Upper Limb Hypertonicity in Children with Cerebral Palsy: A review

Iranian Rehabilitation Journal, Vol. 11, No. 18, October 2013

Iranian Rehabilitation Journal

Reviews/Short communication

Upper Limb Hypertonicity in Children with Cerebral Palsy:

A review study on Medical and Rehabilitative Management

Rassafiani, Mehdi

, PhD.

Pediatric Neurorehabilitation Research Center,

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Akbar Fahimi, Nazila

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Robab Sahaf, PhD.

Iranian Research Center on Aging,

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Hypertonicity is the most common type of cerebral palsy consists of 85% of the affected children. It has a

very complex nature making intervention and management very difficult. This article tries to make reader

familiar with various types of intervention and introduce a new intervention process to help clinicians

decide better. Literature was reviewed with two criteria including: identifying various interventions and

their effects on upper limb hypertonicity and level of invasiveness of each intervention. This paper

suggested a new way of looking at hypertonicity based on its two components (i.e., neural and

biomechanical) and effectiveness of each intervention on these components. In the treatment and

management of hypertonicity, clinicians are required to look at all aspects of hypertonicity and then based

on the provided decision tree, decide which kind of treatment to be used for the child.

Keywords: hypertonicity, cerebral palsy, spasticity, intervention, decision making

Submitted: 15June 2013

Accepted: 27September 2013

Introduction

Upper limb (UL) Hypertonicity is a complex

problem in children with cerebral palsy (CP) that

needs to be fully understood in clinical decision

making. Three main issues need to be taken into

account in a successful model of intervention for

upper limb hypertonicity, including components of

hypertonicity, effectiveness of each intervention on

the components, and level of invasiveness of the

intervention. Based on these issues, a therapist can

follow a stepwise management of hypertonicity.

Hypertonicity has two components, including neural

(positive and negative symptoms) and biomechanical,

along with their specific subcategories described in

our previous article (1). All the components need to

be considered when managing such a complex

problem that is so important to expert occupational

therapists (2-4). Furthermore, a therapist should look

at the influences of various types of managements

and decide which management is useful for each

component. In other words, the management

strategies adopted for each of these components,

differ based on the nature of the problem. For

example, the biomechanical component of

hypertonicity responds to treatment involving

stretching, positioning, splinting and casting, but not

to drugs, injections, and intrathecal administration of

baclofen (5). Management of the negative symptoms

of the neural component differ, and include neuro-

developmental treatment, biomechanical approach

and constraint-induced movement therapy. Table 1).

summarizes the influence of different intervention

methods involved in the management of UL

hypertonicity on the neural and biomechanical

components of hypertonicity The next important

issue in the management of hypertonicity is the level

of invasiveness of each intervention. Different

methods of hypertonicity management can be

classified on the basis of their degree of invasiveness

see(

Figure 1). Level of invasiveness refers to the

level of harm that can be accompanied by each

intervention. Using this parameter, hands on

1- All correspondences to Dr. Mehdi Rassafiani, Email: <mrassafiani@yahoo.com>

Vol. 11, No. 18, October. 2013

techniques can be seen as the least invasive at one

end of a continuum and orthopedic surgery the most

invasive at the other end (6). This classification

helps occupational therapists identify an intervention

method, but the most important question is how to

choose the management method for a particular

client.(Figure 2). presents an overview of the

hypertonicity management process based on the

works of Barnes (2001) and Copley and Kuipers

(1999) that helps therapists in their clinical decision-

making by asking key questions (7). These

intervention methods will be elaborated in the

following section.

Table 1. The Intervention Methods and Their Influences on the Components of Hypertonicity

Neruo-developmental treatment;

Biomechanical approach;

Splinting;

Casting;

Constraint-induced

movement therapy;

Antispastic Drug;

Botulinum Toxin-A;

Itrathecal Baclofen;

Surgery.

Figure 1. Various managements of hypertonicity from the least invasive (hands on techniques) to the

most invasive (surgery)

1- Neuro-Developmental Treatment; 2- Constraint-Induced Movement Therapy;

3- Botulinum Toxin-A; 4- Selective Dorsal Rihzotomy

Iranian Rehabilitation Journal

Figure 2. Flow chart outlining the approach to the overall management of hypertonicity

(adapted from Barnes, 2001, p.8; Copley & Kuipers, 1999)

Vol. 11, No. 17, April. 2013

Hands on Techniques: Neuro-developmental

Treatment

Various frames of reference and approaches to the

treatment of neurobiological dysfunction have been

developed since the 1940s. Neurodevelopmental

treatment (NDT) is one of the most commonly used

frames of reference in the management of UL tonal

abnormalities (8). NDT was developed by Berta and

Karel Bobath in the 1940s. Originally, it was

developed for the treatment of children with

neurological impairments, especially those with CP

(9). However, NDT is now utilized for clients

(children and adults) with movement disabilities

such as neuromuscular disorders, and developmental

disabilities (10).

NDT was previously based on two important

principles: (1) the use of reflex inhibiting postures

(RIP) aimed at decreasing muscle tone by the use of

postures to oppose the primitive reflex patterns

typically assumed by the child and, (2) the facilitation

of normal motor development through righting and

equilibrium reactions (11). The aim of facilitation was

to help clients achieve motor developmental

milestones. Current theoretical foundations of NDT

include an in-depth understanding of normal

development, components of movement, and atypical

development (11). These theoretical foundations help

therapists to critically evaluate clients with CP, as well

as to develop appropriate treatment planning.

Normal development:

NDT adopts a developmental frame of reference and

while it was initially assumed that normal motor

development passed through a cephalo-to-caudal,

proximal-to-distal, and gross-to-fine sequence, this has

been replaced by the interactional idea, in which

development of a motor milestone depends not only on

improving the control of the distal part of the body, but

also at the same time on the proximal parts (11). For

example, developing sitting control is dependent on a

certain degree of pelvic and lower limb control. In

other words, the head and trunk, and lower limbs

interact in achieving control, alignment, and posture.

Therefore, development occurs through an interaction

between proximal and distal control (10).

Two other important concepts of normal development

in NDT consist of mechanisms of ‘feedback’ and

‘feed-forward’. Feedback is used to refine movement

during a task. For example, while a person is

writing, s/he may use proprioceptive, touch and

visual information to correct her/his movements

(11). Feedback can be either external (knowledge of

results) or internal (knowledge of performance) (10).

NDT puts an emphasis on feedback from three

primary sensory systems- vestibular, visual, and

somatosensory- during the execution of movements

(10, 11). Feed-forward is the anticipation of

movement and postural control that is very

important in functional activities (11). Feed-forward

happens, for example, when a person decides to pick

up a mug. If the person anticipates that an empty

mug is full, s/he will apply more effort to picking it

up than if the mug is thought to be empty.

The third concept of normal development in NDT

involves postural alignment, postural control, and

the base of support. Postural alignment is the ability

to maintain a center of gravity over the base of

support. The base of support is that part of the body

that makes contact with the support surface (11). For

example, in standing, the plantar surfaces of the feet

form the base of support. Postural control is the

ability to assume and keep postures during static and

dynamic movements, while postural alignment is a

prerequisite of postural control.

Components of Normal Motor Development:

Normal motor development has three components:

(1) interaction between stability and mobility, (2)

postural tone, and (3) ability to dissociate

movements. Stability involves retaining a posture

against opposing forces (11). The point of stability is

the body part in contact with the support surface. For

example, in the quadruped position, all four limbs

provide stability to the person. Mobility refers to

smooth, controlled, coordinated movement based on

a point of stability. The point of stability provides a

base of support to the person to achieve a weight

shift in any direction. This enables the person to

move and manipulate the environment (11). For

example, when in a quadruped position, a child can

shift weight onto his/her legs and left arm, in order

to free the right arm to reach out for a toy.

NDT emphasizes postural rather than muscle tone.

Postural tone is defined as the distribution of tone

throughout the body rather than in specific muscles.

Normal postural tone is an amount of tone that is low

enough to allow movement against gravity (mobility)

and at the same time is high enough to maintain a

stable posture against gravity (stability). Another

component of normal development is the ability to

dissociate movement, i.e. the ability to differentiate

movements between the various parts of the body. This

ability occurs within the first year of life and is a

demonstration of CNS maturation. It is illustrated by

separate movements between parts of the body and

Iranian Rehabilitation Journal

within a given part. In a normal infant, a variety of

movements can be observed when interacting with

objects in the environment. This variety of motor

development is the basis for the performance of

functional skills in which the person pays attention to

the goal of the movement rather than on the

performance of the movements (11).

Atypical Motor Development:

There are two assumptions underlying atypical motor

development, first, the disruption in feedback and feed-

forward mechanisms, and second, abnormal postural

control. Traditionally, NDT was modeled on the

hierarchical structure of the CNS in which there are

four levels of postural reflexes and reactions (i.e.,

spinal, brainstem, midbrain, and cortical level) (10). It

was believed that abnormal movements were caused

by the persistence of primitive reflexes or

compensatory attempts to gain antigravity control (11)

as well as sensory feedback (10). However, this model

has been changed to a ‘distributed control model’.

Based on the distributed control model, the CNS is

viewed as a system capable of initiating, anticipating

and controlling movements (10). The CNS is not a

passive system, but an active one using feedback and

feed-forward mechanisms to control posture and

movement. It is currently believed that abnormal

movements are the result of a disruption in the

feedback and feed-forward mechanisms. This impairs

the acquisition of postural control and changes the

experience of learning movement skills (10, 11).

Another assumption for abnormal movements is

related to problems in postural tone (11). For

example, increased muscle tone can limit

movements causing a reduction in the degree of

freedom of joints. This limitation leads to shortening

of muscle fibers and contractures. Abnormal

postural tone also interferes with movements

causing total pattern of movements (flexor or

extensor) (11). For example, when the person wants

to reach out to pick up something, instead of

coordinated and well-controlled movement in the

upper limbs, a whole flexor pattern can be seen that

is sometimes followed by abnormal head and trunk

movement. This is a kind of compensatory pattern of

movement resulting from abnormal postural tone

which the person employs to achieve some degree of

independence in functional activities.

Intervention:

Intervention within a NDT frame of reference occurs

through handling, preparation, and facilitation (11).

Handling is graded sensory input provided by the

therapist’s body, mostly hands, at key points of

control. It is used for preparation and facilitation of

active postural control and movement patterns.

Preparatory activities aim to promote mobility in

those areas with limitations in passive range of

movements and facilitate alignment of the body

before active movement. Based on improved body

alignment, muscle contraction around joints enables

stability and mobility to be achieved. Consequently,

movement and postural control are developed (11).

In other words, through handling, preparation and

facilitation, therapists utilize selective tactile and

proprioceptive input to produce alignment, gain

elongation of muscles, or facilitate normal muscle

contraction and movement (12). Therapists usually

employ compression, traction, deep pressure, weight

bearing, and weight shifting in the intervention

process and handling to facilitate motor control (11).

Two important considerations in the management of

clients involve active participation and gradual

withdrawal of direct input by the therapist (10, 11).

NDT sessions should be designed to include

functional activities that are important to the person

and encourage participation. These functional

activities, which use goal-directed feed-forward

mechanisms, should include activities of daily living

(e.g., dressing, feeding), and play (10).

Effectiveness of Neurodevelopmental Therapy:

Only a few studies have been conducted to

investigate the effectiveness of intensive and regular

NDT, with or without other types of therapy on

upper limb hypertonicity of children with CP.

Kluzik, Fetters, and Coryell (1990) studied the

influence of NDT on five children with

hypertonicity (13). The results indicated that NDT

improved the kinematic properties of reaching. The

smoothness of reaching improved and reaching

movements became significantly faster following the

intervention. In a similar study, Fetters and Kluzik

(1996) investigated the effectiveness of NDT on the

reaching behavior of eight children with CP (14).

The results supported those of Kluzik et al. (1990).

However, small sample sizes limit the confidence

with which these finding can be generalized.

Moreover, these studies did not show the influence

of NDT on functional outcomes.

Law et al. (1991) examined the influence of

intensive (two times therapy per week and 30

minutes daily home program) and regular (once-

weekly therapy and 15 minutes daily home program)

Vol. 11, No. 18, October. 2013

NDT, and casting on hand function, range of

movement, and quality of movement of 72 children

with hypertonic CP aged between 18 months and 8

years (15). The results demonstrated no differences

between the two interventions; however, casting

improved the results of the NDT. In another study,

Law et al. (1997) investigated the effectiveness of

NDT plus casting and occupational therapy on the

hand function of 50 children with CP aged between

18 months and 4 years (16). The results

demonstrated that both programs led to a significant

improvement in hand function, quality of upper limb

movements, and parents’ perception of hand

function, but no significant differences were

obtained between the two interventions. These

findings suggest no beneficial effects were achieved

by intensive NDT alone for the children in the study.

The effectiveness of NDT on upper limb

hypertonicity requires further investigation due to

limitations in the current literature (17). In addition,

the application of NDT has changed over the last

two decades; therefore its effectiveness needs to be

further examined. It is also necessary to compare

different intensities of NDT, as well as the results of

NDT interventions when used in conjunction with

other types of therapy.

Biomechanical Frame of Reference

The biomechanical frame of reference addresses the

implications of physical and physiological theories

on motor development (18). It applies the principles

of kinetics and kinematics to the movements of the

human body (19). This frame of reference aims to

improve range of motion, muscle strength, and

endurance, and reduce deformity or decrease the

effects of deformity (19-21) in people whose

capacities for functional motion are reduced.

The biomechanical frame of reference is based on

five assumptions (18). First, a biomechanical

approach provides external supports to substitute for

inadequate or abnormal postural reactions. In this

way it contributes to independence. Second, it

assumes that motor patterns develop from sensory

stimulation. In infancy, movements are mostly

reflexive and result from tactile, proprioceptive, or

vestibular stimuli. These reactions, in turn, provide

additional sensory input helping children to develop

motor control. Third, automatic motor responses

which maintain posture develop in a predictable

way. Righting and equilibrium reactions help

children to move to a position, and maintain that

position. The biomechanical frame of reference

concentrates on function within a relatively static

position (i.e., supine, prone, side-lying, sitting, and

standing) rather than dynamic situations. Fourth, the

development of normal postural reactions is

influenced by dysfunction or abnormalities of

muscle tone, bone, or the central nervous system.

Lastly, the level of postural dysfunction and external

factors that may affect performance must be

determined.

The biomechanical frame of reference is mostly

employed to treat people with orthopedic disabilities

(18). However, its basic concepts are utilized in

fabricating splints and casting to prevent or reduce

contracture and deformity in the limbs of clients with

hypertonicity. Intervention in the biomechanical frame

of reference happens through activities that provide

passive stretching of muscle, passive joint ranging (6,

22), positioning, head and trunk control, as well as

functional skills that promote head and arm

movements, mobility, feeding, and toileting (18).

Splinting

Splinting (for the upper limb) involves the use of

any medical device applied to or around the upper

limb to address physical problems (23). Splinting

aims to maintain muscular balance between

hypertonic muscles and their antagonists, to prevent

muscle and joint contracture and deformity, to

reduce hypertonicity and assist function by

positioning the upper limb, to reduce edema, manage

skin breakdown, and to maintain upper limb

appearance (6, 24).

Mechanisms of splinting can be explained through the

biomechanical, neurophysiological, and cognitive

motor learning frames of reference (6). Based on the

biomechanical frame of reference, splints provide

passive stretch, joint stability, maintain joint

alignments, and reduce pain. According to the

neurophysiological frame of reference, splints can

reduce hypertonicity through applying pressure on the

insertion of muscle tendons and constant stretching

over the hypertonic muscles, and providing neutral

warmth to the limb that is splinted. In addition, splints

assist people with hypertonicity to improve positioning

and achieve more normal movement patterns leading

to more effective function. There are various

classifications for splints based on function and the

major joints included (24). However, the most

important splints employed for hypertonicity include

resting hand splints, functional hand splints, elbow

splints, static splints, dynamic splints, and semi-

dynamic splints (6).

Iranian Rehabilitation Journal

Constraint-Induced Movement Therapy

Constraint induced movement therapy (CIMT) or

forced used training has been used as a method of

treatment for clients with stroke-induced hemiplegia

(25-27), and recently for children with CP (28-30) to

improve upper limb function. Charles and Gordon

(2005) reviewed literature and identified a moderate

success in motor performance following CIMT (31).

This technique employs motor restriction of the less-

affected or non-affected arm, as well as intensive

training of the more-affected arm (25). Results to

date suggest improvement in upper limb function in

the areas of reaching, grasping, releasing, and

weight bearing. It also reportedly assisted children to

develop motor abilities needed for play and daily

activities. However, the influence of CIMT requires

more investigation to understand the characteristics

of children who benefit from the intervention.

Moreover, it is essential to study possible adverse

side effects of this intervention (i.e., the client’s

emotional distress) (32).

Casting

Casting is another adjunct technique employed to

reduce hypertonicity and contracture. Casting has

been shown to improve range of movement and

decrease exaggerated muscle tone resulting from

hypertonicity (33). There are two mechanisms

underlying the effectiveness of casting: mechanical

and physiological (15). The biomechanical

mechanism of casting helps to promote muscle

lengthening and joint range of movement by

reducing soft-tissue contractures resulting from

long-term hypertonicity (34). The physiological

mechanism of casting is through provision of neutral

warmth and cutaneous pressure, and therefore

reduction of hypertonicity (15, 35). Suitable clients

for casting can be divided into two groups (36). The

first group is characterized by high physical

disability, little functional use of the limb, and

intellectual impairment. Casting aims, in this group,

to reduce hypertonicity and contracture in order to

make hygiene management and positioning for the

caregivers easier. The second group comprises

clients who have more active, functional use of the

upper limb and are more cognitively aware. Casting

for these clients aims to improve functional use of

the limb in activities of daily living.

Medical Management

Medical management of hypertonicity is complex,

multi-professional (37) and includes pharmaceutical,

neurosurgical, and orthopedic surgery. Choosing

among these strategies to control hypertonicity

depends on a number of factors including: age,

severity of spasticity, cognitive abilities, and

preference of family and/or doctor. The results of

these methods can be permanent such as orthopedic

surgery or reversible such as taking Valium. These

methods can be either general, such as selective

dorsal rhizotomy (SDR) or focal, such as Botulinum

toxin - A injection see Figure 3) (38).

Figure 3. Roles of different methods of the management of hypertonicity available for CP (adopted from

Graham et al., 2000, p.71)

Note. ITB: Intrathectal Baclofen; SDR: Selective Dorsal Rhizotomy; BTX-A: Botulinum Toxin- A.

Pharmacotherapy

Pharmacotherapy is a temporary management

strategy (38) regarded as additional rather than

substituent for physical management (39) of

hypertonicity in children with CP. It is easy to use

with a short term effect which can be given as focal

Vol. 11, No. 18, October. 2013

treatment such as botulinum toxin -A (BTX-A)

injection or generalized such as intrathecal baclofen.

Indications for pharmacological treatment of

hypertonicity include: (1) increasing tone despite

physical stretching or casting; (2) pain due to

hypertonicity; (3) prevention and treatment of

contracture formation; (4) prevention of deformities;

(5) management of skin hygiene; (6) cosmetic effect;

and (7) decreasing caregiver burden for performing

caregiver tasks (37). Medications may also help to

address hypertonicity in various methods and

include oral drugs, chemical neurolysis, intrathectal

baclofen, and BTX-A (37, 40).

Oral anti-spastic agents are generally given in the

presence of widespread hypertonicity rather than a

local problem (37) and consideration of a number of

issues is required. First, clear goals need to be

determined and communicated to clients in order to

ensure appropriate expectations (41). These goals

should be part of the rehabilitation process (37).

Second, the drug’s side effects should be explained

to the client. Third, anti-spastic drugs are usually

introduced at low doses and incrementally increased

to a point where it is clinically effective. Fourth,

most anti-spastic drugs can be given in combination

with each other to improve the clinical effects and

decrease side effects. Finally, it is important to

measure the outcome of drugs on the client’s

hypertonicity to see whether the goals of treatment

have been achieved (37). The most commonly used

drugs for the reduction of hypertonicity include

baclofen (lioresal), diazepam (Valium), tizanidine,

and dantrolene sodium, (40, 42).

Chemical neurolysis:

Chemical neurolysis is another method used to

reduce muscle hypertonicity. This method relieves

hypertonicity in most cases without significantly

affecting voluntary movement (43). In this method,

phenol or alcohol is employed in three ways to

provide chemical neurolysis including: peripheral

nerve blocks, motor point (intramuscular) injections

and the intrathecal administration (44). These

procedures are preferred to oral anti-spastic agents,

which often cause general adverse effects

influencing both normal and hypertonic muscles

(44). Phenol or alcohol injection is indicated in UL

hypertonicity to facilitate activities of daily living,

and improve hand hygiene. However, it may result

in vascular damage and loss of skin sensation.

Therefore, BTX-A is preferred to phenol and alcohol

for the management of UL hypertonicity (44).

The intramuscular injection of BTX-A is becoming a

popular procedure to reduce hypertonicity in

children with CP, and others. It causes a local

temporary muscle paralysis (45, 46) by inhibiting

presynaptic release of acetylcholine at the site of the

neuromuscular junction (47) leading to decreased

hypertonicity with minimal side effects (38). BTX-A

has also been reported to have positive effects on

cosmetic appearance (e.g., it helps correct the

“thumb in palm” posture) (48), quality of functional

movement of upper limb and functional capability in

children with CP (46, 49). BTX-A is also helpful in

surgical decision making for children with

hypertonic CP (50). When BTX-A is injected prior

to surgical intervention, it results in a condition

similar to tendon or muscle lengthening and tendon

transfer. This provides suitable information to the

surgeon to make decisions more efficiently.

BTX-A is indicated when a child has moderate

hypertonicity, no fixed contractures, fairly good

sensory awareness, and the ability to initiate movement

in the hand, as well as adequate grip strength prior to

injection (38, 46). However, these characteristics

require more in-depth research to understand the

criteria for indication of BTX-A injection and a

generally accepted treatment protocol (38). Moreover,

because the effects of BTX-A only last four months

(47), it is necessary to examine the long term effects as

well as the effects of several injections over a long

period of time. Although, BTX-A is an adjunct to

therapy (51), the influence of BTX-A plus

occupational therapy, physical therapy, splinting,

casting etc, requires further investigation to better

determine any interactions and the impact on various

aspects of disability such as strength, passive range of

motion, abnormal patterns, functional outcome, and

activities of daily living.

As previously mentioned, Baclofen can be delivered

orally to reduce hypertonicity. Additionally, it can be

administered intrathecally (Intrathecal Baclofen

Therapy or ITB) (T4-T6) to reduce hypertonicity in

upper limbs (37). Baclofen inhibits both monosynaptic

and polysynaptic reflexes causing a reduction in

spasticity (37, 52). It is used in clients with widespread

hypertonicity, and those in which alternative methods

of management are ineffective and inadequate, or

cause unacceptable side effects (52).

Almedia et al. (1997) used a single subject

experimental design to examine the effect of ITB on

a child with spastic diplegia over two years (53).

They demonstrated that ITB decreased spasticity,

but had no effect on range of movement. Upper limb

Iranian Rehabilitation Journal

movement speed, as well as dressing and the ability

to transfer improved. Since these results are based

on just a single case, more investigation is required.

Moreover, in the long term, the influence of

maturation needs to be considered. Albright, Barron,

Fasick et al. (1993) examined the effects of ITB on

upper limb hypertonicity of cerebral origin of 37

people aged 5 to 27 (54). They showed that ITB

reduced hypertonicity, and promoted upper limb

function, particularly it greatly improved the ability

to reach upward and supinate. It also improved

activities of daily living (ADL). Methodological

limitations such as the absence of a control group

limit the confidence with which these results can be

interpreted. In addition, there were no standard

assessments to assess ADL and functional changes.

Surgical Management of Hypertonicity

When hypertonicity is not controllable by drugs,

BTX-A, ITB, or chemical neurolysis, it may benefit

from neuro-ablative procedures, or orthopedic

surgery (55). Neuro-ablative procedures involve

selective lesions that can be performed at the level of

peripheral nerves (peripheral neurotomy), or spinal

roots (dorsal rhizotomy) (55). Peripheral

neurotomies (PN) are a technique indicated when

hypertonicity is localized to muscle groups supplied

by a single or a few peripheral nerves that are easily

accessible (55). In the upper limb, PN may be

performed in the musculocutaneous nerve for

hypertonic elbow flexion; in the median and ulnar

nerve for hypertonic wrist and finger flexors; or in

the brachial plexus branches for treating hypertonic

shoulder. PN helps to reduce hypertonicity and

deformity as well as improve motor function by

rebalancing the actions of agonist and antagonist

muscles. Selective dorsal rhizotomy is another

technique used to cut selective dorsal roots in the

spinal cord to decrease hypertonicity (55). Selective

dorsal rhizotomy is mostly employed to reduce

hypertonicity in lower limbs rather than in upper

limbs (56).

Orthopedic surgery aims to reduce pain, prevent or

correct deformity, and improve function, cosmetic

and hygiene (57). Common orthopedic procedures

include tendon release, muscle lengthening, tendon

transfer and osteotomies (55, 58). In the upper limb,

flexor digitorum lengthening is a common procedure

used for a hemiplegic hand to obtain a more

functional position. Tendon transfer is employed to

normalize articular orientation in case of muscular

imbalance (55). Osteotomies are another type of

surgery that aim to correct bone deformity resulting

from growth distortion used mostly for lower limbs

deformities (55).

Summary

This review provided a new model of practice in

children with upper limb hypertonicity based on the

components of hypertonicity and the level of

invasiveness of the intervention. These components

were used to help structure an outlook of

intervention strategies currently used in the

management of hypertonicity.

References

1. Rassafiani M, Sahaf R. Hypertonicity in children with

cerebral palsy: A new perspective. Iran Rehabil J.

2011;9:66–74.

2. Rassafiani M, Ziviani J, Rodger S, Dalgleish L. Managing

upper limb hypertonicity: Factors influencing therapists’

decisions. Br J Occup Ther. 2006;69(8):373–8.

3. Rassafiani M, Ziviani J, Rodger S, Dalgleish L.

Occupational therapists’ decision-making in the

management of clients with upper limb hypertonicity. Scand

J Occup Ther. 2008;15(2):105–15.

4. Rassafiani M, Ziviani J, Rodger S, Dalgleish L.

Identification of occupational therapy clinical expertise:

decision-making characteristics. Aust Occup Ther J.

2009;56(3):156–66.

5. Barnes MP. Overview of clinical management of spasticity.

In: Barnes MP, Johnson GR, editors. Upper motor neurone

syndrome and spasticity: Clinical management and

neurophysiology. Cambridge: Cambridge University Press;

2001,pp:1-11.

6. Copley JA, Kuipers K. Management of upper limb

hypertonicity. Therapy Skill Builders; 1999.

7. Rassafiani M. Occupational therapists’ decisions about the

management of upper limb hyertonicity in children and

adolescents with cerebral palsy. Brisbane: University of

Queensland; 2006.

8. Wilton J. Casting, splinting, and physical and occupational

therapy of hand deformity and dysfunction in cerebral palsy.

Hand Clin. 2003;19(4):573–84.

9. Bobath K. A neurophysiological basis for the treatment of

cerebral palsy. Cambridge University Press; 1991.

10.

Bly L. A historical and current view of the basis of NDT.

Pediatr Phys Ther. 1991;3(3):131–6.

11. Schoen S, Anderson J. Neurodevelopmental treatment frame

of reference. Fram Ref Pediatr Occup Ther. 1999;2:83–118.

12. Boehme R, Boehme J. Improving upper body control: An

approach to assessment and treatment of tonal dysfunction.

Therapy Skill Builders; 1988.

13. Kluzik J, Fetters L, Coryell J. Quantification of control: a

preliminary study of effects of neurodevelopmental

treatment on reaching in children with spastic cerebral palsy.

Phys Ther. 1990;70(2):65–76; discussion 76–78.

14. Fetters L, Kluzik J. The effects of neurodevelopmental

treatment versus practice on the reaching of children with

spastic cerebral palsy. Phys Ther. 1996;76(4):346–58.

15.

Law M, Cadman D, Rosenbaum P, Walter S, Russell D,

DeMatteo C. Neurodevelopmental therapy and upper-

Vol. 11, No. 18, October. 2013

extremity inhibitive casting for children with cerebral palsy.

Dev Med Child Neurol. 1991;33(5):379–87.

16. Law M, Russell D, Pollock N, Rosenbaum P, Walter S,

King G. A comparison of intensive neurodevelopmental

therapy plus casting and a regular occupational therapy

program for children with cerebral palsy. Dev Med Child

Neurol. 1997;39(10):664–70.

17. Butler C, Darrah J. Effects of neurodevelopmental treatment

(NDT) for cerebral palsy: an AACPDM evidence report.

Dev Med Child Neurol. 2001;43(11):778–90.

18. Colangelo CA. Biomechanical frame of reference. Fram Ref

Pediatr Occup Ther. 1999;257–322.

19. Kielhofner G. Conceptual foundations of occupational

therapy. FA Davis Philadelphia; 1992.

20. Pedretti LW, Early MB. Occupational performance: A

model for practice in physical dysfunction. LW Pedretti Ed

Occup Ther Pract Ski Phys Dysfunct. 1996;3–11.

21.

Reed KL, Sanderson SN. Concepts of occupational therapy.

Wolters Kluwer Health; 1999.

22. Trombly CA. Conceptual foundations for practice. Occup

Ther Phys Dysfunct. 2002;1–15.

23. Lunsford TR, Wallace JM. The orthotic prescription. In:

Goldberg B, Hsu JD, editors. Atlas of orthoses and assistive

devices. 3rd ed. St Louis: Mosby; 1997,pp:3-14.

24. Deshaies L. Upper extremity orthoses. In: Trombly CA,

Radomski MV, editors. Occupational therapy for physical

dysfunction. 5th ed. Philadelphia: Lippincott Williams &

Wilkins; 2002,pp:313-49.

25.

Taub E, Uswatte G. Constraint-induced movement therapy:

bridging from the primate laboratory to the stroke

rehabilitation laboratory. J Rehabil Med. 2003;(41

Suppl):34–40.

26. Taub E, Uswatte G, Morris DM. Improved motor recovery

after stroke and massive cortical reorganization following

Constraint-Induced Movement therapy. Phys Med Rehabil

Clin N Am. 2003;14(1):S77–91.

27. Taub E, Uswatte G, Pidikiti R. Constraint-Induced

Movement Therapy: a new family of techniques with broad

application to physical rehabilitation--a clinical review. J

Rehabil Res Dev. 1999;36(3):237–51.

28. DeLuca SC, Echols K, Ramey SL, Taub E. Pediatric

constraint-induced movement therapy for a young child with

cerebral palsy: two episodes of care. Phys Ther.

2003;83(11):1003–13.

29. Pierce SR, Daly K, Gallagher KG, Gershkoff AM,

Schaumburg SW. Constraint-induced therapy for a child

with hemiplegic cerebral palsy: a case report. Arch Phys

Med Rehabil. 2002;83(10):1462–3.

30. Willis JK, Morello A, Davie A, Rice JC, Bennett JT. Forced

use treatment of childhood hemiparesis. Pediatrics.

2002;110(1):94–6.

31. Charles J, Gordon AM. A critical review of constraint-

induced movement therapy and forced use in children with

hemiplegia. Neural Plast. 2005;12(2-3):245–261; discussion

263–272.

32. Gordon AM, Charles J, Wolf SL. Methods of constraint-

induced movement therapy for children with hemiplegic

cerebral palsy: development of a child-friendly intervention

for improving upper-extremity function. Arch Phys Med

Rehabil. 2005;86(4):837–44.

33. Teplicky R, Law M, Russell D. The effectiveness of casts,

orthoses, and splints for children with neurological

disorders. Infants Young Child. 2002;15(1):42–50.

34.

Tardieu C, Huet de la Tour E, Bret MD, Tardieu G. Muscle

hypoextensibility in children with cerebral palsy: I. Clinical

and experimental observations. Arch Phys Med Rehabil.

1982;63(3):97–102.

35. Yasukawa A. Upper extremity casting: adjunct treatment for

a child with cerebral palsy hemiplegia. Am J Occup Ther.

1990;44(9):840–6.

36. Stewart K, Chapparo C. Wrist casting to improve control of

the wrist and hand during the performance of occupational

tasks. Occup Perform Model Monogr. 1997;1:95–102.

37. Ward AB, Ko Ko C. Pharmacological management of

spasticity. In: Barnes MP, Johnson GR, editors. Upper motor

neurone syndrome and spasticity: Clinical management and

neurophysiology. Cambridge: Cambridge University Press;

2001,pp:165-87.

38. Graham HK, Aoki KR, Autti Ramo I, Boyd RN, Delgado

MR, Gaebler-Spira DJ, et al. Recommendations for the use

of botulinum toxin type A in the management of cerebral

palsy. Gait Posture. 2000;11(1):67–79.

39. Ko CK, Ward AB. Management of spasticity. Br J Hosp

Med. 1997;58(8):400–5.

40. O’Flaherty S, Waugh MC. Pharmacologic management of

the spastic and dystonic upper limb in children with cerebral

palsy. Hand Clin. 2003;19(4):585–9.

41. Wade DT. Neurological rehabilitation. Disability &

Rehabilitation. 1987;9(1):45–7.

42. Pirpiris M, Graham HK. Management of spasticity in

children. In: Barnes MP, Johnson GR, editors. Upper motor

neurone syndrome and spasticity: Clinical management and

neurophysiology. Cambridge: Cambridge University Press;

2001, pp:266-305.

43. Khalili AA, Betts HB. Peripheral nerve block with phenol in

the management of spasticity. J Am Med Assoc.

1967;200(13):1155–7.

44. Bakheit AMO. Chemical neurolysis in the management of

spasticity. In: Barnes MP, Johnson GR, editors. Upper motor

neurone syndrome and spasticity: Clinical management and

neurophysiology. Cambridge: Cambridge University Press;

2001,pp:188-205.

45. Davis EC, Barnes MP. The use of botulinum toxin in

spasticity. In: Barnes MP, Johnson GR, editors. Upper motor

neurone syndrome and spasticity: clinical management and

neurophysiology. Cambridge: Cambridge University press;

2001, pp:206-22.

46.

Fehlings D, Rang M, Glazier J, Steele C. Botulinum toxin

type A injections in the spastic upper extremity of children

with hemiplegia: child characteristics that predict a positive

outcome. Eur J Neurol. 2001;8(5):145–9.

47. Friedman A, Diamond M, Johnston MV, Daffner C. Effects

of botulinum toxin A on upper limb spasticity in children

with cerebral palsy. Am J Phys Med Rehabil.

2000;79(1):53–59; quiz 75–76.

48. Wall SA, Chait LA, Temlett JA, Perkins B, Hillen G,

Becker P. Botulinum A chemodenervation: a new modality

in cerebral palsied hands. Br J Plast Surg. 1993;46(8):703–6.

49. Denislic M, Meh D. Botulinum toxin in the treatment of

cerebral palsy. Neuropediatrics. 1995;26(5):249–52.

50. Autti Ramo I, Larsen A, Peltonen J, Taimo A, von Wendt L.

Botulinum toxin injection as an adjunct when planning hand

surgery in children with spastic hemiplegia. Neuropediatrics.

2000;31(1):4–8.

51.

Hurvitz EA, Conti GE, Brown SH. Changes in movement

characteristics of the spastic upper extremity after botulinum

toxin injection. Arch Phys Med Rehabil. 2003;84(3):444–

54.

Iranian Rehabilitation Journal

52. Rushton DN. Intrathecal baclofen for control of spinal and

supraspinal spasticity. In: Barnes MP, Johnson GR, editors.

Upper motor neurone syndrome and spasticity: Clinical

management and neurophysiology. Cambridge: Cambridge

University Press; 2001,pp:223-38.

53. Almeida GL, Campbell SK, Girolami GL, Penn RD, Corcos

DM. Multidimensional assessment of motor function in a

child with cerebral palsy following intrathecal

administration of baclofen. Phys Ther. 1997;77(7):751–64.

54.

Albright AL, Barron WB, Fasick MP, Polinko P, Janosky J.

Continuous intrathecal baclofen infusion for spasticity of

cerebral origin. J Am Med Assoc. 1993;270(20):2475–7.

55. Mertens P, Sindou M. Surgical management of spasticity. In:

Barnes MP, Johnson GR, editors. Upper motor neurone

syndrome and spasticity: Clinical management and

neurophysiology. Cambridge: Cambridge University Press;

2001,pp:239-65.

56. Styer Acevedo J, Tecklin JS. Physical therapy for the child

with cerebral palsy. Pediatr Phys Ther. 1999;107–62.

57.

Chin TY, Duncan JA, Johnstone BR, Graham HK.

Management of the upper limb in cerebral palsy. J Pediatr

Orthop B. 2005;14(6):389–404.

58. Ratliffe KT, Ratliffe CE, Robertson J. Clinical pediatric

physical therapy: A guide for the physical therapy team.

Mosby; 1998.