Pediatrics
Special Issue
B.D. Ulrich, PhD, is Professor and
Director, Developmental Neuro-
motor Control Laboratory, School
of Kinesiology, University of Mich-
igan, 401 Washtenaw Ave, Room
4745H, Ann Arbor, MI 48109-
2214 (USA). Address all corre-
spondence to Dr Ulrich at:
bdulrich@umich.edu.
[Ulrich BD. Opportunities for early
intervention based on theory, basic
neuroscience, and clinical science.
Phys Ther. 2010;90:1868 –1880.]
© 2010 American Physical Therapy
Association
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this article at:
ptjournal.apta.org
1868 f Physical Therapy Volume 90
Opportunities for Early Intervention
Based on Theory, Basic Neuroscience,
and Clinical Science
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Beverly D. Ulrich
Therapeutic approaches in the pediatric population have generally been less aggres-
sive than those implemented for younger and older adults. Several factors contribute
to this, starting with the challenge of engaging infants in the “goal” of therapy, their
resistance to initiating behaviors that are uncomfortable or fatiguing, the desire to
make therapy as functionally relevant as possible when many functional skills have
yet to emerge, and residual history of outdated theoretical concepts. On the practical
side of who will pay for this more aggressive approach, there is limited empirical
evidence based on randomized controlled trials to convince third-party payers to fund
more extensive services. This article outlines a theoretical perspective prominent in
developmental science that argues not only for the importance of frequent bouts of
functionally relevant activity on the self-organization of behavioral patterns, but also
for the impact that should be expected from the use of rigorous interventions on
underlying subsystems, such as neural organization, that support these outcomes. In
order to propose some future opportunities for clinical research and application,
examples from recent activity-based clinical studies are presented, along with theo-
retical principles, neuroscience, and other tissue science data concerning mecha-
nisms that contribute to behavioral changes. One such opportunity is to increase the
structured engagement of caregivers, guided by therapists, in administering well-
defined activity intervention programs focused on the development of specific
functional skills. Such an approach may be one of the few financially feasible options
for generating sufficient therapy that adheres to principles for optimizing develop-
ment of neuromotor control.
Number 12 December 2010

T
his is such an exciting time!
Health care systems are in-
tensely focused on the need to
be efficient and cost-effective in
treatments, coverage for everyone is
a central goal of the US president’s
administration, and theory and data
support the importance of early and
aggressive intervention to reduce
long-term costs and improve out-
comes. The question is, can we cap-
italize on this moment in time to
expand support for early interven-
tion for infants and young children,
thus leading them to a future in
which they optimize their own de-
velopment and functional outcomes?
I believe efforts such as this, using
the power of the American Physical
Therapy Association’s media to speak
to so many readers, is a critical and
important step in that process. How-
ever, the message also must reach
legislators, funding agencies, and the
grassroots support of families to pro-
mote both the quality-of-life value to
citizens and the economic efficien-
cies of early, sustained, and aggres-
sive therapeutic interventions.
One important goal in the overall
plan to improve health and curb medi-
cal costs is to decrease obesity and in-
activity. Activity-based protocols also
are core to therapy for motor disabil-
ities to improve neuromotor control,
muscle strength (force-generating ca-
pacity) and endurance, and cardio-
vascular function. In the following
pages, I highlight the importance of
significant levels of activity very early
in life for optimizing behavioral out-
comes. I outline contemporary theo-
retical explanations for change, dis-
cuss research on change in some
specific mechanisms that are impor-
tant to optimizing motor behavior,
and highlight clinical studies focused
on changing motor behavior via in-
creased activity. From this founda-
tion, I propose some opportunities
for future developmental neuromo-
tor control research and clinical
interventions.
December 2010
Opportunities for Early Intervention
Theoretical Foundation
Finding an agreed-upon name for a
unified theory to explain the emer-
gence of, and change in, motor skills
over time is more difficult today
than it was a decade ago. In 2000, I
would have selected easily the term
“dynamic systems theory,” although
even then “theories” (plural) would
have been more appropriate, given
the diversity of disciplines from which
the core principles emerged.1,2 To-
day, terms used more frequently that
embrace similar underlying concepts
and expand to include the growing
body of neuromotor data include “de-
velopmental systems approach,”3–5
“probabilistic epigenesis,”6 and
“neuroconstructivism.”7–9 To avoid
the confusion of adding another term
to the mix, I suggest that the material
that follows may cluster under the
more inclusive of these options: devel-
opmental systems.
One of the most important conclu-
sions scientists examining and devel-
oping these approaches, including
dynamic systems, support is that the
extant body of data moves us be-
yond relevance in continuing to ac-
cept or debate a nature-nurture di-
chotomy with regard to the causes
underlying emergence of and changes
in patterns of behavior over time.
This conclusion holds, whether we
examine change early in life or later,
at all levels, from subcellular enti-
ties to human organisms and popu-
lations. Replacing this is focus on
processes—the ways in which many
components in a system interact,
sometimes including those with no
obvious relevance, causing change
among each other and in behavior.
Smith eloquently laid out such an
approach during a speech delivered
at the International Conference on
Infant Studies in 1998 and subse-
quently in publication.10 Spencer and
colleagues updated this argument
recently in a target article in Child
Development Perspectives.3 Their
point is that attributing behaviors,
Volume 90
even those as persistent across intact
humans as the emergence of walk-
ing, to an a priori genetic code for
primacy is neither defensible empir-
ically nor helpful in terms of facilitat-
ing the emergence or recovery of
this functional skill. Genes, to quote
Spencer et al, “do not create any-
thing. . . . Genes participate in the
production of proteins and in the
regulation of other genes. The build-
ing of brains, bodies, and flexibility
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involves a cascading developmental
process in which genes and their
products interact within their local
environment to create the substrates
for further development.”11(p104) Nor
does this argument accept that hu-
mans or their brains are blank slates,
on which organization and behav-
ior are created exclusively by a
process of learning or exploration of
the world around them. However,
development is a process of self-
organization, among multiple fac-
tors, within the organism and with-
out, driven by interactions and
experiences. For description alone,
one might ignore processes that
drive change; to have an impact on
change in a system, we must under-
stand the history, context, and inter-
actions that constructed the current
state in order to facilitate subsequent
adaptations.
That behavior is dynamic and adap-
tive may be illustrated by a series of
Available With
This Article at
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• Discussion Podcast: Special Issue
authors Linda Fetters, Regina
Harbourne, and Beatrix Vereijken
discuss the clinical implications of
their work. Moderator is James
(Cole) Galloway.
• Audio Abstracts Podcast
This article was published ahead of
print on October 21, 2010, at
ptjournal.apta.org.
Number 12 Physical Therapy f 1869
Opportunities for Early Intervention
studies that addressed historical ob-
servations of an inverted U in the
development of stepping in infants,
part of the traditional sequence of
motor milestones in infancy. Matura-
tionist and some neurophysiological
approaches proposed that neonatal
stepping is a reflex, the essence of
which resides in a central pattern
generator (CPG), that is innately pre-
scribed, located in the spinal cord,
and, ultimately, is the core compo-
nent for, later in life, walking.12,13
Sensory stimuli, provided by holding
newborns upright and moving them
forward over a firm surface, activate
the neural program and cause step-
ping. By 2 to 3 months of age, this
behavior disappears, to reappear be-
tween 8 and 11 months of age when
infants cruise and walk. The argu-
ment was that as the nervous system
matures, higher levels of the central
nervous system inhibit the free-
running action of the CPG, then re-
structure in subsequent months to
drive the onset of walking.14,15
Thelen and Ulrich16,17 illustrated the
dynamic and plastic nature of infant
stepping by showing that intralimb
and interlimb temporal and kine-
matic characteristics of newborn steps
persisted in other postures, such as
supine kicking, and that stepping dis-
played its own trajectory of interlimb
coordination patterns when the con-
text was shifted and infants were
supported upright on a motorized
treadmill. Even when stepping was
supposed to be inhibited by higher
brain centers, the behavior was eas-
ily elicited when infants were sup-
ported in water,18 and given prac-
tice, stepping never disappeared at
all.19,20 Furthermore, the behaviors
infants generate when supported on
a treadmill are not stereotypic. Sev-
eral researchers17,21–23 have shown
that when babies step on a treadmill,
their leg movements are highly vari-
able, yet adaptive. Early in life,
the treadmill elicits a variety of inter-
limb couplings (alternating, single,
1870 f Physical Therapy Volume 90
parallel, and double steps), and in-
fants produce lots of nonstepping leg
movements, then settle into alterna-
tion over time, without directed prac-
tice.17,22 They used multiple foot pos-
tures to contact the support surface at
the end of swing, including heel-strike,
which was not deemed available
based on maturationists’ arguments,
until several months after walking on-
set.12,24 When the treadmill belt was
split down the middle and one side
moved twice as fast as the other, in-
fants adapted spontaneously by mod-
ulating the “fast” leg to a slower fre-
quency and increasing the frequency
on the “slow” leg to maintain a steady
interlimb coordination.17,25
Yet, underlying these overt alternat-
ing kinematic patterns on the tread-
mill were muscle activations that
only began to show signs of consis-
tency or rhythmicity late in the first
year. While the many muscles and
joints in the legs and pelvis con-
verged to produce the net effect of
patterned behaviors, the underlying
neuromotor system vascillated among
many of the possible combinations
of muscle activity to respond to this
context (unpublished research).26
Just as toddlers explore their many
options for which muscles to use,
including the timing of their onset
and duration, to control upright loco-
motion before they settle into a stable
activation pattern,27,28 infants demon-
strate similarly on a treadmill the dy-
namic and adaptive responses possible
to produce this kinematic pattern of
globally rhythmic leg flexions and
extensions.
The implication of these data is not
that organized populations of neu-
rons in the spinal cord and brain do
not play critical roles in the emer-
gence of stepping and walking, but
rather that the essence of walking
does not reside in any of these neu-
ral modules. Stepping behaviors, like
other patterns of movement, are dy-
namic, fluid, and adaptive; their
Number 12
essence is in the convergence of
many innate and external factors, in-
cluding the context and goal of the
performer. Furthermore, popula-
tions of neurons in the spinal cord
are themselves dynamic, affected by
the process of perceiving and acting,
of changes in the periphery and cen-
trally, like other populations of neu-
rons throughout the nervous system.
Research also has shown that hu-
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mans, including infants and young
children, have multiple, redundant
pathways for achieving the same
functional goal. Variability in
individual behaviors was a hallmark
of the earliest descriptions of motor
patterns observed by developmental-
ists such as McGraw,29,30 Gesell,31
and Shirley.32 Collapsing their many
observations into normative age
means and categories seems to have
obscured the fact that infants who
are typically and atypically develop-
ing skip common milestones, revert
to earlier patterns after more com-
plex ones emerge, and produce their
own unique patterns under varied
environmental contexts and their
own performance goals. To be clear,
these early scientists themselves cor-
related their developmental se-
quences and progressions with un-
derlying neural maturation. Yet, as
McGraw30 concluded in later writ-
ings, attempts to uncover unique
neural substrates that drove these
maturational outcomes had largely
failed.
For a vivid illustration of the flaws in
attributing motor outcomes to single
causes, such as neural substrates, we
can draw from populations such as
children and others with Down syn-
drome (DS), in which multiple fac-
tors play a more visible role. One
lovely example is in the solution
such infants tend to discover for
shifting posture from prone to
seated. Like infants with typical de-
velopment, they begin the transition
by pushing their chests off the
December 2010

surface with their arms, but there the
similarity ends. Infants with typical
development swing their legs to-
gether around to one side and for-
ward; infants with DS slide their
legs first in opposite directions into
abduction (doing a split) and then
forward.33 Given the extreme laxity
in their hip joints, this pattern is the
path of least resistance for accom-
plishing their goal. Not directed by a
prescribed neural plan for their ac-
tions, infants with DS, like their
peers without DS, are opportunistic,
discovering through exploration and
practice actions that accomplish
their goal, given their current state of
subsystem characteristics and the
context. Infants with DS can shift to
producing more typical patterns for
this transition if extrinsic constraints
are imposed, such as placing thera-
peutic bands around the legs, mak-
ing parallel leg movements the path
of least resistance.
Similarly, children who are healthy
with relatively shallow hip joints
may discover that scooting on their
bottoms provides better overall sta-
bility, yet allows a more upright
trunk during locomotion than creep-
ing on their hands and knees. Both
patterns may occur less frequently in
the population at large than the
mean pattern, but they reflect similar
processes in their emergence. That
is, each new behavior builds on the
foundation of previous experiences
and solutions discovered, the func-
tional repertoire, and subsystem
strengths to allow discovery of sub-
sequent patterns of movement that
accomplish the ever-changing and
expanding goals of curious and ac-
tive young humans.
That history matters at all levels of
interacting subsystems, and the out-
come of these interactions may ap-
pear close to or well downstream
of their initial convergence, has
been emphasized in developmental
work recently and referred to as
December 2010
Opportunities for Early Intervention
“cascading effects.” Karmiloff-Smith8
described a sequence of behaviors
that illustrate this effect in which
motor and cognitive factors inter-
twine in ways that might not be ob-
vious without close longitudinal ex-
amination. Early in development,
infants born with Williams syndrome
show impaired planning of saccadic
eye movements. This impairment
leads to decreased ability to follow
finger-pointing actions, which re-
sults in diminished capacity to use
referential pointing in parents’ nor-
mal efforts to help their babies con-
nect objects to vocabulary words.
This diminished capacity fosters
atypical trajectories and delay in lan-
guage acquisition, although, ulti-
mately, fairly functional language
skills emerge. In an example more
central to the motor domain, Holt
and colleagues34,35 conducted a se-
ries of experiments with children
with cerebral palsy (CP). Their re-
sults led them to argue that the high
stiffness seen in these children is
due, at least in part, to their early
muscle weakness and emerges as a
solution to generate sufficient force
for locomotion. They created a me-
chanical model of the actual walking
patterns for each leg in children with
spastic hemiplegic CP. Data showed
that these children generate more
force with the less-affected limb than
a child with typical development.
They use this force to project their
center of mass forward, but upward
too, with each step. This movement
enables them to use the stiffened,
affected (and weaker) leg as a stiff
vertical spring. When the body drops
down onto this foot, a pogo stick–
style rebound is created, propelling
the system forward. These data and
theoretical arguments suggest the
next question to be asked is, could
very early efforts to improve leg
strength reduce secondary levels of
high tone and stiffness in this
population?
Volume 90
One hallmark of complex systems—
open, thermodynamic systems, such
as those in humans—is that they
seek higher levels of complexity.36
This fact fits both the behaviors we
observe in early postnatal life, in
which infants continually explore
and discover new actions, each a bit
more demanding than those that led
up to them, and our explanation for
them. Empirical studies show that
even the youngest babies create
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adaptive, goal-directed movements
and demonstrate systematic learning
from their experiences,37–39 and we
know that existing neuromotor
strength and control form the scaf-
folding that supports each subse-
quent level of construction. As new-
borns use their available eye muscle
strength and control to attend to ob-
jects or people moving through their
space, they push their systems, bit
by bit, to go farther, to see more and
longer. These repeated cycles of
moving and perceiving the conse-
quences lead, over time, to sufficient
control of head and neck muscles to
lift the head and eyes upward, lead-
ing to new, interesting things to ex-
plore. Their efforts have cascading
effects, enabling more and longer
movements through greater dis-
tances, toward objects, people, and
sounds that attract them. Bit by bit,
the foundation takes shape and ex-
pands for discovering new concepts,
consistencies, and motor control. A
predesign for this sequence is not
necessary, or likely, given individual
differences within infants who are
healthy, as well as infants with atyp-
ical neurophysiological and biome-
chanical constraints. Yet, probabilis-
tically, the similarities in sequential
progressions follow, given the simi-
larities in goals, substrates, and con-
texts they have to work with.
That rigorous practice—repeated cy-
cles of perceiving and acting—af-
fects recovery of neuromotor func-
tion via distinct changes within areas
of the brain in children and adults is
Number 12 Physical Therapy f 1871
Opportunities for Early Intervention
commonly accepted.40,41 The same
processes are less often acknowl-
edged in the very early foundational
organization among neurons. In
1987, Edelman42 published a de-
tailed account of early brain develop-
ment based on what was known
about neuroembryology, neuroanat-
omy, and principles of physics acting
at molecular and cellular levels. To-
gether, the system’s biochemical and
physical properties and environment
interact prenatally to produce cell
proliferation, migration, adhesion,
differential growth, and the forma-
tion of vast numbers of connections.
The impact of the organism’s own
movements and environment con-
tribute both to the typical organiza-
tion of areas of cortical specialization
and to individual variations in con-
nectivity. Labeling his proposals the
theory of neuronal group selec-
tion,42,43 Edelman argued that the
primary repertoire of broad patterns
of network connections established
before birth becomes ever more or-
ganized as the interaction with in-
creasing numbers of sensory inputs
and history of experiences grows af-
ter birth. Stated simply, through re-
peated cycles of perceiving and act-
ing, synapses among populations of
neurons within local areas of the
brain, as well as globally, become
strengthened to work together syn-
ergetically in their contributions to
patterns of behavior. This process
shapes the behavioral repertoire of
the organism, according to what is of
adaptive value in its eco-niche.
Whether the vast overpopulation of
neurons and connections that
emerges prenatally and the cell
death that begins early to accom-
pany the emergent synaptic organi-
zations are sculpted or constructed
continues to be debated. However,
the significant role of the baby’s own
activity in facilitating these changes
is not at issue.44,45 Karmiloff-Smith
and colleagues argued that very
small differences in emergent prop-
1872 f Physical Therapy Volume 90
erties of areas in the brain make
them somewhat more relevant to
processing certain types of input
than others. However, it is time and
through the repeated processing of
information that some become more
proficient than others and more
actively involved in processing par-
ticular inputs. Although plasticity
in early brain development is not
totally unconstrained, it seems evo-
lution has resulted in increasing flex-
ibility for humans, rather than in-
creasing complexity of built-in,
domain-specific constraints.8 Rather
than activity being able to invoke
neural plasticity only in recovery
from neural damage, plasticity
underlies the process of develop-
ment in infants who are healthy, as
well as in infants with atypical
development.46 –51
To summarize principles from this
brief discussion of a developmental
systems perspective, I offer the fol-
lowing principles:
1. Behavior patterns and changes in
patterns emerge via self-organized
interactions among many subsys-
tems, intrinsic and extrinsic to the
organism, within a context, and the
performer’s goals.
2. Behavior is dynamic and adaptive,
changing in response to repeated
cycles of perceiving and acting
and to variations in the contex-
tual demands or intrinsic capaci-
ties of the system.
3. There are multiple, redundant
pathways to achieving the same
functional goal.
4. History matters; factors that may
not have obvious relevance to a
particular outcome may have a
profound, cascading impact.
5. Organization and change at the
level of the nervous system are
Number 12
significantly affected by repeated
cycles of perceiving and acting.
Critical Subsystems:
Neural, Bone, Muscle,
and Adipose Tissues
Early Development
of the Nervous System
Theoretical approaches to the orga-
nization of and early changes in the
nervous system derive very clearly
from empirical data, including stud-
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ies of humans and lower animals, as
well as the impact of lesions occur-
ring naturally and induced. My goal
here is not to provide a comprehen-
sive review of what is known about
the developing nervous system, but
to draw attention to interactive pro-
cesses and changes at many levels
that engage the nervous system. Par-
ticular emphasis is on the critical
role of activity in optimizing the out-
come of these processes.
When human babies who are healthy
are born, they are in the midst of
enormous change in their nervous
systems. However, their unique neu-
ral history and makeup began nearly
9 months earlier and were influenced
along the way by many converging
subsystems, from the biochemistry
of their genes to the nutrition, exer-
cise, and external sensory environ-
ment experienced by the mother
and their changing fit and comfort
with the space within which they
existed. Their embryonic neural tube
gave rise before birth to the vast ma-
jority of neurons they will have
throughout their lifetime, and they
have begun already to lose neural
cells. The intricate interplay among
complex cascades of gene expres-
sion interacting with influences of
activity and ever-expanding local and
more-distant environmental stimuli
results in cells migrating to regions
and creation of tiny differences in
type, density, and orientation, neuro-
transmitters, ratio of white matter to
gray matter, and so on. Changes in
connection strengths begin to take
December 2010

hold via repeated cycles of perceiv-
ing and acting, and competition
leads some local areas to settle into
more specialized responsiveness to
some input versus others.8,48,49
Learning, in the neurophysiological
sense of biochemical changes and
the neuromuscular system’s attrac-
tion to some patterns of movement
over others, is already in evidence.
Fetuses show distinct arm and leg
patterns that are repeated, yet change
over the prenatal months. They
emerge and disappear with an aver-
age sequential order and with wax-
ing and waning frequencies.52,53 Nu-
merous studies have shown that
auditory inputs, such as particular
types of music played in the home or
the mother’s voice, lead to soothing
or aversive responses to these same
sensory stimuli after birth.54 Even
some areas of the visual cortex have
been shown, via animal studies and
models of early human develop-
ment, to rely on specific stimuli, al-
though not visual, to drive prenatal
organization.55
Birth marks a significant event on
the nervous system’s developmental
continuum. The frequency, amplitude,
and variety of sensations, actions, and
contexts increase dramatically. New
functional stresses impose on the
system to thermoregulate, actively
ingest nourishment, perceive the dif-
ferences between wet and dry dia-
pers and between light and dark
rooms, and distinguish shapes and
movements floating all around them.
These converging forces bring a
flood of exploration— of perceiving
novelties and consistencies, acting,
and discovering consequences. Den-
dritic arborization, axonal growth,
and strengthened synaptic connec-
tions proliferate and become increas-
ingly complex, continuing at an in-
creasing rate through the first few
years after birth. Many cortical re-
gions initially process all incoming
inputs and become more specialized
December 2010
Opportunities for Early Intervention
to specific types of input through re-
peated cycles of perceiving and acting.
However, their function plays out in
concert with multiple areas of the
brain to produce behaviors in early
life and in adulthood.8,42 Stiles50
stated that development of the ner-
vous system, from the very begin-
ning, engages “both inherited and en-
vironmental factors and rel[ies] upon
their continuous interaction.”50(p196)
When neural development is inter-
rupted, when developmental or acute
lesions occur in the brain or spinal
cord, we turn to basic principles for
optimizing neural outcomes. Dobkin56
identified 3 ways in which neural
recovery can occur: (1) new cell
growth, (2) regrowth of connec-
tions, and (3) retraining of existing
connectivity. The opportunities for
each of these vary by area of the ner-
vous system affected, extent of dam-
age (eg, cell loss, amount and type of
nerve loss, availability of sensory mo-
tor linkages), and timing of the insult.
Regardless of the specific mechanism
of neural recovery to be affected,
some things are clear. Research shows
that copious amounts of activity and
specificity of training are critical for
maximizing neuromotor control and
functional outcomes.57,58
Both angiogenesis and increases in
circulating levels of neurotrophins in
the brain and spinal cord are mech-
anisms known to respond to bouts of
motor activity in animals. The im-
provements in functional outcomes
emerging from significant repetitions
of motor behaviors in humans may
be strongly supported by these neu-
rophysiological responses. Angiogene-
sis has been demonstrated to occur in
the motor cortex and cerebellum.59,60
In particular, in animals with central
and peripheral nervous system dam-
age, researchers have shown that neu-
rotrophins, particularly brain-derived
neurotrophic factor, increase in the
spinal cord, hippocampus, and other
brain regions.61,62
Volume 90
Issues of optimal timing of interven-
tions must be considered in terms of
efficiency for specific tasks, stability
of vital functions, risk of infection,
postsurgical interventions, and so
on. This is true across developmental
time and warrants scrutiny with re-
gard to intervention at earlier ages.
That aggressive therapy has recently
and publicly been championed for
older children and adults with spinal
cord and brain lesions was brought
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to prominence by the sustained ef-
forts of scientists who used basic sci-
ence knowledge and dared to push
the system, and some visibility has
been brought by celebrity (eg, Chris-
topher Reeve).63– 65 Many research
groups and significant research fund-
ing are currently devoted to these
issues in order to create more basic
and clinical evidence intended to aid
in recovery of neuromotor control.
Early intervention needs to catch up
to the level of research and interven-
tion effort dedicated to supporting
development and recovery in “older”
neuromotor systems.
Impact of Activity on Bone,
Muscle, and Adipose Tissue
Tissues other than neural tissues are
affected by early activity, but they
often are given less focused research
attention, at least by neuromotor
control specialists. Understanding
the multilayered interactions that are
involved in the emergence and con-
trol of behavior compels us to exam-
ine the reciprocal interactions that
emerge among neural, bone, muscle,
and adipose tissues directly under
conditions of aggressive neuromotor
activity prescriptions during early
development. Bone and muscle, in
particular, respond to the “form fol-
lows function” principle. The impor-
tance of muscle tissue strength
seems obvious for its role in oppos-
ing gravity, moving body parts, and
maintaining upright postures and
gait. Yet, how much activity is opti-
mal for pediatric populations, partic-
Number 12 Physical Therapy f 1873
Opportunities for Early Intervention
ularly those with disabilities, is not
clearly defined via research.
Deformities of bones, and joints in
particular, tend to be seen as malle-
able, via external interventions, such
as surgeries, castings, positioning
bars, and orthoses. However, how
activity itself can contribute to better
joint alignments is relatively unex-
plored. Excessive adipose tissue can
strain joints and vital organs that may
already be compromised; being over-
weight can cause fatigue and make
balance difficult for locomotion.
These issues may be raised by medi-
cal professionals with patients and
parents of infants and young chil-
dren with disabilities. However, dis-
cussions tend to focus on nutrition
and genetic influences. Infrequently
has research, and thus recommenda-
tions, focused on the potential ben-
efits of increasing activity very early
in life to improve status on this as-
pect of development of body fat and
motor behavior.
During the first few years of life, the
histochemical properties of muscle
and bone tissue change dramatically.
Babies’ bones are dominated by carti-
lage. Cartilage is softer, more pliable,
and less dense than ossified bone, and
cartilage cells are gradually replaced
with minerals that add stiffness and
length. The ends of long bones, and
the shape of short bones as well,
mold to fit function, with changes in
shape and density occurring in re-
sponse to the tensions placed on
them. For example, babies’ hip sock-
ets are relatively flat at birth, the
head of the femur being stabilized
with the pelvis by tendons and
ligaments.
As infants begin to bear weight on
their limbs, to creep and walk, the
acetabulum deepens from the forces
transmitted through the head of the
femur to its contact surface. Babies
for whom weight bearing is delayed,
such as those with CP or spina bifida,
1874 f Physical Therapy Volume 90
have more-porous bones and are
more prone to breaking a hip or leg
when they fall during locomotion.66
Increasing weight-bearing activity
has been shown to enhance bone
density in children with CP,67 and
infants with spina bifida who walk
earlier also have denser bones than
later walkers.68 Bone growth also re-
quires activity to optimize its length.
Recently, Teulier et al23 showed that
infants with the most common form
of spina bifida, myelomeningocele,
“lose ground” in the growth of their
lower legs compared with infants
with typical development over the
first postnatal year. At birth, shank
lengths were not different. In utero,
babies with spina bifida have been
shown to be as active as their peers
with typical development. After
birth, leg activity is less rigorous and
active.69 –71 By 1 year after birth, the
slower rate of growth for babies with
myelomeningocele revealed a signif-
icantly shorter limb segment. Al-
though this relationship does not
prove cause, the fact that this pat-
tern emerged over time and selec-
tively, at least by this point, points to
inactivity and lack of weight bearing
as a potential cause.
Therapists know the impact of repe-
tition and overload for increasing
muscle strength. Yet, how to trans-
late these principles developed for
adults and children into baby ther-
apy is not obvious. Overload training
involves determining maximum ca-
pacities, followed by multiple repe-
titions of submaximal resistance, re-
peated over at least 3 days per week,
with progressive increases in the re-
sistance used. No such guidelines ap-
pear in the literature for infants and
toddlers, nor do valid and quantifi-
able strength measures. Early in life,
muscle tissue has different biochem-
ical characteristics than those of
adults. They are more watery and
have lower peptide levels, and fiber
types are not well differentiated.72,73
Yet, change in these characteristics
Number 12
are linked to the activity and stresses
placed on them, generally through
the seemingly incessant activity self-
generated by babies who are healthy
and who are eager to move and to
challenge their bodies to ever more
interesting opportunities.74
The worldwide trend for humans to
be overweight continues to rise, ex-
tending into childhood, with concerns
now being voiced more strongly for
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infancy. Evidence increasingly high-
lights the importance of the pattern
of adipose tissue growth during the
postnatal period and the possibility
that these patterns may interact with
subsequent lifestyle factors to cause
obesity and metabolic syndrome.75
Numerous studies have shown cor-
relations between infant growth in
weight and body mass index and
childhood and early adulthood adi-
pose tissue levels, particularly in in-
dustrialized nations.75–77 Chomtho
and colleagues77 found, specifically,
that greater weight gain during the
first 6 months of infancy was most
strongly associated with greater fat
mass in childhood, whereas the sec-
ond half of infancy did not relate
significantly to any of the body com-
position measures they assessed.
Some of the rate of gain in body fat
may clearly be attributed to feeding
practices and some to genetics, al-
though this relationship is poorly un-
derstood and genetics studies have
not focused on infancy. However, it
is clear that the most basic expla-
nation for the current epidemic of
obesity and overweight humans is
excessive energy intake and physical
inactivity. Although pediatricians at-
tend well to issues of the need for fat
in babies’ diets for proper brain
growth and encourage parents to dis-
cuss babies’ weight with them regu-
larly, little mention is made of ba-
bies’ activity levels as a piece of the
equation for balancing healthy in-
take with overall healthy body com-
position and weight. For populations
with motor disabilities that are prone
December 2010

to difficulties moving and weight
gain, this is a factor we can no longer
ignore.
To summarize this section, the ner-
vous system— central and peripher-
al—is not passive, static, or pre-
scribed in detail. Failure to engage
infants and young children with mo-
tor disabilities in the energetic, ex-
ploratory, and focused efforts to
move and control their bodies that
infants with typical development ex-
perience means not only missing op-
portunities to help them find func-
tional solutions but failing to prevent
cascades of secondary and tertiary
problems, including, but not limited
to, negative consequences to bone,
muscle, and adipose tissue.
Clinical Challenges
and Opportunities
Contemporary theoretical approaches
and developmental neuroscience de-
mand a greater emphasis on rigorous
and early activity intervention for
infants and young children with
motor disabilities. The call for early
intervention is not new, but new tech-
nologies have advanced, enabling
scientists to demonstrate empirically
the link between babies’ physical
activity and normal developmental
processes. The mandate is clear that
for infants and young children with
diminished capacity to optimize their
own developmental outcomes, the fo-
cus must be not only on very early
but also on aggressive and function-
ally relevant activity protocols. Func-
tionally relevant protocols emphasize
activities of daily living, engaging in-
fants in actively moving their limbs
and bodies through space and re-
sponding to realistic perturbations as
they show the capacity to adapt ap-
propriately. Delaying interventions
until motor milestones are missed
or waiting until they have appeared
and then trying to fix what looks
“wrong” is to lose ground, perhaps
irreparably in some cases. Although
plasticity is more the rule than the
December 2010
Opportunities for Early Intervention
exception, we must remind ourselves
that time marches on. Each infant,
child, adult, and geriatric system
builds on a history of accumulated
experiences. Our delay may mean
lost opportunities for a child that in
some cases may never be fully recov-
ered, such as lost bone length or the
joint’s capacity to reshape on its
own without surgical intervention,
or it may allow the emergence of
a compensatory neuromotor strategy
for control and force that increases
stiffness and tone and that may never
be overcome.
Very early and aggressive interven-
tions have become increasingly com-
mon in surgical and pharmaceutical
treatments for disabilities. For exam-
ple, babies born with DS who have a
heart defect are likely, today, to re-
ceive cardiac surgery within months
of birth. Cardiac muscle recovers
quickly, and babies improve cardio-
respiratory function, becoming more
active, alert, and stronger overall.
These improvements create a better
physiological basis for development
of other subsystems as well. In 2003,
the National Institutes of Health be-
gan funding a major clinical trial to
determine empirically the potential
benefits and negative consequences
of in utero surgery to protect the
spinal cord of fetuses with myelo-
meningocele: the Management of
Myelomeningocele Study (MOMS).78
The hypothesized outcomes include
decreased shunt-dependent hydro-
cephalus and possibly improvement
in leg function, among other things.
Yet, activity therapy for these same
babies, those with DS and myelome-
ningocele, and those with many other
motor disabilities, tends to lag. Phys-
ical activity therapy for babies and
very young children tends to be:
(1) less aggressive than prescribed
for older children and adults, (2) less
focused on functional skills (tending
toward precursors, control of spe-
cific postures, or joint range of mo-
tion), and (3) delayed months beyond
Volume 90
onset of disability, which would not
be the strategy followed for older
children and adults. These efforts
may help, but they are not likely
sufficient to promote optimal devel-
opment of neuromotor control.
Multiple factors contribute to these
disparities. Perhaps the most salient
to therapists is the unwillingness, too
often, of third-party payers to fund the
onset of therapy until milestones are
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missed and to pay for the amount of
time a therapist needs in order to take
an aggressive approach with patients.
Unfortunately, a second factor sup-
porting the third-party payers’ stance
is a dearth of empirical results that
show, via well-controlled and general-
izable samples, the: (1) functional ben-
efits (behavioral as well as in underly-
ing mechanisms), especially over the
long term, and (2) the cost:benefit
ratio. Although we have strong theo-
retical and basic science arguments
for the functional and long-term cost
benefits of aggressive activity inter-
ventions for both younger and older
adults, the data are not as conclusive
for early interventions. Third, the rem-
nants of old theoretical models, such
as the maturationist approach, hinder
a broader, more comprehensive ap-
proach that includes infants and
young children in models designed
for older people. Waiting for a skill
to appear on its own, then fixing
aspects that look “wrong”79 ignores
the enormous weight of develop-
mental science showing that the pro-
cesses and activities and contexts in
which the infant engages lead to
both the quality and rate at which
patterns emerge. A fourth factor is
the challenge of finding ways to mo-
tivate infants to engage in the thera-
pies we design. Motivating adults
can be challenging, even when they
understand the advantages to their
focused efforts. Infants’ motivations
are quite different from ours, and
their reticence to repeat actions that
are not fun or comfortable can be
compelling.
Number 12 Physical Therapy f 1875
Opportunities for Early Intervention
Dynamic systems/developmental sys-
tems theory pushes us to think out
of the box about ways, from the
psychological to the physical and
contextual, to engage pediatric pop-
ulations in self-generated repetitions
of activity. “Self-generated” implies
that children engage in generating
muscle activations in order to adapt
to the dynamic context we create for
them or to explore or pursue their
own goals. This process builds the
subsystems necessary for new and
more effective functional patterns to
emerge. Basic neuroscience identi-
fies real mechanisms, such as neural
transmitters, dendritic arborization,
synaptic strengths, and brain activa-
tion patterns, that are dynamic and
change in response to physically ac-
tive engagement, even in, or perhaps
particularly in, very young children.
Muscle, bone, and adipose tissue
mechanisms also show similarly pos-
itive responses. Dynamic systems/
developmental systems theory ad-
dresses the processes by which
these mechanisms change, affecting
each other in an integrated manner
and converging to allow new pat-
terns of behavior and stronger bod-
ies to emerge. Together, the ground-
work is in place to support the goals
of those who need to provide and
guide intervention, but more needs
to be done to expand the empirical
database to design protocols for im-
plementing these goals.
Funding may always be the bane of
our health care existence when it
comes to providing the level of ther-
apy required to optimize outcomes
in the short term and long term. Cur-
rent funding for nonacute phases of
long-term problems averages 1 hour
biweekly of one-to-one service with
a medical professional. We know
this is, alone, not sufficient to change
anything. Yet, how much therapy
we need to fund, how much repeti-
tion is needed, remains open to ques-
tion. A mountain of research evidence
has accumulated for adults, allowing
1876 f Physical Therapy Volume 90
some consensus and guidelines that
at least 3 to 4 times per week of in-
tense repetition and progressive over-
load training will increase motor
strength and control, although for
focused neural control therapy, the
amount of time needed to optimize
outcomes is much more.80,81 No one
really knows the frequency and inten-
sity of therapy required to enable in-
fants and toddlers to significantly im-
prove their muscle strength and neural
control. Adolph and colleagues82 re-
ported that toddlers take about
9,000 steps per day and travel the
distance of more than 29 football
fields when practicing their new
walking skill. Yet, improvements in
their gait parameters, while showing
the typical negatively accelerating
learning curve seen in motor learn-
ing studies of adults, require between
3 and 6 months for the rate of im-
provement to asymptote.83 The nec-
essary and sufficient frequency of
treatment may be less than 9,000
repetitions per day, but do we ap-
proach this in practice?
One option for overcoming the cost
of direct services problem and in-
creasing practice repetitions is to de-
vise therapies and develop technolo-
gies that can be administered in the
home by caregivers and directed by
therapists or other professionals. In a
series of studies, my colleagues and I
designed a portable pediatric tread-
mill and protocol for caregivers to
facilitate the development of trunk
and leg control and strength needed
to reduce the significant delay in
walking onset experienced by in-
fants born with DS. As multiple stud-
ies have now shown, infants are not
passive when supported on a tread-
mill; rather, they engage in active
exploration of muscle activation pat-
terns, adapt muscle activity to pertur-
bations, and show residual (real-time)
and more sustained (over develop-
mental time) learning effects.21,84,85
Number 12
In one study, we gave parents of
babies in the experimental group a
treadmill and prescribed durations
of practice and number of days per
week.86 Caregivers supported their
infants upright, on the mini-treadmill,
8 minutes a day, 5 days per week. By
their own reports, parents enjoyed
both their dedicated “face time”
spent in social interaction with their
babies and the clear boundaries we
prescribed for their efforts, and they
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expressed optimism that they were
contributing in a tangible way to
the health and development of their
infants. Both experimental and con-
trol group infants also received tra-
ditional physical therapy sessions
biweekly. The mean advance in
walking onset was 3 months for the
experimental group, which was grate-
fully embraced by families. Although
this lag may not seem large to some
people, it seems the design was a
step in the right direction. Our in-
tervention provided a maximum of
960 steps per training session, 5
times per week, which did not ap-
proach the step frequency Adolph
and colleagues82 indicated toddlers
who are healthy use in their normal
“work” of practicing their control of
walking.
The next step was to build on these
baseline data. We designed the orig-
inal protocol with no data to guide
us on how many days per week or
how long practice should persist. We
did not know what parents as well as
their babies would tolerate without
fatigue or frustration. Post hoc, we
believed we could be more aggres-
sive. Ulrich and Angulo-Barroso and
colleagues87,88 subsequently repli-
cated this study but tailored the inter-
vention to each child’s rate of
progress, increasing the treadmill belt
speed and adding small weights to the
shank to build on the strength and
control improvements each child
demonstrated along the way. These
modifications led to greater behavioral
gains, resulting in an average 5-month
December 2010

advancement in walking onset com-
pared with controls. Furthermore,
toddlers, after training, showed signif-
icantly greater spontaneous activity
levels, as monitored by actigraphs.
This secondary impact, greater spon-
taneous activity levels, was not the
initial target outcome, and it may not
be the only one. However, it was a
relevant subsystem and one particu-
larly meaningful today, given the
global recognition of the need to
increase activity and reduce adi-
pose tissue levels to improve health.
Their results illustrate the need in
clinical research to design studies
more clearly aligned with develop-
mental systems theory.87,88 Multiple
factors affect and are affected by mo-
tor activity and patterns. In recent
studies of infants born with myelo-
meningocele, my laboratory group has
shown that throughout the first year
after birth, these babies will respond
to the treadmill context by produc-
ing some steps, although at a reduced
rate compared with babies with typ-
ical development and with minimal
improvement (without training) over
the first 6 to 9 months.23 When sup-
ported on the moving belt of the
treadmill, even when not stepping,
babies with myelomeningocele moved
their legs in other ways, more fre-
quently than when simply held up-
right on a stable surface. The popu-
lation with myelomeningocele is known
to show osteoporosis, reduced rate
of bone growth, asymmetrical pe-
ripheral sensory and motor neural
loss, and reduced frequency of spon-
taneous leg activity.23,69,89 To address
this set of factors and the facilitation
of walking onset, my colleagues and
I are designing an early treadmill in-
tervention study that will include as-
sessment of changes in several levels
of subsystems that we hypothesize
will be affected by this rigorous ac-
tivity, as well as monitoring external
factors that could affect outcomes,
such as nutrition, medical history,
and so on.
December 2010
Opportunities for Early Intervention
Other encouraging examples of re-
search that shows the impact of in-
tense, activity-based therapy on in-
creased neuromotor function are
growing. Mattern-Baxter and col-
leagues90 showed significant im-
provements in standing and walking
skills in children with CP as young as
2.5 years following only 4 weeks of
intensive treadmill training (1 hour,
3 times per week). These laboratory-
measured improvements were re-
flected in increased independence
and reduced reliance on caregivers
for functional mobility. Research
documenting the effectiveness of
constraint-induced movement therapy
(CIMT) for upper-limb function in
children with hemiplegic CP has
grown substantially in the past few
years.91–93 Huang et al93 concluded
that among the most rigorous of
these studies, the one significant out-
come they had in common was in-
creased frequency of use. In 2009,
Coker and colleagues94 demon-
strated that modified CIMT can be
effective, even when the child is un-
der 1 year of age.
More new, creative approaches that
can be adapted for home-based, parent-
administered use also are within
reach. For example, Needham and
colleagues95,96 created “sticky mit-
tens” to improve pre-reaching in-
fants’ experiences in reaching for ob-
jects as a vehicle to investigate how
they develop an understanding of
the intentions of others. To build
their experiences perceiving and
acting with objects, they placed mit-
tens dotted with Velcro* on the
hands of 3-month-old infants and
provided them with 2 weeks of daily
practice interacting with toys that also
wore Velcro patches. This inter-
vention led infants who were healthy
to explore objects more (visually and
manually) and to increased arm activ-
ity, especially swipes toward objects,
* Velcro USA Inc, PO Box 5218, 406 Brown
Ave, Manchester, NH 03103.
Volume 90
even when not wearing the mittens.
This clever, yet simple, idea could be
modified for use with infants with dis-
abilities who need assistance building
strength and control of their upper
limbs. Mobiles hanging above babies’
cribs were shown years ago by Rovee-
Collier and Gekoski97 to elicit sig-
nificant increases in leg activity in
3-month-old infants who were healthy
when their ankles were tied to the
mobile with a ribbon. Very recently,
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movement scientists have begun to
study how this simple, yet elegant,
perception-action contingency can be
harnessed to help babies with DS and
those with white matter injury im-
prove neuromotor control.98,99
A developmental science and activity-
driven process approach to facilitating
change pushes us to think more criti-
cally than ever about the effects, pro
and con, of the use of passive devices,
such as parapodiums, serial castings,
orthoses, and Dennis Brown bars, in
intervention therapy. We must take se-
riously other options, including en-
gaging the child in repeated cycles of
activity to stretch ligaments, engage
the child in accepting weight on his
or her limbs, and aligning joints prop-
erly via guided movement through
functional ranges of motion. Certainly,
the rationales for these static position-
ing devices are well reasoned, and
the empirical data may show gener-
ally positive outcomes. However, are
these outcomes at the expense of
other aspects of development of ac-
tive neural control of movement,
motivation to move (spontaneously),
and movement through normal ranges
of motion? Decreases in muscle mass
and strength and loss of bone density
also are outcomes of casting that
have been documented in adults, as
well as reductions in the cortical
motor area responsible for activat-
ing muscles surrounding the affected
joint.100 The demands on caregivers’
and therapists’ time are high, and
Number 12 Physical Therapy f 1877
Opportunities for Early Intervention
the physical strength required to as-
sist children as they grow in prac-
ticing functional tasks grows with
them; overall, the plan for optimiz-
ing the child’s development must
be balanced. However, without well-
controlled, aggressive, and multifac-
eted empirical studies, we fail to pro-
vide professionals and caregivers
with optimal information from which
to make choices and to promote via
the health care financial system bet-
ter support for building strong and,
ultimately, cost-effective foundations.
Summary
To date, the idea of very early and
aggressive activity-based interven-
tion for babies has, I would argue,
suffered from a concern that babies
are not able to withstand rigorous
efforts to perform repetitions of their
own body segments designed specif-
ically to effect change in their sub-
systems, from neural to ligamentous
tissues. A growing body of basic and
clinical science results suggest we
are missing the boat on opportuni-
ties for infants with motor disabili-
ties if we do not develop more em-
pirically based protocols to use very
early in life in order to optimize de-
velopmental outcomes. Fundamen-
tally, I hope this article encourages
more empirical studies that build on
theory and basic science to test the
impact, at multiple levels, of well-
controlled and assertive activity-
based intervention programs, the
short- and long-term effects, and es-
pecially interventions that can be
administered by caregivers with pro-
fessional guidance. Without greater
opportunities for early treatment, the
costs associated with health care
needs in subsequent years will be
higher, but the real cost is to those
affected with early-onset neuromo-
tor disabilities.
Dr Ulrich thanks Beth Smith, Annette Pantall,
Jennifer Sansom, and Sandy Saavedra for
their very helpful feedback on early drafts of
the manuscript.
1878 f Physical Therapy Volume 90
This work was funded by the National
Institute of Child Health and Human Devel-
opment (grant RO1HD047567).
This article was submitted January 29, 2010,
and was accepted May 23, 2010.
DOI: 10.2522/ptj.20100040
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