTEVELOPI'ENI ,3

Between 4th and 6th Birthday

Level I: Children get in.o irnd out of, and sit in, a chair lr,ithout thc nced for
hand support. Children mo\.e from the floor rn.l lioln chair sltling to standinS
witbout thc nccd lbl objects ior sLlpporr. Childrci walk indoors and outdoors,
and climb stajrs. Fmer-ging abilitJ to run andiump.
Level II: Childrcn sit in a chair 1\jth bolh hands free to anipulate objects.
Children move froD thc flo(n to strndi S and from chair sitting to standing but
ol'ten require a stable sr:rIau: ro push or'pu11 up on ra-iah their arns. Chjldren walL
\rlthout the need tbr any assisti\(: mobilia] device indools and for short distances
on lcvcl sLn faces ollldoors- Children clinb stiirs h.rl.ling onto a railing but are
unahltror norjLLmp.
Level III: Children sit on a reBular chair hut may requile pelvic or Lrunk
support to rnaximize hand lilncrioD. ChildreD no\.c in ancl o!t of chair silting us
ing a srable surfar:e to prlsh on or pull up \rjLh their arrns. Childr cn walk wlth an
assistive mobilir) dc\ icr: on lcrcl surfaces and climb stairs \,vith assistiln(c from
an adult. Children fr e(lLr(ialy ar(' rr'.rnsporred when lravellins fbr long distanccs
or-outdoors on uneven terrain,
Level Iv: Children sit on a chair but rccd aLlaptive seatinS lbr uunk control
and to mnximizc hand Iunction. ChildreD mo\'e in alld out of chair sitLinB wirh
assistance fronl an :rdolt or e stable sLll face to push or pull up on \rith their arms.
Children rnal rt br:st nalk shorl distances with a walker and adult supcrr.ision
brLt have difficul turnjng an.l maintaininS balance oD uneven surfaccs. Children
are rransported in the commr.rnitv. Chilclren may achieve sellmobilit!' using a
pou,er wheelchait.
Level V: Phvsical impairtnerlts restrict volurt:lry control of nlovemeot and ahe
abilit), to lnaintai r.tigravit,v head and trunk postr.rrcs. Allareas ofmotor tirnction
are limited. |unctional limitations in sirLin8 and standing arc n()t full! compensat'
ed for drrough the r.r se of adaprive equipnrenl and assistive technolog),. At T,e!,el V
childreil have no meaDs ofindcpclrdcrr mobility and are transported. So[rc chi]-
drcn achieve sellmobility using a poner r,r,hcclchalr with exLensive adaptations.

Between 6th and l2th Birthday

l,evel I: Children \ralk indoors and outdoors. and cli b stairs without limi
tations. Chiklrcn pci f{)rm gross motor skills includinS rulllling and junrping but
speed, balance. ard (oordi1r arion ar'e .educed.
Level II: Children walk indoors and outcloor-s, and climb stairs hokling onto
a railinB bul experieDcer limitarions w,alkjng on Lrneven sLlrfaces and inclines, and
\,valklng in cr'o$ts or confined spaces. Childrcf ha\ c at best only nlinimal aLrility
to pr:rform gross n-rotor skills srLch as runnln8 and jumping-
Level III: Children u,tilk indools or outdools on a ler.el sur'facr: with an assis'
tive rrobjlity d(:virc- ChllLlren rrra\' clifirb slairs holding onto a railiDg. llcpcndirlg
on upper lilnb frn(ion. childlen propel r $4reelchair manuall)'or are transported
r'lre'r' r.. n/' l .! ,1,., .,r '. , \, r r, rr.'r..
Level Iv: Children ma! maintain lervcls of functi()n itchle!cd bel(r1e age 6 or
rei\ more on r"rheeled 11lobilit]' at hone, school, and in thc communit). Children
mr! nchie\e sellln1obiliL)' rLSinB a pol\,er \,!,heelchair.
(condnEd on next page.l
f4 ]EACH]NG MOIOR sK]LLS IO CHILDREN wlIH CEREBRAI PAL5Y AND SI]\/IiLAR A4OVEMENT DISORDERS

(c antinued Jf o t n Pt er i o 6 p d4e. )

Level V: Phvsical impairnletlts restrict voluntal.y control oI mo\.emelll and

thc ability to nriri[taln ant]gra! irv head nDd trulk postures. All arcas of motol
f ncrion alr liuited. Funrrjonal linritarions in sittlng and standing ate not filily
compellsitcd fol thro gh the use of adaptive eq!lpDent and assjstive rechnol
og_1. At h\ cl V, childrcn have no mcans of indcpcndent Inobiljtl and arc lrans
ported. Solne childrcIl achiexc sclf n]obiljtv using a pow,cr l\'heelchair with
extensj\c adapLations.

DISTINCTIONS BETWEEN LEVELS AND II

Comparcd r!,ith' childrcn in Lel'el i. childlen ln Lc\€l II havc linitations in the
case of pel forntj]lg ]rnrvemaltt transjtiolts; \,rralking outdoors rnd lt the communitl,;
the need lirr assisti\€ m.rbilitlr de\,i,-cs when beginDing to t ralk; qualiry ofmove
menl: ilnLl rhe .hilitv to pelforfi gross nlotol.skjlls such lrs rurnin3 and junrping.

DISTINCTIONS BETWEEN LEVELS II AND IrI

Diflerenccs iire seen in the degtec ofachie\,emert of fulctional mobillty. C1i1
dren irl Level III nccd assisrivc mobilir\, .lcvices a d frcquenllv orrhoses Lo waiL
\,!hile clildr! jl1 Level IIdo norreqLllrc assistil,.e mobilitydeviccs aftel age,l.

DISTINCTIONS BETWEEN LEVEL ItI AND TV

Diffetences in sirting abilltr- and firobilitl, erist, cven allowing for extensive
use of nssrslive h chroloS),. Children in Lcvel IIt sit independentl).. have inciepen
denr floor mobilit\, and l!-irlk \,!ith assisri\e mobility dgvi6g5. 6h;1d.en in Level lV
frncrion in sitring (usualh supported) bur indepcndent mobiiit), is very limited.
Children ln I .,r,el l\i:1re more ljkelv to be transported oi use pouier mobility.

DISTINCTIONS BETWEEN LEVELS IV AND V

Children in Lcvel V lack indepetldencc c\.e11 in basic antigra!ity posrural
co.rr'ol. Sell nr.rhility is achj$ ed only if the child can learD hoN ro opetate an
ekctricallv powcred \,vheclchajr.

Relerencei Ddtlrprre u l r,Ldi.nr & (r7rii.l ,yon.olo8), t9 97: 39:274 223.

o 1997c ichlld centrc lor chirdhood Dis.riritl Resear.h (f.,rmerly NCRU), Mc[4asrcr unileNiL],. Hamjtron, oN, cana.la
L8S 1C7: icw$.l hs.mcmasrer..a.tardrild

The :r .hors ol tltc stlLdies L.lie\.e rhirr rhc CfrIFCS and GI,lFN,l provide \.eluable
if tbrmati(n1 to pare.rs oi chil.lr.Il rl,irh ccr( bra1 pa1s,v' arcl ro profcssio11als r,rorkiflg
r.ith rhr: r:hililen. Ihc].gi1'e gcncral SUiLLrlines con.o nit13 Lhe gross mot.n progtess
arld ponrlrial ol rhc chi[dren. Hor^,er.er. rhc aLlthor.i] srate: .,This infot trari(nt may bc
useliLl in anticip.rin,r chingc over LimI brrr shoul.i nof be u.e./ ro p re.Iict the
fuiure
8ross ,Iotor.function _for on indtrtiduol child.', ! hev recoflrmend thar rhe intbrllrir
tion h.r used in (,onluncLi(n1 [.ilh (]rhcr reler.anr irlorm:Lti(n1 r.i1en : liing dc(isions
c{)f (ernijls iL sPccrlic.h jld.
 cRoss lvtolo I lltvEloPlltEN I I5

Frequently Asked Ouestions

a, "You talked about how different posirtons affect babies. Is the satae true for older
child,ren?"
A. Yes, for example, a child who mostly sits in a rcclined position or lies on her back
will not exercise her back muscles.

A. "I want Megan to sit by herse\. How does the Gross Motor Function Measwe tell me
when she will do this?"
A. The Gross Motor Function Measure does not tell you when Megan may sit. The chaft
tliat accompanies the test gives general guidelines. For instance, it te11s you which teBt
items most children master before they sit on their own on a belch for 10 seconds.

a. "Dustin is fi,e years old.. His physical therapisr told ils thal Duslin i s at lelel III of the
Gross Motor Functian Aassification Systefi. Does that mean that he wiIL not walk? we
ore lery upset about this-"
A, I understand your feelings. Who wouldn't be if told that their child may [eed a
walker or crutches for walking? Your reactiorl shows how much you love Dustin.
Remember that the Gross Motor Function Classification System gives only 8en-
eral guidelines. Do not give up hope too early. You have nothing to lose when working
with him toward independent standing and walking. The training will be valuable
even if Dustia ultimately does not succeed in walking without some support. The
balance and coordination he gains will make walking with support easier and more
efficient. This means that his endurance will improve. Also, when Dustin becomes
really comfortable with his walker or crutches they may bother him less than you may
think. I have seen quite a few happy smiles on the faces of children who walked with
assistive devices.

A. "Wouldtl't it be better not to know my child's level and aLL the informatian about it?
A. I dont have a good answer to this. This is new information and time willtell how
helpful it is- I believe, however, that the information is very valuable for parents of
older children with cerebral palsy.It confirmswhen their child has reached her full-
est potential.
aaoao
a
3 a
a
a
a
Obstacles to Motor
a Development
a aaaaaaaaa

The previous chapter touched oLr two of the effects that cerebral palsy has on a
I childs rnuscles. It calLses problems with muscle tone and also with involuntzrry
or abnormal movemeflts. This chapter fbcuses in more detail on holv differences in
muscle tone, as well as abnormal movement patterns or reflexes can complicate the
acquisitioD of motor skills.

Muscle Tone
What is muscle tone? X4uscll] tonc rtfcr's to rhc amount of tension an- resistencc to
movemcnt within a musck:. \'lusclrs havc chsrjc proper ties, similar ro a nrbbr:r brnd.
Rubbcr bands arc sofr or rard depending on hol, easill thel,rre stretchcd. Xlr.rscicrs
har.e lon or hiSh tone, rvhich makes rhern easl'or less easl to stretch.
Muscle tone 1'aries liom person to pelson. Sonle people hal,e lo,,\'muscle Lone.
Their nluscles are soti. hr\ e litdr tenslon. and ir'r rasil) strrtchrd. orhcr ptople har c
]righel luscle tone. Nlore resistancc is lr]lt $hrn thr:ir musclcs a(: strctrhcd. F.rcn
when resting. their nrrsclcs ar c sorrr:rthat ratrr and har.e rnorc rcnsjon.
Chilelren u'ith cerebrul palsy have rn.lscie tone thof i5 oufsidc the norntal
vcriotior. tf the tone rs !erv lou il is ca11ed hvpotonic or flaccid. A hypotonic or
/'loccid muscle is sofi and very stretchable. There is hardh'anr resisrance Llt when
an arm or le8 is moved.
11 the Lone is ver\ hi8h it is .alleLl hvp!rt(nic or spastjc. A ,ryperto[ic o,'rpos-
tic tnllscle.feels lfird. ond resirti" being stret lred. lfthe spastic nuscle is stretched
18 TEACHING Ai]OTOR 5(ILL5 TO CH]LDREN !/ITH CEREBRAL PALSY AND S]A4ILAR A,IOVEA7]ENT D]SORDER5

slowly, the same amount ofresistance is felt until the muscle is stretched to its full
length. But if you stretch the same muscle qrickly, the resistance increases and stops
the movement before the muscle reaches its full length.
Children with cerebral palsy may have hypertonicmuscles or hl.potonic muscles,
or a combination ofboth types ofmuscle to[e. Children with milder forms ofcerebral
palsy may have a combination of muscies with norrnal and abno ral tone. Some
children have fluctuating muscle tone. This means that the tone ofa muscle swirSs
fuom being very low at rest to very high when the muscle works. At birth, however,
most children with cerebral palsy have low muscle tone. Often, it is not untii many
months later that the first signs of abnormal high muscle tone are seen. and additional
months pass before a diagnosis ofcerebtal palsy is confitmed.
Muscle tone is regulated by nerve cells in ourbrain. Children with cerebralpalsy
have damagetothose Derve tiss[es. Which parts oftheirbodies are affected and how
much they are affected byabnormalmuscle tone depends [pon where and how much
daurage has occurred in the bmin.
Your child's m[sc1e tone affects his movements and motor development. Hypo,
tonia very low muscle tone-makes it harder for children to move against gravfuy,
resistance aDd to move forcefully.In stomach-lyi[& for instance, it is difficullforthen
to push off, straighten the elbow, and raise their chest off the floor. After much prac
tice, as the children get sffoDger and more coordinated, the effect of the 1ow muscle
tone willbecome less noticeable.
Hypertonicity-very high muscle tone-means that children have to wod( ver y
hard to overcome the resistance of spastic and tense muscles. Forinstance, ifthe innel
thigh muscles are spastic, theywill prll the leg inwad. whenthe child wants to move
his legs outward, he must overcome the tension ofthese spastic muscles. Depending
on the child's position and the task at haDd, this maybe easier in some situatio[s than
in others. The exercises and activities yorll therapist tecommends and the ones given
in this book try to minimize the iofluence of the spastic muscles.
The abDormal muscle tone caused by cerebral palsyis not progressiye.In other
words, it will not get worse over the course of your child's life. It also will not get
better. Your chiid will not "grow out" ofhis muscle tone problems, nor will exercises
help normalize his ton e. Howel)eL thet apeutic exercises dnal activities witlhelp him
mastef motor skills itt spite of his c.bl].ortudl muscle fone. And, as disc[ssed later
il1thebook, exercises and stretching are very impoatant in preventing complications
such as joi[t contractions that can make movementmore djfficu]t.
Muscle tone is afJected W etuotions. yo:u Iiray already know this from experi-
ence. You quiver with joy or are frozen by fear so that yor stiffen your neck and back.
The same happens to childrenwith cerebral paisy, only much more so. Theyliter-ally
may la.l don n lcugl_ ing or go to pieces cr) ;ng.
Strong emotions bdng about an abnomlal i[crease of mLrscle totle in children
with cerebral palsy. Theymaylose control of their nuscles, aDd abnormal movement
patterns are more likely to occur. For this reason it is best to keep excitement-good
or bad-.o a 'rinimum uhen you work w:lh )our.l-ilo on mo.o- ski s.
Yes, you want to motivate your child to roli over onto his tummy. Encou a ge him,
but don't cheerhim on as he goes about it. E>rcitement iDcreases his muscle tone ancl
ma) .cuse hinl .o tumble onto I i' ba. ( again.
Loudsounds andbrightlights may also afJect muscle fone. Ifthis is so for yout
child, avoid both when you work wirh him.
 OBSTACLES TO I\4OTOR DEVELOPAIENT T 9

Abnormal Movement Patterns

Children with cerebral palsy may exhibit not only abnormal muscle tone but also ab-
normal movement patterns. A movement pattern is a sequence ofmovements. When
we use our muscles, we usually do not make one sitgle movement but a seque[ce of
movements. For instance, when we take a step, turn around, or shake hands, we use
a movement pattern to do these things.
When a child with spastic quadriplegic cerebral palsy wants to reach and grasp
something, the following may happen: the arm comes up, but instead of straightening,
the elbow bends; instead of turning out, the arm turns in; instead of straightening,
the w st twists; and instead of opening, the hand fists or curls.
It is not that the child wants to make this abnormal movement. If you tell him to
try harder and do a betterjob, most likely the outcome will even be wotse. The extra
effort will increase the tension of the child's h)?eftonic muscles. This in turn can
make the resulting movement even more abnormal.
Childrerl with athetoid cerebral palsy show i voluntary arm and leg movements
even when they want to stand still. Reaching for an object, their hands may move be-
yond the target. When they walk, their body and arms may move so much that they
have difficulty keeping their balance.
me abnormal extension pottern of the legs is one of the fiost frequetutly oc-
curritg atypical movementpatterns in childrcn with cerebml palsy. It is called scis
soring. Even children with mild cerebral palsy may show this pattern when they are
firct standing. They stand on thefu toes with stiff legs, which are turned inward and
pushed together. If children walk this way, their legs cross over with each step (hence
the name scissoring). Mary children with cerebral palsy show only some featu.es of
the pattem. Childien may soon learn to keep their legs apart, even though they may
slill sLand on Lheir Loes.

:OMBINED NORMAL AND ABNORMAL MOVEMENT PATTERNS

Childrcn with moderate or mild cerebral palsy most likely wiil not show full abnormal
movement pattefiB. lnstead they may use a vadatioE of normal movements combined
with some abnor mal features. For example, a child may only partially stretch his elbow
and partially open his hand dudng reaching. Why this is so is not fulIy understood.
Fortunately, we know from experience that the motor patterfl, inthis case reaching,
does improve with therapy and training.

Reflexes
Abnormill rellexes n1a1'caLrsc sornc ofthr irbnormal nor-ements r,e see in chilLlen
u,ith cerebral palsy. Rcilcrr:s ar r: invohrrarl, mor-errenls that occrLr in responsc ro a
sLimLLlLrs sLlch i:rs tolrch. prcssrrre. an joint mol,enletrl- NIost i-efleras arc hdpful, Ior
exampL, r,r,hr:r sonlcthjrg is sruck in vour throat. thc coughirr. or gag reflex helps
yot to rcnole it quicklr'.
1'here aie solne reflexes lhirL oni\ or:(rir iu iffaDts duillg the fir'sL months ofl]f.
aDd then rher lade i1\\,a\,: The\ rre rirllcLlpr imirir,e refleres and are l1orfiral. kr chilLh cn
20 TEACH|NG MoToR sKtLLs To CHILDREN wtTH CEREBRAL pALsy AND slMtLAR tvtovEl\tENl DIsoRDERs

with cerebral palsy, these reflexes maypersist and may be more pronounced. They
are then called atypical or abnormal

ABNORMAL REFLDGS COMMON IN CEREBRAL PALSY

Depending on the severity and type of cerebral palsy, there maybe severai ty.pes of
abnormal reflex patterns, including:
1. rhe tonic labyrinrhine reflex,
2. asFnmetrical tonic Ilecl< rcflex,
3. sl,rnmetrical tonic neck reflex,
4. startle reflex-
The fi$t two arc more lilGly to occur in children with more severe cerebral pa1sy,
al1d can cause major problems. (Bobath, 19BO). These reflexes are most likelyto occur
when the clrildren lie on thetbacks.

Tonic Labjrrinthine Reflex, When lying on the bacl! the tonic labyrinthine re-
flex causes the muscle tone ofback muscles to increase. The child,s back straightens
ot even curves backwards- The legs are straight, stifl pushed together or crossed,
and the feet are pointed. The arms are bent at the elbows. The wrists are bent and
the hand is fisted or the fingers are cu ed. This reflex is also referred to as abnormal
extension pattern or extelsor tone.

AsyrDmetdcal Tonic Neck Reflex (ATNR). When children with severe cerebral
palsy push their head back and turn it sharply to one side, this will rrigger anorher ab-
normal pattern. The arm on the face side stretches out, the other arm bends at the e1bow,
and the legs show a corresponding pattem of one 1eg straight and the other bent.
The tonic lab1'rinthine and the asymmetdcal todc neck reflex patterns are totally
useless. Theyhinder funcdonal activiries such as rollin& bringingthe hands together,
or even bringing the hands to the mouth. Over time, the reflex patterns can cause se
dous damage to the growing child'sjoints and bones. The ATNR may twist rhe spine
i[to a curvature (scoliosis). Both the tonic ]abydnthine reflex and the ATNR may cause
the head of the thighbone to slip partially our of the hip socker (hip subluxarion). Or
the head ofthe thighbone may move complerely out of the socket (hip dislocation).
For these reasons, a backJying position may need ro be avoided for a child who
has these persistent reflexes. Fortunately, it is less likely that the abnormal reflexes
will occur and affect the childt muscle tone in otherpositions such as side-lyin& re-
clined sitting, or straight sitting. Ifthey do, they ate not as stronS, and are iess likely
to affect the whole body. Even for young children wirh milder forms of cerebral palsy,
who show little ptogress with "happy baby,, activities (See Chaprer 7), ir is best nor to
have them lie on theirbacks for long pe ods of time when they are awake.
In addition, parents of children with cerebral palsy are told nor to cally rheir
child with the trunk and legs all straight, because a backwards movement of the child,s
head may trigger the extensiot reflex pattern. Instead, parelts are advised to snuggle
the child close to their body with both or one leg bent.
As anotler preventive measure, all small children at risk of, or diagnosed with, ce
rebral palsy should be discouraged from pushing rheir head back and tu rning it fat to one
side. Even if the child does not show an ATNR reflex pattem, the posirion ofthe head and
 OB5TACLFS IO fu]OTOR DFVELOPI.4ENI 21

neck changes the muscle tone in the arms and makes it harder for the child to use therr
It is always best ifyour child's head is in the middle and faces forward. \ivhen your child
starts to play with his hands and feet in back lying, this precartion may be disregarded.

Symmetdcal Tonic Neck Reflex (STNR). A rhird abnormal reflex that may
be seen in children with cerebral palsy is called rhe symmerrical tonic neck reflex
(STNR). When the head is extended, the STNRcauses the arms to straighten and the
Iegs to bend. When the head is bent, the STNRcauses the arms to bend and the tegs to
straighten. The reflex may assist the child to come to alqJtrryposition. yer, when the
child is ready to crawl on hands and l(nees. the reflex may cause him to..bunny hop,,
and hinder the development of a reciprocal crawl (in which the left arm and riSht 1eg
move forward, foilowed by the righr arm and left ieg).

Startle Reflex. Some children with cerebml palsy are very easily startled by sud,
den noises or events. A door opening a dog barking, someone ca1ling, or the telephone
ringing may cause these children to stattle. The startle reaction sharplyincreases the
children's muscle tone. Muscle coltrol decreases, and, as a result, the children may
momentarilylose their balance and fall.
For some parents, their childt startle reflex is a constant concern. Safety features
ofadapted chairs or stande$ address rhis prcblem. yourchild,s physical rherapistwill
assist you in findinS the right equipment for your child.

In summary the degree to which abnormal reflexes hinder a childt development

varies greatly. The more persistent aDd pronounced these abnoamalreflexes patterns
are, the more they interfere with learning useful movements such as reachin& crawl-
ing, or walkin& as well as positions such as sitting, kneelin& and standi[g. parents
of children with cerebral palsywant to avoid triggering abnormal reflexes. They can
do this by following the general guidelines mentioned here and the specific advice
uhei are receir ing irom rheir child s rherapist.

Lack of Motor Control and Coordination

@e inability to control the muscles is the mosr pervasive problem of children with
cerebmlpalsy and similar movement disorders. This lack ofcontrol is most obvious if
a culglganpClliglly. Ir the past, it was believed that hy?ertonicity caased the lack of
muscle control. It is true that spasticity interferes with muscle control. yet, it is not its
cause. Muscle conffol problems aae present independent ofmuscle tone issues. That
is why medici4e, which reduces high muscle tone, will not automatically improve the
child's muscle control. Childrenwith cerebral palsy and similar movement disorders
who have hypotonia also have difficulty wirh muscle contoD
What exactly is muscle contrcl? Mqscle _cpntrol allgwq..u,! !Q qse.aq muscles and
91 we rqaDLllo. It allows us to regulate rhe fo rcedlEed, and timin&oflour
mo_v-q_qqg !g(y
movemeits. A g].rnnast who does a g:raceful forwardl.o=i-lor back flip shows very good
muscie conrrol and coordination. No one expects that a small child willdo something
like this. Yet, even when a baby sits or stands up, he conttols the fotce, speed, and tim
ing of his muscles. A baby may first sit up clumsily. As he does it again and again his
22 IEACHING A,4OTOR SKILLS TO CH]LDREN !i/]TH CEREBRAL PALSY AND SI]\4ILAR A/]OVEI\4ENI D]sORDER5

movements may become smooth. We may say that he sits up with good coordination.
T]?ica1ly, children develop muscle control and coordination as they grow t1p.
Children with cerebral palsy have less muscle control. They have difficulty mov-
ing strongly or lightly, quickly or slowly, or sequencing and timing their novemenrs.
Instead of moving one leg, they may move both legs; instead of lightly taking a plas ric
cup, they may grab it with too mrch force and crush it; instead of quickly stretching
their arms to catch a ball, they may move too slowly and miss it. The children show
imptovernent of muscle control and coordination with therapy and training, rnless
they have very significant disabilities.

Muscle Weakness
Children with cerebral palsy and similar movement disorders also lack muscle strength
and endurance. If a child has low muscle tone, the lack ofstrength is very obvior-1s.
When lying on his stomach, the child maybe too weak to lift his head and push up
with his arms. As he improves, he may push up foI a short time. He lacl(s the endur
ance to push up longer After more practice, he s1ow1y will get stronger and becomes
able to hold up his head and push off with his arms for a longer rime.
Muscle weakness is also present in children with high tone. A spastic muscle
feels hard and tense. Therefore, you may believe the muscle to be strong. However,
the muscle may be weak. The latest research indicates, in fact, that spasticity and
strength are not inte(elated @gq!!{LEnSsberg, 20021. Frequently the spastic muscle
and the muscle opposing it are bothweak and need to be streDgthened. This can be
done. Previously it was believed that strengthening would harm the spastic muscles
afld that their muscle tone would become even mote spastic by strengthening. New
research proves otherwise (!owler, 2001).
How much a lack ofmuscle strength inte eres with a child's motor development
varies. Usually, however, slow progress is caused by problems with muscle control
and notbyweal(ness.

Abnormal Sensory Awareness

Children $ith cercbrirl pnls\ rrral' have i1n injurv to thr pirrt of thc hrain, r',,,hich ln
Lerprets scnsor] informirtjon frotn Lhe senscs of t()uch. posjtioning. and moventenr.
As a r'csult. (hiLdr.rD lna] be l1vp.r orh\pcrscnsiti!c.Achild\,\,iahlltp.rsensitivirlto
to ch rcccives lirtle irlformalio. whrn tou(fiing sonlerhing or ulten being touched.
Thc reduced sense o1 Louch ,,r rll nralie it harder tbr him rc use his hirnds. ImagiDe that
!ou are wearin8 8lo\'es as \'ou grasp sonlethiog or Llv Lo tic a knot. Thc gloves redrrce
the sensor\, inlbrnlarion vou rcceive and make thejob hardcr. A .hild r,ith llvposen
'it'rit1 tot.'t,"rr.. "" | .r ., r '.
Children vrho (:ccive less inibrmation rhan rsualfrom their feer and $cir scrrsr
ol positi.r. harc troublefielnlS r"-he.r thr:ir fccr are and ho\,!,D1uch prrssllrc thevexert
onthcground. lheirsitualionma\h.simihrtorvharvorLexpcritncurvhenvousrand
in dccp rvater and the inlifinrri()n vo! receil'e from vour farrt is rathcr 1.aBue so that
standing still is more difficulr rhar on 1and.
 OBSTACLES TO AIOTOR DEVELOP,,IENI 23

Chiidren with hypersensitivity receive too much information. For this reason,
touching something or being touched may be unpleasant and these children may
avoid both. A child may receive more information than usual from his sense ofposi-
tion when he puts weight on his feet as he stands or on his hands as he crawls. This
hypersensitivity makes it unpleasant and uncomfortable to bearweight, so children
try ro avoid ir.
Chapter 9 describes how abnormal sensory awareness interferes with a child's
motor development and shows how he gradually overcomes this obstacle.
 C i:l

l
4
a
Helping Your Child
Learn Motor Skills
i( :I otooaaa

lfyou have read rhe p.eceding chaprers, you may be wondering how i. is possibte for
I child ren with cerebral palsy or similar movement disorders to mastet the gross motor
skills they need. If their difficulties with muscle tone, abnormal movement patterns,
lack of motor control, muscle weakness, abnormal sensory awareness, and slowed
development are due to a brain injury or a developmental defect ofthe cenffal nervous
system, what can help them overcome these problems? There are two answers:
1. The blain can, to a certain extent, recover from, or compensate,
for iqiury, and
2. Parents and therapists can teach children the most effective ways
to learn and practice motot skills.

Neural Plasticity
At birth, an infent's braitl is not t ll\ del,e1oped. Durlng the fitst and second r.ear oI
life, the Ln ain is sril1 grou,in!i. rhangill8, tlnd fo rjrg lle\ r co[necti.]ns. 'I herefore, rt
is possiblc rhat othet cells fitirv rn (e over Lhe u,ork ofthe damaged cells. With sLimuln-
Lion ind naining. Lhis is morc Iikelr.to happt:r. l'his capacity ofthc brain ro a.lapato,
and supplcment lbr. a ,:leicir is ca1led neur.l plasticit\..
As brail Brou,th sUbsides, neural pliisticitv dec]-eascs. NeN research, hou,eYer,
indicates Lhar somr: capacitt' ior recrxtr ), re]Ileins throughout a person s life, llven if
an adult sullers an iniurv to her cclrtl rl nert-ous syst(rl1, other nervc cclls Dray take
over all or part ofrhe funcrion .)1 thc danlaged cclls. Special tlainin!i as soon as pos,
sible aier thc inj r I rnakes Lhis ]nrn e ikeh,.
26, TEACHING I\,'IOTOR SK|U,S TO CHILDREN WTH CEREBRAL PALSY AND SlMiL,AR MOVEA,IENT DIsORDERS

Physical Therapy Treatment and Motor Learning

Another possible way children with cerebral palsy may acquire a basic ski11 such
as crawling or sitting up is by training. How this tmining is done has evolved over
the years. There are several sources of information that Suide therapists when
they work with children or advise thei( parents, caretakers, or teachers. one is a
rapidly expanding body ofknowledge called motor leaming. The other sources are
concepts and teclrniques developed by professionals intimately familiar with the
characterisrics, problems, and potentials ofchildren with cerebral palsy or similar
movement disorders.

Motor Learning
Physical education teachers, athletic trainers, and coaches specialize in teaching
children and adults a great vadety of motor sldlls we call sports. Chiidren learn to
swim, skate, dance, ski, horseback ride, do gymnastics, playtenois, and so on. They
are not born with the ability to perform these sports. It is exposure to and training of
the skills that lead to their mastery.
How quickly and how well a person learns a new sport depe[ds on many factors.
Aptitude, motivation, and opportuoities for practice are important. But how well a
sport is taught also plays a significant role. Scientists have been investigating how
people learn a new motor skill and how to teach thembest. As they asked questions,
tested, got answers, and arived at conclusiofls, they gained newinsights and under-
standings. A whole field of study developed-the science ofmotor leaming.
The klowledge of motor learning pertains to how a healthy person learns a
physical skill. Does this knowledge apply to people with aneurological deficit? Does it
applyto childrenwith cercbmlpalsy? Some studies have tried to answer this question
(Thorpe & Valvano, 2002). So far, there is no clear answer. Yet, at this time the general
consensus is that insights gained in the field of motor learning may also explain how
children with cerebral palsy learn basic motor skills (Shumway-Cook & Woollacott,
2001). The following section presents some ofthe findings.

PRINCIPLES OF MOTOR LEARNING TO KEEP IN MIND

1. Learning a new motor skill is an active process.
It invoh,es fiDdi[g an efficient. consistent solution to a motor problcn]. What
does dlis mean? let's use an exanple -u-'our child rs ablc to sit but is unable to get
do ,n lronl sitrinS. The nlolor problem she has to so1r.e is how to rnove frorn sittin8
to thc floor wjth rase and c.fitroi. For a sn]all chiid, rhe best 11,a,!- to do this is to turn
to thc sicL: ancl placc 1n)th hnnds {). the floor-. \,\-irh her anns ln a good posltlon t()
guiclc hcr movr:mr:nts rin.l \ofrcrl thc iDrpiict, she fit:iv oo!,, lolr,er her trunk and slides
down ou hcr bcliy wrthour g$ting h!rt. Thc thcr'episL rtill sho\i \ ou how to help your
child perforn this rnovement sequence. As you follor thr: ir sn uctions at home, yoru
c1i1d r'r.ill geL acquainted r,irh the r:rovemelt partern and her alm mlrscles may get
srronSer as she bears u,eiSht oll them. But true skilllearni:rg rri11onlyhappen if _vorr'
child also participales with problem solvinS. \\'hen I rur chrld 1!,ants to move (there
 HELP]NC YOUR CH/LD LEAR\I ]\4OIOR 5(ILL5 27

is a toyon the floor she likes

toplaywith), gets oniy some help from you, and does as
much as possible onherown, then she takes part in the problem solvingprocess and
ski1l learning happens.

2. Motivation is an important palt of skilt tearning,

l'hereibr-c, bcfore vou ]rr.ctrce a skill u,ith lour chjlcl.look lor rJirTs to Jn.rti\ate
hcr. l.or insrancc. r\,hen ,vo r r hild is happilysiLLi g ard p1a).ins, ir is Dot a
tooLl Time
t{) pracrice Ino\ing dor,rn to.he lloor- Shc \,!ill nor be motivar.d ro do so. Tnstead.
lvair until shc is done plir].iDg anLl nrird\. to ger to rhe intelesting to1,1rll placed on
the Uoor. Only ifshe r,arrts to Lre on rhe tlo.rr v1,ill she be rotivaredLolearnandrrrro
petlbrrr thc movenenr sealuence of lo\\'erl n\r hr t\cll oLtt rrt \ttttrlg. Lri I rt ng aloei n(]t
take pla(c h.ithout mori!,ation.

3. Active exploration helps ski tearning.

'l'he more child is !tllowed to acti,,clv e)ipbr. and find soluti.Ds Lo Jn.rtor prob
a
lems, rhe morc sl<ills she r\,ill learn and rhe beLLel shc vrrill learn rhcm. you rnav believe
that helpiig yollr clild to move perfi:ctIl rnd .m, ,
'rhh t1..rn \rrrillg tu thr flno1 rvil]
cnhance good iearning. This is 11or n ue. padding rhe floor r,rith an extra r.ug and allo\,v-
iDByourchildtodoasmuchaspossibleonh$olvn$illfurthernlotorlcarrling.Hcr
movemcnrs mat be choppy, end lack grac. rnd Uuency as she strLtggLes on her.(^,vr.
Yet, do not wor r\,; she \ri1i bc lcirrni[3. Nloror skill learning requircs nr arr\. repetitions
beforc, t-ou may r:xpect ellicicn(v and smoothness. Vru ha.,.e ro ftrrcmber ho\\r oflel
yor.i had to ber a baseball or do a
Bolfsnoi(e belin.e lou got !oo.l at ir.

4. A d€monstration may help your child.

A sibling may model for your child how to do a movement such as getting down
fuom sitting oryou may show her using a doll.Ifyou do, emphasize the outcome ofthe
movement sequence in our example, it would be sliding onto the belly and reachirg
the toy. Researcllers found thar this is the way children leambest. Also, modeling a
new skill smoothly and perfectly is nor as helpful to abegiflning learner as warchiflg
someone struggle to peform the skill.

5. VariaDility helps skifl tearning.

I[itially, your consistent help will make it easier for you child to perform a new
movement sequence. As soon as your child improves, however, vary your apptoach.
Try not to always help her in the very same way- Do not always place the toy she wants
to get to in the very same spot. The more vadable the practice, the betteryour child
will leam the new skill.

6, Practice a skill until it is well learned.

,Iust becallse your child slrccesslL|ll\ noved lio sittitlg tohertunlJn1 (nlcedoes
not ncan she has lnastere.l fi. skjll. Fll.olLrase hcr to practic(: rtlril rhc sliill is \,\,ell
learned. Onll after a skill is rvell learfcd uill your child alrvays be iLl)lc ro do ir. Ifir
is not r\,ell learneLl. she mn\.1()se lt agaitl. \,!.h(]11 your child nol.es ij.oln sitLjng ro the
floor with casc and does so on her orr! n dLLring pla\,, Lhis skill is well lt:ar.ned. Ir is now
parr oI her skill repertor..
28 TEACHjNG A.4oloR s(LLs To CH]LDREN !(/tTH CEREBRAL pAlsy AND silvrlnR t\4ovEAtENT DISORDER5

7. Transfer of learning may occur.

'lial1sfcr oflearnjn rnean
g s thaL lear n ing one sl(i11 rnay hclp 1ou r ch i1c1 to lea rn another
skill.\Ihenalldhou,rruchhansteroflcarDirlgoccursisinportantrokno,.Researchels
fo!nd Lhatthe belter a skill is learned:nd rhe morel?r-iehh.itis practiced. rhe Dlore likelv
"..t;'.ot lerrn vrt.r.ar p, \'\, rlrprr,,p jl ,,;.'l ,r" ru,oe rr- L,
for transfer o1'learlring to occul. For instanrr if il c h lcl l e il r n \ (, trto\.r: tLolnstttrn!, ro th.
r

floor rvcll, she maylearn rc push irro sirtlng fiom l)cing on thc floor fir irlr- c u ic l<6i 11r"..,_
atier. \,loving into sitting and movjDg our of stltlng are r!\,, \lo1is th rr sh. r, mortmelL
components. Therelorc. nlaster v ofon{: sldl11\-il1 help a child learn the orhcr.

8. Some skills may have negative transfer effects.

A t\'\o yeai .rld child mal Leitch herselfto movc ftom slrting Lo thc Uoor b).s1o1vil
rolli11gbacku,ar.lr. Doing so t!,i]l not ha1,e a positi\,c i:ansfer cffect in r egald to 1l1o!rrB
inro sitting. Thar js. 1t wlJl not hr:lp her lcarn a related skil1. lf she rr ies to sit up LtsiuS
the silnle motor patLer'n she usr:d rolling dou7n. she u.ill not succe(:d.Ir is onlvbetrr,eefl
68 and 72 mondrs of age Lhar a rvpjcrlh.de\t lopirry r.hilcl r. rhle Lo sr rrp thrs \aI
(Pe:rbodv DcVelopmclltal Nloror Scalc, 2000). A chil.l wirh cercbral palsy
will nor be
ablc to do ltar1vearlicr. On the other.hand, going dorvn and sitrttg Llp blrplacjngboth
hands ib ,,,ard and side.,\,avs is masrered h\ rr.prL,r de\elupi]13 rhrlclirn hetleen
-\
7 to 9 nlonrhs of age. C{)nsequcntlv, children \,!lth cerebr.al palst are more likely
ro
\enorr, .r.e rr u r. l- ,r.. r ri. rep. r., r.

9. Similar motor skills may need to be tearned separatety.

Research indicates thet \,!-e learr motor ski11s more specifically thal once u,as
essumeLl. For illstance, yo! rnav thjnk Lhar sirting oD a chair and slfting on rhe
1.loor
:lre one aDd the salne skill. In borh silrlartDs the person sirs, so it lnay be assLLmcd
that1"-hc[ she ]cams to sit, she hecomes able to sit either on the floor or in a chair. In
facl. this l11avnotbe LIrc. Sittlngona chairand sittingo. a floorma],be two separate
skllls. To master then, both ma,v ha\,c to be trained.
Specificity oflaarning ald transter oflcatning are interrclated concepts. At thrs
tlme 1\,e do nol yet kno1l/ horv they apply ro manyplactical situatlons. Futuie r esearch
should tell us.

tO. Feedback helps ski tearning.

Through fcedbirck. the rhild reccives inli)rmaLion about ho\r. shc perlormed a
task. Ireedba(i( may rolne in manv fin ms. \rvh(:ll vour rhild tro!.s iiom sitting on rhr
lloor rostomach lving she pcr(eil,es how rLlecls to turn h.rrbo.lI slj3htlvto rhc iide. pur
\\ r/rl rh..i I ,F rl ,.1., ..r r. .. 1 :r I llnor',,..
llrei;.-o r, r., ,.r \,,I nl., .\. .,- 6 rr,.r , .rr..n.
fi:ces and hear thcir applause as she surr:ceds. All of rhts is helofu I feedhack
Vl,, u1 ,il. t-, \-.. ,.,Jp-.r,'.,
(hi1drcD. Researchers asked rhr
!uesriof ofhow often r.erbal teerJhaik shoull br: gir,tn.
'l'he,v foLrnd thar steaLlv r.erbal teedbar:li
is not rs eile.rir e is rIlterJnirtent fccibacl(.
ljspc(:ia11t iniria11\,-. \,crbal fr:cdback mav disrract childi
el i.orr Lhc rask end mav 1eL
the pavlcssatLe.tiootorllelee.lbackthL\ rerr .frnuLrtr r ir\ps.Sl i1\,,Lrfee1
theurge to t;rlhtoand encourag! yolll .hirl. 1Fl. j rd.i rrll -1.,,.,r,."nda
rl4rjlt:. On thc orher hai1d. a [o\ ing smi]e or applo\ i!q n..i sho,.Ll.l a1r.,.1.":s be hr:lpful.
 1]ELP]NC IOUR CH/LD LIARN ]\4OIC]R SK]LL5 29

ff. Don't ask your child to show off a new skill too soon.
Researchers invcsrigated Lhe iru.ljcnce eflict. They found rhar lrell lear.ncd s1iil1s
becoDle better jn frorr ofan au,:licntr: brt a ner,y skill n1aY deredoraLe. This c xpLaills l\,h_v
!'our child mav nor be able Lo drnronstrate her ner\,(:st trick to her gr:rndlrarents or Lhe
therapisr. After more precticc. rs the nel,v skill l)ccomes ljrmer, thjs shoLrld changr.

12, The more p.actice, the better.

The uore practicc ou can pro!i.lc foryourcllild. thc nrore she learns. This makes
1,

seose, alld motor lcar[ing research has confirlned ]t.

Holv rnuch should vou pracri(|e a skillurith your child? SholtlLl you pra.Lice Nith
her moving from sitting to thc floor ol1e Lime. rhc11 gi\.e her sonrc free tilne. and lijrcr
practice agajn? Or should \'ou practice lots.rftime iD a rou,wlth lirrLc resL in bet\,!ccu?
II!ou Practice cra\'\,ling \,vith )rour chil.l, should _vou take carc th at she pt acticcs onl} a
\!! encoutage hct to continue cr.it!\]ljrlg as tar as she possibly
shor-t distance or sholllLl
can? R€rsearchers ha\c looked inro this. l'hey found that it is all right to practice the
sa me task again and again with ljftlc r:est iil betNccn. I'hey call ir massed practice.
F.\.en if a person got
tired alier many repetitions and did not do thc task as well ils
bcfore, reseirrchcrs forLDd that lcarning occulrrd. 1n fact. at timcs uassed ptactr(:c
brings bettcr learning than practice distriburcd over a lo ger pcr iod of tine.
Aftcr a child has in itlal l) beerl rel uct. n o practice a ne w skill. it fi equend v h appeDs
thatsuddenivsherealhlikestopracti(tl.I\ihene\.erthlshappens,lettoulchildpractice
as nluch as sheL-ants to vou kno[, she is learning. ]f, after nally repetiti( ns, she gets
tircd and does norLlo as $,ell as beforc r-ouknolr/shc is stilllearning. you llrirl.have ro
lvatch her mor'c closely for sality reasons, howevcr. Alld don't lbrgcr ro praise a1]d h!i3
her alterwards. (Not ill betr{ccn. as thaluoUld intertare \,!.jth hcr Lcarning.)

13. Ask the therapid how often to practice with your chitd each week.
'fhe oplimal emount of tine t.r pr acrice exercises dcpeDds on Lhe typr: of€rxercise.
StretchinS exercises have to be dore every day. FortuDatel)., sLretching does nol takc
much lime- Depending on h.Nr manvstretcltcs yourchildneeds, astretching progran
may be done in less Lhan 5 to 15 minutes. (Sce Chapter 5 for jnformation on str ctch
ing.) Strengtheni[g exercises are eltecti\'c if done dlree ro four times a r/eek. Skiil
anLl halaDce traininlidocs not ha\.e to hc dolle on a specific schedule. yerrin1cr oD task
matters. Morepracticc will brijrg about more learning- Ifin doubt about thc frequetrcv
and iell8Lh ofpr'actice sessions, bc sure to ask -vour child's phl,sical thcrirpist.

Physical Therapy for Children with Cerebrat patsy

Decades ago, beforc scientists started studying treatment outcomes, therapists learned
fuom thet experience-from their successes and failures howto help childrenwith
cerebral palsy and similar movemeDt disorders. Experienced therapists with a keeD
sense ofobservation and insight shared their expedence and adva[ced the treatment.
One ofthese therapists was BerthaBobath. Fiftyyears ago, while working in a London
hospital, Mrs. Bobath ooted the difficulties her patients had as she treated rhem lying
on theirbacks in their beds-as was customaryin this hospital at the time. Compas-
sionate, gifted, and energetic, Mrs. Bobath instead placed the children in different
30 IEACHING MOIOR SK]LLS TO CHILDREN WITH CEREBRAL PALSY AND sIMILAR AIOVE]VIENT DISORDERS

positions and supported and assisted them with her large, strong hands While Mrs.
Bobath worked with the children, they were able to hold their head or move their
arms inways they had notbeen able tobefore. Delighted, she shared her observations
withherhusband, Karel, a physician. Together they developed a new way oftreating
children with cerebral palsy called Neurodevelopmental Treatment (NDT).
The Bobaths devoted the rest of their lives to improving and refinilg tl]eir treat_
ment method and taught it to therapists all over the woild. Many therapeutic tech_
niques that therapists use today were filst advocated by Bertha Bobath. But some of
the NDT pdnciples had to be changed orwere repiaced as sciences advanced.
lt is not the intent ofthis book to describe the NDT treatment or any other treat-
ment approach. Instead the following tries to summadze treatment components
understood as best practice in providing physical thempy treatment ofchildren with
cerebral palsy and similar movement disorders.

BEARING WEIGHT wlTH GOOD POSTURE

Beadng weight putting weight on your arms or legs encourages the muscles to
work. When you lean onyour arms and the weight ofyourupperbody bears down on
them, your arm and shouldermuscles work to hold you up. whenyou stand and the
weight of your body bears down, youl leg, hip, and back muscles work to hold you up.
Therapists use this response to strengthe[ the muscles of children with hypotonia.
Even if a child is too weak to hold herselfup, assisted weiSht bearing is beneficial for
her. Her effort to stand or hold he$elf up with her arms has a strelgtheninS effect.
In children with hypertonicity, weiSht bearing may bring about an extremely
strong response. The children may stiffly straighten their arms or legs. All their muscles
respond instead ofjust the ones needed to hold themselves r1p. This type ofreaction
to weight beadng is not he1pful. When the arms are stiffly straightened, the child
cannotbend hel elbows. Yet, bendingthe arms is necessary-for instance, when the
child sits on the floor, ptops on her arms, and wants to lower he$elf onto her tummy.
Likewise, when the child stands with stiffly straightened legs, she cannot bend her
knees or her ankles. Therefore, she cannot sit down or walk.
Therapists discovered that when children with cerebral palsyweight bear with
a good posture, they show a more normalmuscle response. When beadng weiSht on
their arms, therapists helped the children to place their openhands down and suppolt
their shbulders in a good position so theywere not pulled up or back. Theyplaced the
hand, elbow, and shoulderjoints in alignment. Now the arm muscles responsebecame
more normal. With trainin& the children could learn to bend the elbows with control,
shift their weight over one arm, and so on.
Vtrhen the therapists help the children to stand with feet flat on the floor, toes
pointing for-ward or slightly outward, hips and trunk straiSht or slightly tilted forward,
the children no longer stiffened their 1egs. Instead ofall theirmuscles responding at
once, they began to use mostly the muscles needed to hold themselves up. With con_
sistent training they could now bend thet knees a little and straighten them again,
shift most of their weight onto one leg, and so on.
Weightbearingwith good postute can be done in many different positions on
hands and knees, propped on elbows, and in side leaning side sitting, squattin&
kneelin& half-loeeling, half standing, and more. It is an importart tool. It improves
 HELPJNG YOUR CHILD L-EARN A,IOTOR SK'LLS 3f

strength and coordination. Dependiflg on the position, it a]so stretches specific

muscles. Th€rapists teach beadng weight with a good post[rc to parents and profes_
sionals working with the children. The illustrated weiSht bearing activities in this
bookshould make the task easier.

: O I\,JTROLLED WEIGHT SHIFT

The ability of shifting weight means thar you move yourbodyweight from one parr
of
your bodyto another. Trying to tap dance is an easywayto experience weighi shift.
You stand, move youl body weight over one foot, and thafl tap with the other
foot. As
you- take turns tapping with rhe right and then the left foo! you
will notice how you
shift youaweight before each tap. Watch someone else tap dance and you can easily
observe hershiftherweighr. Frequentlyyou shift your weight without noricing
it. you
maybe surprised to leam that all movements entail some weight shifts. The weight
shifts are often very small and subtle. you only shift as much as needed. This way
vou
"cna in stable and balanced as you move. The more fine r uned you r r,r eigh, i1. are.
rhe more fluenr and coordinated your movement s ar e. "h
Uncontrolled weight shifts produce jerky movements. A person who cannot
control her weight shifts in standing will lose herbalance and fall.
Children first lea.n ro shifr their weighr when lying orl the floor. The skill rhar
most obviously involves weight shifts is rolling. Once children are able to roll over
on
thei own they ftequently enjoy the activity. They may teach themselves to roll and
roll thereby traveling on the floor wherever they want to go.
Wher the children sir up they slowly leam to control weight shifrs and balance in
sitting. Ir the begirning your child will sit very quierly on the floor yor want to reinfo(e
this. As she quietly pla1s, she leanns to control small weighr shifts. Small and slow
weight
shifts are easiest to control- After they are mastered she may progress to control
faster and
larger ones. The direction ofthe weighr shifts also mal<es a difterence. Shiftingyourwdghr
forward is easiest; shifting ir to the side is harder; backwards weight shifts ani those that
involve tuming the trunl< are haidest to control whether sitting or standing.
Physical rherapists train small weight shifrs by working wlth the ihildren on a
mobile suface. For instance, when therapists work with the childrell sitting or lying
on a large ball, the sliShtest movement will bring abort some weight shift. ihe
sarle
is true when the childreD sit or stand on a rocking board. These activities
train chil
dren to respond to weight shifts in a generalway.In addition, children need to learn
to initiate a weight shift and control it ill specific situations.
In summary leafiring to shift her weight with control enables your child to move
independeotly. Ma4y activities in this book prepare your child for weiSht shifts or
help
you to train specificweight shifts you waft your child to master

CLOSED KINETIC CHAIN EXERCISES

One may rhink ofthe parrs of a 1eg-rhe hip, rhigh, Iower leg, and foot_as a chain.
The parts ofthis chail1 are ]ilked al1d move together. The arm is a similar chain.
The
shoulder, upper arm, lowcr arm, hanLl, and fingers are linl<ed and move as a rnir
Wher the end oftire chain furthest away fro the body is fi \ed, it is called a closed
kinetic (moyement) chain.
32 TEACHING MOIOS SK]LLS TO CHILDREN WTH CEREBRAL PALSY AND sII\IILAR A/OVEI\7]ENI DISORDERS

When vou squatdown, your feet are not moving but fixed on the floor. Whenyou
lie on your stomach and pr-rsh yourselfup with youl arms, your hands press against
the floor and do not move. Doing squats, pull-ups, orpushups ale examples ofclosed
kinetic chain exercises.
in an open kinetic chairL the erd furthest away from the body is ftee. When kick-
ing a ball, your foot moves freely and so does your hand when you reach for something.
Kickin& stepping forward, or rcaching are examples of open kinetic chain acti\rities.
When doing an open chain activity, your child has to controlthe direction of the
movements around each joint. For instance when thfowing a ball, she has to control
the direction ofthe movements atouDd her shoulder, elbow, and wristjoint, as well as
openherfingers at the right time so the ballwill fly forward. PressinS theballbetween
her hands-a closed chain activity is a far simpler movement The directions of all
j oint movements are predetermined and the outcome of the movement hardly varies.

Doing a movement sequence-pressing the ball, letting go some, and then pressing
again the childt arm muscles are learning to work together in a predictable way.
Physical therapists often use closed kinetic chain exercises when training basic
postures and movemeats. Abnormal reflexes and involuntary movements are less likely
to interfere with a closed kinetic chain exercise. Therefore, ffaining of a contrclled,
coordinated movement pattern becomes possible.
Closed kioetic chain exercises may train skills that require weight shifts and
bearingweightwith a good posture. These exercises are especiallyhelpful. Theytrai n
coordinated muscle work, reinforce a good posture, strengthen the muscles, and often
sffetch impofiant muscles at the same time. The Sit Srand-Sit arld Squor Stand-Squct
exercises descdbed and illustrated in Chapter 12 are examples ofexercises that train
good posturc and coordinated leg movements as well as stretch and strengthen youl
child's leg muscles.
The exerciseRocking onBigArms in Chapter S is an example ofa closed chain
arm exercise that combines bearing weight with Sood posture and shifting weight
with controi, This exercise shows you how to help yolrl child to push up and then
hold the position while you rcck her from side to side providinS small weight shifts.
This strengthens the arm muscles aod encourages coordinatiol. At the same time the
exercise stretches the muscles that bend thewrist and fingers.

JOINT STABILIZATION
Closed ldnetic chain exercises hclp chiidren in many\,/ays. Bul ill ordcl for the chil
dren to play and to walk, physical therapists have to uain open chain rnol'cments as
weil. How can this be done? lf your child makes abnormal atm movements and can-
l1ot reach for a toy, how can she improve? Ifher legs cross over ei]ch time she tries to
step, horar can she learll to do itbetter?
Tlierapists have found thatjoint stabilization helps to control movement. Joinl
stabilization means that the thcraplstholds lhejoint close to the body and guides the
child's movements. For instance, the therapist holds and guides the shouldel joint
while the child reachesj 01 the therapist holds and gtides the movement around the
hipjointwhile the child takes a step.
Why is this helpful? when closely observins the childrens a n movements, the
therapists noted that the abnormal pattern ofthe arm movementbegan at the sho[1der.
 HELPING YOUR CH]LD LEqRN ]IIOIOR SKILL5 33

The shoulders moved up and back as the children tded to reach. It gave the movement
the wrong start. Therapists found rhat by heiping the children ro sir in a good position,
rclax their shoulde$, and stabilizing the shoulder of the reaching arm, they can guide
the childt arm to move with a more normal pattem. With consistent tmining and many
repetitions, children s1ow1y learned to reach and touch a toy without assistance.
Joint stabilization du ngiegmovements follows tlte same pdnciple. Thetherapist
helps the child to stand with a good posture holding onto parallel bars orhetwalker.
The therapist supports the hips, srabilizing the sraDding leg while guiding the srep-
pingleg. Stepping to the side is practiced similarly. The srandingleg is stabilized and
the other leg guided to srep out to the side.
Skillful and corectjoint stabilization is avery helpful tool for therapists. They
will use it as needed and fade it out as soonas possible. Regardless ofwhere and how
jointstabilization is done, the goal is always for the child to become able to do a useful
movement independe4tly without any help.
There are drawbacks to thejoint stabilization rechniques used byphysicalthera-
pists. It takes training, skill, and experieflce to do them. Therefore, they are difficult
to teach to parents or other professionals working with the children. If parents master
a specific technique helpful with their child theywill norice rhat it is time consuminS
to implement. It may also be strenuous. Forinstance, stabilizingyour child's hips and
guiding her steps is hard work.
Another problem with the tech[ique is that the children maybecome used to it
and rely on it.Iostead ofbecomingindependent, they may become dependent on this
help from their therapist or parent. Therefore, how to fade out manual joint stabiliza
tion has to be as weil plaoned as when to lrse it.

JOINT STABILIZATION BY POSITIONING

A position may stabilize ajoitt. In side-lying on the right side, the right shouldet is
firmly wedged beneath the body. The left shoulder is stabilized by the effect of grav
ity. The child's hands restclose ro each other. Therapists use side-lyiflg ro ercourage
fine motor skills in a small child who canflot yet control her shoulder muscles and
therefore is [nab]e to play lying on her back or tummy. As the therapist places a rattle
into one hatd, the child may move it, shake ir, hold it with borh hands, or pass it f.om
one hand to the other. Thereby the child learns to use herhands and gains hand and
finger coord inar ion.

GENERAL STABILIZATION TECHNIOUES

'l'hese te.hniqrcs are used ro hclp childten \\,ith ( r cbral palsv ur ,,Llissociate,' or to
isolale mo\cue11ts. Dissocintin,r is the Lernl thr:rapists use u,hen cL:scr ihin.r rhe abilirl,
Lo rro\c ofe bodv p.11r \\,irho r ntol,rns odr.rs. tivoru chil.l rn(N(, her.head. chcsr,
anLier's$.ithoLLLnro\inghcrhipsilnllh.gs.shedissociatcshr:r!pperborlvlromhct
lo\u,lcr bodli 1I she nto\ cs one anr !\,irhouT utol.i11g rhe r csr of her bodr, shc is able ro
dissociate the arm lnovenent.
YoLLr chil.l rra\' be helped ro rroYe.jusr ol)c l){rdv parl Lrr,. r}rr sc of a srabilizir-
tjo[ techniq!c. ] hc e\ercise tri.kir.! r1,lrll Onr I cg irl Chapter 12 is :rr r\an1p1e ol h{),,,r,
stabilizinghclps thc child L.r..rnlr1 the r )vr:nrcris of one leg :rr rr rlme.
 34 IEACHINC MOIOR SKLTs TO CHILDREN \iflTH CEREBRAL PALSY AND SI]\,IILAR A/]OVEMENT DISORDERS

Isolating a movement means that the child controls a specific movement such as
bendinS the index finger when she taps a computer key. The therapist may initially
stabilize the child's wdst, haid, and other fingerc as she learns this discreet move-
menL Moving one leg to the sidewithoutbendingthe hip ortuming the 1eg is a[other
example of an isolated movement.
Most general stabilizatiol tecluiques are not difficult. Therapists may teach them
to the child's parent or teacher. Specific positions, braces, splints, sffaps, sandbags,
weightedvest, afld most recentlyJ even suits, mayalso be used to provide stabilization
to help the c1ild better control her movemelts.
Aswithjoint stabiiization, general stabilizationtechniques are to be used during
initial leaming. As soon as possible they are phased out. The 8oa1 is for the child to
become independent ofthe help by another person.
Therc are limits to the benefits of stabilization techniques. They are very helpful
when your child needs to learn a new movemelt but not ifshe needs to gain control of
aposition. Let's look at the following situation: You want to teachyourchild to kick a
ball with her right foot. So yor support her while she stands on her left foot, ask her
to concentrate on het dght foot and kick. You make ldcking easy and fun and your
child succeeds. she learns to swing her leg forward aDd ldck the ball. Now you ask
her to kick without you supporting her and she may notbe able to do it. The reason is
that without your support she cannot stand long enough on her left leg to kick with
her right one. Your child learned the movement (ldcldng) brt not the postural control
(brieflystanding on one leg) to llse the movement functionally.
For your child to progress further you had to use exercises or activities, which
train postural control andbalance. For iNtance the exercises in Chapter 14 under the
heading E ctra St.rndin gTimefor the WetTker Leg would be beneficial. Another possibil
ity would be that you teach your child a self-stabilization technique, which enables
her to kick without youl help.

SELF-STABILIZATION
self stabilization means that children learn to stabilize ajoint ortheirposture bytheir
own action. There are many ways children can stabilize themselves. In the situation
mentioned before your child may be encouraged to lean against a wall with her left
side when she kicks with her right foot. Or she could hold onto something stable like
a dooframe or a banister, brace henelf witl one hand against a wall, orjust touch
the wall with one finger to stabilize herself. With no need to suppofi her-she does it
herself- you are ftee to become her partner in the kickinS game. With pmctice your
child may slowly become able to support herselfless and eventually succeed to kick
the ball without holding on.
Usually physical therapists teach self-stabilizing techniques as part offunctional
skill trainirg. The therapist may askyour child to brace herselfwith one hand on the
bench or on her upper leg as she leans forward to puil up her sock with the other hand.
When using the toilet, she may be taught to hold onto a wall bar with one hand while
pulling herpants up or down.
When she learns to color or wdte, the therapist may teach her to hold onto a rod
or grab barwith one hafld. The barwillbe firmly suctioned to hertable or desk in such
a way that by holding on, her shoulder is pulled slightly forward. This will help her to

G
 I

HELPING YOUR CB]LD LEARN Ir'lOTOR 5KLLs 35

keep her shoulders in a goodposition, stabilize her upper body, and make it easierto
control the movements of her working hand.
There are mafly situations in which children maylearll to stabilize themselves.
It is a useful technique, which is easily adapted to the home or school environment.
Therapists may combine joint stabilization they provide with teaching of self-srabili
zation. This way, as the childt movements improve, the therapist may withdraw her
supportreadily and encourage the child to stabilize herself.

-IACHING FUNCTIONAL SKILLS

How much time should physical therapists spend preparing children for functional
skills as opposedto training functional skills directly? Eorexample, shouldthe rhera-
pist work or improving a childt sitting balance using a variety of t)?es of rherapy
equipment? As the child's sitting balance improves, she becomes able ro shift her
weight with control. This should help her to play ot do work while sitting or to move
in and out of sitting.
Or should the therapist work with the child as soon as possible on functional
skills? In this case, the therapist would spend less time on sittingbalance exercises.
Instead she would work oo functional activities such as doing a specific dressingtask
while the child sits, or ask the child to move in and out of sitting. The reasoning wouid
be that as the childmaste$ these skills, she would improve herbalance and abilityto
shift her weight with control at the same time.
Which approach will bring better and fastet resulrs? There is an ongoing debare
aird study ofthis question (Ketelaar, 2001, Ahl Ekstrom, 2005). So far, however, rhere
are no definite answets,
For parents of children with cerebral palsy and similar movement disorders,
functional progress is important. You are glad when your child does well with an
activity dudng her therapy session. Yet, when your child becomes able to move in or
out ofher car seat, yol] are really happy about it. Your child learned something useful
that will make your life easier.
Physical therapy is notjust about teaching your child to walk. Ir is the therapist's
goal for your child to become independent with all daily moror tasks. Feel free to ask
yolll therapist to help you with all movement problems your child encountem.

The "Road to lndependence" for Children

with Cerebral Palsy
"With somuch to leam, how will my child ever become independent?', vou wonder. yes,
tlere is much to learn for a child with cerebrai palsy or similar movement disorders. But
instead ofwofiying about tomorow it is best to look at today. Tate one day at a time,
appreciate small progress, and enjoy major achievements as they are mastered.
The "Road to Independence" lists mqjor achievements you want to look for. Each
one will help youl child to do more on her own and is a building block for the skills still
to be mastered. The initial skills arc listed sequenriallyin the order children usually
master them. The firsr ofthese may be skipped by children who are able to play with
their hands when they lie on theirbacks or in their infant seats.
 I
36 IEACHING IV]OTOR S(ILLS TO CHILDREN WITH CEREBRAL PALSY AND SIIV]ILAR MOVEA/]ENI DISORDERS

Two of the initial skills are listed in bold letters. They are especially important
building blocks. Many later skills depend on tlrcm. Holds head andlooks dround propped
onforearms in stomach-lying is important because it shows that a child has basic head
control, has gained some shoulder strength aIId coordination, and likes to be on her
tumrny. Your child may master this skill with ease. If oot, you want to provide as much
help as needed. Your special attention and training will make a difference. Chapter
6 and B address this in more detail.
"Bunny" - fron stom(Lch-lying: child pulls both legs up and props on both or"ms is
another eady skill pdnted with bold letters- Moving into the "bunny" position is the
easiest way children with cerebral palsy and similar movement disorders can lift their
body off the surface. The sooner your child learns this, the better. As she becomes
independent with this skill and does it many times during the day, the strength and
coordination ofher trunk, shoulder, and arm muscleswiil improve. At the same time,
she will be challenged to shift her weight and keep her balance in ways not possible
ifshejust played lying on the floor.
The intermediate skills are clustered. The oader they are mastered may vary
from child to child. Sits and stands holding onro o bdr is listed in the beginning to
assure that it is trained early. Chapter 12 explains the reasoning forthis. The sittiDg
and kneeling skills are listed side by side. It is good to work on them concurrently.
Children with hr?otonia may show steady progrcss with floor sitting. Children with
hypertonia often have difficulty there. (See Chapter 10 for details) They may show
better progress with kneeling. Training sitting and variations ofl(neeling concurrently
will assure that the children progress to the best of thet ability. Training loeeling
after a child is able to sit could delay her progress.
Training of pulling to stand, cruising alorg furniture, and assisted stair walking
are listed with walkillg with an assistive device. Again, these skills are best trained
concurently. They improve )our child's leg muscle strength and coordination. (See
Chaprer I2 for details.)
The advanced skills start with Stands wirhout Supporr, which is printed in bold
letten. caining independent standingbalance is the keyto all advanced skills. After
your child learlls to stand without holding on, tmining ofwalking without arm sup
porr becomes a possibiliry.
The "Road to Independence" is meant to be a general guideline of how children
with cerebral palsy or similar movement disorders master gross motor skills.It does
not tell or predict the order in which your child may learn the ski1ls. Your child's gross
motor development will depend on her specific potentials and problems.
 HELP]NG YOUR CHILD LEARN A/OTOR SK]LLs 37

'Rono ro lruoeprruoerucr" Sr<ll-l-s Guroeurue

! ITIAL SKILLST
. ,r'i r!! hands rogether and pla!s in sidc,lving. llitolo 4.ll
. ::,lJs hearl in Lhe midr11c. lrrirgs hands rogethel. a .l pla."s in dn irfaDr seat. alrtolo,,l.iJ
. i{olds head and looks around propped on tbrearms in stomach-lying. fpltolo 4.3)
. i. steer off Lhe l1ool ir hack 1t.ing and ro11s o\.er. ltfi r)n).1.4)
. ' i l' s and moves ab{)Lrt on s(lmach. (lrloro 4.5)
. ::ii 1\.iri1 both arlrls propped. apltolo 4.ail
. 'Bunny'froDr stornachlying: child pfllls both legs up and props on both arDs. {pholo,7.7l

t
i

...rq&

I F.

+ r TTI
{pt
I
1'\ 0

(contin ed on nexr poce.)

38 IEACH]NC I\,IOTOR SKJLLS IO CHILDREN W]H CEREBRAL PALSY AND S]AIILAR ]1,4OVEI\7]ENT DIsORDERs

( co nt inle d.li on1p r e y io u p n ge. )

TNTERMEDIATE SKILLS Ir s{!t

. Sirs al]d srands holding onto a Lrar. ,
3- ,sI
"l:
.,, i.l
ldroto 4.8.1 & 4.8b)
. PuLls llun bunll\ position Lo kneeling it I bor *:ffi
and ph\ s. aploao 4.!)) .8
. SiLs u,irh s(nrc arDl sLlpporL nnd pl!vs.
(Phak) 1 10)
. Pl:r\s in bunrlposirbn. (phatil.ll)
il-.irr,r.
i",,w
,*n
te'
l
posirion. aph.t0 4. i2)
. Sits ,ilhorLL rrm support anll mo!rs
sittin8. aphorr).,1. l3J
i11, out of
-.l EL.}'

q*
*
,6j

I
*.a

i lit;
F B

ra #
,;":' F-
::r/

c
{
t; 'I I

f'
'I
t {,
I t':
T h
h**
1.13
 HELPJNG YOUR CHILD LEARN A,IOTOR sKJLLs 39

I INTERMEDIATE Sl(ILLS lIr

. Crar"-ls on hards and knees. apltoto 4 _l4J
. Sits \r,cll (m a bench .rr chair. allioto 4.15)
. P!lls ro stand aL ltLrllitruc. plavs. and crltis(:s.

.
.
(phoro 1.16)
WirLks u,ilh a u,allicr . lpltoto 1.17)
Wirlks \r,iLh forear crutches. (pi.)rlr4.l8)
. Walks stairs vvith assislancc.
-
. A a.r,r

6\ i'
ADVANCED SKILLS:
. Stands without support. (phata 4_19)
. Walks wirhout suppott. (phota 4_20)
i
I &

. wallc up and down stairs, walks up and

down curbs, and may mn.

o |'
40 IEACHJNG l\lOrOR 5K]LLS IO CHILDREN WTH CEREBRAL PALSY AND SIi\/]|LAR A/OVEA/IENI DISORDERS

Frequently Asked Ouestions

a. "How Long',alill it tal.e our son Hayden to learn each skill?"
A. This varies gleatly ftom child to child. Hayden may learn a few skills mther quickl,
while others may rcquire weeks or even months of daily practice.

a, "Should, we work with Hayden on one skill at a time?"

A" In general, it is good to work on several skills at a time. As mentioned you may
want to work on sitting aIId kneeling at the same time and practice standingwith arm
support also on the same day. some times, howevel, it helps to concentrate on one
skili and practice it over and over (see massed practice). This all varies depending
on circumstances. Your child's physical therapist will Sive you Suidance fol specific
sitrations. Shewill explainwhich skills need to be practiced more than other skills'

a, "Does Celeste have to crawl in otder to walk? "

A. Children with developmental delays or cerebral palsy may learn to walk with a
wall(er without first being able to cmwl. Yet, crawling will help Celeste in many ways'
It teaches her coordinated reciprocal arm and leg movemelts and sttengthens her hip,
shoulder, and arm muscles. Few children walk independently without ever crawlinS'
An exception is tlle child with hemiplegia whose arm is seriously affected by cerebral
palsy. she will be unable to crawl, but still progress to independent walking'

a,'Does Celeste have to wolkwith awalker bet'ore shewolks onher own?"

A. No. Not all children with cerebral palsy walk with a walker first, but many do'

a. "Our son Mohsen has hemiplegia. Only one side of his bocly is affectedby cerebral
palsy. How willhe develop gross motor skills? "
A. on his own, Mohsen will rely mostly on his stronger arm and leg By doing so,
he may learn most skills almost as quickly as children without cerebral palsy until
it is time to walk. Now the abnormal muscle tone, the lack of coordination, and the
weakness of the affected leg may delay the onset ofwalking. Nevertheless, he will
progress to indepelldent walking.
It is best for Mohsen to receive physical therapy early. It will assule that he uses
his affected arm and leg as much as possible and does not "neSlect" them Even though
it is not essential that children with hemiplegia crawL, they benefit a great deal from
crawling. The more Mohsen cmwls, the strolger and more coordinated his affected
arm and leg become. For the restofhis life, he will benefit from crawling
 s

5 B
d[

&
$
Flexible Muscles
& and Joints
& taiaaaaaa

your child has been diagnosed with cerebral palsy, you were probably told rhat
lf
I
his developmenra. delay was caused by damage {o the ner\ ous s} slen. fl-e Driir
was sending the waong messages to the muscles and this caused the muscles not to
work correctly. Your baby's joints and bones were just as perfect as any other baby's.
Although this is true, older children with cerebral palsy may develop problems wirh
joints andbones, whichmaybejust as worisome to parents as the delays theirchild
may be experiencing in achieving important gross motor skills.

Possible Muscle Problems

"If my baby was born with goodjoints and bones, why does this change when he gets
older?" you wonder. It has to do with the way muscies and bones grow. Bones have
growth plates and they grow as children age. Muscles, on the other hand, grow longer
when they are stretched. As the bones gtow anil children move, the tuuscles dre
stretched, co,using them to grou,. This way the lengrh of the muscles will match rhe
length of the bones. This is how it should be-muscles of the right length work besr.
Let us use the growth ofthe biceps muscle as an example. The biceps is the muscle
ofthe upper arm that bulges out when the elbow bends. One eid of rhe biceps attaches
to the shoulder and the upper arm bone (humerus) aIld the other end attaches to a
lower arm booe (radius). When the elbow is straighrened, the biceps is stretched. As
the arm bones grow, the biceps is strctched more each time the elbow is straightened.
This strctch causes the biceps to grow
42 TEACHING ]\,1OTOR SKiLLS TO CHILDREN WTH CEREERAL PALSY AND sIM]LAR AIOVEMENT D'SORDER5

When the arm bones of a child with cerebral palsy grow, however, the biceps may
not match the growth of the bones. This happens if the child cannot fully straighten
his elbow on his own due to spasticity of the muscles that bend the elbow, Iack oF
strength and coltrol of the muscles that straighten the elbow, abnormal reflexes, or a
combination of all three. Consequently, the biceps muscle is never stretched to its full
length. The normal stretch with the message from thebones: "Hello, we are growinS,
hurry and catch up!" never occurs. Therefore, the biceps does rlot Srow even though
the arm bones are Setting lollger. At the same time, the triceps muscle opposite of
the biceps on the back of the upper arm is constantly stretched over the bent elbow'
Consequently, this muscle becomes longerthan necessary.
Cerebral palsy, then, is the secondary reason that the muscles fail to Srow ap-
propdately. The primary cause is the lack offulljoint motiofl. Cereblal palsy is the
reason that your oile year-old cannot straighten his elbows, but you can sffaighten
them for him. And if you do so each day, the biceps muscles will be helped to grow,
as they should. Doily s tretchittg witlhelp prc\,ent muscle shortenitg.
The benefits of preventing the muscles from becoming too short are enormous.
Muscles of the right length work best. They are strongel than muscles that are either
too short or too 1on8. Muscles of the riSht length are easier for your child to use and
therefore make iearning new skills easier. A shot't muscle is not ortly less useiul, it
intet:fereswilh skill acquisitiofl atud thc ddily care of children with cerebral palsy'
If the biceps become so short that the elbows can no longer be straightened, it will
interfere with weight bearing on arms aIId learning essential skills such as catching
yourself with outstretched arms or crawling. Additiorally, the bent arms will make
dressing the child difficult.
The biceps of the upper arms, the hamstrinSs at the back of the thighs, the in
ner thigh muscles, and the calf muscles are most likely to shorten as the result of
insufficient use. They are bis, strong muscles which work on twojoints. The biceps,
for instance, not only bend the elbows, they also help lift the arms at the shoulder
joints. The hamstrings bend the knees and help to straighten the hips. The inner thiSh
muscles pull the legs together and also help bend the knees. The calfmuscles prrsh
the feet down and also help bend the knees.
Short inner thigh muscles will interfere with floor sitting or daily care. Short calf
m[scles limit how much the ankle joiots bend and thus may prevent the heels fiom
touching the floor in stalrdio8. Short hamstring muscles will ]imit the length of each
forward step or even hinder the knees from being strai8htened. Short hamstrings
also interfere with floor sittinS. Their pull tips the hip bone (pelvis) backwards and
makes you sit with a rounded low back. These muscles play a majofiole in the way
your child sits, stands, or walks.

Possible Joint Problems

CONTRACTURES
when ajoint is not or months, the fibrous tissues (liSaments)
arornd thejoint are affected. Some become shortel and
some longer. These range ofmotion of the joint. Now it is not only
 FLEXIBLE N,]USCLES AND JOINTS 43

the short m[scles, but also Wxnr ls Rnruce oF MorroN?

the short ligaments, which
prevent the fulljoint motion. Rangc of Motion (RoM) is Lhe narurxl djsLance
This is colledjoint contac- rI1d Llirrction ajoint nro\.es.
ture. Ajoint contmcture that
persists will, over time, brinS Active RaDge of Motior (AROM) is ho\'\, far the
about changes to tle bones at r t. 'o.. lt"'t rro,l'-'o .r '. ,,' o. lr 'o tr
, the joint and ultimately be ThaL is. it refers to how far the pelson hirnselfcan
come ireversible. Stretching firove thejoinr.
at this point will not reverse
the coltracture. passivc RanSe ofMotion (PRONI) is h{)w Iar d
Understanding how a joirt can bc uovcd passircl]. l'hnt is, it rcfcrs to
joint contracture develops how fnr soncorc else can trlo\c thc pcrson'sjot1t.
will help to prevent it. Let's
use the kree joint as an ex-
ampje. Several two-joint muscles affect the kneejoint, including the muscles ofthe
back ofthe thigh-the hamstrings. The hamstriog muscles are stretched to their full
length (full mnge of motion) when the knee is straight and the leg is 70 to 85 degrees
bent at the hip.If a child is unable to get his leginto this position, a knee flexion con
tracture can develop. This means the knee can no longerbe fully straightened. The
development of knee flexion contractures can be categorized into three stages:

Stage 1: Little or no active range of motion with

full passive range of motion. Due to weakness, spasticity,
or lack of coordination, the child is unable to straighten his
knee and move his straight leg forward. Another person can
straighten the childt knee and move the leg through its full
mnge of motion.
Daily stretching exercises can be dorle with ease and
will help to assure that full passive range ofthe hamstrings is
maintained as the child matures and his bones grow longer.

Stage 2: Little 01 no active range of motion with

limited passive range of motion. The clrild is unable to
straighten his k[ee and move his straight leg forward. Another
person can straighten the child's knee fu1ly, but the straight 1eg
can no longer be moved into 70 degree ofhip flexion. When the
child lies on his back and the straight leg is lifted up (bent at
the hip) the knee soonbegins to bend. How soon the knee will
bend depends on how tight the hamstrings have become.
At this point, stretching exercises have to be done with
care. Daily stretching will prevent the muscles from shortening
further. Over time the daily stretching routine may improve the
flexibility of the hamstrings and full passive range of motion
maybe regained.
ll4 TEACHJNG MOTOR SKILLS IO CHILDREN WTH CEREBMT PASY AND SIIIIILAR MOVEA'4ENT DISORDERS

Stage 3:
No active range
of motion and significantly re-
duced or no passivejointrange.
The child is not able to straighten
the knee oII his own and another
person cannot straighten the knee
either. This is called a knee flex-
{i
ion contracture.
It is very difficult to loosen a
joint contracture with stretching
exercises. The longel the contrac_
ture persists the less likely it is that
it can be reversed.

JOINT SUBLUXATION OR DISLOCATION

Another sedous consequence ofshortmuscles is that they place stress onthejoints'
The cor.sto:ftt pult of tight' short mttscles wiLL affect how joints grow Short
biceps will affect the eibow joints. Short hamstring and inner thigh muscles will
affect the hipjoints. The bones will grow in such a way thatjoiot subluxations or
dislocations become more likely. (A subluxatiol means that the joint has moved
partiallyout of its socket; a dislocation means that thejoint has moved completely
out of its socket.)

Daily Stretching to Prevent Muscle and

Joint Problems
You can prevent your child's muscles from becoming too short Daily stretching a
muscle will help to maintain its length. Strctching is easily done when your child is
small. Hisjoints and ligaments are soft and his muscles flexible Most babies like to be
touched. They usually enjoy range of motlon exercises and don't mind stretching'
The problem is that you have to do sffetches every day while your child is sma1l'
you need to spend so much time feeding, dressing, and cleaning him that the addi
tional time needed to futly straighten his joints is insignificant and is easily fit into the
daily routine. Continuing to do daily stretches with an oldet independent' or opinion-
ated child is another matter. Ior children, the stretches become boring, and may be
somewhat uncomfortable. For parcnts, doing the sffetches becomes more strenuous
as the child's limbs grow longer and heavier' Sometimes it just seems easier to skip
the stretching exercises. Unfortunately, this will have its consequences A couple of
weeks without any stretches is enough for some muscles to lose the length achieved
by previous stretching. The next time the muscle is stretched, it will be mole uncom_
fortable and the child will like it even less.
A parent may decide: "This is too difficult for me I'd better let the therapist do
the stretches." And it is true that physical therapists do the needed stretches as part
of each therapy session. The problem is that therapy sessioff are usually once per
week, and this is Ilot enough.
I
FLEXIBLE A4USCLEs AND ]OINTS 45

The shorter a muscle becomes, the more difficult it is to stretch. There comes a
point when manual stretchingloses its effectiveness. perhapsweeks ofserial castl g
may now be the only way to lengthen the muscle_ (Chapter 17 has information con_
cerning serial casting.) Surgety can also be tlsed for this purpose. But surgery will
not lengthen the muscle fibers. It will increase the length ofthe rendon rhe muscle is
wmpped in. A surgically lengthened muscle tends to become weaker.
In sumtudry, it is rery impottant that your child,s muscles match ttle letugth
ol the bones they are paireil with. You w@nt to keep them this w.ty. Daily stretch_
ingwillhelp do this,

How to Do Stretching Exercises

Like many parents, you may be familiar with stretching exercises. you may have done
them when you trained for a sport or you maystretchwhenyou do a regular exercise
routifle. This knowledge and experience is very helpful when you do stretching ex-
ercises with youl child. There are, however, special considerations and precautions
when stretching a child with cerebral paisy. your child,s therapisr will explain them
to you, decide which stretches youf child oeeds, and demonstrate them.
Technique is important when you do stretching exercises. The joint needs to
be well stabilized. Furthermore, if an exercise calls for straighte ng or bending, no
twistilg or turning may accompany the motion. parents are advis ed not to attetupt
stretching exercises on their own. Instead, practice them with the therapist,s gridance
before you work wirh your child at home-
Be forcwarned that it may take several days or rnore than a week before you and
your child are comfortable with the daily stretching routine. For reassurance that
you are doing the stretches corectly, it is a good idea to have the therapist watch you
doingthem at the next visit.
The following are general guidelines for srretching a child with cerebral palsy:
. Move slowly. As explained in Chapter 3, if you stretch a spas-
tic muscle slowly, the same resistance is felt [nti] the muscle is
stretched to its full length. If you do it quickly the resisrance in
creases and stops the movement befote the muscle has reached
its full length.

. Position your child well. Closeh lbllo!! the Lherapist's jnstr!c

tions. Strctching mav be easicst to .l.r \,\rhen ].our child rests on
1is bad(. LluL thjs is Lhe posirion in \fhich abnormal re1l.r\cs are
morc likelv &) occur. Thcrelore. Iou need ro rake pl-c( autions to
minirl ze thcse relhxcs, as t-our therapist adl.ises. or an altrr-
nirti\.e positiut ma! hiive t.r br: r]sed.

. Talk to your child. llar'r I con\:ersiltior l!i.h l,oul chikltrhen

vou alo streLchcs. thlking connetrs \-olr and keeps ror: iD Lrrnr:
l,vl$ vour child. li1'.)Lr child lo,,,r,s musir:. sing a s()llg to him.
Thc sound of lolLl \ oice llalics \.our chi [d coJnfor ral]le ar(l
puts hiln :Lr {rase. ald the conversation \\,i11disrr acr hi .Ihe
1[5 TEACHING MOTOR SK]LLs TO CHILDREN WTH CEREBRAI PALSY AND SII\IILAR A/OVEI\IENI DISORDERS

more relaxed your child is, the more effective the stretch is.
You want to create a calm atmosphere. Remember, spasticity
increases with excitement, discomfort, or any other emotional
respoNe. Nothing is accomplished ifyour child fights you and
pushes against you.

. Know when to stop and hold the stretch. When you stretch
yourself, you canfeelwhen amusclehas reached its full leogth.
Further stretching becomes [ncomfortable and then painful.
whenyou stretch your child, it is important to calefullywatch
his face for any signs ofdiscomfort. Ifthis happens, immediately
stop sffetching the muscle and reduce your Pressure Do not
thiftk that you cdn judge W the rcsistance you feet whetu to
stop stretchittg. Small childrer have softjoints and ligaments
and their muscles are weak. Ifyou child is relaxed or has low
mBscle tone, it is easy to stretch too much. This could seriously
damage his muscles andjoiflts.

. Do not overstretch a muscle. This is advice for parents who have

been following a regular stretching routine with their child. After
weeks of regular stretching, there wili come a time when, for in-
stance, the hamstring muscles achieved a flormal length and show
good flexibility. At this point, you are advised to bdng the ieg up
to the highest position without stretching it any further' Normal
flexibility is good and nothing is gained by too mrch flexibility.
Maintaining oormal flexibility as your child grows is the goal of
the regular stretching toutine.

Ihc following ale examples of suetcling exercises. Only.rse rhem asyourchildt

therapist directs yotl The lherapist knows your child al1d wi11be able to make any
special adjustn-rents that maybe needcd.

ARM STRETCHES
Arm Stletches in Back Lying
YourchiLdlies onhis back. You kneel facing him. ?lace your left thumb or index
finger into his left palm and between his left thumb and irdex finger. Drape your
other fingers around his hand and wrist. With youl dghthand, grasp your child's left
shoulder and uppet the arm over your child's chest toward the
opposite shoulder ease. Then:
1. Gentiymove the therapist recommends or until the elbow
is straight. noa lift offthe surface. Hold the stretch fbr 30
seconds (photo 5.1).
2. Movc the 5.2) and upward as fai as the therapist
floor beside your child's head (photo 5.3)
LIold thc you talk to your child.
 FLL-XIBLE I.4USCLEs AI\]LT ]OINTS 47

*
x
{6*
\
;!

3. Move the straight arm forward and thenouttothe side as far as the therapist
recommends or until it touches the floor (photo 5.4). Hold the stretch for 30
seconds while you talk to your child.
4. Move the straight arm forward and then slant it diagonally across your child's
body until the palm ofhis hand touches his .ight thigh (photo 5.5). Flold the
stretch for 30 seconds while you talk to your child.
5. Move the slanted arm straight up and out to the side until the back of the hand
rests on the floor with the palm facing upward (photo 5.6). Hold the stretch
for 30 seconds while you talktoyoulchild.
6. Reverse the position ofyour hands and stretch your child's right arm.

i *t .all

ry
ttr f:
tI ;;;;

w' i;,

Note: A11 arm movements begin at the shoulderjoillt. Your hand at the upper
arm will start the movements. Your other hand follows the movement, supporting
your child's lower arm and hand. Do Dot pull at your child's hand.

Arm Stretch in Sitting

This exercise and the following exercises show the same stretches done in a sitting
position, which may be more pleasant ald comfortable for you and your child. This way,
however, you cannot obserye yolr: child's face. Use this position after you have detemined
your child's level oftolemnce and according to the directions ofyour child's therapist.
Your child sits on youl lap with his back against your trunk. Place your left thumb
or index finger into his right palm and between his right thumb and index finger. Drape
your other fingers around his hand and wrist. Grasp his right shoulder and upper arm
with your right hand.
1. cently move the arm over the chest as far as it will go with ease (photo 5.7).
Now straighten the elbow fully or as much as the therapist recommerds. Hold
the sffetch for 30 seconds while you talk to your child.
48 TEACHING MOIOR SKILLS TO CHILDREN \UTH CEREBRNL PALSY AND SIMILAR MOVEA,IENT DISORDERS

&
{ i

I ?
5.8 5.1u

2. Change your hand position and hold his dght hand with youl right hand. Move
the straight right arm forward (photo 5.8) and then up as far as the therapisr
recommends or until it touches your child's riSht ear (photo 5.9). Hold the
sffetch for 30 seconds while you talk to your chi1d.
3. Move the straight arm forward and then out to the
side as far as the therapist recommends (photo 5.10).
I Hold the stretch for 30 seconds while you talk to
youlchild.
4.Move the straight arm forward and then slant it
I diagonally across your child's body until the palm
of his hand touches his left leg or crosses over it
"x*il (photo 5.11). Hold the stretch for30 secondswhile
you talk to your child.
]J s lf 5. Move the slanted arm straight up and out to the side as
far as the thempist recomrnends (photo 5.12). Hold the
q
sEetch for 30 seco[ds while you talk to youl child.
s,tl 5.12 6. Reverse the position ofyourhands and stretch your
childt left arm.

Forearm. Wrist and Hand Stretches

Your child sits on your lap with his back agairst you. With your right hand on
his right shoulder and upper arm, move his arm forward and over so yor can com-
fortably hold his right handwithyour left hand and stabilize your child's wrist. The
$,rist shoulll be streight. nor bent forward or backrvards. r.ith the
t Lhumb poinring uf.
itr
*tr ? : a
a t It l. Slrr,rh, roratr: thc rlrisr as ti:r as the therapist recoun elds or
!,
* b unrii rhe palm is facing up (phoro 5.13). Slo\,vly sLraightcn thc
elbow as rnuch as possible (phoro 5.14). H.rl.l thc sfiClch for
30 seconds uhile vou talk to !ollr .hil1:l. Rcturr vour child's
haod Lo thr srarti g position wirh thc thumb poinring L1p.
t 2-Yoor'right hirfd supports torrr chilcl's ri3,ht elborv and lotr,er
irrm. \,llrh yoLlr lefr hancl, slor11'bend the u,risr slighrly tov,,ard
rhe thunlb side. as shor,n in d1e illusrrntion (ilhstr ation 5.14aJ.
lhis is a small rnor.en1eilr. I Iold Lhe stlctrh f(n 30 secondsu'hi1e
r-ou Lalk t.r \our child.
 FLEX|BLE I\4USCLEs AND ]OINTS 4'

J
! \
,I
+ ffi \x L..

\ t a
I
I Y
Y ;i

3. Slowly bend your childt open hand backwards. The movement is from the
wrist. Your mild pressure is against his palm. After you move the wdst as far
as the therapist recommends, geotly srraighten his finSers (photo
5.1s), Hold
the stretch for 30 seconds while you ralk to youl chiid.
4. Reverse the position ofyour hands and stretch youl childk lefr wrist and hand.

Finger and Thumts Wiggles

Hold your child's hand in a position that is comfortable for both of you, with
yourchild's elbow bent and youl hand stabilizirghis wrist. Start with rhe litile finger.
Gently straighten each finger and,
with a slight puil, circle it around s
: times clockwise and 5 times coun-
,ti terclockwise (photo 5.16). Do the
4'* I same with tlte thumb.
Next hold your child,s thumb
'1-, i and gently spread it away from his
- I fingers out to the side and hold the
stretch for 30 seconds (photo S.17).
Repeat the stretches with the
fingers and thumb of youl child,s
other hand.

-EG STRETCHES

-ilt .{ffit
One Leg Up - One Leg Down (Hamstrings Stretchl
Yollr cllil.l lies on his Lracli. yolr sir at his lcft sidc near his
lor,er lcgs. lacinghin. l,ift hls left 1eg:rnd slidc _vour 1.g undcrltis
lF .lo - i , .8. 1,,\j \. j 1 ,ir ,:.9i ,n
riSht lc8 d.r"-n rhe floor.. No ,. raise his leIL 1cg, r,r,ith linee
L.r
srr ajghr. up as high as ir \,-jll
to (photo S.l8).IIold rhe srrfich l;r
1 llltture rthile \'ou taik ro 1,our child.
Do the sllnte sllttch holdint thc left le.q dol\,rl and liftiDg
the rish.1eg LlP.

5.78
50 TEACHING ]\,4OTOR SKILS TO CHILDREN WTH CEREBRAL PALSY AND 5|MILAR MOVEMENT DISORDERS

ffi t

\r t

I v
s,20

-{ ffg-99ry'" 3

* 5 E
-.4

522
One t(nee Up-One Leg Down lHip Stretchl
Your child Iies on his back. You kneel facing him. Bend both knees and move
them up toward his tummy. Next hold the left leg where it is while you suaighten
and lower the dght leg to the floor (photo 5.19). Hold the stretch for 1 minute while
you talk to your child-
Do the same st.etch holding the right knee up and the left leg down.

Windshield Wiper Stretch llnner Thigh Muscle Stretchl

E Yourchild lies onhis backwithhis legs straight andtoes pointingup orslEhtly
fl out.Crasphi.legsabovehiskneesandspreaoyourchildsleg'aparlaslarasrJley
II wit l go rphoto s.2O). Hold the snetch [or l minuie whi re you ralk ro your child.

f nolling ort stretch lHip Rotator Muscle stretchl

k* Your child lies on his back with his legs straight. Grasp his legs above his
f knees and roll your child's legs out as far as they will go (photo 5,21). Hold the
stretch lo' t minute while yJu Lalk with your child.
!
Butterfly Stretch (Rotator and lnner Thigh Muscles Stretchl
Your child ljr:s or his hncli (phoro 5.221 or sits on the i'loor (photo 5.23)
r,lith his k:gs so aighr if fr on. oI him. BorLl both knees and BenLl_1. pltsh thern
j out Lo lhe sides as hr as thel r,i I go. HoLI rhc strctch f{rr 1 Trli LLLe \,"hile l,ou
5.23 talk rliLh r.our chi1d.
 FLEXIBLE I4!5CLE5 AND JO|NT5 5'

il ,

i
f
IE',
br

Calf Muscle Stretch

Yourchildlies onhis backor sits on your lap withhis backagairstyou. Wirh his
right knee bent, cup your hand around his heel and genrly pull rhe heel down and
push the foot up as far as it will go (photo 5.24). Pause, making sure the foot is in a
good position, facing forward, and not pointing inward or outward. With the foot 1n
this position, Sently straighten the l(nee (photo 5.25). Hold the stretch for 1 minute
while you talk to your child.

!J Calf Muscle Stretch in Deep Squatting

Place your child's favorite toy on the floor. With his
feet shoulder-width apart and toes pointing forward oa
14
slightly outward, help him to squat down in front ofit while
keeping his feet flat on the floor. Help him to mainrain rhe
position by placing your hands over his knees. Encourage
your child to lean for_ward, relax, and play for a few minutes
(photo 5.26).
Note: Play in squatting is a very effective way to strctch
the calf muscles, which attachjust below the knee. Once
theybecome used to this position, children tolerate it very
well. Ankle stretches in bacl(-lyiIrg are usually less well
tolerated. Yet, they stretch the other calf m[sc1es, which
cross rhe knee.loint. These mrscLrs r.-ill nrrt
\' | .',l-l .. .. ,,r... 1,. ,%
lna_t recomIItenLl L]ri:]t \ oL
stretches \firh \'our child.
r{)1lrf f lv do both
i
r!1 ln
Ankle Rolls
Your child lies on his bad. {)r si.,.r ll \,lnlr
laP. Hold his ri8ht le8 still with ()1rc hnDd arld
tr ,{
grasp his right f.ror u,ith.hc other. cenll)'
cilcle it. li!u rimcs (lo(ku,ise and Lhen h\c F
Limes aarrlntcr(lork\,r,ise. Repeat Lh! crrrtisc
\\ith his l('ft fbor (phoro 5.271.

qSf i-
s l.^
52 TEACH]N6 ]\4OTOR 5K]1L5 TO CHILDREN WITH CEREBRAL PASY AND S]]\4]LAR IV]OVE]\4ENT DI5ORDERS

Wiggle Each Toe

Grasp yot1r child's toes one at a time *
and gentiy stretch and mbve them around
(photo 5.28). Play "This Little Piggywent to
Martet." I
Note: Relax and keep it light. These
stretches should rtotbe strenuous for you or
your child and should not be painful. The key \
is to da them regutarly,
As you gently hold your child's leg or
ar-n in a bLreLchingposilion. you may nolice
that after 15 to 30 seconds the leg or armwill
\
stretch a little fufther. This lets you know that
your child is getting a good relaxing stretch
5.24
and that his range of motion is incleasi[g.

Stretching Exercises for the Older Child

As yorLr child grorns 01der, he llav bcc{)mt able lo do strctchinB e)ierciscs on hls o\rn.
Sclf-strerchin3 u,il1 makc hi11] rnore illdcprndent and rcsponsible. lt $,iIL bui]tl the
fbundation lor a lifetlrr(: hebit ol Laking goocl cirre of hi[rscll
lnirirlly, !'ou u, ant to l)c ncxr lo 1'our child as he does h1s \n t tLhes. LilLer, aft, r r "rr
are assured thal he does a good ioL on llis o\'\,n, lou mal'ledrr.e r "ul srpeLr isJon.

Stretching the Leg in Sitting lHamstrings Stretchl

Yo r-child sits in a .hair or i[ his whce]chair in front oi e lou'tablc r:rr anot]rer
chair. Hclping uith his hends as nmch as neeLled, he placcs his riSht leg \!ith toes
pointingup o Lo Lhe tablc. N(n- he relares lcansbacku'ards and I Ltll-v straiShten s
rhe right l(Ilec (pholo 5.29). Kccping the kl1ee soright. he then sits 1rp as srraight as
possible.leaning foru,:rrd from .hc hip $,ith arm support if needcd- ancl holds tire
position for 1 min tc (ph.,Lo 5.3rll. Hc $,ill leel the strctch behind his rjghl knee and
bdor, his r ighr buttocli. NexL he repeat! tht stretch \,f ith the lelL le3.

li

5.29 5.30
 ELEXJBLE ]\4USCLES AND JOINTS 53

Vadation: To stretchthe hamstrings more, yourchild does the following: After

he sits straight with his ghr leg strerched our, he leans forward fuom the hip, bri[g-
ing his tummy closer to his rhigh. He will feel the srrctch behind his right knee and
below his right buftock. Ask him to hold rhe stretch for 1 minute.
Next he does the same stretch with the left leg.

One Knee Up-One Leg Down Stretch

lHip Flexor Stretch,
YouI child sits at the edge ofhis bed or another
similar surface. He pulls the right knee up towards
his chest and rolls backwards inro back-lying with the
left leg hanging over the edge of the bed. Ask him to
relax and slowly pull the riShr 1eg closertowards his
chest until he feels a stretch in fuont of the left hiD
-. . .., :.." (photo 5.31). He holds the position for 1 mimte.
Next he repeats the stretchwith the left knee.
:- 3l
Leaning Forward Stretch llnner Thigh
q
and Buttock Muscles Stletchl $
YouI child sits at the edge ofa chair with his legs *
as far apartaspossible and feetflaton the floor. Ask
him to sit up straighr. Then, bending from the hip, .!
lean far fotward until he feels a stretch in his inner
thighs and his buftocks (photo 5.32). He holds the ffi,.q
stretch for 1 minute.
Note: Your child should not feel a strerch in
his low back. If he does, tell him to keep his trunk
straight as he leans forward. AIIow him to brace
himself with his arms as he holds the strerch.

lnner Thigh Muscle

Stretch In Sitting
Yourchild sits on a sola, bed,
or sinlilar f rlliture. He p lls the s.32
right hnee up u/irh rhe hclp of
his hands ifneeded. Heplaces the right foot next to the lefrrhigh.
He sits straight up, leans slightly fotward, and pushes the right knee
down with his right hand (photo 5.33). He will feel the srretch in
his inner thigh muscles. He holds the srretch for 1 minure.
He repears the stretch with the left leg.

Calf Muscle Stretch in Standing

YbLr i rhrld s.ands tir(ir1s.r \{a1l\!jth lis leir les lor r\,ar.d in
fronL
of his rightle.g. His ()r!pointstriighrahe.Ld. noLLLrne.lin oroLLt.
!\iiLh his hrntls. hr braces himself aSainsrrhe r,rn [. t]e hcnd\ his
leILkfrennLll(eepshrsrighrknecstraishr. l.ell him ro lean tbr r.-a r rl
5.33 unLil re lecls .t str rrch ir his r.ighr calf lnuscles (phol() 5.34). Ask
54 IEACHING A/OIOR SKILLs ]O CHILDREN I/ITH CEREBRAL PALsY AND SIM]LiR MOVEA/ENT DISORDERS

himto hold theposition for l minute. The

heel of the right foot should not come up
off the floor.
He rcpeats the stretchwith his right
leg in front ofhis left 1eg.

'M
celf Muscle stretch in squatting
Yorrchild srands in (.or. oia hea$
pieceot lJ r, irur". supports h im"ell w irl-
ris arm: at .he irr|riture, and bends \is
kreesand hipswhile keepirS his leer far
o r r'e
toor and toespo'nrir8 br\ ard or
srjShrly ourward rplro.o 5.35r. {.k h;1,
to hold rre loue"t po"'ible po"irion fo.
: .t.
1mi[ute.

Frequently Asked Ouestions

a. "Sha ld I do all these e&r.ises with my child? "
A. This is a question for your child's therapist to answer. These range of motion ex
ercises and stretches are a substitute for movements your child is not able to do on
his own. As your child imptoves and his active range of movement increases, some of
the stretches will no longer be necessaty.
For instance, whenyour child starts to crawl onhands and knees, he most likely
has gained contiol of his arm movements The sho lder', elbow, wrist, and even fin-
ger and thumb joints will stay flexible and the muscles will not shorten. The range of
motion afld stretching exercises for the arms are not needed an]Tore. Remembel
though: All rules have exceptions and your child's therapist will have the final say.

A. "which of the Leg stretches are most ifiportant?"

A. The hamstring stretch, the hip stretches, and the calf muscles stretch are most
important. Most children with cerebral palsy need them throughout childhood. These
daily stretches will help keep the legmuscles at a good length and plevent the serious
medical problems due to muscle tightness.

o.'llthcr.srrirl.h.soreiol/,4r,:rrarlnl.rrhrirtfuo[ldlilfiradt)ir].gri.rr?lttithrl-1'Jlild?''
A. IL is Lrest to srarr .Lrin!t Lhem \1,hen vorrr chlld is sti11 an infart. lnstead olwaititls
rrnril ,voul child needs thcm nnnslaLed: Oh. f{r, his n]Llscles are gettingright" starl
th(:m vlher rhelr are ers\.rl) rlo. This wn1, stretchi g will noLLre ttncomforla hlc for- ).rtlr
ch ild. !or \\,i11 learn rhe strctc ring trchniques lIe11, lo r thild \"rill 3et Llsed to thc ,
aDd. bcst of ill, r-ou u,il1 establish il .liril\ habiL and a specjal timc lor r''ou both.

o.'r!,ddir.qiacr,Chrisli.,do.s/roll,ea.r'rr l,r'rvoik..SlLould-ldodilaicl!gjtret.hes
\tiLlLlLeil'
A. NoI allchildren hencitfr(]n r]rc \\,indshiekl $,iprr. rolling oLLL. or Lrulterflt' strctch.
I)r) rot do the/ll tl,tl.ss Chrirl.i( li afi.r.ri)rst lellsr,'oii i..
 FLF:X]BLE I,/]U!CLES AI"]D ]O]NI5 55

a. "My daughter, Amanda, does not like her arns stretched. She immediately
pulls her
arms away and fights me. I try to be yery gentLe, but nothing helps.
What sniia t aoZ,,
A._ TalktoAmanda's therapist about it. He or she will give you the mostknowledge-
able advice.
As a percon who does not kDow you oaAmauda,I recommend
.
Amanda and find out how much and how far she moves her arms
that you obserue
on he. o*n. for
instance, how far does she straightefl her eibows when she plays
and reaches for
something? Duringthe dailystretching time, move her arm this
much, no more, and
hold it while you ralk to Amanda. Do this for a week or until
Then, very gradually, straighten her elbow a little more than
she r"tur.". t you. *i
she would on her owlr.
Ifshe does not resist, you are on the dght track.

A. "Does it help to do the stretching o.fter Amanda takes her bdth

at night?"
A. Yes.It is a good routine to do the stretches after a warm bath. Evln then it is 1m_
portanr ro do rhem gently and be mindful ofyour child,s reaction.

a.'WiLl rubbing the insi.de of Amanda\ elbow help?,'

A. Yes, rubbing the muscle that you arc stretching may help. But do not stretch the
muscle forcefully and rhen rub it ro make it t olerable. Neteiuse
force.
a, "My son, Johrr tolerates it l"vell when my wife stretches him but
complains when l do
it. what arnl doing wrong?,'
A. Have John's therapist obseNe as you do the stretches and follow his or her advice.
Men are physically stronger than womefl. Therefo{e, your stretch
could be more force_
ful (and more painful) thar you believe.

a, "How long will it take my ehild to get used to stretching?,

A. This vades from child to child. Whenever your child complains, reduce your pres-
sure and give only a very mild stretch. Ifyour child continues
to compluln fo. th.""
days in a row, stop rhe daily routine until you have a chance
to talk toii, tfr"rupi.t.

A. "Do stretches h@e to be done as shown here?,'

A. No, therc are manyways to stretch muscies. These stretching
and range ofmotion
exercises are examples of how to staetch particular muscles.
dthe. may -ai. *o.k
better for your child. It is always besr to follow your therapisr,s "
instructions.
O. "Our son, Jordarr, olwayshad goodflexibiLity. yet, his physiciantells
us now that his hlp-
bones are coming out of their sockets and he may need sirgery.
Why is this nappeninlz,,
A, Unforrunately, in spite of good flexibility, som" childien uth .",_"1*i pui.i ao
develop hip problems. Imbalance of muscle strength, strcng abnor.a
."fi"r"i, o,
abnormal postures may be some of the contribudn; factors.

a. "1,1'lry slloLl1tl I haLLl th.str.r.lr.r_/ir.:10s.ratLd\arlir.1ll.inuttt.,

A-. Researchhlssholvllthathitmstrin3sr(rchrsdonL hr Jn jl\er rSr
JLlulL j rF ln,rst
effcctir,c il done lirr :10 scconl once a da\.. A stretch shorrer thau
:it ,,,.orr.t, i,
Dart as effecLlve. L(mger ()r repcater:i sttrr(htr{
dor\ ltot rrcre.,\e Lh,.plt.(ri\eness
(Bandy, 1997 aild t99B).
 56 TEACHING A/]OTOR 5(ILL5 TO CH]LDREN W]TH CEREBRAL PALSY AND 5II\4iLAR A,1OVEA4ENI DISORDERS

A recent study ofchildrcn six years of age and olderwith cerebral palsy showed
good results with one-minute long hamstring stretches repeated five times (Stuberg,
2005). However, no studyhas been done to find out ifone stretch a day would be as
good as five stretches. Until more research can be done, one daily stretch seems to do
the job instead of five rcpetitio[s, which canbeverytime consrming.
Ttre recommendation for stretching the aams is 30 seconds because the arm muscles
are easierto stretch than the leg muscles and 30 secoflds seems to be sufficient.

I
.aaaa
a
6 a
a
t
a
a Head-Up
a taaaaoaaa

"Ves, Keirh is able ro hold hishead up we11," confirms the physical therapist. you had
I been waiting for a response, wondering why the therapist had been talking and
smiling at your seven month-old baby while holding him up in the air rhis way and
that way. Wasn't the physical therapist supposed ro look at Keith's muscles? Nothing
like this had happened. Shejusthad played with Keirh andwas having fun, ir seemed.
"Keith has very good head control," the therapist repeats. You are happy about the
good news, but you aie unsure what it means.
Heoil control is a ffuciol developmental milestone. It is typically mastered in
infancy, befo.e children sit, cmwl, stand, or walk. Withouthead control, childrenwill
nor acquire an) ofrhcle advanced sk ills.
There are two aspects ofhead conffol. One is the ability to moveyourhead and
the other is the ability to hold it still and to auromatically adjusrthe head posirion as
you move about. This is a very important function. To focus your eyes on objects or
to eat, you must be able to hold your head still. When the rherapist played with Keith,
she had beentestinShis ability to hold his head in various positions.

The lmportance of H
You have head control. up,liou can turn it. you can ir, end
LilL
you can hold yourhead positions. Best of all, you can hold your
head still with you your body twists, bends, or turns. These
abilities come natlrrallv drive, you reach inside the glove compart
58 TEACHING |\7]OTOR SKLLS IO CHiLDREN WTH CEREBRAL PALSY AND S]I\IILAR A'IOVEIVENT DI\ORDERS

ment and get your sunglasses out while keeping your eyes on the road aIId your head
updght and sti1l. You can kick offthose pinching shoes, but your head remains stjll-
Ifthe sunbeats in through the car windows and you 8et too warm, you can evel take
off your sweater without moving your head while stil1 scanning the road.
When did you learn to do such tricks? It happened during infancy. You started
to develop head control from the day you entered this world. Some time, around 4
months ofage, you mastered it. You were able to move your head in all directions, and
you were able to hold it still with your eyes level, regardless of the position ofyour
body or the movemeflts of your arms and legs.
How would your life be if you could not lift your head upwards and keep it there?
You would not be able to look around and see where you were. You would only see the
floor and your feet. The only place where you would be comfortablewouldbe propPed
in a recliner,just the way an infant is propped iD her infant seat.
Like Keith, children with milder forms ofcercbral palsy start to hold their head
in positionwithout special treatment. Only later, when most infants typically crawi,
sit, or stand, do these children with cerebml palsy require special intervention. Chil_
dren with more sedous developmental delay or cerebral palsy may not develop head
control spontaneously and benefit from help as early as possible.

Meet Nina
Nina was bom prematurely and diagnosed with cerebral palsy when she was thrce
months old. Nina is small for her age and such a cutie. Her big smile and sparkling
eyes charm evetyone who meets her. Her mother, Pam, takes Nina in her infant seat
for physical therapy. The treatment session proceeds nicelyuntil the therapist starts
to work on head control. These exercises are done in stomachJying, a Position Nirla
dislikes. Ninat smile fades away and shebegins to cry. Afterthree months and many
therapy sessions, Nina still cries when placed on her stomach.
The therapist has given Nina's mother written home instructions and many
suggestions on how to work with Nina, like propping her up on elbows while lying
on her tummy (prone propping) on the floor, the diaper table, or a big ball. Nina
doesn't like any of them. Everyone in the family, including Nina's grandparents,
aurlts, uncles, and friends are convinced that Nina simply will never want to be
placed onher stomach. They reason that, just as some kids prefer vanilla while oth-
ers prefer chocolate, Nina does not like to be on her stomach. lt'sjusther preference.
Since everyone, especially Pam, Ioves to see Nina happy, they have been avoiding
the iritating stomach-lying position.
The therapist afld Pam have failed to communicate effectively about Nina-s dislil(e
ofbeing on her stomach. Pam follows all the therapy instructions that work on arm
and hand movement and on rolling. she does them while Nina is side-lyifl8 or back'
lying. Lying on her mothe/s lap or in her infant seat, Nina enjoys these activities. She
is learnilg. Soon she can Srasp and move a b ght, colorful rattle. She can bring her
hands together over her chest. With Pam's help, Nina begins to clap herhands. Soon
she claps them all by herself. Nina loves to show off her new sl<ills, and her family is
delighted. In addition, Nina learns to roll, first from her side to her back, and then
from her stomach to her back.
 HEAD*UP 59

But the real question is, how much progress has Nina made with head coDtrol?
After three more months of therapy, Nina can nod her head when she is in her infant
seat. Yet, when placed on her trmmy, she cannotliftherhead and look around.Instead,
she curls herselfup, flips over onto her back, and happily plays in back-lyin8. When
Nina is held updght or sits or her mom's lap, her head droops forward. She maybring
it up briefly, but she is not able to keep it up for longer pedods of rime. After mary
months ofweekly sessions, Nina has not acquired basic head control.
The once friendly atmosphere ofthe treatment sessions becomes strained. The
thempist is clearlyfrustrated. She has made little progress with her p marytreatment
goal for Nina to improve head control. She might blame herself. "My ski11s are not
adequate. Despite mybest efforts,I cannothelp my patient tchicve head control.,,
In therapy sessions, Nina tires quickly and cries easiiy. She cannot tolerate sus-
tained physical activities that are challenging for her. Nina needs short exercise tirnes
interspersed throughout her day. Therapists know this and rely on parents to maintain
a daily exercise home program.
The wotk done dt home by the parents is most important, eren tuore impor-
tctftt than what the therapist does. Without follow-lrp at home, the exercises done
dudng therapy time are like the proverbial "drop in rhe bucket." It evaporares before
the next drop comes down. Eor children under two years of age, it is essential that
at least one parent works with the child aIId caffies out the recommended activities
regularly. It is best when both parents work with the child.Ifneither of the parents is
able orwilling to do this, sadly, the weekly therapy sessions will be ineffective.
Pam has regularly worked with Nina and is generally happy with Nina,s progress.
Nina plays with toys, rclls over, and claps her hands. But Nina's head srill droops for
ward when she is held up and Pam can't help but blame the therapisr. ,,Why doesn,t
shejusttake care of it? Afrerali, she is the professional. She should be able to ger Nina
to hold her head up."
Why has Nina shown so little progress with head controi even after five months
of therapy? Did the therapist use the wrong exercises or activities? Were the hone
instructiors ill suited for Nina? Neither of these is true. The therapist selected jusr
those activities that Nina needed. She gave good home instructions_
On the other hald, it is possibie that Nina has such seyere celebral pa1s, that,
no rnatter what, she will never gain head control. Unfortunately, it is true that some
children with cerebral palsy, regardless of how much the therapist and the parent
work with them, will never masterhead conffol.
There were signs very early in her life that Nina had a significant defect withir her
nervous sysrem. FortuDately, she was able to acquire some muscle contol with persistent
training. Thereforc, we can reasonably assume that she also has the ability to slowly but
surely acquire some basic head-holding skills, if given the right kind of exposure and
training. The eJcercises proted inefJective because they were tuot used enough. The
therapist worked with Nina once per week for an hour. This was simply not enough time
for Nina to strengthen those muscles needed for adequate head control.
Does the entire fault rcst on Nina's parcnts fff not following the therapist,s instruc-
tion for daily activities in rhe stomach-lyin8 position? No; rhe truth is not so blackand
white. Nina c ed in stomach-lying in therapy and at home. No oDe develops strorS
ttuscles and gains motor control by crying. Only when Nina is happy and motivated
will she put forth the enormous effort needed to activate her muscles.
60 TEACHING A4OTOR 5KLL5 TO CHILDREN WTH CEREBIiAL PALSY AND S]N,1]LAR A4OVE]\4ENT DISO]IDE]IS

Motivation is the key! Motivatioi is everything! Without motivation, children

(dll of us, for that matter) will not leorn.'Iherapists know this, and always te11 par-
ents to make home instruction fun for the child. Nina never had fun on her tummy, so
she was never motivated to work in the position. Consequently, Pam no longer used
the position athome.
Activities and exercises done in stomach-lying are the most effective approach
to improving your child's head control. Disagreements on how much this position
sho11ld be used are not helpful. fhe rherapist andthe parenttueeal to team up, tryi\1g
different ways to modify the activities until they find a way rhar is acceptable to tlle
child. Only then can the trainingofhead coutrol get started. Pam may try inviting the
extended family to participate in the effort. Attention afld praise will go a long way
to sustain Nina throrgh her initial hard work. Abandoning the activity in therapyor
at home is not an option ifher parents want to help Nina-

Head-Up Practice
The neck extensors are the muscles that lift and hold our head up. They run along
the back of the neck and are assisted by the upper portion ofa latge, flat back muscle
ca1led the trapezius (named for its trapezoid shape). Tlte neck extensors work together
with the bacl( muscles.
Test this on youlself. Stretch out on your stomach with your head down. Put
one hand on the backolyourneck, and the other onyour lowerback. Lift your head
and feel both your neck and your back muscles tightening. Next, iiftyourhead only
an inch off the surface and hold it there. You will feel the muscles getting taut. Yo!
arc probably surprised how much work it reqoires to holdyourhead off the floorthis
small distance. Someone watching you might think you arer't doing anFhing at all.
Now roll over onto your back, then again onto your stomach, and rest thete. Notice
that before you relaxed, you lifted your head and moved it intojust the righr spot for
easy breathing and comfort.
What you just experienced provides you with a good strateg y for strengthening
your baby\ neck muscles. Sta rt each head control exercise with your baby stretched out
onher tummy. Right after being placed in this position, yourbabywill most likely lift
and move her head. Even lifting the head a small amount strengthens the muscles.
Initiaily, itis not at all importanr how high your baby lifts herhead or how long
the pedods are that she spends on het tummy. You know that each time she tries to lift
her head she is working. You shouldn t worry if she cries aftet spending a minute or
even just 30 seconds on her tummy. Roll her out of the position and do it again later.
Many short practice sessionswill add up to a good work out, and will strengthenyour
baby! neckmuscles.
 frEAD-t]P 6'

:iSY HEAD-UP EXERCISES

These.cxetcises u,jllget voul Labv srurted. Let.vour phvsical thetapist
choose rhe
ones that :tre best for vour bitbv an.l \.ou. practi(:c them r\,irh the therapist.s
help or
supcr visiorl until you fitcl con1for tairle doing thcn at home.

Head-Up After Diaper Change

Aitcr a diaper cha]1gc, roll vour (hild onto hcr tunrny u.irh her
\',r Brryr4r - ..',,.'lrJ ' r-.1 .r. r, i . . .t ne: ,.,r r.l, hea.l ro\\,ard
Lou/er yourself so vou are at e).e level r",.ith your child. Co:lx her
wlth lou voi(.e
rrrr"l b ..rlrr ',.Jr,,io ....tr. ...\-t.l .tp t . \4rt, .r, If,\ ...6 .. lj.r , i.roli,o.

I
'll.dq ln
<{.
e

t'
6.2

Head"Up on the Floor in Front of a Mirror

1. Place your baby on her tummy facing a mirror. Bri[g her arms forward
so her
elbows are in front of her shoulders.
2.Place your hand on herbottom and give some downward pressure.
This will
shift rhe weight from the upperbodyand make raising the iread
easier (photo
6.2). Observe herhead, as wellas her neck andbackmuscles. Anychanges
in
these areas tell you ifshe is trying to lift her head.
3. Reward her with your voice or make happy eye contact using
the mirror if her
head comes up high enouSh.

Head-Up on You
1. Relax tvith your child ir1 ir (on
fi]lrablc back-lt jng posjrjon. %l"s
2.OD hcr tulr1lnv prop t,.r r child
Up on VoLlr chest.rnd se(ure hcl
;ffi
bottom (phoro 6.:l).
3. You are in a good positrorl t.r
notice anv head up moyelrents
ard rewarr:l hcr elforts.
6,2 TEACHJNG AT1OTOR 5(lLL5 TO CHTLDREN wiTH CEREBRAL PALSY AND sll\4lLAR A/]OVE]\4ENT DISORDERS

Head-Up on a Slanted Surface

!VheD ] or.r r child's hcrd is highci than h!r b{r.lt. Lhe ellect of graviLv is reduced.
makirS it easier to lift the head.

On an Exercise Batl
1.In front of a millor, place yotll child on her tummy on a large exercise bal1.
secureherbypressingherbottom againsttheball.
2. Gently move the ball a little from side to side orforward and bacl(wards. This
will stimulate her to lift her head. (photo 6.4)
3.You are iIr a good position to notice all head-up effofis. Reward your child
with words or happy eye contact using the mirror if her head comes up high
enough.

OnYour Legs
1. Sit relaxed against a comfonable back support. Bend your legs and place your
baby on your lower legs facing you (photo 6.5).
2. Hold her well around her bottom.
3. Eye contact willbe easy in tlis position. Reward her with a big smile as she
bdngs her head up.
Note: Use this position only ifyou therapist recommends it. Do not use it if your
child arches backwards or leans to one side.

On tWedge
For thir exercise. rlse r r onrmtrcially e\'ailable $redse, or use a couch c shion
to malic a slantccl surfaL:( . Plir(|(, thc cor-l(h c!shjur on thc floor and slint it b) slicling
t1,o or three binders or teLepirone books of sirnilar height iD a row r.rrder one side of
the cushion.
1. Place your child on her tLlmml on a r,redSe u,ilh her head at the highesL end.
2. Sit ir l'ront oIher. securing her shorLl.lel-s and upper arms. Or ifshe props \!rll
on her lbl-errnrs. be ar her side irnd trol.l h.r l)ottonr Llor\n (photo 6.6).
3. Talk ancl smiLr as shc lifis hr:r hcad.
 HEAD-UP 63

Head-Up in UPright
Stand in front ofa mirror. Hold vour child facing
g
arva-v from you rvith one hand supporting irer hrps
and the othcrhand supporting her chest (photo 6 7J.
lnltialll, thc chlld's chin ma)'be supportcLl as \\'el1
F.ncoura8e your child to lifr hcr head up and look at
hcrsell in the mirror-.

r! Head.Up with Wrinkles

When ,vour chjlLl is u'orking
extra hard to brillg hcr head up,
fl e horizontal v!rinkles will appear on
"! her forehcarl (pholo 6.8). Thls is
I an indication rhnt she is doing her
bcst and deser|es an extra bi8 kiss
aftenlards.
After-_yolLr child briefly lifrs her
head each time you place her on her fttmmy, you want her to hold her
head up for longer periods oftime. You wallt her to build up her endur
ance until one day she can hold it up for as long as she wants to

Head-Up Fun
Children work harder wher they are having fun. Find out what your child enjoys
most while being on her tummy. will she hold her head up longer ifyou make funny
sounds, sing, Iet a puppet talk to her (photo 6.9), or play peek-a-boo? For ar older child,
looking at her favorite book may encourage her to hold her head up longer'
Place your child on her tummy in a net swing. Hold her by her hands and gently
swing her. Play "Where is my baby?" "Here she is!" you call out as she lifts her head
and your eyes meet (photo 6.10).
Place your child on ascooter and secure her with a soft, wide strap. Holdingonto
her outstretched arms, pull her gently forward. An older child may hold onto a hoop
andbe pulled by it (photo 6.11).
Note: The last two activities are favorites of older children who still need to
work on head control.

&
l\
"#
W.6
3
iy &
I

s
 64 TEACHJNG A,4oToR 5KILLS To CHILDREN ]I/]TH CEREBRAL PAL5Y AND SIMILAR MOVEA,IENT DJ5ORDER5

Integration of Head-Up lnto Daily Life

Ali the extra effort aDd the exercises are wo nd erful to ger your child
started; ro get her
to unde$rand and experience what she has to do to lifr
her head ana lofj ir i"nay.
By usin-g the head-lifting and holding exercises described above,
you u." _Jing u
very difficult learningprocess easier by motivating and rewardinj
you, .hitJ. Orr."
your child has developed some head control by doing rhe
exercisle. i" ,fri, .iur,"r,
head-up teeds to become po:rt of an c.cti.uity, part oieach
day, a"a p"rr-"tliii r_
this to happen, your child needs ro Iift her head and-hold
it tp, no, f6. u."'*JJ t*
because she wants to. She needs to take over. She needs
to make haai"S h".i"ua
up part of her life. Askidg her to lifr her head and praising
her ifshe ao", fl. rrrorrtn.
and months will hinder this process. Instead, as
soon as pissible, we *urr,fr".,o iuL"
ownership of her ability and incorporate it into her daily life.
This means drawing the child,s attentiol to the tasit at hand.
For instance, when
Mom and Nina stretch out on the floor to lool( at a book
together, Mo- rro'lorrg.,
coaxes herwith: "Head up, Sugar!,, Instead, she talks
about iile pict*" i",1" l"'"f..
Onc€ Nina raises her head, Mom accepts this is the
normal thing to a. t""p,
reading the story. If Nina holds her head up for 20 seconds,
inslead of ""a ""
lO as #tor.,
Mom willbe happy about it and smile, but will not ralk abour
it. Sh" ir."uaing
to Nina_and wants hff ro stay focused on her story. This is ";oot
l,rhat integ r"tion'oJi"oa
controlituto on acti.vity tneans. No tnore requests to holdthe
heaa ip, no tatt
about it, and no more extra pt o:ising. ^oi"
The following are ways to integrate head-up into your
child,s torrtine.
. Every time after diapering, roll your child onto her stomach and
let her stay in this position as jong as it is convenient for
vou. you
may have a litrle pla, roul ine
)ou lile lo do wilh,e,. o irh"
lie rhere while you srraiBhten up rne djapcr rabte. "rn
. l\crl'ti e lou plarc her oD thc floor. put her on her
sL.mach fit st. Ne\ur: mird rhat she wi11srrcn 11ip or t:r
on her back. or fusses and you will then mln her
o\,er or1hai LLraal(, Regardlcss, alvt al,s put hcr on
hel
t .
stomnch llt st.
{ Lvcr \. time ]'ou pick her up 1i.nr barh lyint, pljt 11er
or hel sromach lirsr. 1et her srat- rhcr.e a short time
ilt \ and thcn picl her up.
a E! el! time cirrrv ],our chil,:1, har.e her face al!a\.
]oLL
. . , I .li.r, tr r,. ., ,,, r'
js sho\vn ir phoro
6.2 "
I:::j . li\, carrtirg vour child in sromacir llinS (phoro
{ r*" '::' ':: *l 6'12). Obser\.e 1\,hether your chlld jnterlnjttenrlJ
lif.s a.d h.rds her head. or ar least rries to 1il.t hel
6.12 h.ad. If so, use thjs rnode of c:Lr rving hei whcn jt
is conVenicnt 1a, \-olr.

Yoqr Chitd Practices Head.Up tndependently

Find sonle to\s Lhar ale jnr(:restjng fL, ,,.1r cl rltl L,r L.arih rnd lrsteri tu. Use
 HEAD-UP 65

Place your child on her stomach with a rolled-

'l
rp towel under her chest. The towel rollwili lifther
a
f chest off the floor and ensue that she is propped up
o11 hei elbows and that they are rmder or in ftont of

n the shoulders. Drape afive-pound ankle weight over

your child's buttocks. (A sock filled with rice or dry
beans and tied shutalsomakes agoodweight.) This
will help to straighten the hips and shift the body
weight backwards, making it easierto lift the head.
Hold atoyup for her to watch (photo 6.13).
i-1 Next, choose a music box (or simiiar toy that
F!= moves and makes sounds), place it in front of your
child, and walk away. Or you may put on a video or
DVD to encourage her to look up. Even ifshe lifts her head only briefly once or twice
to look and listen, it's a start of independent play in stomach-lying. It's the start of it1-
dependeftt, itegrdted hedd cotutrol. Stop the activity as soon as your child fusses.
Note: Do not encourage your child to use her hands during this activity.
Don't tel1 her to touch the toy. Stretching and reaching with the arms makes lifting the
head more difficu1t. lnstead, encourage your child to remain propped on her elbows
and enjoy watching and listening. Without moving, it will be
easier for her to hold her head up.
i
Head-Up on a Boppy Pillow
Placed on a Boppy pillow, a bigger child may enjoy being on
her tummy and holding her head up while propping on elbows
(photo 6.14).Itt a good position to hang out, watchwhat's going
oq and exercise the necl(, upperbacl! and shoulder muscles at
i "e.r_
I the same time. (A Boppy pillow is a curved firm pillow, which
is available in stores with baby items, many general stores, and
even some drugstores)

Use of a Plone Standel

For an older child who still needs to

t work onhead control, use a prone standet

as much as possible. With the stander set
in forward leaning position, the child will
a
exercise her neck cnd upper back muscle..
with the stander setin anuprightposition,
.:: basic head holding ski1ls willbe reinforced.
In preschool, your child can be in a prone
stander during story time and during
I o[e-on-one instructions (photo 6.15). At
a home, she can be in the prone stander
:r" when looking ar books. watching TV e,c.
(photo 6.16).

6.16
 66 IEACHING ]\,4OIOR SKILLS TO CHJLDREN WITH CEREBRAL PASY AND SIMILNR MOVET,4ENT DISORDERS

Frequently Asked Ouestions by Parents

a. "How oftenshouldl do thehead'up exercises. ithny child?"
A. the time. Wetl, no. Your therapist most Iikely will give you sensible directions.
A11
"Please try to do this three to four times a day." Considering how much your infant
sleeps during the dayandhow much time feedings take, this is a good schedule. Yor
want to catch those times when your child feels well, is not hungry, and is rested,
active, and alert. There are usuallythree or fourperiods during the day that fit that
description, and this is when you want to pmctice. Remembet initially it is not im-
portaDt how high or how long your child lifts her head. If she fusses, ro11 her over,
give her a minute ofrest, and then try again. All those short practices will add up to
a good exercise session.

Q. "I llenwill l see improvement and h,hcLt are some of the sigils of progress?"
A, All the time. Ofcourse, there willbe variations. Sometimes your child will not do
as well as at other times. But overall, there will be a steady trend ofpro8ress. It will
start to take less time, less coaxing, and less extra effort on your part foryour child
to lift her head. The head will come up higher. It will come up sffaighter-with her
eyes level. She will be able to hold her head rp longer. First she may hold it up only
seconds ionger. Yet, each second counts. Observe what she does whenherhead is up.
Does she look around? Does she look at you? Does she smile? All these are signs of
progress. This first intensive work on a new skill is exciting and rewarding.

A. "How long should I do the head-up ocercises? Days? Weeks? Manths?"

A. As short a time as possible. "Why ooly for a short time if it is helping?" YouI goal is
foryourchild to holdherheadup all the time, notjlstwhen she exercises. To achieve
this I recommend that you fade out the exercises as soon as possible and follow the
recommendations of Ia tegration of Head up into Daily Life.

A. "wW is integration important?"

of head control so
A. Head control is an automatic response. We do it without thinking about it. When
we move, ourhead position chanSes without us paying any attention to it. Yes, if we
want to, we can pay attention to the positions or movements of our head. But usually
we don't even think about it. You hold your head up all day long. Can you remember
ivhen you did it consciously? I bet you cant, and this is my point. As soon as possible,
you want your child to hold her head as automatically as you do.

:-
 aa
a
7 a
a
a
a
Happy Baby in
a Back-lying
a aooaoaooa

fhere is a yoga pose called happy baby." It is easyto do. You lie onyourback, stick
f your arms and legs up in the at and enjoy. That's it-happybaby.It mimics how
babies spend their first happy hours in play. They look at their hands and watch as
they move. Their hands touch; they feel it and are fascinatedbythe sensation. Their
legs come up, they touch their feet, and thefu world is full of wonder.
In this position, the muscles that are workinS are in the front ofthe body. They
bend the joints and are called flexor muscles. It is in this back-lying position that in-
fants learn their first functional skill-putting hands to mouth. Even ifparents don't
want them to, babies succeed in sucking their fingers or their thumb. You may regard
it as a nuisance. But think about it. Isn't this the first step toward selffeeding? Eating
independently is a very important skill.
Full-term infants can do this hand'to mo[th movement very ear]y because they
are born with thet arm and legjoints slightly bent. This is called physiologicdlflexion
ofthe netuborn.\t gives them an advantage that makes bendingthe a neasy. Babies
are born this waybecause they have spent the last months before deliverycurled up
inthe crampedspace oftheir mothe/s womb.It is easier to bend your shoulder or hip
joint if you start out faom an aheady mildly bent position.
Tryto experience this yourself. Lie stretched out on your back so that all parts
of your arms and legs touch the floor and then lift your arms and legs up into the air
Try it again, butbend your legs and arms abit before you mise them. You will notice
that it is easier with your limbs slightly bent.
Infants who are born at 29 weeks or earlier show little or no physiological flexion
at bifth. By the time their nervous system has matored enough to allow voluDtary move
ments in back-lying, they have a harder time doing them than fl1ll,term babies.
68 IEACHING ]\4OIOR S(ILLs TO CH]LDREN U/]TH CEREBRAL PALSY AND SI[4ILA]i ]\4OVEA4ENI D]sORDERS

There is another hurdle for premies to overcome. In back-lying, their imma-

ture nervous system causes a[ increase of the muscle tone oftheir back muscles
(extensor tone). Their back is straight and stiff, their shoulders are pul1ed back,
and their legs are stretched out. This makes bending the shoulders and hips even
more difficult. Consequently, premies may not start playing with hands aIrd feet
as early as they should.
Infants born with very low muscle tone and infants bornwithincreased extensor
tone due to a defect of the neNous system show a similar delay ofhand to-mouth,
hand to-haod, or hand-to-foot play.

Happy Baby Exercises

For children who need help acquiriflg early play skills in
backlying, physical therapists
may recommend some or all of the following activities. The first three are pcssive
range of tuotion exercises. They are called passive because the children do not move
on thefu own but the parent curls up the child's trunk or lifts and moves his arms for
him. The exercises are meant to loosen your child'sjoints and muscies, mildly stretch
them, and allowhim to experience normal movement patterns.
Technique is important when you do passive movements with your child. For
instance, when you do Moying One Arm at a Time, your child's shoulderjoints needs
to be in a good position-not pulled up orback. Therefore, the shoulderjointis placed
just right, stabilized with one hand, and only thefl the arm is moved. Keeping your
childt muscle tone and his bodysize in mind, the therapistwill show you where and
how to place your hand to stabilize the shoulderjoint. Be sure to practice the exercises
first with the therapist before vou do them at home. The written instructions will thefl
be a reminder for you. They are not sufficient on their own.
The firstexercise is meanl to loosej1 and
mildly stretch vour child's back muscles and
the muscles aroLrnd the shouldcr hladcs.

Spine Curl.Up
Yofi child lies on his back. Grasp under
his upper legs and curl him into a "ba11" so
EL*:,:*.sc
his bottom is up in the air. Roll him slowly to
the right, then to the left and then back down
(photo Z1).
<a'
Moving One Arm at a Time
This actir.irl rvill help )-ou loosen \.our
child's shoulder muscles and stinlLrlate arm
llovelllents,
l. Your chlld lies on his bacl. Slirk:
vour right hirnd under hjs lefr
shr )u llkrr so \o!r lingers restontop

of thc shoulder and \,'our Lhumb

,,.,,r aps rround ir (phoro 72).

^r&
 EAPPY EAtsY NE LYING 69
'(

x 2. Gently pull the shoulder do\ ,.n in the dircction of rhe feet.
Bend the arm at the shoulder
3. Holding his left hand with your left hand, move his arm toward the
opposite shoulder as far as it goes without pulling the arm (photo
73), and then move it back out to the side.
4. Repeat five times with each arm.

If your childt shoulderjoints do not need to be stabilized, the

-a' therapist may recommend that you move both arms at the same time
as shown and expiained be1ow. This is done at three different speeds.
At the slow speed, you move the arms through their full range of motion and mildly
stretch the arm muscles. At the faster speeds, you move the arms as far as they go with
ease, which will not be less than their full mnge. The faster movements do not stretch
the arm muscles. They arejust meant to loosen them. Do aof do the faster movements
if your child tenses his atm when you do them.
When you do the three arm movements, make sure you look at and talk to your
child. Happy eye contact encout ages your cltild. to keep his head, itt the middle and
not flop it from side to side.

Three Arm Movements

Your child lies on his back facing you. Hold his hands by placing your thrmbs
into his palms. Letthetips of your thumbs restbetweenhis th[mbs and index fingerc
and looselywrap youl other fingers around his hands and wrists.

Boxiftg
1. Gently pull the
ght arm up until rhe elbow is straight. pause (figure Z4).
2.Gent1y push the arm down while you pull the left arm up until the elbowis
straight. Pause.
3- Repeat two times.
4. Next, rcpeat the boxing motion at a faster speed, and then do it very fast.

OLtt ond OlPr

l. Gentl! pulL both arII)s LLp 1lrrjlthe elboNs irrc straight.
2. Slonly s$,ilg dre ar ts orrr to the side!. Pafse lfigLLre ZSe).
3. Slorvlr, srvin8 rhe ar'ms up and cross rhem o\.er Lhe chcst. Pause (tigurc 7.5b)
.+. Rqreat tl\-o Liml]s.

5. Nexr, Llo iL nr a fuster speed. enrl thcr at a r.erv irst spced

tl

)
70 IEACHING A4OIOR SK]LLS TO CHILDREN WTH CEREBRAL PALSY AND 5]]\,4]LAR A/]OVE]\,4ENT DISORDERS

windnill
1. Gently pull both arms up until the elbows are straight.
2. Slowly swing one straight arm up beside the head and the other arm down
beside the trunk. Pause (figure 26).
3. Now move the arms until theirpositions are reversed. Pause.
4. Repeat two times.
5. Next, do it at a faster speed, and then at a fast speed.

To do all three movements after each diapea change does not take long. It is time
well spent- Mostbabies like them very much, especiallyifyou change the movement
speed as recommended. They like it ifyou move slow - pause - slow - pause , fastet
faster, faster, faster, and then fast/fast,/fast/fast/. Ifyou child did nor smile before,
by fast/fast/fast/fasthe will surely giggle! Talking or singing while you do the move-
ments makes them even more fun.
Ifyour child enjoys the three arm mor/ementsJ you may notice that he does l1ot
remain passive but participates with the movements, which willbe very good.
Note: Remember-do the arm movements only at a slow speed ifyour child does
'ke rhe
"or fas. mo\emenrs afld Lenres his arms.

Happy Baby Plays with You

Now your child is ready to play.
YouI child lies on your lap facirg you. Cradle both shorlders with youl hands.
Smile at him and b ng his hands to your face by bending his arms at the shoulder and
holding them up (photo z7). Have him touch your cheeks, mouth,
and so on. You may tell him what he is touching "that's mama's
ear." Yolll child's head should be in the middle [the eyes are ]evel)
as he lool$ and listens to your baby ta1k. Yorl may playpatty-cake
or peelca-boo with him or what ever comes to mind.
Next, bring his legs up as you did for d1e spine cud'up, and have
P F his feet touch youI face. Play with him as long as he enjo]'s it.
vadation: When your child is familiar with the play situation,
encourage him to do more on his o\,'n. Help him bend his arms at
the shouldels, talktohim, andsee ifhe touchesyou.Ifhe does not,
move his arms up and place his hands on your cheeks or mouth.
il .J
See ifhewillkeep them there for a few seconds when you no longer
support his arms.

Happy Baby Plays with Feet

Oncc volLl l)el)\, (ifr bring iris arms up and his hands rogrthcr. he is ready ibr
dlis acLi! ir\.
1.Yr)ur birht li.rs on ]'oLLr hp lacr !l\ou.Tiill(rohirnasvougrasprLnderhisrppcr
Lrgs, arld hrinS them up.
2. Encourage him Lo torLCh his knccs or teet. lf he cannoL .1o thjs, hokl his right
1eS LLp r,fith \'oLr. l.fr hajrd, a]]d, Nith vour right hind, support his leh upper
arrl ns rluch as n.rcssar).tbr him ro be able to rouch ris legs (phoLo 7.8).
3. Repcat rhis irnd h.Lp 1.our child Louch his lcfi lcg,"vith his ri3ht hand. PlaY es lorg
as vour bebl cqovs it.
 HAPPY EABY IN BACK.LYING 7f

rlsa

tl
-j
79

Variation:
1.Ylurchild lies on the floor. Bypushingup his searyou make ireasy for him to
lilt one leg witlt krees rurned ou..
2.EncorraSe him ro touch his foot and pull off his socl( with rhe
opposite hand
or both hands (photo Z9).Ifneeded, help him to grab oato the
soik and then
Iet him pull it off on his own.
3. Repear with the opposire leg and arm.
Colorful socks orbooties withbells on them provide vadety and an
extra incen_
tive to bring up the hands and feet for play.

lndependent Play rn Back.Lying

.. Now your baby may be ready to play by himseli Follow your physical therapist,s
directions on how to position him oII his back.
\Aihen your child plays in back-lying, you want his head ceorered berween
his shoul_
ders, his rrunk srraigh! his atms benr at the shoulde$, and his legs
benr at rhe hips.
Ro11 rp a rowel ftonl
each side, turn it over,
t3
tt and place yollr baby be
tween the towel ro1ls. In
photo 710a, the rowel ro1ls

D
[,
are alonSside the baby's
body for support and to
help bend the arms at
:., the shoulders. The baby,s
head is placed on a folded
diaperso itis inthe middle
.ir*,*f. with the chir tllcked. In
photo 710b, rhe towel rolls

sho.tders to clisc.ur.ag*he rh,.1ri(rn rrrnjrr*n"r,r"r,,",,lil ]1,"Ji1li'f,lX;i;,**.l

atthesho!lders.ALriggerLoriclrollispl:r(edLrnclerthr,legsagainsrtheLabv.sbo(or,.
t' lt''r ' irl
Placeal)ab1-g\lno\rrroLrr (hjlLl. ihedangljfBto!stviilcnricrhimroreachup
r\,irh his arns and n) 1iIL his le(J
72 TEACH]NG I\4OTOR SKJLL5 TO CHILDREN WITH CEREBRAL PALSY AND SIAIILAR I\4OVE]\4ENI IJI5ORDER5

ls Your Child Ready for Back-tying

Lying on their back by themselves dudng their waking hours is not a good position
for many children with cerebral palsy. Abnormalreflexes and abnormal muscle torr.
will affect the childrcn more in this position. In back-lying they may not be able ro
bring their hands together for play or roll over onto their sides or their tummies. Con-
sequently, rheywill nor be happy on theirbacks. cood positioning in side-lying, in an
infant seat, car seat, teclininghigh chair, a speciallyadapted seatrecommendeibvthe
rlerao'st or inaprone.randerwiJlberrorebenefi.ialtor.hen.hvritnal,eitea:-er
for them to play and socialize with people. It also protects their muscles, joints, and
bones. Ifyou child's physical thempist rccommends rhat you nor place your child in
the back lyirlg position for play, follow this advice. Chapter 3 explained rhe reasons
for these precautions againstback lying.
Note: The happy baby activiries may also be done with your child lying in an infant or
car seat. Ifneeded, supportyour child's head and bodywith a folded diaper and a rolled_up
towel as described above. You wailt you. child,s head in the middle, his shoulders 1er,.e1,
and his trunk straight. Ifyour child siouches to one side in the seat, avoid using it as much
as possible rlnless your child's therapist can help you solve the problem.

Freguently Asked Ouestions By parents

A. "Emily is 6 fionths old. She likes to play inback-lying, but tuhen l pullher ta sittirrl,
her headJlops backif I don't support it. I qmyery woried about this, but Emily's therapist
doesn't seem concerned. She is pleased that Emily holds her headup when I carry herind
when she sits on my lap. She says Emily is making good progress. What do you think?,
A. Emily has mastercd rwo very impofiant skills. She holds her head in upright and
she plays in backJying. Next, yor wanr Emily ro be able to lift and hold her head
whel]
she is on her tummy. After she masters this, her therapist may show you how to work
with Emily so she learns to hold her head when pulled up from back_lying.

a,'Abbylikestopktyinback-Iying.rfrhenshewassmoLler,Iproppedherupwithtowels
and she tolLchedthe dangliLg toys of thebaby gymwith either hand. Naw that she
is big
ger and propping her up with towels no longer works, I obsente her using only
her right
hand dnd slTehequently turns her head to the side. What should I do?
A. What you describe indicates that abflormal muscle tone and abnormal reflexes
are interfedng with Abby's arm movements. When Abby,s head was in midline and
her shoulde$ were sliShtly rounded-as they were when you propped her rp with
towels-this happened less. Since you can no longer position Abby well in back-lyilrs,
use_the position only for short periods oftime. Talk to Abby,s rherapist. togethei you
will find better ways to positiorl Abby fo. playtime.

Q. "My son Chris is ayearold.Inback-lying, he has sterl3dta scoot around on thefloor.

His therap(t does not.Nant him to do this. V{hy? Isnt it good that he is learning to mo\)e
around onhis otun?"
A. Yes, it is good that he moves around. But his therapist is right, neyertheless. It ts
not good for Chris to scoot around on his back. It does flot teach him coordinatiux
 HAPPY EAEY IN BA'( LY]NG 73

and does not strengthen his muscles for other skills that he will need to learn. I am
sure you want Chris to learn to ro11over, crawl, sit up, stafld, and walk. Scooting on
his back does not help him to acquire any ofthese abilities.
o[ce scooting on his back becomes a habit for Chris, it may even hinder him from
learning other ways of movilg about. When scooting on his bach Chris pushes his
shoulders backward. When rolling over, however, the shoulders I1eed to be pulled for-
ward just the opposite ofwhat he is doing. When he sits o. stands, pushing the shoulders
back can cause him to fall backwards and prevent him from regaining his balance.
Please, follow your therapist's advice. The sooner Chris learns to move about
by rolling or crawlin& the better itwill be for his motor development. Placing chris
on his tummy will keep him from scooting. It will encourage him to use his muscles
in ways that will help his motor skill development. If Chris does not like to be on his
tummy, fo11ow suggestions and activities given in Chapters 6 and B, which may help
him to like the position.
 a
t
8 a
o
t
a
C Tummy Time
a eaaaaaaao

Ctarting in the early 1990s, pediatricians ir the United StatesbeSan recommending

rrthatinlants sleep on their back. This directive has graduallyreduced the incidence
of SIDS (Sudden Infant Death Syndrome). It also has reduced the time infants spert
on their stomach. As a remedy, physiciarm ask parents to give their infants "tummy
time" duringthe day when they are awal(e.
This is good advice. As explained in Chapter 3, the amount oftime your baby spends
on her stomach makes a difference. In stomach'lyin& infants start to use the muscles of
d1e backside of their body, the extensor muscles. Ttrese ar e the muscles that t]?ically arc
weak in children with developmental delay or with cerebral palsy. Therefore .tumtuy time
is especially importantfor childretwith gross motor delays or with cerebfttl palsy.
A good way to start tummy time is outlined in Chapter 6, Head Up. Place your
child on her tummy throughout the day for briefperiods again and again so that she
gets used to the position.
The fiIst battle will be won when your child, after being placed on her tummy,
contentedly looks around. She may, however, not lil(e to be on her tummy for long
periods becausejust looking around gets boting pretty quickly. Before your child will
be happy in this position for any length of time, she needs to be able to play on her
tummy, interact with toys, and have fun.
"Playing in tummy-lying is easy. Babies love it." This iswhat everyone believes.
But is it uue? Fird out for yourself. Stretch out ofl the floor and pretend to play like
a baby. After a few minutes, you will know that it is hard wodc A great deal of up-
per bodystrength and arm coordination is required. Childrenwith cerebral palsy or
similar movement disorders need much practice to master it.
76 TEACHING ]\,1OIOR S(ILLS TO CH]LDREN WTH CEREBRAL PALsY AND SI]\,4IL,1R ]\,4OVEA/ENT DJSORDERS

Prerequisites for Tummy Time with Play

what are the necessary components that make it possible for a child to play on her
tummy, or in prone position, as your therapist may callit?
Easy Head-Up. The higher your child can lift her head, the easier it is for her
to hold it up. Plain physics is involved. Ifthe head is lifted 45 degrees, its center of
mass (weiSht as acted on by gravity) is in ftont of the shoulders and muscle strength
is required to keep it up. Once the head is lifted 90 degrees, the weight of the head
rests over the shoulders and little effort is needed to keep itthere.
A child who is able to bring her head all the way up may do so to rest and rela). her
neck mllscles dudng play. A child who can lift it rp only 45 degrees has ro pur her head
down when she gets tired. As long as youl child still needs to intermittently
put her head down and rest, it is only safe for her to play with soft toys while
on her tummy.
I
ProppingUp on Elbows andForearms. Did you ever see an o1d fash-
ioned baby picture with the baby propped up on a fur rug? This is exactly
what you want your baby to do. Whefl your child is solidly propped up on both
t elbows, she is ready to take her hands off the surface and touch something.
While her elbows stay propped, she will be able to cradle the toy berween
her hands (see photo 8.1).
a.l

Propping Up on One Forearm. For more interesting

play, babies do notjust touch the rartle. They tum it, shake
it, drop it, and reach for it. To do so, they take one arm offthe
surface. For successful play with one arm, the weight of the
upper body is first shifted over one forearm, which frees the
other arm ro reach and play (photo 8.2). This weight shift
andpropping up on otueJorcdrtuk a chc,ller.ging taskfot
many children with cerebral palsy. Some acquire the skill
slowly on their own by spending lots of time on their tummies.
Others need extra help to learn the task, and for some it may
always be difficult.
4.2

Exercises for Tummy Time with Play

't he fir'st Lurc tLrfirn)\ r\tr risr:r hclp ro preparer.our chlld to shifr hcr,,""cight, reach. an.l
pla\.in sromach-l!ing. lheldonorLakekrngantJarceasl.todoif).ourchil.l isus(l
Lo spenLling sorrrc tint, ir1 sLorracli l\. ing. Pra(.i(ing rhetn with a child u,ho do.rs Dot
like to bc on hcr sromach is a diffirenr st(n]. [floLrr chi]d is not Llse.l n) bcing on her
stomach, srrrr rhe erercises trrv gr arha llr. llegin 1.'irhjusr Lhe fir sr crcrcise. Ro.kLn.g
on lu_cdrms. Do the acLi\,irv oll lv as long as rour child llkcs ir. Tfshe fusses alLer 10
sc(onds. do ir ool! 10sc(r)Ild!. lbnaheLlplort]teshorrri c, do it as olten as r,ou can
rlana8e or rl.]lat \\{)rks for \'o!: llach tirne belire anrl .rftcrr.ou change her cliepr:r, cach
rime Lrelore lorL pirk h.r up, L5elbre and rlier hrr nap anLl so on. Il lou l\,ork ourside
lhe hone. ,vou rna\ c\,clr ask,,-out Lribv sitter or d.rr care n orket Lo do tt.
 rut4tu]Y rll,l[ 77

Keep doinS the routine until your child likes it when you rock her on forearms.
Now you may expand her tummy time. After Rocking on Forearms do Rocking @nd
Reoch with her If she is happy and alert after both exercises you may follow the rec_
ommendatioos of Indep endent Tummy Time Cradling Toys and have her spend some
more time on her tummy.
Use the exercises as directed by your child's physical therapist and follow any
specifi c directions given.

nocking on Forearms
1. on the changing table, on your bed, or on the floor, help your child to roil onto
her tummy facinS you.
2. Support her upper arms so her elbows are uflder or s1i8ht1y in front of her
shoulders.
3. Gently rock your child ftom ofle forearm to the other. Do it as you sing or play
a 1ittle song for rhythm and fun (photo 8.3).
Do this several times a day.
After your child is used to the exercise, reduce your support to her upper arms.
lnstead, with your open hands lightly touch the arm and shoulder as you rock her

r&

11
! {
I r. s
't
ffi *,
; ,&. i 1'
"'r-
D
Rocking and Reach
l. srarr r,irh r ocking on iorearnls. as dcs ibed tlbo\,e.
2.NerL,1eanrcr:rchildi,rllLhel\iat'o\.ertorhcrightforearm rocl irn.l,sLlpporL
ing the upper ar m anrl clLou,. sLrerch the lcft nrm orlt reach (Phorc 8.4).
.1. Plircc the lelt lorearrr back or the suriace. lhenlcanherallLhel{a!'ovcrto
rhck:ftforearm rocli andsrrcrrhoLLlLhetiShtarln rt:arh.
Ilo ten repcririoas sel.erai tirnes a da\.
Trytocrcarc irrh]thm.l sLead-vritlthrr and sri,i S"rock and rcach"willheip
.l rolr .-, l o , tr .. , r..
",r
Independent Tummy Time Cradling Toys
ls lour rhiLl lor some inarprnLlcnL Plel'on her lunllll\? T\)siLioni.8 hel
reacl,v
as explairl.d hurc \\, ill ureke il easier. [ir st do rhis w ith the helP oiyour tht:r aPisr ancl
lb11o\r, arl sPc(:ili(.lirecLions Sr\.e11
78 TEACHING l\/]o]oR SKJLLs To CHILDREN WIH CEREBRAL PALSY AND SIMILAR A/OVEAIENT DISoRDERS

1. Place your child on her sromach with a roll (tolled rp

receiving blanket ortowel) underher chest so her elbows
are positioned under or slightlyinfront of her shoulders.
L 2. Place a five-pound ankle weight or sandbag over her but-
tocks. (This will l1elp straighten the hips and shift the
bod]'weight backwards, making ir easier for her to hold
her head up.)
:i 3. Set a soft toy between her hands for independent play
(photo 8.5). See the Appendix for rips on making yo11r owrl
I sandbaSs.
Have your child playlike this several times a day.

Tummy Time with Reach

1. Positionyour child as described
in the above activity.
2. Stretch out in lronr ofher
with an interesting toy. Suppoft her left elbow, help her
to lean ovet to the left, and wait for her to reach for the toy with her right hand.
3.Ifyour child does not reach our for the toy, place her hand on ir and let her
figure out what to do.
4. Later, support the ghr elbow while your child reaches with her left hand.
5. Have your child play as long as she is interested.
If your child has hemiplegia have her always teach with her affecred hand when
you practice with her.
Variation: After your child has shown some
progressr try the activity wirhout propping her up
with a towel ro11 or using the weights (phoro 8.6).
For an older child who sri1l benefits ftom lummy
Time with Reach, use an age appropriate activity
*J instead of a toy.
?:
I Note: Usually children soon prefer one arm to
reach and play with and rhe other arm to prop up
on. For manyreasons, it is important that youl child
learn to prop or play with either arm. Continue the
assisted play in stomach-tying until your child can
play indeperdently with either hand.

What's Next?
Afterl'our. hild is able Lo piav iD
stomich l1iDg. sher,r,i11lihr: rhe posrti(]]r. \,Vhenp1ace.l
on herbacl(, dte trill roll o,"ct, and ii sht:rrrnor d.r so, shc u/on't be hirpp\ until!oLl hclp
her to gr:r onto her trnr
\'. As \.our ch ild spellds m{rrc and nlore tiir. on her tumDL\.
her arms. shoulders. atld uppei boLll nl1rsc1es lrill hccolne nlor.c roordinaLed. She,,vill
learn ro stretch hcr irrln lar laruard teach |.r rhc side, turn ro the sjde. and lna\.be
c!cn scooL backward or lin ward. Pro8less is ilo\!' t.elati\rlv easv:1n11 firsr.
\?r, !\cr r{nl1 plerrr! olot1te or] h.r nrnunr.. a chikl u.iLh ccicbLal pals] nla\
ror lear n all rhe skills sh. n.eds LUlhss shc r.( ei1es spccial help. S(:rll,s stoIt, bclolr.
shor,s ho\r rhis help rnir\ b.r soundl! n,icctt'd tr1 tht (h]ld.
 TU[4]\4Y T["]tE 79

Big Push-Ups for Sean

Sean is eighteen months o1d. He is a dever, busylittle guy. Sean has a diagnosis ofcerebral
palsy and has been receiving physical therapy for a year. Today his mom brings him to
his session. She purs Sean down and proudly tells the rherapist thar Sean is leaming his
colors. The tlerapist is impressed. As the adults talk, Sean seizes the moment. He quickly
ro1ls on his tummy. Ready to play, he scans tlle room. .,Hmm-what,s interesting around
here?" Ohyes, he likes rhe Sesame Streetpop up toy. Offhe goes, pullinghimselffor-ward
with bodl arms, digginS his little elbows into the carpet. The left knee also comes forward
and helps with the forwatrd lunge. It is not easy to drag crawl (a1so called commando
crawling). You can try it and fiIld out. you may run out of breath pretty quic]dy. Sean
s[re knows how to make a go of it. He pauses, looks at Mom, and his expression says:
"Aren't I doing great?" 'Yes, you are, Sweetie," Mom,s proud smile answers.
Sean jllst leamed to drag crawl. Three months ago he had been barely able to
move a bit to the side. Moving forward js so good: it's liberating. Sean is no Jonger
helplessly immobile. He moves and explores. He is eagerly using his new skills. The
therapist is pleased with Sean's progress. Independent mobility is so very important
for a child's overall development. Nor swprisingly, Sean is making progress in other
areas too. But, ofcourse, there are better ways to move about than drag crawling. It
is the therapist'sjob ro improve and build up rhe gross motor sldlls ofhis or her lirtle
patie!rs.Th:s's I te pu"Dosco[rhe therapysession.
The therapist moves Sean's right leg up after he has pushed off with his left as
he tates offagai[. She is helping him learn ro crawl reciprocally. Ar least this is her
intention. When reciprocally commando crawling, children push off with one elbow
and the opposite knee. It teaches them to move the right leg together with the left arm
and the left leg with rhe dght arm. Doing so, children learn an alternatin& coordinared
movement patternwith their alms andlegs. This is something new that will prepare
them for crawling on hands and knees and for walking.
When reciprocally commando crawling, the body lifts slightly off the floor, and
moviog for-ward becomes easiet than when the tummybrushes the floor. Sean thinks
differently. "This does not help me at all!" He stops in his tracks. No more crawling for
now. No coaxiflg by Mom or rhe therapisr helps. Sean has made up his mind. ,,Eirher
I do itmywayorno way!" The therapist does not getthe message. Next she puts him
on hands and knees. "Oh no, not this again!" Now Sean is realLy upset. He iries, his
arms give, his legs stretch out. He has had it!
Why doesnt Sean like to be on his hands and l(nees? Does the position hurt
him? No, most likely he cries because he feels uruafe in this posirion. Mosr likely he
feels afuaid that he could fall on his face at any moment. His arms are too weak to
hold him up. Even with the therapist's assistance, he is not sure he can stay up. Also,
keepinS his legs bentis hard for him. When he lifrs his head, allhis extensormuscles
are woaking. Unfortunately, the extensor muscles of his legs want to work too. They
straighten his legs and make him drop down onto his tummy.
For Sean, being on hands and loees probably feels as risky and unsafe as you
would if someone asked you to stand and balance on a movitg ball. ,,Whywould I
do that?" you ask.
All stretched outon the floorand propped up onhis elbows, Seanfeels comfort
able. He can lift his head, he can play, he can move-ir is fun. Why would he want to
do something different?
80 IEACHING ]\IOTOR 5K]1L5 IO CHILDREN WITH CEREBRAL PALSY AND SIMILAR A,1OVE]\IENT DISORDERS

A typically developing seven or eight-month-old infant who has just started

to move forward on his tummydoes not miI1d beingp]aced on his hands and l(nees.
Months earlier when he played on his tummy, he had pushed tp to "big arms," gaining
strength and control ofthe muscles that hold the elbow straight. Sean skipped this
developmental "exercise." He progressed ftom elbowpropping to moving to the side
on elbows, and now to crawling with elbow push-offl But he has never straighteled
borh elbows and pu'led to a big arm position.
Sean has a type of cerebml palsy that increases the tone of the muscles that
bend the elbows, thereby making it hard for him to straighten the elbows. When
hewasyounger and played inback-lying, hekepthis arms close to his chest.Ittook
special effort and much promptingto get him to reach up high, and usuallyhe never
fully stretched out his elbows. Playilg on his tummy, hewas eagerto reach far, and
with time became able to fully stretch out his left arm. But he can only partially
straighten ort his right elbow. Children like Sean need much extrawork and ttain-
ing to gain strength and control of their shoulder and arm muscles, especially of
thet triceps muscles.
The triceps is the muscle that runs along the back of your upper arm from your
shoulder to your elbow. You can feel youl left t ceps when you run your right hand
over the back ofyour straightened upper left arm. Squeeze it and feel how big it is.
Rest the weight ofyour upperbodyol your arm or lean on your straight arm and feel
how you, fficeps works hard to keep your arm stable.
For Sean to progress in crawlilg, his triceps muscles need to become stlonger
and more coordinated. Bearing weight on straight arms is a l(ey component of many
skills. once Seancanpushhimselfinto a big-arm position, manynew possibilities will
openup tohim. He may push to a hands-and-knees position, start crawling on hands
and knees, and push into sitting. Beadflg weight on big arms willalso help him learn
to sffetch out his arms as he protects himself when falling.
In summary, strengthening Sean's triceps muscles is a top pdority at his physical
therapy sessions as well as his home program.

"Big Arm" Exercises

If your child is at risk for cerebral palsy and shows tightness of her arm muscles, it
makes sense not to wait, but to stimulate elbow straightening-wod( of the triceps
muscles-ear\ on. Chapter 7 describes the range of motion exerci,sesi Three Arm
movemenrs. Doing these exercises aftea each diaper change encourages your child to
straighten her arms with your help in arl easy and fun way. The movements mild1y
stretch the biceps muscles as well as stimulate the triceps muscle to work.

Shoulder-Elbow-Hand
I his exel cisc is a lgoorl rlar ro so engLhen Lhe rliceps rnuscle earlv oD r,ithout
geLring dre babl upset. lfl'ourrhcrrPirisLrgg.stsrhil1 \ou .1o Lhe exercise ,ilh \'.rur
child. carelirll,"_ obser\.e heI demorlsrrirtifq rt. lirur r:hild mr,' want to prll hcr'shoul
dcrs back[,2]rds .lurin5l L]re exercise and rhr r rcr rpist ur ll shor,r, 1,or: hrxv to p(:r,cnt
this Irom hippeninS.
1. \i)rrr child lics on h.r l)ack 1acirl8 l oLl
 TUI'NN4Y TJfulE 8f

--t
I

flr
Ir
Fr-

,4.
!.-

2.Holdyour child by rhe left upper arm, roll herto the right and lifr her so that
she comes to rest first on her ght shoulder, then up onto het right elbow,
finallypressing down on her hand (photo 8.7a, B.7b).
3. The elbow is now strai8ht and the weight ofher upper body rests on it. With
your free hand, support the elbow as needed.
4. Have your child prop herselfup like this for S to 10 seconds (photo B.7c).
5. Ease her into back-lying the same wayshe came up. Changehands and do the
same with the other arm.
Do this exercise several times a day. Ifyour child has hemiplegia, always practice
with her affected arm.
Variation. As yout child gets used to the exercise you may sta to puil her up
by the hand instead of holding onto her shoulder It is a sign ofprogress ifshe stays
on the straight arm with less support to the elbow.
Note: The Shoulder-Elbow-Hand exercise is not a preparation for sitting up.
Small children do not sit up from back-lying. They roll oyer onto their sromach and
then push into sitting.

lndependent Play in Back Lytng

Have your child play in back-lying as recommended in Chaprer Z After she shows
interestin playinS wirh the roys, starthanging them a little higher This will encout-
age her to straighten her elbows as she plays.

Weight Bearing on "Big Arms"

Full! srraiSht(ring bolh ,rns is a So(xl ski11. buL 1x:ing able to ltcep then straighr
while berrin:{ r!eighr.rr rhem is ercr more r \LtLr LherJprsr\practjce\rrrdhtbear
irg on both rrms in a ',arlen ol $,:r's. I'he1 \!-ork cn the floor. ol,er a r..rll. or1 a b.lll.
over a !\cdge. atrLl ir! c1.en usc sLrspendeLJ rrpipn ent_ Thev choose thc eallLiplnent
ro rnakc r'r,erght bear ing on srraighr anls casicr. more jnrcresting. rnorc challe.girB,
orjLLst rnore Iu. tor the chilcl. Accor,:lirg ro vour child,s needs and lihat lrorks iresr.
lhc phvsicil th(:rapist lvill .gi!.c \.oLL spc( lfic insLrLr.riuts tbl !ou to rLse i1t h(nre.
lhe nexr c\ct cises ar. crxanlphs for eight bearing on straiehL ar..rs. l,he\. d.)
r .. l- ,r I.t p.r,Jlrro. ,,lJ l,.rrp,
rnd follou, anv speciiic irstructlo.s gilen.
82 IEACH]NG []]OTOR 5K LLS TO CHILDREN !(/]TH CEREBRAL PALSY AND S]I\4ILAR ]\4OVEI\4ENT D]sORDERs

% Rocking on Big Arms

1.11a\.e lour chjld lic on her sromach, prelerablv
a hiSher surface such
on
rs rh! dinp.rr table or a lirm
*rI t ..i
-& hed, Iacing vorL.
2. Grnsp ero nd ]'oLlr child's upper arms ard elbous.
,l and hclp hr:r ro come up, sLraighLe1rherelborrs. aDd
t r5ear rveighr on hcr hands.
3. Loosen vour grasP. Prcltribl\,
\,ou supportjtlst the
back oI the elborvs as littlc as rr:cdcd r'rhilc vou
genLlt rock,1rcur child flom side to side. Talkto hcr
oi sing whilc you do this (phoLo 8.8a).
Do this several times a day
The rockingmotion causes a sliglrt weight shift ftom
ore a rn ro rhe other. Th is maLes r he exercise easierJ more
ellective, and closer ro rea I life siruations.
a
variatioo: If your child is older and bigger, put a
folded-up beach towel, a firm pillow, or a Boppy pillow
under her chest (figure B. Bb). With the chest lifted up, less
weight is on the arms and straightefling them is easier.
Notei Ifyourchild'sarmsmusclesareweakorspas-
tic, your therapist may recommend thatyour child wear
soft elbow splints initially during this and the following
two exercises.
8-8b

Big Arm Taps

The next two exercises are similar to the one before and are done in the same
position. when your therapist decides that your child is ready for them, you may add
rhen ro r he ''Rocking on Big Alms practice.
The first exercise requires your child to mal<e a brief, complete weight shift ftom
one arm to the other. It helps her practice the arm movements necessary for cmwling.
Later, when your child is ready for crawling, this training will pay off.
1. Place your child onher stomach.

$#
2. Gmsp around your child's upper arms and elbows
and help her come up, straighten her elbows, and
bear weight on her hands.
't
i l,
rlr .

j:
3. Talk to your child, encouraging her to lift her head
and feel secure and confident.
4. Next, help her lean toward her dght arm. Now lift
her left hand about an inch off the srrface, and then
I -. :)
let it drop dowr-tap (photo 8.9). Help her lean
U toward her Ieft arm, lift her ght hand about an
inch off the surface, and let it drop down tap.
Repeat 10 times several times a day.

Bi9 Arm Touchdown

'I'his eriercise encourages a qLri(k l csporsc Il o ahcshouldcraDdarmnrusr:Lcs.
especiall_v the triceps n1usc1es. 1t r!_ill b!ild sn cn.,{rh iD the rriceps al]d r,r,i11 rrigger
 rut\lMY T["4E 83

\ F

f---"- {.,

4.10a a.7ob

immediate muscle activation. A quickresponse from the triceps muscles keeps the
elbow straight when you fall forward. The Big Arm touchdowns are early training
for catching oneselffrom a fall with outstretched arms.
1. Practice as before but instead ofliftingjust one hand, Iift both hands
abour
2 inches off the surface, and then let them both touch dow[. pause (photos
8.10a,8.10b).
2.Repeat.
Do 10 repetitions several times a day.
Variation: whefl your child is used to the exercise, try to lift her arms a ]ittle
higher and rhen let them tap down. If the hands fist or turn over wirh the touchdow rr,
lilr rhemless.
Note: fhe efercisa u.,itlhelp your child only if done daily for several weeks.
Just doing them occasionally will not make a difference. you may follow the Shoulder_
Arm Workout totrtine to make the exercises fun for you and your child.

Shoulder-Arm Workout
This is for a child who cannot yet hold herselfup on hands and knees. Ask your
Lherapisr iIyour child is ready for I his workout. It combineq thc pre\ jous exercises jn
a pleasant sequence.
1. Put on some music you and your child enjoy.
2. Place your child on her tummy on a comfortable firm surface s1lch as youl bed.
3. Sit or kneel in ftont ofyour child and do exercises:
. Rocking on Foreams
. Rocking and Reach
. Rocking on BigArms
. Big Arm Taps
. Big Arm Touchdowns
. Shoulder-Elbow-Hand
Start out doing the exercises at a slow pace for only 4 to 6 repetitions each. Make
it fun. Stop if your child fusses or complains. When your child ii used to rhe routirre,
do more repetitions ofthe exercises, Do the workout session two times daily.
 -
84 TEACHJNC i\,1OTOR S(|LLS TO CHILDREN iI/lIH CEREBRAL pALSy AND SIM|LAR MOVEATTENI DT5ORDER5

Frequently Asked Ouestions

A. "Whenmy doughte\ Susan plays onher tummy, she always uses her Lefthand. Her
-
therapist wants me to encourage her to also play with her right hand. But, whenever
Susan tries to rcach with that lland she rclls to the side. Why does this happen andwhat
can I do to help her with this?"
A- Although Susan plays well with her left hand, her left upper arm and shoulder
muscles are weak. Whe[ Susan tdes to reach with her dght hand, the weight ofher
upper body is over her left elbow and forearm. If her arm muscles ate not strong and
coordinated eoougl\ the elbow straightens, causing Susan to roll over oflto her side.
Daily pmctice of lummy TimewithReachwillbehelpful. When you do the exercise
with Susan always have her reach with her right hand and support her upper left ar1lr
as much as needed. Stabilizing the left elbow by propping a small saodbag againsr ir
may be another way ofpreveoting Susan from rolling to her side as she reaches. Or it
may help if Susan's chest is propped on a roll-up towel as shown in ac tiyity Independent
Tumtuy Time Crddling Toys.
Before you proceed talk to Susan,s therapist about it aDd follow her recommen-
dation.

A. "My son, AI" can prop himselfup onbig arms, but does notprop himseLfup onforearms
and cannot play while lying on his tummy. I/fhy is this so and what should I do? "
A. Some children with cerebral palsy show an abnormal reflex pattern in stomach-
lying orin a forward leaning position. When they lift rheir head or tilt it backwards,
both of thefu arms stiffly stretch out forward; when they lower thetu head, borh
arms bend, are drawn to their chest, and may get stuck under their body. Al seerfls
to show this reflex when he prcps up on hjs extended alms. He does not have the
coritrol of a child who pushes onto big arms. He cannot move his arms to the side,
shift his weight, and briefly lift one arm. He is using al1his arm muscles at oncejust
to remai[ up on big arms.
Al has to learn to bend and straighten his elbows withour moving his head ar rhe
same time. He needs to learn to reach with one arm and with both arms. Most iikely
he can learn this besr in side-lying or supported sitting. Dailyptacrice of..Shoulder-
Elbow-Hand," "Rocking oo Forearms,,' and ,',Rocking and Reach,, may benefit Al. But,
do not start on your own. Work with Al,s therapisr. She or he knows AI. you will be
most effective as a team.

O. "Miss-r,islbllr,_y..r,solddr(].itill/loa.o r ottable on htt t u|,.ny.,Vv hrsbonrl arrd l

o . /r.r. ' r .. o ,. ,.,^ t..
... t'tjr, ,. r t, . .. ., rl
A. lloth tou arld rhe thcrapisr hirr c a \.alid point. Il h-liss\' does nor like to bc on her
ru1lln11'bv noir. sh. probabh, n(:\ .,1.\\'jll bc able ro p1a." on her ru[tr1v on h.]r ol,!.n.
Ne\,erthclcss, iI N{iss\ doesn'r lllitld bcin,q place.l {)n her L!mlnv iI sht is proppcd
on a u,cdge or assisred b\ ]o11. a d:Lil\, p1a,v prriod in rhir posilion rvill be ,,.crt
benefjcial lor hr:r. 1t 1\,ill srrengrh.n her back. neck. shoulder. anrl arrn muscles.
Strcrgthening rhese rnus(1es will help her ro sit Llp berti:r and :Lrtluire rhr nanual
skills she srill neer:1s ro lcarn.
 I

Ilut"lY |r,1E 85

A, "I am o special education preschool teachet. I think one of my students may benefit
from seteral exercises in this chqpter. Should I tell the schoal physical or occupational
thPropirt aboul rltem?'
A. Yes. I am sure the therapist will be glad abour yorr iniriative. Togethet p1a n a good
|
:n_e
lo' r\c r rerapist ao sl-ow ) ou how to -vrork wirh ) ou-.rudcnr.

Q, "I feel uneasy about this.

I am not trained to do therapy. Wouldn't it be better if the
th?rcpist d;tl hP exPrti'cs:'
A, No. These are simple exercises. Feel free to do them as the child,s therapist recom
mends them and teaches them to you. It is much bettet if you do them once or twice
dailythaD ifthe therapisr does rhem once aweek.

A. "But tlese are home instructions. Wouldn,t I interfere \)ith whet the parents do
4t home?"
A, I am glad you bring this up. Yes, the parent should know about the exercises your
student does duing the school day. Most likely they will be very appreciative.
 &s

I &
0
s
*
*
Guarding
a Against Falls
& ooaaaoaaa

lFhildren acquite basic moror skills during their first year of life. When infants
\rhrst orard and wa'r. tlrey learn by rrial ard c.ror. Ihcv [requeFrl] losp their
balance and fall. Fortunately, most ofthe time children can catch themselves with
olltstretched arms and do not get hurt_ Children are not born with the capability to
catch themselves when falling. It is an automaticresponse tllat emerges between four
and ru elve norrls olagP.
The ability to quickly stretch out your arms to protect yourselffrom serious injury
is ca11ed the protective extension reaction, When you lower six-month-old babies
head fir$ to the floor (mimicking a fa11), their arms srretch our. They are ready to
catch themselves. Do the same with three-month-old infants, and no response is seen.
h sittinS, ifti1nrs ciiD catch then selvcs r,rten thev lall for\\-arcl
rt si\ lnonths. Lo thc sides b\.six to cjght monrhs. and LackuTer.d
1 bv t1!el!c nlonLhs.
The protective extension reoction is an (r:utomd.tic re-

a
a r
sponse. lhis nteans rhat no \,oLunlal.y cffoLr is tequjrcd. l.he
siLuilrion rhc dangr:r of lalling h.iggers tir(] tesponsc. C)nce
establish.'Ll. the prorcctite cxtension reacti.r. will sLe\ rtirh you
for rhe resr olvour lile. Test yourself. Sit or knt:cl on thc iloor and
hrr,e anorher per-sou push vou ir anv directjon. Notjce hot- lour
l- r.n or, .
Anromati( r eacLions are faster than volmtar v Dlo\,!menls
||'.t_ ',rnt r.o.,,r,l t,.l\ ir.l.-O^
mrlliseconcls or mor. rLnLil hc actually Do\,es. lor an i:rutolr:tti(l
88 TE cl[N(j A,loToR s(LLs ro CH]LDREN wtTH CEREBRAL pAlsy AND srMtLAR l\4ovEr\4ENT DtsoRDERs

reaction, this lag time (latenc, is only 90 ro 150 milliseconds. Speed is of the es-
sence ifyou are falling. To protect you, your arms have to be faster than the force
of gravity onyourbody.
The most crucial protective extension reaction is the one that protects us when
we fall forward. It is often refered to as the porachute respoisebeca$e of the way
it looks whe[ children catch rhemselves with outstretched arms (photo 9.1). Children
with spastic armmuscleswho cannot straighten their arms or bear weight with them
do not show a parachute response. The same is trrle for childrenwith severe h,?otonia
whose a ns are too weak for beadng weight. Most child.en who fail to develop an
effecti\.e parachute response do notprogress to independent walking without use of
an assistive device such as a wall(er or crutches (Bleck, 1975).
Sometimes there appears to be an additional sensory component such as an
aversion to touch or to weight beadng which the child needs to overcome before the
parachute response emerges. The following story describes this.

The Boy \vho Did Not \yant to Touch the Floor

Ben, age one, came to therapy with both parents. He was sma11 for his age, had big
chubbycheeks, and a cute smile. Developmental gross motor testing showed thatBen
had the skills ofa five-monrh o1d. He rclled, reached for toys, and played with them in
back-lying. He did not iike to be on his rummy and toiled out of this position quickly.
Placed in a sitting posirion, he could hold his trunk nice and straighr, yerwithin rhirry
seconds he wouid topple over to the side or backwards. Ben behavedjust like mafly
four or five-month old babies do.
Therewas a differcnce, however, when the therapist lowered Ben headfirst-he
did notstretch out his arms to touch the floot but drewthemto his chest. playing on
his bacl! he stretched our his arms efforrlessly. Why nor in rhe othet situation? Nexr
the therapisttried to place him onhands and knees. His body and his muscles seemed
to be ready for it. Yet, as soon as his hands touched the floor and his arms carried the
weight ofhis upperbody, he cried and tried ro pr lhis arms to his chesr as if in pain.
Lowered to the floor feet fiIst, Ben pulled his legs up and would not stand. When he
was placed into standing with his legs supported, he c ed and tried to pull his legs
up as ifhe had been forced to stand on needles.
Why did Ben show these reactions? We do not know for sure. There are theories
about these avoidance responses, but no conclusive facts. Ben may have a defect to the
part of the b(ain that interprets information from the senses oftouch or position. We
do know, however, that ilthe parachute reaction does not emerge, the child most likely
wi111earn to sit up but will not crawl on hands and knees, pull to stand, orwalk.
Ben is only a year o1d. At this young age, treatment cafl sti11 be effective. With
therapy sessions a1ld a home program, Ben can slowly leam to tolerate beadng weight
on his arms and progress with his motor development. Is a good outcome certain?
Unfortunately not.
Most physical therapists who work in pediatrics haye encountered some children
who avoid weight bearing. Yotll therapist will address the issue one week at a time,
one therapy session at a time.
 GUARDING AGAIN5I FAL15 89

Right now, Be]l has to get used to being on his tumm, as well as bearingweight
on sffaight arms. Lots of tunmy time is needed so that Ben has the opportu ty to
catch up, gain strength and coordination ofhis back and shoulder muscles, and start
propping himself up on his forearms. Ben also has to practice weight beadng on his
stra'gl_r arms lor \ery shot r I ime per:ods \ -ile si. I irg on tlre fl oor.
Ben detestedboth activities a11d let everyoDe know it. What to do? During therapy
time, two motiyated adults eitertaining and fussing over him and a truly large toy
closet made things more tolerable. Tummy time slowly but surely improved. Once
Ben was able to hold his head up and look around, he realized that tummytime was
not so bad after all.
Unfortunately, at home and at daycare, progtess was not as easy. It was asking a
great deal of daycare worl(ers to do the extra work ofplacing one of their charges o11 his
tummy and keeping him from crying. For a pare[t coming home from work, it would
also be too much. Yet, the parents made a very sensible decision. Eyery time they put
Ben dowr, they would place him on his tummy_ Usually he did nor stay long before
he flipped over onto his back. He always did some playing. though, and besr of all, he
stopped crying about it. When his parents had time to relax on the floorwith Ben, they
would playwith him and tiy to incrcase the amount of time he would stay on his tumrltv.
Thi5 aDproach v\o-kpd hell.l l-e paterts oDserr"d r rar on lti" ow- B",: o
on his tummyfor longerpe ods oftime. The reallygood news camewhenBent ",u-,ed ",ny
mother
beamed: "He likes to be on his tummy now. Last night he rol1ed onto it on his own.,.
How was sitting with anns propped coming along? Ben did not like to touch the
floor with his hards period. In sitting, he learned ro straighten his back and lift his
hards off the floor So nowJ when Ben was placed with his arms propped, he did ror
mind. Hejust sat up and lifted his hands offthe floor. The rherapist then had Ben lean
forward and again placed hls hands firmiy on the floor. Again he sat up straight. Ben
cordd do five repetitions ofthese "touchdowns.,, So his new home instructions were
to do five touchdowtu. Ben's parents did them, and even the daycare wod(ers found
time to do the exercise with him.
During treatment sessions the therapist had been working on eliciting the para
chute reaction. Benshowedprogress. He no lo[ger drewhis arms to his chest. At times
he would touch the surface lightly with ofle hand.Itwas a begiming.
Ben's progress in stomach-lying continued. He played on his tummy, he could
move sideways, and he started to move backwards. Then one day it happened. Ben
pushed himself up, his chesr rose off rhe floor, and his arms srretched out with his
hands firmly planted on the floor. Hooray, this was the breakthrough! He was no
longer "the boy who did not want to touch the floor,,
A couple ofweehs later when the pamchute rcactionwas practiced, Ben brought
both arms forward. Borh hands rorched rhe s[rface. Theylanded 1ight1y. More repeti,
tions, and his halds came out faster al1d touched 6rmiy. Soon itwas fun. Inste;d of
crying, he larghed as he bounced hands first off a softly inflated therapyball_
Ben had become able to weight bear on his arms ald acquired the parachute
response in spite ofhis sensory problems. Weight bearing on feet was trained simi-
larly and Ben started to tolerate it for shortperiods of time. Sometime later his sittirS
balance improved, he sat up byhimself, and he started to crawl on hands and knees.
Still, despite all his progress) Ben's sensory problems are persisting. More tiaiDirg
wi1lbe needed before Benwillwalk.
90 TEACHING l\4OrOR S(IU,S TO CHILDREN WIH CEREBR L PALSY AND SIl\/llL R I\,1OVEA/IENT DIsORDERS

Encoura g in g Protective Extension Reaction Forward

Ihr: story ofBen shor,r,s ho\\'the parachute responsr: r:an bcronte ei lecLile alter a child
has learned to bc:rr r._cight on his arnls r"-ith straight elbows. Snong l)irck, shoLLlder.
and arn ntrsclcs arc ncrrlctl firr-this. Plenlv ol LLlmnv timc aud crrlv training of
u'eight bearing on big ar s adc it happtn lir Ben.
For an effectile prorcctivc rxtolsion rt:rcriorl, children ha\:e Lo be able to bear
weiSht ol1 their arns wit]rour rhc clbows collapsing, and d1e! have to Lre able Lo do so
verl'quickl). If_vou fhll fbrrvarcl or l orr r a r nr s ri nd ] { )u r clboll s g i\,e o ul, ,1oLLr lace u,il1 hil
the[]oor o uch I If ]'oLL ra11 and -r'our arns strctchor.rttoo slowl\. ]olr willgelhurltoo.
Ihe srJbscqurntactivirics cncoLrraBe the de\:€10pmel1t oftheparachute rcspo1rsc, Usc
then as direcrcd h! ),oui rhilLl's thcr-arpist and follor"r anv specilic instrLlctions given.

Touchdown in Sitting
l. Your child sits vvirl. arms propped.
2.You sit or kneel in ftont of him and put youl hands around both elbows. Lift
your childt arms slightly offthe floor (photo 9.2a), pause, and then place them
quickly down (photo 9.2b).
3.Next lift your child's arms a couple inches off the floor, pause, and then 1et
them drop down.
4.\ rhen he is used to the exercise, lift his arms a little higher and thell let them
touch dol,n.
Repeat 10 times.

Note: If )'oLlr child llsLs or [Lms his hands so rhc hii(]i oI th(: hirncl ftrtchcs thc
floor, scr: if lifting rhc arm\ lcss u ill prevent Lhis. lf not, don'r LLse rhe erercise. Your
therapist can rc(ommr:ncl an arrivit', irottr soiLeLl lor voul child.

FIying Touchdown
l. While vou are knee11n3 on the f1oor. hokL lour child facin.t ar,r,ay fro[r ]oLr ils
shor"-n jj1 pholo 9.3a. support his chest Nirh both hands. YouI child's legs are
hug8ir18 your waist.
2. l,owcr your .hilLl unril his hends torLch rlte lloor (photo 9.3b). Then lilt hirn
up ard rcpcat.
 GUARDING AGA]N5T FALLS 9'

-
$rtrR:'

l'
*
-* '|

;rr

Keep youl back srraight so you do nor srrain it. your child may like rhe activiry
but do nor use it if it is roo hard on your body.

Touchdown from Short Kneel

So far, you have practiced the protectiye reaction in easv situations. As your
child masters these, he is ready for more taxing exercises rhar will firm up his;kill
and prepare him for everyday life situations. The development of the skill witt give
him the confidence that he fleeds to cope with unexpected balance loss.
This exercise is for children who can stay on hands and knees with little help
bnt cannot yet balance in short kneel (kneeling with hips bent). practice it on a
carpeted floor.
1. Help your child to raise himself from hatds and knees to short kneel bv suD,
porting him around the chest.
2. Tell him: "Stretch yout arms out and put them on the floor,,, as you lower him.
If needed, guide his arms forward as shown in phoro 9.4.
Repeat 10 times.
After a good pmctice session, see if he will catch himselfwithout yorl{ help. Warrr
him: "Be ready-put your arms out," as you take away your support and Iet l m drop
fuom short kneel onto his arms.
You want your child to become very good with touchdowns, so dorlt stop practicing
as soon as he caa do them. practice 5 to 10 touchdowns daily for weeks, even months.
The more you practice, the quicker and surer the arms will come forward. As your child
becomes confident about catching himself, he will like rhe exercise. Now you may do
the touchdowns as a reward after doing the more ,.bo ng,, exercises lil<e stretches.

Touchdown from TaIl (neel

When 1'or r r hild is ab1. ro sh{)r. kDeel, pla\.in this positi.n. nnd easjlI rno\'e cn:t
o' .,.. rJ\or.,r. , t.9 tr l.i.t-..|r ..r-,, i .

children r,ho can rall hncel (k.ccling rl ith hlps sti. ightl at fuDtitlLl e.
1. Pftctice on a ( arpeted f oor. Ilclp I our child to comc to rall hnccl and slllpol.L
him at his hjps or aft)Lrnd his chcsl (phoro 9.Sa).
92 TEACHiNG ]\4OTOR SK]LLS IO CiIILDREN WTH CEREBRAL PALSY AND SI]\4ILAR A/]OVE]\4ENT DISORDERs

2- Ilarc hlm lean slighllyforward and wam

, hin:'r-e a d,v a-n d touchdorvn, ' as you
I
help hi conle do\.-n (photo 9.5b).
Repeat 10limes.
h I'q
Whenvourchildcan handle it, hold him
arhis hips orhavc him dotheto chdownson
& t i.o.r .''.r1, ,:,.ice'".un.'r ri rl',
Louchdo,,lns are vcry \!-el1 learncd.
Note: Tn dail,vlifc. chitdren (or adults)
do not drop out ol' tall kneel Llis way. In
srcad, the-vlou,crthemseh cs from tal1lncel
to shortkneel, and Lhen comc to hands iLnd
knees oi-sit do$,n. Flol\,evcr. touchdowrrs
fiom rall kncel\,\,i11 11npr'o\e alld pcrf ect J'our
child's prot(:ctile e)itcnsion reaction.

Encouraging Protective Extension Reaction

to the Sides
SPECIAI PRACTICE FOR CHILDREN wlTH HEMIPLEGIA
Protective extension reactions to the sides are important when children fimt sit and
play in sitting. Their balance reactions are not yet refined and they easily topple over
to the side. A stretched_out arm will save them, or atleastbreakthe fall Later, when
children beSin to stand and walk, the protective extensron reaction to the side will
protect them ftom hurting their head if they fall sideways
Children with good protective extension reactions in forward fal1 may acquire
the ones to the sides with little training. Children with unequal arm skills, espe-
cially children with hemiplegia, however, need special training Children with right
hemiplegiawill develop protective reactions forward and to the sides with their left
arm, but need special traidflg to acquire them with their right arm children with
left hemiplegiawill need tEiniog for left protective extension'
Ifyour child has hemiplegia, youl child's therapist maywant you to startweight
bearing exercises with your childt affected arm as early as possible Early training
is more effective and accomplishes more in a shorter time. It gives the affected arm a
head start and prevents your child ftom neglecting that arm lt is also easier for you'
A baby likes to sit with your support. He may not mind leaning on his affected arm as
long as you give him the assistance he needs. A toddler, howevet may have a definite
opinion about things
Use the exercises as directed by the thempist and closely follow any specific
instructions 8iven.

Weight Bearing on Straight Arm in Side Sitting

with your child sitting between your legs facing away ftom you.
1. Sit on the floor
2. Place youl open left hand against the inner side ofyourchild's upper right arm.
Use youl finSers to straighten out his eibow.
 GUARD]NG AGAINSI FALL5 93

3. With your otherhand, open his right hand and place it onthe floor
4. After your child is in a good side leaning positioq support his right elbow with
youl right hand. Place a toy in easy .each and have him play with his left hand.
5 . Encourage youl child to play in this position for two minutes,
or as long as he
lii(es. Srpport him iess ifhe does we11.
Reverse sides for practice with the left arm.

Variation A. If youl child fists his hand, try this maneuver:

Slide your open right hand around his wdsr into his palm and
open his hand. Place rhe back of your open hand on rhe floor so
your child leans onto your hand with his opefl hand (photo 9.6).
Have him side sit like this.Ifhis hand stays open, slide yourhand
out from under his, placing his hand on the floor.
Valiation B.Ifyou child's arm is very weak or very spastic,
your therapist may recommend that he wear a soft arm splint
during the activiry-
Note: Do not expect quickprogress wit+r this activity. Most
tB likely it will take over a month of daily practice.

One Arm Touchdown to the Side

After children carr support themse]ves sidewa)rs on one armj
thcy are readvfor the next t!\ro exercises. Do rhem as dirccted bv
\rl,t .tio l..r,p:,Jn. t, wr^Jn\.oec'fiI n. trt..ion.gi\pn.
1. Yonr child sits lacjng alvay from you.
r 2. Hold hirr b), the upperarms and move hirn to\,vard the l ight
side, guiding hirr to touch down wirh his iiqht arln.
Repeat 10 times.
Wher )rour child does this we1l, gir,eless gtr idarce to the right
I arm and do the side moveneDt laster (photo 9.7). Switcit sides if
vorL \!arlt to trai[ the ]eft arnl.

Alternate Touchdown to the Sides

I Hold \.our child around his chr:st.
2. Tip hirn to rhe right and then to the Lf. for a rouchdorvn
(phoL.r 9.8).
3. PlaI mu\ic ol sing l'in a ljftle teapot...'' for rhl.thnr and
frLn.
Llo 10 rrrrchdo!\ ns aler-nirti]18 l.] rhe risht irnd iej t sjde.
Note: tl)'our child Llor:s r.ell or one sidt but has.lifficultics
of the other. do rh is eriercise onlr, 0ccasionall\'. For.lirily pracrice.
voLL 1lr:l\ rtant to [.olk \rith dle ]r:ss skilleLl a n as desctiberl for
F"a. .t . l. ,r ... or :'t,le'-,.1-'_e.
94 TEACHING ]\4OTOR SKILL! TO CHJLDREN ! TH CEREBRAL PALSY AND 5I/\4]LAR A4OVE]I4ENT DISORDERS

Frequently Asked Ouestions

a. "My daughter, Anno, is just learning to cotch herself with her arms. She often has
one handfistedwhen I practice with her. I am worried that she is qcquiring a bad hobit.
Sllouldn't both ILer hands be open?"
A, First let her do it however she carl and worry about perfection later. Most likely
the fisting will slowly brt surely diminish.
At rhe same time, you have a valid point about not teaching a bad habit. Share
your thoughts with Anna's physical therapist. Knowing Anna, she will be able to give
you good advice.

a. "Our daughter Liana does not like to touch things. Her occupational therapist says
she is sensory defensive and has problems with sensory integration. She showed me how
to bruslt Liana to reduce her sensitivity. why didn't you recommend brushing?"
A, This book is about teaching motor ski1ls- It shows how children like Liana and Ben
can leam basic motor sl<ills. Ifyour child has significant problems with sensoryprocess-
ing, it is wise to work with an occupational therapist with training in these issues.

O.'!11,1'sort,Ri.k,hash.mrp/€.qrd.-Hrsr-ishra|misycr_r,rvenkcrndrrrlcoordindacd.His
th.rrpistgdfe ,r. horne inilrucllons rolr-a.ti.. side silli/18 a/ld leoni]ls orr Iis rl3/rto|rn.
/ fiol,e nr suppr-,r'r his |i.gh t elbo| antl sl Loukler whlle he sits this xro-y, Rrck doesTl t 7[ind it
bccarr.sc I lcr hirr p?n]'n,il/r hir l.'Lrl./r b.rl.a, s. rtlichheLaves. But I ant
.trsr].dt€d. Rick.i

drrn.loes rotsecrr a{) gca dn_v bctto: 11,'idl.shou/d Ido?"

A. The activity rhe therapist gale vou is r.er_v good. lt will traiD Rick to bear r,veight
u, irh his ri8hr arm. This is verl'useful and lYill ]rake his arllr stronger as rvell as more
coordinated. UsinS his iavorite Loys durinS the exercise is tun for Rich. Just ha[g in
there. .lo the erercise dail!, and !our- eflblts will pay oll Yes, proSress [ray be verv
slolr. Ttmay fcel lihc yr)u r'c sittingo. \'orn-la n watchingthe grass g1o1\,. Shalevour
frustrations withRick's therapist. Tog{hc, you can find a sol tlon.Therherapistmay
recornmend bracing the right arm n,ith a soft elborv splirrt. Thc splint may provide
enou8h support thar Rick could side sit \,r.ithout your he1p. I'his u'ill [rake exercise
tine easiel fbi both ofyou. Also. it is m_v experierlce Lhar pro8ress is easier to see and
tojudge when vou are not involved in supportiig the chi1d.
 faa

to &
w
at

&
@

@ Sitting Pretty
@ aaaaaaaaa

Meet Elli
Elli is sitting up! Elli's parents are happy and proud, with good reasofl. Sitring is a
major milestone in the gross motor development of ary baby. As infants develop, they
typicallylearn to sit up wirhout support berween six and eight monrhs. Childreflwirh
cerebral palsy need more time. The physical thelapisrt obj ecrive is to have them sit up
by the time they are two years old. This isbecause childter with cerebral palsywho sit
by two years of age are morc likely to walk than children who have not achieved this
goal. Sitting by two is a major treatment goal and therapists want their little patients
to sit with a nice straight back. They want them to sir pretry
Elli is eleven and a half morrhs old. She was referred to therapy because her
physician was wo(ied abotther gross motor development. At the time ofher doctor,s
visit two weeks ago, Etli still wasnt able to sit on her own. As mom brings E11i to
therapy, she wonders: "Because Elli is able to sit now, maybe she does not need physi_
cal therapy after a11."
The assessment shows that Elli sits with poor balance and posture. Her back
is rounded, and her shoulders and head are hunched forward. Instead ofresting on
the floor, her knees stick up. Falling backwards is El1i,s way of getring herself out
of sitting. Once on the floor, she needs help to sit back up. Elli is not able to crawl
or pullto stand.
The therapist supports rhe physician s recommendarion thar E11i will benefit frorn
physical therapy. The parents agree and weekly treatment is started. The therapist
concentrates oD strengtheningthe trunkmuscles, especialiybackmuscles. She trains
96 iEACHING ]\4OIOR S(LIJ IO CHJLDREN \i?]TH CEREBRAL PALSY AND S]I\4]LAR ]\IOVEIVIENT D]SORDERS

Elli's sitting balance and all missing age-appropdate gross motor skills. The parents
work with Elli at home, following the therapist's instructions.
After six months, Elli is showing good progrcss. She is able to move ifl and out of
sitting on her own, come up ooto her hands and l(Ilees, and crawl. She enjoys crawl
ing ever).where. Standing is still difficult, however Her trunk leans forward against
the table in ftoflt. If the therapist or her parents do not help, her legs tnm in and her
heels fise offthe floor.
How is Elli sitting? Her back is stronget and her sitting balance has improved.
She sits nice and straight on a little stool or the therapy ball. On the floor, however,
Elli does not sitprettyat all. As before, herbacl{ is rounded, and because herlegs have
grown, her knees stick up even higher off the floor.
why has Elli made no progress with sitting on the floor? It has to do with the
position of the hipbone (pelvis). I44ien rve sit straight, our pelyis is in an upright
(neutral) position; it is neither tilted forwaril nor backv,ord- Sitting straight re-
quircs coordinated work of low bac11 hip, and low stomach muscles. Maintaining a
good sittingposture is difficult for children with cerebral palsy, and it is even harder
to sit onthe floor than on a chair.
Find this out for yourself. Sit stmight in a chairwithyourhands onyourhips. Tip
your pelvis forward (youl low back arches), tip itbackwards (your 1ow back rounds),
and then hold that in-between position with yolll back straight. Notice how ir feels.
Next, sit on the floor with your legs out in front ofyou and your hands on your hips.
Do you notice that your hips want to tip backwards, rounding your back? It takes
effort to bring your pelvis into an up ght position and sir rall and straighr. This hap-
pens because your hamstring muscles are stretched and pull your pelvis backwards
when you sit on the floor. When you sit in a chair with knees bent, your hamsffillgs
are not stretched ard do flot pull your pelvis backward. Therefore, it is easier to keep
the pelvis upright and sit nice and straight.
Elli has gained the strength and coordilation to hold her pelvis upright when she
sits in a chair, but not enough to do so on the floor. Elli's hamstdngmuscles are tight,
which makes floor sitting especially difficult for her. When Elli plays on rhe floor, she
seldom sits withherlegs in ftont. She prefers to crawl or kneel. In kneeling, she likes
to restherbottom on her heels-a positionwhich therapists call heel sitting or short
kneeling. This is her favorite play position.
During the following year of thempy, Elli masters many more skills and she starts
to walk on her own. She does not have a good walking pattern; one footturns in and
she often toe walks with the other foot. Yet, E11i gets around and that's what matters.
Floor sittinS has improved just a little over the year.
Realizing how difficult the floor sittingposition is for Ei1i, the therapist has de-
cided that Elli ieeds some exfta help. Wher she works with E11i on the floor, she has
her sit with legs spread apart, her knees slightly bent and tumed out. She helps Elli
to sit straight and then drapes two five po[nd ankle weights or sandbags over each
thigh. The weight ofthe bags helps ground her legs to the floor. This gives her a wide
base of support and makes it easier for Elli to l(eep her trunk straighr. She no longer
has to hunch her shoulde$ and bend forward to stay seated.
Floorsittingis important for small children. It stretches the hamstring muscies,
and stretches and strengthens the muscles around the hipjoint; the muscles of the
low back, stomach, and thigh work together in a coordinated way. Sifting with legs
 5]TT NA IREI'Y 97

apart and tu.ned out puts healthy prcssue into the hip joint and helps the growing
joint form a nice socket for the head of the upper leg bone (femur) to nestle in.
At home Elli sits with her sandbags for half an hour each day whe1l she watches
her favorite TV show.In pieschool she uses the bags during storytime. She does not
mind using them because this way she does not have to sit in a chair but canjoin her
frieods on the floor sitting pretry

Helping Your Child to Sit

ofchildrenwith diplegia. The muscle tone of the legs is increased
El1i's storyis typical
and theback and stomach muscles usually are veryweak. Children with quadriplegii
have similar problems. They too need help with sitting.
In orderto sit on the floor, children need:
. S?'ong trunk tuuscles. Strong back and stomach muscles will
hold youl child's trunk up while sittiflg. when you work with your
child while in a stomach- or back-lying position, you strengthen
her trunk muscles. This gets her ready to sit.
o Balance. Pure strengthis not enough. For the children to develop
trunk control arrdbalance their muscles have to worktogethei in
a coordinated way. when your child sits with a straight back and
as little support as possible, herbalance willbe challenged. With
experience, her balance responses will improve.
. FLeibLe hc.Il/.string muscles. Hamstrilgs that are too short pnll
the pelvis backwards and make it next to impossible for your
child to sit on the floor like other children. DoiDg daily straight
leg stretches with your child will keep the hamstring muscles
flexible. (See Chapter 5)

Supported Sitting
Before your child can sit by henelf, you oeed to support her. Your child's physical
therapist will show you how to place and support youl child in a good, straight sitting
position. YouI child's first accomplishment will be to hold her head up in supported
sitting. Next the therapist will guide you to lower your ievel of support and challeoge
your child to hold her head and upper trunk up by herself. The more progress your
child makes, the lower you will place your hands as you support her. Finally, you will
need to supportherjust at her hips.
The following are examples of how to support your child in sitting. Use
them as directed by your child's therapist and follow any specific instructions
she may give you.

Sitting with Chest Support

\\,ith l our legs aparr and havc a rol rcadl for plal.
1. Sit oD the tLoor
child srder"-avs betrveen vour 1egs. Her legs arc rpart. n:rrcd ort
2. Place _\oLLr
and sli8hlhbent at d1e knee.
98 TEACH]NC I\4OTOR sKILLS TO CHILDREN W]IH PALSY AND S]]\4ILAR ]\4OVE]\4ENI DISORDERs .f
'FREBRAL

3. support your child with your ]eft open flat hand against her lower back and
youi right open hand flat against her chest. Give firm pressure with your hands
so she sits straight and ta1l.
4. Next help her bend fuom the hip so her trunk tilts forward. You want her to
lean forward into your right hand support or against your right leg (whichever
works best and is most comfortable for you) while keepingherback straight.
5. Elcourage your child to play with a toy in front (photo 10.1).
variation. After your child is used to tle positioq see if she is able to keep her bac].
straight without your supportive hand at her lower back. If she can, tum her so she faces
away from you ard support only her chest with your open flat hand (photo 10.2).
Keep watching your child's lower back. If she slouches backward, intermitrently
give lower back support and cofiect hel posture. Do not have your child lean back
and rest againstyou.

i I
I *
&
I

,.*:

14.1 10.2

Sitting with Hip Support at a Table

After your child is able to hold her tmnh nice and straight with chest support,
she may be ready to sit with low back or hip support.
Equipment. For this activity you need a low bench or table. A bed tray would
make a good table for a smallchild. A taller child may sit better at a lowbench or a
step stool. A low coffee table may be best for an oldel child.
1. Piace youl chiid in front oftle table with her 1e8s apart, trmed out, and s1i8ht1y
bent at the knee.
2.From the side, support her firmly with one hand against her lower back ald
the other hand against her chest. Have her sit strai8ht and tall.
3. Help her lean forward and place her arms on the tab1e.
4. Take your chest support away and only support her low back while youl child
leans on her arms or against the table and plays.
Variation. Sit or kneel behiod your child. Open your hands wide and firmly
hold her hips from the sides betweeoyour thumbs and fingers. This way you willbe
able to l(eep her low back and trunk straight or slightly tilted folward (photo 10.3).
Encourage her to lean with her arms on the table and play with a toy in fuont of her.
 SIIAING PRE'ry 99

t- Sitting with Hip Support

1. Sit or kleel on the floor
2.Your child sits between your legs facing away fuom you. your
child's legs are aparr, tumed our, and slighrlybent at the knee.
I 3. Openyourhands wide and firmly hoid herhips ftom the sides
be-
tween yofi thumbs ard fingers. Wirh the little finger side of you.
hand give some downward pr e,sur e ro her r 1igh. {photo 10.41.
4.You warr you. child ro sit with a straight back, tilting slightly
15 forward.
A 5. Encourage her to play with a toy in front ofher.

Sitting with Thigh Support

After your child sits well with hip suppor:
1.Move yolrhands ftom her hips and place rhem firmlyon herup-
per rhighs close ro her groin.
2. See ifyour child does well with the reduced support (photo
10.5).
3.Increase your support whenever your child starts to slouch
backward.
Do not have your child leao back and rest against you. Keep her
interested in playing with the toys in front her. If she gets tirej. en_
courage her to lean more forwaad and s[pport herselfwith her arms
propDed on the floor or have heJ la ke a resr:nuggling io our
l lap.

Heel Sitting with Hip Ssppo.t at a Crate

:.
A child who sits well with hip support most likely will enjoy the next
.
activity in heel sitring (also ca lled short kneeling) at a crate. ihis position
allows her to be up higher and brings variety iDto her sitting routine.
1. Heel sir on the floor al1d help your child to sit the samewaywedged
berweenyour thighs (phoro 10.6).
2.Have a plastic crate with interesting things inside in front of
your child. Encou rage he. to ltord onlo I he r im ol rhe crare wirh
her left hand
3. Place youl hand over hers to secure it. With youl otherhand,
sup-
porryour child at the hip.
EI 4. Encourage het to play with her.ight hand.
Do not allowyoua child to leanwithherchest against the crate
and
play with both hands. Ifshe gets tired holding on;ith her
left hand,
\ have her switch hands-rhen hold on wirh her right and playwith
her
.'!:{!i.. left hand. Leaming to always hold on with one hand will make her
independent sooner.

Independent Sitting with Arm Support

r\ftcr ]1)ur child is eble ro sir r,ltll rvirh hip or thigh support, o! n):rY
) expL(t t]titt she
r\,ill slart sitLing \!,irhouL irrv sLtpPorl. ltDlorrunatcly-, rhis ma1:not
h:ppen soon. Nlanv
.hildrrrt"-ith(etel)ralpalsvntakegoodprrgressr,r,irhsuppor.tedsirtin3""(],fr".,r1.,.,,
 TEACH]NC 1\4OTOR sK]LLS TO CHILDREN !{/ITH CEREERAL PALSY AI..ID s \4ILAR 1\1OVEA4ENI DI5ORDER5
'OO

theyseem readv to sir on their o1vn, progress st:rlls.1,\ihv does this happen? Ithas to do
with the natul e ofccrcbral pals_v. caining the str.ngrh rc hold up the trunk is e:1sicr'to
achje\,e fbr-thr childr:cn than del,'eloping goocl coordinarbn and sullicientbnliuce.
Sitrjng o[ the floor is especially difficult for nost children. Whcn sittiDgwithout
support. spastic and Li8ht inncr rhigh and hamstring rnusclcs affcct their posture
ilnd intertere ryith einerging halance reactions. YoLl ca l-cd (c the influence ofthcsc
rruscles lf J'oLi ha1.e voLlr child sit t"-irh her boLtom on a foldr:d beacll Lotrel. No\! thc
hips are hishel rhe. thc legs. less bending occur's at rhe hips, the halnsrrings are less
stretched. and thcr'cfor c the backl"-ards p|ll ofthe pelvis diminishes. Plircing \,-eights
or-er yollr chil.l's rhighs u,ill lLLrther imprort her stabilit_v.
Yd, e!or when,vou placc I o r riikl on a rou.el and tlse rrjghts to stabilize her-
1egs, shc mrv not have enough l)iilance to sit on her orvn. Unsupported. she r:T at stav
trp for onlv a feu. seconds nn.l rhcD topple ot-er.
\!hat can you do to hcLp herlr SrLpporting her in sittiDg fbr hours each day lli11
becone old cluickl! and 111ay nol even help. Your child mal. get used to vorir supporl
alld rely on it. You maY place vour ch]ld in a special chairu,ilh good support. She u,ill
sit uell and pla\' \icll in the chair, ver hcr balarce lvill not be challengcd aDd, there
Iore. r,vill not irupror.e. Fot her balan(c ro i[lprove lufther, \,our (hi]d needs ro sit on
her on,n and support herself r'r itb her arms.
\\'hen childr en s ir qu icr l) $,ith arm s uppor-r, thc! cxperience hor,r. grir\:ltv aft:e cts
them. Slo\\ll],, the\ mal lcarn \,r.hat they necd ro do ro stav up. First, thcy sir leanir8
for\rard supporring themselves 1\,ith both irrms all the Lime. The n1r)rc rhe]- sit this
u,a\', Lhe longcrrhq/ can do it. \ext thr), will sit up straighter-. der'c ro Iift olle orboth
hands .rlf $c support. and sit t'rec for short periods. Quiet pkly rtitl help them stuy
rrp longc,'. Later. alter Lheir birlance has improved, the) mav dare ro do larger arm or
bodr, nor.erne11ts rrithout toP]rling or.er.
'l'he follo$,inlt exanples demoDstratc I\,nJ,s to p]ace your chjld s.r that she can
supporrhersell 1\,ith hcr arms all bvhersell Havc yourchild's rherapist hr:lp 1ou choose
a position ind praclice il ,ith ],our child. lrollou, the therapjsfs specific instructions
uhen \!u Practice u,ilh rcxr'ch jld ar home-

Sitting with Propped Arms

l. Your child's lcgs are aparl. LLlrned our. and slighdy bent at thr: knee

w' 2. Help her to bend at herhips,lean forward, and placeborhhands

on rhe floor (photo 10.7).
3. If it is difficult for your child to sit this way*her back is (ounded
a4d her loees do not rest on the floor-have her sit on a folded
up beach towel and place a five-pound ankle weight or sandbag
over each thigh to weigh them dowr and stabilize them. (See
the Appendix for instructions on making the sandbag.)

'I'his is
:L \ cr\ .qo(xl p.rsirio[ 1bI childrr:n tu learn to sir safclv a1l b\.

themsel!cs. Thct ha\e au.ide base ois pPorrand Lhe] cnnusetheiralms

Lo srLpp(n'.theln. Ytt, children do no.llk. to sil Lhis wa\r'lbthemiris rathci

poind.rs tr) sit and do no*rin!r. \\_irh rite hands planrcd oll Lhe ll.ror. thc\.
cnn'tc\,er suck L]teirLhrrmL. N{osr chrldren soor r calize: '1l l let myselffall
to thc side this excltis. is o,.cr inst.'So Ll[\ don't trv Lo sta\ up unless,
 SIlIING PREITY IOI

that is, !'or entettain rcur child u,hile shc sirs_ yor might sing or.sho\",. a pictue book to a
youuger child, but to nloti\,ate an older.child to sit rhis lvay is definjtelyhirrder.
One !val- to get around Lhis is to ambed the excrcise inro oLhr:r actl\.ities. you
krow\!ur chlid enjo),s sitting and playing on the floor\,!.ith ],our suppoI-.. Nert riDe
l,ou do this givehetjustoneroyroplal,lvithandscttherestasidc.Noircachtimcsjre
wants a diller cnt to\,. tell ho to lenn fbrunrd and place hcr hancls oD rhc floor
and stt
br",r.eir lp..r<p, lt o..\ r. .o.\) ,. .p\,i i gh...o.r i-rt,r.p .ur
olr)2.o<.,o_o\. l' .\,. ..!.to q\-.onJ.rl,-r,. o,ti.: .-, ,J_,,,rr
Onceyourchjklisablctou,aitforlo!\\jLhurttlosingherl,-rLanc rLhrL r,-,Lr se.rrch
lbr alolher to)-in rhe nexr room, )-ou hnot\ shi has r rj dc96 ,!l pro$r\s ,1JrJ
dcqu ir( cl a
!cr\. useftrl skili. Froir no\,! o., \,.oll cnn sir her dou-n this wnvtbt a \hor L tlllle $ihcner,er
it is convenienr for \.ou \-iLho!t ha\iing to urorlv that she will hll ro the side and
hum
her head. You tirught \,our child somcthilg rhal is of i]np{)rtance ro borh oI rrcr.
What
shelearnedby\rcurpcrsistentiniriariveblnHsher.rbrgsrr-pcln.rrt srtinq; nd pl.r_v
in8 on her o$,n. An.l there js a Iringe benr:fit_ Earh tilne she sits \,virh :,,,rN p.,,l,rp",i. 1,".
hamstrings are srrctcheLl as u.ell-somdhing that is vclvhelplrll indeed.

Sitting with Back Support and ptay

Thcfollowillgactiviriessho\,!,youho,roposition]rcurclildsoshecansitand pliy
()tl her-01!11. Thclr are
l:ropLllar homc instt-uctions. well lil(ecl by parents and
children.
They will give both of you some free time of your own. With the help ofyour
child,s
therapist, choose the one best suited foryour chilLi alld lo]lor{, the therapisr's
specific directions
1. Help your child to sit with good back support (against awall,
srair srep,
couch, or other solid piece of furniture).
2.Her1egs are spread apartJ tlllned out, and slightly bent at the knee. The
hip is bent and the trurk leans slighrly forward.
3. Drape a five-pound ankle weight or sandbag over each thigh for stability.
4. Ifyolr child's pelvis is rilted backwards, causing her back to round, wejge
arolled-up rowel berween rhe wall and herlowbaclc It will also heln if
she sits on a folded rp beach towei. Wirh her searhigher than her
les: it
will be easier Ior her ro sir !Lrai8hr.
5. Place a sturdy toy in front of her or on her legs. Encourage her to lean
forward and brace herselfwithone hand onthe flooq on herlegs, or on
rhe toy while playing with her other hand (photo 10.8a). A bu; box or
a p{)ll tLp tuv rs a gooll n)\'to Llsc.
6. lIl orrr chiirl is in danBer offalljrg ro rhc sides. place pi11ou,s
on rach si.lr.
,.} Variation A. Some chikh.en do not sil $,ell in Lhis Dositi(nr
llc rl ,r,1, I ro.h,,tlJ..t11. ..t. rb... .l ,lp
the chlidrer if rhc rol.lh(:! p1a! !\,irh js placcd or.er their lcgs or
f 'lr8n, .n,'.'i,\,4 r.Ir
ifro ur'cli1d .ir nnoL sjr l\'-ilh her legs rlLt ne.l out and slightl)
.br:nt arAlso,
the kncc, hart her cr()ss her legs and tailor sit
ll0.gb,).
Variation B. Obser\,! \.our child. Ifl ou feel she is no longer
in danger of falling backwards, \,ou m!1. hi:t ve her play without
back suppor r. For safet\', a bi8 pillou,b ehind her.
:r.8b
tu
qs7t
i
f02 TEACHING ]\4OTOR 5(ILL5 TO CHILDREN WIIH CEREBII,AL PALSY AND S \4ILAR A4OVE]\4ENT DEORDERS

Sitting with Arms Supported et a Table

Equipment. For rhis activity, you need a low bench or table. A bed tray would
make a good table for a smali child. A raller child may sit berter at a low bench or
stepping stool. A low coffee table may be best for an older child. parents may also
purchase an adjustable floor table.
1. YouI child sits in fronr of rhe table with her legs placed under rhe rable.
2. Her legs are apart, turned out, aIId slighrly benr at the loee. If needed, stabilize
the legs with weights as before.
3. Help her to sit straight, lean forward, and support herselfwith her arms on
the table.
4. Place pillows at her sides and behind her to soften a possible fall or have her
sit in front of a couch.
5. From her side or front, show her apicture book orread a story (photo 10.9a).
6. After youl child can sir qdetly with both arms propped, see if she can play
with a toy that requires minimal arm movements (photo 10.9b). A busy box
may work well with a younger
rl l* !"'
child and an older child may
enjoypaging through a book.
Variation. If your child
quickly loses balance when
playing, sit in front and srabi
lize her resting armbyfirmly
placinS your open flat hand
oll her hand and forearm. Do
this for the next one to three

ffi weeks and then have her try

to playby herself.

Sitting without Arm Support

The more time children spend sittinS on t}le floor in a good position-wirh rhe pelvis
in neutial, the back straight, and leaning slightly forward-the more opportrnity they
have to improye their sitting balance. Instead of using thetu hands for support, they like
ro plrr' rvith rhenr. Firsr the\. \,erJ. bricih flav r.ith both hands and
ther brace Lh. scl!,cs a8aitru,ith {)rc haD.l on the iloor, on theil le!i,
or on the Lov thc\i pla\'urith. r\s rhc) gain the conh.lcnrc that Lhey can
hold the scl\ cs up t\.ith L]tcir'tni nli ]lluscle s. thr:r' gradLrallv LLsc th c ir
ill ms krss tbr supporL. Sitting without arm sLrpport1!'ill challenge their
balancc responses. Thc), slor11,impr-o!c r\it I pracLjce.
Thefollo\{ jn. alti\,it\: recomrrtr:nrlations are 1irchildreDu.hoslr
k .{ on.herir o$,n iar short periodsbrltcirf rotsiL itncl plar iLtdependentlt
for a lon8er timc. Use them if\orr rherapisr recommends iL. Thc first
v
) one is esp.cialh- helplLtl if \,orrr child Lenrls ro fa11 backr,rards. you
have hcr si. ben-een \our lcgs facin3 rou. thisu.ar]ourchildhas
a lirr\,!ard orientxrion she ui1] irtorr lilr:lvlean lbrward and catch
hcr sclf r,.,,ith hrr arns il she loses hr:r baliLlce.
 SI]TING PRFrIY IO3

:!rr,!",es

10.11

Sitting Between Your Legs

1. Sitwithyourlegs stretched out and apart.
2. Your child sirs between your legs, facing you, with a pillowbehind her Brace
herwith your legs.
3. Encourage her to play with a toy in front of her (phoro 10.11).
4.As your child gains balance, move your legs a few inches apart challengirrg
her to sir and play indepeodently.
5. Watch her closelyand be ready to give her support as needed.

Sitting at the Baby Gym

1. Haveyour child sit at the side of the baby gym.
2.Encourage her to hold onto the crossbat with one hand and play with the
small roys mounted there with the other hand (phoro 10.12). A baby gym is
not sturdybur may provide the light supportyour child may still need.
For a small child, a Boppy pillowwill be a good prorechon in the event ofa side
or backwards fall.

SUGGESTIONS FROM PARENTS

\\ hat elsc can 1'oLr .lo ro enc(nrra8e !()rrr chjlal to sit up louger? Thc 11erL r.corlmenda
tioDs conle fron prrellLs.

Have your child sit in a laundry basket.

_l
ha\.e r\ daughr{:r sit irl rh(. basket \,virh the lrujtdl Ythat comcs
a orLt ofrhe d r\ cr." sl\ s (nte llr(]thcr. .,Shc cnjols p1ar.in3 h irh the trarm
clothes uh.n I sor'. the laLl]ldrf'
A lirurdrl birsliel t\ irh a non slip maL :rr rhe botom placcd inlo
\rnlr Lrathnlb inr\ also provide a sccure spac.r for )lnrr chil.l to sit jn
auring h.rr baLh (phoro 10.13). Ir rnav allo\,v her rc plav Lfurin! berh
.i ..r r. .. l -,. t.tl nor b. ,tt.]e etnt\h ,
r'our child r:rcn monrcnraril] byhersclf.

10.73
IO4 IEACH/NG ]\4OIOR 5K]LL5 TO CH LDREN !/]TH CEREERAL PALsY AND SII\/]iLAR ]V]OVEfu1ENT DISORDERS

Have your child iit in the corner of the playPen or crib,

SLle reports:
_\i.k lol,es his pla)?c.. I har,'e him sit ir a corner and
pft his 1a\.oliLe cars in fronL ol hirn. ln thc plilpen the! can t roll fer.
Hc hirs ltotte so Bood nort_. he can !iet the (irrs fr'.rnt e!el1 the furthcst
corncr oi rh! Pla,lPen.'

Mal(e a protected corner with couch cushions.

"1ta1ic thc scif cushions otTo1rl couch and make a p1a), arce for.Ia
so1r.'Rose explrins. ''Thal's u'here he sits and plavs then l g.rtdinr1.r'-"

Let Your Child Sit at a Play Station or Similar Toy,

_S.nl Lends ro fall bar:hr._ards uhen he sits irnd pla)'s. Widl the
crrcrrainnrenL arld suppor t ir fr'onl ol hiln hi:r is lcss likel,v lo do so, '
10.11
reporrs his lnother (photo 10.1.+).

INDEPENDENT FLOOR SITTING

For mal1y children with cerebral palsy, sitting on the floorwiththeir legs o[t in frolt
of them will never be easy. when they sit this wa, thet legs will not fully rest on
the floor and they have a hard time sitting sffaight and maintaining their balance.
Weighting their legs down helps them. As desc bed in the story of Elli, floor sitting
is important. lt stretches and sffengthens the muscles around the hipjoint, and wjth
the kflees almost straight, it stretches the hamstdng muscles. Ifthe knees ale mote
bent and turned out, the inner thigh muscles are stretched. Al1 these stretches are
good for your child.
In additioll to usiDg weights to help your child sit in this position, it may help if
your child's hips are higher than her legs. This way the hamstrinSs are sffetched less
and the backwards pull to the pelvis is diminished. Again, follow specific recommen-
dations your child's therapist gives you.
The Right weights for Your child. YouI child's therapist will help you find the
right weights for your child. Five-pound ankle weights draped over each thigh [sually
\rork well. brLt some childr'en do bellerwith heavicr' \\,elshts.
Somc parenrs like ho11lernade sandLraSs best becausc thevare
sofrcr and -vou can shift the sancl and contour the bag to thc leg.
(See the Appcndix lor instructions on making saldbags.)

Sitting with Weights

d l. I lelp l.our child to slt on a folded up tolvcl. Her' legs are
iipa.r, rLlrned our. an(l slightl\ benl aL Lhe knee.
2. Drapr an ankle r,eigha o\cr'cach lhish lor support.
:3 Sir ir front .)1 her. enco!rngr hL'. to siL sLrai8hl, bend at
her hips.lcen sl igt L-v tbrl', ar d ardphl vrlth -vo as long
as she Likcs (pho.o 10.1:).
14.15

Sitting with Weights during lndependent Play

lfyour child does well sitting on a towel and with her legs stabilized byweights
have her sit like this dudng independent playtime.
 SITTII'JG P]IE]IY I05

1. Place her fayorite toy onJ between, or in front

ofher legs (photo 10.16).
2.Let her play as long as she wants.
3. Give her a new toy when she is bored with the
one she has.
Variation. As soon as your child becomes able to
crawl and move about on the floor, she will no longer
like to sit still aod play in one place. From now on have
her sit with weights only when she sits still while she {!
watches a video or TV, when you play with her or read
astory, or during circle time in school or daycare.
Note: Do not have ).[rr'.hikl sit rhis l\'a,v iIshe n.]6
leaDs to the side oi stialghtr:ns one leg at rhe kl1ee anc] tums it jnward

ACTIVITIES FOR OLDER CHILDREN

As soon as youl child can sit and play on the floor, have her do things for herself. It
will further improve her balance and make her independent in small ways. The fol
lowing suggestions are for children like E11i, who are two years or older andstillneed
to improve their sittingbalance.

Taking Off Socks-Pulling On Socks

The first job for your child to learn will be to take off her socks.
1. Start out by supporting her at her hips while she leans far forward to reach her
feet. Give her time, let her struggie on her own, and try as hard as she can to
pull her socks off (photo 10.Ua).
2. As it becomes obvious that help is needed, push the socks parrially over her heels
and then let her try again Regardless ofhow muchyouhave to help initially,
you always want her to do the tott pdrt aIIW ftersell (photo 10.17b).
3. Each week i[crease the part she does [ntil she can tal(e the socks off all
on her own.
Now it will be herjob to do this each dgl]t.
Work simila y with her to put on socl$.
1. Start by putting the sock over her foot and rhen have her pu11 it up (photo
10.17c).
2. Next,put the sockjust over her forefoot and have her do the rest. lncrease
what she does until she can put on her socks independently.

.w
106 IEACHING A7]OTOR 5(ILL5 TO CHILDREN WTH CEREBRAL PALSY AND SIA4ILAR AIOVE]\4EN] DISORDERS

Taking Off Shoes and Braces

This is a two-partjob.
1. Fi$t the laces or the Velcro have to be loosened; then the
shoes orbraces have to be removed (photo 10.18).
2. Work with youl child as before. Give her plenty of time to
work on her own. If help is needed, give it during rhe initial
part, and always have her do the last part on her own.
-,: 'r\ #.'- 3. Encoumge your child to lift and draw up her foot when
taking offthe brace orshoe.
4. Once she can do it, it is your child'sjob to do it eachnighr.It
may take her fiye or more minutes in the beginning. Don't
worry. Let her struggle-itwill be timewell spenr.
Variation. Ifyour child struggles to keep herbalancewhen she sits on the floor,
have her sit in a corner Look for suitable comer places: in the ldtchen between tlle
refrigerator and wall, or a pulled out bottom drawer and the next cabinet, in the
bathaoom between the tub and wall, in the bedroom between the chest of drawers
arld the wall.It may give her the support she needs to become independent.

other ways to sit on the Floor

HEEL SITTING
Elli was already walking but srill struggled wirh sitting on the floor. Her story is nor
unusual for children with cerebral palsy. Most avoid sitting rhis way. Instead rhey
choose to kneel and sit down on their heels. Their feet are bent down with toes point-
in8 inwards and the heels turned out. Therapists callthis heel sitringor shorrkneeling
(photo 10.19).
\,V11\'do thc children like to sir rhis $,av? LeL's ftnrl out. Kneel on thc floor
and 1ou,er lrtrlrsclf so 1'olrr bottorr rests on vour hccLs. place vour haDds or1
vour hips :rrl(l norice llo , ras\ ir is ro keep tour pclr,is fon",,lud end lour back
sLraight. \o\r stretch !our k:14s out. sit on tht: floor, alld do tltc sirme. you notic(l
Lhat \ ou r pch.is tl,at) Ls tr) Llr of backw! rds, rori rdi[g vour ].rr..o back and mak-
ing it hrr der Lo siL rrr rrighr.
!\hen siltin,.. o! rheir heels, i. is casier for child.r,r ro keep thcii peh.is
upright. Lheirtr fl. srrai8hL. rn.l to bitlance. IL Jnalil]s fsin8 their hands anll
pla1,ir1B eesi.r. Thrs is r,hl herl siftirg is a l,er)'1rLn.ri( lilposltion ti)rclildren
rrith cerebr:rl prls\.
Thc drar\'back ofhccl sifiing is Lhat rhc hips and kn(]c arebeiltandthe
anhlcs rre benL dorrn. Children rdto alwa,,.s heel siL do not sueLch our their
hanrstrings and calfmlrscles. Therrfbr.. thcsc uruscles tr:nd to become too shorl.
Tf your chilll plcfrJ s .o heel sit r,r,hrn shc plar. s ol her' o\rr, see Lo ir thar she sits

F r"-ith legs strttchr:d ouL se\,l]rrl .illles each dr\. \liLkc it a habir rhar she siLs rhjs
&., rra)'rrhen \ ou plav $,ith h.r ot read to hel. 0r Lr hcn dte rlarr:hes a video or l V.
I (11recom cndedLr\tht:rherapist,hare,or:r(hillsiLonr,,r,edgeorfoldedup
btach ro,,r'e1 and placl r.,,eighls ol er hcr rhrglts.l
 srTlrNG PREITv 1O7

:s*

:).20 10.21 10.22

W-SITTING
When w-sitting, children turn their legs inwards, push their knees together, 1et the
lower legs splay out to the sides, and sit on the floor between them (photo 10.20).
The toes are pointing outwards. Simila. to heel sitting, the position makes it easyto
keep the pelvis upright, the trunk straight, and to balance. Because the lowerlegs are
out to the side, enlarging the base of support, w-sitting is an extra stable position. No
wonder that many children with cerebralpaisy choose to sitthis way.It allows them
to play and use their hands wel1.
Unfortunately w-sitting has a negative effect. In this position the legs tum
extremely inwards, which causes stress to the hip and l(nee joints. Therefore, long
pedods ofw-sitting should be avoided. You may encoumge your child to play also in
side sitting, heelsitting, or tailor sitting. Yet, h allthese positions, the child's legs are
bent- Therefore, to keep her legs flexible, it is important for your child to sit several
times a day with her legs stretched out- Follow tie recommendations given above.

TAILOR SITTING
In this position, also known as "sitting cross legged," the legs are bent and crossed in
fuont (photo 10.21).Itis a stable position that your therapist may recommend. It puts
normal pressure into the hip joint ard stretches the muscles ofthe inner thigh. For
children with cerebral palsyitis easier to tailor sit than sit with legs stretched ort in
ftont oftheo. It is a good position for them when they sit for a longer pedod oftime.
Tailor sitting has the diawback that moviflg in or out of the position is difficult and
many children need help with it.
Tailor sitting does not stretch the hamstring muscles as floorsittingwith legs in
front does- Therefore, parents are advised to use botlpositions with their children.

SIDE SITTING
When side sirtirl8, i
cllild sils m.rsrh on one side \rith her legs beilr Lo\r'.rrLl r]re oLher
side.Sidesitrirl8pl,rl,illesrlrrscbiLsrolsLrpporr(ph.rtol0.22).ltis:Lsrilrl.pliL\Fo i
tio, especiall\ ilrhe chilcl hans or onr: rrm ancl plals rrith th. othr:r.
IO8 IEACHING A4OIOR SK]LLS TO CHILDREN WTH CEREERAL PAIsY AND SIA/ILAR AIOVEA,4ENT DISORDERS

Your thempist may rccommend side sitting for children with cerebralpalsy. How
evet side sitting puts uneven pressure into the hip joints and your child llray slump
to the side instead of sittirg straight. This position should not be used for long time
pedods, especially if your child strongly favors one side over the orher.

Variability of Sitting
At one time or anotheq all children sitin every position mentioned above. Theyalso
sitwiththeirlegs placed out in &ont ofthem in avarieryofways. At times one leg may
be straight while the other is bent at the l<nee. Olle leg may point forward one miDute
and be out to the side the next. Who lihes ro sir still in one spot? Not yourg children
playing on the floor. They constantly move and change their position while pushing
cars, building towers, or drcssing dolls. ln doing so, theyuse and stretch all their leg
muscles at one time ot another
Children with cerebral palsy show less variety of positions when sitting. Most
like1yyour child likes to play in heel sitting or tailor sitting.ln both positions, her knees
are always bent and her feet always point down. While sirting this way, she will not
staetch her hamstrings and calfmuscles or freely move her feet-unless you make it
part of her daily routine. Telling your chi1d, "No video or TV unless you sit with your
legs ott in front (and weights over the thighs ifneeded)" does not make you a mean
parent. It makes you a caring parentl You arc taldflg care that all muscles stay at op-
timal lergtlr. Daily sitting with sandbags and dailyleg stretches will help ensure that
when your child is ready to walk she has the flexibility to do so. This is somerhing she
canDot do forherself-and her thetapist cannot do it alone either.

Sitting on a Bench or Chair

In western culture, adults prefer to sit on fumitrue. At work or at dinner we sit in a
chait on a bench, or on a stool. At leisure time we recline in a soft chair or sofa. When
we travel we sit in a car, a plane, train, or on a bike or horse. Only preschool children
like to sit and play on the floor most ofthe time. Whenchildren attend school, theytoo
will spend more time sitting in chairs. Over a lifetime, sitting well on a chait rather
than on the floorbecomes an important skill.
We may sit in a chair avarietyofways. We may sit without back support-sit-
ting straight or leaning forward. (Therapists call it bench sitting.) ln rhese posi-
tions, otlr hands are fuee to do work. When we relax we sit differently. We lean
backwards with our backs curvitg against the back of the chair. If the chair's
backrest tilts backwards, we may lean backwith a straight back-as we do when
we unwifld in a recliner.
Reclited sitting dilfers sigtlificafitly from sittittg straight up or forward
lenning. In a reclined position our back muscles relax. If we do work in this po
sition we mostly use the muscles in front of our body, similar to the way we use
them when backJyilg. On the other hand, sitting straight or leaning forward
requires work of all trunk muscles, especially the back muscles, and it requires
 SIIT]NG PRETI/ IO9

balance. The straighter our trunk is, the better our balance is, and the better we
can tse our hands.
Usuallyyoung children never sit in small chairs until after they are able to walk
well. This is diffe.ent for children with developmeatal delays or cefebral palsy. Rec
ogniziDg how important a good sitting posture is, physical therapists start to work on
bench sitting as early as possible. Especially for children who cannot sit well on the
floor, training ofgood postlre and balance will be done inbench sitting.
As mentionedbefore, sitting on a bench is easier for children with cerebral palsy
than sitting on the floor. When sirting on abench, the knees are bent, the hamstdngs
are not sffetched, and short or spastic hamstring muscles will not pull the pelvis
backwards. This makes it easier for childreo to sitwith their truDk srraight.
Unfortrlnately, chair sitting also poses problems for children with cerebral palsy-
Iftheyarejustlearning to sit on their own and have poorbalance, sitting on a chair or
bench is dangerous. A fall may seriously hurt them. Another problem is howthey can
safely get into or out of a chair on their own. Usuallypeople sit down from standing
and get up into standing. For children who are not able to stand, moving in and ot1t
ofa chair is a big challenge.
When your therapist recommeods that you work with your chitd in bench
sitting, safetyhas to be a priority. Even when your child sits wellwithout any sup-
port, stay next to her and do notwalk away even monentarily. Only when she is able
to stand up or get down from the bench on her owD consistently will she be ready to
sitwithoutbeing guarded. At that time she may enjoy sirting in a child-size chak at a
play table and looking at books, colo ng, erc.
The following are examples of activities or exercises, which help to improve your
child's sitting posture al1d balance. Use them as recommended byyour child's therapist.
Equipment. For these sitting exercises, you need a good seat for yo[I child.
It needs to be of the right height for your child's feet ro resr comfortably on the
floor and preferably have a nonsldd suiface. Step stools have such a surface, come
in various sizes, and are inexpensive. Use a stooljust the right size for your child.
A small child may also sit on a twelve-pack of soft drid(s and an older child may
sit on an upside down plastic crate. Some parents may decide to buy an adjustable
therapy bench for their child. They are comfortably padded and wide enough so
older children may place their arns at the side for support, and the seat height can
be adjusted as the children grow.
Some parents have discovered that the first step oftheir stairs isjust the right
height for their child and use it for her sitting balance training. If rhe height ofyour
step is such that your child's knees are bent about 90 degrees when her feet are onthe
floor, you may find it convenient to use.

Early Bench Sitting with Hip Support

i.H;r,.r:,"ourchildsiLon; stool placedinhorltofacouch(noDrhefirsLstepof
-vour stairs (il o1 rhc right h.l.qhrl.
2. Kneel irl lronL of \{)ur (likl.
3.lla\,e hrr lciir .gajnsr rhe back support r^,hi1e 1.ou place hrJ'l.gs ij1 a Sood
po\irior. You \\.ant het kn(..s bcnr. slighrh apart. and hcr fctt f rr on rhe 11oor
poirtiDg for\r,ard.
IIO IEACHiNG ]\4OIOR SKILL5 TO CHILDREN WIIH CEREBR/.L PALSY AND SII\/]ILAR A,IOVEI\7]ENI DISORDERS

.j

14.25

4. Next, place yourwide-open hands at the side ofherhips, with yot1l thumbs in
fuoflt and your fingers in the back. Tip her pelvis upwards, so her lowerback
is stmight and encourage her to sit straight (photo 10.23)- With her pelvis
stabilized in a good position she maybe able to sit tall. If she does:
5. Hold her for a couple ofminutes while you sing a song or talk to her.

Early Bench Sitting with Leg Support

1.Follow the directions for Early Bench Sittingwith Hip Support, above.
2. After you child sits well with your help, move your hands away fuom her hlps,
place them onher thighs orknees, and give light downwatd pressure.
3. Encouage her to sit tall while you talk or sing a song together (photo 10.24).
Variation. Ifyour child cannot sit straight-her pelvis tips backwards and her
lower back slouches-see if it helps her if you wedge a piece of foam or a rolled-up
towel between her lower back and the back support.

Bench Sitting with Play

Aher,!our chil.l can sir srill r,! irh Inirilllir I s!pport frotll lou, she ma). enio)-play
in8 \r.ilh:r to! loLr hol(l ilp ir hr:r.
1.1'oui child sits or a stooi placed in front oi a corLch.
2. Hclp hcr ro sir rall l,ith leet flat on rhe floo1 a d knees ap:rr't.
:l.Kneel or sit in fro1]L oiher and ho]d Llp:r strlr.l! toy for hcr to plav Nith
(phoro 10.25).
While p1a_vii18. she n).\ los(: hrJ golxl posrure. 1f this happens, trt'to correct her
rrithouL inlerrupti g h(J plir]. lI rhis is nor possible. place the tov LeJnporarllv to thc
'1 .r,1 . , r.i. ,,1-1
Sitting and Reaching
I Yo!r (hild sits on a srool plnced in fr(n1t of a (ouch.
2. Help her ro sit !all \r'ith icrt tl:rt (m rhc floor and knees aparl.
3. Kneel or sir i front of hcr.
.1. Holcl rp s irlltols and hal'e herreachlbt Lhen1. Holdthc jncasl'reach(photo

I0.26). \i)r !\:rrt to trake slLre she can control hcr irr mo\e]llerlts \,rithout
Iosira h.J .{ood sittirlg bahnce.
 5 TTING FRE]TY 1 1 T

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Ir"

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10.274 10-27b
Follow your therapist's directions and have your child reach up or out to either
side only ilit is recommended.

Sitting and Reaching Down

1. Help your child sit on a bench placed in front ofa couch or on the first step of
your stairs (ifofthe dght heighr).
2.Kneelor sit in front ofher.
3. Help herto sit with herknees apart and herfeet flat onthe floor.
4. Encourage her to lean forward and then come back up as you playwith her.
The boy in photos 1,0.27a and 7O.27b likes ro hear the air stream our of rhe
ball. He will change between sitting straight and leaning far forward as his dad
moves the ba11.
Many other activities may be used lor this activity. For instaDce, you may hold
Mr. Potato Head and place the pieces for it rlexttoyoul child's feet. Now she can lean
forward and dowr to get apiece and come up to putit in its place. Similarly, she may
play with a puzzle.

Wheelchair Posture and Balance Exercises

Older children who use a wheelchair continue to benefit from exercises inbench
sitting. As they improve thet sitring posture and balance, they become able to shifr
their sitting position and use their hands better for table work. Maneuvering and
steeriog the chair or moving in and out of the wheelchair with as little assistance as
possible are important functional goals for them.
For convenience and safety rcasons, children who use wheelchairs may do the exer-
cises while sitting in their chairs. Use them as recommended by youl childt tlerapist.
1. Your child sits in her wheelchair with the wheels locked in place.
2.Sit in ftont ofher and remove any chest support. Loosen, brlt don't open her
seatbelt, move her sliShtiy forward and wedge a tightly folded or ro1led towei
between her lower back and the backrest of the chair.
3. EncouraSeyour child to sit tall without leaning againstthe backrest.
4. Prop a puzzle board on your childt lap, hold up a puzzle piece, have her reach
for it and put it in its place. Have her reach forward and to the sides. Encoura3e
I 12 TEACH]NG ]\IOIOR SK]1L5 IO CHILDREN WTH CEREERAL PALSY AND SII\,,IJLAR I\IOVEA,IEN] D]SORDERS

herto shift her weight in the directioll shewants to reach

before she stretches her arm orlt. Have her rcach with either
a hand (photo 10.28).
5. Hold out a ball, have her lean forward and reach for the
t,
$I ball, and then toss it away.
6. Together with your therapisr, look for suitable bench sit,
ting exercises for your child and adapt them for wheel
chairpractice.
Note: Tighten the seatbelt and refasten any chest supports
before you step away from your child even momentarily.
10.24

Moving in and out of Bench or Wheelchair Sitting

The first activities in this sectiontrain moving from sittilg to the floor and fuom the
floorinto sitting. They are for small children who cannotyet stand independently or
for older childre1l who use a wheelchair. The second set of activities trains children
wllo sit down f(om standing or get up to stand.
Before pmctice you may model the activity for your child using a large doll or
stuffed toy. Make it interesting for her to watch and stress probiem solving. ,,Teddy
sits on the couch. He cries 'I want to get down!' Teddy impatiently wiggles aro[nd
and falls down. 'Oh no, Teddy, that's nor rhe way to get downl place both hand to one
side...." It willhelp your child to be familiar with the movement sequence before yor
practice it.

Sliding Off the Couch

1. Have your child sit and rest against rhe back of the couch.
2. Encorrage her ro rurn, place bothhands to one side (photo 10.29a), roll onto
her tummy, and slide dowr feetfirst (photo 10.29b). Assisr her as needed.
3. Have her pause as het feettouch the floor. Help her as needed to stand leaning
against the couch (photo 10.29c) and rhen lower herself into the floor.
4. Ifthe couch is too high for youl child ro slide off easily, make it lower by taking
the cushions off. Later, after she can do it well, have her try to siide off with
the cushions irl place.
"This was easy," the girl in the photo tells us wirh her smile.

!
 lrrlNc l3

x
PREirr' I

I
)

i, I
I' ? E
',.1''
q ' \
(: ""-'"{
cetting Down from a Bench
1. Your child sits on one side of the bench.
2.Have her turn to the free portion of the bench and place both hands there
(photo 10.30a).
3.Assist with her hand and foot placement (photo 10.30b) and guard herwith
your hand at her chest as she swivels off the bench (photo 10.30c).

Moving Out of the wheelchail

with your child sitting securely in the chair.
1. Start
2. Lock the chair. Remove the footrests or swing them out of the way. Remove
any chest support and loosenbut do not open the seatbelt.
3.Ask your child to turn to the left ard grasp the left armrest with her
dght hand.
4. Standveryclose in front ofher, open the seatbelt, help her tum hertrunk, and
slide dourl with her tummy toward the wheelchair.
5.Assisther to pause and stand as her feet touch the ground.
6. Next assist her into kneeling and thefl sitting on the floor.
After your child is familiar with the activity, help her less. Only when you are
sure that youl child will be safe, have her slide out off the wheelchair on her own as
the boy showr in photos 10.31a-d is demonstrating.

ft F,r
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1A.3lb
I 14 TEACH]NG AIOIOR SKILLS TO CHILDREN I/ITH CEREBRAL PALSY AND SI]\,IILAR A4OVEA,IENT D]SORDERS

I
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qq p! I

10.32b 10-32.

From the Floor to Bench Sitting

1. Have your child crawl to the bench and place her hands on it.
2.Help her as she comes up and places her feet on the floor (photo 10.32a).
3. Help her move her hands (photo 10.32b) and swivel into sittilg on the bench
(10.32c).
4. As yorll child improves, reduce your suppofi and only secure the bench for her
untilyo11 feel she can safely do it all on her own.

From the Floor into the Wheelchair

1. Lock the wheelchair and remove or swing out the footrests.
2.From abunnyposition on the floor assist your child into tall kneel.
3. Help her reach up and hold onto the armrests.
4- Help herplace one foot forward, and push into standing.
5.Ifyour child is tall enough, have her hold onto the edge ofthe bacl<restwith
one hand and an armrest with the other hand, and pull herselfwith your as
sistance into her chair.
After your child is familiar with the activity, help ller less. When she is ready,
have her do it on her ou,n as demonstmted bythe boyin photos 10.33a, b, and c.

*
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'..
 li] I]NG PREITY I f5

Freguenfly Asked Ouestions

a, ,When
my daughter, Amy, sits propped up on her arms, lLer hands are
fisted. The
therapistwants me to open her hands each time I hal,e her sit this
way. I feel this es aseless
because she wiLl fist then again a little while later. What
do you think?,
A. Foliow rhe therapist,s advice_. Even rhough Amy keeps her hands open for oniy
a bdefperiod, each brjefperiod will add up to helpful
training. When she propi
up with hands fisted. she is using all her arm muscles instead
of just the ones
needed for the job. When her hands are open, her arms
are more likely to work
as they are supposed to.

a 'Amy has soft splints, which keep her thumbs out. should she wear them
when she
sits with
arms propped?,.
A" yes, itwill make it easierfotherto keep her hands open and hold herselfupwith-
out stiffening her arms. The longer Amy sits with hancliopen,
the stronger and more
coordinated her arms will become.

a. "Brit_tdny.qLways w-sits. Her theropist soys it sbadfor

her. But Brittany will notLkten
ta me if I teLl her to sit differently. What do you recommend?,'
A. You are not alone with this problem. Other parents have faced
it. Once w_sittng
has become a habit, it is rext to impossible to change it.
Children ar" .o.fo.tult" in
the position and are able to play well when w-sitting. But there
are several sffategies
you can try. Whenever Bfittany sits for a long period
of time_for instance, wien
sir aiff"re,ritv. ltiy
watching TV or a yideo or during circle time in school_have her
having her sit with weights o, tailor sit. lfthese positions
do not agr"" *ntr lr"r]frr""
her sit in a small chair Whatever you decide on. be firm about jt.

. Wien she is playing on the floor, correct her position oolywhen you are play_
ing with her In my opinio4, constant reminders duiing free play
do rnoi" t u.. iiu.,
good. Brittany may feel that you are constantly picking
at her and you do not *arrt
to do that nor have her feel this way. you may as well relax.
Take comfort in the facr
that no study has shown that some w-sittillg is harmful.

A, "Miles does not Like to sit with sandbags oyer his thighs. Soon
after I place them on
him he. pushes them off. I stoppedusing them and insteid put
I myia"ai ni',iign,
when he sits. Don't you think that is just as effecti\)e?,, "
A. Sure, if you have the time and do ir a lot. The only drawback may be that you
will
not notice his progress as much. It is difficult to remember
over ti_e ho* mr_r"h srp_
port_yru give. Ifyou use weights you will know, fot
instance, that a month aqo vou
o-'
used five oounds and now rhree pounds wiildo.
a. "How could I get Miles used to the h,eights?'.
A- Whenever you 1lse them, be sure Miles is ready to sit and play. Also, make sure
tha t he does not take them off when you walk
'l hereiore. see
awuy b".aus" he wurr" ,.;. ;;;;.i;".
how he does when you sit in fiont ofhim a rd play wir h t im. you
ma)
even try to coyer them up. Maybe,but of sight, out of
mind,,wiliwork. you may also
use Miles's favorite video or DVD to distract him
and as an incentive. Ea.h
weights are ofi pause the video. When they are back on,
ti;"
th"
-'
the video play, uga;r.
 lt6, IEACH|NG l,lOTOR SK|LL5lO CHILDREN wlIH CEREBRAL PALSY AND Sll\llLAR I1,'IOVE^IENI DISORDERS

a. "Leifs physical theropist hcls hin sit on a large ball and trains his sitting balance
reactions this wcty. Leif thiftks it's o lot of fun. Why are there no therapy baLI exercises
in this chapter?"
A- To do therapy ball exeacises requircs skill and training. An inexperienced parent
may endanger her child. If Leif's therapist wants to teach you one ofthese exercises,
she will probably have good illustrated home instruction sheets available to give to
you (Jaeger 1997).

S
 &oo

ll o
T
0
I
a
Getting Up
o and Crawling
i eoaaaaaao

fustin is two years old and cannotyet crawl on hands and knees. Durilg his therapy
rJ sessionhe practices crawling, butprogress is very slow.It maytake ayear oftraining
to reach the goal. "Will itbe worth it?" his pare[ts wondet. 'Jusrin willbe three years
old by the time he crawls. No other child irthis preschool class wil1be crawling. The
other childrenwill think he is a big baby ard the preschool teacher will not want him
to crawl. Yes, itis great ifhe learns to cmwl, butwill it be age appropdate?"
It is true that even in special education preschool programs, teachers may not
like thet three-year-old students to crawl. They like fo. them to sir and improve
their cognitive sldlls to be ready for kindergarten. It is not ulcommon for speech
therapists to share this view.
The physical therapist seems to be the only person concerned about crawling.
"Why should I iisten to her?" Justin's mother may think. "The home program the
therapist wants me to do is difficult and boring. Whybother?" "Because your child is
never too oid for crawling!" is the therapist's answea.
Being abie to move indepeldently on the floor is a very important skill that has life-
loog application. cetting up ftom the floor onto their hands and knees and crawling will
help children become independent in many ways. The following story illustrates why.

Meet Jennifer
'llcn sirs ancl pla_vs all bl herscli " hcr morller rells Lhe ph}sjcal rhci al)ist. NollbrIer\
l()ng, though. SomeLinres sh.lrir\ s sel'eralmilluLesi olhcr rirl(:s shc ropples c,r er sorxtcr.
I f8 TEACHING ]\4OIOR SKILIJ TO CHJLDREN WTH CEREBRAL PALSY AND SIA,4]LAR MOVEA'1ENT DIsORDERS

She doesn t mind. \rhen she is on the floor she loves to roll. She ro1ls everywhere-she
even gets irto things. Her twin sister, Jill, is walking afld Jen likes to be up too. Yes
terday Jill was playing at her toy kitchen and Jen wanted to do the same. I suPported
her in standing and she stood for a long time. They had fun playing together."
Jennifer is 2O months old. Likehertwin sister, Ji1l, shewas born prematurely.
While her sister's Sross motor development proceeded as expected, Jennifer's
lagged behind. She was subsequently diagnosedwith cerebral palsy. In other de-
velopmental areas, the sisters develop at a similar pace. Both are learning to talk
and Jenrifer is especially social.
During physical therapy, Jennifer practices the hand and knee position (lherapists
call it quadruped or four-poiflt), sitting balance, sitting up, and kneeling with arm sup
port. Supported by her therapist, Jennifer filst holds quadruped briefly. A few months
later, she maintains the position without help for half a minute and sometimes even a
minute. In other areas, she does even better With minimal support, she kneels at fur_
niture, she stands leaning against a table, and, with the help of her therapist, she walks
up to ten steps with a walker. Jennifer's pareflts are very happy about her progress.
Jennifer is now two years old. Herptogress soundsverygood indeed. It becomes
less impressive, however, when you realize that she cannot pull herself uP to l<neel or
stand. Nor can she sit up by herself or push herself onto her hands and knees on her
own, all she does is lie on the floor and ro11. On her own, Jennifer is stuck on the floor.
Right now it seems not to matter much. Jennifer's loving parents are youngJ
enthusiastic, full of energy, and always ready to help.IfJennifer wants to sit up, they
position her. If she wants to stand, they support her in standing or place her in the
gait trainer. Whatever the family does, Jennifer participates in fully. This is wonder-
ful. But, someday.... someday, Jennifer willbe twelve years old and herparents will
be ten years older. "Ofcourse, by that time she willbe able to get up from the floor,"
anyone would think. This is not necessarily true. Only if Jennifer and her parents
work toward it wiil Jennifer learn it.
Childrerl with cerebrat palsy witl r.ot necessan'ily learn a new skill just
because they get older. Time is not on thef side. The opposite is actually true.
Basic skills are harder to acquire, as the children get older. This is why early in-
tervention is so important.
sure, Jennifer's parents want her to become as independent as possible. With
strong support from Jennifer's physical and occupational therapists it does not take
Iong to convince them that they need to help Jennifer learn to get in al1d out of posi
tions on her own. Mom sums it up well: "We are glad about the things Jen can do
with our help. We will keep it up, but getting up on her own and crawlinS has to be
the plio ty from now on."
Jennifer has already achieved a small part of her goa1. Placed in position, she can
hold he$elfup on her hands and knees. She does it the easiest way possible. In quadruped
her hips and knees are bent so much that her bottom to ches her heels. Therapists call
it the "bunny" position. Indeed, children look like little bunnies ready to hop away.
For many children with cerebral palsy, this is their startingpoint for getrinS up
ftom the floor. From the bulny position they can come up into short kneel, swivel
into sitting, move to a true quadruped position and crawl, or pull up to tall kneel
and to stand. The bunny position is the key to al1this. No wondet herthetapist had
started to practice it earlyon.
 GETTING UP AND CRAWL]NG , f9

Jennifer cannot get into the b[nny position by herself. For now the therapist
has to help her As Jennifer lies on her tummy, the thempist lifts Jennifer's hips off
the floor and helps her pull one leg and then the other up urdemeath her. Then she
helps her push her chest off the floor and put weight on her atms. This is not easy.
Jennifer's legs resist being bent and hei arms are tooweak to push up. Will she ever
be able to do this byherself?
Hard work needs a big motivator. Jennifer is resting on her tummy. The therapis r
moves a large box filled with colorful balls close to hea. 'Jen, come up. Let's play at
the box." The therapist helps her pull her legs up. "Come up and look!" she coaxes.
Jernifer lifts her head and struggles to push up with her arms and lift her chest off
the floor as the therapisthelps her. Such abig efforthas tobe rewarded. The tllerapist
quicklyassists her to kneel atthebox. Jennifer loves to look at the bal1s, touchthem,
and move them around. After a little playtime, the therapist puts her back onlo her
tummy. "This is a good situatio11. Let's take advantage of it," is her reasoninS. Backon
the floor, Jennifer knows what she wants. After the therapist has moved her legs up,
she is ready to lift herhead and push with her arms. Kneeling atthe box, she has flrn
playing with the balls. Again and again, the thempist practices lhe same sequence.
Jennifer likes the activity and is working hard. Soon she needs less help with
her arms and her therapist notices less resistance when she bends Jennife/s 1egs. Is
Jennifer trying to pull them up? After seven repetitions, Jennifer is tired- It has been
a good practice session a good beginning. The next ther apy session will be a little
easier for Jennifet and her parents canpractice helping her come up.
From now on, cominS to hands alldknees is part ofJennifer's routine. Eachtine
she wants to sit or stand, she is firsthelped to come onto hands and knees. The help
is gentle Siviflg hertime to do as much as possible onher own.
Several weeks later, no one rememllers for sure wlleL Jennifer pushed up to
quadruped for the first time on her own. At first, she did it only occasionally. Each
rime it became easier. with help ftom her therapist, Jennifer started to play in the
bunny position. Supporting herselfwith one aim while playing with the other was
another big challenge. She frequently tumbled to the side. Luckily, Jennifer did not
mind. she continued to get into the bunny position. She would reach high to pull the
magazine she wanted off the couch or even try kneeling at furniture. Now spills wel e
potentially more serious. "I constantly wolly that she will hurt hemelf," her mother
sighed. "I have to watchher allthe time." The[ she mused: "First we worried that Jen
was not doing enough on her own now she is doing too mrlch."
Indeed, Jennifer was darinS. Pu11in8 to kneeling or tq/ing to heel sir was more than
she could handle at the time. She did not have the balance, the trunk stIen8th, or the
shoulder, arm, and hip coordination. Instead of pulling up and endangering herseif, it
was time for Jennifer to ]lot only come up onto hands and knees, but to learn to craw1.
when crawling on hands and knees, children constantly bear weight through
their arms and shoulders,legs, and hip. They move amls and legs alternately one at a
time. Theirtrunkis not resting on the floor, and all ffunkmuscles are working hard.
Their balance is challenged with each crawling move. Cmwling would give Jennifer
the training she needed to become more coordinated and stronger, and to improve
her balance. It would get her ready for other challenges.
Jennifer had her own opinions about crawling, however. She neverhad liked to
move forward on her tummy. She had no urge to move forward on hands and knees.
I2O TEACHING ]\,IOTOR SKILLs TO CHILDREN WITH CEREBRAL PALSY AND SIAIILAR MOVEIV]ENI D]SORDERs

To get somewhere, she rolled. Even ifsomethinS was close by, she would go down on
her tummy and roll instead of trying to crawl to it.
Not surpdsiogly, it took hard worl(, persistence, and a 1ot ofpatience for Jennifer
to start crawling. She was three years old when she crawled across her play area for
the first time. It took even more time for her to get good at it.
Was it wofih all the effort? The answer is a tesounding "yes-" Jenniferhas pro-
gressed so much. She gets up fuom her tummy onto hands and knees independently
and crawls. she gained the ability to reciprocally move her arms and 1egs. she can
sit up without help, pu11up to l(neel independently and pull to stand. She is leaming
to crawl up the stairs and pu1l to stand with more ease by placing one foot forward
(half-kneel) as she gets up.
At the same time, her walking with a walker also improved. The arm strergth and
coordination gained by crawling help Jennifer be safe and steer the walker with ease.
Now that her legs are sffonger and more coordinated, stepping forward has become
more fluent. Best of all, she is almost independent with her walker. With stpervision
and some help stabilizing the walker for her: she crawls to the wallter, pulls to stand,
turns aroufld, walks where she warts to go, and lowers herself safely to the floor aga in.
JeDDifer's waller ski1ls, however', did not improve automaticallyjust because she learned
to get up and crawl. They needed to be trained as well Yet, slccess with her floor sldlls
helped her accomplish the walker skills. I unctional indoor and outdoor walking wilh a
walker has become a realistic goal, which Jennifer may reach in the near future.

Up onto Hands and Knees

The story ofJennifer is not an un[sual one for a child with cerebral palsy. while some
children crawl with ease by the time they are two years old, others need as much help
and training as Jennifer did.
The following are examples of how to work with children so they come up onto
their hands and klees, hold the position, and learn to play or move in q[adruped.
Do the activities first with the help ofyour child's physical therapist and follow her
specific instructiofls.

Getting Up Onto Hands and Knees

Ihis acri\,ity sho\,\,s,,_oLL ho\\, to assist l.our child ro geL rLp lrom the floor onto
hands and l(rccs. Ilo it sl{r\r,l\ arld encolLrage your child to .lo rs much as possible b-v
himself. lt u jll ral(c tinlc f(n \ oLlr child to learn this. |or rrosr r,hildr tn, it is easiel t.)
h.rlLl r posirioD on hands rrrl Lrr:.s thrn to push into it. Conse(lueftl\. \on can .xpc.t
ther \,our child ill be able ro hokLt rr: hanrls irnd knee posilioll iDdependentlv beforc
hc (irn p sh into iL on his o1rn.
l. Your chll,-1 lies on his ruurmr. anrl r.ou kncel br:sidr: or bchinrl him.
2. SLidr: onr: hrnLl Lln.1rr his righr hip and rudge his bo.rom up.
3. With lollr othur hir .l push his r-ighl 1eg up so his knee ard hip ar c br:nt
(phoro l1.1al.
,,1. Push Lhe lelt 1e8 Lrp Ihe same ury.

5. Bra.e hls knees ind hips betlleen vour [egs r,r,hi ]c r ou h.lp hjn to lift his chcsr
oil Lhe lloor. -<rlii8hlen Lhe elboNs, a]ld placc his hinds (phon] I1.11)).
 GETT]NG UP AND CRAII/LING I21

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6. Now push his knees a litde closer together, adjust the feet so the toes point toward
each other, shift his weight backwards (his bottom will be over his heels), and
see if he can maintain the posirior with support to his hips (photo 11.1c).
Variatiol. After your child is used to the routine, try to reduce your support.
After yor mdge the right hip up a little, see if he will pull up the leg on his own. Do
the same on the other side. Next, lift his chest some and see ifyour child will push
himself into a bunny position.

Easy Hands and l(nees (Bunny Positionl with Hip Support

1. Help your child lift up off the floor onto his hands and krees as desc bed
above. See to it thathis legs are bent as much as possible at the hip and knee.
Mostlikelyhis bottomwill touch his heels.
2. Keeping one ha[d under his chest, place an interesting-to-watch toy in front
ofyour child (but out ofhis reach)
3. Remove your support to his chest, firmlyhold lis lips with both hands fro the
sides, and encourage him to stay propped up on his arms as long as possible.
VadationA. I1 ! our chjld does noL have sulJicienl
irm \trrngrh (n'.ontrol tu hold Lhe position, place a
r Ltlgc (r notdxrok bin.lcr mev slbstitlre lor e r,,edge)
a=! s r,
'.q
in front of him and have him pr op his ar ms up on rhc
rreLlte lph,rto 11.2). \ou, less \\,eight ni11 be resting
on his !rms. LeL someLhing ro11 dour rhe r,ed8e. h
r lrjll bc inrrrtsting ro wrLch and nrakes the acLil iLl
Iur for rour chilcl.
Variation t]. lf rcr:orrmr:ndrd b\ to i.hil.ls
rherapist. have hirn wear soft ar1n splillts uhilc prac
ticinE this.
Note: \\'hen \rcur child is oj1 hands al]d kI]ees.
his Loes sh.rrLld poirl backwar.ls or in\l'tu.l Lo\viirL]s
1.2
I22 IEACHING ]\4OTOR SKILLS TO CHJLDREN \J(/]IH CEREBRAL PALsY AND SJIV]ILAR MOVEIV]ENT D]SORDERs

It
I rlF $
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iffi
11.3 tl.1

Ouiet Rocl(in9 on Hands and l(nees

lift up off rhe fkn)r on.o his hands and hnees.
1. .\s Llescribed Lrelbre, help )rLLr cli1d
f. SupPorr his hbs end !:cnrlv rock him side to side (droro 11.:l).
3.Nert. rocl him g|nt]1 lbrrvarcls and back\'lards. Be careful not ro mol'e I'our
child more rhan a (onplc ofinr:hcs forward until he has 8ai[ed the needed anD
sLrenBLh and coordil1alio11.

HoIding th€ Bunny Position lndependently

l. As clcscribcd befar-e. help 1:oLLr child lifL up ofi d1e floor orto his hands and knccs.
2. Afrer tou irrc s!rc rhat hls legs ar-e benL as much as possible aDd his arms ate
placed u,ell (as shol ,r ir photo 11.4), see if your child can hold the position
l"rithout -vour help. Sho , hi1n a pi(urc book or-(rhater.er ilrterests him and
.ncoul-age hinl Lo sLal'Lrp as long as possible.
Variation. r\ftrr !our'.hild holds d1e bunilyposition\'\,ell on his olr,n, encour agc
li1D to brhg his bottorr p sonrcwhet and shili more \-eight onto his arns. l'his bdngs
him closer to a true hirrds afd knccs positi.rn as needed for crauilin3.

Playin9 on Hands and Knees

1. Aftcr !oLlr child rs up on haDds and knees, place an eas,_ to plal +vith toy,. lilc
ir rol\, pol! chicken or a pop up loy, in fiont of hiln.
2. [r(nn ir Ir(n1t ot !o i child, encourage hiin Lo lilt his ri8ht arm and tap the
chickcf . Bcrcrdvtu sr.rpporthis lcftnr' if needed.
3. Do the same ith the orher arir.
,,1. Do marlv repelirions.

5. 11 he does r\,ell, encourase hi[1 Lo p]a]' on his ou,n rvlth anY to! of his 1i1dng
(phoLo 11.5).

Crawling. One Move at a Time

I Alrcr Iolf cri (l ls oll hrn(ls rnd knccs. placr: somrrhing intt:r{rsting a foot
out ofrerch P r(. r re rrem on r stool if lorrr child inmcrJirtch, tr ics to roLl or
cra i on his be11\ ro it. le1l him: Ler's crawl to it. '
 GETT NG UP AND
'RAIILING '23

s
r t
I

! I
,.4@rl

2. Help your child move his right alm for-ward a couple inches and then move h is
left leg a small step (photos 11.6a ard 11.6b).
3. Next move his left arm arld help him step with his dght les. lfyour child wants
to slide both arms forward at once, hold one hand in place with your hand while
you encourage the other to move. Stabilize one knee if he wants to move both
Iegs forward together.
4. Repeat the crawling pattern until your child reaches the toy. Repeat the se
quence as often as your child likes to.
Note: Watch yo1ll child. As soon as you [otice that he Dloves an arm or leg on
his own, stop assisting him with that arm or leg.

Crawling
When children first start to crawl, they will do so in vadous ways. They may move
first their arms, then the legs, eithet one at a time or together' They may move the
arm and leg of one side of their body and then of the other side. or they may start out
crawling reciprocally-moving the right arm and the left leg and then the left arm
and the right ieg. Whatever they dq thetu movements willbe choppy and unsteady.
They need time to sort it out.
After your child has been crawling a few days or weeks, you will notice that he
will use a more consistert pattem. If this means that he always scoots forward with
both legs at a time, talk to his physical therapist for advice. You want your child to
altcrrrirtirlr mo1'eoncl(rgntaLilDean.l de\el,:rpacrnrrlinated
recipro(rl rrar'1ir13 parrcrn. This l"-ill Pr(rPa!e hirn lor irlt.r
naLehJ stepDrrg I 011\,ard as wt Llo u,hcD uc walk.
il r.r ..ero , | ''"
hirn cri1u,1e\cr\ where. Ybu nrnrto bLtild ttP his stltfiIil1x and
Lo

cnLlrrince. YoLLNant hin) to craul for l(rtgerand lmger.li-\Lanc

es. Remo\c.lLlLLertiom th. floorand 3i\,(r him elloPensPa{rl
lirr pra(.icc. Soo[ ]'our (hild \rlll be ab c to cra\rl lfonl r(xrrlr
to room (photo 11.71. 11e Will tnlo\, explol jfg his enf ironlr€lrr
berLerthan hr.\trcolrld bvrol)ingor crau,lingon his Lutrlnl].
I24 TEACHJNG l\7]oToR sK]LLS Io CHILDREN WTH CEREBRAL PALSY AND sIA4ILAR AIOVE]\,4ENI DI5ORDERS

Of course, he will get into things you don'r want him to. So be sure to "childproof,,your
house by locldDg up deaning supplies, irsing baby gates and socket covers, etc.
As he becomes more coordiflated, obstacles will no longer deter him, but will
become awelcome challenge. He will crawl around some and over others. After some
practice, he may even crawi over yo1lr stretched,out legs. On a nice day you may take
your child outside and encourage him to crawl in Srass. Most likelyhewill be hesiranr
at first, but crawling o11 aI1 uneveD surface like a lawn wi]lbe good exercise. you rray
also have your child practice crawling up and down an incline. A sloping lawn or a
ramp will provide this challenge.
Next, encourage your child to crawl fast. For fun, have a sibling tace with him
after a ball. If the sibling is older, te1l him to ler your child with cerebral palsy win
sometimes. The more speed the better. The ability to move his arms and legs fast will
be a very useful skill wherrhe startswal]drrg. Fast walking requires less ba]ance. Be
ginning walkers have poorbalance and maycompensate for itbytaking quicksreps.
Frequently they start walking this way and only later learn to walk slowly.
Eventually, your child might be ready to crawl up rhe srairs (phoro 11.8). This
is not easy and is dangerous when children try it alone. Ifyour child is interested io
crawling up the stairs, have him practice when you are with him. Guard him well as
he goes up. When he wants to come down, do not have him cmwl face first, but let
him slide down onhis tummy feet first (plloto 11.9). He may object, but .,feet firsr,, is
a safetymeasure all children need to learn.
It may be boring and time consuming
to watch your child goiDg up and com-
ing down stairs. You may be tempted to
, stop him. Don't! For your child, rhis is an
adrenlu_e ard ir r gleat e\er.ise. Ar rhis
point, crawling up and down stairs gives
:w him more of a workout than he may get at
the playground or even duriig his physical
therapy session.
b&, There are ro cravr ling e'.e'cise. ir th i"
book because as soon as your child is able
to crawl reciprocally on hands and knees
he will find the "exercises" jusr right for
him in his e[vironment. AIl you have to do
is allowhimto take off, moniror his safety,
and edoyhis antics.
rl.a 11.9

Rising Up and Moving Down

\or all chil.lr cn srrrr ro cl a\,- I ;rfrcr rhevsucccr:d in comin3 to hands and knees. hstead,
some childrrr plr1lto kncrl asJenniler.lid,liseuptositorrhcirheels.or.s\ri\.elinto
sitling{)]lrhefloo1.Th.lk:arnr,r'hrrrhcrapistscall,,transitional,,movernents.This
sinply means Lharthr,\ mo!'etio on. positionro anorher. So lar.thcY havenlastcrcd
r1r'o o'irrsi.l.Its Th.\ l|irr turn lr.rm rheir back onto rheir trutmils thev roll irlld
Lhcl crn geL up trrnr stomach 1r'irg onro Lheir hards and krret:s.
 GETTING UP AND CIiIWLJNG I25

The arm strength and coordination gained bypushingiflto quadruped nowhelps

them to master the transition into or out of sitting, and puiling to a l(neel. More hip
and trunk shength and coordination will help them to make the tralsition into tall
kneeling. Additional leg strength willallow ior a ffansition to standing.
For yorq moving fiom one position to another is easy. Yet, for sma11 children, especially
for children with cerebral palry sitting up is a major hurdle. They master it first by pushing
up onto hands and knees, al]d from there theyffansition into sitting. Lowe ngthemselves
from sitting to stomach-lyin8 on the floor is just as difficult for them. Indeed, what they
master fi6t-sitting up or going down-depends on a child's preference. A child, who
likes to sit and play, will work hard to sit up by himself. A child who would rather move
about will more likely figure out how to get down when he is placed in a sitting position.
The next actiyities show you how to help your child to sit up and move out of sittirrg.
Use them as directed by your child's therapist and foilow any specific directions given.

'&i

t :.i

11.1t)b 1:1101

Sitting Up
l.Aftr:r rour child has prshr:d up oDto his hrn.ls and linc,es, place a to\ rn
his left side.
2. Support his hips l\,e11 alld ]o\\,er his hottom L1o\!n Lo r]tc righr sjde (phot.)
11.10a1. Hc r.-ill he ir1 a siLle le:Lning position r,irh inost of hi! \r,cighr or h1s
righr ir r' (fhoro 11.10b).
3. Encour agc IouI chrl,-1 Lo Lr irll hitlselfloru.iir.l in.l ovcl tolrard Lhe ro\ (plroro
I1.10(J. Contilnle Lo riulrpor. his hips as he str ugglcs ro sir up.
4. RcPeat this acLiYit\ w irh him silling up o!rr his left side.
5. As vour chrld rrrpr o\1rs. reduce \ollr ruppnrt,
Encourage !our chi d ro siL r iLh his Lrg! our in liont r)r llir!ir hinl taltor slt ljkrl
the girl in the photo.

Moving Out of Sitting

l. Your chlld sits on rhc floor'.
2. P!t a tov oLrL oi his r cach to his right sjdc.
ts
3. Nowhave\'oui riild tutnhis tnlnk irnd place bolh
01'his er s ro rhe side on thc floor llrhoto ll.t l).
.+.Ilelp hi irs mLrch as recdcl ro lifL his bottom. l
coarr up utto his hands and knees. or krwcr
hi sc fro d1e 1loo..
11.11
126 TEACHING ]\4OTOR S(ILLS TO CH]LDREN !i/]TH CEREBRAL PALsY AND 5I\,,]ILAR ]\4OVEfu,]ENT DISORDERs

Pulling to l(neeling
1. Your child is on hands and knees in front ofa sturdy toy box filled with inter-
esting things. For stability yor may kneel behind him and brace his legs and
hips between your legs.
2 . Encourage him to shift his weight over one arm, r each up with the other, hold
onto the rim of the box, and pull to kneeling (photo 11.12). If he stru88les,
place yo[r hand over his haod so it will Dot slip
offthe rim. T4i not to suppofi his chest. You want
him.odoa. much a"po" bl.or I isor/r.
3. Once he kneels at the box, encouage him to
keep holding onto the rim with one hand while
playing with the other hand.
For a child who can hold aposition onhaDds and
knees without help or who crawls independently, pdl-
ing to kneeliog at a sturdy box may be easy.
Grard or support him as needed ftom t}Ie side but
do not sit or kneel behind him. Initially, youl child may
lose his balance backwards. Ifyou are behind him, he
will feel safe,lean againstyou, and will not leam to
prevent a backwards fall.
11.12

Moving into Heel Sitting

Afreryour child can l(nccl \,vjth ar1ll support, he mavbe l-ee.ly to hcel sit.
l. From hands ancl linccs, encorLrage voltr child to shift hjs weight backu,ards
into a bunnv position.
2. Kneel in fro[t of him holding a busy box or
another slJrd). ir rere.ri.1B roy he likeq.
3. Encourage your child to sitback on his heels,
come rlp, and p1ay. In the beginningyourchild
ffi
will lean onto the toy as he plays. Later, dis-
Y' courage him fuom doing so by tilting the toy or
,]l
holding i. rerricalll (phoro I l.l3ar. fh;s vla)
he will heel sit and playwith less supporr.
4.Later have him hold a small toy and see if
he can balance and heel sit all by himself
(photo 11.13b).

Doing lt All
\1ostchjldlenhirrnto(!rrl,sitLtp,prLlll.]knccl..ndimprol,erheitbalanccinsrt
rln8 and kneeli.g iill a. rhe sarle rime. s rh(:] gcr heftel u,iLh Lhesc sltills dnd gail1
rtore inchpt:fdcrcc. parenLs ma\ noti((: chaDges in their childrcn's bchavior. A quieL.
pessi\(:. irt tines moodl .hil.l ma\ becolne an acLir,t, outgoirg 1iftle lello who is
intcrcstcd in his en\.iro.m.n..
Nlan.\ cllildren \rith ccrcbral palsy ej1]or crar,rling and p1a_v1ng on rhc floor b_v
trro l-ears oi aBe. Borl !o1] and 1'our child \rill br: happl rhat he is nor,r, indcpendently
 GETTJNG IP AND CRAWL]NG
'27

moving about, playing on his own, and no longer has to be constantly helped and
carried from room to loom.
Savor it! Your child willbe{efit from lors of cmwling. His arms, legs, shoulders,
hips, and trunkwill get stronger and more coordinated as he iearns to crawl faster, to
kneel straightet and to traruition ftom one position to anotherwith ease. It willhelp
him with standing aod walking but not if his ieg muscles are allowed to shorten.
The two-year-olds who crawl and kneel look so cute- Parents relax and think
of them as "cured." Ifyour child is one of those cute children be glad abort it, bur
do not forget his daily 1eg stretches. And do nor forget to work on pulling to stand,
standingwith arm support, and stepping. As the "Road ro Independence" in Chaprer
4 describes, it is bestto work on these skills at the same time your child practices sit-
ting and crawling.
Typically developing children sit, then crawl, stand, and fina1ly walk. They master
the skills in sequence. So you expect the same from your child wirh cerebral palsy.
"Why then the rush into standing? My child jlrst started ro crawl," you woflder. Ir is
best to practice standing and stepping concurently with l(neeling and crawling. It
assures that his knee and anklejoints remain flexible. It teaches yollr child to weight
bear over his feet as well as over his knees. It saves time and assures that no oppor-
tunities for standingwill be missed.
As you already l(now, yot1l child needs more time and practice to learn motor
skilis. He may be three years old or older before he sits, kneels, and crawls well To start
standing and stepping practice at age rhree is late. By thar rime youl child may not like
to stand but mther be independently crawling. Between one and two years is a good
time to start standing practice. At that age, childten like ro stand.Itis a good rime to
lay the forndation for this important sld1l. The next chapterhelps you ro do this.
As soon as your child crawls on his own-you no longer have to practice itwith him-
stafi to emphasize sranding. Practice it daily as directed by you. physical therapisr.

Frequently Asked Ouestions

a. "When Josh crawls, he does not moye his legs olternately but scoots forward with
both et the same time. whcLt can I do?"
A. It wiil be best ifyou ask Josh's physical therapist. He knows Josh and can give you
specific advice- A generalrecommendation is to have Josh practice crawling inplaces
where scooting is difficult and where you have some control over the situation. you
can spread a large blanket or quilt on the floor and see ifthis discourages Josh ftom
scooting. Dudng the warm season, have dailycrawling practice on your lawn. Scooting
is difficult there and Josh may let you help him to reciprocally crawl to ar inreresting
target. Most likely, Josh is not able to scoot up an incline. With your help have him
move up one 1eg at a time. Ifyou have stairs in your house make it part ofhis routine
that he crawls up with your help. The more Joshuses his legs reciprocally, the easier
it will become, and the more likely he will crawl this way on his own.

O.'lfh.rAirdr€r,.rory?s,.\1./lstsltdr irunds. Shou[11be or]-il.idboltaltdt?''

A. lrlost likel_v islinli \r,ill be a tenrporar\, occLLrrence. As Audre\.crallls nor. and
crawlingbecomescesir:rforhet.vour,r,ilLnoticerhathcrhandsr.illisrless.ighrh,and
I28 IEACH NG l\,4OTOR 5KILLS TO CHILDREN \VITH CEREERAL PALSY AND S]IV]ILAR 1\4OVE]\4ENI D]sORDERs

cventuall-v open. Al the sa ettnethercaielhingsIo cirndothatrrillhelpArdrcl. .

PracLice opcn hand u,eight bearing \iith Alldre]-. Ask for actif itjcs thal practicc lt lf
Audre,v s therapisL has not yct 8i\,en you an)'.
Does Audrcy ha\.e sofl hand splillts:' lf shc does, make sure she uear's them. The
splirts help her to open her ha[ds and she u,il] bc more likei-v to crau'l witholt fistil18.

a. "Melissq likes to hold things in het hands when she crawls. ls this bad far her? "
A. No, it shows that Melissa has progressed with her crawling skills and is now abie
to carry her favodte things along with her.

O. "Naseri sias Up lr,ilhoul corrirr.gri,rt onro hi.s ionds ond knr:r:s. Is this r1'ron8?"
A, N{). $,hile ]llost children sit up b! first coning onto Lheir lands and knees, some
push into sittillg from stomach 1ling. ChildreD !r'ho sit tlp this \\a) have flexiblc hip
joints and sholv good (oordjnetion of thcir hip, trunk, shoulder, arrd arrn muscles.

a. "Braderl lotes rolling around.. Hefinally Learned to cravllblltlle still rolls most of the
time - What should we d,o? "
A, Most likely rolliilg is still easier for Braden than crawling. Do not scold him for
roliing. Observe when Bmden is most likely to cmwi and make the most of these situ_
ations. For instance, will he crawl out of narrow sPaces when you play with him? Is
he more likely to crawl in the kitchen than in the living room, or is it the other way
around? Have him spend more time h the room he prefers to crawl in. Hallways are
great places for crawling. Have Braden pLay there and encourage him to move about
by placing his favorite toys at different ends ofthe ha11. Instead ofverbally leminding
or praising him for crawlin8, you want him to take ownership of his new skill and use
it because he wants to.
 &

l2 o teg Exercises
*
and Standing with
o Arm Support
s aoooaaaa

The previous chapters gave you many activities and exercises to strengthen your
I chilcl s arm and shoulder and trunk muscles. This is because children primarily
use these muscles when theylearo early funcdonal ski11s. Theyuse them to push off
the floor into sitting, kneeling, and onto hands and loees.
"Shouldn't I also exercise my child's feet and 1e8s as early as possible?"you may
wonder. Yes, of course. Most likely you have already been doing so. \l/hen you played
with your child in back-lying and did a Spine Curlup or Happy Baby Plays with Feet yon
started to exercise your child's legs. Whenever you diapered and dressed your child,
you touched and moved her legs, and this too stimulated muscle activity.
Sensation is impofiant. sensation stimulates movemerlt. Yorl know your arms
are sensitive to touch, but your legs are too. The palms of your hands have a special
keen sense oftouch and so do the soles ofyour feet. When you walk barefoot on grave1
you quickly expe ence how sensitiye youl feet are.
Your child's legs and feet are sensitive and when you touch them you stimulate
muscle work. Ifyour child plays with her feet or if she touches the floor with them,
rhis too will encourage foot and leg muscle activity.
The first advice to parents who want to stimulate their child's leg movements is
very simple. lt requires no work or time, but rather saves both. It even saves money.
This is the advice: don't cover your child's legs unless it is necessary, ar'd never covet
her feet ulless it is absolutely essential. Sleepers, which hide your child's feet, are
alI right for sleep but not for daytime when your child is active. You want your child
to see her feet and toes and move them freely. Ior the same reason, don't cover her
feet with socks.l-ittle socks look cute, but dorlt have your child wear them except on
f30 TEACHING I,IOIOR SKILLs TO CHILDREN U/ITH CEREBRAL PALSY AND 5I]\4]LAR I4OVEA/ENT D]SORDERS

special occasions or when she is wearing shoes. Socks do to feet what mittens do to
hands they greatly reduce the sensation you receive. Mittens intedere with every
thing you want to do with your hands and get in the way ofyour sense oftouch. You
don't have your child wear mittens all day long. You know it would hinder the use of
herhands. Likewise, try not to use soclG indoom. Her foot muscles will develop bet-
teI without them.
"But my child will get cold feet!"you object. Yes, without socl6 her feet maybe
cold. But as long as her thiShs are warm, you do lrot have to worry. If you worry nev-
ertheless, have her wear two pairs of long pants durinS extra cold days.
"Butmy child needs shoes!" you decide. shoes hinder and restrictyour child's
feet even more than socks do. shoes a(e meant to protect your feet when you are
walking. As long as your child does not pull to stand or walk, shoes have no
functiofl. They are just an adornment and a hindrance to your child's gross
motor development. In shoes, children cannot stretch or curl up their toes freely.
These movements strengthenthe muscles ofthe feet and stimulate leg movenents.
AII these spontaneous movements are good. Theyhelp the muscles getstrorger and
more coordinated.
"But won't shoes help my child to stand and walk?" you counter. I may smartly
answer that shoes possess no magic and will not make your child stand and walk. It
takes balance, sufficient leg strength, and coordination to walk. This is correct, but
it is also true that shoes and good ankle braces make a difference when your child
stands and walks-
Children with delayed motor skil1s rsually have veryweak antle and foot muscles.
Children wirh cerebral palsy ofren have not only weak but also spastic calf or foot
muscies. Both theweakness and the spasticity make it difficult to place the feet afld
hold the ankle joint in the best position for standing and walking.
The feet and the ankle joints are your base when you stand. This base affects your
standingposture. Changes ofyourbase andyourstandingposture may causebalance
problems and even a fall. Forinstance, ifyour calfmuscles areveryweak, yot1l ankle
joint may bend far forward, causing your knees and hips also to bend, possibly caus-
ing you to fall down forward. Tight, spastic calfmuscles may cause the anldejoint to
bend backwards, which causes the knee to bowbackwards or the heel to be pulled
off the floor so that the children stand on toes. Correct, good fitting ankle braces and
shoes will lessen these ankle problems and provide your child with a better base of
support. For some children, the braces are not onlyhelpful, but essential for standing
and walking. The last chapter will provide more details about this.
Even though shoes alldbraces help childrenwith cerebral palsyto stand
and walk, they hinder them when they are clawli[g or playi[g on the floor.
This poses a problembecausd most children with developmental delays or cerebral
palsy will engage in all these activities for several years. Like Jennifer, they may
learn to crawl on the floor and to walk with the wall<er at the same time and their
parents waIlt to give them good opportunities for both. Taking s]roes and braces
on and offseveral times a day may prove to be the onlysolution. This is extra work
forparents, daycare workers, orpreschooi teachers, yet ifyou want to foster motor
development, it is essential. As your child becomes more capable, yor can teach her
to help with this chore.
 LEG EXERCISE5 AND STANDING WITH ARfuI 5UPPORI I31

Stimulating Leg Movements

The following are more ways to stimulate leg movements:
Stafi leg range ofmotion exercises with your baby as early as possible. They are easy
to do and most childreD like them. The exercises are done at three different speeds. At
the slow speed, you move the legs throuSh rheir ftl11 raflge of morion and mildly srretch
the muscles. At the faste( speeds, you move the legs as far as they go with ease, which
will be less than ful1mnge. The exercise is meant to stimulate active movements and
keep the hips, 1e8s, feet, aod toes limber. practice them fircr with the help of the physical
therapist and do the fastet movements only ifyour theRpist recommends them.

Kicking the Legs Slovv and Fast

Do this exerclsc after each diaper change.
l-Yourchild lies on herback.
2. Whllc yoli holdherlei't leg d{r\,vn- bend her right
* Itnce and bring it up tor,vard hertummy (photo
12.11. P;rrse
3. Nlove herl ight lcg dorv[ and hold ir dor,vn n hile

J
vou move her left l<nee to hel LLlmmy, Pause.
-* .-:-.-" .... 4- Repeat t\,!o times.
.1. Rcpcat this sel'eral times at a faster pace \,!lth

oUt pausi[S, c]eating a flujd kicking pirttcrn.

Ankle Rolls and Wiggle Each Toe

Do the exelcises as ,:lcsrrihed ]n Chapter 5, Flcri| le r\rus.les ond l)ir]ts

Happy Baby Ptays with Feet and Independent ptay in Back-lying

YoLl also u,ant your child Lo lilt hcr iegs up on her ou,n-together or one leg at
a time. Ha.cl-to tbot play riill do rhis. lt srrengrhens thc nlusclesthaL bend the hip,
sLreLches the rnuscles that str-eighten the hip, and inlproves coordinatfun. Thjs, iD turr,
."\,ill make it easier ior vo r chjld
to ro11 over. crawl, and 1ateI !/aik.
Hal,e )'our chlld do the aclivitlcs ns described in Chnptcr Z HdlpJ Baby rn
Back lf ing.

lntermittent Pressure through the Leg

This cxercise is for chi]drcn u.ho do not yet stand lvith suppoit. It lcts them ex
periencc pressure Lhrough their ankle, knee, arld lipjoints similarly to the l,vay it

t -u $,olllLI heppe11i1 Lhe\ \\,.rc standing. Do thc alrir.it\.onh ilrecorn-

mcnded bv yorr chiLd's rherapist.
l. tbur ch ild lies on her back \,virh her legs srralght.
2. Cu'p \ our right hand around her righr heel and place r-our
othcr hand lightl\, o!cr her riSht knee (phoro I2.2)
3. Gi\,e 3entle. i.tcr mittent pressLlre inio her heel. Dir-ecr
; the pressur. through her anklc and hnee joints lnto her

J hip.ioint. With _\,our lelt hand, make sure LhaL thc linee
doesrlot hcfd.
4. ci\,e inrcrtnitteDr pressure rhrough the leIL leg sjlllilari)'.
f32 IEACHING l\4oIOR SKILLs TO CHILDREN WIIH CEREBRAL PALsY AND SI|\/]|LAR A/OVE|\4ENT D]\oRDERS

Leg Exercises
So far you have heiped your child to move her legs. Now you want her to do as m11ch as
possible onher own. Some ofyour child's muscles maybe especiallyweak and benefit
fuom extra training. The muscles that bend the hip joint are often weak in children
with cerebral palsy. They are strengthened when the children 1ie on thet back and
raise theirlegs against the pull ofgmvily. The next four activities encourage children
to lift their legs high in playful ways. Small children as well as olderchildrenwho still
need to improve thef hip strength and coordination may enjoy them.
Ifyou thempist recommends the exercises for yol.Il child, use them according ro
any specific instructions given.

Kicking a Balloon
1. Hang aballoon or lightball from the ceilingwith a string
and have your child 1ie under it on herback.
2. Have her kick the balloon as hard as she can. Encourage
her to make it flyup as high up as possible (photo 12.3).
Start with the balloon hanging low and close to her feet.
You want her to be successful, have fur, and enjoy doing it agail.
As youl child gets better after a week or two, challenge het by
hanging the balloon higher.

lccking with One Leg

1. Hang aballoon or light ball from the ceiling, as before.
2.This time, hold one of your child's legs down on the floor and askyour child
to kick with the other (photo 12.4).
3. Repeatthis exercise holding the opposite 1eg down
Note: Kjcklng with one 1eg rcquires nror-e le8
muscle control than l(icking .irh both. lvlomcnttn
from rvhole bodyurovcments cannol assist the effort.
l lith one leg pinned tothe fl{)or, the otherle8has to do
allthc \",ork and itshamstdrgs l\,i1lL. str-etched- ].lan8
rhe balloon in just the right spot fbr casr- l(icklng. YoLI
,l uTant your child to ha!,e lun and do this rtr y cffcctive
exercise r"-ith "gusto ' again anLl aSain-

Lift the Ball

12.1
1. Your child lies on her back.
2. Hold a lightweight ball over your child's legs.
3. Have her grab the ball with her feet, b ng it up
toward her chest, take itwith her hands, and then
toss the ball away. If needed, help her by piacing
tlle ball between her feet and holding it there,
and ther b ng her legs up hiSh enough so she
car reach tJIe ball with her haads (photo 12.5).
4. Later, reduce your support and have her do as
& much as possible on her own.
12.5
 LEG EXEIICISE5 AND STANDING !VTH ARI.4 SLIPPORI 133

Foot through Ring

Your child lies on her back.
1. x
2. Ci\.e your child a ring (as used for a x
lriDS toss game or dir.iDg) ancl chal
lenge hc1 to bring her ieli lbot up ald
prt her foor throu8h rhc ring (photo
12.6). lf she car otdo ir. helpherhold
,1" i " "r..1I r '-! D\ Dr rrr-rrE
'rl
lr-' tlt'. l- r,, H .e -. pt r, i,, ;. i

. l . - ri ,t i .h(.. r Dr n" lr-. iool

rhio gh rhe ring v,.irh as liftle help to
her 1cg as possibie.
3. rt, ,.a r,d hrr lrF.D| r.-r .:.Lr our
through thc ring.

Scooting Backwards
For older children who are able to sit on their own, the following activities
may be Llsed to train specific leg muscies. Use them as directed by your child,s
physical therapist.
Have her practice the scooting activities in a large recreation room, a hallway,
or inyour driveway. Ifa siblingjoins the activityirwill be more fun.
1.Your child sits on a scootetboard.
2. Have her hold onto the board with borhhands. and move back-
wards by pushing off wirh one foot at a time.
Scooting backwards trains the hip flexors and the quadriceps
muscles. (The quaddceps is rhe big muscle on top of the thi8h.)
Note: Scooting backwards is easierformost childrenthen scoot
ing forward, which is lisred next. Bur there is the danger of a backwards
fall when your child scoots backwards. you want to be mindful ofthis
and be sureyour child carl handle the activity before she practices in
the d veway.
practice the activity first on a leyel surface. An
incline will make
it harder to control the scooter. O y when your child is ready for the
challetge, have he. try it on a sloping ddveway (as demonstrated by
the boy ir photo 12.7).

Scooting Forward
' o,t'.h .l . r,. 1Cl
i | , .1.
2. This tilne. encofra8e lour child to mo1.e l.rrrvard bv srrcrchins {)n. 1e! .)ur
pushing doNn r\,ith Lhe h.el lvhjlc \llerchtnJ rhe odler l, g io1\\. .l j11.1 ., m.
Scooting fort\,ard tlains rhe hlp flc.\ors. thc quadriqs. and rhc hnmsnlrL!
nluscle-(. (l'he hamsrring js rh. bi8 muscle at thc back of
l,-o1rr rhigh.)

Kicking in Sitting
1.lbur (hild sirs on a bench with firct flar on rhe floor ard braccs hersel1,,,r,th
her:rrns on thr: bench.
2. D.rrtle a balloon or) ir string :r])ole her foot.
I34 IEACH]NG I4OTOR SKILLS TO CHILDREN !flTH CEREBRAL PALSY AND s \4ILAR ]\4OVEA4ENI DISORDERs

3.Askher to slide her dght foot forward, and tell her to kick the bal1oon. Have
herkickthe balloon as often as she likes (photo 12-Ba).
4. Repeat, having her l<ick with the left foot.
kickiDg rhe balloon nill train
vour child's quadriceps muscle.
Variation. If ],our child has dil
ficulty kickirS 1""ith one leg at a time,
changc rhe exer'cise as.lescr'lbed hcrc-
1. Tapc thc hallo.rn string to thc
tablctop irnd have the bal
loon dangle dorvn from the
kitchen table.
2.IIave,Your chilLl sit on a bench
lacing the table $'ith her
!-; I strrtchcd {)rrt righr loot undcr-
ncath thc baLloon.
3. You sit at ther left side of _vour
12.4a 12.Ab child and firrnlyhold dorvn her
left leg with her foot flat on the floor. Encourage your child to kick the balloon
-
with her right foot. If needed, assist her in bringing her dght foot up a few
times and then let her tryonher own (photo 12.8b).
4. Repeat and have your child kick with her ]eft foot.

Supporting Your Child in Standing

As children develop, they pr11l to stand and are typically able to stand at furniture
between B and 10 months of age. Most children with cerebral palsy are not able to
do so until much latea. Yet, it would be good for your chiid to experience standing at
the same age. Standing stimulates leg muscle activity; it stretches and activates the
muscles ofthe ankles and feet, and puts healthypressure throughthebones andjoints.
WeiSht bearing in standing causes calcirm to be deposited in the child's leg bones,
and, as a result, the bones become denser and sffonger.
Children are born with soft bones, which coDtain little calcium. Throughout
childhood, the calcium content of the bones increases. The children are depositing
calcium into their "bo[e bank." Three years after growing stops, young adults have
achieved peakbone mass in thet "account" and can "draw" fuom it later in life.
Children, who never stand, deposit far less calcium in their bones. They ate at
risk of developing bones that break easily. Even short pe ods of standing are benefi
cia1. Active standing, where the weight is shifted ftom one 1eg to the othet is better
than standing sti11.
Often it is not easy to place and supportyo[r child in a good standing position.
Having her stand with poor posture (with a forward leaning or backwards arching
trunk, or standing on toes) will establish bad habits and reduces her chances of learning
to stand independently later. Yo! need to work with your child's therapist and follow
her advice about ways to encourage good standiDg.
 Lf. lXERCI5E5 AND 5IAIiDINi: IIITH ARI\4 SUPPORT
'35

A child shows a good standing posture when

both feet are well grornded, flat on the floor with
toes pointing forward or slightly outwards. The hips
and knees are straight and in alignment with the
shoulders (photo 12.9). The child may lean slightly
forward but not backwards.
{

The following are two examples ofhow to place

and supDorr )our child in a good slarding posrure.
Practice the activities first with the help of your
chiid's thempist and follow anyspecific insffuctions
#
she recommends.

Standing with Support D.e

1. SiL on a lo\.- srool or
chair. Sltpport ]'our child
as shc stands siderva_vs beLll,,een !o r'krccs and lower le8s (phoro 12.10).
2. With hards, make sure rhar hcr'hips alld knees are sLraight and hcr feet
"-our
rre planted firn11von thc floor a bir apart and with toes pointjngforv/ard or
sli8hdy ouLu,ar-Ll.
3.l,Vhen yorrr- child sralds with good posture gradua]ly supporL her less $,jth
\'our'lcgs. so that mosL or all o1'her u,cight is upon hei legs- Assist her'at the

VariatioDA. lfyour child s hgs bucklc ot tuminr\,henever theybear some rveiglrt.

observe rrhich leS is most lll{cLv to do so. llave }'oLLr child stand wirh her r,eaker 1eg
closest to !oLl and sLlppor't thc krlee of that leg firfit]ywlth both hands.
As soon as v.rrr'child is able to stand 1br- a longcr pedod of time, do the activir\r
in liorr of a tablc \,yith sorne roys 1br hcr to plav rvith.
Variation B. lfbuckling ofthe knccs is a
persislenr problem, your ch jld's therapist may
. 2g-. L: r .,,- Ll,r J...1tIp- rIroDi i,
+${ ers lvhile standlng. Have her lie on her back
whllc vou put the inmobilizers on.
4L As hefore, har-e vour chilcl stand be
recn 1'our legs ln tiont of a low table. Your
ldr', r .5hr .l-' Jr,rlncp.;
.;tr"oi. eirtr.,i r/,r. B rl\ lb6er\P
ibr vou to help hcr' stirnd n ith her hips ancl
tn knees srlaight part of the time. Encourage
lour child to pla1, u,irh loys on thc table and
stand as lon8 as she likcs.
Variation C. Ifit is diticuk for,!-oll .{)
have your- child stand sidel,a,vs ber!^rl]cn
)'orr legs, trv supporliDg 1'our child facing
).10 :12.11
arval froml-orL as sho$,n in photo 12.11.
136 TEACHING ]!lOTOR S(ILLS TO CH]LDREN !/]TH CEREBRAL PALsY AND 5]A4ILA]I ]\,IOVE[/]ENT D]5ORDERs

Standing with a Lean.To Board

Ifsupporting r,or r child in sta ding is espe
citrll_r' cbalJcnging. a parldt:d hoald firl r orLr chllcl
to lean agaiDsr may help. (Sr:e rhe Appt:rni' f,"
insrnrctions ro make rhe horrd )
Place the boar d slighLlv Ionvard, slanLed
rb rl '.' ..,1' \ . t.,L1'7 " '
of fr.r rn I tr-lr'e.
Ll: r, .'rltl .t rrd rnd I ' : .' .t
thc boiud whilc you supporr hcr from l)chin.l.
llncourage ,volu child to plal'in this position for
several mlnutes.
The child h phoro 12.12 does best iI he is
allou,ed to stand on \'1om's legs.
Notc: Support !ou child irt:rll tinles \,vhcn 12.12
using thc board.

Supported Standing with Weight Shift

1. Sit on alow stool arrd support your child between your knees and lower legs
as she stands facing yorl-
2.As shebears weight, mal(e sure thatherlegs are in a good position-feet flat,
abit apart, and toes pointing forward or slightly outward (photo 12.13).
3.Now hold her with both hands around her chest and move her
sliShtly to the right side so most ofher weiSht is on her riSht Ie8.
$t
Pause.
4.Moveherbackto the middle and then to the left side. Pause.
5. Move herbackto the middle and then a little forward. Pause.
6.Repeat 10 times, creating a rhythm. Play some music with it
for fun.
Variation A. Ifyou child tends to come up on toes, try the following:
Take your shoes off and place your feet over your child's feet. The weight
of your feet may be all it takes to keep her feet in place.
Variation B, once your child is able to do the activityweli, you may
tr.1 accent the weight shift by giving some downward pressurc during each
pause. This encourages her to bear all her weight first over the ght and
then over the left leg. lfthe dou,nward pressure causes her klees to buckle,
lighten up, or discontinue the pressure-
Note: Do not do tlle forward movement if it causes your child to bend
12.13 her hips or come up on toes.

Leg Exercises with Weight Bearing

Leg exercises i. stending r ill rot orlr'snurgrh.r vour child's 1eg muscles but also
trair thc coorrljnatcrl r:p ard dor,-n rror,emeDt patrern at dre hip, knee. and ankle
joints. As so(nr irs \ ou arc comibrtable sLrpporrillg loLlr child in standins. her phvsic.Ll
lr'p.rr,r.,,r' lo" l "ol o.\ rF\-'. ..
 LE' EXFR'ISEs AI]D SIANO NG !V]TH ARful SI]PPOIII f37

ff !
f" (

L I

! BE

1X
ta 1lt)
Sit.Stand-Sit with SuppoIt from Behind
A bar sucrioncd ro the surlace yout child srands at rvill make rhe erercise easier
iir a beginrer. Holding on an.l p!l1i113 \vith hcr ilrms, she can assist her lcgs as they
push up. (A sucrion bar may be purchased in a hard-
> ,'\!4, ware store or ordered from a pediatric equipment
catalogue. See the AppendixJ
1. Place an interesting toy oo a table or sturdy
3ti.: chair ofa good height (aboutwaist high to your
v' child). Suction rhe bar at rhe edge closest to
your child.
2. Kneel in fuont of it and have your child sit on your
leg (photo 12.14a). Direct your child's attention
to the toy. Have her lean forward, grab the bar
(photo 12.14b), and stand up (12.14c). provide
as much hip support as needed for safety.
3. Latet encourage hea to lean forward and push her
bottom backwards. Help her as needed to bend
her h ips. knees. a rd an k'es ano sir do\ n again.

.4'o Sit-Stand.Sit with Your Child Facing You

. r .i 1,1 i....r n -P, .t,. r, r.
;,
t1 (rn r stool. (Or'. as in the illLrsh'arion. ashoeb()x
.in tnake e lo\,\, seat.J
l. Sri or k rclfac]]lgyourchild.\\ithloorrighr
hand. hold borh ol toLr chikl's hands.lirurlefr
.n hiLr.l srabilizes hcr right hip ancl i]-igh lronr
thc slde (phoro 12.1saJ.
3.lhl \oLLr chilLl for\tard and up ilto sLanding
lphoro 12.15h) and Lhen havc her srL.lo\.,,n
\ a8ain.Irruse.
.+. Rt:prar an1- Ll rcs or as loil3 iLs \ oLl
child
1." .r. r' 1ro j ,. ,.. r i:
12.1sb
T38 IEACHING AIOTOR SKILLS IO CHILDREN WTH CEREBRAL PALSY AND SII\,1ILAR A/OVEA,IENT D]SORDERS

Variatiofl. lf youl child pushes mosrly with one leg (strcrger), do the following:
Adjust the position ofthe other leg (weaker). Make sure that the hip, knee, and foot
are aligned and the footpoints forward. Place your free hand on the hip and thigh of
the weaker leg for extra assistance as your child moves up and down.
Initially, your child's attempts ro stand up and sit down will be veryjerLl. The
more you practice the exercise, the smootherthe movement will become.
To 11rre your child to come up, put a small toy, a ring, or beanbag on your head.
Note: Your child should 7l.ot push balckwdrils when standing up. Do not use
the exercise if pushing backwards cannot be ptevented.

\,

_{
1

}}'

ti

12.16b 12.16c

Sqsat.Stand-Squat
During this leg exercise, the child also moves rp and down wirh yorr help. It is
well suited for children with increased muscle tone. Use the exercise only as directed
by yow thempist, follow her instructions, and be sure to practice with the therapist,s
help before you attempt it at home.
1. Place a kitche[ chair close to the play area. Put your child,s favorite toy on the
floor nearby.
2. Help your child to squat down in front of the toy with feet flat. Assist your
child by holding her knees apart and out. Encourage your child to relax, lean
for-ward, and play a few minutes (photo 12.16a).
3. Briefly support youl child with only one hand while pulling the chair in frcnt
of her. Put the toy on the chair.
4. Ask or help your child ro reach up with ore or both hands (photo 12.16b) and
to push into standing. Place your open hand between her knees if she tries to
push her knees together irl standing (photo 12.16c).
5. After about a minute of standing, move the toy back to the floor and help her
to squat down again.
6. Repeat as ofte[ as youl child likes to play.
 LEG E\ERCISES AI'.]D STANDING !T1]TH,lRiI'l 5UPPORI I39

Your Child Stands Holding on with Both Hands

Your child stands rvell $'hen ]-oLl sLLpport her a d she lihcs it. "Ts thcrc a rvay she could
stand bv herself?" ]'ou u,clnder'. lf lour child already crawls and sits independentl),,
i
the pht_sjcal therapist lr,lll soon shor,,, ,,ou hotv to help her pu11 ro sland at r-nlturc
and pla,v \Nhile sranLli.g. On the other hand. children rvho cannot crarvl and sit rvill
not be read! for'this. As crplained ill Chapter ]3, children lilst galn l)alancc iD sirting
nncl kfccling bcfore thel are able to acquire it1\,hlle stan.lln!t. Chil.lrettdre not able
to stdnd without orm support before they can sit itTdependently.
Ho\,r.ever. even children rvho cannot sit indcpendentlv nav learn to sil as well as
stand holding onro a bar. Th.\' m!v lcarn the follo\,ving sequence: lroln sltting h()ld-
in8 onto a bar Lhey pull rc stand. hold onto the bar as the,v sLand, and then thcv lo\\,er
Lhemsel\es back.lol"-n irto sitring still holding on. This ma),be a very di fficu lr activ it)
1br voLLr child. It ma\ tahc tine, and much patience and tr-alning. for lour child ro be
ablc to do this. Yet, r'our child's proud and happv srrilc as she srands a11b,vher se1fr,vi11
be rvorththe efiolt. UrllbrtLlIlate]),. bcceLlsc shc nceds to hold on a11rhe Lime. she rvill
not be able ro pla!'u,hi1e sLanlling- Nererthelcss, sraDding \'\rith arm suppoft is a vel-v
useful ski11, especiall,v lbr childr(]ll \!, ith nlore se\-ere types of cerebral palsy.
The earlier childrcn lcarn to srand rhis wal-. Lhe better. Pulling to stand and
standing holding onto a bar (,ill enable thenl to assist irrith .lrcssing aDd toileting. lt
r,r,ill mairc it possible forthem Lo move lLransfei) fr'orn onc chairto aDother for to Lhrir
h(I, etc.) on their own or 1\,ith minimal hclp. Tbc), rvill become more independent
irs the,v incorporate "transler sliills. iis thcrapists call rhem, into their dail_v ro rint.
lvhen theyare gr-o\'\ n. a.Ll lifting thcn b.rcomes dithcult or impossible, these tr'ansfcr
skills \'\:ilI be !erv inlportant.
Thcfollowingdescribes.stepb)'sLep.hor,\,toteachvourchildrostardup.stand,
i polrantthat volr practice thisfirst\,viLh
and sjt down rvhile she holds onto a bar.It is
the help oflour child's therapisr. Onl! eftcr !our chikl is participarir8 well and the
rherapist directs yo , av vou do these acti\.iries at home.

Equipment, You will need a stool orbench for your child to sit on and a bar
to hold onto.
The seat has to be of the right height so yout childt feet rest comforrably on the
floor. For a small child, a twelve-pack ofcanned soft drinks may make a perfect seat.
For an older child, a stepstool or an upside- down storage crate may be just dght. Place
the seat in ftont of a bar she can reach and grasp onto, and then use to pull herself up
into a standing position.
A bar such as a towel bar or bathtub safety bar attached securely to the wall will
work well. Right under a window would be a good place to atach it. This way your
child may look out as she stands. The bar should not be too thick but just right for
your child's hand to grasp. Ch stopher's parents attached a bar for Chdstopher to
stand at in their family room and there he practices standing. Another option is a bar
with suction cups that can be suctioned to a smooth surface. This kind ofbar maybe
ordered from a thempy equipment catalog (see the Appendix).
Ifyou do nothave a bar for your chiid to use,look for something stable and easy
to grasp. Your child may hold onto the top of a playpen, the slats of a crib, the rungs
of a ladder-backed chair, or the edge of a weighted don n trashcan or clothes hamper.
I40 TEACH]NG IV]OTOR sKILLS TO CHILDREN WIIH CEREBRAL PALSY AND S]]\4ILAR A'1OVE[4ENI D]5ORDERs

PutmaSazi]1es, old phone books,

ol a stack of ncwspaPers inlo a
ncwtrashcanorha persoitwill
not tiP ovcr.
If vou would like to ha\.e a
special piccc of.qulpmenl for
_vour child ro pull up io, yor may
build a ladder box as sr:cn in
photos 12.17a and 12.17b (sce
the Appendix 1or dimensiors, or
pLrrchasr: a walking ladder [also
called Pcto ladLlcr). The Iadder
is available thr olgh pediatric
therap-\' equipnlent catalogs.

Standing while Holding On with Both Hands

1. I lelp )-our child to sit on a stool with her teet shouldcr'v!idth apart, flat on the
floor-. and toes pointing forrlard.
2. Ha!. her lean 1bru,ard. reach up. an.l hold onLo the bar r"-ith both hands. Be
at hcr side and place one hand over hcrs to rnsure that drev dont slip oflthe
bar (photo I2.17a).Withvourolherhard bercadytohelp,voLrrchildliftupoff
herseat. (Work\\,ith \o!rtherapislLo findthebcstwayto assisLl'ourchild.)
3. Tell)-ol1r child: lcan f{n $rard. ptlsh up, and stard." As she stands, plaise her.
fnd hnve her sLand by herscrlf \,vhile still securing her gritsp ilround the bar
(photo 12.17b).
4. When shc is r-eaLl\', ]relp her to sir dot,n slo\rly. \,rhile sLill holdhg onto thc bar.

Some points to remembet when you practice this actirity with your child:
. Do not have your child pull to stand with her arms only.
Instead have her lean forward, putting weiSht ovet her feet,
and push to stand with her legs, and notjustpull up with arm
strength a10ne.
. Have youl child hold onto the bar [or top edge of a trashcan,
playpen, etc.) with both hands at alltimes. The goal ofthe ex-
ercise is that your child learns to stand up, remain standing for
a pedod of time, and sit down all byhemelfand do it safely.
. If you use a weighted trashcan or hamper for your child to pull
up at, she maywant to leanwith hertrunkagainst it. Do not al
low this, as it may tempt her to take her hands off. This is very
unsafe. A child who does not yet sit or kneel independently is
in constant danger offalling ifshe does not hold onwell.
. when your child no longer wants to stand holding on, have her
sit down and end the practice sess:on.

After _vour child is irbl( to prrll to sLand. as \ve11 as stand and sit do\\,u rvith rour
help. vorL rvant hel to do it bv herscli H(:rr ara soine goals voLL can set to pace lrour
child s pr-oSress-
 LEG EXER'IsEs AND sTANDING WJT]-] ARII4 sUPPORI I41

l"' Goalr Holdins on *,itl1 both hanils, your chila! srands up ond ,its dolvn
h)itllout help.
\\hen vour chtld stands do\\,r, trv to reduce vour assjstance except for
Llp or sits
safeF,'r-eesons.C.rntinLrerost:cureIoUrchild'shInds\!ithl,outs.Guardherrvelilrom
rhe sidc (Pholos 12.18aa.ll l2.l8b). t he elnphasis is not on standing 1or ir Long time
\r .,,."..t"r.' -o.1..-t :lo.....,LJdo, -.

k ?I
Y
t
The mor. \'oLLr chjkl plactices,
thc casiel it $/ill becorre and the morc
llkcl_l'she rvill no ion gcr neeLl voru boost
cornin[lup or\.our help holdingon goi[g
do\'\ n. Ile prepar ed ibr itro take sc\,.eral
Teeks of dailv practice ro achieve the

Boal. lr \,!.ill rcst your' jlnaginatioD t.)

m{)ti\.ate lour chil.l to coJnc up agein
anda8aln. "Come p and givc Mommva
big kiss" mar-\,vork tbr a 1\,hjle. but afrer
Nlom has gotten kisses on hodl chc.rks,
and Tcddy onc on his snout. vour child
might tire of this gantc. If norhing else
secns to \!o*, pieccs oflavorite lbods
fr& maY do rhe trick-
12.1ab

2"'t GoaI: Holditrg on w itl! both han(|s, your child stands safely
for 30 secon.ls.
Nor,vyou can make srirndi|g fur and otivate your chlld to stand lon8el-. praise
her for standing srraighr antl t:rll, have h.rr sing a soDgl,,,ith you, or p1a1,murt. *ar,"
she stiln.ls. You ma,! evc11 encourage hcr to \,!1ggle side-to side urirh the music_ It rs
1un and gets her Lo shifther \veight from one lcg to the other so[lething she neecls
to learil- Sri[ting out, n]ake sure her hands dor't slip off as shc -dances.,. Cuard vou
,|.lo, lll-o- lp ..o \.,t- ,..\\rj ). ig.
You mat,l)c surprlsd hour long 30 s.,conds arc. it tIaJ take several days orweeks
ol .lajlv pradjce to reach Lhjs goa1. It mal, get ririDg to cDterlain vour child as sh(l
F,rdi t,p\.ti rt'tro.A.te,;,r r.-.. ior ...t opfp,J.,orro|- .,.""1r.,go".

3'd Goal: Holcling on witll both lla]nds. your child

stflnds durins doily tasks-.
Thirk oI rimcs ir Inat, help vou i1 lour child
srnnds. For insrarce. rvhr:n she gds dresscd il1 thc
;td lnol airlg, \'ou c n hate hcr sit rvhi1c vou put her pants
olcr hel 1cl:t. then she can pull to st;ud, and r.ou
pLrll her parnrs Llp 1,!hile she sra[ds. Jf \.orL1 child uses
"",.4 r r,, heelchair, her rheraplst nav givr: \.oll a rr ansler

Lb lbr
orce rco have dccided on
.,j .lr - . .t r .,:
,/orL. SeL
trp
yorLr
| ,\(.r.\-
up a "staDdijrg station"
rhild
r .l
s d;rilr

i. rhe bedroon.
:
Lrr. rto,t. ,. I uot..,t -rr,...o I

bc standing las illusLrared in phoros ]2.19a :Lnd

I42 TEACHING i\/]OTOR sKILLS IO CHILDREN WTH CEREBRAL PALSY AND sI]\,4ILAR A/OVEMENT DISORDERS

t2.l9bl. \ou havc rucceeded when sLpervised standinB B

is no lorSeran c\ercisebut a lrseFul task lhat helpsyou H
with your child's daily care.

Insu,nmo,y: St(lndin8, holdingo,l lvith botlr hands, I

benejtts bones, joints, and musclcs; it enobles cltiklterr
to be more indepenclen! and it boosti theirsef estcem.
)
Children ,,\,ith more sc!rre types of ccrcbral pals-l u,ill
Ler-1' ,- || 'i " " li n., | 'lt lJ, ' '..'l 'lru\
their balancc, IirsL in sirtirg and hneeling, and then also
in standii8. Ior thcse children, srirndinS u,hile holding or
\\,ith boLh arms hridges the gap b$\!e en Lhe ti1re thtl' ate
ready for slanding and u41en d1e) hiile the balancc to do
so u,ithout holdillg on.

Helpful Bars
Frequently children with cerebral palsy show limited improvement with theh standing
balance. They leam to stand well with one hand support but have difficulty stand-
ing with no support. If they have good arm and hand strength they like to hold onto
sturdybars.It makes them feel secure and allows them to do thinSs they otherwise
would not be able to. For you[g childteq barc a11ow for efficient training of stand
ing and stepping skills. For older children, bars may make it possible for them to be
independent with personal hygiene.

A Banister along the Wall

Banisters are longer and sturdier than bars. Their brackets space them away
irom the wall. For young children, they make a good station for practice of pulling to
stand, standi[g balance, and stepping (photo 12.20).
For older children, a banister in the hallway provides security as they put oll a
coat, grab their bookbag, and head out ofthe door with their walking aid.

lq J Grab Bars in the

Bathroom
g craLr bars in th.l
barhrlx)nl provide per
:l'-
( sonal frccclom and pri
\,ac,v to older childr-.n-
Tn photos 12.21a a n.l
12.2 [b a teenater shows
I off his balhroom. "k is
I so convcrlicnt. wher

\ q
L
...",1..'
.1...:.'.-'..! !.'..,
.,..t:.'l..**d-r.
everlamlbartabar
t0 hold onto. I leavc !
for'r:a rnr cr rLtches by
rhc do(n-[,]ren I slep in
12.20
 LEC TXER'I5Es AND 5IANDIN6 W]IH AR[4 sUPPORT I43

here," hetells us. "IfI drop something,I hold onand pickitup.Ir,s easy, much easler
than when I llave only a crutch to hold onto.,,

Frequently Asked Ouestions

a. "In back-lying, our son Juliankicks his legs really well. We tellhim: .,Kick, kict\
kick,
and he kicks up a storm. Shouldn t this help him to walk?,
A. Yes and no. Yes, because moving his legs on his own is good and will help Julian.
No, because rhe kicking paftern is differcnr ftom awalkingpattern.
The patterns may
look alike but they are different. Kicking is an alternating up and down movement
pattern. Walking is about stepping out and moving forward. In order for Julian
ro
wa1k, he has to learn to move his legs in othet ways too.

A. "My daughter Madison stands yery well when l hold her around her knees
and pulL
them backwards, so her legs are straight- Madison's body leans a little
forward, but she
keeps her hips and. back lery straigl:rt_ Why don't you rccammend this
exercise to par-
ents?"
A. I do not recommend this tJ,?e ofstanding because it encourages the child to use only
the muscies at the back of her body to stand up. WhenMadisonitands as you
describe,
she uses the muscles at the back of her thighs, the muscles ar the back
of the hip, the
back muscles, and the shoulder extensor muscles. For good standing and balanci.rg
in staflding, Madison has to use the muscles at the front ofher body and at
the sides
of her hips as well. Holding herself upjust with her back muscles esrablishes
a habir
that will hinder her when she wants to move, bend down, reach, or take a step.

A. "My son\ therapist is able to help Tom pullhimself up to stand reqlly weLl. But
at
home he connot do it. I help him so muchbut he still does iot pull to standihe
right way.
What should I do?"
A, Don't feel inadequate about rhis. Be patienr. your rherapist has been helping chil-
dren fot years-it's no wonder it is easier for her. Have your spouse, n reluti.ri
o. u
friend assist you. Ask your helper to accompany you to Tom,s therapy session. This
way they can observe the therapist and both of you can pr actice with the therapist,s
help.

O. "lirll rr.orrm.rrd t}.Il .hil.rrrr J.) nol L1,ia,.bruccs durin,q llrror plo,r: L |1awtlu.ee
sltrd.rl, i,i ,. Jr,-.s.hr),i .ldJ! n/1. r1,,r.r, 11FOs. 1 likr: rojbllru, you,.d'i.c hrrt find it rs

A.\t .,., 1, , i , j,..o .. r,,.,j J'. j I o..tF.,

no .qood so r]tiar . You nrr\ delcgate Lh. task to l,our.aide or \ollLurrar. lilou
do thrs
t-ot have to mahc sur e. ho ,er t:r. Lhat yoL r. hr lper L no$, h,,rv r rhe IrrJLr\ on.
J,r]t
Vru rna1, irsh rhc pht sicr thel irpist to .each her h.^,r ro do rhis col r ccth,.
l}aata

t3 a
a
a
a
a
a Balance
a aaaaaaaao

lVrhatis so special abour our abiliry ro balance? We are inbalallce when we sir or
llV stand and orr center ofgravityis over oul base ofsupport. A plastic do1l, ifplaced
just righ! may be balanced so that it can stand. yet, there is a difference between the
doll and us. We can actively shift our weight and move ollr center of gravity, while an
inanimate object cannot.
Lett see what this means. A strongbreeze swishes by-the doll falls down-but
we don't. We are constantly adjusting our posture and keeping our balance when
conditions in the environment change. No healthyperson is blown over by wind.
Now, bend the dollat the waist and see what happells-it falls over. We do the
same and we don't lose our balance. Wlry? Before we bend forward our muscles are
busily working. They shift our body backward, counterbalancing our forward move
ment. We do this without conscious effort. Our brain (oul centrai neNous system)
directs the muscles to work preceding all voluntary movements.
Regardless ofhow our balance is challenged-by the environment or by our own
movemeDts-our muscles are ready and working to l(eep us updght. They do so with as
little effort as possible and without voluntary command. A special organ in our middle
ear, smal1 receptors in our joints and skiq ald our vision perceive information about
our bodyt position, and send itto the brain, where it is ptocessed and then sentto the
muscles for action. This all happens very fas! wirhin a splir second. How sreadily we bal_
ance depends on how smoothly this processworks, and how well each paat functions.
Ifthe sensory inpnt or information we get is poor, we don,t balance as well as
we otherwise could. Trystandingon one 1eg, first with your eyes open and thenwith
your eyes closed, counting how many seconds you are able to balance. I am sure you
146 IEACHING I\4OTOR s(]LLS TO CHILDREN WTH CEREBRAL PALSY AND 5I]\4ILAR fu']OVE]\4ENT DISORDERS

do be(er with)rcur e_vesopen. This demonstrates hour inportant vision is for balancc
and explains wh_v a person \'vilh Sood visioD has better balance than a blind person
or someone u:ith poor\rision. r\lso,lihenu,e look at quiel surroundings, it is easier to
billancr th:rn vr,hen lye look at moving objects or people.
lf a pr:rson has poor'musclc coor.llnatlon and muscle u,eakness. he $'ill not
balance as n ell as a strong person rrirl good (oordination. This cxplains lvhv a frail
elderl,vperson is rrrore 1ike1-u* to lose his balance and fall thaD a health] athlete is.

Balance in Children with Cerebral Palsy

Children u,ith ceiebral pillsy have poor balance. How much thelr balance is affected
varies from child to chil.l. There are several possible reasons for balancc problems:
1- The deficjcncy may be calsed by the fact that children with ce
rebml palsy are unable to produce the file-tuned nuscle work
needed for balancing.
2. Difficulties naybe due to interfering abnormal reflexes.
3. The brain maynot properlJrprocess information about the body's
position in space and,/or send outthe information needed by the
muscles to react to this information.
Problcms may also be due to a combination ofall these factors.
Soure childrenwith cerebralpalsyseemunable to perceive rvhen they are in dan
ger offalling. Others appear to be acutely aware of their body's position, understand
Lhat their muscles are not doing theirjob, and gr-ow anxioLls and frightened drring
an activity that requires balance skills. These children may overreact to a perceived
balance loss and thereby tirrther endalger rhernselves.
Balance ski11s emerge like $oss motor skills in head to toe fashjon. As children
develop, theyfirst become able to balancc their head and ffur1k fot sitting; the head,
trrnk, and thighs folknccling; iurd fura11ythe whole bodyfor standhg. Childrenwith
cerebral palsy develop balance skills in the same order.
How lfell childrel balance depends on their experience and ho."v lve1l their nervous
systern and muscles function. Apefionudth extensive training ofstancling on one foot,
like aballerina or a gymnast, has better balance than a person wjthout this traiDing.
This makes sense, alLhough scientists have previo!siy disputcd this. Todayitis proven
that experience makes a dilference and is er'en required for the der,elopment ofbalance
skills. This is true for typicalll, der'eloping children and for childrenwith cerebral palsy.
Recentresearch showcd improved standingbalance il1 childr en r,vith cerebral palsyfol-
lolvilu standing balance training sessions (Shum\,ra_v Cook,2003 and 2005).
(nowing hor,v diffic uh it is foi children with cerebral palsy to develop balance ski1ls,
r,,e want to provide them with the best opportunities for practice and lots oftraining.

Balance Training
I)uring balance trairlinS )'our child r\,orks rostl! on liis olrD. \\.ithout vour physlcal
support. It is LresL nol to LoLrch hinr unL:ss thc cxcrcise directions call lar it. Your iob
is to guard vour chrld Irom thc sidc and pror idc safe sLuroundings. Il vour chjkl loses
 BALANCE I47

his balancc. t ou trant to be close cDough Lo pr cr\€rlt a f:]ll ilrd assLlre that he Llocs Dor
get hLLrL. Do nof slnnd behitldyollt. chikj during balance work. Tr l,!.ill :li\,e hirr a
t', p.-' Jt r,. .\ i, rrr ll..nc."r. lr.l.t ot .n..ngr,r
the samc acrivil\, hr himse]f ar a larer ri]ne. If a situation requires
".n",-i..
1-oll to be behlnd
volrr chjld, nlake sure thaL ttc attends ro something in tront of him.
Safetvis mostirnportant. yoLl ,antro makc sure thntyourchild does notfall and
8et hurt. lvhen vour chll.l tries something ncw and difficuLt. sta) vcry close to hirD.
Be r'cadv to qujcldr- and calmlv sLlpporr him r,vhen necessilry.
lle a ltood obser!cr. yout child's postur e and hls no\.emenrs wili tell vou when
hc is insecure and ma), need i mediateh(lpo[rrhr]1heissah I he mnr (, \ ou lvork
n ith l our child, thc bcfter vou rlill becomc in dcr. i rin8 rhe\c nHns ynu rr ill b. r ble
tojudge his proBress and knr;u, rhen hc gune.l rh,, h.rlilnce \u vou cln sr.p astde and
have him sateh rr] an activiry on hls o\",u.
Bc patient. Balance a(:ti\.ilies are more .lifficull than the). appear Lo br:. Doint
n1i:ln! repeLiLions ofbasic tasks rlill build confidence. Ifvou noricc that an cxcrrcise is
diffir:u1t and fnrsrraLjng folr-our chiid, rrlal{c it simpler or do otuseiLuntjlyouhavr
had a chancc to talk ro lour child's therapist about it.
Lle awarc that ir js arasiet to balance in a quiet environrnent ll,here nr)thing rnovcs
and no noise disLracts. Calm. relaxed concentration helps your chilcl to acconplish a
new balalce Lasli. After hr has Bain.d col]idence. have hinl do the a(tivitvur-hcn other
people are pi.scrt. As hc lcams rO cope rv th Ll isrrcrrr, rns he ltr.m. up hrs ncn ski11.

Balance Training in Sitting

'Ihe chapterSittin.q Pr€tty shoh'ed vou howro helpvorLr
child sit indeDeDdenth. With
Lhe biggest hrrdle accomplisherl-your chr ld LraLl sjt on hjs orvn-)ou nr.ry luok for
wavs to fulther impro!c his sitting posturc alld balance. yoLl \,vaDt l-our child to be
able to sit and lean far dorvn, rcach up with borh ha ncls, relch far foiwlr,l, tar to the
side, and trun his tntDk wlthout falling. :llaininghis sitting postrLre ancl balance r,r.i11
.t oN i.r,.o.^rru."lo ri'l ."1 tl,Jr re-norrs.hool.
Use t11e exerljses as dirccted your p11sica1 therapist. The first turo rvill ,take up', the
b_v

lrun k rnuscles and geL rhem ready for more urork. Boys especially iikc rhese exercises.

e Stay Up
l. YoLlr chlld
touchirg.
sirs \,! ith his leer tlat on rhc floor and his knees not

2 Tell hi]ll Lo iold his arrns, sit straight, and bc strong.

s 3. Sir\'to hinr ' l am a mcan guy $/ho t/ants ro push vou dorl.n-
.lot1't leL mc. ' civc \,erl' nlild pushes fl,irh 1-our opr:n hancl ro
rour child\ Lrllnk ro Lhe sirles, lorward, b!.:l\\,.ards. end
dia8on:rll\ (phoro I3 t)_ Srarrwirh slow.liShr ptshes. incr,i:ase
r the pr'csslLre. irnd then gi\.e qllick taps. Adjust the prrssrtre Lo
l,o r child s irbilitv ro \vthstand it. you \!ant to chall.nge l.o!r
child r,irlx)ut causing a loss of balancc.
z1.Ilo threat sets ol tcn pushes.

13.1
I48 IEACH]NG I\IOTOR sKJLLS IO CHILDREN WTH CEREERAL PALSY AND SI]\,IILAR A,4OVE]\4ENT DISORDERS

13.2 13_3

I Lift weights
1.Your child sits with his feet flat on the floor al1d his knees not touching.
2. Put a half pound weight in each ofhis hands. Ifyou do not have little ba.bells,
you may make a hand weight. Take an old sock, put some beans or rice in it,
and close it by making a knot at the open end.
3. With youl guidance, have him train lil<e the "big guys." Count with him as he
does 5 arm (biceps) curls,lifts his alms 5 times out to the sides and 5 times up
(photo 13.2). Does he want to do more? Let him exercise as much as he lihes.

Let's Make a Snake

Does your child sit u,iLhout pr.ltting Ncight on his leet do hjs fi:r:t seem to lloat
over the lloor? I hc following activities make hj bear \!-ei8hl on his fcct a s he stretches
and reaches far dor"rn. 1ty to find ad.litional activities that plovide tlle same practlcc.
1. Y.[li child sits \\rith his fcet flat on lhe floor and ](nees nol Louchtlg.
2.Placcp.rpbeadsonthefloorandhar''evourchildreachforthenroneb-voneashe
brilds a long sn:1ke lphoto 13.3). If rccded, help hirn push thc bcads togeLher.

Letl Dress Up Teddy

1.Your child sits with feet flat on the floor and his knees not touchinS
2. Place your child's favorite toy or stuffed animal by his feet.
3. Encourageyour child to lean down and dress it
up with necklaces, a hat, etc. (photo 13.4).

Press the Squeaker

1 Your child sits \\,irh lcr]t tlar o Lhe iloor and his
linees not toLLChirg.
2 Plncc ii soil. squeaking dr;.t .o\ tn,:lel vour
chil.ls fooL.
3 Encoui-:rge him to press dorvn and mrhc lt
squeak (fhon) l3.5l.Ilhe cannot do it. tell htr
Lo iean for\\,ar(l and prcss rL\r,n on his knee
rr nhsl-r J r I I r'' oi P
he likes. Bi\.ing each firot a tr.rrn.
t3.s
 BAIANCE f49

s!D" Playing with a Ball

Ball playing challenges your child's balance and is urore
difficult than you may think. Make it easy and frn. The more
yourcl^ild li"e' it, rhp nore l'e willexercise.
1. YouI child sits with his feet flat on the floor and his
i(nees apart.
2. Choose a lightweigh! mediumsize bal1. cently roll the
ball to your child and let him roll ir or pick it up and
throw it back to you.
3. Next, throw the ball to him (phoro 13.6): ,Are you
ready? Catch!" Srarr out by dropping tlle ball into his
hands. "Good catch."

Beanbag Toss
For this game yor need beanbags and a wide bucket,
storaSe biD, dishpan, or similar container.
l.Yolll child sits with his feet flar on the floor and his
knees flot to[ching.
2.Place the buclrctjustin fronr ofhis feer.
3. Start by holding a beanbag within easy reacll (phoro
13.7). "Here, drop it in the bucker.,,
4.Next, hold it a little further away. Brt don,t spoil
the game byholding the bearbaS too far away and
frustrating him. Instead chailenge him, keep hold-
ing the bag as he grasps it, and let him pul1it out of
yourhand. Haye your child reach with eitherhand.
Make reaching high, to the side, and turning part
of the game.

Throwingbeanbags is fun for children ofany age, especiallyifthe target is well

placed-neither too far nor too close. Emphasize rhe rhrow' Keep score to keep the
game going. This will make your child eager to play often.
Ifyour child only wants to use one hand, it may work ifyou 1et him hold some-
thing with this preferred hand. cet his fayorite action figure: ,,Hold Jeff. He waflts
to watch you throw." Be ready to make adjEtments for the not preferred hand_ The
target, aswell as the beanbags you hold or1t foa him, will need to be closer

Reaching with Both Hands

Challergc lour chjiLl .o reach Ip wirh boLh halds. Thjs requires more u.ejgh.
4 shjlt and is hirrdel thrn \ou n1a\ rhirk. tl\. rr, illrir rt\ ,-,nLr.rs ,lrr ,rrLi br , ,ur
i r,., ..,. , r.'or .,,
I
1. .hild sits uirh llis Ie..l et on rhc floor and his knees nor rouchtrg.
\'oLrl
2. Som(hin8 largc and lighr lilie a ho{)p or a beach ball providr:s a good inccntive
for voLLt chiklto rerch \\ lrh borh hands. plecc it on the floor for hi .npickup.
har-e hinr sn eLch lir ir as \'(ru Ilold jL up (phoro 13.8), or.jusr 1et hiIll pla1, r,r.i.h
it. Usjn.g lxrrh haI].ls ,,!,i11 ch:rllcnge his balance.
138
I5O TEACHING ]\,4OTOR SKLTS TO CHJLDREN W]IH CEREBRAL PALSY AND SIMILAR ]\4OVEA4ENI DISORDERS

Balance Training in l(neeling

Soon after or at the same time as children with cerebral palsy start to sit indepen-
dently, they mayalso learn to kneel. The children first kneel with their hips bent.In
this position, their hips rest over their ]egs-they short kneel or heel sit. The baiance
requirements for short kneeling are very similar to those needed when sitting on a
bench; the trunk muscles do most of the work.
From short kneel the children learn to pu1l up to tall kneel. Now the hips arc
straight and only the knees and lower legs rest on the floor- Balancing in tall kneel
requires the coordinated effort of the trrnk, hip, and thigh muscles. This is something
they have not done so far. They need much practice as they slowly acquire the ski1l
with arm support; some children progress to tall loeeling without arm support.
Tall kneeling is a seful skill for childrer with cerebral palsy. It allows them to
reach further and higher As they move up al1d dowl, into and out of tall kneeling,
theirhip and thigh muscles become stronger and more coordinated. All gains made
intall kneel will be useful when your childpractices standi4g afld wal]dng.
The subsequent activities will help your child to improve his balance in kneeling
with the hips stmight. The first two will encourageyour child to fise to tallkneel. Use
them as directed by your childt therapist and fo11ow any specific
instructions given.

Play at the Toy Box

l. Cet a stLLrd,l, to_\,box. A oldfashione.l\'voodcuboxisgood,
*r.-: i, but a plasLic crale will.lo ifyou placc som(hing heavylike a
telephone book on the bottom so it rvill tlot easily rip over.
2. PLLt sone lnteresting things iD the box and erlcourage _vour
:
child to criwlovcrrc it. pull up, and p1a1-. Be athis side to.lakc
surc hc clocs notlose his balalce to the side orback\,vards.
3. As ],ou become assured thalt'our child is silfc, have him p1a1
13.9 indeperdently at the box (photo I3.9).

Play at a Drawer
l. Sclccr a drarrer in Lhe kitchcn or bcdt ootr thal he can easily reacb
llp ro.
2. PLrce things 1,our chil.l likcs to plav $,ith in d1e drahrer. Srnnd a tall
1 i
bo\ or book on rn.l in the drar,l er. and rape it ro rhc sidc corner olthe
i drar.-er ro krcp it ol]c!].
3. EilcorLrag. \ (nrr child ro pul1up on the dr:rw.r irnd lookinside it (photo
I3.10). Bc !\'ith vour child iniriall! to lnakc sure he is sale. Whcn he
is r cad_r ro plav bv himscll gi!e him plerlry ol .rpportunjri.rs.
i
Yolrr child ma\ choosc to p[a_v in heel sitt]ng anLI not trl to pu11 to tall
lineel. Shoulll l hclp my chikipull ro talikneel? '\, (N lnavl\onder. In thls siru-
aliorl rL is best not to rvorr'1'. Let1''oLlr child pla\ hot\, er.er he likes. Chjldren are
cLlrioris. Ir is orr [v a ]naLLet of timc lrt:tor r: voul child r,ill srrugglc up to lookat
r\,lrais hidden at the boLront ofrhc lrr or rlrar,-er. Such a]r i.irirti1,e, preciolts
13,10
anrl fr.mo|ab1e, js r'rhiLt r ou rnLl lour chi1,:1 hrre Lecn prcparin8 ibr.
 BALANCE 15f

r t-
i il-.d il
s#d!qsl/'

c:
i;/
-,d td
13.11 t3_12 13.13

Play in Tall Kneel

As soon as your child is able to rall kneel, ptovide ample opportunity for
him to practice. As he gains experience in the new position, his balance will
improve. You will notice that it becomes easier and more enjoyable for him to
play in the position.
. A couch or a coffee table may provide a good place for your child
to play while rall kneeling.
. As youl child improves, a large upside down cardboard box will
make a good play table (photo 13.11).

Knee Walking Pushing a Toy Cart

When your child can crawl and play in tall kneeling, he is ready fot this activity
(photo 13.12).
Help your child to hold onto the carr (or othet suitable walking toy) and stabilize
it forhim. This way he car get srarred slowly.
when your child knee walks pushing a ca , his hips ate bent and the leg move-
ments are similar to crawling, except the trurk is highet and only the legs propel him
forward. Most likely your child will enjoy cruising around rhis way.

Knee Walking with Sticks

\,\hen!ourcrjldu'lrlksrnrallkneel,histrunliandhiprn!sclesmoveinmuchthe
same 1\,a| thc\.do uhe. srcpprns an,:i r,-.lking jn sran.ling. lhe nert ndjvir\, enc.rlrr
aSes \"-alkjng on knees r,irh hips s$.ighr. trse iL as .lir.rcted b).
),our r:hild s rherapr:r
and ftrllor', anv specittc irsrntclions givel1.
1. Get rro sticks a broonrstick cLrL in half tr.ill do.
2. 1la1e \'our c hild Lirll knce1. SLan.l l).hinc1 him holdtug the sticl s irr shorLl,]tr
ievel .rr rirher sjlle so he can tresp (nrc $,idr each hand.
3. Nor'\, r\irh both oi'\1)Lr holdirg ollro d1e sLicks, gotbral\:alli rotLrchilJ on
his l<nees in fr(n1t and vou r'ighr behiJrd srabilizillg the sri(lis alld helpin,{ r\ rrh
rvei8hl sh iltirg betbre eirr'h srep (photo I3.13). I11otr r|llild hangs brr lir.,.rrrls
trv the se.lc ircti\.i['t-ith vou i]] child.
dtill',, lrd
,,
5 ngp111,,rn;,",
I52 TEACHING 5KILLs To CH]LDREN WIH CEREBRAL PALSY AND 5]A4ILAR A4oVE]\4ENI DI5ORDERS
^,loTo8

Tall Kneeling without Arm Support

v
nu\
,.*[J F*-:r
Tall kneeling rvirhoLu arm support is very chirllcrgin8 ibr chlldren
rirh ccrebral palsy. Ifvour chikl s therapist recoDlnencLs thal
].ou practice
indcpe1rdent raLl loteeling rvith )-oLlr child lou nlny try this a$i\/it\,,_
l. "r ,l il. I -,. L n Ion. ..rou.
2. Str'erch l'oul- erms out rnd hold two s
all balls out of his rcach.
t" Encolrrasae him: "Come up and get thr bouDcyballs,, (photo 13.14).
Wait forhjnl as he struggles to co.1a up. Louier.rhe balls jfDeeded.
You u,ant to reu,ard his effor ts evcll if he docs ltot slLccecd.
3. After lorrr child has tossed the balls, have him try to comc up again.
4.Repeat as oflen asrourchild rc[ai]ls int(:rested.

Some children arc notinleiesrcd in balls. '-Reese iikes ro eat cr:1ckers.,,

his nother rcporls- "S(nreti[les lvhcn he lr,ants one of his fa\orire (rteese
13.11 crackers I t.rll him r{) come up for it and hc does beaLlrjftllly each time.,,

Standing Balance
In staDding, your child has ro control andbalance his whole body-norjusr the head
and trunk as in sitting, and the hipjoint as itr kneeling-but also the knee and ankle
joints. Whe[ we stand, only the soles ofour feet rest on the f1oor. This is our base of
support. How large our srlppofi base is depends on the size ofour feet, their position,
and the distance betweenthem. When children first try to baiance in standing, they
place thet feet far apart, enlarging their base as much as possible. Still, theystart our
wobb l :nc t requenrly tall a' rL"y lear- Low Lo coo|dira c a I pr rs or r\ei- bodr
Forchildrenwlth cerebral palsy, standrng brings Lrnjque challenges. They have to
keep the hip and kneejoints straighr, rhe anklejoints in a neutralposirion (neitherbent
nor straightened), and naintain balance.Ifyou havepracticed the actiyity,,standiflg
HoldiDg On with Both Hands" with your chi1d, you know he can sLand straight and
you maybelieve that standiDg with one orno hand supportwillbe easy foryo rchild
to achieve. Unfortunateiy, this is not true. Standirg straight is good tor your child,s
joints and muscles but is not a good position to leam to balance in standing. As soon
as the child lets go ofthe arm support, he is bound to fall backwards and get hurt.
Ten-month old infants who stand at a table lean thet trunlc forward to prevent a
backwards fa11. Childrenwith cerebral palsytryto do the same. yet as thevbend their
hips to lean forward, theia loees and ankles also wanr to bend. whrch wo[ld make
rkern oucUe urdernearh Lhen .lo sLa\ uo. rne.hildrer..i l,n thctr legs. \,Il ch ll g
gers the reflex partern ofscissoring. When scissorinS, the hips bend slight1y, the legs
tum inward, push togethet and the knees and the alkles stretch out. Childrenwith
cerebral palsywho show this pattern in back $ing are prone to rely on it in upright.
Unfortunately, other children with cerebral palsy may also exhibit the paftetn or a
milder version ofit (with less turning in of rhe legs) when standing.
Whenchildrenusethescisso ng patter n, they stand on their toes with their feet very
close together and turned inwa rds. They are able to stand this waywith suppot t. Standr
18 r

without suppot is anothet matter. Standing on their toes with their feet close together,
their base of support is extremely small, maldng it impossible for them to balance.
 EALANCE I53

Tr,vit_r'ourselfalld srar]cl on your t{res v\,ith knees Loucling. You caD do it \,\rhcn yor.r
have sornedlinS to hold onto; but rvithout suppoit \.otL become r'erl'unstead,v and fccl
as il)-orL couldloseyour balaf(c rr! onlent. Trv Lo walk this u,al'up ollyourtocs a1ld
r{ith k ees touchin8- It feels a\,r,kward but you can do it. Some children \vilh cerebral
palsysrar't.r t\,"alking Lhis u,a),. IL l\,orks for dre1n as longasthcyarc s
all-Inthelong
run, howc\,cr', rhis trpe ol r,ralkir8 prodLlces se\.ere and lasringjointpr oblcms that nray
lead ro ar inabiliry ro walk by thc time the child becomes a teenager or adult.
Stondingond rralkin&with a scissoringpottern is,1ot o shorr c&t that a child
h)ith cerebral palsy nr ay use t?mporo,'ily, but 4 alend el,(l stl eet. It .loes not lead to
irnprovemenL and progress. lnsre ad. it l ndersthe childfronr k:arningto stand \'\jthour
armsupport:rnd\.,ialku,ilhabeLrerBail(8,aitisatermfrequertl_vusedhlthcrapists
and rncans \'!alking pattel n).
Afrcr y( )rrr rhlld i s able to pr ll to kneel, ]-ou lvant hin] to learl1 to pull to staDd, staDd at

thc tablc with{ )ut c.r lapsing or'sci sso ng, be able rc plavindepeildenrl_\r and lo erhimself
to the floor r"-hen he \\,a11ts to. Ib acco plishthis, )our child nccds speciel n-aining.
Ilou, 1on8 it \\ ill take and iror",, diificult rhe lvork rvill hr:. r,ar ics from child to
child. It will take tirne and patience. lhe more _vou Lvork with lotr riild nhcn hc is
initiall,v learnins to slaild, the beLler he u,i11 learl1 hou, to stand not compared to
anothcr child or to ]1)Lrr eliarr, but ro hrs polential.
You rvill ha !c hr:lp Nith .hjs tasl.. YoLLr chll.l's physlcal Lherapisr will lfork with
_vour chlld ancl rvill guid.r the hom.r prograin. For tLrnatcl],, today \ o r chlld's doctor-
can also help _r'ou. He mav prescribe braces that \lill support )1r!r chilcl's anklc ioints
and set then in a neLLtral position- II _vour child's 1eg rnuscles arc r,cry hrDertonie.
the ph,vsician rna,v prescriLre nledicatioll or 8i1,e iniections directl),into thc musclcs
to rcducc lour chil.l s nlus.lc tone. All this helps. e\.en thouBh there can be neSati\e
side effects to considcr. Thr: Dcrlicrl tr'catm(]llt. lts bcnefits, and jts side ellects are
described in [rore deraiLin Chapter ]7.
Whatel.er trearment_vou and \our doctor decjde upon, physical therapy and ahor1te
progr-anl \,\, ill be the mosL lmporlanl parl ofit- Ankle braces call he]p kccp yor'rr child's
fcct flat on rhc floor instea.l ofup on his toes. But u:earing braces u,i1l nor auromaticallv
llrakc vourchiLl aLlt:to stan.lor \frll. Phlsica l therapy and 1.o Ltr horne pro8 ram rrill tr]1n
yor.u chikl's coordjratior, ncight shift, and bnlnnce. h \iill strengthen his nLLscles and
keep hisjoints f1exib1e. lhereisnobrace.orLrill,ori[jectionthatnill.loan]'ofthis.

Standing with Arm Support and Moving ln and

Out of Standing
Ifyour childhas high muscle tone and tends to stand on his toes, your therapist may
recommend that you do the following exercises ftom Chapter 5 before practicing
standing with him. They will loosen and stretch his ankle and foot muscles:
. A/rkleRolls and
. ColfMuscle Stretch in Deep Squatting
Do them as described in Chapter S.

The slrnd ing acLivir res belo\,, r.airr \ olrr chrld ro pllll tu stand. ple) 1,"h ile stending,
ancl krwrr himsclf Lkrwn rr rhc fkror. T hc ht:st lrar to gr:t irro standing is by pullirg to
r
f54 IEACHING 5KILL5 TO CHILDREN !(/tTH CEREBRAL pAlsy AND S]A/|LAR MOVEA.4ENT D]SORDER5
^4OIOR

ta11kneel, raisingoneknee forward andplaciDgrhe footonthe floor (half-kneeling),

and then pushing to stand. The same sequence in reverse orderwill help your child
to lower himself from standing to the floorwith control.
Pulling to stand via halfkneel is difficult for mosr children with cerebral palsy.
Tightness and weakless of the muscles that bend the hip may interfere with the
lorward movement of one knee while weight beadng on the othet knee with the hip
straight. Initially mosr children need much assistance with the task. As tlley gain
strength and coordination, they gradually require less help. The training is very
valuabie for childrenwith cerebral palsy. It teaches them to use one leg at a time and
strengthens and stretches their hip and leg muscles. The goal is for the children to
become independentwith rhe taskand integr are it into their daily life.
The next activities show how to assist yoru child to kneel on one 1eg and push
to stand with the other le8, to place him in a good position for play in stafldin8, and
to get down from standing. Use them as directed by your child,s therapist and follow
a ny speciqc irsrructions he may gir e y or-.

Ifyour child has ankle braces, have him wear them during the practice.

Half Kneel to Stand

* 1. Place somethingfun and easy to play with or rhe table.
2-Kneel behind your child and encourage him to reach up to the
edge ofthe table.

lilt i v
3.Afterhehas pulled to tall kneel, stabilize his dght hip with your
right hand ftom the side. Place your left hand at rhe side ofhis
left thigh.
4. Help him shift his weighr overhis right knee, bringhis iefr knee
forward, and place his left foot on the floor.
t 5. Now place your left hand ovet his left l(nee and assist him ro push
into standing photo (13.15). Make sute his trunk leans for-ward
-:-a)
as he stands up.

13.15
6. Have him practice standing up wirh the dght leg rhe same way.
Variation. Formore support, kneelvery close to your child. place your right
hand in fuont ofhis right hip and stabilize jt with your body fuom behind. Then
proceed as befo.e.

I Standing with Ptay

l. As abol'e. plirce somethjn.q fun and rasy ro plav \!, jrh on a Lablc.
2. Kneel Lrthind rour .hild and assisr hiln to stand qr ,, ia hali kncel.
:1. Help hjm to srand wirh feetllat on rhe floor and shoulder r,ridth aparr.

11is I nrcs anll lifi should point forr,",.ard or slighth-.rut\!ard.

,,1.]\s hc srands r,rcl . o1ol:e Lo llis side anll rrcourage hi
to plav quietlv
irr thc table. \,Vhcnevet lbrr child Lur.ns his legs inwrrrcl aild r.is.s L1p
ontr) his toes, .(n recL hls pl)siriorl. Step l)cliDd him. place
)-our.hands on
top of his thi.qhs and tUrn his legs slightly oLrr. Ask or he\) hiln ro srirnd
tall an.i place his fi:ur f at on rhc floor. Il r,.) i child is eborrr to losc his
balancc or becomcs rrred. help hirn to conlc (loun r ia halik11ee].
A plal table rrlrlr an cdge. as shown in phoro t3.t6, will allo rhc (hilli
rc h.rld .r for stabilit.r rvhen nee.l(1.
 EALANCE
'55

The more quietly your child plays, the easier it willbe for him to balance and to
keep his feet flat on the floor Ifitis difficult for you to placeyour child's heels on the
floor after they se rp, your child's therapist will gladly show you how to do it.
Note: Remember not to be behind your child, as it tempts him to lean bacli-
wards against you. This oflly encourages him to remain dependent on you, instead
of gaining independence.

Lowering to the Floor Via HaIf Kneel

l. T(ncel behind your c1i1d. Place your Iight hand aBainsl thc siclc of his IiSht
thith and to r le1't haDd ar the side of his k:ft hip.
2. Ask or help hlm to shiit his weiShl over his right foot, bend his lelt linee, and
slide the foot bachr,,erds.
3. Assist his right leg as hc slowlv lowers himself into a hall-Lneel and the[ Lo
knee1lng. liron taLl krd it will be eas-v to mol,e into short l(neelin8. siLlii13.
,n to hands .nd knees.
4. Hav. vour-child practice lou,ering himsclf dor,n wlth his lelt 1e8 rhe salne \\, a).

Crouching Down to Sitting on the Floor

When ten'month-old children stand at furniture, they may lower themselves
bycrouching down and then dropping onto theirbottoms to sit onthe floor. Mastery
of this movement sequence is also beneficial during a sudden backwaads fa1l. If your
therapist believes that your child will benefit from this ski11, you may practice it as
described below. A grab bar suctioned to the edge ofthe table will make the activity
easier and safer for abeginner.
1. Place a couple ofcouchcushions
on the floor behifld yo1ll child as
he stands.
2. When he wants to get down, ask
him to hold onto the bar, lean
ti x forward, bend his knees (photo
13.17a), and sit down (photo
13.17b). Stand athis side and, if
necessary help him to bend his
hips and knees.

W 3.When he is able to do this well,

L have him pmctice sitting down

onjust one cushion.
4 4. Finally, have him crouch low
13,1?b
and sit down on the floor.

Crouching Llo\!n is eesiel 1.rr Lhe l,rung childrc)r thxr g{rir!r.lo\r n 1 ii hallkneel
because the1.r:sr: borh lcgs in Lht same $,4\' It allou,s then ro btu)nrc rndepen.ient
earlier. As dreir legs hccornc sti{)ngtrirnd more coordinated, dre}'thtn mrri li rrn tir
come clou,n over halfkneel.
Simllarll. iL is easier lor nlanv childrer \|rth ccr.bral p:Llsy to stend up Ilom sqrLaI
till g or low sirri.g Lhan lrom hallkneeli[8. lf mol ing irto halfkn.:c] nnd then pLlllirl8 Lo
stand is rhlrllcngirg i)r ]our child. \our Lherapist n1a,,'adl,ise I'ou n) pr ar:rii:r thc othcr
f56 IEACH]NG ]\4OIOR 5(]LL5 TO CHILDREN WTH CEREBRAL PALSY AND sI]\4]LAR A4OVE]\4ENT DISORDER5

\'vals ofpulling to stand too. From squattlng or lo,,v sit, your child pushes into standing
wjth both 1egs. As he does so. helvill Sain strength, coor-dirarjon, aDdbalance control.
A1l of this r'r.ill help him Lo galn the abilitv to stand qr iDdependenrlv in Lhe flrture.

.a'
Y-

.an L

13_18b

Low Sit To Stand

1. Sit on thefloor cross-legged in fuorrt ofa table with a dm or another
piece ofsolid indooror outdoorfumiture with a rim or edge for your
child to hold onto.
2. Have youl child sit on your leg. See to it that his feet are in a good
position-flat on the floor with toes pointing forward or slightly
outward (photo 13.18a).
3. EncouraSe your child to pull to stand (phoro 13.18b1. Ifneeded, assist
at his hips or knees.
4. Wheo he wants to lower himself back dovm, tell him to hold onto the
rim well and slowly lower himself to sitting. Assisr ifneeded.

Standing with One Arm Support

The next three activities challenge your child to further improve his
balance and coordination while standingwith arm support.
1. Your child stands at a table or orher fumiture with his feer flar on the
floor and his legs shoulder width apart.
2. As you play with your child, hold up somethirg of interest to him ard
have him reach for it (photo 13.19). Doing so teaches himtobalance
in standing using only one hand for support.

Standing and Turning

1. \bur chil.l stafds ar a Lable $'irh his fcc. ilat ot1 Lhe lloor ard loss
sho ldi:r !1idth apart.
2. As \on plavlvith \ oLLr rh ild, hold a tov at his sidr .nd lncourage him
to t!u1 xnd reach foi it. lhe graLr bar srLctir)n(:d ro rhe r:Lble nralrs
the irctil'rr\ r:asir.r for rhe chil,:l in photo I3.20.

13.24
 BALANCE
'57

Bending Down
1. Your child stands at a rable with his feet flat on the floor and
shoulder-width apart.
2. Give him small toys to play with blocks, toy animals, plastic
figures, or a similar toy with small pieces. Place most of the pieces
on abench or stool at his right side and entice him to reach down
and get them. Ifneeded, help him place his right foot out to the
1 side and stabilize it as he bends down reaching for a toy.
3. Move the stool to his left side and have him rcach down to the left.
4. After a week ofpractice, or whenever rcaching down becomes
easier, try placing the toys on something lower.
5.Fi[ally, after more practice sessiols, you may drop a toy to
the floor and see if he can bend all the way down to pick it
13,21 up (photo 13.21).

Frequently Asked Ouestions

a. "My dclughter, Emily, has a Little chair rrith armrests just her size. It is safer th1fl a
bench. Shouldn't we use it instead of a bench?"
A. Sure, use it. Ifyou have a little table for it, you have a perfect set up for independent
table work. But do notuse the chair for sitting balance exercises.Its backrestwilltempt
Emily to slouch back and lift her feet off the floor. The armrests will give her something
to hold onto. She will notbe challenged to sit with arms free and balance.

a- "Chandler sits well on a little stool all by himself. But when l practice reaching with
hi1n, he becomes very insecure, hunches ltis ihoulders, and rounds his back. Why does
he do this end what should I do about it?"
A, It seems that the reaching exercise is too difficult for Chandler. Most likely he
hunches his shoulders and rouods hisbackto protecthimselffuom fallingbackwards.
Talk to your therapist about this. Together you may be able to change the exercise so
it is just right for Chandler. You want him to have a good posture when he reaches.

A, "My son- Coleb, will come up to tdll kneel but does not stay there. Why? "
A, What you descdbe is very common. Caleb shows good strength by being able
to come to tall lGeel even briefly. What he is missing is eodurance and balance.
This will develop through practice and experience. Progress maybe slow but you
will notice it.

O. (o|kr fios b|Ilcrs. l.,r1l!r,./ixh.rrih.tr.!.salcn.si(srtrnd.rr.,nhtrto,]i.Sllorrldlairr(

rhrnr o/i hcLrrrrsr rht1. s..rrr rtot l. b.: hrlplns:'"
A. Ueforc ]or.r do an!rhing, ha!e tlre ph1'sician or therapist Who or.lcreLl the brices i1I1Ll
rhe person who nraclc rhcm lool( lt rhrnr. \'IosL 1ike1v lhe braces nccd n) b. aLltrsted
or changed. 11 Ll1e braces are properrLl fitrcd an.l T{nrla still Lries to stald on hcr toc:
shc ml) be one ol a leu, persistelll children rlho Llo nor \,vant to change their rlat's
F.\,(!r so. T rcconrmen.l Lhat volr donl 8i1.e up. Work closcL! \"_irh liarla's doclor and
theraprsr. logcrhcr \orr rrill Finrl a u,:rr, tcr solve the problen.
I58 IEACHING It4OlOR 5(ILL5 TO CHILDREN I{/ITH CEREBRAL PALsY AND SI]\4JLAR ]\4OVE]\4ENJ DJ5ORDERS

A. "One of the students in my earLy interyetltion class constantly tries to puLl to stand.
He endangers himself and fi"equently falls. I/t4 Lat should I do?,'
A. Pulling to stafld imporrant sldll. A child wirh cerebral palsy needs much practice
is an
to master it. You want to guide your studentt initiative, pro\ride safety, and reward his
efforts. Assign your classroom aide or voiunteer to supervise and grard your student
during a portion of the class time and discourage him from pulling to stand other ti1lres.
W.tl' _naay ca fe prac.ice opporrunirics. yor I .ntde l na) soo irprove.
aaaa
l4 C
c
c Standing without
c
,
Arm Support
t and Walking
a caaaaaaaa

\x/l;lyi:xTH'Il"ff i;:,'*l-"Hi:1#',lxf x;J[::ff :il:i:Jff:;

easyto answer them. Instead, let's find outwhatmakes itpossible for children to walk
on their own. Before they walk, childrcn have ro be able to do the following:
. Wctlk t^,ith support along furniture, wirh awalker, orheld by rheir
hands. Children who learn to walk with support have a betrer
chance oflearning to walk independently.
a Balance in stdnding- The straighter children can stand and the
longer they are able tomaintaintheirbalancewhile standirg, the
sooner and better they will be able ro wa1k.
o Balancetery brieJly oter oneleg.Eacl,legltas to be sffong and co
ordinated enough to support the child's body weight, so she is able to
stand and baiance briefly on one leg as the othet leg steps forward.
a Lower themseh)es fromfree star.ding to the fLoor with control.
Children may drop down into sitting or forward onto their extended
arms. \\lhatever they do, if they are able to control thek fal1, they
may not be frightened of huring rhemselves. Knowing this will
give them the confidence to tate off and walk without support.
which ofthese is most important and which should be practicedfirst? Let's look
at how one-year old babies start to walk. They usually walk with support for two to
three months and then within one mooth they start to stand and walk without sup-
port. They seem to learn it all at once-standing witiout support, falling safely, and
balancingbriefly on one foot as they take their first steps.
 160 IEACHING I\4OIOR S(ILLS IO CHILDREN wlTH CEREBRAL PALSY AND SIA4ILAR &,]OVE]\4ENI IJISORDER5

Children with cerebral palsy try to follow the same sequence, yet it will take
them much more time and effort to even partially master each skill. Balance skills
especially require muchtraining. parents need to be patient. After the childrenlearn
to walkwith arm support, some may slowlyprogrcss to walkingwithout anysupport.
Telling them to be brave and just walk does nor help them if rhey do nor have the
necessary balance skills.
To shorten the ttansition ftom walking with support to wali(ing without. the
physical therapist may recommend early training of free sranding. st;ndrng on one
leg, and lowering fuom sraflding. So, insread of leaming one skill afrer the orher. a
chr.d ca n improve si_F ltaneously in u a lk ng wjrh sl ppofl a nd ba la rcinp.

Walking with Arm Support

WALKING SIDEWAYS-CRUISING ALONG FURNITURE
Nlosr children \rill lake thcrir ilrsr stups r,vhile s pporting th.rmselves at a bencll or
tahlc. AILeI P! I1ii18 t.r stirrd and plii\iDg in strndin3. Lhe," ui11 trv r{) srep to thc sicle.
This is n.rt casl.Ior th(rn to do. Thc\.n1av lcan heavil],on rheir rr s,comerpontheir
roes, and accomplish onlv rinv sreps. mat.he crosslng theit legs iD the effi)rr. lo sidt
sLep. thcvhave to shift Lhejr weight o\{rr oDe ieg in order L.r Litl(c a sLep \,!,irh the othcr
leg. The nerit a$ilities tr.ajll this. Do rhem as.]jrccted b\ \()1lr chilll,s rheraDist ir1l .l
r.,1 -, r

f"" Stending and nocking

1.Your child stands at the table supporting herself with her
arms afld not leaningwith her trunk against it. Her feet are
flat on the floor, shoulder-width apat, and her toes point
forward or slighrly outward.
2. place a musical toy on the table and encourage her to rock
from side to side wirh rhe music. Kneelbehind her, hold her
at the side of her hips, and help her move all her weight over
one foot a4d then over to the other (photo 14.1). Say or sing:
"Rock . . . and . . . rock," and give some dor,r,nward pressure as
11.1
you say "Rock." Repeat rhis for as long as your child likes.
3.Next, have her rock side to-side without your help.

Rock and Step

l. 1\frer 1ou hirv.r pracLiccd rocking as descriLcd abovc. no.,.e
the t.r\ {)rr ofreach ro the righrside.
2. lell roor (ltiLd: "L.r's tock a.cl then sLcp to the tov.,'
ti :1. Kneelirg behilr.l her, help hcr rock Lo rhe letr and then stqr
to thc ri8hL si.lc (pholo 1.+.2). C!. hcr bv sir|jng: .,ro.l(...
and step. r.rdi ... and stcp.''
.1. Aftet]'olrr rhildhas rtached thc.o1'and plavedr,\,irh
I rr to Lhe lcfr side a.LI har,.e htr step to thr: Left.
ir, n1o\t

11.2
 STANDING WTHOUT ARA,I SUPPORI AND WALKJNG f6f

Starr out by having youl child do only 2 to 4

sidesteps while you assist hea. Later have her do
more side steps and help her less.
Valiatioo. If your child has difficulty step
ping outto the righr side, do the following:
l.Afteryor have helped her rock ro the lefr
side, support her left hip well with your
Ieft hand.
2. With your right hand, lightly pllsh against
the inner side ofherrighrleg, helpingher
liit the leg out to rhe side as you say.,step,,
(photo 14.3)
3. Practice similarly stepping our to the
left side.
14,3
Walking Folward - One Step at a Time
This activity practices forward stepping with srppofi and guidance. you fleed
something stable for your child to hold onto as she walks. Ifyou child is small you
may use a stable walking toy with old nylon hose wrapped around its axles so ir will
not ro11 away. A taller child may hold onto a rung of a ladder box or a peto walkiDg
ladder or hold onto rhe back of a chair. Helping your child to forward srep with control
is not easy. Make sure to practice rhe technique with rhe help ofthe physicalthempisr
before you try it at home. Also walk with your child only a short disiance this way.
Longer practice may make your back ache and knees hurt. you do not want this ro
happen to you.
1. Your child srands holding onro rhe ladderwithboth hands. Her feer are
apart,
flat on the floor, and toes point forward or slightly outward.
2. Stand closelybehind yout child. Openyourhands wide and Dlace them firmlv
on the sides of her hips.
3. Ask or help your child to shift her weight over her right 1e8 and support
it well
with youl dght halld. Slide your left hand a few inches down so your fingers
rest on her upper thigh. Encourage her to stepforwardwith herleft leg while
you guide her movement from her hip and upper thigh wirh your lefr hand.
After she stepped, help her to push the ladder forward as nuch as needed.
4. Repeat and have your child step with the right leg.
5. Have her practice walking this way for a specific short distance.

Walking with a Watker

If yorrr child is o1'er rr,o \cars o1 agc bv rhr tinle shc pulls to stanll. her rhLrapisrs
Soirlwillbcforhertol,!alkindepcndenLh,\irh.r,\rkplJ\\n.[r\l],,ssiL,li i,tr,.,
vour child will nq:d a alker.Lhnrpro\,idcsher,ithsupport.Thcrcareurn.,dtiiiL
cDt tvpcs oI\valliels alailabk tbr chjldrer Lr rrh cer.,lrral pitl\r \or I rl r:p - ill
inlbrm and ecl,,.jse vou abolLt.hem. Togelhrr r,,ulrll ,lecrde r rich r l.r L,,,,.ide.
. , ','l' I .. I', rl 1,,. t, \ . I .l ,i.r ,j
school, and outdoor s.
 TEACH]NG ]\4OIOR S(]LLS ]O CH]LDREN \I/]TH CEREBRAL PALsY AND S]AIILAR ]\4OVEi\4ENI DiSORDER5
'62

n There are three basic types ofwalkers available for children with cerebral
palsy: forward walkers, reverse walkers, and Saittminers.

FORWARD WALKERS
Forward walker s have vertical or hodzontal handlebars to hold onto (photo 14.4).
The children hold onto them ard push t}le walker in ftont as they walk. Forward
walkers are economically priced and easy to use. The children learn to stand up to
them from chair sitting and to lo\{'er themselves to chair sitting or to the floor when
they no longer want to walk. A forward wall(er is most useful for a child who needs
just balance support (photo 14.4). lfthe chitd needs to lean onto her arms when
she stands and steps, the wall(er has se ous drawbacks. It encourages children to
bend at t}le hip and lean forward with their trunk. This position will reinforce the
6 q abnomal scissoring patrern of a child who tends to walk on forefeet and toes.

REVERSE WALKERS
The reverse walker discoumges toe walking. It has a horizontal U shaped bar that
gives hand support at the sides, as well as back protection (photo 14.51. Instead of
pushing it, a child pulls it aiong as she walks. The design oftlte walker provides safety
against abackwaids fall. It encourages children to stand tall and walkwithout leaning
forward or crouching. The walker is sturdy, not prone to tippin& fairly easy to steer,
and dre basic model folds flaL wi*r some training, a child maylearn to stand up to the
4 walker and lower herselfto the floor thus becoming ftll1y independent with it.
t,i$. I I Children who have good strength and control of the muscles of both arms
tl usually do well with a revene walker. If your child has been pushing to hands and

;
$1 1 knees afld crawlin& this O?e ofwall@r maybe recommended for her The therapist
will ffain your child to walk with the walker, and, as soon as possible, show you
iU , how to use it at home. Soon, standing up to the walker and lowering to the floor
will become part ofyou. child's training. The following activities are examples of
how to do this. Use them as directed by your therapist.

Pulling to Stand at a Reverse walker

1. Elcourage lo!r (hild to cr au.l Lo the walker, rcirch
! LLp, place her hands on the si.lebars, and pull to tall
kneel (photo 14.6a).
{. 4 2. stiiLilizr the \\,a1ker ior
her and encourage her
to stand up via half
kneel or as shown in
photo 14.6b. She will
be facing the bar in the
[} t: back of the walker and
needs to turn around
before walking with the wall(er. (see next
activity.)
14,6b
 sIAND]NC WIII]OU'I AR]V] sUPPORT AND WAL(]NG T 63

Turning Aroqnd in the Walker

1. Stabilize the walker for your child.
2.Askherto stand rall, step into the walker
with her left foor, move her right hand
over ro the back bar or left sidebar (photo
14.7), and bring her right foot forward
and around.
3. Have her take baby steps to adjust her l
feet.
4.Have her adjrst her hands. When she
is ready, have her turfl her ttunk and
reach with her left hand over to the
other sidebar.
5. Some morebabysteps to the left, and she
will stand facing forward, ready to walk
wirh the walker. $
Do rhe activity in rhe opposite direction if
tuming clockwise is easier for her.

Lowering from the Walker to

1
the Floor
l. St:rbilize thc r,a1ke. for)orr child.
1 2. Askher lo srand rrll and pUr all hcr
Y rveight rxr her ar ms.
3. With !ourhelp as needed. have her.
kick one tbot l)ack. b.]ld the o.her
knrc. bend het elbows. 1or,r,cr her
self irto h.lf loreel (phoro t.+.8a),
al1d the. ]oteel on the lloor.
t 4. Nor,' she is readY to hr go crl the
.l \'r.alker (photo l,l.8b), r:arch h|r
sell /ith her arms (nr the tlo.rr.
and crar'vl arvat..

GAIT TRAINERS
Chjldren Nho do nor har'r good rurrol orer Lh(:ir arm rud shofldet mlrs(1e.e \r iU
necd molc supporr rhan rhe re\urse 1\lell(cr pr.ovjdes. If\.our chji(l is unable Lo prsh
to a hand and knce posirioll or ( rara or all Iorrs, \r.alking in . rct.ersc ll,alke. \loLLlLl

The gaitrraineris rire !\alkerofchoicc for chjldren r,r,hose arlns.t Ll estsarc

serioosly alfc(:r.,d b! (.creLrr. i pals! (phoro 1.+.91. Gait trili.crs havc the srDpor L end
saietv fearurcs thesc chiLlrcn nct:d. Ih.\ har.e (hest slpport, r,r.hich l,\,ili hold
tlre
child m an rLprighr posiriorr. Wi.h L]re rhesL supporL sacut.ed, cven e .hi1d 1r ho can
n()t iull_\ ]rcar trrcight o\ cr her l(:gs mir\, sranLl and takc sreps_ A saddL
ot sljrg seaL rs
ilrother tcatlLrc nl.rst laiiit tt.aincrs ha\e. IhL\, se1\.LLorvth(chrkitL,sLrrJJlesrtjt
hcr legs bucklc.
T64 TEACHING A4OIOR 5(ILL5 TO CHILDREN WTH CEREBRAL PALSY AND sI]\4ILAR ]\4OVE]\1ENT D]SORDERs

Gait trainers are more expensive than other

walkers. They roll easily, but may be difficult to
steer for the child who uses it. Transfers in and
ort of a gait trainer maypose a problem. Initially,
a child may need the assistance oi one or two
persons. However, these walkers provide the op
portuDityto stand and take steps forchildrenwho
otherwise would not have it.
I '4
cait traine.s are bulky and difficulr to rrans-
pon. The exception is the Pacer Gait Trainer. Its
ftame folds for transport in the trunk of the car
After the child is able to rake steps fully sup
poated, she is taught to hold onto the bars of rhe
walker and stand or step with less chest support_
The Soal will be rhar eventually the child walks
without chest support.

lmproving the WayYour Child Walks with a Walker

The better your child walks with a walker, the easier it is for her, and the more she will
walk. Aokle bmces (AFOs) wiil help her to piace her feet flat on the floor. Stepping
for-ward without tuming her legs ir\ crossing over the other foot, or stumbiing may
take time. practicing and learning a variery ofstepping and walking skills will help
youl child to gain morc control over her leg Drovements. Mastedng sidestepping alolg
furniture, tuning around a comer while holding on, afld stat walking with assistatce
will improve her strength and coordination. A11 ofthis willhe1p her to walk better.
Strong arms willalso help herto walk better with a walker. you maybe surpdsed
to hear this and wonder why. Holding onto the walker with stro[g arms will make
your child feel safe.Ifshe can rely on her arms she won tbe afraid of falling each time
her legs tangle up and cause her to stumble. Her strong arms will hold het up, give
her time to fix her feet, and contiflue on.
As your child improves she may start to like to walk with her wall(er anywhere.
You are glad about it, but you may also wory. Your child may walk her own way and
not howyou and her therapist want her to walk. She maytur4 one foot in, not put her
heels down, walk too fast, run into things, and so on. What should parents do about
this? Tell their child she walks sloppily, to warch her steps, al1d to slow down? Walking
is a very personal thing. You wouldn't wal1t to be criticized about the way you wal1q
would you? The same is rrue for your child. She worked hard to be able ro walk with
a walker She does not want to be told she walks sloppily. And yer it may be good for
her to improve the way she walks. Her walking pattem may shess her hip or knee
joints if she walks like this for many years. What to do? The following is a sugSestion
on how to train your child to walk better.

Wall(ing with cuidance

l.Chooscaspecrlicrrmca]]daspecrti(:distance]or\olrrchildLo\,valliwithvoLl
each d ar.
 ITANDING li/ THQLJT ARI\4 SUPPORT AND WALK]NC I65

2.Have her stand in her walker with feet apart, flat on the floor, and toes point-
ing forward or slightly outward.
3. Choose a specific problem you want her to fix, such as placing her right foot
more forward- Ask her to walk very slowly and do her best to place her foot
better. Walk next to her Help her with youl words. As she readies to step with
her right foot you say "step forward." You may have her say it with you.
4.Praise her whenever she succeeds inplacinS her foot better.
5. Make the daily good walking trip a game. Count each good step, write down
the total as her score for the day, a1ld post it onthe refuigerator.

Walking with Reduced Support

The next exercises train children to walk with less support than a walker provides.
YouI therapist may recommend them after your child has learned to walkwellwith a
walker orifshe believes that your child is capable ofwaiking independently without
using a walker first. whatevet the case, please follow your therapist's instructions
when using these activities.

Walking wlth a Toy Cart

l.YouIchild stands with feet flat onthe floot shoulder-
width apart, and toes poioting forward or slightly
outward.
2.Have your child hold onto a toy cart as shown in
photo 14.10, a toy shopping cart, or another suitable
walkin8 toy.
E
r 3. Secure the cafi for her as you encoutage her to step
forward. After a few steps, see if she can walk with the
cart on her own.
If the cart rolls too fast, causing her to tdp and fall, slow
it by wrapping nylon hose arcund the axles. Encourage your
child to keep her feet apart. If she is unable to do so, discon-
tinue the activity.

f Walking with Sticks

l. Your chil.lsrailds 1\,itir lcctflat on the floor, shoulder r"-idth aPart.
and rocs pointing ior\\,ard or slighllv oulward.
2. Lrse rhc srmr sticks -lou Lrsed jr "Knee lvalkhg wirh SLicks'' or cur
broonlstick irr hirlf. SLand in fronl of\! rchildholdingthesticks
a
\,(J'tic.Lllv irl lronr of hcr so thaL she can gr'i'rsP them at \,.,ritr_lt\ tl

ffi
or slillhti-v abo\.e.
3. As \ r)rjr child grasps the srid(s. encoutaSe hcr to s1orvl,-vu'allllith
vou (plroto l,+.1 l). lbLl]na\.cr.rc hcrb]'sa-viDg: "stcpanLl slep and
sLep.... lf nc( ssarr. r'emirtd her not to tr-lrn her feet i]l .

lf ),oLlr child is able to \', alk l\,ilh -vou, ]nakc \ialhinB wilh sricl.s a

dall! routinc nnLl increase rhe distrnce lr,alked.

11.11
156 IEACHING A,IOTOR 5(ILL5 TO CHILDREN WTH CEREBRAL PALSY AND SIMILAR AIOVE]\IENT DISORDERS

Walking with a Hoop

1. Your child stands wirh feet flat on rhe floor, shoul
der width apart, and toes pointing forward or
x*r
slightly outward.
2. Stand in ftont ofyour child, and hold a hoop out so
she can grasp it at waist level with both hands.
3. Encoumge her to hold onto the hoop and walk
with you (photo 14.12). Remind her not to rurn
her feerh. Wdk with her as long as she likes.
Variation. If your chiid needs more support, try
the following. Stand behind your child and let your child
stand inside the hoop, hold on to it, and walk forward
with you.

Walking with Crutches

When your child is three years or older, walks well with a waiket but is nor ready ro
walk independently your physical therapist may recommend forearm crutches. In the
past, parents often frowned upon crutch walking. yet, todaycrutches are becomilg
more acceptable. Pediatricsupplycompanies sellnice, sleekforearm crutches invari-
ous colors. Still, you may wonder why crutch walking is an advantage for your child.
"Don't they provide m[ch less support?,, yorl wonder It is true that a walker proviales
sturdier support than crutches. youl child needs good shoulder and arm strength and
coordination to walk wirh crutches. Once a child has leamed towalkwith them and
feels secute with crutches, she will prefer them to a walker. Crutches allow her to walk
fast, make tight tums, get around in a small space, go through narrow door-ways, walk
stairs, and do curbs with ease. A child who is used to crurches will feel thatwalkirg
with a walker is slow and cumbersome.
Walking witi crutches is best trained by a physical therapist. Safery is important
idtialiy. The physical therapist mosr likelywill use a gait belt during ctutch trainirrg.
There are no cr[tch training home instructions inthis book. They are avaiiable else,
where if your physical therapist wants to give them to you (Martin, 1998) .

Standing without Arm Support

Srandinli halance rrai1l lS iJrcludcs standi]lg 11 irh srraight anLl brnr knees, standirg,
and stooping, as yrr:11as mor ing iu and cnrr ofstanding h,ithour supporl. It is a continu
etion of the standillg balirn.e acri\,lriIs practicrd previoLtslv lr,ith ar support. lt 1s
Lresr tu use Lhem daih dLtriIlg the nt(n1rhs voLlr child is learniD.q to r,!elk u/ith sLlpporl
rnd is eetting r cadr' lir jrdepenLlunt r\,a1king.
When cLildren b:Llance in srirnditrg. thc rrruscles of their lower 1egs. f.ret, anLi
loes h!\,c to \{ork !cr\'hiral. lheseaftt usuallv \lctt,r,r.eali and nlat- Lc spastic tn
(hildren r.,,ith cercbr:r pals1. lfr-oLuchilrlhashighrnuscletoneancltcndsLostancl
on her toes. loosrn and srr:r,th her arlkle and foot mllsclcs r\,ith Lhitse activitjes
describ.d i11 Ch.Lprcr 5:
 STAND'NG WITHOUT ARAI SUPPORT AND WALKING 67
'

. Ankle Rolls
. CalfMuscle Stretchin Deep Squatting
Yorlr therapist may recommend that you do them before practicing standing
balance with your child. when worldng on the following exercises, your child should
weartennis shoes or flexible braces, orbebarefoot, but should notwearrigid braces
or socks alone. These exercises cannot be done with gid braces because they do not
allow the ankle to bend, and socks are too slippery.
Use the balance activities as directed by your child's therapist and follow ary
specifi c directions given.

t Your Child Stands between Your Legs

or the edge ofa chair and have your child stand berween your legs,
1. Sit
t holdinB onro them and facing you.
2 . Help youl child to stand with feet flat on the floor, shoulder-width apart,
and toes pointing forward or slighrly tumed outward.
3. Look at a book together. Have youl child point to pictures, turn pages
(thereby taking one or both hands offyou leg), and eventually even hold
thebookand stand with no hand support. Ot hold a toy and encourage
your child to take her hands off your iegs and play with it, finally hold
t ing the toybyhetself (and statdingftee).
4. Guard your child well and protect her ftom fa11ing. Whenever your child
loses her good leg position, help her to come bacl< to it.
Variation. Ifyour child tends to turn her feet inward and come up on her
toes, take youl shoes off and place your feet over her feet (phoro 14.13). The
weight ofyour feet will help your child to keep her feer flat on the floot provide
some stability, and make it easier for her to stald without arm support.

Your Child Stands between Yosr Legs I

and Bends Down
Aftei your child is comfortable standing and
playing without holding on to you for a minote or
more, trythe following.
1. Play as before, but now occasionally hold
somethiflg low so your child has to bend
down as she reaches for it (photo 14.14).
2.Observe her legs and remind her not to
press her knees together as she bends
down. If she ioses her correct foot posi-
tion, wait for her to regain her balalce
and "fix her feet."

Pushing to Stand and Coming Down

Afrctvour child has lcarncd to bend and thcrl
.r. v,,'. r lr- p-. r.. r.
"ir rol r;. ,lr,
r'caclvro trvthis acti\ ir\'. ltlrillteachhern)riscrostandii[:andtosi]irlr[.n!.erherseli
froDstanding. Thjs Nill boost hersr:lf-trrnIicLeDce and filnl{c hcr lrssiea.itiloiiirllir !.
Llse rhe acri!jt\ as directed b1 \!ur' chilcls therapist.
I68 TEACHING A/]OTOR SKILLS TO CHILDREN W]H CEREBRAL PALSY AND Si]\IILAR /\/]OVE]\4ENT DISORDERs

1. Place a bench or heavy box in the middle of the room away from
\ furniture.
2.Ask your child to crawl to it and put her hands on the box. Help her
place her feet on the floor about shoulder-width apart (most likely her
heels will not touch the floor).
3. Now, ftom in ftont of her, ask her to rise to starding. (A high bench or
boxwill make this easier and a iow bench more difficult.)
4. Encoumge her to blow bubbles while she stands as long as possible
(photo 14.15). As soon as shebecomes uflsteady, enco[rage hertobend
B atthe hip ard support herselfwitlr her arms on the bench.
,..

Another time when she rises to standin& togetheryou can look at a sheet
ofnice stickers or Colorforms. Have her talk about them, choose one, take it,
bend down, and affange one sticker after another on the box.

,i!" vadation. Ifyour child has difficulties l(eeping her feet flat on the floor,
see if adding some weight might help. Put soft wdst or anlde weights with Vel-
cro closures loosely around your child's ankles. They will weight your child's
11.:15
heels down, makingit easier to stand with firmly planted feet.

standing in Front of a llvall

When standing in ftont of a bench, youl child will lean slightly forward with her
trunk. This helps prevent a backwards fa1l and allows her to quickly catch herself with
her arms. It is a good iflitial standing postuie. But you also want your child to stand afld
balance with a straight posture. This may be safely practiced as described below.
1. Help your child to stand straight with her back against a wal1. Stand in front
of her so she can suppoft herselfwell on your outstretched forearms.
2.Ask your child to step a few inches away from the wall and stand with a nice
straightposture-hips andknees straight, feet flat, shoulde.-width apart, and
toes pointing forward or slightly outward.
3. Challenge her to take her hands off your arms and stand by herself. lf she can
do this, positiofl yourself at her side and guard her well withort touching her.
4. Together count how long she can stand by herself. When she becomes unsteady,
have her regain her balance bybending her hips slightly and resting her bot-
tom against the wall.
5. Practice the activity until youl child does it consistently well. Now you may
14.16 have her practice on her own like the child in photo 14.16.
Note: Be a good obse er. Always quickly and calmlysllpport your child when she
is in danger offalling. Du ng early indepeodent standing balance exercises, children
may be very fearful of falling. Even a fall that does rot hurt may make them overly
cautious and reluctant to try the same activity a8ain. On the other hand, childrenwill
thrive and Sain confidence from safe, successf[l balance experiences,

Pushing to Stand from the Floor

I Ask vour chikl ro crrrr,',[ ro rhe middle of rhe loon arla1: tiom an\. furnitlLre.
2. Incourage her ro place her lier on Lhe 1]oor about shouldel u,idL]r aper t (nost
likeh'i1is heels lrill not Louch Lhe llood, straighten her legs as nrLLCh as posslhl!.
and rise Lo sLan.ling.
 STAi'lDlNlG U/ITHOUT ARL4 SUPPORT ANLr \r(/ALnNG 169

3.During initial practices you may help her to place herfeet in the correct posi-
tion. As your child improves, have her do it on her own.
Variation. If your child cannot stand up by pushing up from the floot have
her push up from a low bench or stepping srool (photo 14_U). As she improves place
something lower such as a telephone book on the floor. Continue to practice witl her
until she can stand up from the floor

Standing Up and Sitting Down

Holding onto a Hoop
This activity and the rwo following acrivities train your child to stand up from
sitting and sir down wirh conffol. Use them as directed by yotll therapisr.
1. Have your child sit on a bench or stool with her feet placed comfortably on
the
floor. He( I(nees are apart and hertoes point forward.
2. Stand in ftont of your child with a hoop. Ask her ro hold onro the hoop wirh
both hands (photo 14.18a), lean her trunk forward-nose over toes_and stand
up (14.18b). Renind hetnot to press her legs rogether as she comes up.
3. Nexr have her sir back down slowly and sofrly.
Try to do several repetitions. A reward after five up and downs will make it more
fun for your child.

Standing Up and Sitting Down with

Minimal Help
1. Have your child sit as before and have her hug
her favodte stuffed toy.
2. Ask her to lean forward and have piggy stand up
with her (photo 14.19). Ifneeded, help her briefly
* and tell her not to push her knees togethe.
,n/ - 3. Later have her sit down slowly and sofrly.
4. Asl! "Is there another animal you want to bring
up?" As she holds diffetenr things, have her
come up and sit down as often as she is willing
to play the game.

I
 70 TEACH]NG A4OTOR sK]LLS IO CHILDREN !flTH CEREBRAL PAIJY AND SII\4]LAR ]\4OVEA/]ENT D]sORDERS
'

...' t

I
*
T ,,

11.20b

Standing Up and Sitting Down without Help

E.,en aftcr vorrr child is ablc to stand r,4r rvrthout assistrncc. mor: practicc rvill
be helpful. lr r,r,ill further improve her coordination and leg strength. You \,r,ill notice
that she \'r.i11 come up 1\'irh rnore ease aDd sit do$rn lrith more conuol.
1. Choose a pla)'acLif itl'lour child likes Lhat she can pla1, in sittinS or stand
ing. Placln!: chbs int{) a music bo\ or' plav oney into a small cesh rcgisrr:r'
may trc tun.
2. Hold thc ro1 ricstligh lir plar in stardirg(photo 14.20n) ard hold ir lo\"- for
pla)'1ll sittint lphoto 14.20b). Ha\.e her stand up and sit doNn r"-ith each turn.
3. II_vour child loses her Sood lbot or le8 position her feet turn il1 or her knees
rouch have her "lir her leel" and Lhen corltinue.

Standing and Reaching Up

As your childt standing balance improves, your therapist
may recommend the next two activities.
1. Help your child to stand up in the middle of the room
away fuom any fumiture or other things she could fal1
and hurt herself on. Ask her to place her feet flat on the il.1..r
floor, shoulder-width apart, and toes pointing forward
or slightly outward.
2.En8age her in a play activity and have her reach up
with either hand and later with both. For instance, you k
may ask her to reach up high with both arms and then
geotly drop a balloon into her hands (photo 14.21).
This activity requires concentration. Stop as soon as you
notice that youl child is getting tired.

Playing Ball
l?
L. Ask vour child ) sllrr.l p i. thc midcllc of thc roon 21

a liom l ul niL LLre or an! chrtter'.

'a]'
2. Hnvc hcr rrrlrd \r,ir[r her leer 1]at or1 the 1'loor', shollclcr wklth apart, and toes
pointing fon,,,ard or s1i8hd1 ouL ,ard.
 STAND]NG W]THOUI AR]\l SUPPORT AND U/ALKING
f7f

a
.a
,|
{*-""*
11.22b

3. Gently ro11 a ball toward her feet and encourage her to slowly bend
down, pick
it up (photo 14.22a), and hand itlo you.
4. Next ask her to hold her arms out. Say, ,,Good catch,, as you
drop and later
throw the ball into her hands (photo 14.22b). .Now toss the ball to me.,,
centle ball play is fua and will develop your child\ balance. Keep ir as
simple
as possible.Ifshe loses her good footposition, pause and wait
for her to,.fix her feet,,
before you contime.

Assisted Standing on One Leg

As you wa1k, your lefr leg supports youl body weighr when your right
1eg swings
forward. As you put rhe right foot down, both iegs iupport your weifht. rien yout
left leg swings forward and your right leg carries youiweight unril yJr-t."t yo,r,
i"ft
foot down and both legs support your weight. This cycle is iepeated
or,". urrd or".,.
you walk. Bearing all body weight on one leg is an essential
component ofwalking
without arm support.
When children walk with a walker or forearm crutches, they beaa part
of their
weight with rhefu arms. Instead of bearing all their weight on one teg as
they step
forward, they dist bute ir on rhe leg and their arms.
Yor might have experienced this yourself if you hurt one leg and your
.
ordered you to walk with crutches while your injtryheated. Walliing
doctor
with crutches
without puttingweight on one legwas possible but cumbersome and-tiring
for your
hands, arms, and shoulders. you were relieved when you were allo*"d
to"prrt *nr"
weight on the injured foot. Now crutch walking was easier.
Similarly, the more weighr children can bear on either leg, the easier
it is for them
to walk with a walker or crutches and to progress to walking without
an assistive
device. Physical therapisrs recommend rhat parents practice
ine leg ,tu"ai.rg *itf,
theirchildren as earlyas possibie. They can do rhis by iocorporaring
o'rr" t"g.tu;anrg
into theirchildrent dressinS rourine. This will provide a briefbut
clo"i.t"rrlt
time and also trains an independent dressing skill. """i.1".
I72 TEACH]NG 1!4OTOR 5K]LL5 TO CHILDREN WITH CEREBRAL PALSY AND sI]\4]LAR A4OVE]\4ENT DISORDERS

l One Foot Standing While

Getting Dressed
I 1 vnrr.hild sr.rdr ai.l holds u,irh
both ha.Lls .r.to the slats .)1'rhe
crib. the cdgc of rhc playpcrr, !
\!a11bar. or a slandirl8 ladder.
2. Kileel behind her a]1d support
her as firrrch as needed. Ask her

II n) lift one lcg et iL tifire 1,_hile you

puJ) tLrr: prnts L:gs ovcl hcr fcct
(phoro 1.+.2:la).
3. I'hen have her stan(l tall on both
i
legs rvhile ,vou pu11 her pants up
(phoro 14.23bJ.
4. Reverse the process whefl you help her to take off her pants.
variationA,Ifyouchild does well, have her stand holding onwithontyour srp-
port. Hold the partleg opefl and ask herto lift her leg and puther footthrough it.
variation B. After you have helped her to pull the pant legs overher feet, see if
she can stand holding onto the wall bar with one hand and help you pull her pants up
with her otherhand. Similarly, have herpractice takingher pants off.
Discontinue the one leg standing practice dring dressing time when yot1l child
is readyto put herpants on allbyherself. Teach herto sit and pdl her pants over her
feet. Then have her sta[d up, hold onto thewall bar with one hand, and pul] herpants
up with the other hand.
For more one 1e8 standing practice, use the exercises descdbed in the next chapter.

Extra Standing Time for the Weaker Leg

Most childrenwith cerebral palsy have a marked difference between theirlegs. Usu
ally one is stronger, more coordinated, and shows betterbalance than the other. This
is especially true for childreo with hemiplegia. Naturally, children will favor the less
affected leg and mostlystand on it. This may work for standing but not for walking.
When a child t es to wall( and one leg is too weak to support her weight or too uDco-
ordinated to balance ovea it, she is unable to walk safely without an assistive device.
To improve the strength and coordination oftheweakerleg children are asked
to place their strongerleg on a stool and stand on their weaker leg (this is called half
standing). Now the muscles of the weaker leg have to do the work to keep the child
standing. As children play in half-standing, they will move slightly and shift their
weight. This will challenge the child's starce and lead to improvement of the coordi-
nation and balance responses of the weaker leg.
Exercises in half-standingmaybe used to prepare children for walking or to im-
prove the gait of children who are alreadywalking independently. Half-standing with
straight knee and hip ofthe standing leg and good heel-to-floo. contact also stretches
tight calfmuscles and trains full weigllt bea ng through the straight knee. DependinS
on your child's capability and the training objectives, her therapist will choose the
best-suited half-standing position and determine the height ofthe stool used.
 STAND/NG WITHOUT ARAN 5!]PPORT AND \T'AL( NG , 73

You may find that the exercises in half-standing are difficult for your child at first.
She mayeasiiylose her balance.In the beginnin8, supportherwell. As you sit orkneel
at her side, wrap your a rm around her waist or hips until she stalds solid1y. Then move
your arm a few inches away so you are no longer touching her, but be ready to supPort
her again as needed. Also be a good observer. Your child may"cheat" when she half_
stands. Instead of standing mostly on the straiSht leg, she maylean onto her bent 1eg
This defeats the puryose of the exercise and increases the danger offalling.
Itwill take some time for you and your child tobe comfortable with half-standing
activities. Ooce learned, they will be easy, even relaxin8. They will allow for many
different play situations, and most of all, they are very beneficial for your child, es-
pecially if she has hemiplegic cerebral palsy.
Use the exercises as directed by your child's therapist and follow any specific
recommendations givefl.

Haf"Standing at Furniture
1. Have your child stand at a table or other furniture of Sood heiSht.
2. Have her stard on her weaker leg and place her stronger 1e8 on a
stool or a thick phone book (photo 14.24). The foot and the knee
are pointing forward. If idtially your child cannot prevent the knee
from turning in, hold the knee in the ght position. Later reduce
your support.
3. Place her favodte toys on a table or otlter fumiture of a good height
in front of her and encourage her to play with them.
4. Initially support your child well at the hips and make surc tlat her foot
is flat on the floor with toes pointing fon /ard or slightly ortward.
5. Take your hands off her hips, have her stand without your suppofi,
and guard her well.
Discontinue the activity if her standing leg is bent and hel other knee
points inward.

Standing on the Weaker Leg

1. Sit on Lhe edgc of ir chair and havc !orlr child stand
bctn,cen 1'our legs facin g r,ou u,ith hcr stronger Ieg
placccl on a stoo1. I his r at mosL of hcr \vllghL is
on her wcaker le8. 1f ncedrd. leL her hold of to \ou
&
for suppor't.
2. Look ar intel csti.8 picture bool(s to akeLheacti\_
it\ eiljolable for hoth o1 \,'ou.
Variation A. If)'our ch ild s bent kllee rurns inlvard.
supporr it so it points lbr1\ ard (Photo 14.25a).
Variatjon B. i1',voLrl child hcncls rhe knee of thc lcg
she stands on. tr] ro brace it \rith vour lcg. Disconlinue rhc
actixiLf ilshe cannot streiShlen the kncc with l'oul help at
least part of the tilne.
Variation C. iIl'our (hild.lors well. have hcr tr') to
do rhe acti\,lty lvilhout any sxpp{n l. F.rr itlstance havc her
look at a pop-up book. Ler her trrr n thc pa8es, pull thc taL,
,74 IEACH]NG ]\4oToR SK]LLS To CHJLDREN WTH CEREB]i1L PALSY AND SII\4]LAR ]\,1oVE&,]ENi IJ]5ORDER5

etc. When she plays with a shape drum, have

her hold the drum with onehafld and reachfor I
lhe shaDe wi h lhe ot 4el. Also nave l-erpracl i.p
reaching up and bending down (14.25b).

Progress with Standing Balance

SLandillg bala]tce Lal(rs mlLch \,vork t.r irclieve.
It is not atnotterof\ torkingon itseve,"oldo],s
or weeks. but daily pt actice of nTaybe severnl
rnonths. 'l don't have rhat much time., vou
nishr protesr. Think ab.rfr iL iigiin. I lotv mlrch "]t
i-. -.rr..or I ir"
r\:ith \our chil(l'l filost liliely it is rnore thfll ha]f
a]1 hour. This is the rime\,oLlran Ltse ti)r balancc
trainin& Use books ortoys yourchild likes for the 14.25b
standingbalance activities-soon you and your
child will feel like you re playing together instead ofworking. yer, work is being c1one.
Progress will be slow but will occur- Watch fot the little changes. The first week,
your child may lose the corect foot position within 10 seconds, tile next week she
maystand nicely and balance up to 20 seconds, then for 25 seconds and so o1l. Feelilr8
more secue, your child may start to move more in standing. But when she does so,
she becomes more likely to lose her good leg position. you may feel defeated
because
the tendency to tum the legs inward will nor go away. Don.t quit. The tendeltcy to
turn the legs in may never totally disappear but will happen less otten. become less
d i\rupt ir e. a nd mo\r o[ a l] \^ jtl nol lecp her from ,,1a l(,ng wirn reer flar.
Your child has already learned to stand very still. Now she is learning to con_
trol her posture and balance while her body moves. Each time she does somethilg
new reaching up, bending down, throwing a ball-she will start out very unsteady
and show a poor postue. Then, slowly her posture and balance will improve. AII
this worl( will pay offwher your child ties towalk. The betterher srandingbalance
is, the better her chances are for independent walking without a walker or-crutches.
Paogress with half-standing may be even more subtle and more difficult to detecr.
Yet even a slight improvement of the weaker leg will make a difference. your
child
mayfallless, walk fasret become able to ldck a ball-all because her more affected
1eg has improved in coordination and balance.

Strength and Ouick Action

G(x)dlruscl.srreng.halll,a\.she\rs.bL[beingab]etomor,efastanclquickhrighten\qu.
fillrscles is also i.lponinr. When \!alking. \.oll lifi vour n,n\c ir fbnvarcl. and then
rt! L rnnr jr rrrh.: ,,rheLr rs,,
fut iL do\rn. \Ixs(les t]lirr lieep \!r]l kncc straight ha\.e ro'ior,
loucordnots.andrlrrrhelellandtehranorhrrsrep.Infacr.ourlegntuscleic6norhavc
to be !.r\,strorg LOic(nIse.rheynerLlrobestrongenoughtoholcjLrsup.JAsI(n1Basrhe
urusclcsdoLht:ri3hLrrnt.rrher Shrrirre rnclrLrht Lighr speed. wccarlvalkllnc.
 SIANDING WJTHOUT ARA/ SUPPORT AND WALKING t 75

I These exercises train quick stepping and sta11dlng. Theymaybe used

to get your child rcady for independent walking or to improye the way she
walks. Use the exercises ifrecoEmended byyour child,s therapist and follow
any specific instructions given.

Ouick Step Up and Down

This exercise works beston stairs.
1. You sir on the rhird or fourth step facing your child.
2. Have your child hold onto rhe banister wirh her hands and place
her left foot on the first step. Make sure her foot and knee point
forward.
3. Brace her left kree with your right hard (photo 14.26), preventinS
it from turning inward while she quickly steps up onto the first ste;
with her right leg. pause.
4.Askher to quickly srep down wirh the fighr1eg. pause.
5. Repeat 10 rimes.
11.26 6. Repeat 10 rimes with the opposite leg.

Ouick Step-Down
1. Stafiwirhytru child standing fi$r step,
on the I HI I

facing downstairs, holding onto the banister

with her hands and ready to step dom.
2. Sit in a chat in front ofyour child, bracing
her left lolee with your right hand_
3. Ask her ro quickly step doia.rr with her ght
foot (photo 14.27). pause.
4. Then have her bring her right foot back up.
Repeat 10 times.
5.Repeat rhe exercise 10 times with the
other leg.
Notq These are rcal exercises-no playatall. A
school-age child may be agreeable ro do them, but a
two-year-old child may noL. Tr willhelp rohave a nicc
reward lor her after she compleLes a sel of e\ercises.

Walking
''Srand Lrp, Ca don."hismorhcrco.\cs..,Sh.r1!.NIrs.fr{arritr,il:Lr\oucrndo.,.Tir:t
vear old CamLlo[plLshes rqr from rhe floor rnd |rs,,s Lo st.ftclir.l Hp d, . r ] , n.l
carefull].. "That s righr, pLrr rour hccl r:1orr n. Ln,,l ho\rr(eh.\uuillesr,rrLlirr .lo l]
ispleased. CrDdo. has nranagecl tosLan,l Lp r. irh.L r, rrilr.ln :n.l r.lt.tri r hir
6cl I I r,,trl, J,.h. ...'r ti ri t. . ,.I.o.t.
t.. E,, "
lor the thcrapist. Ar e l ou t eir.T\'? ' NIur asl s arld ljghth,tosses :r Lall Lo h in.
CrLl.,1.loIl
srvar-s as he catr:hes Lht: ball. For a br ief monenL ir looks as ifhe rnar.ios.
ris b:Llrr1ct.
B!tilpassesandhedoesnorfa1l...y(nrnr-rdot1lggrerr,.hisrn,rherb,,.tLr-..,r.:l.lr.g
(onlldcllth' irgain, Candon hall rhro\\,s nnd half tlrops rhc ball bar:k
ro hrs tnorher
T76 IEACH]NG IIOTOR SKILLS IO CH]LDREN U4IH CEREERAL PALSY AND s]fu,]ILAR A,IOVEA/]ENT DISORDERS

CaLching it, shc trrns to the therapisl: "1sn'L he doing $,cll? Hc learned it d s u'eek."
The therapist is trLl! amazed. None oI her parients \!,ho had not vet beBun to walk
rrithorlt support had c\.er done aD),thing like this.
Camdon still stluS3les r\,]ren walking,,\,ith a ualker. I'i8hr1y holding onro the
lirr\,_eld an.l his lcgs drag behind. I le u,anrs to stcp first buthis legs
r,r,aLker, his bod_r,_1eans
are not cooperatiil8- Thev cross over alld his heels do not to ch thcfloor. WhenCalndon
r,\ralkswithhis moLher, hc rJocs a better.iob. She slorvs hlrr clown. askshim to1\,atch his
feet. and place each lbotfllton .he tloortyithour clossingovcr. \,\iheD he tralks lhis v!._v,
his bodvsnavs fiom side to si.lc an.l he firn1lvhollls onto hir other'shands.
Having obset\-ed him $,alk rhis ri r\., rhe dletapist has becn doubttul LhaL Canrdon
ould bc able to u,a1k \rjthour suPport aln time soon. Bur ro\,v rratching hlm srand up
and plav bali in sr:rnclin.g, shc becomes much norc bopeful. Camdon secnls to sense
vvher he stands r,r,ell, knorr,s u/hen his brlancc is tbreatened, and car rcgain a goocl
standing posilion \,r,hr:n his balance is mildly r:hirilenged. IIhe loses his balance, he
does not fall uncolltrolled bur cro cht:s and gentlv drops to thc side.
Ca dor is Do lol8er aliai.] to stand. He enioys it. Each !\,eekhis standingposture
becomes a littlc surer. A Ierl rvccks later. at rhe sLai t ofCamdon's sessioIl, the moTher
and thc thcrapisr talk and dr:cirlt, to trv someLh jng .c,,\,. After Canldo. stilnds up, the
thcraPist places a rherapt roll uprighl in flonr of htn, abouL a fiDr out of his reach
(photo 14.28). Shc p!ts a toy animal on top ofthe ro11. "Take a srcp and get Lhe hor sc,
Cafi1don," NIon] cncoura8es. The therirpy ro111ooks substanrjai but rvould topple ovr:]r
if Camdon tricd to rake a big stcp and lunged 1br it. Camdon plavs ir safe_ H. takes a
small stcp w ith his righr lo.rt alld theD \\.ith his lefr foot. Alnost close enorgh, he stops
to regain his ba1ar1ce. \,Vith briefhelp fron the rhcrapist, he succeeds. TNo more sreps
and he 1ight1_v rouchcs thc ro11. reaches fbr thc toy and regaiils his standing balance
without he1p. What. successl
With little pauses in between, Camdon practices the same activity
again and again. Regaining his standing balance after one or two steps

,{ti becomes easier. Walking further does not yet work out. A week latet
howevel he manages to walk foul steps in a row, stop, and regain his
:s balance without any help. This is the way Camdon is learning ro walk
and make proSress-one sma ll \lcp ar a time.
"Willmy child start to walk the way Camdon did?" you wonder.
Most likely not; each child is unique. Before you decide to help your
child to walk on her own, you must find our if she can walk fasr or ii
she needs to take very slow steps.
One-year old children usuallychoose a fast start. When they tal<e
off on thet owrL they do not take measured, slow steps, but almost
run. They step/step/step/srep, fall down, get up, step/step/step/srep,/
:14.28
step, hold on, and so on.
Children (11o begin ro nalku4ren thcv ar r: tr.r,o vears or.rdcr tcnd to tralk slorvcr
an.l vvill be nlole caleful ro a\.oid a 1all. Bcing taller. dropping o:rro their borrorn !s
onc year olds ma! do is unconllirr-rabl(: forthem. Ihel nrii,v plaltallead ancl rrv ro hold
on to sorlething rJhen thev liar rhat ther- inar l0,rc their balance.
Wirtch your chJld r,,,,alk \'vith ! \ralker or when ),ou hold her h.rnlls. Ntanl chit.I.cn
with celebralprls\'lose control u,hcf the\'\\,alk fasr. Theirlegs tLtrn ir\r,ard and Lhe\.a rp
and lall. r\t i slou speed. this is less likeh, r.r happen. Conseqornrl\i. thev ha\.e ro stilrr
 STANDING WTHOUT ARAI SUPPORT
AND WALK]NG f77

uaJk.ngalavetyslow.peed.fhisposeraptoblerl.Walk.ngalasJowspeeareqLires
betterbalance than walkjng fast. becaus
o,, iu.t o,," root r, .ng".;;".;"';;j:H:? [X'ffi H:Ilj"'J*l
;1:j1T:,n*,
If you, chitd needs ro walt slowtvin
oraerto conrrJ;;;; i"o.,,#;,".,1,f}.r,.
tani rhat you set a feel for her situation.
)ou,w-ork rogerher u irh her r he'apisr so
unders,""ai"g h;; .t !
your child
,i ;"; *"illiiii",,
p1691._ 16f ,;:;:;po,1,
goa t. PrerFFd you 5ave ro
walk ove. a narrow b.idge"ar -d
rather cr"oss ir quickly or very sJowty?
soanning a,wift c*;; ;;1ilr",",
rnro rhe vr...er. So ou har.e ro otay .afe
Walking f"rt;rt ;;;;;;,r#"lil
] ir and,"a* ,r"*i1. ilr i].i_'irr;; ,n".,;l;."
",
;;; "' ".
manl chitd r en wir h cerebra I oal:v Face
Wal king :lora 11 is oei_
Ifyour child has low mi ..i" torr" n ";j,
pist may adwise you-thii
recommend that your child choose
;;;;;;::; :fl ilff ;:.JffffHHl
ffl:J:]:1.,:T,;
her own walki"g ,p""d *; th" ;i;;;h,";r."
to walk on her owrl.
The subseqlent activities practice
slow controlled walkin& first wirh
-_. miDimal
1; ;l',ff : #l,:r;.liili jl;
i;l J"iI,,
econm.nde; ;; v;"u r ;; ;. ; ;;: ;,.,

Watking with One Hand against a Watl

'1.
Ha! e your child \rand at a q0-degree
angle ro a wa ll, close enolloh
ro louch it. with her Ieer shoulder-widr;
forward or slightly outward. "r"., ";;';;.;.;;;;*
jc 2. Stand a few feet in front of her
and encourage her to walk toward
you while bracing hersellwith
onc hand a;"ir., ,t" *ulf foii,i
J4.29). fts6jnd fis1 1e walk slowly
and nor
"p"iil". .""r']"I.ro]
If she does well, have her waik increasingly
^ Repear in rhe longer distances.
3. opposire direction
Variation. Ifthe activity is too difficult
for your child, give her more
supporr. Walk besides her. hotdinS
a shon stict<. and have hir toia
with her free hand_ on,o i,
Repeat in rhe opposite direction.

Green Light - Red t_ight

llljriall\., Catud()D coLll(l orrh ru: llr:
hi,r,,,r0,,.,, p,.;;i.;;;;i;,,;,;;:J:i:il:Hl;,iiil::il1[:H:lii,[:ll::fi]l
1. Yor:r chitl.sr;rrrls as bctore. j
s.pportir g hcr."lf *,i,t
I "'" '' ' '' ' ','6,, ',. .o,,,rut/. ";";;;, ";;;;:;;;" ,*,,
',ll; ll: ;"'*:',i l;:l'iflli .I,,*0 srop rviLh

J Ne \t \.Rr.l
r\ : Il!ht.. \oL 1),, h c
"*' )'ou sa\:'Grecn r-i3hr'

, r,," i". ffi:i:ii:ll illil,ii:lil.l1i,,ilx.":.:.#il

r,.,,r.,,31 *,*,,
4.Hol,1",,,
,nr, L], sri } 1:rur\\hen\t xrisre'rdvfor'GreenLight"anclmorer""alk
ingsjdeblsictr.
Ptacti.c:]s 1o[!] as \oor child is xlr el'(rslcd'
l'or variery lel her bc lhc one u'}nr
savs 'Red Lil{ht ' or 'G.e.r1 l ighr.'.
Variation. Afrer l(\r1 chilcl Llocs rvell
. vrirh .he activjti_, see if she (:an
holdinlr onro rh€r sti.k $.jth orle han.l :rna lr,aLk rvjrh
),ou
o. fv figf,tfr, to.,Jr;rrg;';,ir^;";,,r ,n"
I 78 TENCHING ]\4OIOR 5K]LL5 IO CHILDREN W]TH CEREBRAL PALSY AND 5I]\IILAR MOVEA/]ENT DISORDERS

fingers ofthe otherhand. Durirg red light have her hold the stickbyherselfand stand
with just her fingers at the wall for supporL

Your Child Walks Slowly toward You

Ifyour child is abie to control a fall, use this suggestionto encourage herto tal€
independent steps. Practice it as directed by your child's therapist.
1. Ask your child to stand on her own with feet flat, shoul-
der-width apart, and toes pointing forward or slightly
turned outward.
2. stand or squat about one to two feet out of her reach and
hold a ball with both hands (photo 14.30).
3. Tell her "Slowly step ard step and get the ba11."wait for
your child to come to you. You may reassure her with
your voice but do not try to give support. Your stretched
out hand will not be helpftil. It will make your cllild think
abour hold ing on ins, ero o'corc"nr ra t'n8 on ma intain-
ing her balance.
4.Ifyour child succeeds, she deselves a hug and a short
breal( before you have her try again.

Walking Between Two nopes

This exercise may help a child who is able E-
to place her feet well and appears to be ready to
walk on her own. Walking between ropes will
provide minimal support, but will be easier than .
walking entirely unassisted. It teaches what frce
walking is all about.
1. Attach two ropes to solid pieces of fur-
niture. Mate them parallel at tlle height
and widthjust right for your child. When
child ren firsr wa lk. rhey hold rheir arms
out to keep their balance. The ropes yl
should be where your child would hold
her hands if she wallrcd on her owl.
2. Have your child walk between the ropes
(photo 14.31).

TYPICAI- METHODS OF ENCOURAGING WALKING

There are time honored and popularways parents enco[rage their children to wal]! in_
cluding the three listed below. How helpful arc they for children with cerebral palsy?

wall(ing from One Person to Another

Sarnanrhirsrafd!rlirh\1()rr.DaLlisilel\ieeta\,r,al.,suetcheshrsirnrsorrt,rnclcalls:
"Sammt', come to l)rd(l\ l' Sr mr \rillr:Lke a lawquicksteps and lil iDtol)u(l'sarm.Thrs
is 1irn. LaLer Dad rri11 discorr rr.sr SrInnr\' fr.rnr lunging lbr$,ald. lle u,i11cal1her to conrcr
ar.l not sLreLch his arms oLt.lle \ril1hr]g hcr aftur'shc hirs $,alked all Lhe \r'a\, to l1in.
 ITAND]NG WITHQUT ARII4 5UI'PORI AND WALKNG f 79

? ftis dctivitl,]vill not h elp ach[ldtlho needs to w..lk slowlJ.in orLler to control
etch step and keep her bdence.

Walking with and Then without Support

Sammy holds onto Momt finger and walks with her After several steps, Mom
pulls her finger out of Sammy,s hand and has Sammywajl( on her own.
Most likely rhis technique will not help a child wirh cer.ebral palsy. lfyou want
to ffy it nevertheless, m c.ke sure that your child knows when she is to longer
s:!lp'
ported. The awareness ofbeing on her own will help your child to concentLte
and
deal with any balance threat as best she can. Ifyour child believes she is protected
from a fall by you, but is not, she may ger hurt if she falls unexpectedly.

Protecting Your Child from Falling by Hofding onto His Clothing

Holding onro Sammy's co11ar, her mother wall(s with her. After several stepfshe
lets goofit and has Sammy continue on her own.
This does not help rnost begi titLg w@lkers with cerebral palsy because in
_
order to keep their balance, the children sway from side to side. Holding
onto their
clothing will interfere wirh rhis.
You may use this techiique to provide safety when your child climbs onto
fur-
niture or playground equipment.

Ready for Walking

The following are genenl recommendations for children ready to walk:

A Play Corner for Standing and Stepping

a With seveml pieces offurniture, create an area where it is fun for
your child to stard and play (photos 14.32a, b, c).
. Use child-size play kitchen furniture, a rable, heaw large boxes.
or\ hateveryou can find that is I he right heighl to encourage ) our
child to playwhile standing.
a leave spaces betweenthe furniture to encourageyour child to move
about with minimal arm support or to tal(e an independeflt step.

Ia , rfll
F:
& *t & I t*
I
G ?T
a

I
.1
I80 IEACH]NG ]\4OIOR sKILLS IO CH]LDREN !/]TH CEREBRAL PNLSY AND S]fu']ILAR ]\4OVE]\4ENT DISORDERS

Days Filled with Walking

o IGep your child physically fit and ready for those first independelt
steps with lots of sranding and walldng with srpport.
. Instead ofpNhing her in a stroller or carying her, have her walk
withyou.Ifshe goes to preschoolor daycare, talkto herteachels
orcare provider about ways that can encourage hea to wall(
. On weekends, keep the time your chiid sits in a car, ddes in a
shopping cart, or watches TVorvideos at afl absolute minimum.
A child who spends most ofher day sitting is not likely to start
independent walking.

Frequently Asked Ouestions

O. "Chehea.loesnotliketosrand.S/reusedtr-, ,I.nrihe,orlillle.Brltnaw\tholtrybgct
h€r rr).srond lrcrrvcirn nly lrgs, she d|ops to thi: flr.,rrr and crtDr,?s arL ar: Whttt shoultl I tlo?"
A. Whnt yolt clcscrjbc happcns fr cqur:ntly. While suallchildr r:n r:srrally likc ro stirnd,
older preschool childrerr rnay rather p]a_v on the tloor.'lhlkto Chelsea's therapist about
this. I he thei apist ma-I recommend that Chelsea n ear knee inrnobilizers u,'hen she
stands. ILu.i11n1ake stanLling easier ior her and she maylike iLbeLrer. r\s her attitude
lnpro!es. she miy l:1rer also stan.l u,ithout th! immobilizcrs.

a,'"Tomhosahetuiparesis.ftisrighrlegisrhinnerandhalfaainchsharterthanhisleft
Ieg. I can't beliet e that half-standing exercises will make any difference. His hemiparesis
will not go away."
A. It is true that half standing will not cure Tom's leg. No exercise in this book or other-
wise will cure cerebral palsy. The exercises will train Tom's muscles and may imprcve
his functional skil]s. Ifyou do 15 minutes ofhalf-standing with Tom daily for several
weeks, you may notice that his ability to stand on the ight ieg improves. For instance,
he may then be able to stand on his right leg while he kicks a bali with the left leg.

O.'Oursonilfi.r'dp,r.tr)ldirrrr.).rolrd.ti..rrolknrt{rrithirm..Sh(.\d,.l.idtifillu,oirkl
l,trlkrllnlll,osrr:ud,r',.rr(llfillr/nlstrrrn)u,ol/ron/ri.sotrr. l1'in do_1,rlrr giytso nr dr
udyicr: conr:r lnirrg l,rrlking'"
A. Children !!ith cerebral palsv have diiierent capabilities. Youl therapisL k e,,\i
\\i11 and tave vou Bood ad\,ice. OLher children u,ith cereLrral palsl benefit fron
8ail Lraii1i11g. The \rilkln8 exercises rre lor Lhese childr.n an.l shoLrl.l bt donc:s
direcreLl b\ theil Llrerapisrs.

O. "Wficn.fdron.sadndr u,ial his /!et slorrld€r- n,ldrll (?a]-r. /r. ir rLor-d llkely to llrrr his
/irca in drd .orrc !I o/rao hir Io..i. tr!htn l/lr\ ore .lose together-, fu. strlllds bertrr ShrrLld
I lcr hir,l ra.r,td thi.! n dy,' '

A. l lale him sLand the \!a! he do.:s hcst. Brrt Jo not ha!e hi1l1 staDcir!ith legs touch
in8. StanllinS ith lict should.r-w iclrh apar t,qives childrerl a ider base and n ukes
b:ilancing easjrr'than standing r,r,ith fect close together. flou,ever, some children
$,ith ccrdrral p;rls,\'can conrrol their legs better il they sLand 1"r ith feer.losc t.r.gcthcr.
Ailron is oDc oithosL, children.
 SrnNDiNG WtTltOUr ARtut SUppoRI AND \,AL(NG lgf

A,. "I am amazedthatyou say thot doing abalance exercise withyour chiLdis like playng.
When.I am hame fiomwork, I enjoy hanging outwith my kids on the
floor. We roll-ariund_
they sltow me how atoyworks, andsimilar sruff that's playing. Tellmehow
aparent cen
hold fuIL time job and IM1le time ond energy for somethingyoule reco**"riirg?,.
o

A. You are right. Parents who work f11ll time may only have time or energy-for this
on.weekends and even ther it may be very difficulr for them if they haie
several
children. You may askfor a volunteer inyour church, at your neighborhood
asso.ra-
tion, or within your earended family. If you find a helpet to work with
vour chitd.
nake srrc rl-ar nealendsoe\eralollourchildsrleraplsessionssorherherrp.s,
can teach him the home exercises.

a.'Jfi,oneofthechiLdreninmyearlyinteruentionpresclbolclass,wouldbenefitfram
more play in stonding. Howel)er, I om concerned about his safety.
I do ,o, *ori hi^ ,o
fall and get hurt. I44ot do you recommend?"
A. You have a valid concern. Children with poor starding balance will fall at rimes.
Falls cannot be lOOo/0 prevented. Talk to Jeffs parents and iris physicaltherapist
abour
how well Jeff is able to prorect himself when falling and foilow thefu
advice. Also,
when Jeff plays stancling ar a table, remove objects he cotld fallagainst.
Childrenare
more likely ro ger hurt falling against something than falling down.
A carpet or rhe
fl oor will provide additional protection.
Sraoa
o
T5 a
a
a
I
Walking and
a More
a oaoaaoaaa

,, I wish Marion would walk more," her mother sighs. "It has been three months since she
f took her first sreps and she is still reluctant to wa1k. I thought once children started
to walh they wanted to do it all the time. But ifl dont prod Madon to walk she would
ruther crawl. Are there any exercises I can do with Ma on to motivate her to walk?"
There are no exercises that Marion's mother needs to do with her daughter
riSht now. Apart fuom continuing Marion s sffetchilg routine, this is a good time for
her parents to take a brcak from doing exercises with her. For Marion to walk more,
faster, and for longer pedods, she needs to ta]te ownership of her new ski11. Instead
ofwalking because she is praised or prodded, she needs to walk because she wants
to go somewhere or do something.
Chapter 6, Head-Up, talked about Nina and how important it was for her to in-
tegrate holding her head up into her dailylife. In similar ways it is best for Marior's
parents to stop doingwalking exercises and instead help her to integrate walking
into her daily routine.

Opportunities for Walking

INDOORS
All bcginnjng \\,elkcr's n.r.rd ti . irn.l rnlplr opport|nit) to rcfinc their .err sklii.
Chilclrcrbct!!ccnthcagr:sofoncandrrlor,,uarsarccalk:droddlcrsforgrrorlrt:rsors.
't he1'totter as the_l Lear r to sort out r,irat their 1egs, bod-v, and arms halt to rio in or
der to n alk faster or slouer, stop and tum, step around, and move side to slde or oler
I84 iEACH]NG II4OTOR S(ILLs TO CH]LDREN WTH CEREBRAL PALsY AND SII\']]LAR AIOVE]\4ENT DiSORDERS

something. It takes time andpractice, and more practice for them to coordinate their
movements and improve thet balance.
The same is tr[e for beginning walkers with cerebral pa1sy, only more so. Waiking
will improve with practice. Easy opportmities for walking and successful attempts
will encoumge them to walk more and find new challenges just right fo, them in their
environment. Atthis point, parents need tobecome good obseNers, notice what their
child 1ikes, and be responsive to it.
Parents may like to plan ahead, structure their day, and be productive. It is not
always convenient for them to stop what they are doing and relax, j ust to watch their
child try something new and be ready to provide assistance if necessary. Yet, this
approach is the most helpful for their child. Instead ofdirecting their child to walk,
thempists recommend that parents mal(e the environment "walker friendly" and let
the child take the initiative.

Making Walklng Easy

. open areas or hallways will help your beginning walker.
. I(eep clutter at a minimum.
. Have your child or children play in one area and l{eep the rest of
the house open for walking.
a Remove throw rugs or mats and keep your house well lighted.

Areas for PIay ln Standing

Beginning walkers like to play irl standing, and the
more opportunity they have for such play, the more they will
walk. If they have to get down to the floor in order to play,
theywill most likely stay there and not practice any walking.
Although they know how to stand up, it is not easy for them
and crawling seems more convenient.
Here are a few ideas for play stations in standing.
o A play kitchen with a child's table placed next to
it may make a good standing play area.
. A large play table with a rim will provide an ideal
surface for your child with cerebral palsy and her
siblings. The rim prevents building blocl(s, puzzle
pieces, doll furnishingsJ or cars from falling off
(photo 15.1a). And ifsomething should drop to the
t1oor, holdin3 onro the riln rrill provide e)itr a secLll ilv Ior l,our
child as he beDds clo n to retrie\.e ir lpholo 15.lb).
) TheheighLol th{r t.blcshown mayh. arlj1] str:d asyour
chiLl gr or,,s (t:rblc rourrcs\. of Nilo to\.s).
. A card trLre placr:d in a co|r.rr [1av pror,ide a large enough
srLr iilce,,vhcrc a t. l lcr chi cl lnay plal-r",.ith cat s, .icLion 1 i!torcs,
or Llolls.
. T$,o kitchrn chairs rvith a \,r.ide board placed ovcr rhr:m and
streppcd dowr \,\,ith bunslee cords may alic; plav table ior a
smallrlhilcl.
. Ifv(m have lou lrindor\:sills, \,orn child can use thetD as a plav erce.
 A]\D r\lORE 185
''JAL(ING

. An eascl rill pro\iide a1l oppor

tLrnity for )-o!r chjld t.r sran.l anr:l
color or ling.rrpaint (l)horo 15.2).
. plal w,ith n doll carriate .rr a play
t shopping cart \,!il1 encoLll.age
sranding an.l rvalliing.

Reasons for Standing and Walking

,i" a Whene\-er voLir child tranLs a
sl1ack, have hinl srald up alld
choose somethin3 our oithe t efrig
erator (photo 15.3). fhcn pli1ce ir
on the countcr oi l(itclt(]1t table.
a When washi[B his hands or facc,
have hira stand ar thc si.k. WheD
15.2 75.3 he is done, l* him go the to1rcl
and use irbvhimself
a Whene\,er you go somewhere with your child, do
nor caft v him
bur har,e him walk with you.
o Send him to give messages to others in the family.
For example:
"co te1l Dad itt time to go to the library,,; ,.Go ask Sarah what
she
wants to ddnk.,,

Walking and Hetping

t,\er,hetf rlrL parenrs..the beginnijrg walkcr cir
,....-.llll",,n1lr,.l
D\ pr \f lnii \olrrfthxrg
help _\,ou

. r\sli him to help Mom push the l(itchen chairs ro Lhc tabLr rn(
pi aise him for bcjng n good helper.
a Ask hitr to push the (iairs a\,vay 1\.hcD
].ou vacllur itnd later DUsh
r r- r o;,., 'rrfl,
. A pla_v shoppins (atL js iLleal lbr rrore hcipin[l tasks. Ti
e Lo
cleirn Lrp'l 1tilve hiln load rp his shopping cair aird r,r,
alk rhe Lor s
L.,I ,.. r'.. - , o,.,. ',np ,, / nrrp" t.r ,r. -o:rc ,
napkins, bxns. n1a\.be silvert\.are into hjs sh{)pping
cart anrl prLsh
rhe cart ro dtr: tablc. Frien.ls co.le Lo visir?-fl,,it]t yotr.hclp.
hr
can pul ca11s of colLl soda and a bag of ctrips lnto his
cari and
tali(: Lhcln to rhe gues.s.

Clutter Comes Back

-l.' When \,()u obset Vc tha..".oor child t!alks vvilh rrore confiden.e.
rrl"t i,F.;
scc iihc is r (:ad !

. Put rhe rhro\\ rlLlt (x.Jnat ba(hi. placc and see ifhe ran t\,a1k o\ el
it irhoLir rrippjng.
. Thc laundrl baskelsjttrngtl Lhehalh,r.rvmal, be a \,tektonle obtect
.,. t. .,r
-.
C,mril tn e.p.n.,t1 rhrn8\ rnLl roys ouL ofhis ,ay,
, l,,re .. howe\,er. IL ma1 .ake il
'
.i, .. . , l..n,.r r o. i.-
3
186 TEACHJNG MOTOR SKILS IO CHILDREN WITH CEREBRAL PAISY AND SIMILAR ]\/OVE|\/]ENT D]SORDERS

Carrying Objects
Have you observed your child cafying a doll, stuffed animal, or aball? Ifhe does
so without falling or tripping you may ask him to carry things to be a good helper.
a After you have helped your child out ofhis coat, ask him to take
it to the closet.
. Instead of having him use his shopping cart, you may ask your
child to hand carry the napkins and other items to the dil1lrer
tab1e.
. Ask him to go and get the book he wants you to read to him and
to put it back on the shelfwhen you are done with it.
a Put his favorite videos or DVDS on top of the TV or on a shelf, so
he has to stand up and walk over to the TV to get them.
Soon your child will enjoy more difficult tasks.

Opening and Closing a Door

sliding door,like a closet door, willbe easiest to open and close (photo 15.4).
A
For safety reasons, you will have to watch your child as he tries to open or close
the door. This will be time consuming
for you. But ifyour child takes the ini
tiative and wants to do it, you may be
surprised how fast he will learn. Once
he is able to open the door safely on his
ownyou may encourage him to use the
sl(ill and be a good helper by putting
things in the closet.
Opening and closinS a regular door
may be more than he can handle at this
time (photo 15.5).Ifyou obserue him t(y-
-Y ing to turn the doorloob and it proves to
be too difficult for him, talkto his thera
pist and fo1low her advice.
15.4

Cleaning Up
Cleaning up a LrLLnch ol Lor,'s
strel\ill over the llool is ir Lig jol). It
meaj1s bendirl8 do '., c{)mi11g up.
c.rrryirg the toy. erLl plir(:i1lg it r!hcrc
it bclorgs (ph{).o 15.6.1. Starr b\.ask
ing your child to clean rLp trvo or
rhrce ite11ls and praise hi1Il 1ir1 it. I1'he
does u,e11. har,e hilrl prLt i:r\rir\' rnor(l
ite[rs rhe lollorving \\,ccli. Yorr fra," t(^
be surplised h.r\\,prorLd hc rlill hc to
d.r this. If hc hirs lloT previousl)'been
rcsponsiblc for putting his ow .1irt!
dotLcs in the hamper, this is e good 75.6

trlne to starL.
 !r'At (iNG AND trlaRE 187

WALKING OUTDOORS AND IN PUBLIC PLACES

When your child walks indoors faom one room
to another without holding on or falling, he may
also want to walk outdoorc. This will bring new
challenges fot him. He will have ro tackle wide-
open spaces and will encounter rough, uneven
surfaces that may be littered with deb s, small
sticks, stones, or leaves. His arms will be out-
stetched at his sides as he concentrates on walk-
irg (photo 15.7). It will not help to hold his hand
because this inrederes with his abiliry to use his
arms to balance or catch himself. Holdiflg onto
his clothing will be equally counterproductive.
Instead, consider the following suggestions. 15.7

Easy Walking Outside

a If you have a porch ot dech have your child venture out onto it
on a dry day. Let him explore it on his own. Jusr watch that he
doesn't ffyto step down ftom it onhis own.
a Ifyour driyeway is level, he maywall( there next. park your car in
the driveway and have him walk to and from it when the two of
you are going somewhere or are returning. When he is not being
distracted by other family members, yollr child will have the best
chance to walk the distalce successfully. As he gains confidence,
he will be able to show off his new skill to the rest of the family.
(Don1 try this if your d veway is not level, or nearly level.)
a Park the car further away from your house and therebyincrease
the distance he will walk.

Walking on Grass
Your child mrv want L.r 1.-itll( to \.out s\ving sct, sandbo\. oi splashing p.r(,l. lLl
gctrhere,hehirsto$.alkorcrgrass(photol5.SJ.Uralking{)r1rne1:ersLLrl:ir(,,::u.,1
asa1a nisrotcas\,,butltjsgreatexerciscandilhesturrhlcsrl1t]tegra;s hat!lej!
likel),Lo hurt himseli thai if he lalls orr :rspha1t.

Walking and Playing

g AfiervoLLrchildhasgaine.lthcconlldenccr),,\,alktohispr.cti]lredoLirsidr:rlrr.r:.
trer:,; x he \'vi11r'l,-ant to plal.rhere tr ith siblin3s or fr'icnds.
. Plirlint in rh. sdndbox \"'ill lre the salesr ilDd mosl 1u. l,!r\ ilr
your besilning walker r{) plal.oLltsidc wirh other chiLlnrn.
a Atthe sr'!ing sa,r. _loLl mir\ hrr'e apiecc ()f a,(lLipmentsUch rs ai la,l\
slide or safc swrng scar that he can use and enjo\.
.qffi . Pla! ill the dri\.e!!al poses a prohlc[r Ior a bcginni[g lt a]k.r rt iril
tcrclrral pr1sy. Ihe sale r'iding toys are oftcn roo sntall rirrri rue
!FE{Ef} ([cs oI Lhe rjghr size eru: ofrcr roo clifficr:lt to pedr]. hsr.rd o!'
7.5.8
helpin8 h irn to get inro or on a Iiding to\i atld push i])g htr arot:|11.
I88 TEACHING l\,loIoR S(ILL5 To CHJLDREN !?ITH CEREBRAL PALsY AND SII\4]LAR [4OVE]\4EN] DISORDERS

your child may have as much fun and get more exercise if you
encourage him to push a toy. You may bdng his shopping cart or
baby cariage with his favorite doll outside for p1ay. He may enjoy
pulling a little wagon or pushing a play lawn mower.

Walking in a Malt
Yo[ maybe reluctant to have youl child walk into a store, the libmry, or any other
public place. Perhaps you wolly thar it is too difficult for him. Carying him or pushir8
him in a stroller is safer and easier. You are right in your assessment. Walking il1to a
library or a big crowded mall is tricky for a beginning walker. Being in a busy place with
al1its distractions makes it harder for him to baiance and concentrate onhis steps.
Go to an indoor mall when there are few shoppers and see if your child is ready
to walkaround.Ifhe is able to cope, have himwalkas much as he likes. provide safety
by having him stay away from escalators and automatic doors that swing open. It will
be great practice and exercise for him. The newness and excitement of the experience
will make him walk for longer distances and teach him to focus in spite of rhe many
distractions. It will provide valuable tmininS forwalking in school.

WALKING STAIRS
The more Marion walks, the more dadng she becomes. A couple of times she tried to
walk up the stairs but then decided that crawling up was still easier. When she wants
to come down the stairs, she sits down and scoots down from stair to stair. Dudng
her therapy sessions, Madon practices stair walking, and as she makes progress, her
therapist asks her pareDts to walk stairs with Marion at home.
Stairwalking is an important daily living skill. Masteringirwill give youl child
more independence. Walking up and down stairs strengtherN the leg muscles and
improves coordination. Stepping up, childrei leam to lift one 1e8 high while standilg
on the other leg. Stepping dou,.n, tltey leam to slowiy lower one leg while bringing the
other leg forward to stafld on it.
If your house does not have stai$, use the step up fuom the garage or from the
front or back door into youl house for practice. As there is no handrail, have your
child hold onto the dooframe i[stead. Practice the one step srep up with youl child
similar to stair walking.
The following are examples ofways to pmctice stair walking. Use them as directed
by you r ch ild's therapisL and lollow her specific in\rrucrions.

Walking Up Stairs Sideways

L Asl( lrur chlld tlr srard sidelrays facing the raili11g and hold onto it l\,irh
boLh hinds.
2. lf his risht sid! is closest ro LIle stair(asc. ask him ro lift his right tboL up onro
Lhe first stair. lean ovcl th. r ighr 1e8, push, and srr aighten ir \"-hilc lifrinS rhe
lcft foot aDd placin.q it neril Lo the righr tbot. and then srand straighL.
3.llale rour child mor,e his hands up the railing and step up onto rhc next st.tir
the sarre \1,:l! ind so on.
Alsoha\.cvoulchildpr'a(:ticerhislvithhislctiiegsteppirrg pfirstif\.oL[stajrca\r
has rails on both sid.s. Dorot pracLicc !"-irhout a handrall for vour child to hold ol1to.
Good rilils o,,.ide saletv nnd malie srair \,-alking easier lbt lorrr chikl.
pr
 WAL(ING AND I..4ORE f 89

Variation. Ifyorr child caonot step up or ifhis knee turns irr:

1. As above, have your child face the rail and hold onto it. Help him step up with
his ght foot. The foor and knee point srraight forward toward the raii.
2. Place your righr hand over the righr knee and stabilize it.
3. Place your left hand on his left hip and help him come up and place his iefr
foot next to the dght foot.
4. Help him in the same way to step up wirh his lefr foot firsr.

Walking Down Stairs Sideways

Fimt have youl child practice walking down the last few steps. Later, as he im
pfoves, he maybe readyro rackle a whole flight ofsrairs.
1.Ask your child to stand sideways facing the railing and hold onro it wirh
both hands.
2. Stand a step or two below and guard himwell.
3.Ifhis right side is closest to the stair, ask him to lean over his left leg step
down wirh his right foot by slowly bending his left leg, and place hii right
foot on the lower stait.
4.Then have him srep down with his left leg and place the foor next ro the
right one.
5. Have him move his hands down the railing and step down onto the next stair
in the same way and so on.
6. Nexr have him practice rhis with his left foot stepping down first.

Variatiot. Help youl child ifhe canrot step down

or if his knee turn s i n :
1- Place your lefr hand over his lefr knee and your
I
right hand or his dght hip.
I
2.Ask or help him ro poitt his knees ard feet for-
r ward and shifr his weight ovet his left leg.
3. Stabilize his left knee as he bends it and puts his
dght foot on rhe lower stair. Have him put his left
foot down beside it without your help.
4. Help him in the same way ro step down with his
F left leg first.
Note: When yolll child is able to step sideways up
and down stai6 safely, have him do ir withour any help
(phoro 15.9).
15.9

Walking Up Stairs
l. Hal,e \,(^rr child hold orto rhr railing r,r,irh his right hard and srand r! jrh \1!
iect poirting iortvar d or-slighth, {)ur$,ar.l.
2. Hold his elth:rndan.l(]ncoLlragehim.ol,!alkupthestairsr,,,,ithl,oLl.Forltlorrl
assjstance, \'oLt ntev srLppor t his rpper ar.nr t\iith ()re ha.d irncl his han.i ,r irl1
your othcr hand (photu tS.i0)
3. Have him place hrsr the r jghl loot and rhC]t the lcit loot on each stnrr.. ConrinrL.
't lrre.! ro..l r".
,l.l\t a later .ime hirye hrm hold onto the railrDg r,r,ith his lefr hrnrJ anrl rrcp up
r,ilh his lelr tbot tirsr.
IOO TEACHING ]\4OTOR sKILLS TO CH]LDREN I/ITH CEREBRAL PALSY AND SIA,1ILAR MOVE]\,4EN] DISORDERs

Vaiiation. Assist your child ifshe cannot step up or if her knees or feet turn in:
1. Have your child stand at the bottom of the stairs holding the rail with his left
hand. Stand at his side and help him lift his right foot onto the step. Ask him
to point the foot and knee forward.
2.You may place your dght hand over his right loee and stabilize it as he brings
up his 1eft foot and places it next to the right one. With your left hand Suard
him from behind.
3. Next have him hold onto the railirS with his right hand and walk up with his
left foot first.
Note: Encourage your child to lean forward as he steps up. Do no r have him lean
backwards.

Walking Down Stai15

1. Have youl child hold onto the railing with his lefthand and standwithhis
feet pointing forward or slightly outward.
2.Hold his right hand and encourage him to walk down the stairs witll you.
Havehimplace firstthe left and then the right foot on each stair. Continue
u a lking wirh hinr down the fl iSht of sLa irs.
3.At a later time have him hold onto the railingwith his right hand and step
down with his right foot first.
4.Have him practice walking down on his own when he is ready for it
(photo 15.11).

Vadation. Assist your child ifhe cannot step down or if his knee turrs in:
l.Instead of holdirg his hand, stand two or thlee steps below facing him.
Place your left hand over his right knee. Place your right hand on his left
hip or hold onto the handrail.
2.Ask and help him to stard with his feet pointing for-ward and to shift his
weight over his right leg.
;
3. Stabilize his knee as he bends it and puts his left foot on the lower stair.
15_11
Have him put his right foot down beside it without your help.
4. Help him in the same way when he walks down holding onto the railing
with his ght hand and steps down with his dght leg first.

When to Practice Stal] Climbing

The best time to practice is whell your child needs to come up or get down the
stafus for a reason. Instead ofsetting an o.laa practice time, make assisted or supervised
stair walking part of your child's daily routine. If your child is independently crawl-
ing up aIId scooting down stairs you may be reluctant to change this. Helping him to
walk down in the morning and up at night as well as other times during the day will
take time. Yet the 2 to 5 mirutes it will take to walk sraiis wirh him will be timewell
spent. It will get him used to a stat walldng routine. With constant practice he will
become able to climb stairs all by himself earlier than he otherwise would.

More Advanced Stair Climbing

After your child is able to step up or down by placirg both feet on each step, pactice
with him altemately stepping up or down by placing only one foot on each step. If you
 \T/AL(]NG ANI] 4ORE I9I

have practiced stepping up with either foot, your child may leam to walk up alternating
his feet rather quickly, as long as you hold his hand. Walking down alremaring feet will
take more practice because it requires more coordination and balance.
Walking up stairs alternating feet wirh one hand on the handrail and not holdilrS
your hand will challenge your child's balance. When your child walks independently
up or down the stairs, have him choose the way he feels safest. Initially, he will most
likely walk up and down sideways holding onto rhe railing with borh hands. Later, he
may walk up facing forward placing both feer on each step while conrinuing to walk
down sideways. With more practice, he may choose to alternate his feet as he walks
up the stairs and come down facing forward while placing both feet on each step. Last,
he will feel safe enough towalkdownstaifi alternatingfeet onhis own.

lmproving Balance and Coordination

Marion is walldng. Shewalks around thehouse, outside, and up and down stairs. She
never crawls anymore, but wall(s wherever she wants to go. Her parents are happy for
her. At the same time, they cannot help noticing how unsteady she is. She is able to
walk up the wheelchair rarnp at the library but needs help walking down. She cannor
step up or down a curb. At home they constaltly have to remind her brother to c]ean
up his toys. Anythilg in Madon s way may cause her to ffip. Even stepping over a
Matchbox car or train tracks is a big deal for Marion. Especially at night when she is
tired, Marion easilyfalls. Her parents wonder how they can help Marion.
Further improvement ofthe coordination of their leg muscles and theirbalance
helps childrenwith cerebral palsy to acquire rhe additional sldlls they need for safe
walking. When the children firstwalk, they take short steps.In order to step over an
obstacle, they have to make a big step and bring their leg up high. The same is required
when they wa[t to step up a curb. To do this, the children need the musc]e power to
lift one leg high, the balance to remporadlybear all rheir weighr on the other Ieg, and
the control to s1owly bend or straighten thefu legs.
The next activities are designed to improve yor1r childt balance and practice
controlled up and down leg movements. Use them as directed byyour child's therapist
and fo11ow any specific instructiols given.

fi l(ing of the Mountain

1. Pl!.r: ir stcppillg stool ill ir safe place in thc middle of the roor| ir\r.r.,
tr(nr tirtrlilrrie or if fra)llt oivoLlr bcLI or your couch.
2. Har,c voul chiLl ho 11 onro lour hrncl, stcp up on the sLool. rnrl srilDd itl
the middlc ol i.. His teet point str:ighr foffard or slighrh .ur ned oiLr.
3. IncoLLr'i]gc llinl ro sLa nLl ri(, and ta1l. lel g.r ofvorr hand srLpFor-r. :rJ
sLanLI {)1l his o\!i1.
.+.Cornr togerhel ho\r long he can st.n.l illl by hxnselt. clr.,! d hir]l
rrrll rnLl intmer:ljirtr:h help hiin to srcp do$'r u,hen hl i! ica.i,. 1rl
'l becotles rLrstcacl,".
Variation. Tf !our chlld docs \r,c1l, 1eL hinr play ](illg oi rhe \l.runr:irl
1

I while trlor,r,ing brhb es (photo 5.12) or prelendi.g to bc an ellLelLiLincr aitd

sirr8ing lor \'(nr. Continue ro gr:atd hin closcl\, \,r,hile he sLands .n .he stool.
T92 TEACH]NG A,IOTOR 5KILL5 TO CHILDREN wilH CEREBRAL PALSY AND 5IMILAR ]\,IOVEAIENT D]sORDERS

I *
a
e hl&
J ,,48
t
a I

PIay in Squatting - Ptay in Stan.ring

1, Place an interesting toy on the floor and have yotll child squat dowo and play
with it. Make sure his feet are flat on the floor and pointing forward or slightly
our (photo 15.13a).
2.After some play, slowly lift the roy (photo 15.13b) and encourage your child
ro slowlysrand up (phoro I5.'l3cJ.
Variation. Have your child squat and play with blocks, a stacking ring, a puzzle,
a Color Form board, etc. Stand next to him and hoid additional blocks, rings, puzzle
pieces, etc. Have him stand up for a new piece and sq[at again for more play.

Standlng on Foam
Another way to imprcve youl childt standing balance reaction is to have him
-s stand on a piece of deose foam. (For practice at home, you maybuy a 3,,rhick 16 x 16,,
* square piece of dense foam in a fabdc storeJ
Have your child hold ooto your hands, step onto the foam square and stand with

r .-i
his feet pointing forward or slighrly tumed our.
1. Encourage him to stand flice and tall, let go of youl hand support, and stand
on his own (photo 15.14).
* 2.Together count how long he can keep his balance.
3. Have him hold onto your hands again while he steps down.
Variation. Ifyou child does well, you may place the foam square in rhe middle
of the room away from furniture and have him hold and bounce a ball while he stands
and maintains his balance-

Half-Standing in front of a Mirror

Ixer cjscs in hlrlf strndl1rg har c beej1 r ecomrrended pr.cvioLLSh,ioi srretching rhc
calfmusrlcs and intpro\ rn.i ritc c(xrrdination rnd balanr ofthe !rc;,rht:r 1eg oI a smail
chi1d. Thr:v ma,vbc uscd tbr Lhc same reasors ,,vith an oldcr child r,rho is alreadr rvalk
n1g. Hillir stand irg r.. ilh eilhcr tbor do!\,n 1.. 1 t,,.f fr pp illi,,n t ,i sl<ills th rr i"!u1rc
shortperiodsoiiinBle1egsrandlngsr-rchos:t.irf lBl glr,,rppj[3up nddor,na
c|rb. or cli rl)ingsrails\r,irhouLhol(lillgo11toerirlling.Usrrhernas.lircctedbt\oul
' r'p.r I
 U/AL(ING AI]D [4ORE I93

1. Place a stepstool or low bench in front of a full length mirror or glass door.

fl
4r
cather the necessary supplies-shaving cream and foam blocks or foam animal
shapes, aswell as a towel, washcloth, and sponge for clean up.
2. Holding onto the millor, your child places one foot onrhebenchwith the knee
ard toes pointing forward. The other leg is straiShr ar the hip and knee and
the toes also point foaward or slightly out.
3. Spray a blob ofshaving cream on the miror and encourage your child to spread
it all around (photo 15.15). Show him how to dmw a picture in the shavins
r"eam. maLe handpr inrs. orsricL foam an imalshapes ro r he m irror and rhen Jei
him continue to play as long as he likes. Irwillbe OK with you ifhejustmesses
the shaving cream all over the mirror. protecthim from falling as needed.
4. When he is done playing, have him half stand while he cleans up wirh a big
wet sponge. Sloshing it over the mirorwili be more fun and good exercise.

15.15

Standing on One Leg

Standing on one leg is rhe most difficult balance skill. If children rnaster rhis skill rhey
may progress to more advanced skills such as walking ol a beam, skipping, or hopping.
Parents may star practicing supported one leg standingwit}I their children before they
are walking (See Chapter 14, under the heading ,Assisted Staflding on One Leg,,).
For more one-leg standilg practice, use the following exercises or activities as
directed byyour child's rherapist.

Standing on One l-eg at a Wall

1. Your child braces himselfwithbothhands
against a wall.
xtl E
-# 2. Ask him to shift his weight onro one foot,
make sure the foot points forward, and
l'.1;i$
the4 lift rhe other foor (photo 15.16a).
Have him:
{ a Count how long he can stand on
one leg.
. Do 10 knee bends with his
t .
standingleg.
Come up onto toes 10 times.
3. Have him practice the same way while
b- standing on the other leg.
Variation A. Have your chiid stand
sidervays and s!pport himself with one hand
against the wall. Have him practice standing
15,16b on either leg as before.
Vadation B. Have your child stand side.lvays
and suppot himsellr,virh iusL onc finger on thc r,a1l r,lhjle he tr ies ro sran.1 on ciriLer
lcg for 1.5-30 seco..ls (d1or.r 15.1arb). 11 hc is able to do this, lrar.c, him erLrrcise as
bcfore .lo 10 knee l)cnds end 10 heel risr:s.
I94 TEACHING ]\IOTOR SKILLS TO CHILDREN WTH CEREBRAL PALSY AND SII,4]LAR A4OVE]\4ENT D]5ORDER5

Standing on One Leg

I'or children with cerebral palsy, the easiest way to stand on one leg is to lift the
other leg out to the side. This way they can compensate for weak hip muscles. The
following exercise has you practice thiswithyour child.
1. Your child stands with feet pointing for-
ward or slightly outward.
2. Stand very still seveml feet in front of
your child. Ask him to shift his weight
onto one leg and lift the other leg out to
the side (photo 15.17).
3. Calmly count with him how long he can
balance on one leg. : I1ffY':
4. Have him practice standiog on the other
leg the same way.
Variation. Practice with your child the
same way, but askhim to lift his footback and
R fl
up bybending his knee.
15.17
One-Foot BeanDag Game
This activity makes standiflg oII one leg fuIl and is a good exercise to
lt&', use during plaltime. It encourages concentration and good standing posture.

ffi (-r Beanbags and a shallow box or container are needed to play it.
1. Your child stands with his back at a wall without leaning agairst it.
2. Place the box in front ofhim and put a beanbag on his foot.
3.Ask him to lift his foot and drop the beanbag into the container. If
he misses, let him try again. Ifhe succeeds, encourage him to drop
another beanbag into the container, and so on, ulltil all the bags are
in the box.
4. Have him play the same way with the other foot.
Variation A. If your child does well, have him move away ftom the
wall and let him play in the middle of the room away from any ftirniture he
hi) could fall on (photo 15.18).
43 Variation B. Ifyour child does well and the game becomes too simple
for him, challenge him by placing the box on top of a stack of books or srool,
or use a taller contaioer. Now youl child has to lift his foot higher and stand
longer on one leg when dropping the beaflbag into the container.

The Way Your Child Walks

Nfirrion hiLs bcen rtalkin3 iot serr:rrrl ,!rirrs ror,-. Hel balarlce anrl enrlrrrntr ha,.c
impro\.ed. She l1o 1.n13e! hrr io hol(l onto her uroLher's ]rand !\herr sh. srcps Lrp onto
acurboru.alksdo(,nrr)ilr(lrnc.Hctpxrentsarehnpp].1orltL:r-:Lrrltr.cl blcssed Arrd
l'el. ilL Liirles Lhtr obs|r'"c NJnrioll a1ld hope sht wouLl rvali r.r'cr betret. InsLead of
sLepping str.righr for \frrd. she sr{ings hc. Lrgs rnrr to the stle an|1 Lhen Ln-ings rhrl
lirr'\ ir.l. \,Virh circh stc,p. her hodr s\\ r\ s from slde to side, and rl..hen sltc is rir cd her
lcf. lbot nr ns il .
 !,AL NNG AND ]\IORE 195

Madonk story is typical for children with cerebral palsy who walk independeDtjy.
Because ofthe abnormal muscle tone, muscle weaknesses, and lack of coordination
and balance, theywalk differently than children without these problems. How much
their gaitdiffers varies from child to chiid. But usually rhere is room for improvement
and parents wonder how they can help their child walkbetter.
Physical therapists will rell you that tfte mo st import@nt thittg parents can do
is to keep up the daily stretchitTg routine. Because oftheir walldng pattern, children
with cerebral palsy do not fully stretch some of their 1eg muscles. Wirhour daily stretch-
ing, these muscles will shorten and the opposing muscles willbecome too long. Over
time, this may cause your child's walking ability to decline rarherthan improve.
Improyement oftutlscle strengtk coordittcttion, andbalancewillhelp the chil-
ilrentowalkbettet'. Swimmin&horseback ding, adapteddance,or gyinnasticlessuns,
or any other physical fitness or spots-relared acrivity will benefit your chi1d. So will
strengthening exercises and tlainiog progams with a stationa ry bike or neadmi1l, which
the physical therapist may plan for your child. (Dodd, 03; McBurney, 03; Lowes, O4).
Another way to bring ctbout improyetnetut is for the therapist to ttain the
child to walk differeitly. This is called go,it trdining. It is an obvious bur also a
tricky solution. Walking is a continuous, repetitive movemenL It not only depends o11
mNcle strength but also on the timing and sequencing ofmuscle activity. Scientists
are studying how people walk and still have many unanswered questions.
Most children with cerebral palsy walk as wellas they are able to. Just because
a child is told to step straight forward does not mean he willbe able ro do so. Every
study done on the subject has confirmed that childrenwith cerebral palsy use more
oxygen when they walk. This means that they work hatder when walking and there-
fore tire sooner than other children.
Physical therapists have two goals for their patients. They want them to walk
with more control and to do sowith less effort.
The children themselves alsowanttowalkwith as little effort as possible. When
their therapist or parent asks the1]1 to change rhe way they walk, they feel that this
newwayof walkingwill require greater effort. Usuallythis is true. ?he walkingpat,
tell1 the therapist teaches will reqdre morc work and effort and will cause the child
to walk slower Only later, after practice and more practice, will the "new" way of
walkingbecome easy and energy efficient. The process oflearning a new gait is very
slow. Gaittrainingisverybeneficial early on when childae[ firstlearn to walk, as well
as later on when they are older and self motivated.
cait trainins with a very young child with cerebral palsy seems ro b ngminimal
results. During the therapy sessions guided by rhe rherapist, the child maywalkwell
in paiallelbars. He takes slow, controlled steps, bdngs his legs straight forward, and
places his heels on the floor. Yet, when the session is ovet he will walk out the door
in the same way he walked in-using his unique pattern. His parents may wonder if
the gait traininS is worth all the effort.
In fact, it r$ually is worrh the efforr. The therapisr is reaching the child a new
way to walk. The child is learning it by walking slowly with supporr. He is leardng
a new pattern, and, as he practices, the new way ofwalking becomes easier. This is
valuable experience even if he is not able to integrate it in everyday iife outside his
therapysessions. Later, if the childundergoes amedicalinteruentiorL which improves
his muscle tone, the early training will prove very valuable. Then it will be easier for
196 TEACHJNC ]\,lOIOR SKILIS IO CHILDREN !(/I]H CEREBRAL PAAY AND SI]\,4'LAR A/OVEAIENT D]SORDERS

him to walk with an improved gait pattem because he will already be familiarwith
it and will now incorporate it into his daily life. or, when he is about eight yea$ or
older he may decide he wants to walk "tall" and a girl may want to walk "pretty."
Now the ea.lytrainingwill help him and may make it possible, with much additional
ptactice, for him to succeed.
The followiflg are examples of gait training exercises. Use them as directed by
yourrhe.cpisr and Follow herspecificinsrructions.

Walking While Straddling a Dlvider

This exercise is designed to train your child to step straight for-ward without cross-
ing his feet in front of each other as he wa1ks. For the exercise you need a hoop and a
divider, which may be purchased fuom a therapy equipment supplier or constructed
using a 2" x 4'board and brackets to secure theboard.
1. Place the divider on the floor. (lf using a

ir
r . board. place it on its edge so ir i\4
rall.r
2. Help your child straddie the divider at one
\ end, witl his feet flat on the floor and his
toes pointing forward. Stand in faont of
: him with ahoop for him to hold onto.
G}C , 3.Ask him to slowly walk with you to the
' other erld ofthe divider.
4.Assist him ro turn around and walk back
*' withyou.
walk several trips with you.
5. Have him
g variation A. when your child does well,
,,
encouragehim to straddle the divider andwalk
ifl { ''
very slowly on his own (photo 15.19a). Guard him
well because you do not want him to fall onto the
board. This is a very difficult exercise. Be sure to
praise him after each successful trip.
15.19b
Variation B. Instead ofa divider, use some
thing smaller. Place a rope, a plastic christmas garland, or wooden train tracks on

r the floor. Use your imagination! Practice as before. Have your child hold onto a hoop.
14{1en he does well, have him walk without balance support (photo 15.19b).

Walking Down the Lane

'i'his ex.rrcisc is foi childror h,ho \\nlk with a \,"ide-based gait- Itchallenges them
to step sLraighl foru,ard insLead ol ouL to the side.
1. Set up a \ra1kwill. rrl,o feet rvide ir a lar ge r oom, on ],or-rr pordr or dcck, or in
!our drl\,eway. xfark thc rvalkwa]'$,irh tape oi cha1k. or LLSe \'\,ooden slals as
used for flooring or thick ropes to create barriers.
2. Ha'rc !orr chilLl stand ilt onc end ofthc w:ilkwaywirh his ltet 1'1at on the floor
j and his toes polnting tbrr"-ard.
I 3. St:l]1d iu front ofv.[ir dlilLl wirh e hoop fin-him to ho]Ll onro a.d har c him r.-elk
I
dou.n rhe lane u,ith vou. Ask him to sLay u,ilirin the llralkrray anrl noL step on
thc brrri(Js.
4. Iihe does r"-ell, have hin] l"-alk dou'n the lane \\.iLhout sLrpporL (photo 15.20).
Encour;rgc him to take many rrips up and do(rr thc lane.
15.20
 \I,,AL(]I.]G AND ]\IORE
'97

vadation A, when your child does well, gradually increase the length of the
1ane. Walking longer distances before stopping will affect the ease with which he
walks and will make his Sait smoother.
Vadatiol B. Whe[ your child does well, make the lane a few inches narrower
and have him practice as before-first holding onto ahoop and later without support'
Beginwith a short distance and Sradually increase it.

Kicl( and SteP

Marian had difficulty stepping over a toy on the floor. This is a common problem
for children with cerebral palsy. To step over somethiflg, children have to balance on
one leg while they lift the other leg high, straighten the knee as they kick the foot
forward, and then place it on the floor. Camdofs family developed the next exercise.
They first practiced with Camdon as descdbed in Vadation A. when he improved,
camdon practiced with his Dad, and Mom took the photo onthe left (photo 15.21).
1. Place 3 to 5 wooden slats on the floor-just the ght dis
tance apart for youl child to step over and between them.
2. stand in front of himwith ahoop for him to hold on to.
3. Ask him to lift and kick out his right foot and step over the
first slat. Then lift and kick out the left foot and step over
the next slat and so on.
4. Have him practice as long as he likes. You want your child
to develop a fluid and easy stepping Pattern.
Variation A. Ifthe exercise is too difficult for your child, have
him p{actice stepping over one slat while yor hold one or both of
his hands. Have him practice steppingwith either leg.
,f
: Vadation B. When your child is able to step over the slats
with ease, have him practice without holding onto the hoop. This
will challenge his balance skills and get him ready for real-life
situations when he will have to step over obstacles in his path.
15.21

BRINGING FEET CLOSER TOGETHER WITHOUT TOEING IN

watking Atong a Narrow Board
The next three exercises are for children who walk with their feet far apart and
with theirtoes turned inward.In oider to do the exercises, the children may have to
r,r'alk vcr), slolr,ll' and concelltratc on each step. IIol(llnll onlo a
hoop rvill he]p thern initialh'. Use the cxercises as directed b! \ oor
l, .1. .1 r jl .r ' r. lo .!1 r'.. P' l I ' '
1- Place sevcrnl r"rooder slats in a or'on the floor and hrr rr
r

P- '!q ]olrr child streddle them so Lhal his h.rels are \'.r1 closelo
thc cdSes and his leel are poinLtrg, lbnrard.
4 2.Askhi Lo,,va1k vcr]'slo\,-1-v, ah"/a\.splaciDghis heels rlose
to rhe bar'r'ier1\'ithout stepping orr ir wilh 1is f(n eleet fpho.o
15.22). lf ncc,-1ed, have him 1"ralk \!lth voLr. holdin!l orllo il
h(n)p or onlo sridis. Ifhe loscs colltlol and places hjs heel
awa] irom the slat, .tsk him to stop, plar:i: his Ieel into thi
srarrin!l position and thel1 begin to ll/alli agein.
I98 TEACHJNG A,IOTOR S(ILLS TO CH]LDREN WITH CEREBRAL PALSY AND SJI\,4]LAR 1\,1OVE1\4EN1 DISORDERs

Sliding Along
When wearing thick white socks, your child can practice the following exercise
on a smooth and slippery floor.
1. Have your child stand with his feet staight forward.
. 2.With a marker dmw a fotward pointing arrow on each sock. These arrows will
give him a visual cue that will heip him keep his feet poinring straight ahead.
3. Now askhim to keep the feet on the floor and alternately slide them forward
as ifhe were skating.

Walking Straight Forward

1. On a piece ofcardboard orposterboard, draw
two arrows about 1.5" inches wide and 4to 7"
inches long. Cut out the arrows aod tape them
onto the tops of your childt shoes so that the
arrows poiflt straight forward. The arrows
should extend less than an inch beyond the
shoes. Otherwise they may cause your child
to trip and fall.
2. Ask him to walk so the alrows will always point
iorward (photo 15.23). If necessary, ask him
to walk very slowly with you and hold onto a
hoop or two sticks you hold.
H
15.23
WEIGHT BEARING OVER THE HEELS
When childrr:n rvirh cerebril pals_\,sran.l, rher-mavha\.e lorr ofrhcir wei8hL shifted
ol'c r thcir foreleet insLead oft:qralll,clistributed ovcr th.ir forefeet and heels. T,carn
ing to stard and biilance \rith 50 pcrceilr or rtore ofthcir r cighr o1-er rheir hecls uill
bc benelicial lor rhrsc drildrerl. Lr illcreases thc sizc oftheir base ol sLrJrpo r. This rill
alsoimproYeth{:irsta[dir1gL]alirnc.iIlrhcbackl\,arlldirecrir)|-iorinslance,iJ'Lhc!
are pushed Lacl vrrds thev\,-illl)ral)lcrcusetheirheels()hclpnraintaillLhelrLal-
ance and prr:r,cnt a fa11. ]L ill rrirk. ir casier for Lhent to srcp backllar.ds and it mrLr
als.r hch rhcln to put their'hC(:ls dou,D tirsL as rhe! irr'c l.-a1king lbI1xard.
Thc nerr exerclscs r r irir rieltht bearinil o\1rr rhc hee1s. Use rhrrn irs cli; ecred bv
forr (hi1d\ Lherepist.
Standing with Toes Up
. Yi)rrr child sLanLls r.-irh his back agai st:r r.-all and his Loes and
foreteet place.l (lnir sandba3. beanbag, or-% thiclistrip rl1'li)ifr
block. lFor : sma l I child, use onl\, ii .'2' thickness .]1 1orln hlo(h.)
No\l morc ofyour chil.l s l\.^ighris o\'erhis heels.
. Ask him no..o leiu ior\rrr d brlt to relan. srand so;rig rt, and lelt
esninst thr $Ja11 il nec|ssar \..
. Hir\,.r him sLanl:l rhis r!etitbr 3 5 mi.llrcs \.,,hi1e qLLierll plaling
wirh a handh.ld to.".
. When],our child s balance has impr o,.,ed. har;e hinr prir.ri(e stand
inr arlar trorr the r'r,all 0)horo 15.24).
15.21
 ltiAt (rNG rND i\XaRE 7qE

Step Forward Standing with Toes Up

1. YouI child stands sideways next to a wall ready to sup-

fl'. I port himself with ofle hand as needed. Ask him to stand
with one foot a step ahead of the other, with knees apart
-!a and toes pointing for-ward.
2. Place a sandbag beanbag, or y/ piece offoamblockunder
F his toes and forcfeet.
3. Encourage him to relax, balance without holding onto
the wall, afld quietly play with a handheld toy for 3 to
5 minutes.
4. Wheaever your child is ready, have him practice standirg
like this away from the wall while doing ar activity such
"\ygtrP \:rt- as shootingbaskets (photo 15.25). Have him pracrice with
either foot forward.

Frequently Asked Ouestions

A, "We belieye that gait training exercises may help our daughter MyIa. Shouldwe do
all of them with her?"
A. Mylat physical therapist. He will tell you which ones are right for
No. Talk to
Myla. Most likely he will pmctice them with Myla and then show you how ro do
them at home.

A, "Should, we do the exercises with Mylo e1,ery day?"

A. Yes, daily practice is best. If this is not possible, do them several times a week

a. "How long should MyIa practice the exercises?"

A. Keep the exercise rcutine up as long as Myla is making prcgress. I-ook for rhe
small signs of weekly progress. Initially, Myla may need to hold onto a hoop, walk
very slowly, and have to stop and fix her feet after a few steps. After a week or two,
she may only hold onto your finger. Next, she may be able to do more good steps in a
row, and so on-

O. "Ifrr.Iro.tiL..Jirr -10 ddyr Lilld r1,1,!ld /ll.tkrs n0 p].r;grcs.s |,irlt t/le f-r.f.isei. sftoxli
r.r sl.rr trrl.ti.inl:"
A, No, as a Seneral rrtle I rccoarmcrd thaa \!! use a neu, exercise lbr rhr'cc \!rcli.
befbre \-ou make a Ll.cision litir rhirt. I oddition, it\villel\\,irlrbcbcsrif\o1r rhilrtl
ar1_v concern aboLLt d)ar .\crciscs as sooll as possible \xilh N{vla's rhcl irllisa,

O. Olikr i.\ S r,ror'.\ old.-ll. har hrr/i x, Ikfig.(ir.c dg. 3. brrt he srill does rrot irli" .,,
rL,L1ilr in rr.srorL:. lrlr-v dolor r'..0rrun.rd tlrlr por(rrrs tdk. rh.ir chlld ro o ,rall? I rL,,rl,1

A. All children are Llilhrft]nt. Sillce Oli\.er does notlilic t.r br in ir srorc,l.orL made L,1i
ritht decision b),not tiikifg hin1 there. Nel.erthclcss. thar do€rs not nleaj1 Lhat anoLh.r
child coul.1 not b(:]l(:fi. froll1 r,"aiking in a nrrll.
2OO IEACHING A/]OTOR 5(ILL5 TO CH]LDREN WTH CEREBRAL PALSY AND 5IA,,1]LAR l\/]OVE]\,1ENT DISORDERs

A. "Our dqughter Kclren is in second grade. Her teacher wo.nts me to bring Karen's
wheelchair to school on library day because it wotrld be too far t'or Karen to walk to the
library. I know the distance and I know Karen can haidle it. Whot should I do?"
A. Talk to Karen's teacher and find out more about her request. Maybe she feels
Karen would get too tired from walking or ir would rake her roo long- Also talk to
the school physical therapist and to Karen. Why not let Karen walk to rhe library
a few times, see how it worl(s out, and then make a decision? This is the course of
action I would recommend.

A. "Tom is 10 years old,. When he was small he needed broces to keep him from toe
walking. Lotely he has started to walkwith bent knees and we have been tcLking him to
physical therapy again. Why did this hoppen and will therapy heLp?"
A. Children with cerebral palsy frequently starr ro walk with bent knees at Tom's age.
It is called a crouch or sinking gait. Therapy combined with spasticity management
wiil help Tom. There are several things you can do:
1. Help Tom do daily leg stretches. This will assure that Tom does
not lose the flexibility ofhis hamstring muscles and the ability to
straighten the knee.
2. If Tom is able to stand straighr, remind him to do so routinely.
Walking with bent knees puts stress on the knee joint. So you
want to make sure that he relieves the sffess and straightens his
knees when he stands. Another way to aeduce stress to the knee
would be for Tom to use forearm crutches whenever he has to
walk longer distances.
3. Have Tom do 15to 20 minutes of leg strengthening exercises 3 to
4 times a week. Tom's therapist will be the best person to give you
an exercise proSram. The exercises Lift Off, Wall Slides, andHeel
Rises, listed in the next chapter under the heading Extra Strength-
ening Exercises, could be part of Tom's exercise progmm.

O.'?oseisSyedrsoldondwalkingonheroltn-Butsheisunsteady.WeplanafamiLy
yacation at the beach. I worry that w(Llking on the beoch rl,iLl be too difficuk
for Rose.
What do you think?"
A. Walking in the soft sand will be more difficult for Rose than walking on a hard
slrlface. She may want to hold onto your hands. At the same time, it will be very good
for her feet. Walking barefoot in the sand will exercise and stretch her foot muscles.
Rose may have a great time playing in the sand. I would not be surprised if Rose will
enjoy the beach vacation very much.
Common sense safety measures should be followed. For instance, have Rose wear
a lifejacket and make sure a parent is close by whefl she piays near the surf.

O. 'Our ftorrsr sits o/l art e]twrion. \\ hct:l out' c ltildre:n |ltly .)rl a.s id., they /loye to 11,.r1li
up and dor|n ou| lorr'n o| di ilortrr: OuI dou3lttd,: r'is. r|d.\jr/ra dlogrlos.d lr/tl .errbrol
/rolry l4/. n].,rder rf ll shorrld rrroL,c ar a hrrurr on lclelgloundl,"
A. lviitand scc ho\'! his u.i1l de\.ebp. k irv turn ouL Lhat l\:alli]l g rp and dor,",.j1 vour
dri\-e$,al'or lar,n !.,,i1[ be ven, gooci cxcr'cisc for het. IiiloL. \.arLl c(]Lrld I ll!,a\.s mo\.e at
&s&&&

l6 s
0
s
{D

s
Extra Strengthening
s and Having Fun
6 00aa'oarlao

Strengthening Exercises
Strong nuscles r'r.r)rk irctter than rrcrli mrscles. Good nll:scle stretrgrh rr rJJ hil1p r.orrr
chikl to siL or stenrl taller. \\.alk bcft(:r and improvc hr:r endur.ance a .l sr:rtina. Be
ing ph1slca11_." fit helps all peoplc. rnrluding chikLrelt tvith cercb]-al pals\ or .qirnl,Lr
movemcnr disordet s.
So firr, the lbcus of this book has bc.n on reachirrg ncn, motor skills. ,\iiirr i eat s
of leirrniDg, there \"-ill (lllre a titte \rh(:n \,our child has rcached irer porenrial. She
rnal,clo \\.e11\",,jth hcr translir skills. She mav r,r,atlh safel1. She nla., uirlli staits ..rLi
llegotiaLe c!rl)s tvithout h.lp. 'Is there srill a need lbr rnote cxercises',,' l.ou r,-ot1dEt..
Yes. rhcrc is. Lxetcis.s r,r,jll help r orrr child maintain her skills as she gr.or,r,s olclcr a[.r
hcr body changcs.
Iror irlany (hildren \\,ith cerebrirl pals].. rransfcr skills or r,r,elliirg mar nerr|
become easr a!tonalic si(ills bLLtall\,i]\!reqlLiresorrcexuaatte|tionatldeiiiia. l
tl pical l! .l c!.clopx13 child ]nav learn ir Dotor skill s!ch as ice skariDg, r,,a1hing on st11rs
or r i.ling a utlic\.ch. Holve\.er, if shc does t)ot r crr.lin phvsicallv fil and agiL: she uLiLr
no Lrngcr do the shilIuei] ol rv(:n lose iL. Lilicrvise, a chilcl \,virh cereb.al palsi m:,.,
no longer u,alk as \\,e11 as prc\.iorls1v iI hrr lifcsrl-1e, bodr rr,eight, or siz. r:hal1,]es. ,rr
lh. l" l. Ol O,'r ,\O |,rg'\
Daih str(chesanLlasctolexc.ciscsaretheLcstrravlbr-LhcchildrenLosirr hranc
mainLirin rhcir indepcndcDCe throughout chilclhood, aclolesc.nce, ancl adulr rood
Thr follouing ar'(: tbur poprlrr !tr.e11gth c\crcises. Earh criercise srr cngrhens :t
diilerrr t muscle gro| p. 1'he er(:r(ises\,!erc drosenbecatscthevcaJ] easjl\ be adrprcd

Q.vt 1
2O2 IEACH]NG N4OIOR 5KILLS TO CHILDREN W]IH CEREERAL PALSY AND SIMILAR A/]OVEAIENT D]SORDERs

to a specific child's level of ability. They maybe used to build up your child's level of
slrength or to maintain it. They may become part of a daily workout session. your
I child's physical therapist will give you specific mmbers of repetitions or goals for
each exercise and combine them with other exercises your child may be[efit fuom.
t Use them as directed bythe therapist and follow her specific instructions.

Wheelbarrow Walking
This exercise strengthens the shoulder and arm muscles. Arm and shoulder
strength is important for children wit}l cerebml palsy. They allow rhe child who uses an
assistive device to walkwith more ease. For a child in a wheelchair, it makes transfers
easier. For a walking child, sffong arms provide safety during a fall.
1. Suppo.t your childt thighs, knees, or ankles while she walks on her hands
(photo 16.1). The lowet down on her legs you support her, the more strenuous
is the exercise.
2. Have your child do this as far or for as many minutes as directed by your physi-
cal therapist.

Litt ott
This exercise strengthensyourchild's bacl(musc1es. Childtenwith cerebralpalsy
usuallyhave weakbackmuscles and benefitfromthis exerciseverymuch. This is true
for children who use a wheelchair as well as for children who walk independently.
1. Support your child as she lies on her stomach on a bed, bench, etc. with her
head and shoulders extending over the edge, as shown in photo 16.2.
2.Ask her to "lift off" by raising
herself up like an airplane.
Firnly hold her botrom down
while she straightens her tr nk
and streLches out her arms.
her to fly straight,
3. Encollrage
curve to either side, tip her
r:
wings, etc.
4. Have herplayas long as direct-
ed byyour physical rherapist.
The longer she flies, the more
sucruous is theexercise. The exercise ffi,q-
is easier if only the upper patt of the
chest is unsupported and harder if
most of the trunk is srlspended over :16.2
the edge of th€j furniture.

WaIl Slides
r Lrg muscle sL.(:rgthening cxcr cise. IL streniirhrrls specjfi.iillv the Llua.l-
I his is
r esplcirlh so ildonu r,r,lth one lcg at a ritne. cood quadlceps srrcntth pr.r\.ertts
iceps,
or realLlccs croltching. Hirve votLr child do rllis err:rcise for as nrarr.t ePerjtion ard ils
h equr:nt11,per 1\ er:L as her therirpis. ad\.ises.
l. Youl chil.l srands r,irit hcr back agairst a u,all. Hcr teet are sho!lder \xjdth
ap.ut ard her loes point tbr\xar.l {rr s ighth, out\vard lph.rLo 16.3a1.
 EXTRA 5TRENGTTIENING riND HAVING FUN 2O3

2.Ask her to bend her

knees and slowly slide
as far downwatd as
possible without lifring
the heels off rhe floor
(photo 16.3b).
3.Then have her slowly
come up until her l<nees
and hips are completely
straight.
4. Repeat as often as di-
rected byyour physical F
rherapist I
Asking your child to lifr t
one ieg off the floor and then
do the knee bends with the
other leg will make the exer- t6.3b

cise more strenuous.

Heel nises
This is a calf mlrscle streflgthening and stretching exercise. Calfmuscles are impor-
tant for good standing balance. During walldng theyprovide push off for efficient walk
ing. Have your child do this exercise as frequently per week as her therapist advises.
1. You rchild stands on rhe first stair step hold
ing onto the ba.1isrerr with borh hand\.
2. Help her to stand on her forefeet (roughly
from the toes to the insrep) with the heels
unsupported (phoro 16.4a).
3.Ask her to slowly lift herself up on toes
(photo 16.4b) and then siowly lower her
I
I t heels as far as possible.
a.Repeat asofuen asdirecred b) yourphls,
cal therapisr.
!,
I 5.Good arm
jl 'upporr rnake' the exer.ise
'l r. easier. Lightly touching rhe banisrermakes
lI it harder.
6.Lifting one leg and practicinS single le8
heel raises will make the exercise [rore
h strenuous.

Having Fun
Chjldren l\:ith ccrebral prlsv benrhr from our(lool.or indoor pllysical r.ririties ijs
much or e\,en rror e then orher chilLlr.rn do. Bur due to thcir phvsical limirarjons. rl tr
tcDd ro spefd iDote tir.c iDdoor:rnd Dlore rj c siltjng. This is a c{rrcern 1ir Darenrs
l,l,- r. ..t. .. ..\r.o,rt....ji -n.tp,lr ..\,r.. ..,
2O4 TEACHJNG ]\/]OTOR SKILL5 TO CHILDREN WITH CEREBRAL PALSY AND sIMILAR fu,]OVEA4ENT D]sORDERS

activities thatparents have reported their child with cerebral palsy enjoyed. The first
activities are for young children alld the last ones are for older children.

Moving along on a Riding Toy

One mother tells us: "I place my hands over my sont hands on the handlebars and
we race around the house.It's a lot offun. He stays on the riding toy and is learning to

?
hold on byhimself (photo 16.5a)."
The child in photo l6.5bshowsthat
he caD sit and hold on withourhelp. Next
he will tryto push forward.
Pushilg off with their feet and rid
I
\ ing forward is not easyfor childrenwith
cerebral palsy. First, practice with yorr
child girtting on and off the riding toy-
36 V*r.J".-i! with yonr assistance as needed. Once he
caD do both safely, you may encourage
7 him to pedal on his own. If your chiid
t.... cannot get ofl on his own, he still may
enjoy sitting on the toy and move about
with youl heip. But do not haye him sit
on the toyunattended.

My Rocking Horse !
The boy in photo 16.6 loves his rocking horse.
He rides it in the kitchen and watches Mom as she
gets dinner ready.
Ifyou have a small rocking horse for yolIl child,
teach her to hold on well with borh hands. Gently
rock her while you support her as needed. After she * (
I
sits well on her own and consistently holds on with
both hands, you may have her rock on her own. r,,
L,*
I A Swing for Me
SiLLi g in ir s\'Yin8
h#
I-*d d@
is a Lreat ior the gir.l in
photo 16.7 l )ad mounte.l
onc for her itl Lhe play-
r(x) . No\,! she cen cDjot
ttrr it e\.e11 on a rninv day.
Pushing her is a relaxing and bonding tlue for mother
and daughter.

Pushing a Toy
.$iri< PLLSh rot s:rr. cas]'Ibr
chjl(l \,"'ith poor l)irlance to usc.
a
J rcre are r !ll'car\.arietl'ofdrc a\ailable. l)arellls reDol.t
? rhar their childrcn like to riil(c thenr olLtside as Lhe\ ioir
t. orhel childrcrt in plar:.
 E\'TRA STRENGTHENJNG AND HAViNG FUN 2O5

lII
16.8b

Holding on with both hands, the girl in photo 16.8a eqjoys pushing a toy along
the deck. The boy in photo 16.8b preteads to mow the lawn.

Riding a Battery-Powered
Riding-On Toy (
The boy in photo 16.9 enjoys riding his
PowerWheels. These types of battery-powered
ding toys do not provide the exercise ofa tfi-
cycle or bicycle. But they allow the child who
cannot de a trike or bike to join his friends
- -^Hx*
ottside. For a child who may use an electric
wheelchair at a later time, a battery-powered
vehicle means freedom ofmovement and valu_
able tlaining in steering and maneuverinS.

,
Pedaling a Tricycle
"41!'ail* fu dingatricycle trains balance
aIId coordination and strengthens

w *A#':}&*
q. .
" i6-
hl the leg muscles. But most of all it is
fun. The child in photo 16.10a has
dif f icultvwalking but enjoys riding
his adapted tricycle.
.i One father mounted the cut
off seat of a babyswing onto his
$
daughter's tricycle. Now she sits
safely on her tdcycle while she is
leaming to pedal (photo 16.10b).

l j" Ifyou want youl child to dde

a tdcycle, ask your physical thera-
pist for advice orassistance. Most
16.lAb early inteNention or outpatient
206' TEACHING A/IOTOR S(|LL5 TO CHILDREN V/JTH CEREBRAL PALSY AND 5l[4lLAR ]\4OVEtulENT DISORDERS

programs have a variety oftricycles for your child to practice on and to fiIId the most
suitable trike for your child.
In Seneral, child.erlwith cerebral palsyare significantly older than other children
before theybecome able to de a tricycle. For youl small childjust to sit, to hold onto
the handlebar, and to steer is a big accomplishment. She may enjoy doing this while
you push her around. A tricycle with a push handle will make this easy for you.
Some children with cerebral palsy or other movement disorders do not Iike to ride
a tricycle even though their parerts and physical therapists believe that they should
be able to do it and would have fun if they did. If your child is one of those children,
remember that tricycle riding is not an essential motor skill.

Playing Ball
T ba1l, softbal1, baseball, basketball, volleyba1l, bowling, mi
ature golf, goll and
soccer are spofis that youngsters with cerebral palsy or simiiar movement disordem
may enjoy in modified form or even in their regular forms.If
your child is able to stand and walk withort arm support, it
ffi
I
may not be too difficult to find a ball activity she may enjoy
playing with you or her siblings in your yard. She may even
Iike to play on a team widr typicaily developing children. Find-
ing an opportunity for a child who uses a walking aid is more
difficult. TopSocceris aprogram, which helps children enjoy
soccer in spite ofthefu limitations. Ifyour child is interested in
soccer, find out ifyour communityhas such a program.
At home parents may find creative ways for their child to
playball. The youngster in photo 16.11walks with a forward
walker. Asked about his favorite activity, he answered, "Play
ing cricket." I-eaning against the wallhe is safe, can concen
tmte on the ball his father thrcws, and bats it right back.

Swimming
Swimmin& especially in warm water, is very beneficial to children with cerebral
palsy. The warmth relaxes tight muscles and the buoyancy of the water enco[rages
nrc\'clncnrs. Splrshifg \\'ith thcir iirns. r:hiLhcr havt: fun ard
srrengrhell rheir arm, shoulder, and bach 1nrsclcs (i(kirg !rith
rherr 1egs. Lhev strengrhen rheir hip and 1eB mlLscles. lr\.en babies
eniol'LhL'r!eLer nnd Lreneiil fro[r it. Find oLlL ii1.oLLr commLr]1iL]-
has r hcirral l)ool drrL ol'lers pi]rent/i larL s1\jinl cliLsses or ad:lpLed
& srtim classr:s. Attur(liDg s!ch iL clrss r', ith lrlrlr rtiLI tr:arfics rou
t hor,'. ro hold r.our child in the u, ater and about safe lloration del rces
1'OLl r11i1\' LLSe lrilh
heI.
r\lter gerting used Lo rhe r,_aLer end liliinS iL. \our chjl.l .rn\
attcnrl rrn irdapr:cl sr,,im program at rr larur timr:. Tt,,r,ill tr:rr:h hcr
tolx:sirli ln rhu w;rcr irnd to s!!im. Sr,inrmif g i! ir \rondo-f!l liic
tirn(. sport lbr a person lrith cerebral pais]_. Ilelore -vour child has
acquired 1\ater saleL),skills, she u,ill need !.rLLi Llirecr super'! lsi.rn
e\.en rn shallou \\aLer'. This Lloes noL mer n LhrL 11)LLl chilal airnnor
hale plcrl\ .rl 1'rr l)\ th. wrrtr. Tht roungstu! ir lrhr)to lar.12r
 EXiRA 5IRTNCIHENING AND HAV]NC FU]\ 2O7

enjoys hanging out at the fountain

by the poo1. At the beach he proudly
shows offthe sandcastie he h as hlr ilr
(photo 16.12b).
Note: Aquaric Therapy is a
physical therapy method, which
teaches exercises inwater.Its goal is
to achieve specific treatment objec- @.
tives. Aquatic therapists do not teach
swimming-

Horsebrck nidind Fre ij

Horseback r'din!.s r\e fa\ or ire kffii
sport ofmaly children with cerebral i6.i2b
palsy. Besides beingfun, it improves
the childrent posture, balaflce, and range ofmotion. It provides them with an endching
experience which gives tllem confidence and boosts
their self-esteem. Ifyou believe thar yollr child may
{ enjoy horseback ddin& find out ifyour community has
a therapeutic dding progmm for childrer with special
needs. Such a programwould provide the safestway
.l: to inftoduce your child to riding. Ifyour child learns
L
to de independently, he mayjoin other chiidren in
regular riding classes late. Potentially, horse bacl(
riding may develop inro a lifetime sport.
Theyoungster in photo 16.13 started ro ride his
horce, Buddy, when he was five. Now a teenager, he
treasures his time with Buddy.
Note: Hippotherapy differs from therapeutic rid-
a.4 ing. It is a treatment method that uses the horse afld
its movements to reach specific treatment goa1s. The
person conducting hippotherapy has to be a certified
16.13
instructor of this treatment method.

Martial Arts
I{aratcr, Kung I1r. and T:L: k\",,on rlo
improvc l out chil(l's stending posturt ard
balance. As shc learns n) do quicl liicks.
controlled f::lls, and trrns. she gains beL
tcr llrotor rontro]. In rddrtion. the sports
pride rhcnr selr,es i n pronlo rin g conllLl e n( c
alld self-respect bv teachirg se]lt.lisci
pline. (oncenLration. lespc(t, anal (our
tesv. Nlaltinl arts atc not team sporls_
Th.refore, rhcl mal bc aclaptt:d ro rn
individrLal chi [d's ]e'" r:l oi compr:rence.
16.11
#., )
2O8 TEACHING ]\4OTOR SKILLS TO CHILDREN WITH CEREERAL PALSY AND SI|\,4]LAR ]\4OVE1\,1ENT DISORDERS

If,vou thinkthat-vou r:hild lvo l.lhave fun doing this type ofsport, chccl(whcther'
your communitl,has a special program or a te:1cher qualified to Nork rvith l our child.
The child in ptloto 16.14 on dre previous pagc:rttends il Tae k\'von do class aDd receiles
some individual instrlrclions. Eve[ tirough she stjl] uscs a r,valker for longer Lrips, she
cojoys the tralnins verv nluch and loves to shovi off to her physi(nl thcr-aplst each ne\\'
tdck she has learncd.

Dance Lessons
Dance improves your chikl's posturc, balancc. anLl motor conlrol. Group lessons
encourage tuln taking, artention, cooperarion. and disciplint:. Tt \flll booster ]'our
chlld s sel f- esteeln and conidence. Butmostofall, movirgrl,lth musicisf n. Gcttlng
dresscd up anci shorving oll nel\, skills malr be more flln for ilD outgoing chiid. If your
comrnunity has an a.l:rptcLl dancc class for children\\.ith special needs, ]rou mali check
it out and see ifyou child likcs it. Children with milder lbrms olcerebral pals,v (Levell
01 the Gross Xllolor |uncti.D Classifi(ation Systcm) may enjov regLllar d:lnce classes-
aaaaa
l7 a
o
o Additional lnterventions
O

a
for Children with
a Cgrebral Palsy Bylisa Barnett. Dpr
a aaaaoaaaa

The previous chapters inthis bookexplore nlany ofthe concepts and activities circial
I
to optimizing gross motor developmentjn childrenwith ccrebral palsy and sinilar
movement disorders. Manyofthese involve activities and exercises that parents can
do with their child at hoDe wirh the guidaDce ofa physical therapist. However, there
are other interventioDs that are vital to helping childten with cerebral palsy achieve
the best possible gross motor function. These include medical procedues such as
surgeryor medication, as well as bracing and serial casting_ This chaptet will attempL
to give you sone key info(mation about these other interventio[s that your physical
therapist might suggest to help improve the function ofyour child.
The goal ofthis chapter is not to preselteverypiece ofevidence about aprocedure
orto advocatewhichtreatmentortype ofequipmentyou should use for your chi1d. Each
child and family has their unique story and needs. The goal of this chapter is insread
to iDtrodrceyou to a number of important topics tobetter educate you before you ser
out onyour ownmedicaljourneywithyour child. Readingthis chapter should give you
increased k[owledge and confidence as you consult with professiona] s involvedu,ith
yolll child to gain more information on each ofthese and other treatrnent options.

Medical Management
'I here is no
rnedical rrcir.nrerlt that car cure a child of his cerebrelp:lsr: \ledtcarurns ::nd
surgerl can. houer,er, r1\luce spnstirjr\'. inprove muscle length. end rLrluce.jotnr Lmtlt
tions. rvhich caD, in rurr. urake it r:asier for thes! .hlldren to achi|\r gross rt.rtor rliilLs
2' O TEAC]]ING ]\4OIOR 5K]LL5 TO CHILDREN W]IH CEREBRAL PALSY AND SI]\4ILAR ]\4OVEMENT D]SORDER5

The types of medical treatment I will briefly review in this chapter are:
a medications take[ by mouth to reduce muscle to[e,
.
rhe intrathecal baclofen pump (IBP),
.
botuiinum toxin injections (Borox), and
. .selective dorsal rhizotomy (SDR).
I will also discuss several interventions that may be suggesred by your physical
thempist. These include sedal casting, neurcmuscular stimulation, and lower exffem-
ity (leg) bracing.

ORAL MEDICATIONS
Sonre ofthe n]or(: (o[1n1on medicalio[s nuscle tone in childrca
useL] t() hclp dccreasc
with r crcbral palsl'iDclude Lraclolafl, danrri , zaDaflex- and l:aliuit. Ali of thcsc
drugs arc oral medications. utich nre!n th(:v arc taken by mouth, Lravel through thc
gastrointestinal tract, and thcn r:ntcr the bloodsrream. OILen thesc oral nedicatiofls
are prescribed b eiore :rn! morc illvilsive medical tlten'ention js c(msidered. although
this is Dot a1 ,a)'s dle cast. Onc of the drau,backs \,vith oi-el cdicatt]r]s is thal the]-
haYe an eliect on thc r:ntire bod\,, alld thus are not as spccific to rhe spastic muscles
as other mcdi(a1 inrerventions Lhat lvill bc dis(rrsscd.
Before anT medicaLion ls starrcd, ia is important to esrablish goals for the use
of the lnedlcation \'r.ith $e pr'ofcssionals cariDg lor _vour chilLl. If rhc ]nedication
is effective Ior voLLr chil.l. impro\.enlenrs mi8hL be seen in inri ca scd ra[ge of mo
tion, better tolerancc to braces, a gain ij1 funcrion:]l skills. or easier marlaBement
by Lhe fafiril\' .]ur'ing (lailv care acti\,ilies. It is rqually jnlportant to tnake speclfic
plans to c\'aluare rhe eitect ol the nredication after a certain peliod of tinre to dc-
terminc ifthe goals have been met. Thjs wili help l.ou and ]'our proiessjonal tea1ll
decide rvhether yoLLr chil.l rhould contiDue to take rhe me.licatioir and u.heLher
the current dosage is corrcct.
As u,ith nll nrcdi(arions, there is always the possjhiljt\ ofunl,ranted side effects.
Drorvsincss is one oithe more cornmon sidc effects ofmedications Lo reducc muscle
tont- Cons!lt \'!ith lrour chilLl's physicjan ro lear[ tnore aboLLL both thr posjrive and
ncgati!.e effects thal votl might obscrvc u,ith a specific medication.

INTRATHECAL BACLOFEN
Baclofen is presently the drug most often used in the treatment of children with
cerebral palsywho have moderately or severely increased muscle tone. Baclofen can
be given either by mouth or through a smail pump that is surgically placed in the
abdomen. Thepump delivers the medication to the spinal cord through asmall tube,
which is threaded under the skin to the spinal cord. Baclofen administered through
the pump is called intrathecal baclofen (ITB).
Children considered for the pump typically have high muscle tone that involves
the arm, Ieg, and trunk muscles and that either interferes with their daily care activi-
ties or causes them discomfot. For example, a parent might report difficulty diape ll8
or bathing their child as a result of the high muscle rone.
Children withjoints that cannot be moved though the ful1 range ofmotion are not
usually candidates, as the baclofen will not corect thesejoint contractures. Coupled
 ADT'IJONAL ]NIFIIVENTIO]\5 FOR CHILDREN
WITH CEREERAL PALSY 2' t

with daily stretchin& however, baclofen may

help prevent future joint contractures
byreducing rhe high muscle tone.
.nt1ln": apump surgically implanted, familymembers
^^*LT,I tevet of resporuibitiry. rmplantation
rake on a serious
of the pump."qu;;;;o.
::T11,::-::-1"*lrh ro six d ays. rhe pump
:i:,]^,:l:lll :y.
:l,:I.eemonr must be refi11ed in aluairi"a pr,v.i.iu"t
hs dependi'1S on rhe oF rne p,np. rr. he m.d i"ar roo
: ::^.-1"::l:
I
r5 iiuppe. .,r slgnfican y reduced over a short period "ize
oftime, bacl.fen withdrawal
car quickly become ar ernersenc] \ituarion.
\ion and rourine follow up care are so impo_Lanr.
Th,.
". hy.;;.;;,;;;;;;,;;i";;"*,

BOTULINUM TOXIN
Bor ulinum to (in { Botoy) is ju,t one of manJ dil
ferenr tvpc, of injcc. ion\ rna r al e gi! Fn
to reduce spasticity. Alcohol, phenol
and Bupi"i.ui"" ui" ur, o't'],p'"r;;l#;r*:
are given to reduce spasticity, but these ,n"
are not as commonry used for ch dren
cerebral palsy. I will focus here on borrtlinum with
tori. urra it, u"."-ior-r"ioi'ti'oi'lirpu.-
riciryin children with cerebral palsy.
fl-erg 11s 5ar., rype: oi borulirum roxin.,abelcd
. A throltgh G. ry pe A, oren
,n.:.sr common type and is now used in .r. pu "iied-"or-Jm
lr.]1"1?.1:i
cme ro reduce ':muscre spasticity, as wel n ,"oi

toxin is dedved from Closrridrm Borulirum,

as cosmeticalryto reducewri"H"r. g.trri;-
p"",ir" U;.*r" i*#*r,
associared with conramioated food. In " S."_to.rn, tii, to*i",rl,r"
its u"pr,ifi"a
humanboulism. The purified medicinal form "1"*
The ptrified forrn ofbotulinrm roxinis
of eotutirru_ i;ri;;;ii;;.; f".r."f
^ an
ofits specific action at the iunction ofthe nelve ".p""iattyettectirre -e;il;;;"."
and muscle.
behjnd.heu,eo.botulinumroyinisthat rhespasricili One therapeutic principle
pr","n,
:llldl:1 yrth ce.rebT]patsy covers up underlyi"g,*.t" *"ut r"r."r;r;;i,;;i;"
.i.,i", "
a.sociated.nuscles.Wirhrl"euseoiborulinrr",oi;,,.,t
ia", i",",.rp"rr.f "r"*,,
,!1r0"
ou, rh i. overl) ing \pasriciry by injecr inB "
dre liquid royin direcrl; inr. ,J*r,.
Then all of the childk muscles cao be iore .1r..
aggressively strengthened " and "
during the three- to six-month dme the botutirr,rrn stretched
,ori. i"
rhe rreq_uencyoF plrysi., r ,i"r"p, i. "fi"'",i,r"
*ir;;;;","
]l:T.j:l]:llf*'"":.
ro maylmtze rhe resIlLs gained b) rhis inler\enr;on.
,,,,"irv i,,:;;;:": ,::-*
The advantages ofborulinum torin injerrions
a.e:
. they cause liftle pain,
. theycan be given in a cli[ic seftio&
o there.is an easy and rapid delivery
of medicine to the desired
muscle sites,
. the effects are reversible, and
inj".,io:r be repeared i" lhe [unrre if requ,red.
".- :]h:
ne Dotutmum toxin :aninjection buys
r ,r m.\ allow hrs muscle growLh. the child with spastic muscles some time,
wh,ch tength ro carch r" l"r"
- g.";,; i,,.,
rr {urn. may postpone or prevent rhe need "p "ir"
fo. or, hop"d i. ,u.g"ry.
Chiidren with manytypes of cerebral p.lry*itl,";;;i;ts
.be approp of spasticity can

;;,.ffi ;i; ;;;;ffi ;'*ii1::i:i#;;::ffi:;il

ate candidates forthese ifliect
,u.g"i,p""rri"
mon sites for botulinum toxin use inthe legs ffi li."jj:
are the inner thigh muscles (adductors),
212 TEACHING A,IOTOR SKILLS TO CHILDREN !(/ITH CEREBRAL PALSY AND SIA,4]LAR A/]OVEA,IENT DISOROERS

the muscles in theback oI the thiSh (hamstrinBs). and the calfrnuscle (gastrocnemius).
Less commonll,', botlLlinLLm Loxin ilriectio[s rna_l a1so be used for spastic [luscles ill
the arm a d hand. ConsLllL h'ith _voLlr lherapist and physician to help _vou determine
iftour child sholild be consiLlereLl for rhis trearment.

SELECTIVE DORSAL RHIZOTOIUY

Selective dorsalrhizotomy (SDR) is anirreversible neurosurgical procedure for chil
dren with spastic cerebral pa1sy. This rype of surgery is usually done only in large
regional centers that see a grealnumber ofchildrenwith cerebralpalsy. The opelation
involves surgery on the spinal cord, specificallyselected dorsal roots ofthe spinal cord
that are sending abnormal infor ation from the muscles to the hrain.
There are two different types of nerve roots iD the spiral cord that transmir
information to and ftonl tlle muscles ard the brailt. TIle veDtra] (motod spiral roots
send information from the brain to the muscles. The dorsal (sensory) roots send
information that is sensed by the mNcles to the brain. It is these dorsal roots that a
selective dorsal rhizotomy targets because some ofthese roots, made up ofrootlets,
send abnormal and distorted infomlation to the brain, whichresults ln spasticmuscles.
onlythe most abnomlalroots are cut, resultingiD areduction of abnorrnal messages
a nd .hJs remo\ iId 50rne ol . he \pasl'cir).

Withless spasticity, children have more controi over their movementpatterns and
are then able to better improve their strength andbalance skills. This surgery usually
targets the legs, inclrlding the musc]es of the hip, and typically results in improved
walking for yoflr child. Aswith anysurgery, there are sks involved and these should
be discL s'eLlex.en"i\eli prior .o,urger1.
Candidates for selective dorsal rhizotorny usually have spastic diplegia, are
between the ages of two and ten, have Sood underlying muscle s[engLh, have the
potential to progress to walking, and are within the average range of intelligence.
Cognitive abilities are a considerationbecause recovery after this surgery will requle
extensive rehabilitation to maximize tlle surgical outcorne. ID some instances, this
surSerynlay also be recomn1ended for clildren with severe spastic quadriplegia with
intelligence below the average range. The goals of surgery for these more severely
involved children are related to the child's comfort, ease ofcare, and qtality oflife.
Itis importantto rememberthat spasticityis notthe only sympto seen in chil'
dren with cerebral palsy. This surgery cannot directly collect poor balallce, nuscle
weakness, and abnormal movernent patterns. The surgerywill rernove some of the
spasticity, which is the underlying cause of limired range ofmotion, buL itwill not cor-
rect a perDalently shortened muscle orjoint contract[re. In some cases, orthopedic
surSerywill be [ecessary to corect these fixed limitations-
Ifyourphysician and physical therapist believe your child mightbe a candidate
ior selective dorsal rtizotomy, you and your child r,,ill likely be refe[ed to a regional
center for assessmentby a team ofprofessioDals who specialize in this type ofsurgery
and rehabilitation. The rehabilitation after a selective dorsal rhizotomy is intensive;
it can last six months to one yeat and requires significant support and commitment
of the farnily. Your child will need physical therapy three to five times a week for the
first six months. You willbe expected to assist your child in conpleting exercises at
home on a dailybasis to ensure the bestpossible outcorne.
 ADDITIONAL ]NTERVENT]ONS FOR CH]LDREN W1]H CEREBRAL PALSY 2f3

Serial Casting
Il\-en though parenrs may lairhfully srrcrch their child,s nlusclcs, ir is soneti[les nor
possible to pre\'cllt lirliLations in rangr ofmotjon. When this occurs. discussion \,,/ith
your therapist or phlslciarr r]1ay rcsult iI1 a recommendi]rion lbr serjal casLlng. l.his
lnterr.enLion is often scd prior to consideration oI anl orthope.lic surger.y. Serial
casting consists of a s(:rics oI casts rhal aru ilpplied Lo inctease rhc Iengrh of specilir
rlruscles. most olten at rhe anklcs. brLt occasiollally rlso for the knees or elbows. Sc-
rial casLing is ]]lost ofren complcted in a hospita] or outpalient clinic b!,a ph_\-sicaL
rherapist \,vho speciilizes in castir3.
If vour chilcl has rhe abjli|v to u,alli, the casrs wi11be dcsiBned so that he or she
."\,ill bc able tu continLLe to rJalk rirh the casts ir place.
Thc casts ar{: ilpplied Nith the
.ioints in a stretched out position ard ilre usnallv leir in place for fir,{r ro seven davs Lo
Ji,L\rrp't.r.1" o.r, r. t.o.F rr,.i e.\,t r,..pd1,. .(r
A second set ofncl! casts is then :rpplied uihich should rcflect the ]lcr,r,ly gainc,d
ranSe of motion fr()n the fir'st ser. This ,,^,i11 be rcpeated fbr s(:veral \,\,ccks until rhe
desired range of movement has been gained_ Thus, the 1rarte seriel casting refers
toase es ofcasrs thal l.our child \!jll lvear. eit(h one reflcctitrg thc gained range ol'
ra i,,n tro r .1,. I F i,,,r ,tr-
Alter vour child's rir llge ofmotion is incr cased and the fina] scr ofcasts is remo\.ed,
a program rvill be pianlled to hclp maintain this iJlcr.cased rangc ofmorion. Ln alldihol1
to resurnillg the ,:]ajl].srretchjllg act]!jties, specific exercises and njghr splintinli lna_\.
be rec.rrnended.ll is ilot Llnilsual Lr childten wirh cerebr.al pals_v L.r hirre seriel casts
applicd everv (nle to Lwo vears. espccialh- durirg periods ofrapi{l gr owth.

Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation (NMES) is a treatment option that is used to
help children who have cerebral palsylearn which muscles should be working du ng
a functional adivity such as walking. It is used to increase sensory awareness and
further stimulate and strengthen rhe muscles the child is using or should be using
during the selected fuoctional activity. Although there are other types and uses of
electrical stimulation, this chapter focuses on NMES because of its well documented
use for children with cerebml palsy.
Neuromusculat electrical stimulation is the application of electrical current to
muscles to help them contract. The electrical signal is transmitted by a small, bat
tery operated elecffical stimulation machine usually held by the physical therapist.
The elect cal signal travels between rwo electrodes, similar to small pads, thai are
placed on rhe child,s skin, and the siSnal is transmitted to the specific muscle. This
stimulation initially feels like a small tingly sensatior. As the child acclimates to rhe
stimularion, the intensiry is gradually incrcased to a rherapeutic threshold level rhat
is tolerable to him.
Neuromuscular elecffical stimulation is only successful when children are active
participants in this treatment and they are encouaged to anticipate afld initiate move,
ment. Active paaticipation is necessary for motoa learoing to occur. One important
desired outcome with this treatment is the cary over of the appropriate movement
2'4 TEACHING ]\4OIOR 5K]LL5 TO C]IILDREN W]TH CEREBRAL PALSY AND Sil\4]LAR I\4OVE]\4ENT D]sORDERs

into thc child's llli\.-ithout .hc usc of n.'LrrorlirLscrlar elecLrical sLinrLLlation. This
trcarnrr:nt woulclthr:rcfore not bc appr opriare fin .Lchild \,yithour Inotorlearntr:t abil
it_v. Neur orrusculal' cl.ctricrl srinml:rri(). is usLallv 1lscLl in a ph!sicel therap_y cliri.
or office, although it cal becomer part of a lomc program if rof and your rhcr apr:r
determine drat dis is effecrive. Consu[ r'ith vour therapisr fol further iffor1llatloo
related Lo this il1Lerventioil-

Lower Extremity Bracing

Braces (orthoses) are (leviccs made out ofstrong, flexible plastic that are useclto im
pror''e gross rnotor fiurction in children and adults r"-ith orthopedic disorders. They
are v,iorn on the lolrer extremities. LlsLLall_v.rt the ankles. N{ost children 1\,iLh cerebral
palslr \\'ear lou'er extrenlitv braces aL sofi1e p oirlt ir theil live s Lo assis t Lhem 11, i Lh mol e
indep.ndent fr.ctioning. In this scction, I ,,vill fo(rls or common hrar:ing ctrnccpts
t.'r l. L,.r.r.rr .n r

Child(:n r'rjth ccrr$ra1 palsr have hraccs presc bed for ir varictv ofproblems.
One comuron reason for wearing braces is to naintail of notion and so IC
vent Jolnt u,her1 muscles u,ith incre.lsed Lone remain ir a
shorte ned position ol'er l edods of time. The bracewill keep the specific muscle
s in a lengthencd statc, ,"r,hich allor,rs .,,,orr chilcl the br:st possiblc fnnction
and may prevent the need for orthopedic surgeryin the future.
help Chil
drer bent to
able to
*h"" pr*id"d*ith br-i"g s caused bythe spasti.
rnui-Gs,children wth @r
heel-to-toe footplacement or frequent stubbing ofthe toeswhilewalking. Bmces that
support these weak muscles usually result in an inproved walldng pattem.
Clildren\\irh poortbor aliBnmenL in such as thos e u,irh Ilat teled arclles
and/or clenched toes ir uentlv show im s a1i nmeill and stL[e
when oL position is corrected and s bracing. These arejust a few
ot' the at respond to bracing. It is important to remember that
cach child hrs his.r\!-rl rniqrc hr ar:ing nr:r:ds rhrt \,villr(luir. c(tuir ll\ uniq!c problcn
soiving to nrr:cr rhcsc nccrls.

TYPES OF BRACES
tn deciding what kind ofbracingwo!1d besthelpyour child, you andyour child's physi-
caltherapist should consider two keybuildiDgblocks. You should consider the position
that allows your child maximum functiol of the body part that is to be braced, and
you should consider how rnuch control is needed to achieve this maximum function.
For cxanrpje. if child needs bracirl8 ar the loor and ankle. the llrsL qurstion ()
ask is, "What is position o1 greatesr function r his foot and anLle"? Ihe second
quesLion Lo ask 1S trol oftha foot.nd a[lde do u,e Deed to;;i;EF
fectiYe brace him? Specificzrllv. v,,hat movcrrcnts do .,l,e restrict and n'lrat do u,e allon-
to move fteely to get and l<eep the foot in the position ofgreatest f[nction? These two
 ADt] IO]'.JAL ]NTERVENIION! FOR WIIH PALSY 215
'I]ILDREN 'EREERAL

key elements ddye the decision-making process in choosing which type of bracing
will work best for an individual child.
Below are descripdons of the types ofbraces commonly used fot children with
cereblal palsy. These aie used t{) bctrer a1 the foo ankle, and lower le 8
for improved ture and to assist the child i[ stance and walking
Ankle Foot Orthoses (AFos). ODe of dre nrost scribed eof
bracc is rhe ankle lbor orthosis (commonly called AFO). which is uscd to control the
anklc and fbot. r\n A|O u,ra around the foot and ankle and fits inside the child's
shoi.TFGual ose of the AFO is to align the foot and restrict u ltv,i
alkle movemett so Lll ild does notwalkori s toes. AFOS can either be
at the allkle, dependi on the child's need. AFOS are usuall usedforchildren
reased tone ln their se their stabili ty and so their
standingand
p}lr'e".4!t&&s!qths!e!1D$@. Forchildren with al5noril e I n1u scle Lone
who are more active, dynamic antle foot orthoses, or DAFOS, may be recommended.
The DAFO ls made ofa thinre r, more flcxible that the rninimrm sup-
port ald control thus allowing him to use his own abilities when
possible- The around the whole ofthe
and raises the toes with the of increased tone in rhe feet
Supramalleolar Olthoses (SMO). F(n (hildren rlho arc a ankle
t need more cise fooL corltrol , srpramalleolar orthoses, or SMOS,
may be prescribed. The SMO wraps around the foot but only comes slightlv above
the chiid's anlde. Supramalleolar refers to above (supra) the ankle bone (malleolus)
sMo s arc used Lo the foot from excessivelv in or out or sid to side
while but still allow free ankle toe movements. SMOS do not usllallv
provide h is increased tone in the legs.
Shoe Inserts. Shoe i]1serts. Lhe lcas t restrictive type of bracing interventiorr,
can be usc.l for clildren r.- ho primariJv need inlprov(l tbol alignnl(:rr bu: har e ,rr .,1
control ofthe knee and ankle. Thcsr: nt insir-le thc (hi1d's slme. usua11_t ln piacr ri.h:
insolc the shoe canre r,,,ith. Thr:sc rvpicalll, pro,, ide an incrcased arch srippor r. , Ir:.
mav be custonizcd forvour r:hi1d\ uniqut: nceds. but pr.r: fahr ic are.l !cr.sion: ate -:r .
commerciall\ available.
Modifications to Braces. Thcr(: irre cerlai. rnodificaLions rhat can Lre iraa(- .
the brace to rralie it lorc ctlecri\e f(n \.our chil.l.
a I'he sLICfgth oI rh. srr r]t (Lhe rall piece ol plasri(:ol1 an lFo thnr
goes Iron the irnkle to the calf) can be in(rcasell il \,orr (ltild
has '"ery hi51h ftnre. Ihe striips olther\FO canbe strcn.grheiled
and can be eirh.r stretch or non stretch fabric, dependifg orr the
ilrrorLilL ofr{mtrol nee.l(\l b,, }-oLlr child,
.'PosLing"can jirlpro!c.helootposirioDiilstrndi]lg. lhisir\r)l!.:
modifling the bort(m oi Lhe br.irce bv addjng c\tra nlrttriir r.l
buil.l l]p the Lrrlrc so thrt ir h.lps maintain the foor llar on rhe
lloor ir the inrpro\.ed alignmcnt.
. Pads madc of a r,arie of cLrshloncd maLerials can Lre aii,i.J r,
anr.bracc. depe|ding on rhe n(:d. |or exenrple. toe p:i.l\ ..ilu
be addcrl ro help cLrrr.ase mLLs(|lc tone, or pads can be adil,r ro
staLrilizc the he.l ilnd,or n)idfoot.
2'6 TEACHING MOTOR 5K]15 TO CHILDREN \IiliTH CEREBRAL PALsY AND sIA,1JLAR
IV]OVE]\IEN I IJ]SORDERS

BRACING DURING SLEEP

According to your child's needs, he may wear his prescr-ibecl blaces a1l.rr
Dart ofthe
da1. ChlldreD do not typjcallv \,,rear rhcit AFO\ or DAFOS \\hrle ther .re slcrpillg.
There are speclalized orthoscs made tirr nighrtime use calleLl tesLing night
spiints_
'l'hese rriShL splinrs may be uscd ro supplemenr (hild,s
)-olrr daill srrr,tching pro!ram.
to mai[tain eppropriate anklc alignment, .lnd ro prer-enL prolonge<l mrLsclc shortcl
ing durin8 slcep. Thcse a1e usualh a mol c i onlfor rahle \ r r sinn ,t voLLr .hrid.s AFOs
or DAI,Os that are used durjll8 rhc da\..
Occasionally, amic res t sma be recommended. These brace
typ es are c e uail sted over time to
These are especially useful if
your growth spurt.
tone ill the in the back ofrhe thigh,
knee inmobilizers nray be rccolnmeDded. Klee lnuloblliz ers uscd tbr children lvith
cerebral palsv are usually made offoajn padded fabric rhat $irap around vour
child,s
leg and are fastened r,.ilh Velcro. The inrnrobiljzcrs include removable sta]rs, usuallr
made o[a]uminun], \,rhich are on each sjde oland behjnd rhe knee to pr e\-ent the
knee
fiom bending drlring slccp.

ORDERING BRACES
Orthoses are typically custom made out of high temperature plastics. A cast ofyour
child's foot oranlde is made and theflbraces are customized fi;mthis cast. Alrhough
the initial casting is often completed by your physical therapist, the braces are usu-
ally fabricated by an orthotist, a specialist in constructiog ;ustomized braces. It is
importanr thatyou and your child workcloselywirh both rhe orthorist aDd physical
therapistto ensure proper fit and functioning of the braces.
Before actually ordering braces for your child, it will be helpful for you to
sir
down and make a list ofrhings you think the braces should help your child accom-
plish. You and your therapist should discuss yo[r child,s skills and be
mindfuj thar
bracing should not take away any of his ftnction. you should then review all ofthcse
considerations with your therapist and orthotist to make sure that all of\.our chil.l,s
needs are considered. Donthesitate to ask qlrestions. Everyone involved wants your
child to get the co ect fit and fuDction ftom the braces. No orle involved wants extra
visits, revisions, or re castings for your child. Revisions may be necessary,
but some
of these can often be avoided by car€ful planning and problem solving before your
child's braces are ordered.
Parent education and active participation in anychosen intervention is
crucial to
the treatment and ultimate outcome for children with cerebral palsy. Asking qrjestioDs
is not onlyencouraged, it is vital. The followiog are common questions
ttiaioccur in
discussions between parents and their health care team about a;ditional
inteIYentiofls
for childrenwith cerebral palsy.
 AL]L] T]ONAL ]NTERVENTIONS FOR U/ IH CEREERAL PALSY 217
'HILI]REN

Conclusion
Using the information provided in this chapter as a jumping off point, I hope that you
will begin your own research to investigate which interuentions might be bestforyou
and yot1l child. I hope you will remember to ask many questions and gatherinforma-
ti6n ftom avadety of sources. Your doctor and other members ofyoul professional
team will be able to provide you more information about the interuentiolls included
ifl this chapter, as well as about other ffeatment options for your owll child. I hope
thatthis chapterhas betterpreparedyou to embark on your own uniquejourneywith
your child with cerebral palsy.

Frequently Asked Ouestions

O. i4rc the inaen,r,ntioirs dir.u !r(d .oycrc d b], i/lsuraTtc.?"
A. Usuallv all of the intcr'\,cntions are covered br- health insurance except shoc or
thotics (e\''en \\'ith a pr'cs.ription tbr the orLhotics). Thcsc shoe inserLs are lsually
reasonably priced, howr:r,er, so they can still bc a viable treatmenl option.

a. "whqt ore possible side effects of Baclofen? Do they differ depend.iflg on whether the
medication is taken oraLly or recei\)edriathe pump?"
A. Ifthe medicine is taken orally, often a much larger dose has to be taken to see the
therapeutic effect of decreased spasticity. Side effects are more common with oral
administration because of this. Side effects from oral Baclofen include increased
drowsiness, reflux, and constipation.
With use ofa pump, Baclofen withdrawal can occur ifthe medication is stopped
or significantly reduced over a short pe od oftime. This can cause iflcreased muscle
tone, profound sweating, skin itching "crawling" sensations without a rash, agitation,
increased heart and breathing rate, fevet and seizures. Baclofen withdrawal can
quicklybecome an emergency situation, and this is why consistent medical supervi-
sion and routine follow-up care are so crucial.
Overdose of Baclofen, although not very common, can cause drowsiness, de
creased muscle tone, sleepiness, irregular breathing and apnea, and a decreased
heart rate and rhythm.

O. "Wilh1TB.hox,r)fnndoah.pu/npJor..1lh.rt.,rs/iilirl.{haaco/)rpli.orrorrri)r.nrrilr...
ldr'. ta w.l. lL iLlL.fo-)'
cd/ p/-obl./ns dir lr,f
A. Sonre complicrtiolts rhaL c:n occUr aftcr pump pleceme.t indudc ific(rion :: -t!-
pump, (arheter. or irlcision srtc. Thcrre can also be drug-rdarcd proi,lells ot ii:t::
ovcrdose or \\,ilhdla\"_al. Thcre is an incleased r'isk for seizures, constipiriar:t :rr- r
ccr ehro spinal 1l uld ]t:rk.:rnd a fluidpocket can foru irround the prLtnp \iech:tIlrrii
the carheter nra) kinh or clisconnecr. anLl a bloclGge or petlbration mi,, Jtrelcl:.i
the level oiLh! cirth$cr. l'he pump can also si pll,nlalluncLion or di\lo(lse :.1rnt,l
these colnpli.atiolrs are cotnmon nou thatthe punphasbccr su,l:cr:ssirLlh usel ,r,:
childrrn lor seleraI lears
218 IEACHINC A,IOTOR SKTLLS TO CHILDREN WTH CEREBRAL FALSY AND 5tt\4ILAR I\4OVE]\4ENT DTSORDERs

Q. "Can childrenwith lTB stilllie down and pley on their stomachs? what if they get
bumped at the pump site?"
A. FouI to six weeks after pump implantation, your child can play on his stomach
without any risk to his pump. Minor bumps at the pump sire typicallv are nor harmful
in any way to your child.

a. How is "how much" determined for each child to ensure the safety of botulinum
toxin injecttons?
A. The physician admi4istering the botulinum toxin injecrions to your child will
calculatethe safe total dosagebased on your chitd's bodyweight, location and size of
muscle, and degree of spasticity.

Q, "Can my child's spasticity cofie backafter SeLect eDorsalRhizotomy?"

A. In children diagnosed with spastic diplegia, rcturn of spasriciry after the surgery
is rare. A few children with spastic quadriplegia have expedenced a retum ofspastic-
ity.

A, "Will my child need braces after the SDR surgery?"

A. Most children oeed to use an anlde brace after surgery to properly align the foot
during weight bearing activities, especially because of the temporary wealoess in the
1eg muscles that often occurs after surgery- YouI child's currentbraces 1naybe modi-
fied for use after surgery, or youl child may need to be fitted for new braces after the
surgery. After the extensive rehabilitation period, your child may no longer require
bracing to maintain appropriate foot and leg alignment during daily activities.

a, "My chililhcts not been able to straightenhis legrforsome time. Will rhis SDR?ro
cedure help him finalLy get his legs s t,11r'8hr? "
A- This surgery will remove the underlying cause of youl child's reduced rangc
of motioD (the spasticity) but it cannot affect a fixed and pelnaneDtly shortenecl
muscle/tendon [nit (co[tracture). Your child might need serial casting or a surgical
interventiofl to corect a rnore sevete contracture that doesn'trespond to an aggressive
positioning and stretching program. Some neurosrrgeolls opt to have an orthopedic
surgeofl address these fixed contractures duringtile same operaLing time that the chi]d
is rcceiving the SDR, brt this is Dot as con]moll as having two separate procedures.
Reme ber that SDR usually prevents any further orthopedic inteNentions, but ir
cannot undo an alreadyformed cofltaacture.

O. Art th.rr drrl, prc.aullonr,firr s.rtrl.ostl/lg:"

A. Imne.liatc cast rerlo\,alis rcqLriled iilour rfiild has iruscle spasDls, siBns ofa fr 1Lr
tion or prcssure sore, e\ ialcn(e su8BesLin.q an aLletgic leaction to the casLiJtg matcrials,
s\,r.eilinliorarrr'othersjgnsofconsLri.rionof\rcLtrchild'scirl:rratioll,otifhcicrfilses
to bear ll,eight on t]1e cnst foot.

O.' Hor.r, ofierr shorrLl ny.hlld tyedr Lh( Ird..s?'

A. Initialh', \-oul chil(l r,lil1probeblr rlear his br:rccs one hollr on/orchour.rlt. bur thls
usually be incn:ased ,-1ail,, as rclerared b\ ){)ur child. Ultj :rrclt., rhe amount of
r'vi11
tirrc the brices ai c \,vorn each (lr\, depetlds on the reason tollr.rhild is txearing them.
 ADD]TIONAL I1\TERVENTIO]\5 FOR CHILDREN WJTH PALSY 2'9
'EIIEBRAL

An older child who wears his braces to improve function in walking will probably wear
his braces most of his waking hours. For a younger child who is learning to crawl, sit,
and kneel, the lnaces will likely intedere wirh rhese ski1ls during floor playtime. For
those younger children who primarily crawl but also are beginning to stand and walk,
it maybe necessary to remove and rcplace the b{aces du ng the day to allow good floor
mobility but to also encourage the child's new starding and walking sldlls.
For childrenwhowearbraces most ofthe day to maintainmuscle length or func
tional skills, it is importallt to remember that they should have some time out of braces
each day to a1low the opportunity for muscle strengthening and freedom ofmovemenr,
as overuse ofbraces may rcsult in weakness, especially of the calfmuscles.
ThebEce-wearingscheduleis differenr for each chi1d, dependinS uponhis needs,
and is somethingyou should definitely discuss with yotll chijd,s rherapisr.

A, "Ho\r \oill I know if the braces fit properly?',

A, Daily skin checks are important to determine if the bmce is plltting abnormal pres _
sure on your childt foot. An area ofpressure can quickly tum into a blister and then a
pressure sore if not found in the early stages. Anyred[ess of the skin should go away
within 15 minutes. Ifit remains longer, your childt braces need some adjustment to
prevent further abnormal pressure. your therapist will discuss this with you and give
you fu her infotmation about warning signs of skin breakdown.

a, "Ihhat kind of shoes should l get for my child to wecLr with his braces and how big
should they be?
A. Your child's braces are designed to provide him with maximum foot support so
the shoes he wears is not the primary concern. Howevet it is importantthat the brace
does not slip out of the shoe when your child is walking, and that the sole of the shoe
is not slippery. The shoes are usually about one size largerthanyour childwould wear
withort braces. The easiest way to find appropdate shoes for youl child is to take the
brace, without the foot in the brace, and slip ir into va ous shoes until you find one rhat
seems to fitwell. The[ have youl child put the braces on and try the selected shoes.
Avoid hea\,y shoes, as they may overly tire your child,s lower leg muscles when
they are wom for long periods oftime. Avoid shoes that are too long or too large be-
cause your childt balance and stability willbe affected. Many children and families
find lightweight sneakers or sport shoes to be the most comfortable and functional
footweaf to be woan over the braces.

O. "Hor,l|,illry(.rri/rgtr.nk](rlDatbrd.tsdlftcrnr_r,c/rrldirfiiponrikrLtrp{r.!iti.liriir:-.
srrnrdin3 and r.r,ollting?
A. hisann(ceptedi:r(]rtharconnololthcfo.rtma!prodLLCeJnorcco]lrrol!a.,-l
and kncc. An easl lr'av ro und.rstand this concept is to Lhirk of loLlf chilLt , -e.] r,i :,
.lt, rr, -..1t,-t i.-1..r.".crr.l e o. L.r,,.|
ollr",l,r:,' l.,'.,. t,l-,1 l.tr ,/l-,-,t r.-r!r,.1
,ll, 'r r r,.o' , l p. ,

O. ,{/-e th(,-. d,ty c.qdaire elfu.ri o/ lra.ir.(1"

A. it is possible thrr ln_acing mal.causc rrllscle wcikness. rspccialh jf rh. nLii.1.!
of the lor.-rr 1eBs. This can heppen in bracc strles rhat prelcnr or lijlrjL mo!.iler.L rr a
22O TEACHING MOIOR sK]LLS TO CHILDREN WITH CEREB]iCL PALSY AND SI]\4ILAR A/]OVE]\4ENI I)]sORIJER5

.ioint. The muscles thnr control rhc n1or.e]l]erlL thar is lin]ited or.prevellted al-e itt risk
lbr incrcased ,eakncss. Llraces which resLLlt in an improted standing and rvalldng
pattcrr nray also interfere rvith highet level gross molor activirjes srLch as runnilg,
hoppinS, and skipping. Becaosc ofthese t1{o concerns, pl-ofcssiollals mLlsrcnsure that
the prescribcd braces do not provide morc irssistance thalr a specific child needs_
i1 vou bcliete rhat volrr child has Lost m[sclc stre[gth or functiona] sklils as
the result of his braces. discuss this rvirh your phr,sical theraplst so that appropriate
adjustn-rr::tts nav be made to the br'aces alrd,,or- r,caring schedulc].

O. "114ll mr,.hiL? c1,il-oritgr.), ii.! ne.d.forbiucin.q?"

A. Both vou and vour prolessiolral team r.ust close]v monitor the ne.rd for yoltr child
to contil1ue rrrirh braces. If your child's muscle length hecomes steblc. as sometjmes
happens follo ,in8 gror\,th, oI iihis muscle conrtol inlproves. rhcre n av no lon3er
be a need f{)r braces. In {)rher cases, additional inkr\,.enaions such as n edication or
sur8ery mav impro\rc srrength, j.rjnr aligt1ment. or function. rcsufting in a situalion
in rvhich bracing 1s no longer rrconmende.l.

References
Albdght, A.L. Intrathecal baclofen in cerebral palsy movement disorders. Journal of
Child NeuroLogy, 11(suppl 1):S29-S35, 1996.
Albright, A.L., cilmartin, R., Swift, D., Krach, L.E.,Ivanhoe, C.8., Mclaughlin, J.F.
Long term intrathecal baclofen therapy for severe spasticity of cerebral origin.
Journal oINeurosurBe,T, AB:291 2o5, 2003.
Albright, A.L., MeJ,.rhaler, J.M., Ivanhoe, C.B. Inffathecal baclofen therapyfor spastic
ity of cerebral odgin: parient selection guidelines. provided through an educarional
grant fuoln Medtronic ,[rrc., 7997.
Baker, L.L., Wededch, C.L., McNeal, D.R., Newsam, C_, Waters. R. L_ Neuro Musculctr
Electrical Stimulation: APracticalGuide, 4,h ed. Downey, CA: Rancho Los Arrigos
Research and Education Institute.
Bary M.J., Albrighr, L.A., Shulrz, B.L. Iffrarhecal baclofen rherapy and the role of
the physical therapist . Pediatric Physical Thercpy, 1,2(2)177-86, 2OOO.
Buckot, C.E., Thomas, S.S., Piatt, J.H., Jr., Aiona, M.D., Sussman, M.D. Selective
dorsal rhizotomyversus orthopedic surgery: Am1l]tidimensional assessment
of outcome efficacy. Archiyes of pb'ical Medicine Rehabilitatian 85i3):457-
485(3):4s7-465, 2004 Mar.
BuckoL C.E., Thomas, S.S., Hards, c.E., piatt, J.H., &., AionE M.D., Sus$nan, M.D. Objective
measuremmtofmusclestrengtiirlchildrenwithspasticdiplegia afterselective dorsal
rhtzotomy. Archit'es ofPhysicalMedicineRehabilitatior\ B3(4)t454 460,2002 Apt.
Campbell, S. (EdJ, Palisano, R.J., Vander Linden, D.W_ physrcol Ih erary
for Cltilclren.
Philadelphia: W.B. Saunder, 1995.
Carmick, J. cuidelines for rhe clinical application ofneuromuscular elecrrical stimula
tion for children with cerebral palsy. pediorric pltysical Theropy, 9:128-136, 1997.
Carmicl! J. Managing equines in childten with cerebral palsy: Electrical srimulation
to strengthen the triceps surae muscle. ,eyelopmental Medicine Child Neurology,
3X11):965-975, 1995 Nov
aaaaa
a
a
a
a
a
a Appendix
a aaaaaoaaa

Pediatric Therapy Equipment

The follo."!illg isa ]ist ofequipment thaL is menLioned or-illustratcd ill this book. The
items depicted in the phoros \,!.erc noL spccifically selecred but shoun l)ccallse
the
child in the photo used them. With a fcrl. exceptions, the eqLlipment js not ncedeLl
to do the activities and exercises rccon ncnded, but pal-ents may find jt useILll.
Most of the cquipment is nalLl[]ctured L,\ a r..rncll ot cc,DrDenics ilnd JVrlilnhl.
through_pediatric equipment calaloEis or ,,nLil]e. Surne nf rhe items, j IcludiDg th.l
lar-ge balls and B.rppy pillor,vs. arc also available in retail stoles thar car
ry baby or
sporting goods ltcms. Thc last two items are not commercially available, but inav
Lr. r'o r.rr:Lred r ,l,orr ng r r"g \.. , '.,,., .'on..

. Boppy Pillo$, (phoro 6.14 pase 65)

o Large ThcrapyBalls (phoro 6.4. pa8e 62)
. 'Iherapy Wedgc (phoro 6.6. pate 62)
o t'herap"- Rc-rlls
o Adjtstable Benches
. A.ijrstable Floor T.rb1e (phoro 10.9a, pa.gc 102)
. Ne. Sr\,ing (phot.r 6.10, page 63]
. Scooler Board (phoro I2.2 page 133)
. imnlobilizers. tbrar.ms a1ld lcgs
o Plone StaDder (one model is shot!n in phoro 6.14, page 65)
. Gait Trainer'(one nodel ls sho n iD phoro 1,1.9, page 164)
224 TEACHING ]\4OIOR SKILLS TO CHILDREN WITH CEREBRAL PALSY
AND SIA4ILAR A,{OVEA4ENT DIsORDERS

. Forward Walker (one modcl is shour in photo 1u1.4, page 162)

a Reverse Walkcrs (one model is sholm ill photo 14_5. page
162)
o Forcar.m Crutches
. r\dapre.l tricycle (phoro j6.t0a, pagc 205)
. Suction bats (photos 12.14a, h, c, page 137)
. Dividcr for gait training contnlercialh, a\.ailab1e or nlade wlth
2 x 4 board placcd o. 2,' edge and secrred in placc aL b()th
ends
(phoro t.5.19a. paSe 196)
. Whlking i addcr commercjallv a\ailahle. Mav be used illstead of
b.rJ" .or. L,"lorr
a Ladder box the r,oodcn box rneasures 12,, L l( 12.,
W x 7,, H
u,ith 46" long extensions Lo jnclease stabilit! aDd 22,,H ladder
extending ofionc side_ Ladder r Lrngs arc 4yr,, aparr. alaLlderbox
.\l .urr'n p.oro t_. t-i J-J D pJ8pl.iO,
. Srandirlg (lean-ro) board _ 14,, W with lengrh adjusred for chi1d.
J..r:rrr"et.e.ru.rrrcJ'e..(. , ppe'tnpr r ul or tG.l!..tit io.t^rl
accorunodales teet. Board is padded \,vith foam alld co!.ered y/irh
viny.l. (Srandlng board is illustrared inphoro 12.12, page
136)
This list teprcsents a mcre fl-action ot the spL(irl need\ p.lrLrlment
a\.Jilab1e.
Manv of the items are designed firr r,.erv specific use. eefore purchasing
cqtrlpnrent,
parents are Lrrged to discuss it thoroLlghly lrith their
child,s therap;st. flc or s-he lv;tt
Dake sure rhat a piecc ol cquipnenr is appropriare 1br
l,our.child. cood equifmr:nt
''-- '
should either help vou rake carc oft our child or foster his ski11
dr:ve1"p,";.

General Equipment and Supplies

The following is a list of tlle supplies used with activities or
exercises recommended
in this book:
a Plal t:rhle h,irh e rim. Ihe olle sho\,!n in phor.rs
l5.la an.l b
(pa8e I 84) comcs w-irh t8.5 legs. A 24,, lec
liir js avei latrkr ro
. CIab hars (photos t 2.2 ta nDd b. pase 142)
. llanjsrer (phon) 12.20, page 142)
. Bed rrav (phoft)s 10.3 and 10.9b, pages 98, 102)
. lvall bar (pho.o 12.2]a, paSe 142)
. Storagc crat('s ol r,ario s sizcs (photo I0.6, page 99)
. I .r tr. I ..1p. ,l.ol, tr. ., p, S, 0.:r
'
a \otebook binder slhsrituring for rhcrap], \,!.edge (phoro
11.2,
page i2l l
. Lleanbags an.l box.n bLLck( (photos 13.7 snf tS.1B. pages 149. t94l
. Sand bags. dlrce Lo six pounds, nlade bv s.rr,r.ing up tire legs ol olcl
.ie:rns ancl filling thcn \\irh sard (phoro 10.Z page 100J
.\4 I r-d r rle, -pr, .ri]..6,,i.p.,..po.r,o\i ,p l\\-r1 Vrl.r,,
.i, 'r..pl ,'o.o,J. r, ro.8r n p,r-:.5 t0
a Hand !\,eights. a qllarter pound or half pound (pholo
13.2,
page 148)
 APPENDIX 225

. Homemade hand vreights - place a quarter or half a pound of

dried beans in a tube sock. Shake beans to center and tie socl<
into knots at both eDds.
. Bells snlall halls, pla)ground ball, IarSer lighrweighr ba11s,
bcach ball
. Rings, as uscd for a ring toss gilme or fol.divin3 (phoro 12.6,
paSe 133)
. Hoop (photos 14-18a and b; 15.21. pagcs 169, 197)
. Sricks, a broomstick cut in halfori[tothree orfourpieces [photos
13.13 and 1,+.11, pages 151. 165l
. Foam sqlLares the size of seat cushions (photo 1S.14, page 192)
a BallooDs arf vilrioLLs slzcs
o Shaving crcan and foam shapcs

Therapy Equipment Supptiers

Here is small snnlple of companies that sell pcdiatric therapyequipnlellt Lhat tua1'- be
a
of u5e to parents of childr en
l,'ith cerebral p.: lsv Theru .1re ntrn\ ,-,ther g,, J soLLLces:
r'kro.'roh..'.c l-r.rfi,,, ..rl .unp;r.,rheo-.1. ecot ln, nl\.
Abilitations
PO. tlox 922668
Norcross, GA 30010
800 850-8602
u,w\r.abiliration s.corn

Achievement ProducLs
P O. Box 9033
Canton, OH 44711
800 766-,1303
,,vww.specialkidszone.com

Danmar Prod crs, IDc.

221 Jackson IndusLriel Dri\.e
Ann Arbor, I,ll4B103
800 783 r 998
danma,-pr()Ciaol.com

Erlttipment Shop
P.O. Box 33
Bedford, NIA 01730
fr0u 525 7681
r,;lr lr,.e qu t pmentsh op, com
226 TEACHING ]\4OTOR SK]LLS IO CHILDREN WITH CEREB]IAL PALSY AND SJI\4]LAR A4OVE]\4ENT DISORDER5

Flaghouse
Rehab Resouices
601 lrla8house Dr.
Hasbrouck Heighrs, NJ 076021
800 793-7900
u,w!^,.FlagHouse-com

Kavc ProducLs
535 Dimmocks Mili Road
HillsboroLrBh. NC 27278
919 732 6414
${vrr.ka\icproducts.com

Nilo
4011 AYenida De La Plata, #302
Oceanside, CA 92056
800'872 6,1s6
www.nilotoys.corl'
(Supplier of play table with rim)

Rifton Equipnlent
359 Gibson llill Road
Chester, NY 10918
800 777 4211

Sammons Prcston Rolyafl Pediatrics

An Abilityone Company
PO. Box 5071
Bolingbrook,IL 60440
800 323-5547
www.sammonsprestonlolyafl.com

Or ganizations Providing Recreational Opportunities

Little Leaguc Challengel Di\.ision
Little Lea guc Baseball Hcf dquafiers
PO. Box 3.+85
Williamsporl. PA 17701
rv rvn .lit tlele r guc org/d ivi sion s/challenger.
. a sp

National Sporrs Cenler for rhe Disabled

PO. Box I290
Wintcr Park. CO 80,182
970-726 7s4A
vl r.- rl,, ns cd. org
 APPENDIX 227

North American Riding fbr Lhe Handicapped Associatlon (NRHAI

P.O. Box 33150
Denver, CO
800 369-7433
NARHA(@NARHA.oTS

Special Ol_vrlpics
1l33 19'h Srreet N$
Washirl8Lon, DC 20036
202 628 3630
1r/1\\'\. sPccialol) t11pics.o1-g

U.S. Youth Soccer TOPSoc(er

ww \ r,vouthsoccel-.org,/progranls/Lopsoccer
18OO 4SOCCER
Chairman Susanne Conlons, conk s@mindspring.conr

Wheelchiijr Sports USr\

1668 320'r Wav
Earlha1n, IA 50072
515 833 2450
 .*-+

aaaaa
a
a
a
a
a
a References
a aoaaaaaaa

Ahl Ekstlom, 1.. et al.I uDclional therapy for children with cerebralpals_vt An ecolo:i-
cal approach. D€relopr]rr,ntdl Medicine dnd Chlld Neurology 2005:47:613 619_

Bandy, W.D. et al. The effcct ofstatic sLretch and dynarnic range ofnlotion trailirS
on the llexlbility of the hamstrlng muscles. Journal of Orthopaedic dnd Sports
P/rysical Ihero71, 1998 27 :295 3O0.

Bandy, W.D. et al. The effect of time al1d trequency ofstatjc stretching on ilexibility
of hamstring rnuscles. Physical T' lrerapy 7997;77 :7090-7096.

Ble(k, L.L. The locom{)tor prognosis in cerebral palsy. refr,loprt€nt.lJ l.,Iedict,te o/Ld
Citild Neurolog_! 1975:17:18 25

Bobath K. Ifoe Neurophys iologicalBasis for the Treatment of Cerebral Palr/. Clinics in De,
velopmental Medicine, No. 75. London: Wiiliam Heinemann Medical Books, 1980.

CottorlE. Conductive Educatton and CerebralPal{z London: The Spastic Sociery, 1974

Da\,, J.A. er al. Locomoror trainin.g r.-irh partial body wcight support on e Lr.endmill
iJl a nonatrbulatotv child lvith spastic tetraplcgic cerebral pals),: A case r.eporL
Prdidali. Plt_l,il.dl TI€rdp_y 2004; 16:106- l 13.
 Porenting/Cerebrol polsy

White most frmilies ofyoung chitdren with cerebral palsy and simitar
conditions work
in coniunction wirh a physical therapisr a few rjmes aweek, jt takcs.laily
irrervcnrjon ro
f.rp lr,ld a,l,hi moro pora.,, Jt arJ h..o. , rn. r i roFt, r ,lpnr
? prcrrx.; Moro{ SIorff is the resource thal parcnrs,
rhcrapists, and other caregivers
can consult ro hclp yourg chitdren wirh gross motor detavs learn rnd Drardcc;oror
"kir\^u .rdp u
rheraor,e..ion v\-r.cn b\,,,
\p- i.n.-L,t),i,J, rh_rrpi, ntro
js also the mothcr of a child with ccrebrat patsy, rhis comprehcnsir,e guide
cxam cs
rhe.physical characrerisrics of cerebral patsv ana sim ar conaitiols_Drusclc rlllllll'],IslrIl
Lightncss
;:rd weakness, ircreased or dccreased ilexibilit, abno lal reflcxes, xrlpai."d
;;""".1,
p-tr"p iorr. hr, d'',(. rchrla. t..rrvru"r .,w. L|,d,, ar rt.rrddr\"Moro!
Siotts offers dozels of easi, to follow cxercises with ac(om^"-.;-^
-,-^,^" ."-. -^-:nrs
lnay rncorporate inro marI, daiiv routines at home rvith t SVNIRTAR I of

. Headcontror ress:
their child's physical thcrapis.. Exerrises addl
lililllllllllllllllllilillilllll
. Protecrive reacrions
. ProPer posirioning
. Independent sitlingwjth and \rithout ar]n s!pporr
. Transitional molemcnrs
. Daily strerching
. Improving muscle strength and coordimrio.
. Batance rraining
. Gaiftraining

Full of anecdotes and frequertti, asked qucsrions. rvirh a chapter on

mc.lical
intcrvtrtions al1d bracing, and al1 appeldix of equipment uuO ,rpph"".
,]ri, ur.,
lriendly suide hclps parents and prolessionats coordinare thck
efTorts t"
bestpossible ourcoJne firr rhe child. ".hi;;,L

"The author pro.t i.let a Lhorough yet clear explanatiotl oJ cerebral palsy wittt i1:;
manv
tam'Ji,dtiotlt in.ludinsabnormal r"u\,tc ton" ond detoyd Jevaovntinr,
o, ue a: i,tnt
o,ttriicstocnhoD.ethrocquisiionolnotot.kitl\_thescnoofi..,edrnelrapt:t*tttteoit,rc
ure d?rs book as dn impor tant ruource
for parenx, teachers, ai.Les and oth;r school personnel
to t\sist.them in understanding cerebruI patiy and their child\
delayed motal. rlevetipnent.
me authot also empho,sizes ho1t, parents can and musr adivety
assrsr tfieir ctr ita i,, ,iq"iii"g
i mp r oy e d m ot or skills."

\,1'.\f , 11,'r,,,\4. t tl
." .,",i*:i#:i.,',:H"1",::::,J:.,:,:::i:iff ;:":,i.:
"My daughter hos had wonderfut therupists t)ho answer my queshoff
.Ind gire aood
sug,estions for Jollo',|, up activities at home. Ijoweye4 untos I rake
nores, I ie/ d;m rcmembet
what they hdre said L,e le.11je the clinic_ 1 plan to use th| helpful resource
.after ,"t"r""r"
to cnnsuk again and ag.tin and to remind me how to wort therapy
into ptayame ", "ani
even
doily carc tosks like carrying my child. diapering, and bo_ric posirroning. ,,

,,..", #iJi.liiiliillti,i:i."J"T.;ll#::i:*t11.J

t21.95
rsEN 973-1 390627-72 0
5 2195>

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