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Issues in Cerebral Palsy

Part 2: Physical Handling Treatment
by Christine A. Nelson, Ph.D., OTR
with contribution by W. Michael Magrun, MS, OTR

Learning Outcomes
The Participant Will be able to:
1. Describe the importance of a physical handling treatment.
2. List the major considerations of a physical handling treatment session.

Disclaimer

The information in this article is not a substitution for qualified professional training, it is
for educational awareness only. Physical handling requires experience and training.
Numerous training courses and seminars are available for therapists interested in physical
handling techniques.Treatment requires the consultation and prescription of the child's
physician or primary care provider.

Preface

Physical handling is a therapeutic approach that essentially matches the clinician's nervous
system to that of the client. Through various key points of control the clinician is able to
feel and observe the quality of the child's movement and how the child reacts to subtle
changes to shifts in the center of gravity. Additionally, the clinician can feel and observe how
the child's posture relates to movement. What compensations the child uses to move and most
importantly how the child initiates those compensations. Through various handling techniques
it is possible to determine what cues and levels of intermittent support are most successful in
achieving a more efficient activation of movement that allows the child to actively initiate
improved quality and control of his posture and movement.

Part 2 deals with with specific treatment techniqiues to achieve identified goals. Part 3 deals
with promoting functional skills.

Physical handling is a process of restoring dynamic balance to posture and movement. The first
and most important step is to establish alignment and promote efficient kinesiological selection
of muscle groups to achieve dynamic postural maintenance that supports more normal movement
components.
 Issues in Cerebral Palsy
Part 2: Physical Handling Treatment Strategies

Physical handling treatment for children with neuromotor dysfunction strives to

provide active intervention to improve control of posture, sensory tolerance of
movement, organization of body sides and therefore improved functional
efficiency. The therapeutic principle of physical handling treatment is to provide
the least amount of control needed to achieve a more efficient response and then
gradually turn over more and more active control to the child.

Within this treatment principle, various techniques are required to prepare the child
for an active response. These techniques include activating muscle contraction
through direct tapping, use of intermittent support to activate stability and
sustained postural control, oscillation to increase or decrease tone, deep pressure
tapping to reduce tightness, mobilization of the body over the limbs to normalize
sensory tolerance in various ranges of movement and improve dissociation of body
segments, and changes in degree and intensity of input, and key points of control to
advance the child's potential for activating more organized movement patterns.

Physical Handling Treatment Tools

Treatment must be directed to a specific goal for each therapy session, as well as
the larger goals for cumulative treatment. Although the goals of independent
sitting, walking, feeding, hand manipulation and other functional goals are always
underlying objectives, they are too general to lend direction to the direct treatment
process. Foundational underpinnings of postural control and alignment are critical
before any efficient skill can develop in functional areas. Practicing functions on
an abnormal or compensatory postural base will result in embedding the
dysfunction and strengthening abnormal compensatory patterns.

Direct physical handling requires an organized sequence that leads to specific

outcomes within each session of treatment. Both general and specific preparatory
techniques are utilized to transmit to the child new sensations of potential
movement and develop the components control of underlying postural stability and
freedom of movement. All functional skills require an organized base of support
and a graded interplay of stability-mobility.

Effective direct physical handling requires experience and training to understand

the normal and dynamic interaction of functional components. The therapist needs
to have an image of the normal components of posture and movement, what those
components look like and feel like, and be able to clearly identify essential
components of abnormal or compensatory movement.

In the beginning of a session the child is briefly placed in a challenging functional

position to observe the child's reactions and attempts to maintain the position and
more clearly understand the emerging problems.
Maintaining alignment in standing requires control of the body over the base
of support of the feet, with the knees and hips extended and the pelvis in
stable neutral or slightly anterior to allow the trunk to extend for core
stability. On this example the child is unable to activate sufficient knee and
hip extension, this the pelvis is in too much anterior tilt. the trunk cannot
extend and the shoulders and neck compensate with elevation and
hyperextension. Without proper alignment any weight shifts will result in
more abnormal compensations in posture.

After some preparation and treatment, returning to the same or similar posture or
position requiring the same components of control, will offer some immediate
feedback as to whether the child is responding positively or whether the therapist
needs to modify her handling. Each therapy session must be a discovery of how
best to vary handling techniques to effect positive change. Treatment should never
be a set protocol. The therapist gauges their effectiveness through the child's
reactions to treatment.

Lateral shifting from a seated position while maintaining control of the arm
and leg allows the therapist to mobilize the pelvis and dissociate the movement
of the pelvis from the trunk and leg. With more pelvic adaptability placing the
child in straddle standing while controlling the knees in extension allows the
possibility for active hip extension and therefore more active trunk control in
standing.
Once there is more dissociation of the pelvic girdle with the trunk, and more
active hip extension, the therapist places the child in a more functional
position in standing in order to integrate the new movement potential into
more functional control. With more mobility of the pelvis and active hip
extension, experience in supported standing allows integrating these changes
into more active trunk elongation and lateral flexion.

Physical Handling Considerations During Treatment

Without analysis of individual problems there is a tendency to fall back to general

treatment techniques and protocols that are not specific to the individual's unique
set of difficulties. The risk of using general protocols is that they may activate
compensatory patterns and further embed the child's limited functional adaptation.
Compensatory patterns interfere and inhibit new motor learning because they do
not allow for adaptation or establishment of postural foundations that support
efficient activation of movement.

Treatment should strive to introduce new motor learning experiences, not only as
functional responses but preparatory in terms of sensory tolerance for ranges of
movement and degrees of freedom of dissociation of movement, displacement of
the body weight, adequate adaptation of respiration in new positions of posture and
movement that are introduced, and the ability of the child to accept and control
changes in movement in terms of velocity and direction without resorting to
compensatory patterns.

Specific sensory experiences are associated with postural change and movement.
The more clearly the clinician can identify these changes through physical
handling, the better the therapist will be able to analyze specific compensatory
components present and therefore more specific objectives for the treatment
session.

Effective treatment supports new sensorimotor learning. Variety in posture and

movement combinations is crucial to for new sensorimotor learning to occur. It is
useful to remember that "feeling" the body weight over the feet results in
proprioceptive activation of standing when the weight of the body is brought over
the feet. The normal system aligns the body over the base of support in the new
posture. Being able to activate and adjust to vertical postures aligns the sensory
systems to their optimal orientation to integrate sensorimotor processes.

In the dysfunctional system the trunk needs special help in experiencing adaptation
to various alignments in upright while the center of mass is controlled over the
base of support.
Bringing the body weight slowly over the feet helps to activate and grade
extension of the legs and hips with extension of the trunk. The therapist guides
the forward flexion of weight over the base of support and once upright,
assists with stabilizing the posture and adjusting the distribution of weight.

Use of a roll increases the base of support and allows the therapist more
opportunity to guide the child over the supporting legs and activate hip and
trunk extension.

Movement, especially new or lesser used movement by the child, requires the
acceptance of the sensation of movement, not only in proprioceptive weight
distribution, but also in musculoskeletal tolerance of sensation and joint and
muscle ranges of compression, mobility and length.
When a child lacks postural control necessary to sustain a movement, the therapist
manages part of the body weight and assist appropriate trunk and limb reactions to
movement. When the limbs are placed or initiate movement the trunk must follow
and be able to shift over the supporting limb in order to grade and activate
transitional movement.

Assisted and facilitated transitions of the trunk over limb placement helps to
increase stabilization of the trunk and activation of core stability and graded
mobility. The completion of postural transitions provides multisensory
experience and fosters sensorimotor learning.

Practice of particular skills can result in some motor learning and is appropriate for
children who can activate transitional movements but needs some assistance in
postural control and stability to organize the movements more efficiently.
However, it is important for the therapist to guide and allow the child to use his
motor skills in a variety of ways in dynamic postural alignments in order for the
new or refining skills to be fully integrated for eventual independent activation.

The simple task of reaching for an object can be used to help integrate rotation
with flexion and extension while maintaining control of the trunk over the base of
support in shifting alignments. Establishing graded dynamic alignment control in
various combinations of flexion, extension, and rotation is critical for refining and
organizing efficient transitional movements.
Assisting the weight shift with input to the trunk helps the child complete a
more fill rotation while sustaining his weight on the side of the rotation. This
input to help stabilize and guide the trunk allows for dynamic postural
alignment to assist the movement potential.

Combining flexion with rotation as well as extension with rotation provides

experience in controlling dynamic alignment in a variety of movement
sequences. Changing the key point of support to the weight bearing arm,
allows the trunk to be more active in stabilizing as the trunk rotates over the
weight bearing arm, thus allowing another level of graded rotational control
on a different dynamic alignment. Reaching activities like these should be
undertaken in various positions of sitting, standing, prone and supine to fully
activate and integrate dynamic postural control and adaptability of efficient
movement sequences.

A major consideration in treatment is the degree and efficiency of dissociation of

body parts, not only passively but more importantly while the child is moving.
Dissociated movement follows dynamic postural adjustments and transitional
movement patterns, while lack of dissociation will result in recurring habit patterns
or compensations.

For example, when one hand is supporting the other limb should be free to move
and there should be ease of rotational trunk movement and reaching across midline
without shoulder elevation or tightness or collapse of the trunk. When there is
movement of the pelvis the legs should not compensatorily follow that movement
but be free to place or adapt to weight shifts without tightness or lack of
independent movement. Dissociation leads to greater control and efficiency of
functional movement patterns.

During treatment special consideration is given to how the respiratory system

adapts and adjusts to movement patterns during higher and higher levels of
postural control against gravity as the base of support narrows. Grading various
movement patterns and allowing respiration to adjust is an important component of
treatment.

Dissociation and Respiration Considerations

 Treatment Discussion from Children Highlighted in Part 1

Summary Comments

There are many aspects to cerebral palsy. Cerebral palsy is a stubborn adversary.
The challenge to the treating clinician, is the need to clearly analyze the individual
characteristics that interfere with the child's efficient use of his body, both
posturally and in movement, therefore providing clues and strategies for the most
effective intervention possible. Physical handling assessment and treatment
requires continuous analysis of the child's compensations. Understanding the
various limitations and compensations the child presents allows the therapist to
intervene to inhibit unwanted responses to postural shifts and movement activation,
while facilitating more efficient movement and organization of posture. Constant
modification in handling is determined by the child's responses to handling and the
therapist is continually guided in refining treatment techniques within and
throughout each treatment session.

Organized movement and efficiency of function cannot be activated from a

dysfunctional alignment, or through practice utilizing the child's abnormal
compensations. Skilled physical handling is critical for leading the child toward
more efficient use of his body and therefore more success in attaining higher levels
of functional skill.
 Appendix A

Physical Handling Preparatory Techniques

PROCEDURE TYPE TONAL EFFECTS INDICATIONS

Quick Tapping Fast & repetitive Increases & builds tone Flaccidity & underlying low tone.
Fluctuating and high tone
after initial tone reduction

Alternating TappingSuccessive & Stabilizes & activates Fluctuating and high tone after
rhythmic contraction in small ranges reduction & low tone after
preparation

Oscillation Fast with periodic Reduces tone High tone & tension areas in
slowing or stop/ fluctuating tone
Slow & rhythmic

Fast & repetitive Increases tone Flaccidity or underlying low tone in

high or fluctuating tone conditions

Intermittent Hold & release in fast Stabilizes & activates co- Fluctuating and low tone after
Support intervals contraction reduction

Compression Sustained Reduces tone High tone

Intermittent & rapid Increases tone Low tone

Activates joint control Fluctuating tone

Deep Sustained over Reduces tone High tone

muscle belly

Sweep Tapping Fast in direction of Increases active extensor High tone

desired movement tone/decreases flexor tone

Slow with pressure Decreases tone High tone

Placing & Position in desired Increases joint High tone after reduction of tone
Holding posture stability/activates Low tone/Fluctuating tone
co-contraction
 PHYSICAL HANDLING PREPARATORY TECHNIQUES
Preparatory techniques are designed to influence the essentially a hold and release technique which
general state of postural tone and are used to prepare supports body weight and releases it with various
the somatic system for movement. Postural tone is frequency and duration as needed to enhance active
influenced by various factors of sensory input, such stability and equilibrium. It can be performed with
as speed, frequency, duration and intensity of the body weight slightly off center to activate
specific sensory cues. in general, fast input tends to automatic responses or in a stable midline condition
increase tone while slow input tends to decrease to enhance stability. It is a good technique for
tone. Input can be long in duration and intensity, stabilizing fluctuating tone in midline postures and
such as compression into a joint or short and activating low tone responses to a shift in the center
alternating such as approximation of a joint. The of gravity.
actual response to the presentation of sensory input
depends on the child's individual nervous system and Compression is a sustained pressure into a joint in
the degree of sensitivity of the handler to monitor alignment. Sustained pressure into a joint has the
and modify the input. effect of reducing tone or spasticity around the joint.
Intermittent compression into a joint, or approxi-
Tapping is a technique which is used as a means to mation can increase joint stability and tone if
apply repetitive sensory input to the surface of a repeated rapidly or decrease tone if performed in a
muscle. Quick tapping, or fast tapping increases slow and rhythmic manner. Deep sustained pressure
tone. This type of tapping is used to increase the over a muscle belly has an inhibitory influence and
muscular activity of low tone children or to balance is effective in reducing spasticity.
agonist and antagonist muscle groups in children
with high tone and fluctuating tone.. Alternating Sweep tapping is another form of stimulation to
tapping is used to control a small range of facilitate motor patterns of muscle groups. Sweep
movement to increase graded control. It can be used tapping is a technique which provides a facilitatory
to inhibit low tone collapse into gravity, input in the direction of a desired movement, such as
overshooting in athetosis and to maintain relaxed sweeping the triceps and extensors of the arm in the
tone in spasticity. direction of extension to inhibit flexor tightness in
the biceps. Slow sweeping can also be used with
Oscillation is a term which is used to describe a deep pressure to tight muscle groups in the direction
repetitive swinging or swaying of a limb. As with all of the desired response, such as slow deep pressure
sensory techniques, the speed of application sweeping of the biceps to reduce tone and facilitate
determines the sensory-motor response. Fast an extensor response of the arm.
oscillation tends to decrease tightness in the shoulder
or hip, when applied distally to a limb. However, Placing and holding is another technique which
this fast oscillation must be interspersed with times places a limb in a desired position. Holding the limb
of no oscillation or slow oscillation, to avoid any in place, perhaps with slight intermittent support,
rebound or musculature tightening. Prolonged allow the proximal joints to gradually increase tone
oscillation, applied bilaterally to the arms, has a for stability, and activate holding power. If done
tendency to increase trunk tone in a low tone child as slowly however, this can result in a sustained release
it stimulates arm motion for the joint receptors. Slow in proximal tightness and rebound phenomena.
oscillation, particularly with slight traction of the
limb can result in decreasing tightness, while Preparatory techniques are a means to prepare the
repetitive quick traction has the tendency to increase somatic musculature and sensory systems to tolerate
tone around a joint. Extreme care must be exercised facilitatory handling. They can be employed prior to
during these techniques to protect the joints from movement as in the notion of the word preparatory,
subluxation or dislocation. but more likely they are employed simultaneously
with facilitatory handling to maintain the readiness
Intermittent support is a term used to describe of the sensory-motor systems for somatic adaptation.
active stabilization within a range of movement. It is
Alternating Tapping to Maintain Active Control of Posture
 Oscillation of Limbs up and down to affect tonal changes in proximal
joints and limbs

Intermittent tapping achieved by releasing support and immediately

regaining control of shoulders.
Intermittent support for stability in prone with quick release and hold to
maintain active control & stability
Sustained compression into a joint to reduce spasticity around the joint
Repetitive approximation into a joint to influence tonal changes
Sustained deep pressure over a specific area to reduce tone
Repetitive placing and holding to establish release and control of
movement
Changing postural tone in preparation for, or body, the result is often an exacerbation of abnormal
simultaneously with, facilitatory handling requires postural tone.
constant monitoring of the child's tonal state.
Postural tone is never constant even in cases of Effective physical handling of a child with cerebral
spasticity. There are usually various layers of palsy requires, therefore, attention to the distribution
postural tone. For example, after tightness in an area of tone, the distribution of weight, and body and
is reduced, there exists another or new level of joint alignment. Because children with cerebral
postural tone. This tone is often referred to as the palsy have habitual abnormalities in the areas of
underlying tone. In some cases the underlying tone weight, tone and alignment, they also suffer from
may be close to normal, low, fluctuating or ataxic. sensory deprivation in somatic adaptation. Before
Many children have mixed tone with predominant certain movements can be accepted by their nervous
tightness. When attempting to change postural tone system, there must be a normalization of the
it is often necessary to alternate various preparatory sensations required for those movements.
techniques to reach a balance of reciprocal
innervation. Additionally, some children require The sensory aspects of movement and posture
different techniques in different body areas include postural tone, body weight, joint alignment
depending on the distribution of their postural tone. and somatic proprioception. It is unlikely that a joint
movement which rarely or never takes place will be
The distribution of tone refers to the specific initially accepted by a damaged nervous system.
tensions of muscle groups in various areas of the When tightness around a joint has been reduced, for
body. Muscle groups which are tight have a higher example, and the joint has been placed in a new and
distribution of tone than muscle groups which are unfamiliar alignment or excursion, there often
flaccid or low tone. Tone may be distributed with results an initial rebound because there is little if any
great fluctuation between high and low, as seen in sensory threshold tolerance for the new position.
children with athetoid cerebral palsy. The Before dynamic facilitatory treatment of varied
distribution of tone affects and is influenced by the movement patterns can be introduced, it may be
distribution of body weight. Weight and tone are two important to establish a sensory threshold for the
sides of the same coin. If there is an imbalance of movements desired.
postural tone due to neurological damage there will
be a resultant imbalance in weight distribution. For By providing preparatory techniques to manage
example, if a child is placed in prone and postural tone, gradually increasing the tolerance of
experiences predominating flexor tightness, the joint movement and placing the child in altered
distribution of that tightness on the alignment of the alignment positions with appropriate weight-bearing,
joints and body parts will cause an unequal or it may be possible to normalize the somatic
improper distribution of weight into the surface, thus proprioceptive threshold required for body
compounding the problem. When the distribution of movement. In so doing it is important to prepare the
tone, weight and alignment are pathologically influ- musculoskeletal system to accept a greater degree of
enced, there is little if any possibility for the child to sensory-motor challenge than basic movements
shift his weight for a transitional movement, alter his require. This of course is to insure that there will be
body alignment in a position sufficient to allow free- sensory tolerance throughout the range of the desired
dom of movement or modify his postural tone inde- movement, position, or transition, without sur-
pendently. Conversely, if the child is placed in a passing the sensory threshold of the child causing
position in an inappropriate alignment or without collapse or rebound into abnormal patterns.
regard for the distribution of weight through his
 APPENDIX B
BASIC TREATMENT STRATEGIES FOR FACILITATING MORE EFFICIENT MOVEMENT AND
POSTURE

Reducing postural tone through deep and sustained pressure to the lateral trunk in preparation for lateral flexion
response or dissociation of the trunk from the pelvis through manually rolling the trunk. This position also effects
some relaxation on the weight bearing side. For low tone children, this positioning can be used with gentle quick
tapping to stimulate more lateral trunk tone, or to stabilize fluctuations in trunk tone seen in children with
fluctuating tone.
Sustained compression of the shoulders toward the pelvis with the head in alignment can be effective in reducing
high tone or spastic elevation of the shoulders, as well as to establish some firm stability in children with
fluctuating tone. The child actively controls the head. Low tone children require a roll to elevate the head and
more rapid approximation into the shoulder area to increase tone.
Maintaining the shoulders down and in alignment, the head can be elevated and flexed forward to inhibit
hyperextension or collapse, and to provide sensory awareness of midline. Adding gentle approximation can facili-
tate increased cervical tone in low tone children, while adding slight traction may" help maintain a decrease in
tightness and lengthen the posterior cervical musculature.
Slowly lifting the head away from the surface while controlling the shoulders allows the child to experience
dissociation of the head from the body. In spastic child sustaining the elevation with slight traction helps to
maintain tone reduction and establish better sensory tolerance. Children with low tone require gentle intermittent
support to help build neck tone and stability, while children with fluctuating tone benefit from sustained holding
to increase sensory tolerance for stability and to inhibit fluctuations.
Maintaining shoulder alignment and control while moving the shoulders through retraction and protraction is
helpful for sustaining inhibition of tightness during movement. Slower, more deliberate excursions with pressure
can assist the child with fluctuating tone to experience graded movement while inhibiting fluctuation. Tone can be
increased in children with low tone by adding firm approximation toward the midline.
Using a ball between the scapulae and supporting the head with a roll facilitates scapular adduction and inhibits
shoulder protraction, allowing more thoracic excursion. Movement of the trunk laterally back and forth adds an
element of dissociation of the head to trunk and the gentle movement helps to maintain inhibition of tightness.
Using this position with children with low tone with the weight distributed forward can be helpful in increasing
tone in the shoulders, neck and trunk. Children with fluctuating tone need to have their arms controlled with slight
traction to inhibit tonal fluctuations.
Elongation of one body side while maintaining pelvic stability and adding slight traction of the opposite arm,
helps promote the experience of lateral flexion, while dissociating the upper extremities. Weight bearing on the
elongated side also inhibits tightness. Children with fluctuating tone benefit from graded control of the response
to inhibit tone fluctuations. This position is not good for Children with low tone because the distal control puts too
much stress on their poor joint stability.
 Figure 34

Controlling trunk and shoulder alignment through the use of a roll, allows the handler to mobilize the pelvis and
dissociate the pelvis and lower trunk from the upper trunk The pelvis can be moved laterally or into posterior tilt,
while the legs are separated through sustained pressure. With gradual reduction in tone the legs can be flexed to
allow posterior pelvic tilts. Maintaining this position for children with fluctuating tone can inhibit tone fluctuation
and establish sensory organization in midline. Children with low tone benefit from sustained forward weight
bearing on the shoulder and neck areas.
 Figure 35

Once tone reduction has been accomplished, the arms can be helped to bear weight through maintaining hand
placement under a roll. The pelvis is controlled and facilitated in various tilts, increasing and decreasing the
amount of weight on each upper extremity. This position is only effective if sufficient tone reduction of tightness
has been accomplished. If the child can easily be positioned without rebound or tightness, then the activity can be
beneficial. Children with fluctuating tone or low tone require handling control and support at the shoulders and
the head and neck. Without this control, this position should not be used.
Using a roll to support the head and controlling the legs in flexion and pelvic stability, the child can be facilitated
in lateral trunk movements with dissociation of the head from the trunk. Sustaining the weight on each shoulder
temporarily allows for graded and continual reduction of tightness in the shoulder girdle area. Maintaining flexion
of the legs also inhibits the tendency for extensor tightness or posturing of the lower extremities. Children with
low tone benefit from proximal compression in both pelvic and shoulder regions, while children with fluctuating
tone can expedience graded movement while fluctuations are inhibited.
Placing the child in side-lying, while elongating the weight bearing side, allows the handler to bring the opposing
arm forward and back in ranges of shoulder protraction and retraction, thus dissociating the upper extremities
while inhibiting tightness. The trunk often follows in small ranges of rotation and contributes to maintaining
decreased tone during movement. The pelvis is stabilized and results in the additional advantage of separating the
trunk from the pelvis. Rhythmic shoulder excursions help to decrease tone while slower excursion facilitate
graded sensory tolerance. This position is also effective for children with fluctuating tone, since the position is
stable and the movement can be managed to grade the response while inhibiting fluctuations. For children with
low tone, adding approximation to the weight bearing shoulder and proximal tapping to the upward shoulder may
help to build tone. Lifting the upward arm and giving intermittent support may also help increase shoulder
stability and control. Respiratory responses should be carefully observed and considered in direct handling.
Specific techniques can be applied to discrete muscle bellies to reduce tightness. Deep pressure into and along the
length of the muscle belly combined with soft tissue mobilization over the surface of the muscle can affect
specific localized changes in tightness. This procedure can also be used for localized areas of tightness or for
children with fluctuating tone. The head is gently kept in alignment while the specific work is done.
Ranges of trunk elongation and lateral flexion are important. Repeated sustained traction between the pelvis and
shoulder girdle, followed by slow release gradually lengthens the lateral excursion of the trunk. Once the trunk is
lengthened through reduction of lateral flexor tightness, a more active lateral flexion response can be anticipated.
Lifting the pelvis in lateral tilt toward the shoulder and guiding the shoulder to depress toward the pelvis initiates
more active lateral flexion. The pelvis can be lifted and held with intermittent support to encourage more active
normalized lateral flexion responses in the anti-gravity alignment. The pelvis can also be mobilized into posterior
tilt to lengthen the lumbar area and reduce is tightness or lumbar stress evidenced by lordosis and anterior pelvic
posturing.
Increasing shoulder mobility can be accomplished through gently placing the arm in full extension in prone.
Slight traction can be applied toward the distal extremity. The arm is then lifted gently to the. point of restriction
and gently moved back to the surface and up to the restriction and held briefly. As tone reduces the excursion is
increased further into the restricted range. The same procedure can be used in ranges of abduction. The scapula
must be stabilized to prevent winging with firm tapping toward midline to encourage more actives scapular
adduction. Simultaneously the pelvis is rocked gently laterally to provide a sensory background of inhibition to
retard the tendency for spastic rebound. The child with low tone in this position requires both arms to be
supported under him, so that the handler can lift both arms together and at the same time give support to the head.
The upper body is raised into a small range of extension and bobbed with intermittent support to encourage
increased extensor tone. When the tone begins to increase the arms can be firm placed on the surface to facilitate
independent head raising if possible.
Placing a child against a ball in kneeling with the hands directly under the shoulders, encourages scapular
adduction, neck extension and forearm support for propping. This is a position which can help activate muscle
control for support in children with tightness after some general tone reduction is achieved, and if the child can
be easily placed in the position. The springy quality of the ball allows constant background movement to maintain
reduced postural tone and also facilitates the tendency for the child to push up. Children with fluctuating tone are
given more compression into the proximal areas and toward the midline of the spine to encourage more joint
awareness and a basis of stability to push up against. Children with low tone will need more complete trunk
support, and lifting and gently dropping the trunk on the ball to encourage an increase in extensor tone.
Using an elbow air splint or a small gaiter splint allows the handler to maintain arm extension and maintain
shoulder control while working bilaterally for upper body extension and elongation of the trunk. Such supports
can also be used for children with fluctuating tone to limit the range of fluctuation of a joint and for low tone
children to stabilize a limb for weight bearing. The emphasis is on giving the child a successful experience.
Full body extension over a roll and with the child's legs around the handler's waist, allows for controlled weight
bearing on the hands and through the upper extremities. children with high tone may need generalized reduction
of tone before weight can be tolerated, and may also require splints on the arms to inhibit flexor rebound affects
or collapse with tone changes. Children with fluctuating tone gain stabilization through deep pressure weight
bearing and children with low tone need more proximal support and control so that only partial weight is applied
to the extremities.
Maintaining the child's arms along the trunk or underneath the trunk allows better isolation of head and shoulders.
Alternating the weight from one shoulder to another rotates the trunk slightly and facilitates head mining and
separation of head and shoulders with inhibition of tonic influences. This can be effective in spastic children as a
tone reduction activity and an active dissociation process that is the basis of the righting reactions. Children with
low tone may need some additional facilitation for head turning to activate neck contraction. Children with
fluctuating tone need monitoring for speed of turning so fluctuations of tone can be inhibited and graded
movement responses introduced.
Routine placement of the child over a ball with surface contact to the upper body can be effective in reducing
spasticity around the thorax and shoulder girdle while controlling the arms in extension. Gentle vestibular rocking
laterally helps maintain inhibition of tone. From this position isolated head lifting can be dissociated from the
shoulders and trunk while the forearms give support to the effort. Children with fluctuating tone can gain midline
orientation and control in small ranges of head lifting without overflow. Children with low tone require more
proximal support and assistance in head lifting for gradual increases in tone and strength.
Use of a small swim ring for mid-trunk support allows more active responses of the young child to supporting
body weight. The swim ring can be tilted laterally for unilateral body supporting responses as well as forward and
back for bilateral upper and lower extremity supporting reactions. A bath towel may be used in a similar way for
dynamic trunk support.
Separation of the lower extremities can be accomplished by placing the child over a bolster and maintaining
pelvic control while extending one leg and allowing the opposite leg to maintain weight. The pelvis can be gently
rotated laterally to increase inhibition of spasticity and facilitate dissociation of the pelvis and legs. Upper
extremity weight bearing can be graded by tilting the child's weight forward and back if there is not significant
upper extremity spasticity present.
Controlling the child through the trunk with legs stabilized around the handler's waist allows isolation of weight
bearing to each arm independently. Control must be given to the upper arm and shoulder and hand placement may
need to be provided for children with significant spastic tendencies for flexor withdrawal. This position also
encourages head righting, but low tone children will require head support and then intermittent support for
fighting reactions to occur.
Facilitation of transitional movements, for example, from side sitting to four point can be accomplished by
stabilizing the pelvis and supporting the weight bearing side while facilitating weight transfer to a four point
position. Oscillation or gentle background movement can help inhibit tightness during the movement transition.
Resistance with trunk compression can be applied to grade transitional components and inhibit fluctuating tone.
Children with low tone will require more firm input and support along with intermittent support to facilitate active
muscle participation.
Controlling the child's legs with the handler's legs and supporting the mid-trunk with a soft ball or small bolster,
allows the handler to control both upper extremities proximally and alternate weight bearing on each arm. Gentle
dropping of the limbs increases proprioceptive feedback for children with fluctuating tone and low tone.
Sustained weight bearing helps inhibit tightness and increase sensory tolerance for joint proprioception.
Placing the child in straddle sitting around the handler's waist and lowering the child to a small ball placed
between his scapula, permit the possibility of reducing tightness in the mid-trunk and bringing the shoulders
out of protraction. The ball provides contact for body areas that never touch the surface due to the effects of
spasticity. The child can be controlled at the pelvis and mobilized to decrease lumbar lordosis if present.
Pressure can be applied to the chest and the soft tissue spread laterally to reduce thoracic tightness. Attention
must be given to fatigue due to the head control.

The shoulders can also be mobilized to decrease protraction and facilitate depression into normal alignment.
Low tone children can benefit from this position with added head support to assist lifting the body away from
the ball and giving intermittent support to facilitate increased postural tone. Children with fluctuating tone
benefit from the midline organization of this activity, and with firm control of the shoulders, graded
movement away from and back to midline can be experienced. Rotational adjustments can be graded.

Once tone is prepared the child can be placed more upright, shoulders back and arms in external rotation to
facilitate active scapular adduction. A bench permits the adult to sit behind or face the child. Additional input
can be provided to the trunk extensors to facilitate more normalized trunk support for the shoulders to react
with. Body weight may be shifted over the hands and arms.
Lateral weight shifts to facilitate righting and equilibrium responses can be achieved with gradual shifts from
the center of gravity. The child can be prepared to feel the change in weight distribution through slow
deliberate shifts and manual assistance with elongation of the trunk and lateral flexion of the opposite side of
the trunk. This movement can be accompanied by firm approximation to reinforce the proprioceptive input,
and slight bouncing or oscillation to more consistently inhibit spasticity. Low tone children require more firm
bouncing and exaggerated approximation, always with alignment maintained to reinforce proprioceptive
input and intermittent support to maintain increased postural tone. Children with fluctuating tone require firm
compression into the proximal joints to increase awareness of joint proprioception and slow graded shifts of
lateral excursion away from the midline to control fluctuation in postural tone.
As postural tone is more normalized larger excursions can be facilitated with more distal control. Slight traction
can be applied to inhibit spastic rebound and short periods of rapid oscillation can also be used to break up any
tendencies toward flexor withdrawal. Head righting can be facilitated by increasing traction of the elongated side
or by supporting the head with the raised arm. The hand can be manually placed on the surface for proprioceptive
placement responses and sustained weight bearing to further normalize tone and allow isolated head righting. Low
tone children should not be given traction to the elongated side, because of joint laxity, but can be elongated with
intermittent support to encourage an increase in tone. Gentle dropping of one limb to the surface from a height of
several inches with immediate control of the distal extremity may help. sustain increased tone in the extremity,
while the handler simultaneously supports the child's head with his upper arm. Children with fluctuating tone may
require alternating points of control from proximal to distal to control fluctuating tone. Lateral excursions should
be applied slowly with firmness to grade lateral reactions and avoid patterns of fluctuation and disorganization of
movement components. Use of a foam neck support can be helpful in maintaining head control in children with
fluctuating or low tone children with problematic fluctuating tone.
Placing the child on the handler's lap and promoting forward flexion allows the lumbar spine to elongate and
decrease tension in tile low back through natural traction from the positioning of the upper trunk in flexion.
Movement of the tissues over the rib cage frees the respiration. Controlling the trunk on the surface with firm
pressure also assists in decreasing flexor spasticity below the ribs. At the same time displacing the trunk laterally
assists in dissociating the lower trunk from the pelvis, shifts the body weight laterally and mobilizes the pelvis in
lateral tilts. Children with high tone with tendency for flexor tightness of the arms may need additional control of
arm splints to help maintain arm extension and encourage free arm movement during lateral shifting of the trunk.
Weight bearing can be added to a total body flexor pattern by placing the child in a squat position in front of a
small ball. Supporting the pelvis and the arms allows the handler to shift the child's weight forward and back over
the feet. This compressed posture is advantageous for children with fluctuating or low tone. Children with high
tone with strong flexor tightness benefit only if the tightness has been reduced and good postural tone can be
maintained.
Kneel standing with proprioceptive upper extremity weight bearing may be accomplished by maintaining leg
alignment with the handler's knees and supporting the trunk and hand placement on a roll. The child's weight can
be shifted forward and back to influence sustained holding and postural support of the upper extremities. Children
with high tone may need continual gentle shifting to inhibit tightness reactions, while children with fluctuating
tone can tolerate more movement with care to control fluctuating tone. Children with low tone may need more
upper trunk support, occasional tapping of the abdominals and intermittent placing or dropping of the arms to
maintain increased tone in the upper extremities and trunk.
Straddling a roll and controlling the shoulders while maintaining hand contact with the surface allows for upper
extremity proprioceptive weight bearing. Gentle elevation and depression of the shoulders can be effective in
reducing shoulder spasticity. Compression into the shoulders increases joint awareness and stability for children
with fluctuating tone or low tone and allows the handler to maintain midline control while shifting the child's
weight over the hands to increase proprioceptive upper extremity support.
Children can experience more independent control in sitting when placed inside a large circular tube with
additional support where needed. This type of circular support may allow the child to initiate and experiment with
isolated head control.
Plantar-grade weight bearing can be facilitated by controlling the child's pelvis and placing a small ball between
the child's knees to maintain separation of the legs. The upper extremities are free to place for support and
forward and back weight shifts can enhance the proprioceptive input to the extremities. With good proprioceptive
support in weight bearing, the child may be able to initiate head lifting and activate trunk extension. Children with
high tone may need additional arm support through the use of gaiter splints to maintain elbow extension.
Kneel-standing allows for the facilitation of initial upright equilibrium responses with a low center of gravity
through controlled weight shifts away from midline in all directions. Forward weight shifting with inhibition of
anterior pelvic tilt and neck hyperextension can result in a graded transition to four-point control supported by
upper extremity proprioceptive placement. Lateral weight shifting can facilitate separation Of lower extremity
positioning. The handler supports the elongated trunk while shifting the weight toward that side and assists the
opposite leg to come forward in a half-kneel transitional posture. Speed of movement and specific points of
control and support will vary depending on the type of the child's tone.
More complete upright control can be experienced by the child in standing over a large ball. The child is
supported throughout his trunk and weight is gradually brought to bear through the legs. Each leg can be
alternately separated to prepare sensory tolerance for dissociation of lower extremity patterns. Weight may be
shifted forward and back and sustained to build tolerance for weight over the feet. Children with fluctuating tone
benefit from firm pressure and approximation through the weight bearing extremity. Children with low tone may
require more rapid approximation and bouncing of the weight bearing limb on the surface to increase and
maintain tone. Spastic children may pull into flexion in this position, and if tone cannot be controlled, alternate
weight bearing positions should be employed, such as supine standing.
Weight bearing on the lateral surface of the foot can be accomplished from a side lying position over a ball. From
this position the child can be shifted over the foot more easily than in a straight forward position. The child, can
be elevated off the surface occasionally to inhibit sensory buildup or intolerance to proprioceptive contact to the
foot. The opposite leg may be facilitated to separate through guided swinging or placement in stride positioning.
As in all other cases, the type of tone will dictate the exact handling requirements.
Standing with both feet firmly on the surface and in a more upright position allows the child to feel more of his
complete body weight over the feet. The child can be brought gradually to a complete upright position for
maximum effect and then lowered to allow recovery from sensory buildup. Children with fluctuating tone can be
given firmer and sustained approximation. Low tone children will require a more rhythmic contact and release in
a quick tapping type of technique to increase tone. Children with high tone will require a combination of hold and
release from the posture with anticipation by the handler to inhibit spastic rebound.
Supine standing allows the. child to experience weight distribution on the lower extremities which enhances
weight bearing on the heel of the foot, with more complete extension of the trunk than is usually accomplished in
prone standing. The handler can place the child's arms behind with external rotation and shoulder retraction to
activate scapular adduction and further contribute to overall trunk extension. Various supports may need to be
used such as leg splints or a neck support depending on the needs of the particular child.
The more involved child may need more total support to experience the benefits of standing, such as a flexi-
stander or standing flame device. Standing devices like other, types of adaptive equipment should not be used to
contain a child or free staff to do something else. Adaptive equipment need continual monitoring and the child
requires adjustments to the rigid position as well as some movement and weight shifting to prevent unopposed
flexor tightness rebound or low tone collapse.
The less involved child may be given more challenging experiences in standing. Firm control of the weight
bearing side in elongation and placement on a surface of challenge allow the handler to provide various degrees of
support to facilitate graded equilibrium and righting responses.
Facilitation of walking can be accomplished in many ways when the child's tone and postural control are prepared
for the experience. Standard walkers are useful for independent walking, however they require careful
observation. Forward rolling walkers tend to encourage tightness in hip flexors for spastic children, and the child's
weight most often remains forward in toe walking. Posture control walkers facilitate more trunk extension and
weight bearing on the heel of the foot, however children may not be able to make the transition into forward
flexion of the trunk to distribute weight over the feet. In this case the child becomes just as reliant on using too
much extension as the child who relies on too much flexion. Children may need to experience the use of both
forms of walking devices to manage the transition of forward and backward weight shifting necessary for
independent walking.
 These are the verification exam questions to be answered when you click on Take
Exam. For ease of completion select your answers prior to clicking on Take Exam.

Issues in Cerebral Palsy Part 2: Physical Handling Treatment

CEU Verification Exam
1. The therapeutic principle of physical handling treatment is to provide the least
amount of control needed to facilitate a more efficient response.
a. True
b. False

2. Preparatory techniques are not required to prepare the child's postural tone for an
active response.
a, True
b. False

3. Foundational underpinnings of postural control and alignment are critical before

any efficient skill can develop in functional areas.
a. True
b. False

4. All functional skills require an organized base of support and a graded interplay
of stability-mobility.
a. True
b. False

5. The risk of using general protocols is that they may activate compensatory
patterns and further embed the child's limited functional adaptation.
a. True
b. False
6. Treatment should strive to introduce new motor learning experiences, not only
as functional responses but preparatory in terms of sensory tolerance.
a. True
b. False

7. Degree and efficiency of dissociation of body parts, is only required in passive

movement.
a. True
b. False

8. Respiration corrects itself and no direct intervention is required for respiratory

support to movement.
a. True
b. False

9. In the dysfunctional system the trunk needs special help in experiencing

adaptation to various alignments in upright while the center of mass is controlled
over the base of support.
a. True
b. False

10. Organized movement and efficiency of function cannot be activated from a

dysfunctional alignment, or through practice utilizing the child's abnormal
compensations.
a. True
b. False