Special Article

Rehabilitation Approaches for

Children With Cerebral Palsy: Overview
Meg Stanger, MS, PT, PCS; Susan Oresic, OTR/L

ABSTRACT

This article reviews the use of the World Health Organization classification framework for assessing children and adoles-
cents with cerebral palsy and the use of outcome measures as they relate to the International Classification of Functioning,
Disability and Health. Various intervention philosophies and approaches are discussed, including the evidence to support
their use with children with cerebral palsy. Therapists will be able to use this information to formulate an assessment plan,
incorporate the use of outcome measures, and employ evidence-based intervention methods. (J Child Neurol 2003;18:S79–S88).

Cerebral palsy is a diagnosis that encompasses a broad
spectrum of motor-related impairments with subsequent
functional abilities. The functional abilities of children with
cerebral palsy also vary immensely in cognitive, self-care,
mobility, and social domains. A diagnosis of cerebral palsy
does not correlate with any clearly defined rehabilitative
intervention strategies, nor does it correlate with a defined
set of expected outcomes for the child and family. This arti-
cle discusses the importance of using a framework to guide
clinical decision making and the need to use appropriate out-
come measures. Intervention strategies that are supported
by evidence in the literature and that correlate with the
decision-making framework are also discussed.
Rehabilitation professionals have an ethical responsi-
bility to use and apply therapeutic techniques and inter-
vention strategies that result in improved functional status
for the child and/or family and prevent secondary impair-
ments and functional limitations, as well as to efficiently use
resources when there is a reasonable prognosis for improve-
ment and change. An increasing number of studies demon-
strate the effectiveness of intervention strategies for children
with cerebral palsy. Unfortunately, there continues to be a
paucity of research on the critical periods for the timing and
intensity of interventions.
Received Feb 17, 2003. Received revised March 19, 2003. Accepted for pub-
lication June 4, 2003.
From the Department of Occupational and Physical Therapy, Children’s
Hospital of Pittsburgh, Pittsburgh, PA.
Address correspondence to Meg Stanger, Children’s Hospital of Pittsburgh,
Physical Therapy Department, 3705 Fifth Ave, Pittsburgh, PA 15213. Tel:
412-692-7074; fax: 412-692-6765; e-mail: meg.stanger@chp.edu.
Prior to determining an intervention strategy, a thera-
pist must decide on an appropriate outcome measure. Out-
come measures must be used to validate the changes or
progress made by the child and are necessary to provide
accountability to the child and their family, outside resources,
and third-party payors for the interventions used. The appro-
priate outcome measures can also be used to establish
more efficient and effective methods of intervention for
children with varying presentations of cerebral palsy. Clas-
sification systems such as those developed by the World
Health Organization can assist with identifying an appro-
priate outcome measure that is specifically used to assess
an impairment, functional ability level, or participation in
a life or societal function.
The World Health Organization classification systems
provide a common language when discussing or coding
information related to health and health care.1 The Inter-
national Classification of Functioning, Disability and Health
provides a standardized language and framework for clas-
sifying human functioning and disability.2 Impairments are
problems in body function or structure such as spasticity
or decreased strength. Activity limitations are difficulties an
individual may have in executing activities such as walking
or raising the arms overhead. Participation restrictions are
problems an individual may experience with involvement
in life situations such as mobility in school or getting dressed
in the morning. Activity limitations and participation restric-
tions include the functioning and disability components of
the International Classification of Functioning, Disability and
Health2; however, contextual components such as envi-
ronment and personal factors also impact on the individual’s
activity and participation in society.

S79
S80 Journal of Child Neurology / Volume 18, Supplement 1, September 2003
A variety of reliable and valid assessment tools provide
information on impairment, functional or activity limita-
tions, and/or disability or participation restrictions (Table 1).
Each tool has its own role in developing a long-term plan
for children with movement disorders. Other assessment
tools provide normative data and can be used to obtain
developmental levels, such as an age-equivalent or stan-
dard score. The rationale for use of an assessment tool and
the identified outcome are key factors in determining the
appropriate assessment measure.
ASSESSING PARTICIPATION AND DISABILITY
The Canadian Occupational Performance Measure, the Pedi-
atric Evaluation of Disability Inventory, and the Functional
Independence Measure for Children are all tools that assess
restrictions in participation or the disability of the child. The
Canadian Occupational Performance Measure is an indi-
vidualized measure designed to detect change in a client’s
self-perception of occupational performance over time.3
This measure not only detects change in performance, it also
assists with identifying problem areas that are important to
the client. The Pediatric Evaluation of Disability Inventory
measures the child’s capabilities on 197 functional items
across 3 domains; functional performance is measured by
the level of assistance needed and the equipment required
to complete the task.4 The caregiver’s assistance and equip-
ment modification scales therefore determine the level of
assistance a child needs to complete a certain activity. The
Functional Independence Measure for Children assesses the
level of functional independence of the child and is adapted
from the adult Functional Independence Measure.5 The
Functional Independence Measure for Children consists of
only 18 items and thus is less comprehensive than the Pedi-
atric Evaluation of Disability Inventory but requires less time
to administer. Data from the Functional Independence Mea-
sure for Children are part of the uniform data set that allows
subscribers to compare outcomes with those of similar
facilities in other parts of the country.
ASSESSING FUNCTION/ACTIVITY
The child with cerebral palsy and a resultant movement dis-
order will exhibit limitations in functional activities such as
Table 1. Tests Measuring Developmental Age, Activity, or Participation Abilities
Test
AIMS
Bruinincks-Oseretsky Test of Motor Proficiency
COPM
GMFM
PDMS II
PEDI
QUEST
TIMP
WeeFIM
COPM = Canadian Occupational Performance Measure; GMFM = Gross Motor Function Measure; PDMS = Peabody Developmental Motor Scales; PEDI = Pediatric Evaluation of
Disability Inventory; QUEST = Quality of Upper Extremity Skills Test; TIMP = Test of Infant Motor Performance; WeeFIM = Functional Independence Measure for Children.
sitting or reaching. Assessments that measure the degree to
which these activities or functional skills are obtained must
be used to guide the intervention strategies and monitor out-
comes. Many of these assessments are tests of motor func-
tion and can also establish a developmental age level if
appropriate. The Test of Infant Motor Performance was
developed to assess the postural control and alignment
needed for age-appropriate functional activities in early
infancy.6 These activities include age-related changes in
head and trunk control for moving against gravity, adjust-
ing to handling, and interacting with caregivers. The Test of
Infant Motor Performance is designed for infants who are
32 weeks’ gestational age to 4 months past full-term deliv-
ery date. Scoring is based on a range of responses signify-
ing maturity through a risk for morbidity. The Alberta Infant
Motor Scale assesses gross motor function, including mat-
uration of skills and postural alignment of infants from
birth to 18 months of age.7 Scoring is through observation,
and age scores are determined, as are percentiles for com-
parison of the motor maturation of the child over time. The
Peabody Developmental Motor Scales assess normative
performance of gross and fine motor function for children
from birth to 84 months of age.8 An age-equivalent score for
the child’s gross and/or fine motor function as well as change
over time can be assessed using the Peabody Develop-
mental Motor Scales.
The Bruininks-Oseretsky Test of Motor Proficiency
assesses both fine and gross motor function as well as
strength, balance, running speed, and coordination of chil-
dren from 4.5 to 14.5 years of age.9 The child’s performance
can be compared with that of a national age-specific refer-
ence group. The Gross Motor Function Measure and the Pedi-
atric Evaluation of Disability Inventory functional scales are
both assessment tools that measure function. The Gross
Motor Function Measure was designed specifically for chil-
dren with cerebral palsy and was developed to measure
change over time. The Gross Motor Function Measure con-
sists of activities in five dimensions: lying and rolling; sit-
ting; creeping and kneeling; standing and walking; running
and jumping.10 The Gross Motor Function Measure can be
used to measure the effectiveness of an intervention such
as a therapeutic technique or surgical intervention. The
Pediatric Evaluation of Disability Inventory functional scales
assess the child’s abilities across the domains of self-care,
Development Function/Activity Participation Quality
X X
X
X
X
X X
X X
X X
X
X
 Rehabilitation Approaches for Children With Cerebral Palsy / Stanger and Oresic
mobility, and social function. The Pediatric Evaluation of Dis-
ability Inventory can be used for children between 6 months
and 7.5 years of age or those older if their functional abili-
ties are below those of a 7.5 year old without a disability or
limitations in activity.
Evaluation tools that assess quality of movement can
be useful but should not be used without also determining
function and level of disability with one of the above-men-
tioned tools. The Quality of Upper Extremity Skills Test is
an example of such a tool, which was developed to evalu-
ate quality of upper extremity function in four domains:
dissociated movement, grasping, protective extension, and
weight bearing.11
ASSESSING IMPAIRMENTS
Children with cerebral palsy will often exhibit a broad spec-
trum of impairments. The therapist must determine which
of those impairments are impacting the child’s function and
ability to participate in home and community activities or
that may result in secondary musculoskeletal deformities
as the child grows and develops. It is critical that the ther-
apist objectively measure those impairments targeted for
change as a result of the intervention strategies. Goniome-
try has been shown to be a reliable method of measuring
range of motion in children,12,13 as have measures such as
manual muscle testing and dynamometry been shown to be
reliable ways of objectifying strength.14–16 Spasticity or
the resistance to passive movement can be assessed using
the Ashworth Scale,17 whereas dystonia can be measured
using the Fahn-Marsden Scale18 or the Barry-Albright Dys-
tonia Scale.19 The Fahn-Marsden Scale comprises a move-
ment scale that is scored by the clinician after examination
of the patient’s functional movement and a disability scale
that is based on the patient’s view of disability in activities
of daily living. The Fahn-Marsden Scale has been shown to
be a valid measure of the severity of dystonia, with an inter-
rater reliability of .985 and an intrarater reliability of .91. The
Barry-Albright Dystonia Scale is a 5-point severity scale
that was developed to assess patients with dystonia who may
have cognitive or motor control limitations that interfere with
their ability to move functionally. The Barry-Albright Dys-
tonia Scale has been found to be a valid and reliable tool for
measuring the severity of dystonia, with an interrater reli-
ability of .978 and an intrarater reliability of .967 and .978.
Additional objective measures of impairments include
the 6-minute walk test for endurance, the physiologic cost
index to measure energy expenditure, balance and postural
assessments, and assessment of gait parameters using meth-
ods ranging from clinical assessments to sophisticated lab-
oratory gait analysis systems.
When determining the effectiveness of an intervention
strategy or assessing change in a child with cerebral palsy
over time, multiple assessment tools must be used. Before
a technique can be deemed effective, change must be evi-
dent for the child or his or her caregivers. Those changes
may exist at the functional level, such as increased partic-
S81
ipation in home and community activities, ease of care for
a family member, or prevention of the development of sec-
ondary deformities or pain. Ideally, the effectiveness of an
intervention also includes outcome measures such as use
of resources and ultimate costs for the child, family, and soci-
ety. Interventions that are planned according to the child’s
prognosis for change have the potential to be the most
effective. However, until recently, there has not been ade-
quate information available to allow clinicians to prognos-
ticate regarding the outcomes of children with cerebral
palsy.
To date, it has been the exception rather than the rule
for pediatric therapists to use classification systems to
guide decision making with respect to the use of various
intervention strategies. However, classification of a diagnosis
or disease process is typically used in medicine to determine
interventions and even predict outcomes. An example would
be tumor staging in patients with an oncologic diagnosis.
Physical therapists practicing in the orthopedic setting are
also more accustomed to the use of classification systems
(ie, patients with low back pain).
Several methods have been developed to assist with the
classification of children with cerebral palsy to predict out-
comes and determine appropriate treatment interventions.
Many of these methods are based on etiology, parts of the
body involved, type of movement disorder present, or degree
of motor involvement. Examples include classification of
cerebral palsy by body involvement such as diplegia or
hemiplegia and by movement disorder such as spastic quad-
riplegia. These methods are often subjective in nature and
focus on the impairment rather than the functional level of
the child. The Gross Motor Function Classification System
for Cerebral Palsy was developed based on the concept of
classification according to abilities and limitations as listed
by the World Health Organization.20 The use of this common
language enhances communication among health care dis-
ciplines when determining the intervention goals and plan,
comparing outcomes related to intervention and ultimately
as a predictive tool for parents of young children with cere-
bral palsy.
The Gross Motor Function Classification System for
Cerebral Palsy is a five-level classification system based on
movements initiated by the child (Table 2). The movements
emphasized are sitting and walking. Differences in the five
Table 2 GMFCS for Children with Cerebral Palsy
GMFCS Description
Level I Walks without restrictions; limitation in more advanced
gross motor skills
Level II Walks without assistive devices; limitations are walking
outdoors and in the community
Level III Walks with assistive mobility devices; limitations are
walking outdoors and in the community.
Level IV Self-mobility with limitations; children are transported or
use powered mobility outdoors or in the community
Level V Self-mobility is severely limited even with the use of
assistive technology
GMFCS = Gross Motor Function Classification System for Cerebral Palsy.
S82 Journal of Child Neurology / Volume 18, Supplement 1, September 2003
levels are based on functional abilities and include the need
for assistive and adaptive devices. The Gross Motor Func-
tion Classification System for Cerebral Palsy can be used
to classify the severity of the cerebral palsy related to mobil-
ity. Initial research has shown that when children classified
according to the Gross Motor Function Classification Sys-
tem for Cerebral Palsy are assessed using the Gross Motor
Function Measure, their potential motor development can
be predicted.21 The potential now exists to classify chil-
dren with cerebral palsy, assess their motor function using
the Gross Motor Function Measure, and begin to make
prognostic decisions regarding the focus of interventions and
possibly the best timing for these intervention strategies.
INTERVENTION PHILOSOPHIES AND STRATEGIES
This article discusses several intervention philosophies and
approaches as well as specific intervention strategies and
the evidence to support their use. Many of the various inter-
vention strategies incorporate theories of motor learning and
motor control as well as dynamic systems and functional
task-oriented approaches.
Neurodevelopmental Treatment
Neurodevelopmental treatment was initially a treatment
approach developed by Berta and Karl Bobath for the treat-
ment of children with cerebral palsy.22 The philosophy of the
treatment approach was based on a hierarchical view of ner-
vous system function. The treatment for children with cere-
bral palsy focused on moving them through normal
movement patterns to experience normal movement. Major
components of this approach included reflex-inhibiting pos-
tures, inhibition of abnormal reflexes, normalization of
muscle tone, and adherence to the normal developmental
sequence of motor progression.
The American Academy for Cerebral Palsy and Devel-
opmental Medicine recently published a review of the evi-
dence regarding neurodevelopmental treatment as a
treatment approach for children with cerebral palsy.23 This
extensive report concluded that there is no strong evidence
supporting the effectiveness of neurodevelopmental treat-
ment for children with cerebral palsy with respect to nor-
malizing their muscle tone, increasing their rate of attaining
motor skills, and improving their functional motor skills.
Conductive Education
Conductive education is a form of special education and
rehabilitation for children and adults with motor disor-
ders.24 The approach used in conductive education was
developed by a Hungarian physician, Andras Peto, in
Budapest after World War II.24 The focus is to help children
with motor disorders learn to overcome problems of move-
ment so that they can live more active lives. Individuals work
on tasks in motor control, mobility, and communication
within a structured program led by the “conductor.” Mini-
mal assistance from the conductor or others in the room is
provided for each child, and the tasks are specific and goal
directed for each child. The program resembles a school day
in length of sessions and necessitates the cognitive ability
to follow directions. Parents often report an improvement
in confidence and motivation as well as bodily control when
their children participate in conductive education. Reddi-
hough and colleagues conducted a randomized trial com-
paring a conductive education program with an equivalent
intensity traditional intervention program for 66 children with
cerebral palsy with a mean age of 22 months.25 Similar
progress was exhibited by children in both groups, indicating
that neither approach was more effective.
Many intervention approaches incorporate a wide
knowledge base that is used to guide treatment. This knowl-
edge base includes theories of motor learning and motor con-
trol and current dynamic systems theory. Multiple
intervention strategies used by rehabilitation professionals
incorporate these current theories.
Constraint-Induced Therapy
Constraint-induced therapy is a rehabilitation approach
designed to enhance upper extremity function in many
patients with neuromotor deficits. Constraint-induced ther-
apy involves restraining the unaffected arm while having
patients perform purposeful activities with the affected
arm. Beginning with animal research during the 1970s, Taub
suggested that a limb thought to be nonusable is capable of
movement by conditioning its use.26 Other researchers have
investigated the efficacy of constraint-induced therapy with
the pediatric population. Willis et al documented improved
Peabody Developmental Motor Scales scores on 12 children
with cerebral palsy, ages 1 through 8 years, who underwent
casting of the unaffected arm for 1 month compared with
a control group that did not undergo casting.27 Echols et al
used operant training techniques for 6 hours a day in con-
junction with casting of the uninvolved arm for 21 days for
18 children with cerebral palsy in a randomized, controlled
trial.28 The Pediatric Motor Activity Log and the Emerging
Behavior Scale showed significant improvement in the con-
straint-induced group compared with the traditional service
group, who received physical therapy, occupational therapy,
and/or early intervention services twice a week for 21 days.
At the end of 21 days, the traditional group also received con-
straint-induced therapy in the ABA design of the experi-
mental group. At the end of the crossover for the traditional
group, the researchers found that the traditional service
group made gains similar to the constraint-induced therapy
group. Both of these studies included restraining the unin-
volved arm of a developing child for a considerable period
of time. The time involved in carrying through with the con-
straint-induced therapy program may be difficult for some
families, and there should be concern with the effect of the
restraint on a growing and developing nervous system. Page
et al reported positive results with a modified constraint-
induced therapy model for six adults 2 to 6 months post–
cerebrovascular accident in three experimental groups.29 The
constraint-induced therapy group received physical therapy
 Rehabilitation Approaches for Children With Cerebral Palsy / Stanger and Oresic
and occupational therapy sessions three times a week for
30 minutes and had their unaffected arm and hand restrained
5 days a week during 5 hours identified as times of fre-
quent use for 10 weeks. The constraint-induced therapy
group was compared with a group that received traditional
therapy and a group that did not receive any therapy. The
constraint-induced therapy group exhibited substantial
improvements compared with the other groups as mea-
sured by change on the Fugl-Meyer Assessment of Motor
Recovery and the Wolf Motor Function Test. Page et al
replicated the study with four patients in the constraint-
induced therapy group and five patients each in the other
two groups.30 Improvements were again substantiated in the
constraint-induced therapy group on the Fugl-Meyer Assess-
ment of Motor Recovery, the Wolf Motor Function Test,
and the Action Arm Research Test compared with the other
groups. A rationale for decreasing the time for restraint of
the uninvolved arm each day for pediatric patients can be
justified following Page et al’s research results with adults.
Body Weight Support Treadmill Training
Body weight support treadmill training is an intervention that
uses theories of motor learning and the importance of early
task-specific training. A postural control system consisting
of a harness worn by the child reduces the amount of weight
that the child must bear in an upright position. The child
ambulates on a treadmill at an appropriate speed while
supported in the harness system. Treadmill training with a
partial body weight support system provides balance and
postural stability for a child while practicing gait with
decreased load on the lower extremities.
Initial treadmill training with partial body weight sup-
port studies included adults with spinal cord injuries and sub-
sequently with adults status post–cerebrovascular accident.
The theoretical basis for use of the treadmill and body
weight support system was to activate spinal and supraspinal
pattern generators for gait.31,32 Similar stepping movements
are also seen in typically developing infants but are absent
when their legs are weighted.33,34 Therefore, task-specific
training in gait that provides support to the trunk and lim-
its weight through the legs may be beneficial in developing
locomotion patterns in children with cerebral palsy.
Initial studies using treadmill training with body weight
support with children with cerebral palsy are promising
but require further investigation. Richards et al studied the
feasibility of treadmill training with partial body weight
support with four children with cerebral palsy ages 1.7 to
2.3 years.35 The children received treadmill training and
their traditional therapy four times a week for 4 months. The
authors concluded that treadmill training was a feasible
intervention method for young children but recommended
further investigation to determine an effective outcome
measure. Schindl and colleagues studied the effectiveness
of treadmill training with partial body weight support on
10 children with cerebral palsy, 6 of whom were nonambu-
latory.36 The children received the treadmill training three
times a week for 3 months. Eight of the 10 children demon-
S83
strated improvements in both the standing and walking
scores on the Gross Motor Function Measure. Functional
changes demonstrated by the subjects varied but included
the ability to transfer from a sitting to a standing position
without use of arms, walking and stopping, and climbing
stairs. The remaining two children were exhausted by the
treadmill training and did not show improvements.
Strengthening
There has been much discussion in the literature over the
past 20 years pertaining to the muscle weakness of children
with cerebral palsy. Wiley and Damiano assessed lower
extremity muscle strength of children with hemiplegia,
spastic diplegia, and typically developing children.37 The
authors documented weakness in all muscle groups of the
involved lower extremity of children with hemiplegia and
both lower extremities of children with diplegia when com-
pared with typically developing children. In addition, they
documented weakness of the iliopsoas, gluteus maximus,
and anterior tibialis with the knee extended in the uninvolved
lower extremity in the children with hemiplegia compared
with typically developing children. Resistive exercise pro-
grams targeted at identified weak muscles have demon-
strated an improvement in increased muscle strength. A
6-week quadriceps strengthening program was found to
significantly improve quadriceps muscle strength in 10 chil-
dren with cerebral palsy.38 In a second study, Damiano et al
researched the effects of a 6-week quadriceps femoris mus-
cle strengthening program for 14 children with spastic diple-
gia. The researchers demonstrated increased strength of the
quadriceps muscles and a decrease in the severity of crouch
gait in the children.39
A number of studies have correlated the increased mus-
cle strength with improved functional activity in children
with cerebral palsy. In their first study, Kramer and MacPhail
assessed the strength of the knee extensors and flexors,
energy expenditure, and gross motor function using the
Gross Motor Function Measure in 17 adolescents with mild
cerebral palsy. They determined that knee extensor strength
was significantly related to walking efficiency and gross
motor ability but that knee flexor strength was not related.40
In a second study, MacPhail and Kramer researched the
effects of an 8-week isokinetic strength training program on
the strength and gross motor function of 17 adolescents with
cerebral palsy.41 The authors reported significant increases
in knee extensor and flexor strength with 9 of the 17 sub-
jects demonstrating significant improvement in their Gross
Motor Function Measure scores. The authors subjectively
reported that the adolescents who did not demonstrate
improvement in their gross motor abilities were also the sub-
jects who demonstrated less significant change in the
strength of their knee musculature. Damiano and Abel
found that a 6-week strength training program for 11 chil-
dren with either spastic hemiplegia or diplegia produced sig-
nificant strength gains in the targeted muscles, increased
speed of gait, and improvement in dimension five of the
Gross Motor Function Measure.42
S84 Journal of Child Neurology / Volume 18, Supplement 1, September 2003

The evidence for the use of strength training as an ferences in range of motion, muscle tone, cross-section
effective intervention to improve functional outcomes of chil- computed tomography of the quadriceps, and a parent ques-
dren with cerebral palsy represents level V, case reports tionnaire between the threshold electrical stimulation group
according to Sackett et al’s levels of evidence.43 A review of and the placebo group.55 Sommerfelt et al found no signif-
the literature in 1997 concluded that progressive resisted icant changes in scores on the Peabody Developmental
exercises increase muscle performance in children and Motor Scales, strength, deep tendon reflexes, six-meter
adolescents with mild cerebral palsy; however, the rela- walk, and six-minute walk tests with the use of threshold
tionship between strength training and functional abilities electrical stimulation to the quadriceps and tibialis anterior
remains unclear.44 Additional evidence has been added to muscles bilaterally.56
the literature, as outlined above, that continues to document
improvements in functional outcomes with strength train-
Therapeutic Riding
ing programs. Research has not focused on the social aspects
Therapeutic riding and hippotherapy are often recom-
of the functional improvements and the possibility for reduc-
mended to enhance the posture, balance, and motor func-
ing the participation restrictions that occur with many chil-
tion of children with cerebral palsy. Hippotherapy is defined
dren and adolescents with cerebral palsy.
as a treatment approach performed by a health professional
that uses the multidimensional movement of the horse as
Electrical Stimulation
a therapeutic intervention.57 A therapeutic riding program
A discussion of electrical stimulation requires a definition
may use a therapist as a consultant, but it is not considered
of terms frequently used to differentiate the types of stim-
physical or occupational therapy treatment. During thera-
ulation. Neuromuscular electrical stimulation is the electrical
peutic riding, a riding instructor is teaching riding skills.
stimulation of the muscle through the motor nerve, usually
Bertoti documented improvement in the posture of 8
with a goal of improving strength, improving range of motion,
of 11 children with cerebral palsy following a horseback rid-
or facilitating motor learning. When neuromuscular electrical
ing program twice a week for 10 weeks.58 A self-designed
stimulation is applied to serve as a support or orthosis, it
postural assessment scale was used for measurement.
is referred to as functional electrical stimulation. Both types
McGibbon et al evaluated the effects of an 8-week hip-
of electrical stimulation are most commonly applied tran-
potherapy program on energy expenditure, gait parame-
scutaneously but can be applied percutaneously and produce
ters, and gross motor function on five children with cerebral
a muscle contraction.45 Threshold electrical stimulation is
palsy.59 The authors demonstrated a significant increase in
the application of electrical stimulation at low intensities that
walking energy expenditure and a significant improvement
does not result in a muscle contraction. Threshold electri-
in gross motor skills as measured by the Gross Motor Func-
cal stimulation is typically applied for a minimum of 8 hours
tion Measure; changes in gait parameters were not statisti-
while the child is sleeping.46
cally significant. More recently, Sterba and colleagues noted
Multiple studies have demonstrated the effectiveness
improvement in Gross Motor Function Measure dimension
of neuromuscular electrical stimulation with increasing
E (walking, running, and jumping) scores after 12 weeks of
range of motion and increasing strength of children with
therapeutic riding.60 Parents also acknowledged improve-
cerebral palsy.47–52 The studies vary in the number of sub-
ments in speech, self-esteem, and emotional well-being of
jects and muscles stimulated and represent evidence levels
their children when they participated in the therapeutic
of III and V according to Sackett et al.43 The studies regard-
riding program. Therapeutic riding is an activity in which
ing neuromuscular electrical stimulation have demonstrated
children of varying functional levels can participate and
improvement at the impairment level but have not vali-
may even be able to be performed with their peers or fam-
dated effectiveness with functional changes for children
ily members. The emotional and sensory benefits that ther-
with cerebral palsy.
apeutic riding may provide may be important factors to
Much of the research with functional electrical stimu-
consider when assessing the effectiveness of this approach.
lation and children with cerebral palsy has been conducted
The last two intervention strategies to be discussed in
with percutaneous implanted electrodes.53,54 These studies
this article, orthotic devices, splints and casts, and assistive
have found functional electrical stimulation to improve the
technology, are most often implemented by a team of pro-
function of children with cerebral palsy as measured by the
fessionals who are involved in the care and rehabilitation
Gross Motor Function Measure, including accomplishment
of children and their families. Physical and occupational ther-
of participation activities such as donning a coat and drink-
apists are crucial members of the decision-making process
ing independently from a school water fountain while stand-
for the appropriate device, training in its use and fit, and edu-
ing. However, at this time, percutaneous implanted electrode
cation of the family or caregivers in safety and appropriate
systems are available only in the research laboratory setting.
use of the device.
Two recent studies investigated the effectiveness of
threshold electrical stimulation at the impairment level55 and
the function and participation levels.56 Both of these stud- Orthotic Devices, Splints, and Casts
ies were randomized clinical trials with 57 subjects and The goals for deciding on the use of a cast, splint, or orthotic
12 subjects, respectively. Dali et al found no significant dif- device are varied but include (1) maintenance, or an increase
 Rehabilitation Approaches for Children With Cerebral Palsy / Stanger and Oresic
in joint range of motion; (2) protection or stabilization of a
joint; (3) promotion of joint alignment; or (4) promotion of
function. For this article, a splint is defined as a device that
is fabricated from a low-temperature plastic. Splints may be
fabricated by a therapist or orthotist and often serve as diag-
nostic tools or interim devices. An orthotic device is fabri-
cated by an orthotist from high-temperature plastic materials.
Orthotic devices have changed drastically over the past
30 years from metal uprights with orthopedic shoes to
orthoses that are individually molded from high-temperature
plastics to fit the individual child. Much of this change has
resulted from the collaboration of physical therapists, ortho-
tists, and orthopedists. Several studies in the 1980s exam-
ined the use of inhibitive casts on the ability to improve gait
parameters, base of support, and heel contact. Inhibitive
casts are short plaster or fiberglass leg casts that incorpo-
rate a footplate with areas of relief to decrease the influence
of tonic foot reflexes. Bertoti and Hinderer and colleagues
reported significant improvements in stride length for chil-
dren treated with inhibitive casts compared with children
receiving physical therapy without casts.61,62 Inhibitive casts
were time consuming to fabricate and cumbersome for the
child and the caregiver. Hylton worked with orthotists to
incorporate the molded footplate portion and total contact
of an inhibitive cast into the fabrication of a high-tempera-
ture orthotic device.63 The result of this collaboration is
the line of dynamic ankle-foot orthoses fabricated by Cas-
cade Orthotics and Prosthetics (Bellingham, WA).63
Orthotic devices for the lower extremity may range
from a foot orthosis to a hinged ankle-foot orthosis. Several
studies have suggested that the use of hinged ankle-foot
orthoses may lead to more normal patterns of ankle dorsi-
flexion at midstance and increased gait velocity.64,65 Clinicians
theorize that hinged ankle-foot orthoses provide an easier
transition from sitting to standing and when ascending or
descending stairs. Baker and colleagues found statistically
significant increases in forward trunk lean angles when ris-
ing from a sitting to a standing position in children who wore
hinged ankle-foot orthoses compared with those who wore
fixed ankle-foot orthoses.66 Further research is needed to
determine which type and style of ankle-foot orthoses are
effective in improving function or managing joint range of
motion and the length of time that a device should be worn.
Tardieu et al determined that children must wear a
device for 7 hours a day to maintain the muscle length of
the gastrocsoleus complex.67 Therapists may fabricate a
resting splint to maintain joint range of motion, but this splint
must be worn a minimum of 7 hours a day according to
Tardieu et al’s work with the gastrocsoleus muscles. A splint
may be custom molded from a low-temperature plastic
material or custom ordered such as those supplied by the
Benik Corporation (Silverdale, WA) for support of the wrist
and fingers. Determining the goal of a splint is crucial to suc-
cessful use and carryover. For example, a wrist splint that
provides proper joint alignment for a child with upper
extremity dystonia may hinder function and cause skin
breakdown. In this example, a night splint to maintain or
S85
increase range of motion may be effective in achieving a
range of motion goal and more practical for the child.
Serial casting is the application of multiple casts over
a period of time with the goal of increasing joint range of
motion. Serial casts are most frequently applied to elbows,
knees, and ankles to increase joint range of motion for
improved function or ease of caregiving and activities of daily
living. There is minimal research to validate their effec-
tiveness, but recent research has focused on the combina-
tion of casting and botulinum toxin A to increase ankle
joint range of motion. Russman and colleagues conducted
a randomized study design to compare the effectiveness of
botulinum toxin A and casting, a placebo and casting, and
botulinum toxin A only for the management of dynamic
equines in 32 ambulatory children with spastic cerebral
palsy.68 Changes were made at the impairment level in both
the botulinum toxin A and casting and placebo and casting
groups, and no significant changes were made in the botu-
linum toxin A only group. Glanzman studied the effective-
ness of botulinum toxin A, serial casting, and a combination
of casting and botulinum toxin A in a retrospective study of
55 children with cerebral palsy.69 The author concluded
that serial casting alone and serial casting with botulinum
toxin A were more effective than botulinum toxin A in
increasing ankle joint range of motion in a short-term fol-
low-up. The evidence points to a need for further investi-
gation of the effectiveness of serial casting with or without
botulinum toxin A, the timing for cast application, and the
duration of the changes effected.
Assistive Technology
Assistive technology is defined as any item, piece of equip-
ment, or product system, whether acquired commercially
off the shelf, modified, or customized, that is used to increase,
maintain, or improve the functional capabilities of individ-
uals with disabilities.70 The goal for the use of assistive
technology devices is to improve postural control and sup-
port and/or increase the function and participation of indi-
viduals in their family, school, and community settings.
The diversity and complexity of devices available, the
modifications often necessary to customize the devices
for an individual, and the expertise needed for ordering, fit-
ting, training, and education necessitate the involvement of
a team composed of multiple disciplines. Assistive tech-
nology devices are typically divided into five categories: pos-
tural support or seating systems, wheeled mobility,
augmentative and alternative communication, computers
and computer access, and electronic aids to activities of
daily living. The variety of assistive technology devices is
expansive and is beyond the scope of this article; how-
ever, highlights pertaining specifically to seating and posi-
tioning are reviewed.
Seating systems promote and maintain proper alignment
and support to the head, trunk, and pelvis with the goal of
improving positioning and function. Nwaobi and Smith
explored the effect of adaptive seating on the pulmonary
function of children with cerebral palsy.71 Eight children with
S86 Journal of Child Neurology / Volume 18, Supplement 1, September 2003
cerebral palsy were assessed in a regular wheelchair with
a slingback and seat and then a wheelchair with lateral
trunk supports, tilt in space, and adjustments for hip flex-
ion. They noted a 57% increase in vital capacity and a 55%
increase in expiratory time. Much of the research compar-
ing anterior-tilted seat angles to upper extremity reaching
and hand function has been completed on static seating such
as adaptive benches or chairs but not wheelchairs. Myhr and
von Wendt found higher arm and hand function scores using
a 4-point rating scale with children seated in an anterior
tipped seat.72 However, McClenaghan et al found no signif-
icant differences in six upper extremity tasks when children
with and without cerebral palsy were assessed at seating
angles of 5° anterior, neutral, and 5° posterior.73 In another
study, the oral motor function of 18 children with cerebral
palsy was assessed in two different chairs with either min-
imal support or one with multiple and adjustable postural
supports.74 The researchers found no significant differences
in oral motor function as measured by the Schedule for
Oral Motor Assessment-Screening Version 2 with the chil-
dren seated in either chair. Clearly, further research is
needed to establish the relationship between seating pos-
ture and function.
Many children and adolescents with cerebral palsy will
use multiple assistive technology devices, including seating
systems for positioning and mobility, as well as communi-
cation devices and access to other equipment, such as com-
puters. A team with expertise in assessing the effectiveness
of the various access methods as well as current knowledge
of the available products is crucial to a child’s successful use
of the technology. Bay assessed positioning for head con-
trol to access an augmentative communication device for
a young adult with a diagnosis of choreoathetosis and spas-
tic quadriparesis.75 She was assessed using her Light Talker
(Prentke Romich, Wooster, OH) with a head switch in a reg-
ular wheelchair and in a modified motorized wheelchair. Rate
and combined rate and accuracy increased significantly
with the modified motorized wheelchair. Angelo determined
that the speed of various modes of scanning differed depend-
ing on the impairments of spasticity compared with atheto-
sis, further emphasizing the importance of individual
assessment and the expertise needed in this field.76
The key to the use of assistive technology is for the team,
child, and family to have clear goals for the use of the
device. The use of assistive technology devices may also
change significantly over the life span. School-aged children
may require an assistive technology device for mobility,
communication, and/or access to a computer. Adolescents
may benefit from additional devices that provide them with
increased independence, such as the use of environmental
controls. Children functioning at levels IV and V on the
Gross Motor Function Classification System for Cerebral
Palsy may benefit from assistive technology to increase
their interaction with their environment or for safety and ease
of caregiver activities. McEwen assessed the interaction
by adults with children with significant and multiple dis-
abilities when the children were positioned in wheelchairs,
in sidelyers, and on a floor mat.77 The adults were found to
increase their interactions with the children when they
were positioned in the wheelchairs compared with the floor
positions. There was no difference between the positions
and the child-initiated interactions.
In summary, the efficacy of various therapeutic inter-
ventions requires further investigation for their use with chil-
dren with cerebral palsy. The evidence is often at Sackett’s
levels I to III,43 with randomized trials beginning to be pub-
lished. The use of an evaluation framework based on the
International Classification of Functioning, Disability and
Health components of health classification will assist the
therapist with decision making regarding the focus of their
intervention strategies.2 The International Classification of
Functioning, Disability and Health model provides a frame-
work for problem-solving the effects of identified impair-
ments on the activity and participation of the child. In
addition, the framework will assist families and the child with
identifying their goals and therefore the focus of the ther-
apy interventions. The use of the Gross Motor Function
Classification System for Cerebral Palsy as a predictor for
future participation abilities will also assist therapists and
families with guiding the use of specific intervention strate-
gies and the timing of these strategies.
Therapists have a professional and an ethical respon-
sibility to use intervention strategies that are supported by
research or at a minimum are supported by sound physio-
logic theories. The responsibility also exists to cease the use
of intervention strategies that research has shown to be inef-
fective. Through the use of classification systems to guide
decision making and intervention strategies supported by
research, therapists will be able to assist families with long-
term expectations for their child and guide them to appro-
priate intervention strategies. Adhering to an evaluation
framework will also assist therapists with timing of the
intervention strategies and the efficient use of their resources
with the ultimate goal of maximizing the participation of chil-
dren and adolescents with cerebral palsy.
References
1. World Health Organization: International Classification of
Impairments, Disabilities and Handicaps. Geneva, World Health
Organization, 1980.
2. World Health Organization: International Classification of Func-
tioning, Disability and Health. Geneva: World Health Organi-
zation, 2001.
3. Canadian Occupational Performance Measure. Ottawa, ON,
CAOT Publications ACE, 1998.
4. Haley SM, Coster WJ, Ludlow LH, et al: Pediatric Evaluation of
Disability Inventory (PEDI): Development, Standardization
and Administration Manual. Boston, New England Medical
Center Hospitals, PEDI Research Group, 1992.
5. WeeFIM System Clinical Guide, Version 5.01. Buffalo, NY, Uni-
versity of Buffalo, 1998.
6. Campbell SK, Osten ET, Kolobe THA, et al: Development of the
Test of Infant Motor Performance. Phys Med Rehabil Clin North
Am 1993;4:541–550.
7. Piper MC, Darrah J: Alberta Infant Motor Scale. Philadelphia, WB
Saunders, 1995.
 Rehabilitation Approaches for Children With Cerebral Palsy / Stanger and Oresic
8. Folio MR, Fewell RR: Peabody Developmental Motor Scales, 2nd
ed. Examiner’s Manual. Austin, TX, Pro-Ed, 2000.
9. Bruininks RH: Bruininks-Oseretsky Test of Motor Performance:
Examiners’ Manual. Circle Pines, MI, American Guidance Ser-
vices, 1978.
10. Russell DJ, Rosenbaum PL, Gowland C, et al: Gross Motor Func-
tion Measure Manual, 2nd ed. Hamilton, ON, McMaster Univer-
sity, 1993.
11. DeMatteo D, Law M, Russell D, Pollack N: QUEST, Quality of
Upper Extremity Skills Test, Manual. Hamilton, ON, CanChild
Centre for Childhood Disability Research, McMaster University,
1992.
12. Florence JM, Pandya S, King WM, et al: Clinical trials in Duchenne
dystrophy: Standardization and reliability of evaluation procedures.
Phys Ther 1984;64:41–45.
13. Pandya S, Florence JM, King WM, et al: Reliability of goniomet-
ric measurements in patients with Duchenne muscular dystrophy.
Phys Ther 1985;65:1339–42.
14. Kendall FP, McCreary EK: Muscles: Testing and Function. Bal-
timore, Williams & Wilkins, 1993.
15. Effgen SK, Brown DA: Long-term stability of hand-held dynamo-
metric measurements in children who have myelomeningocele.
Phys Ther 1992;72:458–465.
16. Stuberg WA, Metcalf WK: Reliability of quantitative muscle test-
ing in healthy children and in children with Duchenne muscular
dystrophy using a hand-held dynamometer. Phys Ther 1988;68:
977–982.
17. Ashworth B: Preliminary trial off carisoprodol in multiple sclerosis.
Practitioner 1964;192:540–542.
18. Burke RE, Fahn S, Marsden CD, et al: Validity and reliability of a
rating scale for the primary torsion dystonias. Neurology 1985;35:
73–78.
19. Barry MJ, Van Swearingen JM, Albright AL: Reliability and respon-
siveness of the Barry-Albright Dystonia Scale. Dev Med Child
Neurol 1999;41:404–411.
20. Palisano R, Rosenbaum P, Walter S, et al: Development and reli-
ability of a system to classify gross motor function in children with
cerebral palsy. Dev Med Child Neurol 1997;39:214–223.
21. Rosenbaum PL, Walter SD, Hanna SE, et al: Prognosis for gross
motor function in cerebral palsy: Creation of motor development
curves. JAMA 2002;288:1357–1363.
22. Keshner EA: Re-evaluating the theoretical model underlying the
neurodevelopmental theory: a literature review. Phys Ther 1981;61:
1035–1040.
23. Butler C, Darrah J: Effects of neurodevelopmental treatment
(NDT) for cerebral palsy: An AACPDM evidence report. Dev Med
Child Neurol 2001;43:778–790.
24. Bairstow P, Cochrane R, Rusk I: Selection of children with cere-
bral palsy for conductive education and the characteristics of chil-
dren judged suitable and unsuitable. Dev Med Child Neurol
1991;33:984–992.
25. Reddihough DS, King J, Coleman G, et al: Efficacy of programmes
based on conductive education for young children with cerebral
palsy. Dev Med Child Neurol 1998;40:763–770.
26. Taub E: Movement in nonhuman primates deprived of somatosen-
sory feedback. Exerc Sports Sci Rev 1997;4:335–374.
27. Willis JK, Maello A, Rice JL, et al: Forced use treatment of child-
hood hemiparesis. Pediatrics 2002;110:94–96.
28. Echols K, DeLuca SC, Ramey SL, et al: Constraint-induced move-
ment therapy versus traditional therapy services for young chil-
dren with CP. Dev Med Child Neurol Suppl 2002;91:44.
29. Page SJ, Sisto S, Levine BA, et al: Modified constraint induced ther-
apy: A randomized feasibility and efficacy study. J Rehabil Res Dev
2001;38:583–590.
S87
30. Page SJ, Sisto S, Johnston MV, et al: Modified constraint-induced
therapy after subacute stroke: A preliminary study. Neuroreha-
bil Neural Repair 2002;16:290–295.
31. Forssberg H, Grillner S, Halbertsma J: The locomotion of the low
spinal cat: Part I coordination within a hindlimb, Part II interlimb
coordination. Acta Physiol Scand 1980;108:269–295.
32. Grillner S, Dubac R: Control of locomotion in vertebrates, spinal
and supraspinal mechanisms, in Waxman SG (ed): Functional
Recovery in Neurological Disease. New York, Raven Press, 1988,
425–453.
33. Thelan E: Treadmill-elicited stepping in seven-month-old infants.
Child Dev 1986;57:1498–1506.
34. Thelan E, Fisher DM, Ridley-Johnson R: The relationship between
physical growth and a newborn reflex. Infant Behav Dev 1984;7:
479–493.
35. Richards CL, Malouin F, Dumas F, et al: Early and intensive tread-
mill locomotor training for young children with cerebral palsy: A
feasibility study. Pediatr Phys Ther 1997;9:158–165.
36. Schindl MR, Forstner C, Kern H, et al: Treadmill training with par-
tial body weight support in nonambulatory patients with cerebral
palsy. Arch Phys Med Rehabil 2000;81:301–306.
37. Wiley ME, Damiano DL: Lower-extremity strength profiles in
spastic cerebral palsy. Dev Med Child Neurol 1998;40:100–107.
38. Damiano DL, Vaughan CL, Abel MF: Muscle response to heavy
resistance exercise in children with spastic cerebral palsy. Dev Med
Child Neurol 1995; 37:731–739.
39. Damiano DL, Kelly LE, Vaughan CL: Effects of quadriceps femoris
muscle strengthening on crouch gait in children with spastic
diplegia. Phys Ther 1995;75:658–671.
40. Kramer JF, MacPhail HEA: Relationships among measures of
walking efficiency, gross motor ability, and isokinetic strength in
adolescents with cerebral palsy. Pediatr Phys Ther 1994;6:3–8.
41. MacPhail HEA, Kramer JF: Effect of isokinetic strength-training
on functional ability and walking efficiency in adolescents with
cerebral palsy. Dev Med Child Neurol 1995;37:763–775.
42. Damiano DL, Abel MF: Functional outcomes of strength training
in spastic cerebral palsy. Arch Phys Med Rehabil 1998;79:119–125.
43. Sackett DL, Straus SE, Richardson WS, et al: Evidence-Based
Medicine: How to Practice & Teach EBM, 2nd ed. New York,
Churchill Livingston, 2000.
44. Darrah J, Fan JSW, Chen LC, et al: Review of the effects of pro-
gressive resistive muscle strengthening in children with cerebral
palsy: A clinical consensus exercise. Pediatr Phys Ther 1997;9:
12–15.
45. Reed B: The physiology of neuromuscular electrical stimulation.
Pediatr Phys Ther 1997;9:96–102.
46. Pape KE, Kirsch SE, Galil A, et al: Neuromuscular approach to the
motor deficits of cerebral palsy: A pilot study. J Pediatr Orthoped
1993;13:628–633.
47. Dubowitz L, Finnie N, Hyde SA, et al: Improvement of muscle per-
formance by chronic electrical stimulation in children with cere-
bral palsy. Lancet 1988;i:587–588.
48. Nauman S, Mifsud M, Cairns BJ, Milner M: Dual-channel electri-
cal stimulators for use by children with diplegic spastic cerebral
palsy. Med Biol Eng Comput 1985;435–443.
49. Hazelwood ME, Brown JK, Rowe PJ, Salter PM: The use of ther-
apeutic electrical stimulation in the treatment of hemiplegic cere-
bral palsy. Dev Med Child Neurol 1994;36:661–673.
50. Carmick J: Clinical use of neuromuscular electrical stimulation
for children with cerebral palsy, part I and II. Phys Ther 1993;73:
505–527.
51. Comeaux P, Patterson N, Rubin M, et al: Effect of neuromuscu-
lar electrical stimulation during gait in children with cerebral
palsy. Pediatr Phys Ther 1997;9:103–109.
52. Treger CP, Mandelbaum L, Parekh MH, et al: Effectiveness of
neuromuscular electrical stimulation (NMES) on selected gait
S88 Journal of Child Neurology / Volume 18, Supplement 1, September 2003
parameters in a pediatric subject with spastic hemiplegic cerebral
palsy, abstract. Pediatr Phys Ther 1997;9:196.
53. Bertoti D, Stanger M, Betz RR, et al: Percutaneous intramuscular
functional electrical stimulation as an intervention choice for
children with cerebral palsy. Pediatr Phys Ther 1997;9:123–127.
54. Finson RL, Akers JM, Mulcahey MJ, et al: The effects of percuta-
neous functional electrical stimulation (FES) assisted walking on
spatial and temporal gait characteristics in children with cerebral
palsy, abstract. Phys Ther 1998;78:S12.
55. Dali C, Hansen FJ, Pedersen SA, et al: Threshold electrical stim-
ulation (TES) in ambulant children with CP: A randomized dou-
ble-blind placebo controlled clinical trial. Dev Med Child Neurol
2002;44:364–369.
56. Sommerfelt K, Markestad T, Berg K, Saetesdal I: Therapeutic
electrical stimulation in cerebral palsy: A randomized, controlled,
crossover-trial. Dev Med Child Neurol 2001;43:609–613.
57. American Hippotherapy Association, 2003. Therapeutic riding pro-
gram. Available at: www.americanequestrian.com//hippotherapy.htm.
58. Bertoti DB: Effect of therapeutic horseback riding on posture in
children with cerebral palsy. Phys Ther 1988;68:1505–1512.
59. McGibbon NH, Andrade CK, Widener G, et al: Effect of hip-
potherapy on gait, energy expenditure, and gross motor function
in children with cerebral palsy, abstract. Pediatr Phys Ther
1997;9:107.
60. Sterba JA, Rogers BR, France AP, et al: Horseback riding in chil-
dren with cerebral palsy: Effect on gross motor function. Dev Med
Child Neurol 2002;44:301–308.
61. Bertoti DB: Effects of short leg casting on ambulation in children
with cerebral palsy. Phys Ther 1986;66:1522–1529.
62. Hinderer KA, Harris SR, Purdy AH, et al: Effects of “tone-reduc-
ing” casts vs standard plaster-cast on gait improvement of chil-
dren with cerebral palsy. Dev Med Child Neurol 1988;30:370–377.
63. Hylton NM: Postural and functional impact of dynamic AFOs and
FOs in a pediatric population. J Prosthet Orthot 1989;2:40–53.
64. Middleton EA, Hurley GRB, McIlwain JS: The role of rigid and
hinged polypropolene ankle-foot orthoses in the management of
cerebral palsy: A case study. Prosthetic Orthot Int 1988;12:129–135.
65. Knutson LM: The effects of fixed and hinged ankle foot orthoses
on gait myoelectric activity and standing joint alignment in chil-
dren with cerebral palsy, dissertation. Iowa City, IA, University of
Iowa, 1993.
66. Baker MJ, Giuliani CA, Sparling J, et al: Effects of ankle-foot
orthosis on a sit-to-stand task in children with cerebral palsy.
Pediatr Phys Ther 1993;5:193.
67. Tardieu C, Lespargot A, Tabary C, et al: For how long must the
soleus muscle be stretched each day to prevent contracture? Dev
Med Child Neurol 1988;30:3–10.
68. Russman B, Ackman J, Thomas SS, et al: Comparison of botulinum
toxin A and casting for the treatment of dymanic equinous dur-
ing gait. Dev Med Child Neurol Suppl 2002;97:8.
69. Glanzman A: Efficacy of botulinum toxin type A, serial casting,
and combined treatment? A retrospective analysis. Dev Med Child
Neurol Suppl 2001;97:33.
70. Individuals with Disabilities Education Act of 1990, Public Law
102-119. United States Congress Senate, 102nd Congress, 1990.
71. Nwaobi OM, Smith PD: Effect of adaptive seating on pulmonary
function of children with cerebral palsy. Dev Med Child Neurol
1986;28:351–354.
72. Myhr U, von Wendt L: Improvement of functional sitting position
for children with cerebral palsy. Dev Med Child Neurol 1993;35:
870–880.
73. McClenaghan BA, Thomas L, Miller M: Effects of seat-surface
inclination on postural stability and function of the upper extrem-
ities of children with cerebral palsy. Dev Med Child Neurol
1992;34:40–48.
74. Reigstad D, Davies P, Rogers B, et al: The effect of adaptive equip-
ment on the oral motor function of preschoolers with cerebral
palsy. Dev Med Child Neurol Suppl 2000;42:35.
75. Bay JT: Positioning for head control to access an augmentative
communication machine. Am J Occup Ther 1991;45:544–549.
76. Angelo J: Comparison of three computer scanning modes as an
interface method for persons with cerebral palsy. Am J Occup Ther
1992;46:217–222.
77. McEwen IR: Assistive positioning as control parameter of social-
communicative interactions between students with profound
multiple disabilities and classroom staff. Phys Ther 1992;72:
634–647.