Report B3 Development of an Intervention Plan of Care for a Young Child with Hemiplegia

Case Report B3 Development of an Intervention Plan of Care for a Young Child with Hemiplegia

Pamela A. Mullens

B3.1 Introduction

When using the Neuro-Developmental Treatment (NDT) Practice Model in the formation of a care plan for a young child with hemiparesis, practitioners should consider the child holistically, within the context of his or her world. The world for many infants includes their parents and family, as well as care providers. As the child ages and develops cognitive, communication, manual-bimanual, and mobility skills, the boundaries of the child’s world expand. The confidence and sense of self needed to venture away from the security and safety of a trusted caregiver evolve over time, with small successes laying the foundation for larger achievements. This case report explores the possible relationships among the body structures and functions, activities, and participation for a young child with hemiparesis, with a focus on the context of his psycho-social-emotional development.

The term hemiplegia is commonly used to describe the manifestation of a neurological insult to the brain resulting in sensorimotor deficits where one side of the body is more affected than the other. Hemiplegia may refer to a complete paralysis of the involved limbs and hemiparesis to a weakness. For the purposes of this case report, we will refer to hemiparesis, or weakness.

B3.2 Common Features of Congenital Hemiparesis

Identification and diagnosis of hemiparesis in early infancy can be challenging for the clinician. One of the earliest signs of the movement disorder is the presence of asymmetrical postures and movements; asymmetry may be seen in the infant who is typically developing up to 4 months of age, with the asymmetrical postures being most evident at ~2 months of age. Bobath and Bo-bath,1 Bly,2 and Kong and Quinton (lecture notes from a course in Neuro-Developmental Treatment conducted in Seattle, Washington, 1978) have described the natural progression of the development of movement in children with hemiparesis from infancy to the mastery of upright function.

Fisting of the more involved hand has been reported as an initial sign of hemiparesis and is seen in conjunction with delayed motor milestones and increasing movement asymmetries.1,2 Initially, the leg on the hemiparetic side is not as active in kicking as the less involved leg.1 The trunk on the more involved side is also affected, initially appearing hypotonic,2 and later may become shortened due to spasticity of trunk musculature as the infant begins to sit and stand.1 Bobath and Bobath1 also noted that, as motor development progresses and the child comes to sitting and begins to play using the less involved arm and hand, the arm on the hemiparetic side frequently tends to retract at the shoulder and may be held with elbow flexion and fisting of the hand.1 Atypical movement synergies in the leg on the more involved side become increasingly apparent as the child develops the ability to stand and walk.1 Hypertonicity in the more involved upper and lower extremities frequently increases as the child comes to standing and begins to walk.

Additionally, failure to progress through patterns of movement seen in typical development may result in bio-mechanical abnormalities. Due to atypical or restricted movement patterns, soft tissue structures, such as muscles, ligaments, and connective tissue, may not receive the lengthening provided by typically developing movement. This failure to lengthen, in turn, contributes to the development of secondary musculoskeletal impairments.2,3,4

Contractures may develop over time if muscles and joints are held consistently in static positions4,5 and may lead to bony abnormalities.2 Limb growth on the affected side may be reduced as a result of decreased and asymmetrical weight shifting and weight bearing and decreased muscle activation.6 Reduction of weight bearing over the more involved limbs may result in osteoporosis,7 and pain and arthritis may occur earlier in the population of adults with cerebral palsy than in the population at large.7,8,9

Sensory deficits, including tactile, proprioceptive, kinesthetic, and visual field deficits, are also reported in children with congenital hemiplegia,10,11 contributing to neglect of the more involved arm. Neglect of the more involved arm may increase when the child engages in reaching activities with the less involved arm. The child attends to movement and function of the less involved arm while ignoring the more involved arm that cannot perform movement effectively. This neglect includes lack of visual attention to the arm and hand and decreased attention to tactile, kinesthetic, and proprioceptive sensation in the involved upper limb. The increasing activity of the less involved side frequently results in increased stiffness of the more involved arm, resulting in fisting of the hand, elbow flexion, and forearm pronation. Gradually, the child appears to ignore and reject the arm on the hemiparetic side. The child may refuse to look at the more involved arm and hand and dislike being touched on that side.1

Therapeutic management of the primary and secondary impairments associated with spastic hemiparesis in cerebral palsy in children requires an approach that takes into account and fosters the child’s psychosocial development and the interaction between this development and body system impairments. NDT offers a viable clinical practice to the management of hemiparesis in young children. NDT’s Practice Theory and Practice Model address the impairments underlying participation restrictions and activity limitations and stress the importance of the prevention of secondary impairments, including impairments in aspects of psychosocial development that may limit function as the child grows and develops. These models also strive to work with the child in the context of the family and to support parents/caregivers in understanding their child’s integrities, impairments, capabilities, and functional limitations so that they can promote optimal function and participation.

Perry’s intervention began in the first year of life. Early intervention beginning, if possible, in the first year of life is compatible with motor development principles of the NDT Practice Model. The earlier the intervention begins, the greater the opportunity for prevention of contractures and the attainment of functional goals. Basu12 supports this principle and recommends continuing efforts to improve early detection of perinatal stroke so that intervention can begin at a time when activity-dependent plasticity in descending motor pathways is active and available.

B3.3 Case Report

This case report documents the diagnosis, the presenting problems, and the integrities of Perry, a young child with hemiparesis. It also documents the development and application of a plan of intervention specifically designed for Perry.

B3.3.1 Case Description

This case report follows Perry during a 2-year period of physical therapy beginning at the age of 9 months. His initial examination findings revealed delays in fine, gross, and oral motor function, as well as the emergence of impairments in the neuromuscular, musculoskeletal, and sensory-perceptual systems.

B3.3.2 Information Gathering

Perry was born at term; his mother reports that her pregnancy was typical, with no complicating factors. A medical evaluation was sought when Perry was observed not moving his left arm and his hand was held in a fisted position. At the age of 7 months, he was diagnosed with right middle cerebral artery infarct with cystic encephalomalacia. Within the first 2 years, there were reported concerns about the possible presence of seizure activity. On account of these concerns and because seizure activity frequently accompanies this diagnosis,13 Perry was referred to a neurologist. Seizure activity did not present problems during this period of intervention.

Perry and his mother participated in an integrated infant/mother group at the University of Washington Experimental Education Unit (EEU) that provided Perry with educational services, occupational therapy, and speech-language therapy. It did not offer physical therapy, so these additional outpatient services were sought and began at the age of 9 months.

Perry is the youngest of three children in a two-parent family. His mother is not employed outside of their home, and his father is a professional employed in the field of special education. Additionally, the extended family was available for support. Perry’s parents were willing to learn and do whatever was necessary to help their son.

B3.3.3 Examination: Observations and Initial Hypothesizing

Perry was first observed both in his home and at the infant/mother program at the University of Washington. The intent of the observation was to become acquainted with him and with his family, to determine his level of function, and to form initial hypotheses regarding impairments underlying observed activity limitations. These observations were made without handling by the therapist to obtain information regarding spontaneous behavior.

Participation and Participation Restrictions

Perry participated in the life of his family in the role of the youngest child. He also attended and participated in the infant/mother class at the EEU. Perry was unable to participate in the life of his family at the level expected of a 9-month-old child, primarily due to activity limitations preventing him from performing at an expected age level. He preferred not to leave his mother’s lap, and he was carried by his mother, since he had no independent means of locomotion and could not actively explore his room and house independently.

Activities and Activity Limitations


Perry played in a sitting position on the floor, supported in his high chair, or sitting on an adult’s lap. His preference was to be on his mother’s lap or to be carried by his mother. He liked to play with toy cars, noise-making toys (toys that made sound when shaken or banged or pressed), balls, and household items, such as pots and pans. He also enjoyed books and pictures. Perry used only his right hand to engage in play; no two-handed play was observed during the initial examination. When seated on the floor, Perry played with toys that were brought to him and presented either in front of him or on the right side. He ignored objects presented on the left. If toys went out of reach in front of him, he reached for them by bringing his trunk forward with hip flexion. Attempts to retrieve toys out of his reach on his right side were not noted.


Breast-feeding was Perry’s main source of nutrition. He also sat in a high chair at the table for family meals but ate very little. He was offered pureed and some solid food. He ate pudding and ice cream from a spoon, and sometimes he held a cookie or other solid food in his right hand, brought it to his mouth, and ate small amounts.

Breast-feeding appeared to be a factor in self-regulation as well as in nutrition. When Perry became anxious, he gestured and indicated that he wanted to breast-feed. When Perry lay on his right side for breast-feeding, he brought his left arm and hand forward to touch his mother’s body. He opened his left hand and held it against her; this appeared to be a purposeful movement and was the only voluntary movement of the left arm that was observed during the initial examination.


As expected for his age, Perry did not communicate verbally during the observation period. However, he demonstrated a well-developed gestural system of communication. He used facial expression, body movement, and vocalizations to indicate his emotional state and his likes, dislikes, and wants. He pointed with his right hand at objects he wanted and made sounds that drew attention to his gestures.


Perry had no independent form of locomotion. He moved around in the environment held and carried by his mother. Infants of 9 months of age typically have a form of independent locomotion.3,14,15 Independent locomotion allows an infant to explore the environment and to gain competence in securing and investigating interesting objects in the environment. Without independent locomotion, these experiences were not available to Perry.

Lack of independent mobility prevented Perry from moving away from and toward other people and from developing age-appropriate separation from and reunion with his mother. He demonstrated no transitional movements, which further prevented him from experiencing independence in moving to upright positions.

Perry’s inability to move away from his mother influenced his social development and his relationship with his mother. Children of 9 months of age are usually able to control their distance from the mother and use her as a secure base from which to explore the environment. They are able to return to her in the presence of perceived threats in the environment or for reassurance. This ability to control proximity to the caregiver allows the infant to consolidate and further develop the attachment relationship.16

Multisystem Integrities and Impairments

Given Perry’s lack of self-driven environmental exploration and spontaneous movement transitions, he was placed in specific developmental positions to examine his movement capabilities, postural control, and motor control. Perry’s mother moved and positioned him because he became easily agitated if he was separated from her or if he was moved or positioned by the therapist. These observations were directed toward determination of single-system and multisystem issues within the domain of body structure and function, underlying observed activity limitations.


In this position, Perry raised both legs from the surface to ~90° of hip flexion on the right and ~45° on the left. He reached forward with his right hand to touch his legs and toes (more frequently the right leg but occasionally the left). He did not reach forward with the left hand. When assisted to reach with his left arm and hand, he appeared frustrated.


Perry tolerated the prone position for less than 2 minutes. He could not move his arms forward for support or push against the surface to lift his upper body. He attempted to move, but he quickly became anxious and frustrated.


From supine lying, he could roll to the right and left sides. He was unable to transition from supine to prone due to his inability to move his right or left arm out from under his body.


Perry maintained static balance when placed in sitting. He could not transition to sitting from the supine or prone positions. Occasionally, he fell from sitting to lying. He did not attempt to correct for disturbances of balance or reassume the sitting position. During play, if a toy strayed to the right side, he reached to the right only as far as he could without losing balance. He did not reach toward the left. He sat with both legs in hip abduction and external rotation, with his left leg slightly more externally rotated than the right. His left arm hung at his side, with the left hand usually in a fisted position. When Perry performed effortful movement with the right arm and hand, the left arm assumed a position of elbow flexion, shoulder abduction, and slight retraction of the shoulder complex.

Postural Control in Sitting

Perry sat with his pelvis upright with apparently equal weight distribution on the right and left sides of his base of support. He demonstrated limited weight shifting in all directions. In the sagittal plane, Perry reached forward until his hips were at ~45° flexion and then returned to midline. Weight shifting and reaching backward in space were not observed.

Supported Standing

Perry took weight over both legs when held in supported standing. He enjoyed this position. He attempted to shift weight from side to side and took forward steps with support of a caregiver holding his right hand.

Balance in Sitting and Supported Standing (Demonstrating Integration of Postural Control and Limb Movement)

Perry exhibited protective and supporting behaviors in his right upper extremity (UE) in the sagittal and frontal planes but not in the transverse plane. Protective and supporting reactions were not observed to the left or in the left UE.

Fine Motor Control

Perry used his right hand for play, demonstrating a radial-palmar or scissors grasp pattern for small objects when positioned in sitting on the floor or in his high chair.

Control and Coordination of Left Upper Extremity (Integration of Posture and Movement)

Spontaneous movement of Perry’s left UE was very limited and noted primarily during breast-feeding. At other times when sitting or held, Perry predominantly maintained his left arm and hand at his side with a slightly fisted hand. At times, he showed some degree of volitional movement in his left arm and hand. When his right arm was manually constrained, he opened the left hand and reached for objects with the left hand. The reach was grossly accurate, but he had no grasp or release with the hand. He became anxious and frustrated because the hand would not grasp. His behavior (crying and beating his head) was interpreted to indicate frustration and a desire that he wished his left arm to remain undisturbed. Additionally, Perry refused to look directly at his left hand and arm. When attention was drawn to his hand, he would not look in that direction.

The initial observations of activities/activity limitations and multisystem integrities and impairments led the therapist to hypothesize as to which single systems needed specific examination. The following systems were targeted for examination.

Body Structure and Function Integrities and Impairments

Muscle Tone and Activity

Perry’s left arm displayed variable muscle tone ranging from low to high tone (measured by resistance to passive movement). At rest, tone in the trunk and arm musculature appeared low, although the left hand was frequently fisted with the thumb adducted. With strenuous use of the right hand, involuntary muscle activity in the left arm increased. The left arm assumed a high guard position—arm abducted at the shoulder and elbow flexed, forearm in pronation, wrist flexed, and hand fisted. Vigorous activity of the right arm also caused the left leg to exhibit increased hip flexion, abduction, and external rotation, knee flexion, ankle plantar flexion, and clawing of the toes. Additionally, in a supported standing position, strong excitement (annoyance or pleasure) or vigorous activity in the right arm resulted in clawing of the toes of the left foot.

Differences in muscle activity between the right and left sides of Perry’s trunk were difficult to assess due to minimal differences between his right and left sides. Muscle activity in response to lateral weight shifting was present bilaterally but was slower on the left. This difference in response time between the two sides may be an indication that muscle activity was slightly lower on the left side when compared with his right.

Musculoskeletal System—Range of Motion

Perry showed full range of motion bilaterally in his shoulders, elbows, forearm, wrist, and fingers. Full range of motion was present in his hips, knees, and ankles.

Musculoskeletal System—Strength

There was weakness of the left elbow extensors. Strength was difficult to assess due to infrequent volitional movements of the left extremities.

Tactile System

Perry’s perception of light touch, deep pressure, and sharp and blunt sensation in his left arm was examined when his visual attention was diverted. Perry did not respond to sensory input to his left arm if his attention was diverted. When he saw that his left arm was being touched, he objected, used the right arm to move the left arm to the right, and covered it with his right arm so that it could no longer be touched. Similar behaviors were not noted relative to touch of his left lower extremity (LE). Perry localized to touch of his legs and did not become upset. He also was observed to touch his left leg with his right arm. Perry responded to touch on both sides of his trunk.


Kinesthesia also appeared to be impaired on the left side with the upper limb more involved when compared with his lower limb. If Perry’s arm was moved when he was looking away from the left side (when he could not see the arm), he did not react at all, giving the impression that he was unaware of the movement or touch. He reacted to passive movement or position change in the left leg when vision was diverted from the limb, by moving his leg and looking toward that limb.

Visual Tracking

Perry visually tracked objects in the vertical and horizontal directions. Visual fields also appeared to be intact.

Vestibular System

Perry’s vestibular system was not formally examined, although it appeared to be functioning at an age-appropriate level, based on observations of the orientation of his head and body in space and the presence of righting responses.

Neuromuscular System

Perry’s movements in the left arm and leg were slow, demonstrating limited control and coordination of muscle activity on his left more so than his right side and greater difficulty with control in his arm when compared with his leg. He had more difficulty in recruiting motor units in the left arm. Perry also had difficulty isolating motor activity on the left side and in the arm more so than the leg. The muscle synergies observed were more massed synergies, with less refined movement, particularly distally. Perry’s left arm tended to pull into patterns of flexion, rather than extension, with stiffness varying from slightly low at rest, to increased with effort and emotion. There were no signs of clonus or tremor.

B3.3.4 Evaluation

The NDT Practice Model emphasizes the constant interweaving of assessing information from many sources to determine their meaning. With Perry, his family life and his personality, his integrities, the central nervous system pathology, and his participation, activities, and body systems were all considered in a holistic picture when determining the meanings of these factors and findings. Using the International Classification of Functioning, Disability and Health (ICF) model17 of human functioning, an evaluation of findings was structured.

Contextual Factors: Facilitators and Barriers


Perry was surrounded by an immediate and an extended family who were interested in helping him. His mother was open to suggestions as to how she might encourage use of the left arm and hand, but she had not received instruction in doing this. She was an important resource. The father is a professional in the field of special education. He appeared to have a good relationship with Perry and to be effective in working with him to achieve the goals of therapy. He did not attend therapy sessions as frequently as the mother due to work responsibilities. However, he participated in meetings related to Perry’s Individual Family Service Plan (IFSP) at the EEU and in doctor’s appointments.

Perry was interested in play and was easily engaged in songs and activities that could be adapted to promote use of the left arm and hand. He also admired some fictional characters, such as Diego, and would perform activities and assume positions if they resembled Diego’s moves. These moves lent themselves to adaptation promoting the goals of therapy.


Perry was becoming proficient in learning to function using only the right hand. In extreme cases, the natural progression of development of children with severe hemiparesis is that they learn to move and function using the less involved arm and hand only. Perry seemed to be progressing in that direction. He discouraged any attention to his left arm, he showed anxiety and anger about weight shifting to the left, and he remained in sitting, playing only with the right hand. He showed passivity in that he ignored objects that moved out of his reach and made no active attempt to retrieve them or to move from one position to another. It was difficult to handle and move Perry because he preferred to be with his mother and his immediate family, and he became anxious if separated from her or if he was handled by anyone unfamiliar. He showed distress and anxiety regarding any attention directed to his left UE. This distress and anxiety made sensory testing and any form of intervention to the left arm difficult, even while he was on his mother’s lap.

Body Structures and Functions

Tactile, Proprioceptive, and Kinesthetic Systems

Perry appeared to have severe loss of proprioceptive, tactile, and kinesthetic sensation in the left arm and hand and/or inability to attend to and process sensory information from the left arm. At 9 months of age, it was difficult to determine whether actual system impairments or inattention to sensory information was the major factor contributing to the neglect of the left arm and hand. Perry responded to tactile input to his left and right leg and to the left and right sides of his trunk.

Vestibular System

The role of the vestibular system as an underlying factor in the activity limitations was difficult to determine. The vestibular system together with vision and other sensory systems is purported to play a role in the development of protective and supporting reactions and the development of balance.

Visual System

No visual field deficits were reported in neurological evaluations, and Perry showed no difficulty with horizontal or vertical visual tracking. However, Perry did not have eye–hand coordination on the left because he did not look at his left arm and hand. He could look at objects on the left but diverted his gaze from his left hand.

Musculoskeletal System

Perry showed no asymmetry of upper or lower extremity length, and there was full range of motion in all joints. There was muscle weakness in the left elbow extensors.

Neuromuscular System

Perry demonstrated the greatest number of impairments of neuromuscular control and coordination in his left UE with some difficulties in the left LE and remarkably few expressions of the impairments in his trunk. In the left arm, the most obvious impairment was decreased isolated control (that was hypothesized to be due to involuntary muscle overflow and loss of selective motor control) within and between the arms, and to a lesser degree within the distal aspect of his left leg. At times, Perry’s left foot assumed a position of plantar flexion at the ankle and clawing of the toes. He demonstrated slightly limited recruitment of postural motor units with his arm presenting with lower tone at rest but with the hand fisting, suggesting the ongoing recruitment of phasic motor units. In addition, Perry demonstrated decreased integration of postural functions and movement functions within his left arm with decreased use of the limb for support during transitions, and decreased use of the limb to move rapidly and then support as in protective reactions. Other signs of poor timing and sequencing of muscle activation were slow and imprecise movements in the left arm. The left arm was typically held in flexion, distally greater than proximally. Movements into extension were infrequent, demonstrating limited synergy or muscle group selection. The stiffness in his left arm varied from being lower at rest but increasing with effort and emotion. The hyperstiffness was greatest in the hand.

B3.3.5 Relationship of Body System Impairments to Activity Limitations

The following list exemplifies the body system impairments as they were hypothesized to relate to activity and activity limitations.

Activity Limitations

• Absence of transitional movements from prone to supine, supine to prone, sitting to lying, or lying to sitting.

image Pushing away from the surface with the arm is a component of these transitional movements at the 9-month-old level of development.3 Perry lacked the ability to push away from the surface with the left arm.

• No independent form of locomotion, such as creeping on all fours.

image Support on an extended arm is a component of creeping. Creeping is a common method of locomotion at 9 months of age.3 Support on the left arm and the ability to generate sufficient force to push with the left arm are necessary to perform the above transitional movements.

Possible Underlying Body System Impairments

• Sensory system impairments or sensory processing deficits leading to neglect of the left arm and preventing use of the left arm for support.

• Neuromuscular impairments.

image Imbalance of flexor and extensor muscles and postural tone in the left arm resulting in difficulty maintaining extension of the left elbow.

image Lack of ability to terminate flexor activity in the fingers and wrist preventing opening of the hand to grasp.

image Limited recruitment of postural motor units, particularly of extensors throughout the arm. Poor integration of postural and phasic motor units. Stiffness varied from low to hyperstiffness. Limited isolated control within and between the arms.

• Musculoskeletal system.

• Weakness of elbow extensors.

Possible Underlying Multisystem Impairments

• Lack of lateral weight shifting to the left in sitting.

• Lack of protective and supporting reactions in left arm.

• Lack of bimanual hand activity and fine motor control.

In summary, Perry’s sensory system deficits, neuromuscular impairments, and weakness of the elbow extensors on the left (musculoskeletal impairment) appear to be underlying factors in all activity limitations for Perry. His refusal to direct vision to his hand was a strong factor underlying deficits in fine motor control. The vestibular system may be a factor underlying lack of weight shifting to the left in sitting.

Hypothesizing the Relationships of Activity to Body Systems

One of the key features of the NDT Practice Model is to evaluate the possible effects of participation restrictions, activity limitations, and multiple system/body system impairments on the functioning of a person throughout the lifespan. For Perry, the following possibilities exist.

• Although Perry did not demonstrate musculoskeletal system impairments at this time, except for weakness of the left elbow extensors, he is at risk for secondary impairments including the following:

image Asymmetrical limb length (due to reduced weight bearing on the left leg and left arm).

image Restricted joint motion including

image heel cord contracture due to increased stiffness in the left plantar flexor muscles.

image elbow and wrist flexion contractures and limited motion in forearm supination due to increased stiffness in elbow and wrist flexor muscles and forearm pronators.

B3.3.6 Intervention

Perry received physical therapy at his home once a week. The physical therapy program at home was coordinated with the infant program at the EEU. The physical therapist attended the meeting where the IFSP was created, and the occupational therapist visited Perry at his home and observed the physical therapy. This interaction promoted collaboration with the staff of the infant program. The infant program placed strong emphasis on promoting independent mobility, drawing attention to the left arm and hand, providing sensory input, and promoting use of the left arm and hand in play and other activities. The teacher, the occupational therapist, and the physical therapist collaborated on this goal, thus providing consistent and regular practice in a variety of settings.

The intervention program (plan of care) was created based on information from observation of spontaneous behavior, from examination and evaluation, from literature related to the development of children with hemiplegia and hemiparesis, and from an understanding of Perry’s interests, preferences, and emotional reactions to his hemiparesis.

The reports from other team members, including the occupational therapist (OT), speech-language pathologist (SLP), and teacher at the EEU, were used to guide the intervention plan. Perry received a concentrated period of play therapy from a child psychoanalyst. The report of the psychoanalyst was another factor used to guide the intervention plan. The physical therapist did not address oral motor therapy because this was provided by the SLP at the EEU. The intervention program included a review of the targeted outcomes and provided specific examples of home program recommendations made for the parents, as well as specific examples of the therapeutic activities performed by the therapist with Perry.

General Aims of Intervention and Global Plan of Care

To assist Perry in developing transitional movements and an independent mode of locomotion

Desired Goals for Physical Therapy

Desired goals 1 and 2 are subservient or preparatory to goal 3.

1. To promote awareness of the left UE by encouraging visual attention to the arm and hand (getting Perry to look at his arm and hand) and by providing tactile, proprioceptive, and kinesthetic input to the arm and hand.

2. To allow muscle length to keep pace with limb growth during development, to prevent secondary impairments such as muscle shortening and joint capsule and ligament tightness leading to joint contracture.

3. To move independently from supine to prone lying, from prone lying to sitting, and sitting to either prone or supine lying, to creep on all fours, and to begin pulling to a standing position. As far as possible, weight bearing over the left arm and leg will be incorporated into the movements.

Desired Short-Term Physical Therapy Outcomes

• Perry will look at his left hand at least twice during a weekly physical therapy intervention session for 4 weeks in succession. This could include looking at the hand spontaneously while performing an activity with the arm and hand independently or with assistance, or when tactile, proprioceptive, or tactile stimulation is applied to the left arm or hand.

• Perry will incorporate the left arm in a simple two-handed activity, such as clapping hands, holding onto a handle bar with two hands, or holding a ball with both hands without assistance.

• Perry will transition from lying to sitting independently, incorporating weight bearing over the left arm during the transition.

Specific Examples of Direct Intervention

The home program was the initial focus of intervention. Later, other activities were included in therapy sessions. Since the intervention began with the home program, this program will be described first.

Family Instruction and Home Programs

Initially, Perry showed anxiety and was reluctant to separate from his mother. Although the aim was to help him to accept age-appropriate separation, it was important to provide effective intervention immediately to encourage the development of efficient posture and movement, to prevent secondary impairments, and to stem his present tendency to perform all activities without using the left arm and hand. In view of the urgency for initiating intervention parent instruction was integral to the intervention plan.

Initially, much of the intervention was given with Perry held by his mother or sitting on her lap. Having the parent carry out parts of the therapy program at home increased the intensity of the therapy. Perry’s mother was advised of the need to maintain appropriate range of motion and muscle length, particularly in the left hamstrings, left heel cord, and left shoulder, elbow, wrist, fingers, and thumb.

The first step in the intervention program was to design a home program that was possible for the family and appropriate to the therapy goals. The parents were advised that the design of the home program was a collaborative effort between them and the therapist and that anything too difficult, uncomfortable, or in any way burdensome could be changed or replaced.

Perry’s mother needed handling skills that would fit into her daily routine of bathing, feeding, diapering, lifting, carrying, and so on. At each home visit, intervention focused on an activity of daily living and worked on making this a time to optimize use of and attention to the left arm and hand and on other therapy goals. Perry’s mother was creative in incorporating the goals of therapy into many play activities and activities of daily living. She was able to incorporate therapy in to a variety of settings, thus providing repetition and variability of practice.

Specific Suggestions for Activities during Diapering

During diaper changing, the mother and caregivers were encouraged to include the following:

• Encouraging activities to provide elongation of hamstrings, knee extensors, and heel cords.

• Bringing both arms into elevation above Perry’s head and playing the game “So big.”

• Flexing hips and knees toward the chest and then bringing both arms forward with hands on knees.

• Drawing visual attention to the hands and knees.

Bath Time Suggestions

At bath time, the mother worked on encouraging Perry to attend to the soap being rubbed on the left arm and in putting soap or lotion on the left hand and having him apply it to the right arm. He also rubbed soap and lotion on the left arm with his right hand. He played such games as splashing in the bath with hands and both feet and hiding the left arm under soap bubbles in the water and having his mother ask Perry where it was. He would then bring the arm out and show it.


The left arm was incorporated into dressing to draw visual attention to the arm as in bathing and diapering. For much of the time, the movement was largely assisted movement, as in bringing the arms forward for pulling off socks.

Other Activities Outside of Therapy Sessions

Based on her understanding of the therapy goals, the mother invented and adapted games. She played pata-cake with Perry and facilitated use of both hands, and when he was on a hobbyhorse at home, she assisted him in holding on with two hands.

Perry’s family enrolled him in a music class for pre-school children. The activities of this class encouraged bimanual activity. For example, Perry held hands with children on his left and right sides when they formed circles for various activities. They also had a variety of bells and percussion instruments that needed bimanual activity. The class was also an opportunity for social interaction since Perry enjoyed being with the other children.

Physical Therapy Intervention Sessions

In addition to the home program and the school program, Perry received individual physical therapy sessions. These sessions included intervention strategies designed to achieve the established desired outcomes.

The following is an example of these strategies. Perry performed assigned tasks more easily with his left arm and hand when the arm and hand were prepared by giving sensory input at the beginning of the session. Due to Perry’s age, this was done in a play situation. Perry was challenged to cover up the patterns on the rug at the entrance of the clinic. The therapist said that she hoped he was not going to cover up the patterns on her rug so that she could not see them. He gave an impish smile, opened his hands, and covered some of the patterns on the rug with both hands as seen in Fig. B3.1. Sometimes, he would do this in a hands and knees position and sometimes on hands and feet. In both instances, this activity provided weight bearing through the arms, and tactile sensation to the hands from the pile of the rug. In this and in the following activity, Perry was in control. He put his own hands on the rug. This sense of control was important in gaining his trust and cooperation.

The sensory input continued with an emphasis on the hands. Sometimes, the therapist would ask Perry to warm her hands. Again, the emphasis was placed on him doing something to her. As the activity progressed, a reciprocal pattern of the therapist and Perry doing something to each other’s hands was introduced. For example, the therapist warmed her hands by rubbing them against Perry’s hands, or Perry’s hands were held against the therapist’s hands and were rubbed.

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Jul 16, 2016 | Posted by in NEUROSURGERY | Comments Off on Report B3 Development of an Intervention Plan of Care for a Young Child with Hemiplegia

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