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Treatment of Cerebral Palsy and Motor Delay Treatment of Cerebral Palsy and Motor Delay SIXTH EDITION Sophie Levitt BSc (Physiotherapy) Wits Fellow of the Chartered Society of Physiotherapy Honorary Member of the Association of Paediatric Chartered Physiotherapists Consultant Paediatric Physiotherapist, London Anne Addison MSc BSc Occupational Therapy MRCOT Clinical Lead Occupational Therapist The Wolfson Neurodisability Service Great Ormond Street Hospital for Children, London This sixth edition first published 2019 © 2019 Sophie Levitt and Anne Addison Edition History [John Wiley and Sons 5e, 2010] All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of Sophie Levitt and Anne Addison to be identified as the authors of editorial in this work has been asserted in accordance with law. Registered Office(s) John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 9600 Garsington Road, Oxford, OX4 2DQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com. Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging‐in‐Publication Data Names: Levitt, Sophie, author. | Addison, Anne (Anne Catherine), author. Title: Treatment of cerebral palsy and motor delay / Sophie Levitt, Anne Addison. Description: Sixth edition. | Hoboken, NJ : Wiley-Blackwell, 2019. | Includes bibliographical references and index. | Identifiers: LCCN 2018025070 (print) | LCCN 2018026692 (ebook) | ISBN 9781119373889 (Adobe PDF) | ISBN 9781119373599 (ePub) | ISBN 9781119373865 (pbk.) Subjects: | MESH: Cerebral Palsy–therapy | Child | Motor Skills | Motor Skills Disorders–therapy | Physical Therapy Modalities | Adolescent Classification: LCC RJ496.C4 (ebook) | LCC RJ496.C4 (print) | NLM WS 342 | DDC 618.92/83603–dc23 LC record available at https://lccn.loc.gov/2018025070 Cover design: Wiley Cover images: © FatCamera/Getty Images; © jarenwicklund/iStockphoto; © olesiabilkei/iStockphoto Set in 10.5/12.5pt Minion by SPi Global, Pondicherry, India 10 9 8 7 6 5 4 3 2 1 Contents Foreword ix Preface xi Acknowledgements xvii 1 The clinical picture for therapy and management 1 Incidence of cerebral palsy 1 Motor dysfunction 1 Associated impairments and disabilities 3 Broad framework for therapy and management 4 Aetiology of cerebral palsy 7 Genetic causes 7 Causes in later childhood 7 Neuroimaging 7 Clinical picture and development 8 Change at different ages 9 Classification systems 11 Topographical classifications 14 Classification of motor types of cerebral palsies 15 Common features observed in all presenting types of cerebral palsies 21 Motor delay 22 Summary 23 2 A collaborative learning approach 25 Working with parents within a family framework 25 Emotional support 26 Parents vary 27 Other adults 28 Family‐centred services 28 Research on home and school visits 30 Collaborative learning approach 30 Opportunities to discover what the parents and child want to achieve 31 Opportunities to clarify what is needed for these achievements, to recognise what parents and children already know and can do, and to find out what they still need to learn and do 32 Involvement in the selection and use of methods 34 Involvement in the evaluation of progress 37 Parent–child interaction 38 Helping a child to learn motor control (body function) and motor function (activity) 39 Observation of parent and child interaction 40 Social needs 41 Parents’ health 41 Teamwork with parents 42 v vi Contents Siblings 43 Alternative and complementary treatments 44 Summary 46 3 Learning motor function 49 Learning methods 50 Development of a child’s attention and learning 52 Practical ideas to promote attention and learning 53 A child’s own strategies for a chosen goal 54 Task analysis 55 Cues for learning 56 Verbal guidance 58 Rewards 58 Practice and experience 59 Summary 60 4 Adolescents and adults 61 Studies of function in adolescents and adults 62 Activity goals 63 Issues of concern for adolescents and adults 64 Adolescents 65 Adults 66 Healthy lifestyle 67 Develop appropriate community mobility 68 Training of self‐care and cosmetic appearance 69 Knowledge about the condition 69 Therapeutic activities 70 Measures 70 Summary 70 5 Outline of treatment approaches 71 History 71 Muscle education and braces 71 Progressive pattern movements 73 Proprioceptive neuromuscular facilitations (PNF) 74 Neuromotor development 75 Neurodevelopmental treatment (NDT) (Bobath approach) 75 Sensory stimulation for activation and inhibition 77 Reflex creeping and other reflex reactions 78 Conductive education 79 Sensory integration 81 Context therapy 82 Strength training 82 Systems‐based task‐oriented approach 87 Mobility Opportunities Via Education (MOVE) 88 Contemporary theories 89 6 Evidence‐based practice 93 Research and clinical studies 93 Research on treatment approaches 93 Theoretical grounds 94 Research studies 94 Reviews of research studies 94 Research on specific procedures 95 Contents vii Other research 95 Clinical experience with evidence‐based practice 96 Definitions 97 The appraisal of research studies for therapy 98 Examples of qualitative research methods (Greenhalgh and Taylor 1997) 102 7 Synthesis of treatment approaches 103 The eclectic viewpoint in therapy 103 Synthesis of treatment systems 104 The postural mechanisms 105 Trunk control 108 Voluntary motion 108 Perceptual–motor function 110 Principles for a synthesis of therapy and management 110 Developmental training 111 Some advantages and disadvantages of modifications of developmental sequences 114 Treatment of atypical tone 116 Training of movement patterns 117 Use of afferent stimuli 118 Management of deformity 120 8 Assessment for therapy and management 121 Approach to assessment 121 Assessment and measurements 125 Examples of atypically persistent postures, movements, and functions 132 Functional measures 133 Specific functional items 135 Measures of upper extremity and hand function 137 Measures of daily activity and participation 138 Quality of life and health‐related quality of life measures 142 Norm‐referenced measures of stages of child development 143 Neonatal assessments 144 Methods of observation of gait 145 Additional assessment required 154 Records 155 Summary 156 9 Treatment procedures and management 157 Motor training 157 Development of the child with severe visual impairment 161 Developmental Training 168 Prone development 168 Supine development 193 Development of sitting 208 Development of standing and walking 230 Lower limb orthoses for standing and walking 263 Development of hand function 277 Techniques for carrying the child correctly 307 10 Function and the child’s daily life 309 Motor function in communication 310 Motor function in self‐care activities 313 Motor function for leisure 326 viii Contents 11 Therapeutic group work 329 General management of groups 331 Selection of children 332 The programme 333 Summary 335 12 Management of deformities 337 Causes of deformities 338 Therapy goals 343 Deformities and gait 344 General considerations related to surgery 348 Therapy and daily care 351 Dynamic arm deformity 365 Deformities of trunk and neck 365 13 Assessment, prescription, and provision of equipment 367 Equipment for self‐care tasks 368 Postural management equipment 370 Sleep systems 381 Other equipment for positioning 383 Mobility equipment 383 Adaptations and the built environment 391 Appendix 1 Developmental levels 393 Physical ability assessment guide 393 Wheelchair use 397 Appendix 2 Useful organisations 399 References 401 Index 429 Foreword It is a pleasure to welcome the sixth edition the practical principles of assessment, the of this book. It is the distillation of the ranges of treatment approaches and their knowledge and practice of two distinguished indications, and the relationships of these to therapists who have wide experience in all function and activities of daily life. They aspects of evaluating and treating children rightly emphasise the importance of enabling and young people with motor disorders, children and their families and also of pro- particularly cerebral palsy. The authors’ moting their societal participation as basic approach is based on a modern under- tenets of the work of therapists in this field. standing of what constitutes cerebral palsy, It is also helpful and appropriate in a on the range of associated impairments book of this nature that the authors help- that may be seen, on its natural history as fully discuss the expanding scientific back- affected children move into adult life, and ground that underpins our understanding on the range of relevant interventions that of cerebral palsy, including how evidence can be applicable. can be evaluated and what can realistically The authors have a clear understanding be researched in children who have a wide of historical approaches to treatment but variety of neurological impairments. What have moved on from these to detail the they have successfully achieved is to com- need for evidence-based practice so far bine this approach with clear views on the as this is possible, and they rightly also practical interplay that experienced practi- emphasise the requirement to work collab- tioners in a multidisciplinary team need to oratively with children and their families utilise when setting priorities for an indi- and to base their aims and approaches on vidual child within the context of his or her the World Health Organization’s current family. International Classification of Functioning, This book remains essential for those Disability and Health. managing children with disability. For those involved, as either therapists or parents, in understanding, planning, provid- Dr Lewis Rosenbloom ing interventions, and understanding and Honorary Consultant Paediatric Neurologist monitoring their effectiveness in motor dis- Alder Hey Children’s Hospital orders Sophie Levitt and Anne Addison have Liverpool systematically taken their readers through UK ix Preface The sixth edition of this book reflects and their family. It was not always easy to where we have been and where we are now. incorporate their essential messages into Ideas are currently from both physiother- our therapy as there are contradictions apy and occupational therapy as there are in  the cultures of different disciplines. two co‐authors. Ideas from the past are still However, we have drawn on their funda- prevalent today, but we fortunately have mental concerns for whole individuals and more studies that confirm the value of tried to integrate them into the develop- some of them. Research on others may not ment of their abilities. be easy or perhaps possible at this time. In The first edition of this book (Levitt order for this book to reflect both what we 1977) originally proposed an eclectic did and what we do now, we have learned approach drawing on topics in neurology, from therapy colleagues and especially orthopaedics, and typical and atypical child from the parents and families of children, development. This was challenging, as it adolescents, and adults with cerebral palsy. involved dealing with contradictory Listening attentively to these individuals, views in physiotherapy for cerebral palsy. we have learned of their fundamental Common ground was found between dif- human needs for respect, for support, and ferent therapy approaches and formed the for a sense of control of their lives. Their basis of an eclectic approach. Mantovani practical ideas, their courage, and their and Scrutton (2014), in their chapter determination to do their best are inspir- ‘Historical perspective’ in Cerebral Palsy: ing. Parents and their children with disabil- Science and Clinical Practice, quote this ities taught us that they needed empathy proposal of an eclectic approach by Levitt not sympathy. How does one present ther- (1977). Since publication of earlier editions apy in this style? Did we have adequate pro- of this book it has been rewarding to find fessional knowledge to warrant the trust of an increase in an eclectic viewpoint and in parents, their children, adolescents, and more functional physiotherapy, which were adults with cerebral palsy? so frowned upon in the past. Fortunately, we had, and still have, con- Our eclectic approach draws on the tact with many professionals in medicine, in Bobath approach, as well on many other therapy, including speech and language approaches and therapy tools. The review therapists, in education, in psychology, and of interventions for cerebral palsy by Novak in social work. This was as members of mul- et al. (2013) seriously disapproved of tidisciplinary and interdisciplinary teams in the neurodevelopmental treatment/Bobath clinical work, schools, and postgraduate approach. However, their review provoked education. We are grateful to the many dif- considerable controversy and, in particular, ferent professionals in various countries Mayston and Rosenbloom (2014) pointed who have given generously of their knowl- out that the interventions range from sys- edge and helped us to understand their tems (such as Bobath) to specific proce- views for the benefit of the whole person dures (such as selective dorsal rhizotomy), xi xii Preface which are hardly comparable, and that the their parents, carers, and teachers in differ- ‘traffic light’ system used to rate the inter- ent communities. This promotes inclusion ventions is oversimplistic. They also in mainstream schools and in the specific highlight that the review was unable to cultural communities in which a child or make recommendations for intervention older person finds themselves. The collab- on the basis of age, Gross Motor Function orative approach is a learning process that Classification System level, or type of cere- can allow parents and others involved to bral palsy. learn at their own pace, so adjusting their In previous editions, there was always expectations and attitudes while maintain- the recognition that children ‘do not move ing hope. by neurophysiology alone’ but that learning processes enable a child to progress through Adolescents and adults. The fourth and stages of gross and fine motor develop- fifth editions suggest the use of the frame- ment. The second and subsequent editions work of the collaborative learning approach continued to include and elaborate learn- with the older person (adolescent or adult) ing principles to develop children’s motor with cerebral palsy. The sixth edition dis- function. Functional therapy grew out of cusses differences between adolescents the question: ‘How do parents and other and adults, and what is common to both adults learn?’ Studies in adult education age groups. Similarly, as with children and showed that people learn best what has parents, it offers mutual respect between meaning for them in their daily lives. individuals and therapists and develops Parents were clearly motivated to improve self‐esteem and confidence in these indi- their child’s daily function, which was so viduals. Meaning is given by the proce- limited by cerebral palsy. dures suggested for their participation in The third edition contained a spe- their daily life. Recreational therapeutic cific chapter on a collaborative learning activities are included to add to their approach. This had developed over some health‐related quality of life. years for working with parents, carers, and others involved with a child with cerebral Family‐centred approach (care). This is also palsy. This ‘client‐centred’ approach based on the ‘client‐centred’ practice first depends on their participation in a learning originated by Carl Rogers in the 1960s, process. Unlike some learning models, this which formerly inspired the earlier collab- model also includes the therapist’s own orative learning approach published in participation in learning, as well as the 1990. Family‐centred physiotherapy and emotional issues affecting learning of par- occupational therapy emerged in 1998 and ent and therapist in collaborative work. in recent years. This approach involves all This approach involves consideration of the members of a cerebral palsy team and is the views and needs of both of them. a welcome development. However, in some This approach develops respect for a places, this demands reflective learning family’s cultural and social values learned and re‐examination of long‐held profes- in Levitt’s experience in developing coun- sional attitudes. ‘We are doing this anyway’ tries and as a tutor/guest lecturer with is often felt by genuinely well‐meaning pro- international students in the Community‐ fessionals, but given the new measures of Based Rehabilitation Courses, Institute of what parents and families really experience Child Health, London, UK. The collabora- from a service there is not necessarily tive learning approach depends on daily agreement with this statement. References tasks chosen by people with disabilities and to such measures are given in this edition.

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