Muscle stiffness and
ture disorders that result from a disturbance in the develop-
strength and their
relation to hand
function in children
with hemiplegic
cerebral palsy
Daniela Virgínia Vaz* MSc PT, Physical Therapy Department;
Marisa Cotta Mancini ScD OT, Occupational Therapy
Department;
Sérgio T Fonseca ScD PT, Physical Therapy Department;
Danielle Soares Rocha Vieira PT;
Antônio Eustáquio de Melo Pertence ScD ME, Mechanical
Engineering Department, Federal University of Minas
Gerais, Belo Horizonte, Brazil.
*Correspondence to first author at Departamento de
Fisioterapia, Universidade Federal de Minas Gerais,
Av. Antônio Carlos 6627 – Escola de Educação Física,
Fisioterapia e Terapia Ocupacional, CEP: 31270-010,
Belo Horizonte, MG, Brazil.
E-mail: danielavvaz@gmail.com.br
This study compared the passive stiffness of wrist flexors and
the strength of wrist flexors and extensors in three different
wrist positions (30˚ of flexion, neutral, and 30˚ of extension)
between children with cerebral palsy (CP) and typically
developing (TD) comparison children. It also examined
associations between these characteristics and manual
function in children with CP. Eleven children with spastic
hemiplegic CP (six females, five males; mean age 8y 5mo [SD 1y
8mo], range 6–11y) and 11 TD children, matched for age and
sex, took part in this study. Passive stiffness of muscles was
measured as the torque/angle relation during passive motion.
Isometric strength tests were performed and the time needed
to complete three tasks based on the Jebsen–Taylor Hand
Function Test was recorded. Flexor stiffness was higher in
the group with CP. Strength of flexors and extensors in the
group with CP was lower with the wrist extended. No
difference among test positions was found in the TD group.
Moderate correlations were observed between manual
function and variables related to strength and stiffness of
wrist muscles in the group with CP. Children with CP showed
muscle alterations coherent with the use of the wrist in
flexion. Intervention on these characteristics could have a
positive impact on manual function.
728 Developmental Medicine & Child Neurology 2006, 48: 728–733
Cerebral palsy (CP) is characterized by movement and pos-
ing brain leading to primary and secondary impairments of
the sensory, neuromuscular, and musculoskeletal systems.1
Although the importance of characteristics such as strength
and intrinsic muscle properties for motor function in indi-
viduals with CP has been underestimated by some therapeu-
tic approaches,2 evidence indicates that these characteristics
may play an important role in movement patterns observed
in these children.3,4
Traditionally, the increased resistance against passive move-
ment in CP (hypertonia) has been exclusively attributed to
muscle hyperactivity caused by spasticity.5 Nevertheless, hyper-
tonia occurs even in the absence of electromyographic (EMG)
activity,4,6 which indicates alterations in intrinsic muscle prop-
erties.6,7 Several studies have quantified increases in passive
stiffness of muscles in individuals with CP.4,8,9 Friden and
Lieber10 demonstrated that muscle cells of the flexor carpi
ulnaris of children with CP are twice as rigid as muscle cells of
patients without neurological impairment. This increased
muscle stiffness can contribute to atypical postures and move-
ment problems in children with CP.
In addition to increases in stiffness, modifications in the
length–tension relation have also been observed.4,11 Brou-
wer and colleagues11 demonstrated that in children with CP
the peak plantar flexor torque is generated when the triceps
is in smaller lengths, compared with typically developing
(TD) children. In more lengthened positions, there is a dec-
rease in plantar flexor strength.11 Because strength is associat-
ed with motor function in children with CP,12 shifts in the
length–tension curves, causing weakness in specific ranges of
movement, may contribute to movement difficulties seen in
this population.
The altered intrinsic muscle characteristics of children with
CP may result from adaptations similar to those observed in
experimental immobilization models. Muscles maintained in
shortened positions demonstrate fewer series sarcomeres,13
reduced length, and increased passive stiffness.14 In contrast,
when muscle is maintained in a lengthened position, the num-
ber of series sarcomeres increases and the muscle becomes
longer.13 Immobilization of a muscle in shortened or length-
ened positions produces shifts in the muscle’s length–tension
relationship, so that maximum active tension generated by the
muscle occurs at a length next to the position at which it was
immobilized.14
As tissues adapt to functional demands, atypical motor
patterns can be associated with changes in muscle character-
istics. Children with CP tend to maintain the wrist in flexion
and show difficulties in extending this joint during manual
activities. This can be associated with increased passive stiff-
ness in the wrist flexors. Additionally, wrist flexors and exten-
sors are probably adapted to generate more tension with the
wrist in flexion. These muscle alterations, if present, could
limit hand function of these children.
This study aimed to compare children with CP and TD
comparison children for passive muscle stiffness of wrist
flexors, as well as the strength of wrist flexors and extensors,
in three different wrist positions: 30˚ of flexion, neutral, and
30˚ of extension. It also examined associations between man-
ual function and variables related to stiffness and strength in
children with CP.
Method
PARTICIPANTS
Eleven children with spastic hemiplegic CP (six females, five
males; mean age 8y 5mo [SD 1y 8mo], range 6–11y) and 11
TD children, matched for age and sex, participated in the
study. Children with CP used the affected hand mostly to assist
the non-affected hand during daily activities. They were able
to extend the wrist and fingers voluntarily, but used the wrist
predominantly in flexion during manual activities. They could
grasp and release objects with reduced quality and speed of
movement; most could move fingers in isolation and oppose
one or more fingers. No child was receiving interventions for
upper limb function, showed deficits greater than 10˚ in pas-
sive wrist extension, had undergone medical or surgical
interventions for the upper limb, or had any associated path-
ologies. Children of the TD group had no history of neurologi-
cal or musculoskeletal pathology. The study was approved by
the local ethics committee; parents signed a consent form.
Reliability coefficients (intraclass correlation coefficients
[ICCs]) for the measures used in this study were obtained in a
pilot study that included all 11 children of the CP group and
seven children of the TD group. Two sets of measurements
were performed 1 week apart. Assessments were performed in
the affected upper limb of the children with CP and in the non-
dominant limb of the TD children.
Initially, body mass (ICC=0.999) and hand length15
(ICC=0.913) were measured. After that, isometric strength
tests of wrist flexors and extensors were performed with the
wrist at 30˚ of flexion, neutral, and at 30˚ of extension. Test
order was randomized for the CP group and repeated for each
matched TD child. Each child was seated on a chair with a
device for upper limb stabilization attached. The hand was
positioned with the fingers extended against a support that
could be moved 180˚ around its axis which was aligned with
the wrist axis. Velcro straps were used to fasten the hand and
forearm (Fig. 1). For flexors tests, the support was positioned
against the palm of the hand and the child was asked to exert a
maximum effort to flex the wrist. The examiner positioned a
Microfet-2 dynamometer (Hoggan Health Industries, West
Jordan, UT, USA) against the support, always in the same area
Figure 1: Device for stabilization of upper limb and
positioning of dynamometer during isometric strength
tests of wrist flexors and extensors.
Muscle Characteristics and Hand Function in Children with CP Daniela Virgínia Vaz et al. 729
identified by a marker. For wrist extensors tests, the hand sup-
port was positioned against the dorsum of the hand and pro-
cedures were repeated. As a high level of agreement was
observed between three measurements in the same position
(ICCs: CP=0.93–0.98; TD=0.97–0.99) only one maximum
contraction of 5 seconds was performed in each position for
both muscle groups. One minute of rest was given between
contractions. Values registered by the dynamometer were mul-
tiplied by the length of the lever arm of the support device
(0.095m) and corrected for the hand length of each child
(ICCs: CP=0.81–0.93; TD=0.93–0.99, according to muscle
group and position tested).
For assessments of passive stiffness, a Biodex System 3 Pro
isokinetic dynamometer (Biodex Medical System, New York,
USA) was used in association with EMG monitoring of wrist
flexors and extensors with an MP100 unit (Biopac Systems,
Goleta, USA) connected to a computer. Forearm skin was
cleaned with alcohol and active surface electrodes were posi-
tioned over both muscle groups. A reference electrode was
placed on the acromion. The child was positioned on the
chair of the dynamometer. The hand was positioned with the
palm and extended fingers against a metal plate attached to
the lever arm of the dynamometer (Fig. 2). For stabilization,
elasticated bands were strapped to the arm and forearm.
The child was instructed to remain quiet and relaxed while
EMG baseline values were registered for flexors and extensors.
Ten passive movement repetitions of maximum wrist flexion
and extension at 10˚ per second were performed for tissue
viscoelastic accommodation. During the test, the dynamome-
ter speed was adjusted to 5˚ per second to avoid eliciting the
stretch reflex, and EMG activity of wrist flexors and extensors
was registered. The range from 0 to 60˚ of wrist extension
was considered for the calculation of passive stiffness of flex-
ors. All EMG data were collected at a frequency of 1000Hz, fil-
tered with a 10Hz highpass and 500Hz lowpass fourth-order
Butterworth filter and rectified. To eliminate the effect of
muscle activity on stiffness results, test trials were discarded
if EMG mean activity 2SDs larger than baseline values were
registered in one or more periods of 250ms of the test sig-
nal.16 Test procedure was repeated with 1-minute intervals
Figure 2: Child in position for passive stiffness measures,
with forearm and hand stabilized and electrodes in place
for electromyographic monitoring.
until three successful repetitions had been performed.
Resistance torques registered by the dynamometer were
treated with a fourth-order Butterworth filter with a low cut-off
(1.25Hz). A biomechanical model, considering body mass, age,
and hand length, was used to estimate the torques generated
by the weight of the hand.15 The estimated hand torques and
the torques generated by the metal plate were subtracted from
the torques registered by the dynamometer, allowing the mea-
surement of the remaining torque produced by the soft tis-
sues. Simple regression analyses between resulting resistance
torque values and joint angles were performed for each of the
three successful trials. The mean of the three regression slopes
was used as the value of passive muscle stiffness, expressed in
Joules per radian (ICCs: CP=0.96, TD=0.85).
Manual dexterity of the CP group was assessed with three
tasks based on the Jebsen–Taylor Hand Function Test,17 which
included: (1) picking up two pencils, two correction fluid bot-
tles, and two erasers and putting them in a can; (2) stacking
four wooden discs; and (3) picking up five round containers
(diameter 4.8cm, height 10.6cm). Children were instructed
to complete the tasks as fast as possible and were allowed a
maximum time of 40 seconds to complete each task.18 The
total time spent in the three tasks was registered in seconds
and used as the hand function score (ICC=0.98).
STATISTICAL ANALYSIS
Mixed analyses of variance (ANOVAs), with two repeated mea-
sures and one independent factor, were used to compare wrist
extensor and flexor strength between groups and between
the three test positions. Independent t-tests and Mann–Whitney
U tests were used to compare anthropometrical characteris-
tics and passive stiffness of flexors between groups.
Pearson’s product moment correlation coefficients and
Spearman’s rank correlations were performed to test associ-
ations between variables related to strength and stiffness of
wrist muscles and hand function in the CP group. A stepwise
multiple regression was performed with the independent
variables that correlated significantly with hand function.

Table I: Group estimates and comparisons between children with cerebral palsy (CP) and typically developing (TD) children

Variables CP group TD group Comparison of CP and TD groups p

Mean (SD) 95% CI Mean (SD) 95% CI Dif. between (95% CI)
means

Body mass (kg) 28.70 (7.30) 23.80 to 33.60 30.26 (9.79) 23.68 to 36.81 1.56 (–6.12 to 9.23) 0.677a
Hand length (m) 0.10 (0.01) 0.07 to 0.11 0.11 (0.01) 0.10 to 0.11 0.07 (–3.24 to 0.02) 0.059a
Flexor strength (N) 48.69 (16.47) 43.08 to 54.31 118.44 (32.50) 107.35 to 9.53 69.75 (57.08 to 82.42) 0.001a
Extensor strength (N) 17.93 (10.61) 14.31 to 21.55 60.64 (22.65) 52.91 to 68.37 42.71 (34.02 to 51.41) 0.001a
Median, IQR (95% CI) Median, IQR (95% CI) Dif. between medians (95% CI)

Flexor stiffness (J/rad) 0.192, 0.195 (0.17 to 0.52) 0.145, 0.076 (0.09 to 0.26) 0.076 (0.01 to 0.21) 0.02b
aDifference tested with independent t-test; bdifference tested with Mann–Whitney U test. IQR, interquartile range; CI, confidence interval.

Dif., difference; J/rad, Joules per radian.

Table II: Estimates for joint positions and comparisons between positions for wrist flexors and extensors strength values in
children with cerebral palsy and typically developing children

Cerebral palsy Typically developing

Flexor strength values at different wrist positions, mean (SD) 95% CI

30˚ extension 36.16 (9.06) 30.08 to 2.25 114.59 (33.80) 91.89 to 137.29
0˚ 49.27 (15.84) 39.09 to 60.36 123.25 (32.25) 101.59 to 144.91
30˚ flexion 60.18 (14.68) 50.32 to 70.04 117.48 (33.99) 94.65 to 140.32
Difference in flexor strength between test positions,
difference between means (95% CI), p
30˚ extension × 30˚ flexion 24.02 (13.88 to 53.93), p=0.001a 2.89 (–13.12 to 18.90), p=0.592
30˚ extension × 0˚ 13.56 (3.61 to 23.51), p=0.015a 8.66 (–4.67 to 21.98), p=0.114
30˚ flexion × 0˚ 10.46 (4.94 to 15.97), p=0.058 5.76 (–8.02 to 19.55), p=0.288
Extensor strength values at different wrist positions,
mean (SD) 95% CI
30˚ extension 9.35 (5.67) 5.54 to 13.15 59.57 (22.32) 44.57 to 74.56
0˚ 23.02 (12.14) 14.86 to 31.18 62.48 (21.36) 48.12 to 76.82
30˚ flexion 21.42 (7.58) 16.32 to 26.51 59.89 (26.11) 42.35 to 77.43
Difference in extensor strength between test positions,
difference between means (95% CI), p
30˚ extension × 30˚ flexion 12.07 (6.64 to 17.50), p=0.001a 0.33 (–7.63 to 8.28), p=0.920
30˚ extension × 0˚ 13.67 (7.408 to 19.94), p=0.001a 2.90 (–3.12 to 8.92), p=0.378
30˚ flexion × 0˚ 1.60 (–6.47 to 9.67), p=0.626 2.58 (–6.54 to 11.69), p=0.434
a Values significant at .p<0.05..CI, confidence interval.

730 Developmental Medicine & Child Neurology 2006, 48: 728–733

 Two children in the CP group produced extensor strength
equal to zero with the wrist at 30˚ of extension. Because the
threshold of the dynamometer was 3.5N, the extensor strength
of these children was possibly underestimated. Therefore, sen-
sitivity analyses, including five different strength values ranging
from 0 to 3.5N for both children were performed for all com-
parisons and correlations involving extensor strength at 30˚ of
wrist extension. As results were not altered by insertion of dif-
ferent values, data presented included the midpoint estimate
of 1.75N. In all analyses significance was set at p=0.05.
Results
Body mass did not differ between groups (p=0.677). The dif-
ference in hand length between groups demonstrated a strong
trend approaching significance (p=0.059). However, the
influence of this factor on results was minimized by normal-
ization of strength values by hand length. Wrist flexor stiff-
ness in the CP group was significantly greater than in the TD
group (p=0.023). Comparisons between groups are report-
ed in Table I.
Children with CP had lower strength values both for flex-
ors (p=0.001) and extensors (p=0.001) than TD children,
regardless of test position. Interaction effects of group by posi-
tion were observed for wrist flexors (p=0.021) and extensors
(p=0.026). Preplanned contrasts revealed no significant dif-
ference between test positions for flexors (p>0.114) or exten-
sors (p>0.296) in TD children. Children with CP produced
significant lower flexion (p<0.015) and extension (p<0.001)
strength with the wrist at 30˚ of extension compared with the
other two positions. Extensor strength did not differ between
30˚ of flexion and neutral (p=0.626). A strong trend towards
significantly greater strength values at 30˚ of flexion was
found for flexors (p=0.058). These results are reported in
Table II.
Moderate correlations were found between hand function
scores and variables related to strength and stiffness (Table
III). Time to complete tasks was directly associated with the
difference in extensor strength between 30˚ of flexion and
30˚ of extension (Dif ES) and inversely associated with the
ratio between extensor strength at 30˚ of wrist extension and
flexor stiffness (ES 30˚extension/FSt). The stepwise model was
significant (p=0.021) and included one variable, ES 30˚
extension/FSt, which explained 46.2% of the total variance in
hand-function score.
To control for possible influences of age on hand-function
scores, the association between these two variables was test-
ed. Results indicated a non-significant inverse correlation of
0.33 (Table III).
Discussion
Like animal experimental models that demonstrate increased
passive stiffness in muscles maintained in shortened positions,14
children with hemiplegic CP who use the wrist predominant-
ly in flexion during manual activities had significantly greater
flexor stiffness in comparison with TD children. Increased
resistance against passive movement in the absence of EMG
activity reflects changes in the mechanical properties of tis-
sues. Therefore, alterations in muscle tissue histochemistry
and histology are probably related to hypertonia in children
with CP. Several adaptations, such as increases in titin (a giant
protein related to myofibril stiffness)10 and collagen concen-
tration,19 or alterations in the orientation of collagen fibres,5
have been reported to occur in spastic muscles. Additionally,
alterations in the distribution of fibre types20 and decreases
in the ratio between muscle belly and tendon lengths have
been reported to occur in children with CP.4
Strength differences between joint positions reinforce the
argument for muscle tissue remodelling occurring in chil-
dren with CP. Children in the CP group produced significant-
ly lower flexor and extensor strength with the wrist extended
compared with other joint positions, which was not observed
in TD children. These alterations suggest shifts in the length–
tension curves of the wrist muscles in children with CP.
Alternative explanations for strength results include influences
of spasticity in muscle activation levels between positions
with different muscle lengths, which were not controlled in
this study. It could be argued that spasticity could contribute
to the decrease in strength observed in children with CP when

a b
Wrist physiological range Wrist physiological range

Maximum 0˚ Maximum Maximum 0˚ Maximum

flexion extension extension flexion
Tension
Tension

Length Length

Wrist flexors Wrist extensors

Figure 3: Consequences of shifts in length–tension curves of wrist flexors and extensors. (a) Flexor curve shifted to left owing
to tissue remodelling caused by maintenance of muscle in a shortened position. Tension decreases with wrist in extension
when flexors are excessively elongated. (b) Extensor curve shifted to right owing to tissue remodelling caused by
maintenance of muscle in an elongated position. Tension decreases with wrist in extension when flexors are excessively
shortened. , normal length–tension curves; , shifted length–tension curves.

Muscle Characteristics and Hand Function in Children with CP Daniela Virgínia Vaz et al. 731
the wrist was extended. Nevertheless, because spasticity is with the wrist in flexion could be attributed to an insufficient
characterized by muscle reflex activity that occurs during pas- number of test positions. Another explanation would be that
sive movement and ceases after movement is terminated,21 this the plateau of extensors could have been displaced to new
factor could not have influenced results of isometric strength wrist amplitudes which include neutral and 30˚ of flexion. A
tests. Strength results could also have been influenced by dif- strong trend towards significantly greater flexors strength
ferences between groups in the moment arms of wrist muscles. values at 30˚ of flexion was found; the 95% confidence inter-
However, no moment arm alterations were observed in chil- val for the difference between 30˚ of flexion and extension
dren with CP undergoing surgery for wrist flexion contrac- demonstrates the possibility of a true and clinically meaning-
tures.22 As no child of the CP group had contractures, moment ful difference between these joint positions.
arms probably did not influence results. Muscle alterations observed in children with CP appear to
A shift in the length–tension curves of wrist flexors and exten- reflect adaptations to the pattern of wrist flexion observed
sors in the CP group is probably the best explanation for the during manual activities. The excessive flexor stiffness and
decrease in strength in the extended wrist position. In adults, the decreased strength with the wrist in extension could make
both extensor and flexor peak strength occur with the wrist in the use of the wrist in extended amplitudes difficult and con-
extension.23 Such peaks were not observed in TD children, tribute to functional deficits. Results revealed associations
probably because of the few positions tested. Nevertheless, between hand function and variables related to muscle char-
results for children with CP were contrary to what is expect- acteristics in the CP group, suggesting that muscle properties
ed for TD children. that may impose limitations to wrist extension are associated
Within physiological range limits, wrist flexors work in the with poorer performance. The greater the difference in exten-
ascending portion of their length–tension curves23, as illus- sor strength between 30˚ of wrist flexion and extension (this
trated in Figure 3. A shift of the flexors curve to the left caused variable would reflect the shift in the extensors length–
by tissue remodelling in the shortened position,14 as proba- tension curve) the greater the time to complete manual tasks.
bly occurs in children with CP, would lead to an excessive Additionally, lower extensor strength in relation to flexor stiff-
sarcomere elongation at wrist extension and a consequent ness was associated with poorer hand function and explained
decrease in strength. On the other hand, extensors work in 46.2% of the total variation in hand functional scores. This
the descending portion of their curves, with tension increas- interpretation would be further confirmed by associations
ing as the wrist is extended.23 In children with CP, because between variables related to extensors strength at 30˚ of
extensors are maintained in lengthened positions, there would extension with better hand function (Table I), which could
be a shift of the curve to the right.14 Thus, with the wrist in have reached significance with a larger sample size.
extension, sarcomeres would still be in a less than ideal length It is not possible to determine if alterations in muscle char-
for tension development, and would only achieve adequate acteristics would cause functional difficulties, or if observed
lengths with wrist flexion (Fig. 3). movement patterns, adopted as adaptations to other deficits,
The fact that greater extensor strength was not produced would result in altered tissue demands and muscle remodel-
ling, as suggested by results. Both alternatives are possible
and may happen simultaneously in children with CP. Movement
and posture patterns depend on resources available to the
Table III: Correlations between hand function score and organism, and at the same time have an impact on these
variables related to strength and stiffness of wrist flexors and resources, establishing a cycle.24,25 It is possible that primary
extensors in children with cerebral palsy deficits such as weakness may lead the child to adopt com-
pensatory movement patterns to achieve functional goals.25
Variable r 95% CI p The weakness of wrist extensors would limit extension against
FSta 0.493 (–0.15 to 0.84) 0.118
gravity during manual activities. The maintenance of the wrist
FS 30˚ extensionb –0.017 (–0.61 to 0.58) 0.961 in flexion and the relative limb immobility would result in mus-
FS 0˚b –0.229 (–0.73 to 0.4) 0.498 cle tissue remodelling, with shifts in the length–tension curves
FS 30˚ flexionb –0.168 (–0.69 to 0.46) 0.621 of wrist muscles and increases in stiffness of wrist flexors.
ES 30˚ extensionb –0.564 (–0.76 to 0.05) 0.070 These alterations, in their turn, would contribute to the main-
ES 0˚b –0.306 (–0.76 to 0.35) 0.359 tenance of the wrist in flexion.
ES 30˚ flexionb 0.210 (–0.44 to 0.72) 0.534 A better understanding of the interaction between muscle
Mean ESb 0.128 (–0.51 to 0.67) 0.708 properties and motor dysfunction is necessary to meet the chal-
Mean FSa –0.073 (–0.64 to 0.55) 0.818 lenge of developing efficient intervention strategies to promote
Mean ES/Mean FSb 0.064 (–0.51 to 0.67) 0.852
functional improvements in children with CP. Interventions
ES/FS 30˚ extensiona –0.509 (–0.85 to 0.12) 0.109
ES/FS 0˚b –0.106 (–0.66 to 0.52) 0.756
aimed at the modification of muscle characteristics associated
ES/FS 30˚ flexionb 0.371 (–0.29 to 0.79) 0.261 with hand dysfunction could promote improvements in motor
Dif ESb 0.612 (0.03 to 0.89) 0.045 abilities for children with CP. Strengthening exercises for wrist
Dif FSb –0.155 (–0.69 to 0.49) 0.649 flexors and extensors in extended wrist amplitudes could
ES 30˚ extension/FStb –0.679 (–0.91 to –0.14) 0.021 promote improvements in strength through muscle tissue
Ageb –0.330 (–0.76 to 0.33) 0.310 remodelling and neural adaptation, as well as decreases in pas-
aCorrelation tested with Spearman’s rank correlation; bcorrelation
sive flexor stiffness. Future investigations should evaluate the
effects of such interventions in this population.
tested with Pearson’s product moment correlation. CI, confidence
intervals; FSt, flexor stiffness; FS, flexor strength; ES, extensor
strength; Dif, difference between strength values at 30˚ of wrist
flexion and 30˚ of wrist extension. DOI: 10.1017/S0012162206001563

732 Developmental Medicine & Child Neurology 2006, 48: 728–733

Accepted for publication 17th September 2005.
Acknowledgements
This research project was supported by a grant from the Brazilian
government through the Coordenação de Aperfeiçoamento de
Pessoal de Nível Superior (CAPES) to the first author.
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Bayley Scales of Infant and Toddler Development™

(Bayley III)

One-Day Training Workshop

9.30am – 4.30pm

Trainer: Betty Hutchon

Course fee: £80

Monday 16 October 2006, @ the Royal Free Hospital, London

This one-day workshop will introduce course participants to the Bayley-IIl.

It will include an overview of the subtests, a broad look at the changes from BSID II, research design,
psychometric properties, and special group studies. The Cognitive Scale, Language Scale, Motor Scale,
Social-Emotional, and Adaptive Behaviour Scales will all be discussed.
Administration and scoring procedures will be described and interpretative considerations discussed.
The workshop is aimed at paediatric therapists, psychologists, paediatricians, and others responsible for
assessing child development, who meet the criteria for a CL2 registration code with Harcourt Assessment.
A certificate will be issued on completion of the training day.

For information and application form, please contact:

Marilyn Dowdye, Administrator, Child Health Department, Royal Free Hampstead NHS Trust
Tel: 0207 830 2003. E-mail: marilyn.dowdye@royalfree.nhs.uk

Muscle Characteristics and Hand Function in Children with CP Daniela Virgínia Vaz et al. 733