Children with Cerebral Palsy: A Manual for Therapists, Parents and Community Workers

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Archie Hinchcliffe

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    Dedication

    To those children with cerebral palsy and their families, and to the therapists and community workers that I have been privileged to know

    Acknowledgements

    This book was written for the many physiotherapists who attended the courses I taught in different countries in Africa and the Middle East. I am indebted to them for the encouragement they have given me to write and the friendship they showed me during the courses.

    In order to teach it is necessary to reflect on one's own learning, and my reflection causes me to be deeply grateful for the opportunities I have had to attend Bobath courses and study days. From these I learnt not only about cerebral palsy and the way it affects a child but also a problem-solving way of thinking. The tutors on these courses were invaluable inspirational role models.

    I am also greatly indebted to the many wise and experienced mentors who guided me in the writing and the putting-together of the book. Chief among these is David Werner, who wrote Disabled Village Children. He took hours of painstaking trouble to check the drawings and provide thoughtful and apt advice on sections of the text. He was kind enough to say that he learnt a lot about cerebral palsy by reading the book.

    During my many years of working with children with cerebral palsy, I have been blessed by coming in contact with people who have helped me to see the children more holistically and less as patients. Chris Underhill, who established Action on Disability and Development (ADD), and his Ugandan counterpart Charles Lwangwa-Ntale gave me the opportunity to understand how to link rehabilitation to the process of development as a whole. Peter Coleridge, who wrote Disability, Liberation and Development, and who invitied me to teach a course in Afghanistan, has also been a good friend and source of inspiration.

    The book would not have been complete without the contributions of Marian Browne and Jean Westmacott and, in this second edition, Annie Brozaitis' chapter on sensory integration. I am deeply grateful to all three of them for the effort they put into writing these sections of the book. I would also like to thank Lynne Price for her gifted work on the drawings and Ann Sinclair and Clare Rogers for the work they did on updating these drawings and creating new ones.

    Without the help and support of my husband, Peter, this book would certainly never have been written. In all our postings abroad, he made sure that my work with children took precedence over my duties as a diplomatic wife and he has constantly encouraged me in the writing of this book.

    Finally I want to thank my daughter, Clare, who took great trouble to sort out a tangle I had made in chapters 2 and 3. With clinical incisiveness, she took the strands of the tangle apart and the words fell into clear, understandable sentences. She did the same for Annie Brozaitis in the new chapter. What a wonderful gift!

    Introduction

    This book has been written with therapists in mind. It is written for those therapists I worked with and who attended courses that I conducted in the Middle East, Afghanistan and Africa. But I hope that community workers, volunteers, teachers, programme managers and parents will be able to find ideas and information in the book that will help them to understand the nature of cerebral palsy and how to help children affected by it.

    During the time that I lived in the Middle East and Africa, huge changes took place in attitudes to the provision of services to children with disabilities. In the seventies, funding agencies were supporting hospital-based programmes and institutional care. At this time considerable amounts of aid money were spent on training physiotherapists (never occupational therapists or speech and language therapists). This approach to rehabilitation (the medical model) was seen to fail when it was realised that so very few children could benefit from it. Even those few children who learnt to walk with aids and who received education during their time in the institutions could not easily be integrated back into their communities.

    This failure and a powerful move by organisations of disabled people led to the development of the social model and the switch of donor funding to community-based rehabilitation (CBR) programmes.

    There is no doubt that CBR and the philosophy behind it have achieved huge benefits for children and their families. The programmes, when they work well, mobilise the whole community so that the child and his or her family become accepted and supported by that community. Ownership and responsibility for the success of the programme is with the people on the ground. This was a very attractive idea for donors and, unfortunately, many of them thought that this would be a cheap way of dealing with a problem that otherwise seemed like a bottomless pit. This short-term view did not take into account the fact that it is not enough that people with disabilities should be accepted by their communities. Expertise must also be made available to them to enable them to be as independent as possible and, especially in the case of children with cerebral palsy (CP), this means good therapy and early intervention.

    Nowadays this need is recognised—but while the idea of CBR was being promoted and developed, therapists' training programmes were being starved of support. Very few new training centres were established and those already running were pathetically underfunded. Curricula and training material could not be renewed and morale dropped very low. In all the countries where I lived and worked, therapists were given almost no teaching about paediatrics in their basic training. They had no models of good practice to aspire to and there were almost no continuing education courses at all.

    The aim of the courses I ran was to start bridging the gap between the good expertise of the West and the learning needs of therapists in developing countries. Western expertise in this field does not have to be high-tech. It depends on good observational and analytical skills to solve problems and good handling and communication skills to treat the child and teach families to do the same. I found the biggest difficulty in bridging this gap was that therapists, doctors and programme managers in developing countries were not easily convinced that such a seemingly simple approach could work. In the Middle East in particular, where many doctors of physical medicine were trained in former Eastern bloc countries and believed in passive treatment modalities such as hot packs and electrotherapy for children with CP, there is still a huge reluctance to consider other approaches. On the other hand, guardians of standards in Western countries responsible for course certification and validation were understandably reluctant to make adaptations to curricula and criteria for participating in their courses. This was because they did not want to be accused of watering down their standards either academically or in the level of skill acquisition. But without changes to entry criteria it is almost impossible for therapists from developing countries to get onto even the first rung of the ladder leading to internationally recognised training and ongoing education. Without adapted to curricula the courses will not prepare therapists in developing countries, either clinically or operationally, to work in their own environments.

    It is my belief that the need for rigorous training programmes for therapists in developing countries is overwhelming. It is in these countries that the majority of children with CP are found. It is also in these countries that therapists need the best possible training. But they will have to work in a different way to therapists in the West because there will never be enough resources for programmes to employ therapists at a ratio of more than one therapist for every hundred children. To work effectively in these circumstances a therapist can only assess a child, plan a programme and then teach the programme to family members and community workers to carry out. There need be no watering down of standards in courses that prepare therapists to work in this way, just a change of emphasis.

    The aim of this book is to be a resource for therapists. It will benefit mostly those therapists who have done a practical course. My hope is that it will give a structure within which those people responsible for children with cerebral palsy can plan an effective and feasible programme for them. This structure will reflect the complexities of the haphazard nature of the damage that cerebral palsy causes to the central nervous system of a developing child. It also takes into account that many of the people working with these children have not had opportunities to learn how to observe children's movement and posture, nor to analyse how CP interferes with these.

    The structure of the book leads the reader through the process of assessing a child, planning a treatment programme and working with the family. The first chapter gives some theoretical background covering the development of normal movement, the way CP interferes with this and what possibilities there are to help the child overcome this interference. The second chapter is devoted entirely to observing, handling and finding out about a child in a holistic way. It encourages the reader to take note of every detail of the child's behaviour and performance. Not until the third chapter is the reader encouraged to analyse what it is that he has seen and taken note of. My idea was to break down into two separate operations the process of observation and that of analysis. The fourth chapter looks at the recognition of present or threatening contractures and deformities and some ideas on prevention. In the fifth chapter I have tried to condense, into what is really much too small a space, the principles of treatment of the different kinds of CP.

    I know from my teaching that most people learn about principles from being given practical examples of how each principle can be applied. The danger with putting these examples in a book is that readers may think the examples are rigid treatment plans. This couldn't be further from the truth. I ask readers to use the examples only as illustrations of one way in which the particular principle being explained may be applied.

    The sixth chapter deals with working with families, and the seventh with the equipment that can be useful both in therapy centres and for families to have at home.

    The eighth chapter in this second edition is written by an occupational therapist, Annie Brozaitis. She is Bobath-trained but has also completed courses in sensory integration and has amalgamated these two approaches in her practice. She brings a new way of looking at the problems that altered sensory processing brings to a significant number of children with cerebral palsy, and imaginative ideas for helping them.

    Unfortunately, in most developing countries there are very, very few speech and language therapists and a huge need for their expertise to be made available. That is why the eighth chapter, by Marian Browne, is devoted entirely to ways of helping children with CP with eating and drinking. So many children with CP in developing countries suffer desperately from not being able to take food into their mouths, manipulate it and swallow without choking that, for many mothers, nourishing their children is their overriding concern. Marian Browne is a speech and language therapist and a Bobath tutor. She worked for several years at the Bobath Centre in London.

    In my own practice I have always used the Bobath or Neuro-Developmental Therapy (NDT) Approach. My aim is to demonstrate the benefits and effectiveness of the Approach and to teach the underlying skills of problem-solving and handling that lay the foundation for therapists to participate later in fully-accredited Bobath/NDT courses. Much of what I have written on the features of different kinds of CP and the principles of treatment come from the eight-week Bobath course. But this book cannot be considered as an official exponent of the Bobath Approach. It is only a reflection of the way in which I myself have interpreted the Approach and used it in the countries where I have worked. I would like to state here my indebtedness to the Bobath tutors who have helped and encouraged me over many years and to apologise to them if I have misrepresented the Bobath Concept in any way.

    Throughout this book I have used ‘he’ and ‘she’ alternately when referring to children. The same is true of therapists. I hope that readers will be able to understand, from the context, which I intend.

  • Appendix A: How to Make Equipment from Appropriate Paper-Based Technology (APT)

    JeanWestmacott

    Appropriate paper-based technology (APT) is a cost-effective way to produce personally designed furniture or other objects for use and creativity from recycled paper and cardboard. It involves using flour and water paste to stick layers of corrugated cardboard together to make flat boards. At first they are soft, but once dry become relatively hard. While the stuck layers are drying they need to be pressed under a flat surface. The flat pieces for the item to be made are measured and cut from the dry board. The pieces will not be strong enough to bear someone's weight at this stage. They need reinforcement. This is done using techniques based on engineering principles to make the cardboard able to cope with the pressure and tension of use. Techniques include using layers of pasted paper, strengthening supports, tension rods and reinforced joints.

    Making a Chair

    These instructions are for a simple chair that lends itself to being adapted. You can make this chair with a curved back, sloping seat or knee-blocks. However, start with a simple version to practice. Your techniques are vitally important, as the weak materials you are using need care and attention to turn them into a strong weight-bearing chair.

    Most of the techniques for any APT work are used in making this chair. They are explained in the instructions, and include:

    • Steps for making paste
    • Alternate layering for boards
    • Pressing
    • Rolling card into a rod
    • Making straps
    • Making ‘angle irons’ using thin card
    • Strapping
    Measuring

    When measuring for a piece of furniture, such as a chair, use flat boards or books. It helps to remember that you are measuring for a chair, not around the curves of the body.

    Measurements neededExamples from a 3-year-old, in centimetres
    1. Seat height: From base of foot to top of flat surface where child is sitting22
    2. Seat depth: From behind knee to flat surface held behind child (at 90° angle to seat)23
    3. Height of backrest: From top of seat to flat surface held on shoulder (length of back)30
    4. Headrest (only if necessary): From below flat surface on shoulder to sufficient support point on head15
    5. Headrest (only if necessary): Width of head
    6. Width of backrest: Between parallel flat surfaces held against arms (see illustration), i.e., width of shoulders25
    7. Seat width: Between parallel flat surfaces held against sides of hips, i.e., width of hips22
    8. Height of arm rest: From seat to elbow
    9. Height for table or tray: Optimal height from seat; check while the child is working, e.g., trying to write14
    10. Footrest (only if needed): Length of foot15
    Step-by-Step Chair Instructions
    • Start by making a sketch of the pieces you will need, along with their measurements. It can be a chair for yourself or for a child you have measured.

    • Make paste. You will need two full tablespoons of flour. Flour can be wheat, maida, finely ground maize or cassava flour. Mix with about 100 ml of cold water until free of lumps, like smooth cream. Add about 400 ml (two cupfuls) of rapidly boiling water quickly, while continuing to stir.

      The resultant paste should feel sticky.

    • Make a large board (or two), big enough so the sides, seat, seat supports and back can be cut from it. Layers can be made up of smaller pieces if you do not have large enough sizes. The number of layers depends on the thickness of the cardboard and the size of the person using the stool, but do have enough layers stacked so that the thickness of each board comes to about 2 cm. The boards will be stronger if the corrugations of each layer run across the width and the length alternately.

      Organise the layers for each board. Rub a thin layer of paste on each surface of the layers where they will attach to each other.

    • As soon as the pieces of cardboard are stuck together, they must be compressed. Place some sheets of dry newspaper under the layered pieces with some more dry newspaper on top. Finally, place a flat wooden board or table upside-down on this, making sure it covers the whole piece. This ensures that the pasted layers will stick together evenly and dry flat. If necessary, put something to act as a weight on top of the flat wooden board. Some books or a few bricks are sufficient.

    • Open up and check and air out the layered pieces and change the newspaper every day until flat and dry. This can take a few days even in dry weather.

    • When the board is flat and dry it is time to draw out the pieces for the chair on the board. Start by making sure one edge is totally straight by checking it with a long ruler made of the machine-cut straight edge of a piece of cardboard. You may need to cut the layered board to make the edge straight. This is now the edge for the bottom of the chair.

    • Cut two sides with the straight edge at the bottom to make sure the chair will not wobble.

    • Measure the width for your back, seat and seat supports (all these are the same width) and cut a long ‘plank’ of this width.

    • Check that the width is the same for the back, seat and two seat supports.

    • Paste one seat support on the base of the back and press under a book or flat piece of wood. This will act as support for the back of the seat.

    • One seat support is pasted onto the back of the chair and the other will be pasted and strapped further forward under the seat. Two rods will be made and used to tension the chair and help support the child's weight. This will be shown further on in these instructions. The second seat support is to be fixed just behind the rod that is under the seat near the front.

    • Now make two rods from thin card. These must be 8 cm longer than the width of the chair. About 2 cm will stick out on either side of the chair when assembled. The ends that stick out will be split so they can be bent back and stuck onto the sides. The most important function of these two rods is to pull the sides together. They will strengthen the chair against moving and pulling tension forces when the chair is in use. The rods will take the strain. As well as tensioning, one rod will help support the seat and the other will support the back.

    • Check in which direction the grain goes, by gently bending or rolling the card in each direction. The direction in which it bends most easily is where the grain runs. Rub paste all over the card. Roll it around a smooth broomstick handle or equivalent, so the grain goes along the length of the rod (so that it rolls easily and also because the rod will be stronger with the grain along its length). Pull it off the broomstick and leave to dry. If the outside edge threatens to pull away, make a small strap to hold them down strongly (see strapping instructions). Use the broomstick to make the next rod.

    • One rod will be placed directly behind the chair back near the top, the other under the seat in front of the seat support. Draw lines on one side of the chair to mark where the chair back will be and to mark the level of the seat. Mark the holes for the two supporting rods by drawing around the ends of the rods, in order to get the exact size and to make sure they will fit tightly in the holes. Cut these holes with the two sides of the chair held together so that the holes are at the same place in each side. Use a knife with a narrow blade to cut the curved edges for the holes.

    • Fit all the pieces together. Trim edges with a knife, if necessary, until everything fits well.

      When every part fits together satisfactorily, it is time to paste.

    • Rub paste on all the edges and surfaces that will be attached to others. Use a strip of cloth or piece of string to tie around the sides of the chair temporarily so that the seat and back are held together and kept steady. Paste up some paper to make straps.

    • Start with the joints and make ‘angle irons’ from thin card.

    • Make two angle irons. Rub paste on both sides and rub the angle irons into the back corners under the seat of the chair. This helps the three sides to connect—but they now need strapping. Place and rub the straps over the angle irons. This may require a little more paste.

    • Use thin card folded in half to make small angle irons to help connect the seat to the sides. Place them on the underside of the seat close to the front.

    • Fix the other seat support just behind the rod, using straps. Attach the seat to the sides of the chair with angle irons.

    • Strap over all these joints. Use straps of layered paper. These can overlap each other. Each strap should be only about 3 cm wide. (When covering edges that are curved this should be far narrower.) Turn the chair upside-down and support it on some bricks to make strapping under the seat easier. Stick straps over the rod and rub to make a tight connection between the rod and seat.

    • Once the inner joints are securely strapped, the strip of cloth or piece of string can be removed before strapping all the joints on the outside of the chair.

    • Now saw cuts into the protruding ends of the rods to make flaps that can be bent back flush with the side of the chair.

    • Bend the cut ends of the rods back and rub to flatten them against the sides of the chair. Then paste and stick back using straps.

    • Check that it is all rubbed down well, with no small pieces lifting up or air bubbles between the layers.

    • Then place and rub straps across all the edges to make them neat and strong.

    • When the joints and edges are completely strapped, the remaining surfaces can be filled more quickly. Use mosaics of pasted paper, each one torn no larger than 7 × 7 cm, so that they do not wrinkle.

    • Leave the chair until it is 100 per cent dry and hard. In dry weather this only takes a week. Keep turning it so the inside is exposed to the air for drying as well as the outside.

    • Then there is the fun of adding a decorative finish. The chair can be decorated with a single layer of gift paper, brown paper or a collage of pictures from magazines. Once dry, clear varnish can be used to give a professional finish and make the chair splash-proof.

    • Alternatively, gloss paint or wood paint can be used (it will block out the newspaper print).

    Making a Chair with a Curved Back

    Once you have mastered the techniques you can make all sort of chairs. The chair illustrated below has a sloping back that is curved, and a seat that slopes down. For this design you need to make the sides slightly longer so the back can slope with support. Make one extra rod to support the seat (the dotted lines show the supports). To make this chair with a curved back, first make the chair with a flat back, then paste on a curved piece (measure from the seat to the top of the back to get the length). This is made from two layers of corrugated cardboard pasted together, with both layers having the corrugations running downwards. This makes it possible to create a curve. Strap this on while it is still damp with paste so it will be held in the correct shape to dry.

    Appendix B: Choosing Appropriate Play Activities to Engage a Child's Active Involvement in Therapy

    Children need opportunities to play in order to learn. Young children play and learn in all their waking moments and, if we want to engage with them, we must understand the nature and purpose of their games.

    At different stages in their development, children enjoy different play activities. The following table may help you to choose activities that the child you are working with is likely to enjoy.

    AgeActivity
    0–3 months
    • Enjoys making eye contact with familiar people
    • Later, smiles in response to eye contact and smile from familiar person
    3–5 months
    • Enjoys being talked to. Enjoys songs
    • Likes to look at toys hanging within reach of his hands
    • Enjoys having toys placed in his hands. Learns to bat a toy with his hands
    • When placed prone he enjoys the sensation of scratching the floor with his fingers
    6–11 months
    • Laughs at peekaboo games. Likes to look at himself in a mirror
    • Recognises family members and know their names if told them often enough
    • Knows his own name
    • Manipulates all kinds of objects in his hands—brings everything to his mouth
    • Likes squeaky toys and rattles
    • Loves to be handled, carried about, bounced on his mother's lap or pushed along in a pushchair
    12 months
    • Enjoys hearing songs and nursery rhymes over and over again
    • Uses hands bilaterally: he can hold cup in one hand and drop object into it with the other or he can hold a large, light ball with two hands
    • Enjoys finding things that have been hidden
    • Enjoys picking up tiny things between his finger and thumb
    • Likes toys that he can pull and push along
    18 months
    • Imitates all kinds of sounds and actions. Loves to listen to his mother telling him what she is doing as she goes about her chores
    • Loves to fetch and carry familiar objects when asked
    • Enjoys putting things in containers and taking them out again
    • Likes to point to a few parts of his body that he knows
    • Enjoys looking at pictures of familiar objects
    2 years
    • Likes climbing, swinging and sliding
    • Loves simple stories
    3 years
    • Enjoys playing with other children
    • Begins to enjoy pretending; pretends to drive the car or sweep the floor, for example
    • Loves to push himself about on a tricycle or pedal car
    • Loves stories with pictures

    For a child with CP, who will find it difficult to do all these things for himself in a normal way, it is important for those working with him to help him so that he gains some of the experiences that will later help him to make sense of the world around him. For instance, it is important for a child to learn to reach out for toys and bat them with outstretched fingers before he learns to grasp and bring things to his mouth. It is important for a child to learn to hold a toy in two hands so that he can later learn to coordinate using his hands together. He can be helped to do these things by handover-hand assistance from those working with him. The experience will help him to try the activity by himself later.

    Using Play during Treatment

    Before planning a treatment session with a child, think about what it is you want to encourage the child to do and make sure the play activity does not do the opposite. For example, if you want to encourage a child to reach out while keeping her trunk upright and her head erect it may not be a good idea to offer her a toy that she will want to grasp and bring to her mouth, because this may cause her to use a total pattern of flexion. Instead, for example, you could arrange for a ball to be suspended on a string just above where the child will be lying in prone. Straight away she will try to reach up and push the ball away. She will then hold her head up to see the ball swing back.

    If, in your treatment, you want to facilitate rotation in a child of about 2 who enjoys putting objects into a container, she will want to reach up with rotation from where she is sitting to where you are holding a small block. She can then bend down and drop it into a container which you have placed near her opposite knee. All the better if the container is a tin, because the brick will make a satisfying noise as it is dropped in.

    Another variation on this game is to prop a plank with raised edges on a chair. The child uses two hands to lift an inflatable ball onto the higher end of the plank and watches it roll down to knock over the light plastic bottle you have placed in its path. This is a very useful game for a child to play while you are trying to facilitate active extension of her hips and knees. You may need to ask her mother to fetch the ball and replace the bottle each time, but you will be amazed at how many times the child will be willing to carry on playing this game. This is because the activity gives her the opportunity to practise and discover how to make things happen, and this is appropriate to her present level of play.

    Often, working with children with athetosis, we want them to hold postures rather than to move. In this case it is important to find interesting things for the child to watch or pay attention to. Perhaps you want the child to hold her trunk steady in standing while you facilitate extension in her knees and weight-bearing on straight arms. You could try getting her mother to read her an interesting story, or you could get her to play peekaboo, or maybe she could watch another child rolling the ball down the plank.

    Action songs that children do as a group are very interesting and exciting for children aged between 3 and 5 years. It is worthwhile trying to arrange for several children of similar ages and conditions to come for treatment together.

    Glossary

    AbductionMovement of a limb to the side away from the body.
    AcetabulumBony cup-shaped hollow in the pelvis that holds the head of the femur in the hip joint.
    Achilles tendonTendon at the back of the heel that connects the calf muscles to the heel bone (calcaneous).
    AgonistMuscle or groups of muscles that carry out the primary action in a movement. For example, the elbow flexors are the agonists when the elbow is flexed against gravity.
    AdductionSideways movement of a limb from abduction back to the body or across the body.
    AlignmentThree or more parts in a straight line.
    AntagonistMuscle or group of muscles that pay out in a coordinated way to allow the agonists to carry out a smooth movement. For example, the elbow extensors are the antagonists when the elbow is flexed against gravity.
    AnteriorIn front of.
    Associated movementCoordinated movements occurring in the absence of spasticity. They are seen during early childhood where movements are more in total patterns. They are also seen throughout life when new motor skills are being learnt or where there is effort. Examples include mirror movements and facial grimacing.
    Associated reactionAbnormal increase in tone in one part of the body as a result of effort in another which is less affected. The reaction is associated with spasticity and is seen as a movement in a child with mild to moderate spasticity and felt as an increase in tone in a child with severe spasticity.
    AsymmetricOne side of the body acts in a different way to the other.
    Ataxic, ataxiaDifficulty in coordinating movement—poor balance—and clumsy, awkward voluntary movements.
    Athetoid, athetosisThis term comes from a Greek word meaning ‘of no fixed posture’. Children with athetoid CP have no fixed posture because of involuntary movements and lack of coordinated co-contraction.
    BalanceAbility to stay in and regain a position when the influence of gravity would otherwise cause a fall. This ability is the result of the interaction of righting, equilibrium and protective reactions.
    Basal gangliaPart of the brain.
    BaseThe supporting part of the body. In standing, the base will be the feet; in sitting, the pelvis, thighs and perhaps feet.
    Body axisAn imaginary line drawn through the body from the middle of the head down to between the feet, when the person is in alignment.
    BotulinumBotulinum or botulin toxin (also known as botox or Dysport) is a very poisonous substance used in very minute doses to treat muscle spasm. It is injected with great care at the exact place where the nerve is attached to the spastic muscle. It then blocks the release of some of the chemical from the nerve that activates the muscle to contract.
    Breaking up patternsChanging one or two elements of the stereotyped patterns of movement that children with spasticity try to use to function. For example, the stereotyped pattern of extension in the lower limb is adduction, inward rotation and some flexion at the hip, extension in the knee and plantarflexion at the ankle. The pattern could be broken up (and be more functional) by introducing either dorsiflexion at the ankle or extension in the hip (or both).
    CalcaneousHeel bone.
    Calf musclesMuscles at the back of the lower leg that plantarflex the foot and flex the knee.
    CallipersMetal or plastic and metal supports that hold either the ankle or the knee joint rigid.
    CerebellumPart of the brain.
    Central nervous systemThe brain and spinal cord.
    Co-contractionNormal co-contraction is the simultaneous activation of agonist and antagonist to give mobility with stability. It provides us with normal postural tone and allows smooth graded co-ordinated movement.
    ContractionNormal activity in a muscle that causes it to shorten and bring about movement in a joint.
    ContracturePermanent shortening of a muscle, muscle tendon or joint structure. Once a contracture becomes established, fibrous tissue is laid down, and then it can only be lengthened by surgery.
    CoordinationSmooth, efficient movement caused by the activity of muscles working together and controlled by the nervous system.
    CortexPart of the brain.
    CreepingMoving around the floor in prone on elbows. Legs are mostly inactive.
    CrawlingMoving around the floor on hands and knees.
    DeformityAbnormal body posture or limb position. It can be fixed or unfixed.
    DissociationAbility to move one body part and keep the rest still or to move one limb in one direction while another moves in the opposite direction, e.g., in crawling.
    DiplegiaWhole body affected by CP but lower limbs more than upper limbs.
    Distal, distallySituated away from central part of body.
    Dorsal spineThat part of the spine between the neck and the lower back.
    DorsiflexionMovement at ankle joint that brings heel down and toes up: standing on the heels.
    EncephalitisInflammation of the brain caused by infection. It can cause lasting damage to the brain.
    EpilepsySometimes called fits or seizures. It is abnormal electrical impulses in the brain causing involuntary muscle contractions. These can vary from very slight to severe spasms and unconsciousness.
    EquilibriumState of balance.
    Equilibrium reactionsAutomatic and highly complex movements which serve to maintain and regain balance before, during and after displacement of the centre of gravity.
    EversionTurning the sole of the foot outwards away from the other foot.
    ExtensionTo ‘extend’ means to stretch out or make longer. Extension in the body means the limbs are straight the trunk is upright or stretched out and the head is up or pushed back.
    Extensor toneThe state of tension in those muscles that extend the body.
    FacilitationA handling technique to make active movement easier—or to make active movement possible where it was not possible before.
    FemurLong bone of the thigh.
    Fine motor controlCoordinated hand function, allowing such things as writing or tying shoe laces.
    FlexionThe opposite of extension. The limbs are bent up and the trunk is curved forward. In full flexion the body and limbs would be curled up into a ball.
    Flexor toneThe state of tension in those muscles that flex the body and limbs.
    FunctionPurposeful activity—useful motor abilities such as being able to hold one's head erect.
    Grading of movementSmooth controlled movement.
    Greater trochanterProminent bony part of femur which can be felt at the upper and outer part of the thigh.
    Half kneelingThis is an upright kneeling position where weight is taken on one knee while the other leg is bent forward with the foot flat on the floor.
    HamstringsLarge muscles at the back of the thigh that extend the hip joint and flex the knee.
    HandlingThe way in which we move or touch a child.
    HemiplegiaKind of CP where the whole of one side of the person's body is affected. It can be the right or the left side.
    HyperextensionExtends more than normal.
    HypermobileAbnormally wide range of movement in joints.
    HypertoniaIncreased tone in muscles. Neural hypertonia is caused by damage to the central nervous system. Non-neural hypertonia is caused by local changes in muscles and joints. If hypertonus is constant, though changing in degree, the child is said to have spasticity.
    HypotoniaLow muscle tone.
    Intermittent spasmsThese are often present in children with moderate spasticity or dystonic athetosis. They often occur in the abdominal muscles and can be uncomfortable or even painful, especially if they are associated with constipation. In dystonic children they can also produce strong extension of head and trunk with rotation to one side.
    Inward rotationThe turning inward of the whole arm or the whole leg. This movement can only take place at the hip or shoulder joint.
    InversionTurning the sole of the foot inwards towards the other foot.
    InvoluntaryHappens without the child wanting it to.
    Key points of controlThese are parts of the body from where tone, postures and patterns of movement in other parts can be changed, controlled and guided.
    LateralReferring to the outer side of limbs.
    Long sittingSitting on the floor with legs extended.
    Lumbar spineWaist-level part of spine, above the pelvis and below the ribs.
    MedialReferring to the inner side of limbs.
    MeningitisInflammation of the outer covering of the brain due to an infection. It can cause lasting damage to the brain.
    Mobile weight-bearingBearing weight on limbs or trunk while there is movement, either in the part which is bearing weight or in the rest of the body.
    Moro reactionSeen in a very young normal baby: when the head falls back, the arms fly up and out and the fingers open. It is abnormal if it persists after about 5 months.
    Opposition of the thumbMovement of the thumb away from the fingers to allow grasp.
    Orthoses, orthotic, orthotistsLimb or trunk supports made of metal or plastic material. These are made by orthotists.
    Outward rotationThe turning outwards of the whole arm or the whole leg. This movement can only take place in the hip or shoulder joint.
    OvershootingInaccurate targeting of a movement such as pointing to or reaching for an object.
    PatellaSmall bone on the point of the knee embedded in quadriceps muscle and unattached to any other bone.
    PathologicalTo do with abnormal signs.
    Patterns of movementWhen normal patterns of movement take place in a huge variety of ways to carry out everyday activities such as walking. Abnormal patterns are seen in a child with spasticity who can only move in a few stereotyped ways that are not functionally useful.
    PelvisBony framework that includes the pelvic bones and hip joints.
    PlacentaAlso called the after-birth, it is the structure that connects the unborn baby to the mother inside the uterus and provides nutrition and oxygen for the baby.
    PlantarflexionMovement at the ankle joint when the toes are down and the heel up—standing on the toes.
    PosteriorBehind or at the back.
    Postural controlAbility to hold the body steady before, during and after a movement.
    PostureThe position in which a person holds the body.
    Primitive patternsDescribes patterns of movement associated with a new-born baby.
    PronationMovement of the forearm that turns the palm downwards.
    ProneLying on the flexor surface of the body. The face can be down or turned to the side.
    Protective reactions or responsesAutomatic movements that act to protect the body from injury, e.g., stretching out arms to protect face or taking a step to avoid falling.
    Proximal, proximallyClose to central parts of the body.
    Pull to standBefore a young child can stand up from the floor alone he pulls himself up by holding on to the furniture or his mother. This is called pulling to stand.
    QuadriplegiaWhole body affected.
    Quadriceps muscleMuscle on the front of thigh that flexes the hip and extends the knee.
    Reciprocal movementComplementary opposite movements as one leg moving forward and the other backwards during walking.
    ReflexAn automatic, involuntary response to a stimulus, e.g., knee jerk when the patellar tendon is tapped.
    Righting reactionThese are automatic responses that work with equilibrium reactions to bring head and trunk back into alignment after activity.
    RotationMovement of one part of the body round the body axis. For example, a person rotates the trunk when they twist the top half of the body to one side, leaving the lower part of the body in a neutral position.
    SacrumThe bone at the base of the spine connecting the two sides of the pelvis.
    ScapulaWing-shaped bone that forms the back of the shoulder girdle and moves freely around the ribs in the upper back.
    Selective movementCoordinated movement in one part of the body that does not influence other parts. For example, grasping an object without flexing the whole arm.
    Shoulder girdleThe bony framework that includes the collar bone and the shoulder blade.
    Side lyingLying on either the right or the left side.
    Spasticity, spasticAbnormal stiffness in muscles that makes a child move in a limited, stereotyped way, or may even make movement impossible.
    Startle responseChild jumps, or lifts his head and arms, when there are loud noises or sudden movements.
    Stereotyped‘Stereotyped’ means always the same; no variety. Used to describe the abnormal patterns of movement associated with spasticity, it means, for example, that the child can only flex his arm with pronation and that when he extends his legs it is always with adduction.
    SternumThe breast bone.
    SupinationMovement of the forearm that turns the palm of the hand upwards.
    SupineLying on the extensor surface of the body. The face may be turned upward or to either side.
    SymmetryBoth sides of the body are the same.
    SynapsesConnections between brain cells.
    TendonThe part of the muscle that connects it to a bone.
    ToneState of tension in muscles or state of readiness to become tense or move.
    VentricleA ventricle is a part of the body filled with fluid. The four ventricles in the brain produce fluid that bathes and protects the brain and spinal cord.
    Visual perceptionThe brain's ability to interpret the messages sent from the eyes.
    WindsweptThis refers to the position of a child's legs when one leg is more abducted and outwardly rotated and the other is more adducted and inwardly rotated, making them look as though they have been blown sideways by the wind.

    About the Author

    Archie Hinchcliffe is a Consultant Physiotherapy Trainer specialising in training therapists and community workers working with children in developing countries. She co-leads a biennial short course at the Bobath Centre in London specifically targeted at therapists intending to work in developing countries, and is a Trustee of Cerebral Palsy Africa, a Scottish charity founded in 2005 to support training programmes for therapists and others working with children with cerebral palsy in African countries.

    Archie Hinchcliffe has extensive hands-on experience of working with children with cerebral palsy in many countries in the Middle East and Africa. She lives in Hutton, near Berwick-upon-Tweed in the UK.


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