| Rehabilitation Guidelines | Cerebral Palsy | Physiotherapy |

Rehabilitation Guideline for the

Management of Children with
Cerebral Palsy

| Physiotherapy Guideline |

Humanity & Inclusion

2018
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Advancing Medical Care and Rehabilitation Education Project
A project funded by the USAID and Implemented by Humanity & Inclusion* in collaboration with
the Ministry of Health in Vietnam

* Since January 2018, Humanity & Inclusion is

Handicap International’s new operating name

Rehabilitation Guideline for the Management of

Children with Cerebral Palsy

| Physiotherapy Guideline |

This guideline is made possible by the generous support of the American people through the
United States Agency for International Development (USAID)

The contents are the responsibility of Humanity & Inclusion and do not necessarily reflect the
views of USAID or the United States Government

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Foreword
In the framework of the "Advancing Medical Care and Rehabilitation Education" project in
Vietnam, and with the guidance and support of the Ministry of Health, Humanity & Inclusion
(previously known as Handicap International) and its partners contribute to the strengthening of
medical and rehabilitation care for persons with disabilities due to brain lesion (i.e. stroke,
traumatic brain injury, cerebral palsy and spina bifida and hydrocephalus).

In order to provide rehabilitation specialists (rehabilitation doctors, nurses, therapists…) with the
tools they need to properly support persons with disabilities, the project, with the financial
support of the United States Agency for International Development (USAID), has developed up-
to-date and comprehensive "Rehabilitation Guidelines".

With the assistance of international experts and Vietnamese specialists, these guidelines have
been developed based on the latest available scientific evidences or, where evidences are still
lacking, internationally-recognized best-practices. The constant involvement and support received
from Vietnamese medical and rehabilitation professionals in the development process ensured
contextualization and ownership of these guidelines as they brought in not only their technical
expertise but also their knowledge and experiences on the Vietnamese context and the local
needs and resources.

Two types of documents have been developed. Besides the General Rehabilitation Guidelines,
which provide wide-ranging recommendations on care provision and quality principles, more
“Technical” Guidelines have also been produced for each of the targeted conditions. These
technical guidelines are specific to one "type" of care (physiotherapy, occupational therapy,
speech and language therapy; and for some conditions medical and nursing care as well). They
provide rehabilitation professionals with more specific, detailed technical guidance, allowing
them to better understand their specific role in the general rehabilitation approach and the
provision of multi-disciplinary, person-centred and evidence-based care.

The result of this process is a comprehensive set of guidelines that we hope will be widely
spread and support all rehabilitation actors in providing better and higher quality care to the
people in need.

The present English version of the Rehabilitation Guidelines has been developed with valued
support from the Vietnamese Ministry of Health. It is our hope that the Vietnamese version of
the respective guidelines will be officially endorsed by the Ministry as national guidelines for
rehabilitation care of persons with brain lesions.

On Behalf of Humanity & Inclusion,

Didier Demey
Country Director

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Acknowledgments
Humanity & Inclusion would like to thank the Ministry of Health, and in particular the department
of Administration of Medical Services (AMS) for their support and encouragement during the
development of the Rehabilitation Guidelines for persons with brain lesions.

We also would like to extend our gratitude to the United States Agency for International
Development (USAID) for their guidance and financial support, without which the present
document could not have been produced.

Furthermore, Humanity & Inclusion would like to thank Dr Patricia Coker-Bolt and Prue Golland
for their support in developing these guidelines. Their commitment towards strengthening
medical and rehabilitation care in Vietnam is greatly appreciated.

Finally, we would like to acknowledge and thank all the national experts and medical and
rehabilitation professionals who, through their participation to the guidelines development and
review workshops have greatly contributed to the development of these guidelines. In particular,
we would like to recognize the members of the Guidelines Development Committee:

Prof. Trần Trọng Hải, Prof. Cao Minh Châu, Associated Prof. Lương Tuấn Khanh, Dr. Nguyễn Thị
Kim Liên, Dr. Hà Chân Nhân, Dr. Đinh Quang Thanh, Dr. Trịnh Quang Dũng, Lê Thanh Vân (MSc),
ThS. Nguyễn Ngọc Minh (MSc), Dr. Phạm Thị Cẩm Hưng, Dr. Đinh Thị Hoa, Dr. Hoàng Khánh Chi,
Lê Tường Giao (BSc), Đỗ Thị Bích Thuận (BSc).

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FOREWORD ................................................................................................................................................................ 4

ACKNOWLEDGMENTS................................................................................................................................................. 5

LIST OF ABBREVIATIONS ............................................................................................................................................. 7

1. INTRODUCTION ...................................................................................................................................................... 8

1.1. THE NEED FOR GUIDELINES ............................................................................................................................................ 8

1.2. WHO ARE THE GUIDELINES FOR ...................................................................................................................................... 8
1.3. AIM OF THE GUIDELINE .................................................................................................................................................. 9
1.4. STATEMENT OF INTENT .................................................................................................................................................. 9
1.5. WHAT IS CP ................................................................................................................................................................ 9
1.6. DESCRIBING CP .......................................................................................................................................................... 10
1.7. ASSOCIATED CONDITIONS............................................................................................................................................. 12

2. PRINCIPLES OF REHABILITATION ............................................................................................................................14

2.1. INTRODUCTION .......................................................................................................................................................... 14

2.2. REHABILITATION CYCLE ................................................................................................................................................ 15
2.3. ICF .......................................................................................................................................................................... 15
2.4. PERSON CENTRED AND FAMILY CENTRED CARE ................................................................................................................ 17
2.5. MULTIDISCIPLINARY TEAMS AND INTERPROFESSIONAL TEAM APPROACH ............................................................................... 19

3. THE REHABILITATION CYCLE ..................................................................................................................................21

3.1. SCREENING FOR CHILDREN AT RISK OF CEREBRAL PALSY ..................................................................................................... 21

3.2. CLASSIFICATION TOOLS ................................................................................................................................................ 25
3.3. GOAL SETTING ........................................................................................................................................................... 30
3.4. ASSESSMENT ............................................................................................................................................................. 31
3.5. EVIDENCE-BASED PRACTICES IN CP - PT ......................................................................................................................... 59
3.6. REHABILITATION NEEDS ACROSS LIFESPAN ....................................................................................................................... 82
3.7. PARENT, FAMILY AND CAREGIVER SUPPORT ..................................................................................................................... 84

GLOSSARY..................................................................................................................................................................86

REFERENCES ..............................................................................................................................................................90

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List of Abbreviations
AAC Augmentative and alternative communication
ADL Activities of daily living
CBR Community-based rehabilitation
CFCS Communication Function Classification System
COPM Canadian Occupational Performance Measure
EBP Evidence-based practice
EDACS Eating and Drinking Ability Classification System
GMFCS Gross Motor Function Classification System
GMFM Gross Motor Function Measure
HIE Hypoxic-ischaemic encephalopathy
HINE Hammersmith Infant Neurological Examination
ICF International Classification of Function
MACS Manual Abilities Classification Scale
MP Migration percentage
QUEST Quality of Upper Extremity Skills Test
WHO World Health Organization

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1. Introduction

1.1. The Need for Guidelines

Cerebral palsy (CP) is a complex disorder. It is the most common cause of childhood physical
disability and arises from multiple and varied aetiologies, resulting in multiple and varied
presentations. Variable characteristics of cerebral palsy include the distribution of motor
impairments, the type of movements seen, the severity of the motor disorder (and therefore
functional abilities) and the presence of secondary/associated conditions.

Children with CP have impairments and support needs that are addressed through the health
care, rehabilitation care and social care systems in Vietnam. Guidelines for the management of
children with cerebral palsy are required to:
• Facilitate clear expectations around roles and responsibilities of health professionals
across all levels of health and rehabilitation care in Vietnam
• Enable timely access to appropriate interventions to maximise functional abilities and
quality of life for children with cerebral palsy and their families.

These guidelines consist of several components - a general rehabilitation guideline (this

document), a technical guideline for physiotherapy and a technical guideline for occupational
therapy. Collectively these documents make up a set of guidelines (known as ‘the guidelines’) for
the holistic management of children with cerebral palsy. Specific technical guidelines for medical
practitioners, nurses and speech pathologists are still to be developed.

The present Physiotherapy Guideline for Cerebral Palsy provide recommendations and guidance
on type of physiotherapy care to be provided as well as "cross-cutting" recommendations in
regard of requirements for a system organization, multidisciplinary and comprehensive care,
person-centred care, family support and involvement, care pathway and referrals, discharge and
follow-up, community reintegration and social participation. The guideline acts as an adjunct to
the General Rehabilitation Guidelines for Cerebral Palsy which have been developed recently.

1.2. Who Are the Guidelines For

The present guideline is primarily a practical resource tool for Physiotherapists who are involved
in rehabilitation with children with CP.

They are also useful to any other professional with an interest in rehabilitation for children with
CP, including doctors, neurologists, rehabilitation doctors, nurses, occupational therapists,
speech and language therapists, dieticians, orthotists, pharmacists, psychologists, specialists in
public health, social, community workers and stroke survivors and their family and carers.

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1.3. Aim of the Guideline
The guidelines are meant to be a resource guide for the rehabilitation management of those
people in Vietnam who are affected by cerebral palsy. The guidelines are not prescriptive. They
contain various ideas for management but, depending on the local situation, not all of the
activities will have to be implemented. In some cases activities should be adjusted to local
circumstances.

They are also intended to not only be a practical resource but an educational tool to assist all
health staff and the public as to what is necessary for facilitating effective outcomes of
rehabilitation care. They may also act as an awareness tool for all staff as to roles and functions
of those people who are concerned with rehabilitation care for children with CP. They can be
simplified in order to adapt to a more junior level trained staff and for children with CP and family
themselves.

They can also highlight the gaps and needs in the workforce for specific staff (e.g. fully qualified
occupational therapists (OT) and speech and language therapists (SALT) as well as give target
recommendations for the coming 5-10 years in how to improve the quality of rehabilitation care
for children with CP in Vietnam.

1.4. Statement of Intent

The guidelines are not intended to serve as a standard of medical care. Standards of care are
determined on the basis of all clinical data available for an individual case and are subject to
change as scientific knowledge and technology advance and patterns of care evolve. Adherence
to the guidelines will not ensure a successful outcome in every case, the ultimate judgment
regarding a particular clinical procedure or treatment plan must be made in light of the clinical
data presented by the patient and diagnostic and treatment options available. However, it is
advised that significant departures from these guidelines should be fully documented in the
patient’s case notes at the time the relevant decision is taken.

1.5. What is CP
CP is an umbrella term that describes ‘a group of permanent disorders of the development of
movement and posture, causing activity limitations that are attributed to non-progressive
disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral
palsy are often accompanied by disturbances of sensation, perception, cognition, communication
and behaviour, by epilepsy and by secondary musculoskeletal problems.’ (Rosenbaum et al.,
2007).

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The prevalence of CP in high-resource countries is 1.4-2.1 per 1000 live births (ACPR, 2016;
Sellier et al, 2015). Vietnam does not yet have a national cerebral palsy register. The
establishment of a national register would enable incidence and prevalence to be determined.

Little is known about the epidemiology CP in Vietnam. An ongoing hospital based surveillance of
CP at the National Children's Hospital (NCH) in Hanoi is aims to define the aetiology, motor
function and its severity, associated impairments, and nutritional and rehabilitation status of
children with CP (aged <18 years) in Hanoi, Vietnam (Khandaker et al. BMJ Open 2017).
Preliminary findings (personal communication 2.2.2018, Prof Elliott, Principle Investigator) from
this study show that among children with CP who attended the rehabilitation department at
NCH, Hanoi:
Mean age of diagnosis of CP was 20.7 months (range 1 month -13 years)
CP type at diagnosis:
o 66% spastic quadriplegia
o 21% hemiplegia/monoplegia
o 6.4% diplegia
1.5% had predominantly athetosis
54% the children had intellectual impairment and 12.7% had probable intellectual
impairment
Using the Gross Motor Function Classification System (GMFCS):
o 16% had level V function
o 27% Level IV (indicating requirement for a manual or powered wheelchair) yet
none had access to a wheelchair
o 13% had Level III function
o 16% Level II function
o 23% Level I function

1.6. Describing CP
This section provides definitions of the motor types of CP. Assessments of spasticity,
hypertonicity, dystonia, athetosis/choreoathetosis are provided in the Guidelines for
Physiotherapy and Occupational Therapy.

1.6.1. Motor Type

Motor type refers to the motor disorder seen. This is closely related to the area of the brain that
is damaged.

(I) Spasticity
Spasticity is a velocity-dependent resistance to stretch by the muscles. It is characterised by an
excessive stiffness in the muscles when the child attempts to move or maintain a posture

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against gravity. Spasticity can vary according to the child’s state of alertness, emotions, activity,
posture or presence of pain (Sanger, Delgado et al. 2003).

(II) Dyskinesia/Hyperkinesia
Dyskinesia/hyperkinesia refers to an increase in muscular activity that can result in excessive
abnormal movements, excessive normal movements, or a combination of both.
Dyskinetic/hyperkinetic CP is characterised by abnormalities of tone and various movement
disorders including dystonia, athetosis and chorea (Sanger, Chen et al. 2010).

Dystonia is characterised by sustained or intermittent muscle contractions causing

repetitive or twisting movements.
Athetosis is characterised by uncontrolled, slow and writhing movements that prevent
maintenance of a stable posture. It involves continuous smooth movements that appear
random and are not composed of recognisable sub-movements or movement fragments.
Athetosis is made worse by attempts to move however it may also be present at rest.
Athetosis is distinguished from dystonia by the lack of sustained postures, and from
chorea by the lack of identifiable movement fragments (Sanger et al, 2010, page 1543).
Chorea is an ongoing random-appearing sequence of one or more discrete involuntary
movements or movement fragments. Chorea is distinguished from dystonia due to the
apparently random, unpredictable, and continuously ongoing nature of the movements,
compared with the more predictable and stereotyped movements or postures of
dystonia. The movements of chorea often appear more rapid than those associated with
dystonia. Although chorea may be worsened by movement, attempts at movement, or
stress, particular movements are not triggered by voluntary attempts with the same
degree of temporal specificity as in dystonia (Sanger et al, 2010, page 1542). Children
with chorea present as fidgety or in constant motion.

Athetosis and chorea usually co-present in CP and together are known as choreoathetosis.

(III) Ataxia
Ataxia is characterised by shaky movements and affects a person’s coordination and balance. It
is the least common form of CP.

(IV) Mixed motor types

CP where more than one motor type is present, for example spasticity and dystonia. Usually one
motor type will be dominant.

See section 5.2 Managing the Motor Disorder for information on assessing the motor disorder.

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1.6.2. Topography
Topography refers to the distribution of the motor impairments or the body parts affected. Motor
impairments can be unilateral (affecting one side of the body only) or bilateral (affecting both
sides of the body).

(I) Unilateral CP
Monoplegia - one limb is affected. This can be the arm or leg on the left or right side of
the body.
Hemiplegia - one half of the body is affected. This can be the left side or the right side.
The arm and leg do not need to be equally affected.

(II) Bilateral CP
Diplegia - both legs are primarily affected.
Children with diplegia frequently have some
impairment in upper limb function.
Triplegia - three limbs are affected with sparing
of the fourth limb. Quadriplegia - all four limbs
are affected with the head, neck and trunk also
affected.

In fig. 1: Hemiplegia includes children with monoplegia;

quadriplegia includes children with triplegia)

Figure 1: Image from Cerebral Palsy

Diagnosis and Treatment infographic
poster ([Link])

1.6.3. Severity
CP can be described or classified according to the severity of the motor impairments. Four
classification systems of motor function, communication and eating and drinking ability are
internationally recognised. They relate to how an individual with CP mobilises (GMFCS), how
they use their hands in everyday activities (MACS), how they communicate with familiar and
unfamiliar people (CFCS) and their ability to eat and drink safely (EDACS). These severity
classification tools are detailed below.

1.7. Associated Conditions

The motor impairments of CP are almost always accompanied by one or more secondary
impairments (Rosenbaum, et al., 2007). For many children, these secondary conditions are more
disabling than their physical impairment:
3 in 4 will experience chronic pain
1 in 2 will have an intellectual impairment

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 1 in 3 will be unable to walk
1 in 3 will experience hip displacement
1 in 4 will be unable to talk
1 in 4 will have epilepsy
1 in 4 will have a behaviour disorder
1 in 4 will have bladder incontinence
1 in 5 will have a sleep disorder
1 in 10 will have a vision impairment
1 in 15 will be unable to eat orally
1 in 25 will have a hearing impairment.
(Novak et al., 2012)

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2. Principles of Rehabilitation

2.1. Introduction

2.1.1. Rehabilitation
WHO describes rehabilitation as “a set of measures that assist individuals who experience, or
are likely to experience, disability [resulting from impairment, regardless of when it occurred
(congenital, early or late)] to achieve and maintain optimal functioning in interaction with their
environments” “Rehabilitation measures target body functions and structures, activities and
participation, environmental factors, and personal factors.” (WHO, 2011)

Rehabilitation can include a variety of activities in various sectors. In the health sector,
rehabilitation addresses chronic, or long‐term, conditions and impairments with the goal of
reversing or limiting their impact. Services may include speech therapy, physiotherapy,
occupational therapy, the provision of assistive devices, and special surgeries to correct
deformities and other types of impairment.

Key aspects of rehabilitation care include:

Multidisciplinary screening and assessment
Identification of functional difficulties and their measurement
Treatment planning through goal setting
Delivery of interventions which may either effect change or support the person in
managing persisting change
Evaluation of effectiveness of the intervention
Reporting

2.1.2. Habilitation
Habilitation involves interventions that help individuals keep, learn, or improve skills and
functioning for daily living. The focus is on learning of new skills when an individual is born with a
disability that impacts typical development (and therefore typical skill attainment). These are skills
that may only be mastered through skilled and targeted therapy services.

Examples include teaching an infant with CP how to roll, sit unsupported, stand, and walk for the
first time. It can also include teaching an older child with CP to ride a bicycle, hold a pencil and
write, and catch/throw a ball for the first time.

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2.2. Rehabilitation Cycle
The conventional approach to rehabilitation is a cyclical process:

2.2.1. Assessment
The patient is assessed and needs are identified
and quantified; (Re-)
Intervention
Assessment

2.2.2. Goal setting

On the basis of the assessment the goals for
rehabilitation of the patient are defined. These
can be short term, medium term and long term
goals; Goal Setting
A plan to reach these goals is formulated

2.2.3. Intervention
Giving relevant treatment in order to achieve the goals;

2.2.4. Re-Assessment
Progress is assessed as to whether the intervention has been effective in order to
achieve the agreed goals. If not then goals and consequent intervention can be revisited.

2.3. ICF

2.3.1. What is the ICF

Rehabilitation can be summarised

in the ICF (International
Classification of Functioning,
Disability and Health) model
developed by WHO (2001). The
ICF conceptualises a person's
level of functioning as a dynamic
interaction between her or his
health condition, environmental WHO (2001). ICF Model
factors, and personal factors. It is
a biopsychosocial model, based on an integration of the

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social and medical models of disability. All components of disability are important and any one
may interact with another. Environmental factors must be taken into consideration as they affect
everything and may need to be changed.

Body Functions are the physiological or psychological functions of body systems.

Body Structures are anatomic parts of the body such as organs, limbs and their
components.
Impairments are problems in body function or structure such as a significant deviation or
loss.
Activity is the performance of a task or action by an individual.
Activity Limitations are difficulties an individual may have in the performance of activities.
Participation is an individual’s involvement in life situations in relation to Health
Conditions, Body Functions and Structure, Activities, and Contextual factors.
Participation Restrictions are problems an individual may have in the manner or extent of
involvement in life situations.
Environmental factors. These factors range from physical factors (such as climate, terrain
or building design) to social factors (such as attitudes, institutions, and laws).
Personal factors include race, gender, age, educational level, coping styles, etc.

For example:
Health Disorder: Cerebral Palsy
Body Function/Structure Impairment: Hypertonicity in upper extremity and lower
extremity; spasticity
Activity Limitation: Unable to put on a shirt or pants; unable to use a utensils
(spoon/chopsticks) to feed self; unable walk
Participation Limitation: Difficulty eating meals with family and out in the community;
difficulty going to school; unable to play/socialize with same-aged children
Environment considerations: physical access to community buildings, school
Personal factors: age and gender of child; motivation of child

2.3.2. The ICF, Rehabilitation and CP

These guidelines have been developed using the International Classification of Functioning,
Disability and Health (ICF) to guide clinical thinking and the delivery of services to children with
CP and their families.

The use of the ICF as a framework for clinical practice provides health care workers with a guide
to the selection of measurement tools, to inform goal setting and decision making processes and
determine outcomes meaningful to children with CP and their families (Rosenbaum and Stewart
2004). Use of the ICF in the management of CP enables us to expand our thinking beyond
“fixing” primary impairments to a view that places equal value on promoting functional activity
and facilitating the child’s full participation in all aspects of life (Rosenbaum & Stewart 2004).

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In other words, children with CP should be assessed and have interventions provided, wherever
possible, within their different life domains including (but not limited to) home, schools,
recreational or other settings, to have a full understanding of the child’s functional abilities in
different environments and facilitate full integration to their community living. This may require
developing/strengthening relationships with or partnering with local charitable organisations,
non-government organisations and CBR projects to facilitate continuity of care once a child with
CP is discharged from hospital.

2.4. Person Centred and Family Centred Care

2.4.1. Person-Centred Approach

Best practice service delivery when working with children with CP and their families is to adopt
person-centred and family-centred approaches.

Treatment and care should take into account individual needs and preferences. Patients should
have the opportunity to make informed decisions about their care and treatment, in partnership
with their healthcare professionals. If the patient agrees, families and carers should have the
opportunity to be involved in decisions about treatment and care. Families and carers should also
be given the information and support they need (NICE, 2014)

A person-centred approach should underpin the goalsetting process. Treatment goals are more
likely to be achieved if patients are involved in setting them. Moreover, there is also evidence
that this goal setting process has positive therapeutic value in encouraging the patients to reach
their goals. (Hurn et al, 2006)

Person-centred practice places the individual in the centre and emphasises building partnerships
with persons with CP and their families in which they are valued members of the rehabilitation
team. It emphasises four aspects:
Each individual is unique
Each individual is an expert in their own lives
Partnerships are key
There is a focus on an individual’s strengths

Person centred practice situates power and control with the person and their family. It tailors
supports to achieve the person’s goals and future and aims for social inclusion, valued roles, and
community participation.

2.4.2. Family-Centred Approach

Family-centred practice adopts a similar philosophy to person-centred practice and goes further
to recognise that families and carers are pivotal decision makers when working with children
with CP. Family-centred practice is made up of a set of values, attitudes, and approaches to

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services for children with CP and their families. The family works with service providers to make
informed decisions about the services and supports the child and family receive. In a family-
centred approach, the strengths and needs of all family members and carers are considered. The
family defines the priorities of the intervention and services. It is based on the premises that
families know the child best, that optimal recovery outcomes occur within a supportive family
and community environment and that each family is unique. Service provides support and
respect each family’s capacity and resources. Family capacity includes the knowledge and skills
the family requires to support the child’s needs and well-being. Capacity is the amount of
physical, intellectual, emotional and spiritual energy necessary to support the child with CP, and
it directly influences the sense of competency a family member experiences when caring for a
child with CP.

2.4.3. Parent Empowerment

The WHO defines empowerment as a process through which people gain greater control over
decisions and actions affecting their health.

Family-centred practice supports parent empowerment. Example behaviours that service

providers should adopt to promote family-centred practice and parent empowerment include:

Encourage parent decision-making in partnership with other team members (to utilise
family empowerment strategies.)
Assist families to identify their strengths and build their own resources.
Inform, answer, and advise parents (to encourage informed choices).
Work in partnership with parents and children and help them identify and prioritise their
needs from their own perspective.
Collaborate with parents at all levels (care of the individual child; program development,
implementation and evaluation; policy formation).
Provide accessible services that will not overwhelm families with paperwork and
bureaucratic red tape.
Share complete information about the child’s care on an ongoing basis.
Respect the values, wishes and priorities of families.
Accept and support decisions made by families.
Listen.
Provide flexible and individualised services (and to respond to the changing needs of the
family).
Be knowledgeable about and accept diversity among families (racial, ethnic, cultural and
socio-economic).
Believe and trust parents.
Communicate in a language understandable by parents.
Consider and be sensitive to the psychosocial needs of all family members.
Provide an environment that encourages the participation of all family members.
Respect the family’s own style of coping without judging what is right and what is wrong.

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 Encourage family-to-family support and the use of natural community supports and
resources.
Recognise and build on family and child strengths.
(Premises, Principles, and Elements of Family-Centred Service. Mary Law, Peter Rosenbaum,
Gillian King, Susanne King, Jan Evans, 2003)

2.5. Multidisciplinary Teams and Interprofessional Team

Approach
The gold standard approach for the management and treatment of children with CP requires a
multidisciplinary team which utilises an interprofessional team approach.

Rehabilitation team members may include:

Physician/Rehabilitation Specialist
Nurse
Physiotherapist
Occupational Therapist
Speech-Language Therapist
Orthotist/P&O technician
Nutritionist/Dietician
Social Worker/Case Manager
Psychologist

This approach focuses on all developmental aspects of the child (including conditions associated
with CP) and on planning interventions in relation to the most important needs of the child and
the family through team collaboration. Team collaboration is the process of forming partnerships
among service providers, the family and child, and the community with the common goal of
enhancing the child’s development and supporting the family.

In the interprofessional team approach, providers work independently, but recognise and value
contributions of other team members. This approach requires interaction among the team
members for the evaluation, assessment, and development of the intervention plan. The role of
each team member is defined and there is an emphasis on regular and on-going communication
among team members. Common goals are developed in collaboration with the child and family.

In a multidisciplinary team approach, professionals still work independently and recognise and
value contributions of other team members, however goals are developed in collaboration with
the child and family by each individual team member (Effgen, 2006; Utley & Rapport, 2000).

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 Speech and
Nurse Language
therapis
Rehab Occupational
doctor therapist

Consultant
Psychologist
physicians

Physio
Orthotist
therapist

Child with
Social
CP+ Dietetician
worker
family/carer

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3. The Rehabilitation Cycle

3.1. Screening for Children at Risk of Cerebral Palsy

Cerebral palsy is diagnosed by clinical presentation based upon the presence of a motor disorder
caused by damage to, or maldevelopment of the infant brain. A diagnosis of CP is made by a
medical professional (e.g. general practitioner, paediatrician, paediatric neurologist, rehabilitation
doctor). Refer to the general rehabilitation guideline for more detailed information regarding
diagnosing cerebral palsy.

Physiotherapists may however be the first health professional to see a child because of concerns
that the child is not developing typically. Therefore it is important for physiotherapists to be able
to identify signs of cerebral palsy and know when to refer children to a medical professional for
further assessment and diagnosis.

For the majority of children, the cause of their brain injury or maldevelopment is unknown. It is
widely accepted that cerebral palsy does not result from a single cause but rather from a series
of ‘causal pathways’ that can result in or accelerate injury to the developing brain.

3.1.1. Risk Factors for Cerebral Palsy

History taking should include screening questions related to the mother’s health, pregnancy,
birth and post-birth period. Risk factors for cerebral palsy may be at the maternal or infant level.

Maternal risk factors include

Thyroid condition
Infection during pregnancy
Pre-eclampsia
Bleeds during the second or third trimester
Multiple pregnancy (i.e. twins or greater)

Infant risk factors include:

Prematurity
Intrauterine growth restriction
Low birth weight
Acute intrapartum hypoxic event
Moderate to severe encephalopathy
Neonatal seizures
Neonatal infection
Hypoglycaemia
Jaundice

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Additional risk factors have been identified in children born at term (in high resource countries).
These include (McIntyre et al, 2012)
Placental abnormalities
Birth defects
Meconium aspiration
Instrumental/emergency caesarean delivery
Birth asphyxia
Respiratory distress syndrome

A small percentage of children acquire cerebral palsy after one month of age. This is generally a
result of stroke, which may occur spontaneously or from complications associated with another
condition or medical intervention (ACPR Group 2009).

3.1.2. Abnormal Reflexes

Occupational and physiotherapists should evaluate the presence of abnormal reflexes in infants
at risk for CP (Hamer & Hadders-Algra, 2016):

In early infancy, an absent Moro or plantar grasp response may be predictive for adverse
developmental outcome including CP
Persistence of the Moro response and asymmetric tonic neck reflex (ATNR) indicates a
higher risk for poor developmental outcome
Abnormal performances on the pull-to-sit manoeuvre and vertical suspension test have
predictive significance throughout infancy

Timeline when reflex is

Reflex Testing procedure
normally present

1) Moro > Birth to 4-5 months > Position: Placed child supine with head in the
of age; midline, arms on chest.
> Strong persistence > Procedure: Support infant’s head and shoulders
beyond 6 months of with hand, allow to drop back 20-30 degrees with
age may be a sign of respect to trunk, stretching neck muscles.
neurologic dysfunction. > Response: Abduction of the upper extremities
> Integration of this with extension of the elbows, wrists and fingers,
reflex coincides with followed by subsequent adduction of the arms at
development of head the shoulders and flexion at the elbows and cry.
control and protective
extension response.

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2) Plantar Grasp > Present at birth to 7 > Position: Place child supine with head in
to 8 months of age. midline and legs relaxed.
> Persistence beyond 1 > Procedure: Firm pressure against volar surface
year should be of infant’s foot, directly below toes.
regarded with the > Response: Plantar flexion of all toes
child’s total
developmental picture.
Can assist the child
with early standing
with support and often
seen until child walks
well.

3) Asymetrical > Present at 1-2 > Position: Place child supine with head in
Tonic Neck Reflex months of age; midline.
(ATNR) strongest at 2 months. > Procedure: Turn the head slowly to one side,
Should be integrated by and hold in this extreme position with jaw over
4 months of age. the shoulder.
> Persistence beyond 6 > Response: Arm and leg on jaw side extend.
months may be a sign Arm and leg on skull side flex.
of neurologic
dysfunction.
> Integration coincides
with the development
of voluntary and
controlled rolling
abilities.

4) Symmetrical > Present at 5 to 6 > Position: Place child in prone position

Tonic Neck Reflex months of age. supported by the trunk, over the examiner’s
(STNR) > Persistence beyond 7 knee.
months of age may be > Procedure: Examiner passively first flexes then
a sign of neurologic extends the child’s head, or facilitates movement
dysfunction. with toy.
> Integration coincides > Response: Flexion of the head (chin tuck)
with the development produces flexion of the upper extremities,
of reciprocal crawling. extension of the lower extremities. Extension of
the head produces extension of the upper
extremities and flexion of the lower extremities.

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 5) Righting > The infant should > Position: This reflex can also be assessed
reactions demonstrate righting during pull-to-sit manoeuvre and during vertical
responses in the head suspension test.
and neck starting at 4 > Procedure:
months. * Pull to sit: Place infant in supine. Grasp the
> Abnormal or absent infant’s wrists and slowly pull the infant up from
head righting supine into sitting position.
responses by 7 months * Vertical suspension test: Examiner holds child
may be a sign of vertically in space under the arms and around
neurologic dysfunction. chest.
> Response: Head orients immediately to vertical
position to align head with trunk.

6) Babinski sign > Present at birth to > Position: Place child supine.
approximately 2 years > Procedure: Examiner firmly strokes the sole of
of age. the foot.
> Response: For children under 2 years of age,
the big toe extends back toward the top of the
foot and the other toes fan out. A normal
response in individuals older than 2 years of age
would be the big toe flexing downward (toward
the sole of the foot) or no response.

3.1.3. Abnormal Muscle Tone / Motor Disorder

The motor types associated with cerebral palsy are identified by physical assessment and clinical
observation.

Points to remember:
hypertonia may still be evolving in the first two years of life with myelination
mixed presentations are common (spasticity/dystonia, dystonia/choreoathetosis)

For details regarding assessment of the motor disorder, see below.

3.1.4. Motor Delay

(I) Clinical Assessment of developmental milestones
Occupational and physiotherapists should evaluate the motor skills of infants and compare the
infant’s motor performance to typical developmental milestones for the infant’s age.

In addition, the infant should be placed in several developmental positions including supine,
prone, supported sitting, and standing to further evaluate anti-gravity movement in the
head/neck, trunk and upper and lower limbs.

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(II) Ages and Stages Questionnaire (ASQ)
The Ages and Stages Questionnaire (ASQ) is a parent-completed questionnaire that may be used
as a general developmental screening tool.

Developmental domains addressed in the developmental screener are gross motor, fine motor,
problem solving, personal-social and an overall section that addresses general parental concerns.

The ASQ can identify children who require further assessment however it is not known to be
predictive of cerebral palsy. It is available in Vietnamese (Singh et al, 2017).

Use of developmental milestones as a marker for cerebral palsy alone, is insufficient information
as there may be many causes for delayed development that are not related to cerebral palsy.
Motor delay should always be supplemented with information related to neurological functioning
(muscle tone and/or abnormal reflexes).

If there are concerns regarding the above signs and symptoms, physiotherapists should consider
a possible diagnosis of cerebral palsy and refer to a medical practitioner.

3.2. Classification Tools

3.2.1. Functional Mobility Ability

(I) Gross Motor Function Classification System (GMFCS)
(Palisano, Rosenbaum, Walters, Russell, Wood & Galuppi, 1997; Palisano, Rosenbaum, Bartlett
& Livingston, 2008).

The Gross Motor Function Classification System (GMFCS) is a 5 level classification that describes
the gross motor function of children with CP on the basis of their self-initiated movement with
particular emphasis on sitting, walking, and wheeled mobility. Distinctions between levels are
based on functional abilities, the need for assistive technology, including hand-held mobility
devices (walkers, crutches, or canes) or wheeled mobility, and to a much lesser extent, their
quality of movement.

The focus is on determining which level best represents the child's present abilities and
limitations in gross motor function. Emphasis is on usual performance in home, school, and
community settings (i.e., what they do), rather than what they are known to be able to do at their
best (capability). It is therefore important to classify current performance in gross motor function
and not to include judgments about the quality of movement or prognosis for improvement.
GMFCS level should be determined in conjunction with the child and family, not solely by a
professional.

P a g e | 25
The CanChild website provides definitions/descriptors of the 5 GMFCS levels for different age
groupings: Before 2nd birthday; Between 2nd and 4th birthday; Between 4th and 6th birthday; and
Between 6th and 12th birthday. The GMFCS – E&R describes gross motor classification across
the following age bands: 0-2 years; 2-4 years; 4-6 years; 6-12 years; and 12-18 years. The
GMFCS emphasises the concepts inherent in the World Health Organization's International
Classification of Functioning, Disability and Health (ICF). The descriptions for the 6 to 12 year
and 12 to 18 year age bands reflect the potential impact of environment factors (e.g., distances
in school and community) and personal factors (e.g., energy demands and social preferences) on
methods of mobility.

Administration
Assessor: Medical practitioners, physiotherapists, occupational therapists, nurses who are
familiar with the child’s gross motor function in conjunction with a parent or caregiver.
How: Clinician asks questions of the child, parent or caregiver to determine functional mobility.
Done either via parent/caregiver report and/or observation during regular appointment.
Time: N/A
Availability: The GMFCS – ER (2007) can be sourced freely online by visiting the CanChild
website at [Link]
expanded-revised-gmfcs-e-r

(II) Functional Mobility Scale (FMS)

(Graham, Harvey, Rodda, Nattras & Piripis, 2004)

The Functional Mobility Scale (FMS) (version 2) has been constructed to classify functional
mobility in children 4 to 18 years, taking into account a range of assistive devices a child might
use over three distances: 5 metres (in and around the home), 50 metres (in and around
school/preschool) and 500 metres (in the community). The FMS is sensitive to detect change
after operative intervention.

Administration
Assessor: Medical practitioners, physiotherapists, occupational therapists, nurses. Clinician asks
questions of the child, parent or caregiver who is familiar with the child’s mobility (not direct
observation).
How: questions asked during regular appointment.
Time: N/A
Availability: forms available from: [Link]

3.2.2. Gait Classification

Classifications of common gait patterns seen in hemiplegic and diplegic CP have been
developed. Classifying gait patterns is important when considering medical and surgical
interventions to improve gait and functional mobility.

P a g e | 26
Administration
Assessor: Medical practitioners familiar with observational gait assessment, physiotherapists
How: Gait patterns are classified following a thorough observational gait assessment and
physical assessment
Time: 15-45 minutes depending on the complexity of the gait pattern and physical assessment
and experience of the assessor

(I) Classification of Gait Patterns: Hemiplegic Gait

(Winters, Gage & Hicks, 1987)

The Winters, Gage and Hicks (1987) classification of hemiplegic gait describes four types of gait
patterns based on the sagittal plane kinematics of the pelvis, hip, knee and ankle:

Foot drop in swing phase of gait, normal dorsiflexion range in stance

Type 1 - Foot Drop
phase
Excessive plantar flexion of ankle in both stance and swing phase of
Type 2A - True Equinus
gait
Type 2B - True Deviations plus limited flexion/extension range of motion at knee
Equinus/ Recurvatum during stance and swing phases of gait
Type 3 - True Deviations plus limited flexion/extension range of motion at hip during
Equinus/Knee jump stance and swing phases of gait.
Type 4 - Equinus/Knee Equinus with flexed, stiff knee, flexed, internally rotated and adducted
jump hip with anterior pelvis tilt.

(II) Classification of Gait Patterns: Diplegia Gait

(Rodda & Graham, 2001)

The classification of common gait patterns seen in children with spastic diplegia has been
developed by Rodda & Graham (2001) and Rodda et al (2004). Diplegic gait patterns include:

Group I - True Equinus Ankle plantar flexion throughout stance with hips and knees extended
Ankle in equinus, the hip and knee in flexion, anterior pelvis tilt and an
Group II - Jump gait increased lumbar lordosis. Often a stiff knee due to rectus femoris
activity in the swing phase of gait.
Walking on toes, however equinus is apparent rather than real with
Group III - Apparent sagittal plane kinematics showing ankle has normal range of
Equinus dorsiflexion but the hip and knee are in excessive flexion throughout
stance phase of gait.
Excessive ankle dorsiflexion in combination with excessive flexion at
Group IV - Crouch Gait
the hip and knee.
Group V - Asymmetric
A combination of any of the above two patterns.
Gait

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3.2.3. Manual Ability
(I) Manual Ability Classification System (MACS) & Mini-MACS
(Eliasson, Krumlinde Sundholm, Rösblad, Beckung, Arner, Öhrvall & Rosenbaum, 2005)

The Manual Ability Classification System (MACS) provides a systematic method of classifying
how children with CP, aged 4 to 18 years use their hands when handling objects during daily
activities. MACS is based upon self-initiated manual ability, with particular emphasis on handling
objects in an individual’s personal space (the space immediately close to one’s body, as distinct
from objects that are not within reach). The focus of MACS is on determining which level best
represents the child’s usual performance at home, school and in community settings.
Distinctions between the levels are based on the child’s ability to handle objects and their need
for assistance or adaptations to perform manual tasks in everyday life. MACS is not designed to
classify best capacity and does not mean to distinguish different capacities between the two
hands. MACS does not intend to explain the underlying reasons for limitations of performance
or to classify types of CP.

Mini-MACS is an adaptation of MACS for children aged one to four years. Mini-MACS classifies
children’s ability to handle objects that are relevant for their age and development as well as their
need for support and assistance in such situations.

Administration
Assessor: Parent, caregiver or health professional who is familiar with the child’s hand function.
How: MACS level must be determined by asking someone who knows the child well and not by
conducting a specific assessment (Eliasson, [Link].2005). Done either via parent/caregiver report
and/or observation during regular appointment.
Time: N/A
Availability: A MACS training video is available as well as ‘The Supplementary MACS level
identification chart’ to be used in conjunction with the MACS leaflet. Forms available for
download from: [Link]

3.2.4. Communication Ability

(I) Communication Function Classification System (CFCS)
(Hidecker, Paneth, Rosenbaum, Kent, Lillie, Eulenberg, Chester, Johnson, Michalsen, Evatt &
Taylor, 2011)

The Communication Function Classification System (CFCS) classifies everyday communication

performance into one of 5 descriptive levels. Communication classification is based on the
individual’s performance as a sender and receiver of a message, the pace of the communication
and the familiarity of communication partner to the individual. All methods of communication are
considered including speech, gestures, behaviours, eye gaze, facial expression and augmentative
and alternative communication systems (AAC). Communication effectiveness is based on the

P a g e | 28
individual’s current skill in everyday communication situations, rather than capacity for learning
new skill.

Level 1 Effective sender and receiver with familiar and unfamiliar partners
Level 2 Effective but slow sender with familiar and unfamiliar partners
Level 3 Effective sender and receiver with familiar partners
Level 4 Inconsistent sender and/or receiver with familiar partners
Level 5 Seldom effective sender and receiver even with familiar partners

Administration
Assessor: Parent, caregiver or professional who is familiar with the child’s communication.
How: Completed either via parent/caregiver report and/or observation during regular
appointment
Time: N/A
Availability: [Link]

3.2.5. Eating and Drinking Ability

(I) Eating and Drinking Ability Classification System (EDACS)
(Sellers, Mandy, Pennington, Hankins & Morris, 2014)

The Eating and Drinking Ability Classification System (EDACS) is a system for classifying eating
and drinking ability in children with CP from age 3 years. It is complementary to the GMFCS,
MACS and CFCS and its purpose is to be utilised both clinically and in research. The EDACS
focuses on the aspects of eating and drinking such as chewing, swallowing, sucking, biting and
keeping food and liquid in the mouth. The distinctions between the five levels consider
functional ability, requirement for adaptation to texture, techniques used and assistance required.

Level I Eats and drinks safely and efficiently

Level II Eats and drinks safely but with some limitations to efficiency
Level III Eats and drinks with some limitations to safety; there may be limitations to efficiency
Level IV Eats and drinks with significant limitations to safety
Level V Unable to eat or drink safely, tube feeding may be considered to provide nutrition

An additional classification of degree of help required during mealtimes can be used to further
supplement EDACS. This includes: Independent (Ind), requires assistance (RA) or totally
dependent (TD). It classifies usual rather than best performance.

Administration
Assessor: Parent, caregiver or health professional who is familiar with the child’s eating and
drinking ability.
How: Completed either via parent/caregiver report and/or observation.
Time: N/A
Availability: Can be accessed via: [Link]

P a g e | 29
3.3. Goal Setting
Building authentic partnerships with families has positive implications for the rehabilitation
process in general, and in particular, on determining which goals will be addressed during the
rehabilitation process. All team members actively participate to reach consensus on the overall
rehabilitation goals. This increases the likelihood of positive and sustainable outcomes, as
everyone agrees as to which goals are particularly important for the family and child (Harty,
Griesel, & van der Merwe, 2011).

Rehabilitation teams should use the ICF’s activities and participation domains as a common
language to help identify important goals for the family and child. The ICF allows both individual,
as well as contextual factors to be taken into consideration, which is essential in successful
rehabilitation approaches.

The two most commonly used goal setting measures are the Canadian Occupational
Performance Measure (COPM) and Goal Attainment Scaling (GAS). In many cases they can be
used together.

3.3.1. Canadian Occupational Performance Measure (COPM)

(Law, Baptiste, Carswell, McColl, Polatajko & Pollock, 1990)

The Canadian Occupational Performance Measure (COPM) is an individualised measure that

assesses an individual’s perceived occupational performance in the areas of self-care,
productivity, and leisure. It is designed to detect change in a client’s self-perception of
occupational performance over time. The COPM is used to identify problem areas and provide a
rating of the client’s priorities in occupational performance, evaluate performance and
satisfaction relative to those problem areas and measure changes in a client’s perception of
his/her occupational performance over time.

(I) Administration
Assessor: This tool can be conducted by any rehabilitation team member.
How: Ensure that the version used is the paediatric modified version. Select parent or child
report as appropriate. The assessment involves a 5-step process nested within a semi-structured
interview that focuses on identifying activities within each performance domain that the client
wants, needs, or is expected to perform.
Time: 15-30 minutes, semi-structured interview.
Note: The COPM has been translated into 24 different languages. It is not currently available in
Vietnamese however it is likely that a translation will be available.

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3.3.2. Goal Attainment Scaling (GAS)
Goal Attainment Scaling (GAS) involves individualised, patient-generated goals scored on a 5
point scale. GAS is used to evaluate services or an individualised program based on the
attainment of individualised goals.

It requires extensive therapist training and experience to set goals adequately. Therapist’s
correct judgement of the impact of the intervention and therapist’s ability to set realistic,
accurate goals may be difficult to establish.

(I) Administration
Assessor: This tool can be conducted by any rehabilitation team member however it is typically
used by physiotherapists and occupational therapists to set therapy goals and evaluate
intervention.
How: A five point goal scale is developed, usually via interview with the client/family and graded
levels of possible goal attainment with descriptions of anticipated outcome are described for
each goal. Goals are scaled from least favourable to most favourable outcome, with an expected
outcome level in the middle. Goals need to follow SMART principles:
Specific
Measurable
Achievable
Realistic
Time frame defined
Time: approximately 20 to 30 minutes to establish goals, 10 minutes to reassess attainment.
Note: Freely available from
McDougall, J. and King, G. (2007) Goal Attainment Scaling: Description, Utility, and
Applications in Pediatric Therapy Services. (2nd ed.). London, ON: Thames Valley
Children’s Centre.
Turner-Stokes, L. (2009) “Goal Attainment Scaling (GAS) in rehabilitation: a practical
guide.” Clinical Rehabilitation,23, 4, 362-370.

3.4. Assessment
Assessment of children with cerebral palsy is guided by the ICF framework. In order to identify
and understand the factors affecting the achievement of a child’s identified goals, it may be
necessary to carry out assessments across a number of ICF domains. The aims of assessment
are to:
Understand the unique needs of individual clients and their families across a number of
life domains
Identify and evaluate the impact of factors limiting attainment of an individual’s specific
goals
Select, tailor and implement appropriate strategies to address the goal limiting factors

P a g e | 31
 Monitor progress and identify concerns early
Evaluate the effectiveness of interventions

Body structure and function assessments look at factors relating to physiological functions of
body systems (including psychological functions) and anatomical parts of the body such as
organs, limbs and their components. Body structure and function assessments aim to identify
problems in body function and structure such as significant deviation or loss (impairments).

Activity assessments look at the execution of a task or action by an individual and identify any
difficulties an individual may have in executing activities (activity limitations).

Participation assessments look at an individual’s involvement in a life situation and identify

problems an individual may experience in involvement in life situations

Body Structure and Function Assessments

3.4.1. Assessment of Range of Motion (ROM)

Assessment of range of motion (ROM) is carried out via goniometric measurement.

Purpose: to identify any loss of joint range/presence of contracture.

Both passive (therapist moves child’s body part) and active (child independently moves body
part) range of motion can be measured. In children with cerebral palsy joint range will often be
restricted by hypertonia and muscle and/or bony contracture.

ROM and the Modified Tardieu Scale (below) are usually carried out concurrently.

(I) Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist,
neurologist or rehabilitation medicine specialist.

How: Individuals are positioned in sitting to test the upper extremities and supine to test the
extremities (where possible) according to standard protocols. Joint angles are measured using a
goniometer. Inter-rater reliability measurements are as variable as 10-15 degrees, intra-rater
reliability are better. The same clinician should perform all measures to increase reliability.

Time: Varies depending on the number of joints assessed

3.4.2. Assessment of Muscle Tone

Points to remember:
hypertonia may still be evolving in the first two years of life with myelination
mixed presentations are common (spasticity/dystonia, dystonia/choreoathetosis)

P a g e | 32
(I) Assessment of Spasticity
Modified Tardieu Scale (MTS)
([Link]

> Purpose: To identify presence of spasticity.

The Modified Tardieu Scale is a scale for measuring spasticity that takes into account resistance
to passive movement at both slow and fast speed. The scale originally began development in the
1950s and has gone through multiple revisions (reviewed in Haugh 2006). The Modified Tardieu
Scale is an adaption of the original, more complex and time consuming assessment (the Tardieu
Scale).

> Administration:
Assessor: The Modified Tardieu Scale is carried out by an occupational therapist, physiotherapist,
neurologist or rehabilitation medicine specialist.

How: There are two parts to the assessment that are applied to each muscle group that is
examined. In the first part of the assessment, the health professional slowly moves the person’s
limb to observe the full range of their available movement (R2). In the second part of the
assessment, the same limb is moved quickly (R1).

The R1 and R2 range of motion values are measured using a goniometer.

Individuals are positioned in sitting to test the upper extremities and supine to test the
extremities according to standard protocols.

R1 is then subtracted from R2 and this represents the dynamic tone component of the muscle.

Upper Limbs Lower Limbs

Shoulder flexors Hip flexors

Shoulder internal rotators Hip extensors
Elbow flexors Hip adductors
Elbow extensors Knee flexors
Wrist flexors Knee extensors
Wrist extensors Ankle plantarflexors (m. Soleus) (knee joint
flexed)
Ankle plantarflexors (m. Gastrocnemius) (knee
joint fully extended)

Time: Varies depending on the number of muscle groups assessed.

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Ashworth Scale and Modified Ashworth Scale
(Ashworth, 1964; Bohannon & Smith, 1987)
([Link]

> Purpose: to measure the presence of hypertonia.

The Modified Ashworth Scale (MAS), a modification to increase the sensitivity of the original
Ashworth Scale (AS), measures spasticity and is applied manually to determine the resistance of
the muscles to passive movement. There is no reference to the velocity of the movement
therefore the response of stretch reflex to the increasing velocity is not examined. The reliability
of the scales is poor and the literature recommends interpretation of scores be used with
caution.

Ashworth Scale
0 No increase in tone
1 Slight increase in tone giving catch when the limb is moved in flexion and extension
2 More marked increase in tone, but limb is easily flexed
3 Considerable increases in tone, passive movement difficult
4 Limb rigid in flexion or extension

Modified Ashworth Scale

0 No increase in muscle tone
1 Slight increase in muscle tone, manifested by a catch and release or by minimal
resistance at the end of the range of motion when the affected part(s) is(are) moved in
flexion or extension.
1+ Slight increase in muscle tone, manifested by a catch followed by minimal resistance
through the remainder of the range of motion but the affected part/s is/are easily
moved.
2 More marked increase in muscle tone through most of the range of movement, but the
affected part(s) is easily moved.
3 Considerable increases in muscle tone, passive movement difficult.
4 Affected part(s) is(are) rigid in flexion or extension.

> Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist,
neurologist or rehabilitation medicine specialist who assesses bilateral upper and lower limb
muscles according to standard physical assessment protocol.

How: Place the patient in a supine position. If testing a muscle that primarily flexes a joint, place
the joint in a maximally flexed position and move to a position of maximal extension over one
second (count "one thousand one”). If testing a muscle that primarily extends a joint, place the
joint in a maximally extended position and move to a position of maximal flexion over one
second (count "one thousand one”). Score based on the classification below.

Time: Varies depending on the number of muscle groups assessed

P a g e | 34
Hypertonicity Assessment Tool (HAT)
(Jethwa et al, 2010)

> Purpose: to identify and discriminate between different forms of hypertonia.

The Hypertonia Assessment Tool (HAT) is a discriminative measure that assists the clinician to
identify the specific types of hypertonia present and how to best manage the hypertonia. It is a
six item tool (Knights, et al, 2013) developed for children between the ages of 4 to 19 years,
whereby the assessor moves the child’s body part in a series of purposeful movements in order
to observe movement, increased tone and/or resistance. The presence of at least 1 HAT item
per hypertonia subgroup ie spasticity, dystonia, rigidity, confirms the presence of the subtype
and the presence of items from more than one subgroup identifies the presence of mixed tone.
The HAT is capable of discriminating hypertonia subtypes for both the upper and lower
extremities.

The HAT was found to have good reliability and validity for identifying spasticity and the absence
of rigidity (rigidity is rarely seen in paediatric population) and moderate findings for dystonia due
to its variable nature. The HAT is stronger in identifying the presence of, rather than the absence
of spasticity or dystonia and the reverse pattern was found for rigidity.

> Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist,
neurologist or rehabilitation medicine specialist.

How: Clinician completes ALL 6 items on one extremity before moving to the next next
extremity. It is recommended that all four limbs are assessed. Items are listed in the suggested
order of administration in the HAT manual.
[Link]

Time: Approximately 5 minutes to conduct per limb assessed

(II) Assessment of Dystonia

To assess dystonia it is important to observe at rest and with voluntary movements as well as to
measure and feel. There is usually variable resistance to movement, often in extensor groups but
it can be both directions.

Hypertonicity Assessment Tool (HAT)

See above.

Barry Albright Dystonia Scale (BAD)

(Barry et al, 1999)

> Purpose: to identify and quantify dystonia.

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The Barry Albright Dystonia (BAD) Scale is a reliable and responsive five-point criterion based
ordinal rating scale for quantifying secondary dystonia. It rates the severity of dystonia in eight
body regions, including eyes, neck, mouth, trunk, upper limbs and lower limbs.

> Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist or
Physician experienced in secondary dystonia and cerebral palsy.

How: Assess the patient for dystonia in each of the following regions: eyes, mouth, neck, trunk,
each upper and lower extremity (8 body regions). Rate severity based only on dystonia as
evidenced by abnormal movements or postures. When assessing functional limitations, do not
score as dystonia-induced functional limitation if other factors, such as weakness, lack of motor
control, cognitive deficits, persistent primitive reflexes, and/or other movement disorders are
contributing to functional limitation.

Eyes: signs of dystonia of the eyes include: prolonged eyelid spasms and/or forced eye
deviations
0 Absent
1 Slight: dystonia less than 10% of the time and does not interfere with tracking
Mild: frequent blinking without prolonged spasms of eyelid closure, and/or eye
2
movements less than 50% of the time
Moderate: prolonged spasms of eyelid closure, but eyes open most of the time, and/or
3 eye movements more than 50% of the time that interfere with tracking, but able to
resume tracking
Severe: Prolonged spasms of eyelid closure, with eyelids closed at least 30% of the
4
time, and/or eye movements more than 50% of the time that prevent tracking
Unable to assess eye movements

Mouth: signs of dystonia of the mouth include grimacing, clenched or deviated jaw, forced open
mouth, and/or forceful tongue thrusting
0 Absent
Slight: dystonia less than 10% of the time and does not interfere with speech and/or
1
feeding
Mild: dystonia less than 50% of the time and does not interfere with speech and/or
2
feeding
Moderate: dystonia more than 50% of the time and/or dystonia that interferes with
3
speech and/or feeding
Severe: dystonia more than 50% of the time and/or dystonia that prevents speech
4
and/or feeding
Unable to assess mouth movements

P a g e | 36
Neck: signs of dystonia of the neck include pulling of the neck into any plane of motion:
extension, flexion, lateral flexion or rotation
0 Absent
Slight: pulling less than 10% of the time and does not interfere with lying, sitting,
1
standing and/or walking
Mild: pulling less than 50% of the time and does not interfere with lying, sitting,
2
standing and/or walking
Moderate: pulling more than 50% of the time and/or dystonia that interferes with lying,
3
sitting, standing and/or walking
Severe: pulling more than 50% of the time and dystonia that prevents sitting in a
4
standard wheelchair (e.g. requires special head rest), standing and/or walking
Unable to assess neck movements

Trunk: signs of dystonia of the trunk include pulling of the trunk into any plane of motion:
extension, flexion, lateral flexion or rotation
0 Absent
Slight: pulling less than 10% of the time and does not interfere with lying, sitting,
1
standing and/or walking
Mild: pulling less than 50% of the time and does not interfere with lying, sitting,
2
standing and/or walking
Moderate: pulling more than 50% of the time and/or dystonia that interferes with lying,
3
sitting, standing and/or walking
Severe: pulling more than 50% of the time and dystonia that prevents sitting in a
4
standard wheelchair (e.g. requires adapted seating system), standing and/or walking
Unable to assess trunk movements

Upper extremities: signs of dystonia of the upper extremities include sustained muscle
contractions causing abnormal postures, score each limb separately
0 Absent
Slight: dystonia less than 10% of the time and does not interfere with normal
1
positioning and/or functional activities
Mild: dystonia less than 50% of the time and does not interfere with normal positioning
2
and/or functional activities
Moderate: dystonia more than 50% of the time and/or dystonia that interferes with
3
normal positioning and/or upper extremity function
Severe: dystonia more than 50% of the time and/or dystonia that prevents normal
4
positioning and/or upper extremity function (e.g. arms restrained to prevent injury)
Unable to assess upper extremity movements

Lower extremities: signs of dystonia of the upper extremities include sustained muscle
contractions causing abnormal postures, Score each limb separately
0 Absent
Slight: dystonia less than 10% of the time and does not interfere with normal
1
positioning and/or functional activities
Mild: dystonia less than 50% of the time and does not interfere with normal positioning
2
and/or functional activities
3 Moderate: dystonia more than 50% of the time and/or dystonia that interferes with

P a g e | 37
 normal positioning and/or lower extremity weight bearing and/or function
Severe: dystonia more than 50% of the time and/or dystonia that prevents normal
4
positioning and/or lower extremity weight bearing and/or function
Unable to assess lower extremity movements

Time: Approximately 8 minutes of video (if used) plus time to score body segment movements.

(III) Assessment of Athetosis/Choreoathetosis

Assessment for chorea, athetosis and choreoathetosis is by observation of involuntary
movements characterised by:
Uncontrolled, slow and writhing movements (athetosis)
An ongoing random-appearing sequence of one or more discrete involuntary movements
or movement fragments (chorea)
Both (choreoathetosis)

3.4.3. Assessment Strength

Muscle strength can be assessed informally via observation of functional activity and formally via
manual muscle testing or hand held dynamometry.

(I) Functional muscle strength testing

Functional strength tests are related to the activity level and consist of multiple-joint movements.
Functional strength tests measure muscle strength, but also balance, coordination and some
endurance. Functional strength tests involve either the repetition of specific tasks in a set period
of time, or the timed performance of a set number of repetitions. Testing is easily performed,
functional and does not take a long time. Formal training is not required.

Functional strength tests can be conducted for both upper and lower extremity tasks.

30 second Repetition Max Test (30secRM)

The 30secRM test is a reliable measure of lower extremity performance.

> Administration
Assessor: This assessment is carried out by a physiotherapist

How: Instructions for administration are outline in the table below

Time: Approximately 5-10 minutes

P a g e | 38
 30 seconds RM
Description of Exercise
score

1. The Lateral Step-up Test L1 R1

The child stands with the extremity being tested on a 20 cm step with its
feet parallel and shoulder width apart.
Appropriate lateral step-up technique is defined as achieving a position
within 15º of knee extension for the tested extremity during the
extension phase of the test.
Repetitions are counted each time the heel or toes of the extremity not
being tested touches the floor.

2. Sit-to-Stand LR2
The child is positioned on a small bench, and seated with its feet flat on
the floor and knees and hips flexed at 90°.
The child has to achieve standing, arms free, without any assistance from
their arms on the bench or their body in the transition.
Repetitions are counted each time the child’s legs and hips are within 15º
of the extended position.

3. Attain stand through half kneel, without using arms L3 R3

The child is positioned on a mat in a half kneeling position, arms free.
This means that weight bearing is on one knee and the opposite foot, and
that the alignment may vary as long as the buttocks are clear of the lower
legs and/or the weight bearing surface.
The child has to achieve standing without using any external support such
as furniture or the floor.
Repetitions are counted each time the child achieved a standing position,
and both legs and hips are within 15º of the extended position.

Total score
LTot = L1 + LR2 + L3
LTot RTot
RTot = R1 + LR2 + R3

(II) Manual Muscle Test (MMT)

Manual muscle testing measures muscle strength using a grading system, Grades 1-5. There
are a number of different scales that are used for MMT (see table below).

Manual muscle testing is an assessment of performance not capacity.

> Administration
Assessor: This assessment is typically carried out by a physiotherapist, occupational therapist or
medical practitioner.

P a g e | 39
How: The client is positioned in the most appropriate position to assess strength of specific
muscles. The position will be dependent upon the level of strength present and the ability to
move the limb against gravity.

Time: 15–30 minutes; Administrative time is dependent on the muscle (s) selected, the age and
cooperation of the participant.

Medical
Research Explanation
Council

5 Holds test position against maximal resistance

4+ Holds test position against moderate to strong pressure

4 Holds test position against moderate resistance

4- Holds test position against slight to moderate resistance

3+ Holds test position against slight resistance

3 Holds test position against gravity

3- Gradual release from test position

Moves through partial ROM against gravity OR Moves through complete ROM
2+
with gravity eliminated and holds against pressure

2 Able to move through full ROM with gravity eliminated

2- Moves through partial ROM with gravity eliminated

No visible movement; palpable or observable tendon prominence / flicker

1
contraction

0 No palpable or observable muscle contraction

Recommendation -
> The Medical Research Council Manual Muscle Testing Scale is strongly recommended for use
with Manual Muscle Testing.

(III) Hand Held Dynamometry (HHD)

Hand held dynamometry is a quantitative and objective method for the assessment of muscular
strength using a portable hand held dynamometer

P a g e | 40
> Administration
Assessor: Physiotherapist or occupational therapist

How: The muscle(s) tested must have the ability to move against gravity to assess using HHD.
Measures are recorded using force production: kilograms, Newtons, or pounds. Two to three
maximum voluntary isometric or eccentric contractions are completed and scores summed.
“Make test” where the person holds isometric contraction for 3-5 seconds
“Break Test” where the tester applies a force to just overcome the strength of the
person being tested, producing an eccentric muscular contraction

The dynamometer is held perpendicular to the muscle being tested at a set distance from the
joint. Recommended testing positions are outlined below.

Hand Held Dynamometry (only if able to achieve anti-gravity movement)

Muscle Position Testing Position Dynamometer placement

LOWER LIMBS
Sit at edge of bed (stabilisation by
hands allowed), feet free. Leg Anterior aspect of thigh proximal
Hip flexion Sitting
being tested is lifted into flexion to knee joint
(thigh off bed)

Knees and hips flexed. Patient lifts

Hip flexion Anterior aspect of thigh proximal
Supine leg (foot should be off bed,
(alternate) to knee joint
keeping knee + hips flexed)

Standing Leg not being tested in slight knee

Hip Posterior aspect of thigh proximal
over flexion. Leg being tested is in hip
extension to the knee joint
table extension + knee flexion

Hip
Extend hip with knee held in Posterior aspect of thigh proximal
extension Prone
extension to the knee joint
(alternate)

Knee Posterior aspect of shin proximal

Prone Knee flexed (angle <90o)
flexion to the ankle joint

Knees flexed at 90o. Examiner’s

Knee arm positioned under the thigh of Anterior aspect of leg proximal to
Sitting
extension leg being tested, so that the leg is the ankle joint
supported on the examiner’s arm.

Ankle PF Knee extended with feet over

Prone Sole of foot near toes
(gastrocs) edge of bed, ankle in dorsiflexion

P a g e | 41
Ankle Knee flexed at 90o and ankle
Prone Sole of foot near toes
PF(soleus) dorsiflexed

Feet on the floor with ankle in

Ankle DF Sitting Dorsum of forefoot
dorsiflexion

Muscle Position Testing Position Dynamometer placement

UPPER LIMBS
Sitting on chair, feet supported,
back straight. Client raises arm
Shoulder Superior aspect of distal humerus
Sitting forwards to 90o, elbow slightly
flexion just above elbow joint.
flexed, and forearm pronated.
Therapist stabilises shoulder

Shoulder Arms at sides with shoulder Posterior upper arm just above
Prone
extension internally rotated (palm up). the elbow joint

Sitting on chair, feet supported,

back straight. Client raises abducts
Shoulder Dorsal surface of distal humerus
Sitting arm to 90o, elbow flexed to 90o,
abduction just above elbow joint.
palm down. Therapist stabilises
shoulder.

Sitting on chair, feet supported,

Shoulder back straight. Arm by side, elbow
Lateral aspect of forearm
external Sitting flexed to 90o thumb to ceiling –
proximal to wrist joint.
rotation elbow must remain in contact with
body.

Sitting on chair, feet supported,

back straight. Elbow flexed to 90o.
Elbow Biceps brachii – forearm supinated Superior aspect of forearm
Sitting
flexion Brachialis – forearm pronated proximal to wrist joint.
Brachioradialis – forearm mid
position

Shoulder abducted to 90o with

forearm flexed and hanging
Elbow Superior aspect of forearm
Prone vertically over side of plinth.
extensors proximal to wrist joint.
Therapist supports just above
elbow.

P a g e | 42
 Sitting on chair, feet supported,
back straight.
Shoulder adducted and elbow
Forearm
Sitting flexed to 90⁰. Forearm pronated. NA
supinators
Therapist supports arm at elbow.
Client attempts to move forearm
into supination.

Sitting on chair, feet supported,

back straight. Elbow and forearm
Wrist/finger
Sitting supported on table (if possible) Dorsal surface of mid hand.
extensors
with forearm in full pronation.
Fingers flexed.

Grip Sitting on chair, feet supported,

Sitting Grip strength dynamometer.
strength back straight.

Pinch Sitting on chair, feet supported,

Sitting Pinch strength dynamometer.
strength back straight.

Time: 5-30 minutes dependent on number of muscles assessed

Hand held dynamometry is an assessment of capacity.

3.4.4. Assessment of Selective Motor Control

Selective motor control has been defined as ’the ability to isolate the activation of muscles in a
selected pattern in response to demands of a voluntary movement or posture’ (Sanger et al,
2006). Selective voluntary motor control (SVMC) is an important determinant of functional ability
and evidence of SVMC impairment is evident in children with cerebral palsy.

(I) Selective Control Assessment of the Lower Extremity (SCALE)

(Fowler, Staudt, Greenberg & Oppenheim, 2009)

The Selective Control Assessment of the Lower Extremity (SCALE) is a clinical tool developed to
quantify selective voluntary motor control (SVMC) in persons with cerebral palsy, in other words,
isolation of joint movement upon request. It assesses SMVC at the hip, knee, ankle, foot and
toes. It has been validated in participants ages 5 years through adulthood, including male and
female individuals with spastic CP functioning at GMFCS levels I-IV with unilateral and bilateral
involvement. Individuals must be able to understand and follow verbal directions.

> Administration
Assessor: This assessment is typically carried out by a physiotherapist or medical practitioner.

P a g e | 43
How: Instructions for administration are detailed in this document
[Link]
SVMC is scored for each joint as:
2 = Normal (movement sequence completed without movement of untested ipsilateral or
contralateral lower extremity joints)
1 = Impaired (able to isolate movement but errors that include: movement in only one direction,
movement less than 50% available passive range, movement occurs at non tested joint or time
taken for execution greater than 3 seconds)
0 = Unable (requested movement sequence not initiated or is performed using synergistic mass
flexion or extension pattern)

Time: Approximately 15 minutes

(II) S Boyd & Graham Selective Motor Control Scale (SMC)

(Boyd & Graham, 1999)

The SMC is a five point observational scale that assesses selective motor control of the
dorsiflexors of the ankle.

> Administration
Assessor: This assessment is typically carried out by a physiotherapist or medical practitioner.

How: Child rests in long sitting with knees comfortably extended, vision of his feet and height
between feet and pelvis adjusted for hamstring muscle length. The child is asked to dorsiflex
his/her foot to a target in the mid position above the ankle joint. The balance of activity of Tibialis
Anterior, Extensor Hallicus, Extensor Digitorum is observed along with the ability to selectively
dorsiflex the ankle without the accompaniment of knee flexion (ie as a total pattern)
0 = No movement
1 = Limited dorsiflexion using EHL/EDL
2 = Dorsiflexion using EHL, EDL and some TA activity
3 = Dorsiflexion achieved mainly using TA but accompanied by hip and/or knee flexion
4= Isolated dorsiflexion through available range, balance of TA activity without hip and
knee flexion

Time: 10 minutes

Availability: Guidelines found in the journal article – Boyd, R. & Graham, H.K. (1999). Objective
measurement of clinical findings in the use of botulinum toxin type A for the management of
children with cerebral palsy. European journal of Neurology, 6: S23-35.

P a g e | 44
3.4.5. Assessment of Posture
Postural assessments examine some or all of the following:
Head and neck
Shoulders
Spine
Pelvis
Legs
Feet

> Administration
Assessor: This assessment is typically carried out by a physiotherapist, occupational therapist or
medical practitioner.

How: Postural assessments must be performed with the child minimally clothed, in order to
ensure a clear view of the contours and anatomical landmarks used for reference. The clinician
should instruct the child to assume a comfortable and relaxed posture. Observe the body from all
aspects - lateral, anterior and posterior and palpate landmarks as required. Assessments can be
conducted in standing, sitting or lying.

Description of the Foot – Non-Weight Bearing

Right Left

Varus / neutral / valgus Varus / neutral / valgus

Hindfoot
Stiff/ Mobile Stiff/ Mobile

Supinated/ Neutral / Pronated - Stiff / Supinated/ Neutral / Pronated - Stiff /

Mobile Mobile
Forefoot
Abduction / Adduction - Stiff / Mobile Abduction / Adduction - Stiff / Mobile
Eversion on Loading Eversion on Loading

Description of the Foot – Weight Bearing

Right Left

Hindfoot Varus / neutral / valgus Varus / neutral / valgus

Forefoot Supinated/ Neutral / Pronated Supinated/ Neutral / Pronated

Abduction / Adduction Abduction / Adduction

Standing, Sitting or Lying

Head Head upright: Forward / Midline / Extended

P a g e | 45
Shoulders Glenohumeral Position: Retracted / Neutral / Protracted

Curvature: Scoliosis / Normal / ↑ Lordosis / ↑ Kyphosis

Spine
Trunk upright: Lean Forward / Upright

Tilt: Ant tilt / Neutral / Post tilt

Pelvis Obliquity: ↑ Right / Equal / ↑ Left

Rotation: Right ASIS Fwd/ Neutral / Left ASIS Fwd

Sagittal: Flexion deformity / Neutral / Hyperextension

Knees
Frontal: Genu valgus / Normal / Genu varus

Transverse: Outoeing / Neutral / Intoeing

Feet Base of support: ↑ Right / Equal / ↑ Left

Width: Narrow / Normal / Wide

Time: varies

3.4.6. Additional Musculoskeletal Measures

The following musculoskeletal measures are frequently taken to identify the contribution of
skeletal mal-alignments to gait and/or postural issues.

(I) Ryders Test

> Purpose
To measure the degree of femoral anteversion. Provides information
around femoral alignment and the potential contribution of femoral
anteversion to intoeing. This is useful information in evaluating the
need for orthopaedic surgery e.g. varus derotation osteotomy.

It measures the point at which the femoral neck lies in the coronal
plane.

> Administration
Assessor: This assessment is typically carried out by a physiotherapist
or medical practitioner.

How: Child is positioned in prone with maximum hip and knee extension. The clinical stabilises
the pelvis by using their forearm or an assistant to prevent rotation in the transverse plane. The
clinician stands on the opposite side of the leg being assessed, flexes the child’s knee to 90o and

P a g e | 46
palpates the greater trochanter before rotating the leg. Stop rotation when the greater trochanter
is most prominent. Measure using a goniometer - place the proximal axis along the bed and the
distal axis along the long axis of the tibia, taken as the line between the midpoint of the femoral
epicondyles and the mid-point of the malleoli. Measure the angle from the vertical. Internal
rotation is positive.

Time: less than 5 minutes

(II) Bimalleolar Thigh Angle

Bimalleolar Thigh Angle is a measure of the orientation of the tibia in relation to the femur.

> Purpose
To provide a substitute measure of tibial torsion. This is useful information preoperative planning
and to assess outcomes of tibial osteotomy.

> Administration
Assessor: This assessment is typically carried out by a physiotherapist or medical practitioner.

How: Child is positioned in prone with knee extended. The clinician stabilises
the child’s pelvis. The test limb is flexed to 90o. The clinician kneels on the end
of the table looking directly over the foot. Take care that rotation does not occur
through the knee joint. Measure using a goniometer - place the proximal axis
along a line perpendicular down the centre of the thigh and the distal axis along
the bimalleolar axis line between the lateral and medial malleoli. Measure the
angle between the bimalleolar axis and the line perpendicular to the line down
the genre of the thigh. The centre of the goniometer is placed lateral to the
heel. An angle made with the bimalleolar axis distal to the line perpendicular to
the line down the centre of the thigh is denoted as external. An angle made with the bimalleolar
axis proximal to the line perpendicular to the line down the centre of the thigh is denoted as
internal.

Time: less than 5 minutes

(III) Thigh/Foot Angle (Foot Progression Angle)

Thigh/foot angle is a measure of the position of the whole foot in relation to the thigh.

> Purpose
To provide a substitute measure of tibial torsion. This is useful information preoperative planning
and to assess outcomes of tibial osteotomy.

> Administration
Assessor: This assessment is typically carried out by a physiotherapist or medical practitioner.

P a g e | 47
How: Child is positioned in prone with knee extended. The clinician
stabilises the child’s pelvis. The test limb is flexed to 90o. The clinician
kneels on the end of the table looking directly over the foot. Gently
position the heel in plantargrade. Take care that rotation does not occur
through the knee joint. Measure using a goniometer - place the proximal
axis along the line down the centre of the thigh and the distal axis along
the mid point of the posterior heel to the 2nd ray of the toes. Measure the
angle between the line of the thigh and the line through the centre of the
heel and 2nd ray of the toes. An angle towards the midline of the body is
denoted as internal. An angle away from the midline of the body is
denoted as external.

Time: less than 5 minutes

(IV) Leg Length

There are two measures for leg length - true leg length and apparent leg length.

True leg-length discrepancies are when there are actual measurable skeletal differences in the
shape and length of the leg bones, such as the femur, tibia and fibula.

Apparent leg length discrepancies are where there are no bony differences and the legs are
technically the same length, instead other conditions such as spinal scoliosis or pelvic
asymmetries create the appearance of one leg being longer or shorter than the other.

> Administration
Assessor: This assessment is typically carried out by a physiotherapist or medical practitioner.

How: Child is positioned in supine with pelvis in neutral and the hip and knee extended. Measure
with a tape measure. True leg length is measured from the anterior superior iliac spine to the
medial malleolus. Apparent leg length is measure from the umbilicus to the medial malleolus.

Time: less than 5 minutes

3.4.7. Assessment of Pain

(I) Visual Analogue Scale (VAS)
VAS is a measurement instrument that helps to determine pain that a patient feels ranges across
a continuum from none to an extreme amount of pain. Validated in children 10 to 18 years of
age.

This scale is a child report of pain and the choice of terms is specific to the type of scale. VAS
can be presented in several ways, including:
Scales with a middle point, graduations or numbers (numerical rating scales),

P a g e | 48
 Meter-shaped scales (curvilinear analogue scales),
"Box-scales" consisting of circles equidistant from each other (one of which the subject
mark), and
Scales with descriptive terms at intervals along a line (graphic rating scales or Likert
scales)
Faces representative of emotions

Types of visual analogue scales:

> Administration
Assessor: The screening can be carried
out by an occupational therapist,
physiotherapist, nurse or medical practitioner. Types of visual analogue scales

How: The child is asked to rate his or her current pain based on the scale; “0” being no pain and
“10” being extreme or severe pain.

Time: Approximately 5 minutes

Available: [Link]

(II) Paediatric Pain Profile (PPP)

The Paediatric Pain Profile is an outcome tool used to provide ongoing assessment and
monitoring of pain in children with neurological disorders and can be used for children 1 to 18
years of age who are unable to communication through speech or ACC.

Assessor: This is an observational and parent report outcome measure of child behaviours which
can be carried out by an occupational therapist, physiotherapist, nurse or medical practitioner.

How: Each of the items of the PPP can by observed by the provider and parents can answer
specific questions to rate their child’s behaviours or reaction during specific activities. The PPP is
a 20-item behavioural response scale with each question scored from “0” (not at all) to “3” (a
great deal), except for the first two questions in which the scoring is reversed. Responses to all
questions are summed to give a total score between 0 and 60. Cut-off scores are used to
determine pain severity: scores of 14/60 indicate clinically significant pain and can be additionally
grouped into levels of severity mild (10-19), moderate (20-29), severe (30-39) and very severe (40
or greater).

Time: Approximately 20 minutes

Available: [Link]

P a g e | 49
3.4.8. Assessment of Sensation
Tactile impairment impacts on upper limb function in a significant proportion of children with CP.
These deficits may occur in tactile registration and/or tactile perception (which may be spatial,
temporal, or textural) and over 77% of children with unilateral CP have tactile perception deficits
and over 40% have concomitant registration and perception deficits (Auld, 2011 & 2012).

(I) Tests of sensation:

Reliable assessment of sensation using these measures requires the patient to accurately
respond to the evaluators questions. These assessments may not be reliable for children with
intellectual impairments (Auld, 2011 & 2012).

1) Tactile registration can be measured using the full 20-item Semmes-Weinstein monofilaments
kit. Starting with the monofilament of value 2.83 (lower side of normal sensation), the
monofilament is applied to the skin surface of the four fingers three times in a random order,
with one response out of three taken as an affirmative response, as indicated by the original test
methodology.

2) Intensity/Texture Tactile Perception can be tested using the Perspex board (AsTex) that
displays tactile gratings of reducing tactile discrimination index. Starting at the rough end of the
board, the therapist guides the child’s index finger, then thumb, then 5th finger was guided by
the examiner along the board at a constant speed in a standardized manner. Children are
instructed to stop immediately when the texture of the board feels smooth (gratings became too
close together to determine their separation).

3) Motor-enhanced tactile perception: Stereognosis. Nine common objects are placed to the side
of the child within the child’s view. These objects include 3 unrelated objects (peg, key, spoon)
and six objects that come in associative pairs (a coin and a button of similar size, a pen and a
pencil, a paperclip and a safety pin). The examiner has an identical set of objects that are placed
in the child’s testing hand one at a time in a random order. The child is asked to manipulate the
object and/or was assisted to touch the object and to either name or point to the object that was
identical to the one placed in his/her hand. The total score is the number of correct responses out
of a possible maximum of 9.

Activity and Participation Assessments

3.4.9. Assessment of Gross Motor Skills

(I) Task/Activity Analysis - Clinical observation of performance of a specific task
Task/activity analysis is the analysis of how a task or activity is completed through deliberate
observation of the individual performing the task or activity. It takes into consideration any
anatomical, biomechanical, physiological, behavioural and environmental factors that may impact
upon the individual’ ability to complete the task or activity successfully.

P a g e | 50
Task/activity analysis can be applied to any task or activity that has been identified as a goal (both
gross motor and fine motor functional tasks/activities).

> Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist or
rehabilitation medicine specialist.

How: The clinician observes the individual performing the task or activity and compares the
performance with a list of essential components and asks the question ‘why can’t the individual
accomplish the task’. A task/activity analysis results in the identification of possible goal limiting
factors. Goal limiting factors may be at the person level (e.g. muscle weakness, spasticity in
certain muscles or cognitive impairment), at the task level (e.g. task is too complex), at the
environment level (e.g. the conditions for performance are suboptimal) or a combination of any or
all of person/task/environment factors. Following the task/activity analysis, the clinician may be
required to complete further assessment of a specific aspect of the analysis such as an
assessment of muscle strength or an assessment of spasticity.

Time: varies according to the task or activity

(II) Gross Motor Function Measure (GMFM)

(Lane, Russell, Rosenbaum & Avery, 2007; Avery, L.M., Russell, D.J., & Rosenbaum, P. 2013)

The GMFM is a criterion-referenced observational assessment designed to evaluate change in

gross motor function in children with cerebral palsy. It has been proven to be reliable, valid and
responsive to change. It assesses gross motor function in 5 dimensions:
Dimension A: lying and rolling
Dimension B: sitting
Dimension C: crawling and kneeling
Dimension D: standing
Dimension E: walking, running and jumping

There are two versions - GMFM-66 and GMFM-88. Both are widely used. The GMFM-66 is the
most recent version and is a subset of the original GMFM-88. It has the same level of detail and
ability to detect changes in gross motor function over time, but it is shorter than the GMFM-88.

There are several differences between the versions. The GMFM-88, which has 88 items,
provides scores for each dimension, whereas the GMFM-66, with 66 items, provides a total
score. The GMFM-66 is only used with children who have cerebral palsy, while the GMFM-88
can also be used with children who have Down Syndrome.

Shortened versions of GMFM-66 have also been developed. The shortened versions of GMFM-
66 are called GMFM-66 Items Sets (IS) and GMFM- 66 Basal and Ceiling (B&C). When using

P a g e | 51
these assessments, a smaller sample of GMFM-66 items is completed and scores are derived by
using the Gross Motor Ability Estimator (GMAE). Both tests accurately estimate GMFM-66
scores at a single time, but GMFM-66 (IS) is the preferred shortened measure for unilateral
(hemiplegic) cerebral palsy. The full GMFM-66 is required if the aim of assessment is to measure
change.

> Administration
Assessor: The GMFM was designed for use by paediatric physiotherapists who are familiar with
assessing motor skills in children.

How: Users should familiarise themselves with the GMFM guidelines and score sheet prior to
assessing children. It may be helpful to practice on several children with and without motor
disabilities prior to using it for clinical assessments. It is recommended that users assess their
reliability with the GMFM prior to using it.

Time: The GMFM-88 takes approximately 45-60 minutes to administer. The GMFM-66 takes
approximately 30-40 minutes to administer however scores can only be calculated using the
Gross Motor Ability Estimator (GMAE) software program.

Availability: The GMFM-66 and GMFM-88 User's Manual which you can purchase from Wiley
Blackwell Publishing. Score sheets can be downloaded free of charge.

Recommendation -
> The GMFM-88 is the recommended version of the GMFM in situations where access to
technology is difficult as it can be scored manually. It is recommended that the GMFM-88 be
used with children who are GMFCS IV and V. If access to technology to score the GMFM-66 is
available, the GMFM-66 should be used for children with GMFCS I-III.

3.4.10. Assessment of Gait

(I) Observational gait assessment (2D Gait Analysis)
2D video analysis can be used when instrumented gait analysis is not possible. It is low cost,
readily available and easy to use in the clinical setting. 2D gait analysis involves a thorough
movement.

> Purpose
To identify the kinematics of gait with particular reference to deviations from normal. This
provides useful information for identifying suitable intervention strategies such as the
prescription of orthoses, botulinum toxin or surgery.

> Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist or
rehabilitation medicine specialist.

P a g e | 52
How: This assessment is to be performed indoors, along a long, flat, straight enclosed corridor,
with a hard surface, and that allows enough room to capture video from the front/back and
lateral aspects (A room size of at least 12m x 8m x 2.5m is recommended). The clinician will
assess the child’s hip, knee and ankle kinematics, and their overall posture. Parameters of gait
assessment include stride time, length, stance time, swing time, joint angles and symmetry,
comparing them to a typical walking style

The camera(s) should be positioned at the correct height and distance from the participant to
accurately capture their full walking pattern from start to finish. A video of the sagittal and
coronal planes is essential. Close-up footage of the person’s knees and feet is also
recommended.

Time: 10-30 minutes

(II) Dimensional (3D) Gait Analysis/Instrumented Gait Analysis

Instrumented gait analysis provides a quantitative assessment of gait and other movements that
can be used to evaluate disease progression, and inform treatment planning.

The use of instrumented 3-D gait analysis is considered the ‘gold standard’ assessment to define
gait deviations and facilitate appropriate treatment options especially decisions around
orthopaedic surgery.

All of the data are collected, processed and analysed and then presented to a team of doctors,
therapists and biomechanists with experience in gait abnormalities and treatment. Final
recommendations for interventions are determined from this team assessment.

> Administration
Assessor: Clinicians employed by the gait laboratory - physiotherapists and biomechanists.

How: Instrumented gait analysis is commonly conducted across multiple conditions including
barefoot, wearing shoes, and using any assistive devices (such as ankle foot orthoses or
walkers). Comparing across conditions allows clinicians to evaluate walking ability and inform
treatment decisions. Note that evaluations of ankle foot orthoses should be compared to shod
(with shoe) conditions, when possible, to evaluate the relative effect of the shoe and orthosis. All
data is typically compared to a database of normative values from typically-developing children.

The testing involves a detailed physical examination, and measurement of multiple joint motions,
mechanical forces at multiple joints, and electrical activity in multiple muscles collected while the
person is walking or making the affected motion. Video recording, measurement of foot pressure
and measurement of the energy cost of walking are also common aspects of this evaluation if
needed to describe the movement problem.

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Specific measures included in instrumented gait analysis include:
Physical examination
Temporal-spatial gait parameters (e.g., step length, step width, speed)
Kinematics (joint angles)
Kinetics (ground reaction forces, joint moments and powers)
Electromyography (muscle activation and timing)
Metabolic Consumption (oxygen cost and consumption)

Time: 1-3 hours plus time for reporting

Availability: 3D gait analysis is not widely available across Vietnam.

Recommendation -
> Strategies should be considered to increase the capability to conduct 3D gait analysis for the
assessment of gait deviations in children with cerebral palsy and to inform decision making
around orthopaedic surgery for ambulant children with cerebral palsy into the future.

3.4.11. Assessment of Walking Function

(I) 10 Metre Walk Test (10MWT)
([Link]
The 10MWT assesses walking speed in meters per second over a short duration.

> Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist or
rehabilitation medicine specialist.

How: The individual walks without assistance of another person 10 meters and the time is
measured for the intermediate 6 meters to allow for acceleration and deceleration.
Start timing when the toes of the leading foot crosses the 2-meter mark
Stop timing when the toes of the leading foot crosses the 8-meter mark
Assistive devices can be used but should be kept consistent and documented from test
to test
If physical assistance of another person is required to walk, this test should not be
performed
This test can be performed at preferred walking speed or fastest speed possible -
documentation should include the speed tested (preferred vs. fast)
Collect three trials and calculate the average of the three trials

Instructions:
Normal comfortable speed: “I will say ready, set, go. When I say go, walk at your normal
comfortable speed until I say stop”

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 Maximum speed trials: “I will say ready, set, go. When I say go, walk as fast as you
safely can until I say stop”

Time: less than 5 minutes

(II) Timed Walk Tests (1, 2, 6 minutes)

Walk tests measure the walking capacity of the child. They are an easy, repeatable and objective
measure. The 6 minute walk test measures the distance a patient can quickly walk on a flat,
hard surface in a period of 6 minutes and is considered a test of walking endurance. There are
other walk tests measuring the distance walked over varying time periods eg. 1 minute and 2
minute walk tests. The type of walk test used in assessment needs to be considered in relation
to the functional mobility of the child and the clinical setting. Increasing evidence in the reliability
and validity of these tests is emerging in the literature. For example, the 6 min walk has been
shown to have good reliability and sensitivity to change in adults with cerebral palsy.

> Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist or
rehabilitation medicine specialist.

How: This test is to be performed indoors, along a long, flat, straight enclosed corridor, with a
hard surface, of 30 m in length. Children should start in the standing position at the starting line.
Children should be encouraged to walk as far a distance as possible over 6 minutes.
Documentation should include the speed tested if fastest speed is not used (preferred vs. fast).
Assistive devices can be used but kept consistent from test to test. Distance is calculated to the
nearest meter using a meter marker or trundle wheel. Retesting: This should be performed in
the same environment using the same splinting, walking aides and measurement technique.

Time: 6 minutes

(III) Timed Up and Go (TUG)

(Williams et al, 2001)

First developed as a bedside balance and mobility test for the frail elderly population with good
reliability and validity the TUG is a dual-task dynamic measure for identifying individuals who are
at risk for falls. Average scores for typically developing children have been studied (4, 6, 8 years)
and good reliability with children with cerebral palsy established.

> Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist or
rehabilitation medicine specialist.

How: The child is seated on a stable stool or chair without arm rests (knee angle 90°, feet flat on
floor) and asked to stand up, walk 3 m, touch a mark on a wall then return and sit down. Usual

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footwear and orthoses are worn and walking aides permitted. No physical assistance is
provided. Timing begins as the child leaves the seat and stops as the child’s bottom touches the
seat. Three timed trials are conducted and the best trial is recorded. The test is performed
indoors on a level surface.

Time: 15 minutes

(IV) Timed Up and Down Stairs

(Zaino et al, 2004)

The Timed Up and Down Stairs was developed as a functional mobility outcome measure. It
requires a certain amount of strength of the lower limbs and trunk, range of motion of the lower
limbs, co-ordination of fast reciprocal movements and anticipatory and reactive postural control.

It has been tested for reliability and validity in children with and without cerebral palsy aged 8-14
years.

> Administration
Assessor: This assessment is carried out by an occupational therapist, physiotherapist or
rehabilitation medicine specialist.

How: The child stands 30cm from the bottom of a 14-step flight of stairs and is instructed to
“quickly but safely go up the stairs, turn around on the top step (landing) and come all the way
down until both feet land on the bottom step (landing)”. The child can choose any method of
traversing the stairs but must be facing forwards, not sideways. The score is the time in
seconds from the “go” cue to the second foot returned to the bottom landing.

Time: 5 minutes

3.4.12. Assessment of Balance - Pediatric Balance Scale (PBS)

(Franjoine, MR.., Gunther, J.S. and Taylor, M.J., 2003)
[Link]

The Pediatric Balance Scale (PBS), a modification of Berg’s Balance Scale, was developed as a
balance measure for school-age children with mild to moderate motor impairments. The PBS is
14-item criterion-referenced measure which examines functional balance in the context of
everyday tasks in the paediatric population.

> Administration
Assessor: This assessment is carried out by a physiotherapist.

How: Instructions listed prior to each item on how to perform and how to instruct participant
who is completing the instrument.

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[Link]
n_of_the.[Link]#P78

Time: 5 minutes

3.4.13. Assessment of Fine Motor Skills/Upper Limb Function

(I) Box and Blocks
The Box and Blocks is a capacity assessment of upper extremity reach and grasp using a
common toy (block).

> Administration
Assessor: This assessment can be completed by an occupational therapist or physiotherapist.

How: The test includes a box with 150 blocks. A partition (divider) is placed lengthwise in the
middle of the box to divide the box into two sides. Directions give to patient “I want to see how
quickly you can pick up one block at a time with your right (or left) hand [point to the hand]. Carry
it to the other side of the box and drop it. Make sure your fingertips cross the partition. Watch
me while I show you how.” Following the demonstration and practice, the patient is given 1-
minute to transfer blocks from one side to the other. The examiner records how many blocks are
successfully transferred in 1-minutes.

Time: 5-10 minutes

Available: Instruction for the Box and Block test are available at
[Link]
[Link]

(II) Quality of Upper Extremity Skills Test (QUEST)

The QUEST is a capacity assessment of the quality of hand and arm movement patterns and
function in children with CP who are 18 months to 8 years of age. There are four sections: 1)
dissociated movement, 2) grasp, 3) weight-bearing, and 4) protective extension.

> Administration
Assessor: The assessment can be completed by an occupational therapist or physiotherapist.

How: The examiner encourages the child to complete movement activities in each section
through verbal encouragement, toys, demonstration, and/or handling the child as necessary. The
child must demonstrate the required position without physical assistance, e.g. the therapist
cannot hold the arm in extension against gravity, but may facilitate this through weight bearing,
placing, etc. The child must hold the position for at least 2 seconds. The order of administration
can be changed to suit the child and therapist. If a child has a fixed contracture, the contracted
position should be considered full range (e.g., if the child is lacking 10 degrees of extension due
to a contracture, that position is considered full extension for that child).

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Time: Approximately 45 minutes to administer all four sections

Available: The English version of the QUEST is available, but can be translated into Vietnamese.
[Link]

(III) Pediatric Motor Activity Log (PMAL)

The PMAL is a parent-report questionnaire measuring real-world use of impaired upper limb in
common daily activities, capturing both perceived amount of use and quality of use.

> Administration
Assessor: The assessment can be administered by an occupational therapist or physiotherapist.

How: The PMAL is completed through a semi-structured interview with the parent. The parent is
asked specific questions about the way the child uses his/her upper limbs from a list of 22 real-
world activities. It is important to determine what the child does outside the treatment or
hospital setting. The parent is asked to rate the “How Often” and “How Well” the child
completes each specific activity using a 6-point scale. After administering the full PMAL, the
mean PMAL scores are calculated for the two scales (How Often & How Well) by adding the
rating scores on each of the scales and dividing by the number of items asked.

Time: Approximately 20-30 minutes

Available: The English version of the Revised-PMAL is available but can be translated into
Vietnamese [Link]

(IV) Assessment of ability to manage routine tasks requiring both upper extremities –
(ABILHAND-Kids)
The ABILHAND-Kids is a parent completed questionnaire that assesses manual abilities of
children 6 to 15 years of age who have impaired upper limb functions.

> Administration
Assessor: The assessment can be administered by an occupational therapist or physiotherapist.

How: The assessment consists of 21 items covering both unimanual and bimanual self-care
activities. Each item is rated as 0=impossible, 1=difficult, 2=each, yielding a score range of 0 to
42. The parent is asked to estimate the child’s ease or difficulty in performing each activity
without assistance, irrespective of using right or left upper limb, and using whatever means
necessary (compensation is allowed).

Time: Approximately 20 minutes

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Available: The English version of the ABILHAND-Kids is available but can be translated into
Vietnamese [Link]
Environmental Assessments

Children with cerebral palsy live and carry out activities in many environments including home,
preschool/school and the community. For many children, environmental barriers will exist that
significantly impact upon the achievement of their goals, particularly goals related to social and
community participation, inclusion and learning. Examples of environmental barriers that may
exist include:
physical barriers (e.g. lack of ramps, uneven roads and footpaths, steep inclines/hills/mountains,
river/creek/stream crossings etc.)
lack of suitable adaptive and assistive equipment (e.g. poor seating options, no
wheelchair/walking aid, no/limited access to learning materials such as adapted writing utensils
or accessible computer/technology/software etc.)
attitudinal barriers (e.g. lack of understanding of cerebral palsy and disability resulting in stigmas
leading to people with cerebral palsy being excluded and not accepted into their community etc.)
governmental/policy barriers (e.g. limited access to health/rehabilitation services outside of
medical facilities such as hospitals or clinics, cost of certain medical/rehabilitation interventions
etc.)

3.5. Evidence-Based Practices in CP - PT

Evidence-based decision making involves the integration of best available clinical evidence from
systematic research, the proficiency and judgment clinicians acquire through clinical experience
and client values and preferences in making clinical decisions about their care (Sackett et al.,
1996). Decision making is also made with consideration to the organisational context (for
example local policies, procedures and beliefs around approaches) (Figure 3).

Clinical
Expertise

Organizational
context
EBP
Best available Patient/ client
research values +
evidence preferences
Figure 3. EBP
framework

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Evidence-based practice should guide the management of children with CP across Vietnam.

The ICF guides evidence-based practice in the management of children with CP. Research
findings demonstrate that interventions for CP are only effective for one domain of the ICF. That
is, interventions targeting the body functions and structure impairments will have outcomes at
the body functions and structure domain only. If outcomes are desired at the activities and
participation domains of the ICF, interventions that are proven to impact these domains are
directed at the activity and participation limitations (Table 1, Novak et al., 2013)

The intervention strategies outlined in these guidelines represent the current and highest level of
evidence-based practice for the management of children with CP.

Table 1. Green light interventions for children

with CP from Novak et al, 2013

The following factors are important when reviewing the evidence-based for interventions for the
management of children with CP.

Dosing represents a critical and pressing aspect of intervention that is central for
treatment efficacy and is defined as the frequency, intensity, time, and type of an
intervention.
Frequency refers to how often, such as the number of sessions for a given intervention
per day, week, or month.

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 Intensity refers to how hard the child works, the amount of effort, within the intervention
session and is recorded as the number of repetitions per minute, day, or week or amount
of work (eg, 75% of maximal heart rate).
Time refers to the duration of the intervention.
Type refers to the kind of intervention and can be focused at any of the dimensions of the
International Classification of Functioning, Disability and Health (ICF): body functions and
structures, activity, or participation. Within types, variation exists. For example, task
practice can vary in the type of behavioural shaping (ie, structured versus unstructured
training) and amount of feedback or reward (Kolobe et al., 2014).

Intervention studies must first demonstrate effectiveness in achieving a meaningful outcome

then follow with carefully designed studies to determine the minimal dose required to elicit or
maintain the same desired functional outcome.

To date, the minimum doses for changing structure and function, activity, and participation in
children with CP are unknown and determining the effective dose of specific interventions is a
focus of future intervention studies.

Maximising outcomes in children with cerebral palsy will most often require a combination of
therapy approaches targeting different levels of the ICF – body structure and function
interventions, activity and participation interventions and interventions targeting the
environment. The relative contribution of each of these approaches will vary according to each
individual child’s presentation and identified needs and goals. As such, an integrated care
approach should be promoted to enable children to receive appropriate interventions in a timely
and efficient manner.

For example, the presence of a muscle contracture in the gastrocnemius or elbow flexors may
require serial casting (a body structure and function intervention) to reduce the contracture
followed by a motor learning based intervention such as goal directed therapy or constraint
induced movement therapy (activity and participation interventions) to gain or maintain functional
skills.

Body Structure and Function Interventions

3.5.1. Stretch Interventions

Stretch interventions are widely utilised for the treatment of contractures in children with CP
with the aim of maintaining or increasing range of motion at a specific joint. Stretch can be
applied in three main forms:
The application of orthoses
Serial casting
Positioning program

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Stretch interventions aim to elongate soft tissue. Low load prolonged stretch is more effective
than short held, passive stretches.

(I) Orthoses
The prescription and manufacture of upper and lower limb orthoses is common practice with
children with CP. A splint or orthosis is a removable external devices designed to support a
weak or ineffective joint or muscle.

The main purposes of orthoses or splints are to maintain range of motion and assist with
function. An orthosis is usually applied at the tolerable end of joint range. Often a variety of
orthoses may be required for different activities and to achieve different goals.

Orthoses are generally manufactured from low temperature thermoplastics or materials such as
lycra and neoprene (by occupational therapists and physiotherapists in the therapy setting) or
from high temperature thermoplastics (by orthotists).

Functional Orthoses
Functional orthoses generally position joints in a biomechanically advantageous position to either
enable or improve function. Examples may include:
Ankle foot orthoses (AFO’s) – a variety of AFO’s are available with varying purposes
Wrist extension orthoses
Neoprene wrist and thumb orthoses

Non-functional Orthoses
Positional orthoses aim to maintain corrected anatomical alignment of the joint and maintain
range of motion around that joint (such as after botox or surgery). This may be important for
ease of care, to reduce the requirement for future orthopaedic surgery and in some cases to
maintain healthy skin integrity. Examples of positional orthoses may include:
Spinal braces
Leg or elbow wrap arounds
Hip abduction orthoses

Clear dosage information around wearing regimes for orthoses is currently lacking. Decisions
around wearing regimes need to be made with consideration to the individual goals identified by
each child and family.

(II) Casting
Casting is the application of individually moulded casts made of either plaster or synthetic casting
materials with the aim of increasing passive range of movement of tight or contracted muscles,
by applying a prolonged low load stretch across a joint or joints to lengthen affected muscles.

Serial casting involves applying a number of casts in succession to gradually increase passive
range of movement.

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Casting is indicated when soft tissue contracture is interfering with function or causing potential
biomechanical misalignment. Casting is not indicated when there are bony changes occurring at
a joint. Casting only provides a short term stretch and is usually required to be repeated at
regular intervals particularly as children undergo a growth spurt. Casting is unlikely to be an
effective intervention for long term contractures where bony changes might be limiting ROM.

Rationale for Use of Serial Casting

Biomechanically, casting imposes a continuous stretch on a muscle/group of muscles, leading to
an increase in muscle fibre length due to an increase in the number of sarcomeres. This
increased muscle length reduces the overall soft tissue contracture. It is important to note here
that casts should never be left on for more than 5-7 days as there is evidence to support the loss
of sarcomeres if a joint is left immobilised in a cast for too long.

When casting is being considered the impact of the current level of soft tissue contracture on
function must be determined. For example, a 10° knee flexion contracture in a child at GMFCS
Level III who walks with a Kaye walker is problematic as the contracture will impact on their gait,
whereas in a child at GMFCS Level V this degree of contracture will not impact on their seating
and positioning. Similarly a 20° flexion contracture at the elbow is not likely to impact
functionally on a child’s day to day activities such as dressing or even reaching but may impact
on their ability to participate in sport or on overall cosmesis when walking, as arm swing may not
look natural.

Who
Serial casting for the upper limb and lower limb should only be applied by therapists who have
completed sufficient training and gained basic competencies in the techniques. An
understanding of the neurophysiological and biomechanical reasons for casting, types of casts,
timings, adverse events and complications is required prior to commencing any casting program.

How
Casting may be considered following assessment and the determination that muscle contracture
is limiting the achievement of the identified goals. Casting material required includes appropriate
stockinette, under-padding, casting material (plaster of paris or synthetic). The advantages of
synthetic materials include ease of application, speed of drying (in comparison to plaster of paris)
and decreased overall weight on the limb. Disadvantages of synthetic materials include the need
to remove rigid casting material with a cast saw (this prevents the ability of the family to remove
the cast at home if required), some materials contain fibreglass which require personal protective
equipment (eye glasses and nose/mouth masks) to decrease risk of airborne particles being
ingested.

The limb to be cast is held at the desired position, usually at the tolerable end point of passive
range, and in the optimal biomechanical alignment. The ankle should be cast in subtalar neutral.
When casting the wrist, consider the alignment of the fingers and thumb.

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The under-padding is applied followed by the casting material. Care should be given to ensure
that the joint does not move during and after application. Ensure that circulation has not been
compromised.

Each cast is left on for between 3-5 days before it is removed. Reassessment of the range of
movement is carried out to determine the effectiveness of the casting intervention.

(III) Positioning Programs

Prolonged stretch can be provided through positioning programs. Positioning programs
frequently involve the use of sitting and standing positions with the use of orthoses or assistive
and adaptive technology. Examples include long sitting using leg splints/leg wraps for hamstring
stretching with or without gastrocnemius stretching and the use of standing frames to provide
stretch across various joints.

Positioning programs for stretch may assist in maintaining existing muscle length. Their
effectiveness for lengthening muscles is unknown.

Standing frames are devices that are frequently prescribed for the management of hip alignment
and the prevention or management of hip, knee and ankle contractures. Standing frames are
discussed further under section 8.3 Prescribing Adaptive and Assistive Technology.

3.5.2. Muscle Tone Interventions

Medical and surgical interventions - please refer to the general guideline for the management of
children with CP.

3.5.3. Strengthening Interventions

Strengthening programmes and resistance training is an accepted intervention for children with
CP, in particular lower limb strengthening (Dodd et al, 2002; Verschuren et al, 2008). There are
no adverse increases in spasticity arising from strength training programmes.

(I) Progressive Resistance Training and Functional Strength Training

Progressive resistance training involves using exercises that are made progressively more
difficult through an increase in the amount of weight or the resistance. The exercises can be
completed in a gym or other exercise environment and often uses pieces of equipment such as
handheld dumbbells, arm weights and gym machines.

Functional strength training is one commonly used form of progressive resistance training. It
involves doing everyday functional activities while the amount of resistance increases. Examples
of this method include repetitively throwing and catching weighted balls, or moving around in a
self-propelling wheelchair to help increase arm strength.

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How
Strengthening programmes applied to children with cerebral palsy can be based on the
guidelines published by The American Academy of Pediatrics (AAP: Council of Sports Medicine &
Fitness, 2008) and the National Strength and Conditioning Association (NSCA) (Faigenbaum et al,
2009).

Strength training involves

Repetitive practice of functional activities with increasing resistance
Training is typically recommended 2-4 times a week (with rest days in between) for a
minimum of 8 weeks
Each training session should last for a minimum of 20-30 minutes
During the sessions, 1-3 sets of 6-15 repetitions of each exercise should be carried out
Exercises should be carried out to fatigue

It is important to note that strength gains achieved in a program of at least 8 weeks will be lost
approximately 6 weeks after training is discontinued.

Due to its intensity and the need for the muscles to rest and recover, it is not meant to be
performed frequently and for long durations. Strength training needs to be combined with other
activity-based programs such as treadmill training or cycling where you can look at other aspects
of function such as endurance or coordination.

(II) Electrical Stimulation

Electrical stimulation (ES) is the application of an electrical current to a muscle through electrodes
which are placed on the skin. This electrical current causes the muscle to contract involuntarily
for the purpose of strengthening the muscle.

Electrical stimulation is also called:

Neuromuscular Electrical Stimulation - refers to higher level electrical stimulation that
causes a visible muscle contraction, with a typical current registering above 10 milliamps
(mA)2
Threshold Electrical Stimulation - refers to lower level electrical stimulation that does not
cause a visible muscle contraction, with a typical current registering below 10 milliamps
(mA)2
Functional Electrical Stimulation - refers to the use of electrical stimulation that is applied
during the practice of functional tasks such as reaching and walking and usually relates to
NMES

Electrical stimulation is used to elicit a muscle contraction for the purpose of strengthening.
Children and adults with cerebral palsy for whom muscle weakness is the primary factor limiting
the achievement of a functional goal MAY benefit from ES.

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How
Electrical stimulation involves the placement of electrodes on the skin over specific muscles.
These electrodes are connected to a control unit (like a battery pack). The settings on the control
unit are set according to the individual needs of the person undergoing ES. A current is
generated from the control unit through the electrodes and into the muscle causing the muscle
to contract. The current creates an intense tingling sensation on the skin not unlike the feeling of
pins and needles. In simplistic terms, the higher the current required to cause a contraction, the
stronger the sensation. Not everyone is able to tolerate the sensation.

There are a number of different units available on the market. Some units allow for multiple
muscles to be stimulated at the same time or at different time points. Some units are wireless
whilst others are integrated into exercise equipment such as treadmills and exercise bikes.

The following factors should be considered:

Not every person is able to tolerate the level of stimulation required to elicit a muscle
contraction
An individual considering ES should be able to follow directions from the clinician and be
able to reliably self-report on the sensation
Best practice treatment protocols in cerebral palsy are not currently available
The cost of units varies significantly and as such access to units may be limited

Evidence for using ES

The available evidence on the effectiveness of electrical stimulation is conflicting.
Functional electrical stimulation appears to be effective in improving foot drop during
walking in people with cerebral palsy who have very mild gait impairments.
There is lower quality evidence that supports the use of electrical stimulation in improving
muscle strength in both the lower and upper limbs.
The available evidence suggests that upper limb neuromuscular electrical stimulation may
offer some functional benefits5, however there is insufficient evidence regarding the
effectiveness of ES in improving walking.
There are currently no best practice guidelines or protocols available regarding the
application of electrical stimulation in cerebral palsy.

3.5.4. Fitness Interventions/Exercise

Fitness training is structured physical activity which uses more energy and is more intense than
daily living. It aims to improve or maintain a person’s physical fitness level. Exercise can be
defined as ‘planned structured activities involving repeated movement of skeletal muscles that
result in energy expenditure to improve or maintain levels of physical fitness’ (Verschuren et al,
2008). Physical fitness is ‘a set of attributes that people have or achieve that relates to the
ability to perform physical activity’ (Caspersen et al, 1985). The major components of health
related-fitness are cardiorespiratory fitness and muscle strength (Verschuren et al, 2014). The

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primary and secondary impairments of CP affect both cardiorespiratory fitness and muscle
strength contributing to reduced physical fitness (Verschuren et al, 2014).

The health benefits of regular exercise for the general population have been known for many
years providing protective benefits against cardiovascular disease, type II diabetes, obesity and
some cancers (Blair et al, 1996). Over recent years there has been increased focus on
interventions to improve the general health of children with CP.

Fitness activities include walking, swimming, hydrotherapy, cycling, dance, gymnastics, martial
arts, and team sports such as soccer and basketball.

Three areas of fitness are important for people of all ages – with, and without cerebral palsy:
Aerobic fitness - the ability of the body to work for prolonged periods of time using
oxygen as fuel. Aerobic activities include walking, running and swimming
Anaerobic fitness - the ability of the body to complete more strenuous activities that are
much shorter in duration, i.e. less than 15 seconds. These are the main forms of activity
for children and include climbing stairs and games such as hide and seek and tag
Muscle strength – improving muscle strength and endurance can assist with walking,
pushing one’s own wheelchair, and improving the efficiency of other exercises.
Maintaining muscle strength may help with sustaining ability to function in everyday life.
Muscle strengthening exercises include lifting weights and resistance training.

Evidence for fitness training

Current evidence suggests that fitness training to improve aerobic fitness provides short-term
benefits for clients with sufficient motor skills to be able to undertake training and any increase in
capacity following training is not maintained when training stops (Novak et al, 2013). There is
currently insufficient evidence to support the use of fitness training to improve function and
participation however the research would suggest that aerobic fitness does not translate into
either activity or participation gains (Novak et al, 2013).

Frequency and intensity of interventions vary across the literature and generally focus on
structured moderate to vigorous exercise. Attention is shifting with a growing recognition of the
importance of reducing sedentary behaviour and encouraging light intensity activities throughout
the day (Verschuren et al, 2014). It is recommended that fitness training to improve aerobic
fitness, muscle strength and the general health of children with CP should be integrated into the
child’s daily life on an ongoing basis (Verschuren et al, 2014).

[For information relating to strengthening, see below]

3.5.5. Hip Surveillance

Hip surveillance includes:
Musculoskeletal assessment
o Passive range of motion

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 o Leg length
o Spine
o Pelvis
Modified Tardieu Scale (specifically hamstrings and hip adductors)
Modified Ashworth Scale (specifically hamstrings, hip adductors and hip flexors)
Functional Mobility Scale (FMS)
Pain around the hip
Anteroposterior pelvic radiograph with a measure of migration percentage (MP)

Interventions that may be prescribed as part of hip surveillance and an individual management
plan include:
Medical tone management
Non-operative orthopaedic management including postural systems, seating and standing
systems and bracing
Orthopaedic surgical interventions including preventive, reconstructive and salvage
surgery (these include both soft tissue and bony procedures)

Hip surveillance guidelines have been developed in Australia and these should be adopted for
use in Vietnam.

Available: [Link]
The role of physiotherapists in hip surveillance involves conducting the musculoskeletal
assessment, referring to medical practitioners for pelvic radiographs and implementing non-
operative interventions (postural systems, seating and standing systems).

3.5.6. Hippotherapy
Hippotherapy is therapeutic horse riding that is built on the concept that the individual and
variable gait, tempo, rhythm, repetition and cadence of a horse’s movement can influence human
neuromuscular development in humans. Hippotherapy is usually provided by therapists
(occupational therapists, physiotherapists or speech pathologists) who have undertaken specific
training in hippotherapy. Goals for hippotherapy may include developing
Strength
Control
Balance
Posture
Endurance
Coordination
Sensory integration
Understanding of visual cues

There is low quality evidence that hippotherapy is effective in improving hip and trunk symmetry
and stability (Novak et al, 2013).

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3.5.7. Massage
Massage is the rubbing or kneading of the soft tissues of the body (muscles and connective
tissues) for relaxation and rehabilitation. There are many different types of massage and many
different techniques that may be used to achieve a desired outcome. Massage may target the
deeper layers of muscle or might focus on stimulating the layers of the skin. In general, it is
thought that the benefits of massage may be achieved in a number of ways including through;
Increased blood flow to specific areas
Physical pressure to reduce muscle tension
Changes to heart rate, blood pressure and decrease in stress-hormones
Increased muscle temperature in specific areas
Decreased sensitivity of nerves

Some of the perceived benefits of massage for people with CP include; pain, improving range of
movement, decreasing muscle tone and improving gross motor skills.

More generally, massage may also be used to assist in decreasing swelling, reducing stress,
improving relaxation, rehabilitation of injuries, bonding between baby and parent, and decreasing
anxiety and depression.

While there are many perceived benefits of massage, there is currently limited research available
to confirm these benefits.

Things to note
Massage has not been shown to be very effective in isolation. It should be used in
combination with interventions that are working towards the same goal. Complimentary
interventions may include goal directed training, serial casting, orthoses (e.g. AFOs) and
medical interventions such as botulinum toxin-A.
There are a number of risks associated with massage and, therefore, it may not be
suitable for everybody. Massage may not be appropriate if you have certain problems
with your circulation, heart, kidneys, skin or bones or if you are taking certain medications.
Discussion and identification of risk factors with a medical practitioner, physiotherapist or
occupational therapist is recommended before engaging in massage.
Preliminary research suggests that some children and adolescents with cerebral palsy
may have altered sensation which could impact their ability to tolerate massage.

Recommendation -
> Clear treatment goals should be identified before undertaking massage and all treatment
should be evaluated to determine if it has been effective.

3.5.8. Acupuncture
Acupuncture involves the insertion of fine needles into the skin to stimulate certain parts of the
body.

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Evidence for acupuncture:
A systematic review by Zhang et al (2010) found that the use of acupuncture with or
without additional interventions such as conventional therapy may benefit children with
CP but lacks sufficient evidence. A systematic review by Yang et al. (2015) reviewed the
efficacy and safety of acupuncture for children and found:
Acupuncture may be a promising intervention for cerebral palsy to improve ADLs scores
when used as adjunct with conventional treatment (e.g. rehabilitation with occupational
and physical therapy, medications, surgical interventions).
Acupuncture may be a promising intervention for nocturnal enuresis, tic disorders,
amblyopia, and pain reduction in neonates receiving a heel prick during blood draws.
The efficacy of acupuncture for hypoxic–ischaemic encephalopathy, attention deficit
hyperactivity disorder, mumps, and myopia remains unclear.
The efficacy of acupuncture for asthma and nausea/vomiting is controversial.
Current evidence does not support the use of acupuncture for paediatric epilepsy

Recommendation -
> Clear treatment goals should be identified before undertaking acupuncture and all treatment
should be evaluated to determine if it has been effective.

Activity and Participation Interventions

3.5.9. Goal Directed Therapy / Functional Therapy (GDT)

GDT (also known as Functional Training) is task specific practice of client-set goal-based activities
using a motor learning approach, which propose that a child, the task itself and the everyday
setting in which the task is carried out all have a part to play when learning or improving a
movement or motor skill. GDT can help children with CP learn activities needed for everyday life,
like doing up buttons, or using a knife and fork. GDT is most useful when there is a specific task
or movement skill that the client would like to be able to perform with more independence. It is
used with clients of all ages and all levels and types of cerebral palsy.

GDT involves the repeated practice of a task/s within the environment where the task usually
occurs. An assessment of the person’s current performance of the task or movement skill is
essential before training starts. This is to ensure that the training is specifically targeted to the
individual needs and skill level of the person and that the best strategies for completing the task
can be identified. The practice task might need to be broken down into individual movements or
modified to start with. As the person’s skill level improves, the task can be made harder.

For example, if the goal is to learn to tie shoelaces, someone may start to learn to tie laces by
tying laces around their upper leg or on a shoe that rests on the table in front of them. As their
skill level improves, they progress to tying laces on shoes that they are wearing.

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It is usual for GDT programs to include a home program. Regular (daily) practice of a task/skill is
required.

How quickly someone is able to learn a new task or movement skill using GDT will depend upon
many different factors some of which include age, type of cerebral palsy, individual motivation
and understanding of the task/skill, as well as opportunities to practice the task/skill.

GDT is utilised in other intervention approaches that focus on improving motor outcomes such as
Constraint Induced Movement Therapy, home programs and sports skill development.

Evidence for GDT:

GDT has been shown to be effective in:
Improving gross motor function
Improving hand function
Improving self-care skills
(Novak et al, 2013)

3.5.10. Gait Training

Gait training is the process of first learning or re-learning how to walk after an intervention such
as orthopaedic surgery and can be used as a therapy intervention for persons with CP.

It can be achieved in a number of ways, but repetition of the actual motion/gait pattern
performed during walking is the most important factor. Depending on the severity of the
person's impairment, one or more physiotherapists may be present to assist in maintaining the
person’s appropriate posture and moving their lower limbs to assist in facilitating the
prerequisites of a normal gait pattern. Parallel bars may be used to help with gait training,
especially in the early stages of rehabilitation as the bars provide support for the child, and the
therapist facilitates the desired movement. Other equipment, such as high support and low
support assistive mobility devices are also utilised.

Gait training may be carried out overground or using treadmills. Both overground and treadmill
gait training can be conducted using partial body weight supported systems.

(I) Treadmill Training

Treadmill training is an active approach to gait training in which the child practices the movement
of walking on a treadmill rather than within the real-world environment. Treadmill training may
include partial body-weight support, in which the child is placed in a harness that supports their
weight, whilst a therapist manually guides the legs in a walking motion.

Treadmill training, including with partial body-weight support, is based on motor learning
theories, in which the child carries out the activities of walking repetitively, with increasing speed
and weight-bearing with the aim of this skill carrying over to walking within an everyday context.

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Treadmill training offers a way for a person with cerebral palsy to get walking practice and
potentially improve their walking pattern, and other aspects of their health.
The goals a person sets for their treadmill training will depend on the type and severity of their
cerebral palsy but may include:
An improved or more symmetrical walking pattern
The ability to walk longer distances (walking endurance)
An increased walking speed
Improved balance
Cardiovascular fitness
Greater weight bearing abilities to strengthen their bones
For infants, the development of walking skills

When someone who can’t support their body weight on a standard treadmill needs the support
of a harness system, this is known as partial body weight supported treadmill training.

Injury can occur if treadmills are not used correctly. A treadmill is a mechanical device with
moving parts and even minimum treadmill speeds can be fast. Therefore, supervision is
recommended and is always required for people undertaking partial body weight supported
treadmill training.

For people who walk with an aid, additional overground practice of skills that are specific to their
walking aid is required. These include pushing, pulling, slowing, stopping, turning and reversing,
and negotiating spaces, objects, and uneven and inclined surfaces.

Evidence for the use of treadmill training:

There is moderate quality evidence to suggest treadmill training without partial body weight
support is more effective for improving functional mobility and gross motor ability for children
and adolescents at GMFCS Levels I to III than partial body weight support treadmill training,
overground walking training or conventional physiotherapy. Overall, for children and adolescents
at GMFCS Levels I to III, moderate quality evidence suggests it is worthwhile to pursue treadmill
training to increase their functional mobility, gross motor ability and dynamic balance.

Dosage:
Studies report positive outcomes following gradually increased walking speed on a treadmill, in
30 minute sessions, two or three times per week, for seven or 12 weeks.

3.5.11. Constraint Induced Movement Therapy (CIMT)

CIMT is a rehabilitation strategy to increase functional use of the weaker or affect upper limb
through repetitive and adaptive task practice while the strong or non-affected upper limb is
restrained (Ramey et al, 2013). It is primarily used with children with unilateral motor deficits,
such as children with hemiplegic CP.

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There are five essential elements for paediatric CIMT (Pidcock, 2017; Ramey et al, 2013)
Constraint of the non-affected or stronger upper limb
High dosage of therapy (30 hours or greater)
Use of repetitive and adaptive task practice (massed practice)
Sessions take place in the child’s natural environment if possible (e.g. home/school)
although clinic/hospital models have been found to be effective also
Transition or discharge program to start when CIMT is completed

Adaptive task practice, or shaping, involves breaking a task into several smaller, more
manageable components to improve the child’s overall efficiency in performing the task. Massed
practice, or high-density repetition of motor movements, helps integrate new motor skills into
everyday behaviours. CIMT is effective for development of unimanual actions brought about by
this type of implicit motor learning. Therapy activities target motor patterns and functional skills
in the weaker, affected upper limb. These movement patterns can include increased reach to
objects, improved grasp and variation in grasp, increased grip strength, and improved and timely
release of objects. CIMT can be provided in individual or in group therapy formats.

Evidence for the use of CIMT:

There are over 100 published studies on paediatric CIMT and 27 systematic reviews which reveal
a modest to large effects of CIMT on improving efficiency and quality of movement of the
impaired arm/hand compared with usual/customary care (Pidcock, 2017; Sakzewski, et al., 2015).

3.5.12. Bimanual Therapy

Bimanual therapy retains the intensive structure and task practice at CIMT, but the focus is
improving the ability to perform bimanual activities. While CIMT appears to be an effective
treatment strategy for many children with CP, CIMT may not necessarily be effective for children
who have mild or severely affected hand function (MACS Level I or V) (Hoare & Greaves, 2017).

Bimanual therapy uses carefully planned, repeated practice of two-handed, or bimanual, games
and activities to improve a child’s ability to use their hands together in daily activities. It involves
intensive, massed practice, similar to the dosage required for CIMT (> 30 hours) and can be
provided during individual or group therapy formats.

Using bimanual therapy, object properties can be adapted to trigger goal-related perceptual and
cognitive processes required for children to learn to recognise when two hands are required for
task completion (Gordon 2011; Gordon & Magill, 2012).

The therapist encourages the child to use both hands during bimanual tasks and discourages
unimanual skills using only the stronger non-affected upper limb. Therapy activities target
bimanual movements such as those required to play with toys with two hands, transfer items
between hands, remove or put on clothing, or carry or move toys.

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3.5.13. Home Programs
Home programs are a ‘form of guidance and advice’ that support the ‘therapeutic practice of
goal-based tasks by the child, led by the parent and supported by the therapist, in the home
environment’. Home programs are home-based activities that can improve the gross motor skills,
arm and hand movements, self-care abilities, behaviour and communication of a person with
cerebral palsy.

The success of the home program depends on the intervention strategies used. Home programs
need to include interventions known to be effective.

Home programs are a way of increasing the amount of therapy for a child or adult with CP.

Evidence for home programs:

There is strong evidence to support the effectiveness of home programs aimed at improving the
performance of functional activities when based upon the following five step model (Novak,
2011; Novak et al 2013).
Establish collaborative relationships between parents and therapist
Set mutually agreed upon family and child goals
Select therapeutic activities that focus on achieving family and child goals that are
supported by best available evidence
Support implementation of home program through parent education, home visits and
program updates to sustain motivation
Evaluate outcomes (Novak & Cusick, 2006; Novak, Cusick & Lanin, 2009).

There is currently insufficient evidence to support the use of home programs aimed at improving
participation – use of appropriate outcome measures for evaluation is recommended (Novak et
al, 2013).

3.5.14. Context-Focused Therapy

Context includes the cultural, personal, temporal, virtual, physical, and social influences which
impact an individual’s participation in daily activities. Context-focused therapy shares concepts
described in other ‘functional’, ‘task-oriented’, or ‘activity-focused’ interventions, such as
involvement of parents, identification of functional goals, and a ‘top-down’ activity-based
approach to assessment and intervention.

A unique aspect of the context-focused therapy is that therapists are trained to change the
characteristics of the task and/or environment rather than focus on remediation of the child’s
abilities (Darrah et al., 2011).

The assumption of this approach is that changes to the task and/or environment will
enable the child to perform an activity that they were unable to do previously.

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 Tenets of family-centred theory are also integrated into the development of the context-
focused therapy protocol, particularly the concept of a collaborative partnership between
families and health care providers (Darrah et al., 2011).
The parents participate in the identification therapy goals and of intervention strategies
for the child.
Context-focused therapy starts with goal identification and specific assessment of how
the child’s performance of the goal-related task. Therapists used a strength-based
approach, first identifying factors within the task and environment that supported a child’s
attempt to complete the identified goal before identifying task and environmental
constraints.
After identifying the important task and environment factors amenable to change, the
therapist and parent agreed on the intervention strategies.
In the context-focused therapy approach, therapists are trained to consider all movement
solutions, even those traditionally thought to represent ‘abnormal’ movement patterns
(e.g. W-sitting, ‘bunny-hopping’ to crawl), and to build on the movement solution that the
child was trying to use.
Therapists ask parents to show how they were currently managing the task and to
consider this as a ‘starting point’ for adaptations. Therapists are cautioned against
assuming a hierarchy of ‘best solutions’, such as if a child should move by crawling rather
than commando creeping or that a mature pencil grasp was preferred over an immature
grasp.

3.5.15. Social Participation

The World Health Organization defines social participation for the lifespan as “the nature and
extent of an individual’s involvement in life situations” (WHO, 2001). Methods of social
participation interventions can be occupation-based and/or use purposeful activities that may be
preparatory, education, and or consultative in nature.
Occupational therapists and physiotherapists must first identify the individual’s goals to
maximise social participation in all context and environments
Assessment involves gathering data on the child’s skills and patterns of performance that
are required for social participation
Occupational therapists must also assess the individual’s habits, routines, rituals, and
roles used in the process of engaging in social environments
Social activities are analysed to understand the specific demands of the activity and the
match to the individual’s factors and performance abilities
Social participation should be considered within the family, with peers/friends, and, later
in life, during dating or a relationship with a significant other
Interventions for social participation can take place in home, school, or community
settings. Interventions may include:
o Remediation of performance skills to increase social participation
o Compensation/adaptation of an activity to increase social participation (e.g. the use
of adaptive sporting equipment to allow child to participate in youth recreation
leagues)

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 o Environmental adaptation to increase social participation (e.g. providing ramp
access to a school or community building for child who uses a wheelchair for
mobility)
o Maintenance of successful performance through parent and child education
o A combination of intervention approaches

3.5.16. Hydrotherapy/Aquatic Therapy

Hydrotherapy refers to a wide range of activities, of which most pertain to therapeutic and
exercise activities carried out in heated pools (aquatic physiotherapy services, water exercise
services, aquatic fitness activities and swimming activities).

Aquatic therapy refers to treatments and exercises performed in water for relaxation, fitness,
physical rehabilitation, and other therapeutic benefit.

Benefits of aquatic therapy/hydrotherapy include:

Allows independence of movement not possible on land
Decreases weight bearing, enabling easier walking and general mobility
Reduces muscle spasm allowing relaxation
Decreases swelling, improves circulation and reduces pain
Improves water confidence, water skill and basic swimming skills
Encourages fitness

Hydrotherapy involves working, in a heated pool, with an exercise physiologist or physiotherapist

on exercises tailored to individual’s unique needs. Along with improving strength and mobility,
hydrotherapy is also frequently used as part of rehabilitation programs following surgery. While a
person with CP is recovering from their surgery, hydrotherapy can help to gradually increase
movement and their ability to put weight through their feet.

Specialist hydrotherapy pools are heated to 32-34 degrees Celsius, as warm water can help
increase a person’s circulation, reduce their muscle spasms and relieve pain.

The unique properties of water mean that hydrotherapy has the potential to benefit people with
CP right across the severity spectrum. Exercising in water may provide greater physical activity
opportunities for people with more significant movement limitations when compared with land-
based activities.

For some people, the special flotation devices used in hydrotherapy may be essential for safety
and independence in the pool. For others, exercise equipment is used instead to provide
additional support or resistance in their program.

Precautions and contraindications for hydrotherapy:

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 Precautions Contraindications

Epilepsy - 1:1 client/carer ratio & management Open/infected wounds/skin conditions – cover
plan wounds with waterproof dressing

PEG tubes and other external medical devices All bacterial infections and infectious diseases

Tracheotomy: use floatation devices to

Increase temperature
maintain safe airway

Faecal Incontinence (some clients can be toilet

High blood pressure timed prior to pool entry which is a
management strategy to decrease risk)

Recent diarrhoea - the person should not

Haemophilia swim until at least a week after symptoms
have ceased

Hepatitis B, C and HIV/AIDS - monitor for High risk obstetric patients (if any bleeding, or
wounds / airborne infections complicated pregnancy)

Active TB, flu and other airborne viral

Severe Peripheral Vascular Disease
infections

Ear infections, grommets – use ear plugs/

Unstable medical conditions, e.g. recent CVA,
headbands. If repeated infections consider
cardiac or kidney failure
excluding from pool

Cytomegalovirus (CMV) - usual infection

control procedures apply e.g. hand washing, Tinea, ringworms
cleaning change tables etc.

Altered sensation - wear protective clothing/

shoes to protect against hitting/rubbing the Perforated eardrum
pool surface

Menstruating Hep B, C and HIV/AIDS

Unprotected menstruation

Alcohol/drug consumption

Recent deep x-ray treatment

Chemotherapy - medical clearance required.

Possibly wait 24-48 hours after dose.

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3.5.17. Hippotherapy
Hippotherapy is therapeutic horse riding that is built on the concept that the individual and
variable gait, tempo, rhythm, repetition and cadence of a horse’s movement can influence human
neuromuscular development in humans. Hippotherapy is usually provided by therapists
(occupational therapists, physiotherapists or speech pathologists) who have undertaken specific
training in hippotherapy. Goals for hippotherapy may include developing
Strength
Control
Balance
Posture
Endurance
Coordination
Sensory integration
Understanding of visual cues

There is low quality evidence that hippotherapy is effective in improving gross motor function
(Novak et al, 2013).

There is insufficient evidence to support hippotherapy in improving social participation (Noval et

al, 2013).

3.5.18. Emerging Therapies – Robotics, Computer-Assisted

Systems, and Virtual Reality
The field of pediatric neurorehabilitation has rapidly evolved with the introduction of robotics,
computer-assisted systems, and virtual reality which may complement conventional
physiotherapeutics or occupational therapies. These systems appear promising, especially the
exciting and challenging virtual reality scenarios which can increase motivation to train intensely
in a playful therapeutic environment. Despite promising experiences and a large acceptance by
the patients and parents, so far, few robotic, computer-assisted systems, and virtual reality
programs have been rigorously evaluated in children with CP and well-designed randomised
controlled studies in this field are lacking. It is unclear which systems are effective for specific
types of CP and the best application for this technology (e.g. duration, frequency, and intensity)
to generate the best results (Meyer-Heim & van Hedel, 2013; Peri et al., 2016).

Prescribing Adaptive and Assistive Equipment

3.5.19. Adaptive and Assistive Equipment

Adaptive and assistive technology is a widely used intervention for people with cerebral palsy
and other disabilities (Novak et al, 2012). Assistive technology is any “item, piece of equipment,
or product system, whether acquired commercially off the shelf, modified, or customized, that is

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used to increase, maintain, or improve functional capabilities of individuals with disabilities” (US
Govt, 1988).

Children with cerebral palsy frequently require adaptive and assistive equipment to support
mobility, activities of daily life and communication, participation in life activities, as well as to
assist families and care givers with providing care.

Adaptive and assistive technology should be a component of an overall management plan and
not an isolated intervention. Interventions involving AAT should also include i) education for
people with a disability and those that provide support (e.g. parents and carers), ii) skill
development and /or interventions to increase participation in functional activities, and iii) referral
to medical practitioners if appropriate (e.g. for interventions for tone management or hip
surveillance).

Examples of AAT include (but are not limited to):

Wheelchairs and strollers Beds and mattresses
Walking aids Pressure care
Standing frames Adaptive mealtime equipment (cutlery,
Splints and orthoses (upper limb and bowels, plates, cups etc)
lower limb) Transfer aids including hoists
Bath/shower aids Ramps
Positioning equipment including seating Low tech communication aids
systems, chairs, side lyers and bed High tech communication aids
positioning Accessible toys
Toileting aids

Sources for adaptive and assistive technology include:

Hospital workshops
Private health-related workshops
Local commercial workshops (wood work and iron work)
Adaptive and assistive technology supply companies
NGOs
Adaptations made by families

Best practice prescription of adaptive and assistive technology involves:

A comprehensive assessment that considers all levels of the ICF
Trial of identified options (wherever possible)
Intervention strategies to support implementation of device(s) including skill development
and parent/carer education
Follow up and review of adaptive and assistive technology to evaluate impact of the
device(s) on goal achievement and to identify challenges with use of the device(s)

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(I) Assessment
Having a clear understanding of each individual’s unique needs is essential when exploring,
trialling and prescribing AAT. It is therefore necessary to ensure a thorough assessment has
been completed to provide information about:

The individual’s movement disorder (Body Structure and Function assessments)

Including: assessment of spasticity and dyskinesia (see 7.1).

The individual’s musculoskeletal status (Body Structure and Function assessments)

Including: assessment of range of motion, posture, leg length and pain (see 7.1).

The individual’s functional abilities and how the individual performs certain tasks and
activities(Activity and Participation assessments)
Including: assessment of walking function, hand function, activities of daily living and transfers
(see 7.2).

The environment in which the individual performs the tasks and activities (Environmental
assessments)
Including: assessment of the physical environment and individual/family/carer perceptions of AAT
(see 7.3).

(II) Trial and prescription of AAT

Wherever possible, trial of the recommended device should be carried out before confirming the
prescription. This is to ensure that the recommended device meets the individual child’s needs
and is suitable for their home/community environment.

Trial of certain types of AAT may not be possible, such as custom made orthoses.

(III) Follow-up of AAT prescription

Whenever AAT has been prescribed, every effort should be made to ensure that adequate
follow-up is provided. Follow-up provides the opportunity to evaluate if the device continues to
meet the child’s/family’s needs and understand any difficulties that might be experienced by the
child/family with regards to using the device. Follow-up can be provided during face to face
appointments, via phone or via email.

Access to suitable AAT may be limited for many individuals with cerebral palsy. This may be due
to limited suppliers, limited options or limited funding. Abandonment rates of AAT increase
when AAT is recommended without trial, when clients and families are not involved in goal
setting and AAT identification, when AAT implementation is not supported in the
home/community setting and when there is limited follow up.

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Recommendation -
> Local rehabilitation departments should identify strategies for increasing access to AAT and
post-prescription follow up of AAT. The use of telerehabilitation may offer one strategy for
increasing follow up.

3.5.20. Standing Frames

Children who’s standing and walking abilities are significantly impaired are at high risk of
developing secondary musculoskeletal problems such as muscle contractures and abnormalities
of skeletal development and alignment (e.g. hip displacement, hip dislocation and scoliosis). If
left untreated, skeletal mal-alignments can progress to permanent and painful deformities that
impair lying, sitting, standing and motor skills and impact upon an individual’s function, comfort,
care needs and quality of life.

Standing frames to enable supported standing are frequently prescribed for children with CP to
achieve a variety of outcomes including:

Encouraging hip development and improve hip stability

Maintaining a straight and symmetrical posture
Preventing contractures of the hip, knee and ankle
Promoting health by reducing sedentary behaviours
Increasing a person’s metabolic rate
Improve bone strength, cardiovascular, respiratory, digestive and bowel function, and
general well-being
Support face-to-face social interaction with peers by supporting a person’s upright
position

Standing frames can be used in home, school and community environments. Different types of
standing frames are available to meet the individual needs of people with CP. They can support
someone in a forward or backwards leaning or vertical position. Close supervision is required for
many people who use a standing frame. The amount of supervision will depend on their level of
cognitive and motor impairment, age and engagement level.

All children with cerebral palsy should participate in an active hip surveillance program to monitor
for hip displacement.

Current evidence suggests that standing frames may have a positive effect on hip integrity,
range of motion and spasticity in the lower limb, and bone mineral density in the lower limb and
spine (Paleg et al, 2013).

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3.6. Rehabilitation Needs across Lifespan
CP is a permanent but not unchanging condition. Musculoskeletal status, functional abilities and
cognitive function can and do change over time. Skills attained during childhood can deteriorate
secondary to musculoskeletal changes, the impact of puberty and early onset ageing. Individuals
with CP require monitoring and may benefit from repeat rehabilitation sessions over time
particularly at key growth points. Monitoring is particularly important at natural transition points
such as the onset of puberty, late adolescence and throughout adulthood.

Gait and Functional Decline

3.6.1. Adolescence
Projections of motor function for children
and adolescents with CP have been well
documented. Gross motor curves for CP
show the average rate of gross motor
skill acquisition for children across the
GMFCS levels. It shows a projected
stability for GMFCS I-II and the average
decline for GMFCS III-V, with decline
occurring as early as 7 or 8 years of age.
This trend is often referred to as the
‘natural history of CP’ (Hanna et al,
2009).

A small number of studies have looked

Figure 6. Gross motor curves for CP
at the stability of the GMFCS in adults
over the age of 21 (Jahnsen, 2006;
McCormick, 2007). These report functional decline even amongst GMFCS I and II, with fatigue,
balance problems, fear of falling and chronic musculoskeletal pain among the reasons for
changes in GMFCS level.

Prognosis of walking function

A child’s walking ability at age 12 years is predictive of their walking ability as an adult
Children who walk using aids or cannot walk lose walking function during adolescence
Ability to walk further declines during later adulthood

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Recommendations -
> Children who walk using aids and their families should be emotionally prepared for potential
loss of motor function in adolescence.
> Children who walk using aids require mobility assessments at the commencement of
adolescence to enable prescription of appropriate mobility devices to accommodate declining
motor function.

3.6.2. Adulthood
25% or more of adults with CP experience deterioration in gait and walking function. Those most
at risk are adults classified GMFCS III and adults with bilateral CP.

Gait deterioration occurs at an earlier age for adults with CP compared with adults without a
disability. Deterioration is strongly associated with inactivity with a lower risk of deterioration
found amongst adults who engaged in regular physical activity. Age, increased pain, increased
fatigue, decreased balance and lack of opportunity to participate in adapted physical activity were
also associated with gait decline (Morgan & McGinley, 2013).

In addition to gait decline, declines in the performance of activities of daily living, eating and
drinking, and cognitive functioning are common in people with CP.

3.6.3. Transition
Transitioning between paediatric and adult rehabilitation services is an important aspect of the
care of individuals with CP.

The following overarching principles should guide transition planning (NICE, 2017)

Recognise that challenges for young people with CP continue into adulthood, and ensure
that their individual developmental, social and health needs, particularly those relating to
learning and communication, are addressed when planning and delivering transition.
Recognise that for young people with CP there may be more than one transition period in
health and social care settings; for example, college, resident educational and adult home
settings.

Recommendations – for transition planning

> Develop clear pathways for transition that involve: the young person's medical practitioners
and clinicians in adults' services, both locally and regionally, who have an interest in the
management of CP.
> Ensure that professionals involved in providing future care for young people with CP have
sufficient training in order to address all their health and social care needs.
> As a minimum standard of care, ensure that the young person has access to adults' services
both locally and regionally that include healthcare professionals with an understanding of
managing CP.

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> Ensure that all relevant information is communicated at each point of transition.
> Recognise that functional challenges (including those involving eating, drinking and swallowing,
communication and mobility) and physical problems (including pain and discomfort) may change
over time for people with CP, and take this into account in transition planning.
> Provide a named worker to facilitate timely and effective transition, and recognise the
importance of continuity of care

3.7. Parent, Family and Caregiver Support

CP impacts the entire family in a manner that is long-term, complex and multifactorial. In studies
on parent experiences and expectations, many families expressed the desire for their child with
CP to be able to live independently in the future. Parents often report a need for information on
what would be realistic to expect for their child’s future. Parents often experienced
disappointments about their child’s progress (Darrah, Wiart, Magill-Evans, Ray, & Andersen,
2014; Kruijsen-Terpstra, et al., 2016).

Families whose child is diagnosed with CP experience complex care responsibilities,

financial hardship, limits to occupational attainments, relationship distress, grief and social
isolation. They may experience significant stress and anxiety about the future and a lack
of understanding from the broader community.
Parents of children with CP need to be proactive, skilled and conscious of their parenting
choices to provide their children with optimal developmental support.
Parenting a child with CP, and optimising their development, involves forward thinking, a
commitment to long-term support, patience, compassion, behavioural management skills
and effort above and beyond the parenting of typically developing children. Further, all of
this requires a strong and loving emotional bond and parental psychological resilience.

Recommendations for ways to empower and support families:

(See also section Parent Empowerment in the General Guideline)

No one empowerment approach can be applied to all families of children with CP and providers
must assess each families’ individual needs to determine the most beneficial approach:
1) Encourage parental involvement in community support groups to connect families who
have children with CP.
2) Develop family training programs to educate and support parents on specific health
needs (e.g. parent training on feeding and nutrition issues).
3) Refer parents to international parent support organisations which can connect families
through the internet, social media, and e-mail Listservs (e.g. Children’s Hemiplegia and
Stroke Association (CHASA), Hemi-Kids)
4) Collaborate with families to develop home programs and goals for therapy.

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Recommendations –
> Practitioners should be educated on the process of parent empowerment and learn ways to
enhance family support and community involvement.

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Glossary
Aspiration – when food or liquids passes into the laryngeal space during pharyngeal phase
swallowing, past the level of the vocal cords, depositing food or liquids into the lungs.

Ataxia – A motor type of CP which affects the sense of balance and depth perception. Children
with ataxia may have poor coordination; walk unsteadily with a wide-based gait, and experience
difficulty when attempting quick or precise movements, such as writing or buttoning a shirt.

Athetosis – A motor type of CP characterised by uncontrolled, slow, writhing movements.

Augmentative and alternative communication (AAC) - AAC includes all forms of communication
(other than oral speech) that are used to express thoughts, needs, wants, and ideas. Special
augmentative aids, such as picture and symbol communication boards and electronic devices, are
available to help children and adults with CP express themselves. This may increase social
interaction, school performance, and feelings of self-worth.

Behaviour disorder – a pattern of disruptive behaviours which may involve inattention,

hyperactivity,
Impulsivity, and defiant behaviours.

Canadian Occupational Performance Measure (COPM) - an individualised measure that assesses

an person’s perceived occupational performance in the areas of self-care, productivity, and
leisure.

Cerebral palsy (CP) - a term used to describe a group of chronic conditions affecting body
movement and muscle coordination. It is caused by damage to one or more specific areas of the
brain, usually occurring during foetal development; before, during, or shortly after birth; or during
infancy.

Chorea – A motor type of CP which presents as ongoing random-appearing sequence of one or

more discrete involuntary movements or movement fragments.

Communication and function classification system (CFCS) - A classification system used to

categorise the everyday communication performance of an individual into one of five levels. The
CFCS focuses on activity and participation levels as described in the World Health Organization’s
(WHO) International Classification of Functioning, Disability, and Health (ICF).

Contracture - a condition of shortening and hardening of muscles, tendons, or other tissue, often
leading to deformity and rigidity of joints.

Cortical Visual Impairment (CVI) - defined as a bilateral loss of central visual function

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(visual acuity) caused by neurological damage to the visual cortex and⁄or visual pathway
structures. It most commonly results from hypoxic ischaemia causing periventricular
leukomalacia
in the preterm infant.

Dyskinesia - refers to an increase in muscular activity that can result in excessive abnormal
movements, excessive normal movements, or a combination of both.

Dysphagia – difficulty with swallowing which may impact a child’s ability to eat.

Dystonia - a movement disorder in which involuntary sustained or intermittent muscle

contractions cause slow twisting and repetitive movements, abnormal postures, or both that are
triggered by attempts to move.

Eating and Drinking Ability Classification Scale (EDACS) – A classification system which
categorises how individuals with children with CP eat and drink in everyday life using distinctions
that are meaningful. EDACS provides a systematic way of describing an individual’s eating
and drinking in five different levels of ability.

Equinus - tightness in the calf and Achilles tendon which limits dorsiflexion (toes to shin) of the
ankle.

Foot drop - is a gait abnormality in which the dropping of the forefoot happens due to muscular
weakness.

Fundoplication - a Nissen fundoplication, or laparoscopic Nissen fundoplication is a surgical

procedure to treat gastro-oesophageal reflux disease (GERD) and hiatal hernia. During
fundoplication surgery, the upper curve of the stomach (the fundus) is wrapped around the
oesophagus and sewn into place so that the lower portion of the oesophagus passes through a
small tunnel of stomach muscle.

Gastrostomy - an opening into the stomach from the abdominal wall, made surgically for
nutritional support or gastric decompression.

Gross Motor Functional Classification Scale (GMFCS) – A classification system based on self-
initiated movement, with emphasis on sitting, transfers, and mobility. A five-level classification
system with distinctions based on functional limitations, the need for hand-held mobility devices
(such as walkers, crutches, or canes) or wheeled mobility, and to a much lesser extent, quality of
movement.

Gross Motor Function Measure (GMFM) – a clinical tool designed to evaluate change in gross
motor function in children with CP. There are two versions of the GMFM - the original 88-item
measure (GMFM-88) and the more recent 66-item GMFM (GMFM-66). Items on the GMFM-88

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span the spectrum from activities in lying and rolling up to walking, running and jumping skills.
The GMFM-66 is comprised of a subset of the 88 items identified (through Rasch analysis) as
contributing to the measure of gross motor function in children with CP.

Hypoxic Ischaemic Encephalopathy (HIE) – brain injury caused by oxygen deprivation to the
brain, also commonly known as intrapartum asphyxia.

Hammersmith Infant Neurological Exam (HINE) - a neurological assessment for infants between
2 and 24 months of age that includes items for cranial nerve function, posture, movements, tone
and reflexes. It can be reliably used to assess infants at neurological risk, both preterm and term
born. The HINE identifies early signs of CP in infants with neonatal brain lesions.

Hip dislocation – a hip dislocation occurs when the head of the femur comes out of the
acetabulum in the pelvis

Hip displacement – a hip displacement occurs when head of the femurs migrates, or moves, out
of acetabulum in the pelvis

Hyperhydrosis - a condition characterised by abnormally increased sweating, in excess of that

required for regulation of body temperature.

International Classification of Function, Disability, and Health (ICF) - a classification of health

and health-related domains. As the functioning and disability of an individual occurs in a context,
ICF also includes a list of environmental factors. The ICF is the World Health Organization’s
framework for measuring health and disability at both individual and population levels.

Interprofessional team approach - providers work independently, but recognise and value
contributions of other team members. This approach requires interaction among the team
members for the evaluation, assessment, and development of the intervention plan.

Likert scale – a widely used scale for patient responses which provides choice of five to seven
pre-coded responses with the neutral point being neither agree nor disagree. It is used to allow
the individual to express how much they agree or disagree with a particular statement.

Manual Abilities Classification Scale (MACS) - A classification system which describes how
children with CP use their hands to handle objects in daily activities. MACS describes five
Levels or categories which are based on the children’s self-initiated ability to handle objects with
both hand and their need for assistance or adaptation p to perform manual activities in everyday
life.

Migration percentage – a commonly used measure for subluxation (dysplasia) of the hip.

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Multidisciplinary team - a group of health care workers who are members of different disciplines
(e.g. physicians, nurses, therapists, social workers, etc.), each providing specific services to the
patient.

Osteoporosis - a medical condition in which the bones become brittle and fragile from loss of
tissue, typically due to hormonal changes, or deficiency of calcium or vitamin D.

Penetration - when food or liquids passes into the laryngeal space during pharyngeal phase
swallowing but does not move past the level of the vocal cords. The food or liquid is typically
expelled from the laryngeal space through a forceful cough.

Quality of Upper Extremity Skills Test (QUEST) - an outcome measure that evaluates movement
patterns and hand function in children with CP. The four domains evaluated by the QUEST
include: dissociated movement, grasp, protective extension, and weight bearing.

Recurvatum - Genu recurvatum is a deformity in the knee joint, so that the knee has excessive
backwards motion. In this deformity, excessive extension occurs in the tibiofemoral joint.

Scoliosis - abnormal lateral curvature of the spine.

Spasticity - velocity-dependent resistance to stretch by the muscles. It is characterised by an

excessive stiffness in the muscles when the child attempts to move or maintain a posture
against gravity.

Telerehabilitation – a means of delivering of rehabilitation services over telecommunication

networks and the internet.

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Disclaimer
Healthcare professionals are expected to take the present clinical guidelines fully into account
when exercising their clinical judgment. However, the guidance does not override the
responsibility of healthcare professionals to make decisions appropriate to the circumstances of
each patient, in consultation with the patient and/or their guardian or carer.

Copyright
Humanity & Inclusion

This publication may be used or reproduced for non-commercial uses only, on condition that the
source is cited.

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