3. Balance InterventionsBetsy Mullan, PT, PCS

a weight dangle on a limb in the absence of muscle effort or external support.

Children should not exercise the same muscle group on consecutive days. If excessive soreness is present or persists, or if muscle tightness worsens as a result of the strengthening program, the protocol should be modified. The presence of a seizure disorder may also preclude participation for some pa- tients if these are poorly controlled by medication and are exacerbated by increased physical effort. Physician approval should be obtained before ini- tiating a weight-training program with any child.

Both isotonic and isokinetic training programs have been shown to in- crease strength and motor function in CP, as quantified by the Gross Motor Function Measure.

Gait improvements that have been reported include increased velocity at free and fastest speed, primarily through increased ca- dence, increased active motion in the muscles trained, and greater stability in stance.

Improved self-perception has also been noted,

but more research is needed to examine these and other effects from specific programs and activities.

Weakness limits functional performance in CP, but can be improved through training. Therapists should also be more proactively involved in pre- vention of secondary impairments and promotion of wellness and fitness in their patients. Strength and endurance training are important components of fitness, and may promote more optimal health across the lifespan and increase participation in recreational, social, and occupational activities in children and adults with CP.

3. Balance Interventions Betsy Mullan, PT, PCS

The impairments of motor control and tone in and of themselves can pre- sent a balance problem to patients, or there can even be further impairments of the vestibular and sensory system, which affect balance and equilibrium, thus creating an even more complicated picture.

Balance cannot be separated from the action of which it is an integral component or from the environment in which it is performed.

Normal bal- ance development involves three systems: the vestibular, visual, and somato- sensory. Initially, vision is critical to postural control development, peaking during times when major gross motor development skill transitions occur in sitting to crawling, crawling to standing, and standing to walking.

Postural responses, such as those of children on a moving platform, vary with the age of the child. The apparent integration of the visual, vestibular, and somato- sensory inputs appears to occur by 4 to 6 years of age, with the responses of the 7- to 10-year-old group being similar to adults.

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Table R2. Sample isokinetic program.

GOAL: Increase torque and rate of torque production in knee extensor and ankle dorsiflexor muscles on a hemiplegic extremity to improve gait

LOAD: Accommodating resistance with “window” set at 80%–90% of maximum effort FREQUENCY/DURATION: Three times per week for 8 weeks

SESSION: Ten repetitions (concentric) at 2 speeds (30, 60/sec) with rests as needed;

10 repetitions (eccentric) at 30°/sec for each muscle group

POSITION: Semireclining sitting position on device using standard knee and ankle attachments and protocols

PROGRESS: Increased to higher speed by 30 as soon as person can exert force to match speed of machine throughout the range (concentric only)

Cerebral palsy is a disorder with multisystem impairments, which may affect the visual, vestibular, and/or somatosensory systems. Nasher et al.

found inappropriate sequencing of muscle activity, poor anticipatory regu- lation of muscle sequencing during postural control, and postural stability that was frequently interrupted by destabilizing synergistic or antagonistic muscle activity in individuals with CP.

It is evident that physical therapists working with individuals with CP need to assess as well as address these bal- ance issues, keeping in mind the action that is required and the environment in which it is being performed.

Balance is a component of most, if not all, developmental assessments including the Gross Motor Function Measure, the Bruininks–Osterestky Test of Motor Proficiency, the Peabody Developmental Motor Scales, and the WeeFIM. These tests can be useful in helping the therapist ascertain whether the balance issue is visual (eyes open or closed), vestibular, or somatosensory (is the surface moving or not). It is also important to evaluate the child’s bal- ance needs and deficits relative to their task demands (sitting independently for dressing versus going to school and navigating the busy hallways), as well as the child’s and parents’ concerns and goals. This information can then be utilized to customize a treatment program.

Interventions should include various handling and treatment techniques mentioned elsewhere in this volume to help the child achieve success. Envi- ronments must be structured and tasks created in both open and closed sit- uations to allow the greatest carryover to functional life skills. Closed tasks

are those whose characteristics do not change from one trial to the next;

these require less information processing with practice. Open tasks

require more information processing. In closed environments

in which surround- ings are fixed, children do not need to fit their balance into external timing, but can manage the situation at their own speed. Open environments require more attention and information processing.

Clinicians should keep in mind the action requiring balance, as well as the environment in which the child needs to function,

to appropriately assess and plan interactions to maximize a child’s function in their environment.

4. Electrical Stimulation Techniques Adam J. Rush, MD

An area that has received a great deal of press and a great deal of anecdotal experience is the role of electrical stimulation in CP. A review of the litera- ture is very confusing, and there is great inconsistency from one medical cen- ter to the next as to what they are referring. Dr. L.J. Michaud probably has the most lucid discussion of electrical stimulation in CP.

Making recommendations regarding which children should receive neu- romuscular electrical stimulation (NMES) or transcutaneous electrical stim- ulation (TES) is a problem. Although there is no literature indicating that any particular group of children were likely to be harmed by it, or less likely to benefit, most children studied were mild to moderately affected by CP and seemed to have fairly good cognition. Furthermore, the worst side effect re- ported was a local skin reaction from the stimulating pads. Therefore, one could say that this is a harmless intervention that might be attempted in any child with CP. However, studies have not been performed comparing vari- ous regimens with each other.

We appear to have a recurring theme of therapists applying NMES and choosing their stimulation parameters based on personal experience, rather than based on good science. Dr. Michaud’s article suggests the following,

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