Does the use of the Contactual Hand Orientating

Response (CHOR) facilitate the attainment of

independent pull to stand and independent

stance in a low toned infant?

Liesel Jansen

Basic Bobath Course

Peter James Centre, Burwood East VICTORIA

January 12th – May 1st 2014

Assignment due date: 14/4/14

Word count: 3, 516

 Abstract

The Contactual Hand Orientating Response (CHOR) has had limited exploration in the adult and

virtually nil attention in the paediatric literature. The CHOR is defined as a frictional contact of the

hand to a surface that allows for the hand to begin its functional role in the development of midline

orientation, balance and limb loading (Raine et al 2009).The theoretical basis and role that the

inclusion of the CHOR has in therapy modelled on the Bobath approach in assisting a 14 month old

globally hypotonic child to attain the pre-walking skills of pull to stand (PTS) and independent stance

are presented in the case of FB. Through attention to the use of the CHOR, alignment, symmetry,

postural control and sensory motor integration, FB was able to PTS independently and stand with

close supervision for approximately 2 seconds with nil external supports as measured by the Goal

Attainment Scale (GAS). This was achieved following seven sessions of centre based therapy and a

home exercise program responsive to changes in FB’s function in the context of Family Centred

Practice (FCP).

2
 Introduction

In typically developing infants the accomplishment of independent walking between 11 and 15

months of age is preceded by a sequence of milestones. The first of these milestones occurs

between seven to 10 months of age when infants use furniture or another object to assist them to

pull up from the floor to a standing position. The attainment of pulling to stand (PTS) is one of the

most memorable developmental milestones for the parents of an infant (Atun-Einy et al 2012).

Whilst infants are progressing through the stages of PTS they are also experimenting with static and

dynamic stance and the development of independent gait by varying the amount of upper limb (UL)

support they use and moving within multiple planes whilst standing. Infants will begin to walk with

the assistance of a support surface; a stage known as cruising. Whilst cruising, infants will begin to

experiment with independent stance with and without the use of an open hand for support on a

surface and by taking a few tentative steps between support surfaces or parents (Atun-Einy et al

2012, Bly 1983). In utilising the extended hand on a support surface the infant may be hypothesised

to be using the Contactual Hand Orientating Response (CHOR); a frictional contact of the hand to a

surface that allows for the hand to begin its functional role (Raine et al 2009).

There is paucity in the literature investigating the CHOR; a concept originally described by Denny-

Brown (1966) and further refined by Porter and Lemon (1993) and Raine et al (2009).The use of the

CHOR in the paediatric population is yet to be explored. Components of the CHOR have however

been investigated which may be extrapolated to guide its use in the paediatric population. This will

be discussed in the case of FB; a nearly 14 month old infant referred to physiotherapy at nine and a

half months of age by his maternal child health nurse as he was not meeting his motor

developmental milestones.

3
 The theoretical principals underpinning how typically developing infants may utilise the CHOR to

develop independent pull to stand and independent stance

Initially the infant PTS by taking most of their weight through their UL’s and actively pulls themself to

a stand whilst their lower limbs (LL’s) symmetrically extend behind them (Appendix 1). With time,

infants actively extend more through their symmetrical LL’s and use their UL’s less to pull themselves

into stand. As control around the hip increases to allow inter-limb dissociation the infant will adopt a

half kneel position. Initially this is with significant hip abduction and external rotation but with time

adducted and flexed in front of the trunk, they then extend through this half kneel and use their UL’s

minimally to stand (Appendix 1)(Atun-Einy et al 2012, Bly 1983). As the child further develops their

motor repertoire to include independent stance and walking they will begin to stand from a squat,

bear stand or from a seated position without the need to pull up to stand (Sheridan 1998). If in a

later stage of life, be it as an older child or adult, the person suffers some form of neurological insult

musculoskeletal injury or deterioration they may revert to utilising a support surface to pull to stand

or assist them into stand as a compensatory strategy for transitioning from sitting to standing (Raine

et al 2009, Shumway-Cook and Woollacott 2012).

The development of PTS marks a stage of significant psychological stage. The ability to be volitionally

upright is associated with self-awareness and pride and a new provides new opportunities for

motivation, attention and exploration (Atun-Einy et al 2012). These positive psychological effects

may contribute to improved motor responses through positively influencing the limbic system to

innervate the dopaminergic system which has been suggested by Rothwell (1994)to improve the

effectiveness of transmission through the motor pathways of the basal ganglia (Ring HA and Serra-

Mestres 2002).

Pulling to stand and supported standing marks a significant stage in the development of postural

control and weight bearing (WB) and a stage of rapid growth of the central nervous system and

sensory motor integration. This transition from quadruped to biped requires the ability to upwardly

4
displace and control the body’s centre of gravity in the context of a significantly narrower base of

support (Atun-Einy et al 2012). In doing so, PTS presents a plethora of novel somatosensory,

vestibular and visual afferent information for detection by truncal graviceptors, otolith organs, golgi

tendon organs and muscle spindles. Information which will be used the contribute to the dynamic

body schema and further refine motor learning and output; key principals of the Bobath concept

(Atun-Einy et al 2012, Gjelsvik 2008, Vaughan-Graham et al 2009).

The antigravity extension of PTS and standing is detected by the truncal graviceptors and the otolith

organs of the vestibular apparatus for integration with visual afferent information within the

vestibular nuclei. The motor output of which is the control of posture and tone via the descending

lateral vestibulospinal system through innervation of ipsilateral trunk and LL extensor musculature

(Angelaki and Cullen 2008, Gjelsvik 2008, and Karnath et al 2000). To a lesser degree postural control

and tone is also maintained by the medial reticulospinal pathway following integration of

proprioceptive information from the golgi tendon organs and muscle spindles by the

spinocerebellum and reticular formation (Gjelsvik 2008, Snell 2010).

The greater role however of the golgi tendon organs and muscle spindles in standing is to detect the

enormous array of afferent information from the postural sway experienced in this new posture.

Proprioceptive afferents transported via the spinocerebellar pathways and integrated in the

spinocerebellum are relayed to the vestibular nuclei for control of postural sway via the lateral

vestibulospinal pathway (Gjelsvik 2008, Snell 2010).

The corticospinal tract also plays a pivotal role in the development of PTS and independent stance.

Whilst using their hands to PTS and to develop control in stand the infant’s corticospinal tract acts to

control the voluntary hand and finger movements necessary to utilise the support surface. A greater

role however is the gating of somatosensory information to allow transmission of only the most

pertinent sensory information. In the case of stance development in the infant this role is critical in

the use of the hand for the CHOR (Gjelsvik 2008).

5
The CHOR has been reported by Raine et al (2009) to facilitate midline orientation, balance and limb

support and limb loading. These uses of the CHOR in the development of independent PTS and

stance although not explicitly supported, may be extrapolated from the literature.

Balance

An important part of developing independent stance is the ability to attenuate postural sway

utilising synergistic muscle chains. With anterior displacement of the body the posterior synergistic

muscle chain is activated initially with gastrocnemius, then hamstrings and truck extensors if

gastrocnemius cannot control the sway alone to maintain a dynamically stable posture. Similarly,

with posterior displacement of the body the anterior synergistic muscle chain will be initiated by

tibialis anterior and then quadriceps and abdominals if necessary to create a moment they will bring

the body anteriorly (Wollacott et al 1998).

At the time infants are beginning to PTS and experience volitional stance the response to postural

sway via the aforementioned coordinated phasic response to body displacement is minimal; instead

joints are held stiff with tonic antagonist and antagonistic activation (Woollacott and Burtner 1996,

Wollacott et al 1998). With further experience in stance the phasic bursts outlined above become

more clearly identifiable with some infants showing responses in multiple muscles. This trend

continues as the infant approaches independent stance. Once the infant is able to stand

unsupported the response to perturbation is seen in all three muscle groups in a more organised

synergistic chain which continues to be refined over several years (Woollacott and Burtner 1996,

Wollacott et al 1998). The development of these synergistic muscle chains to postural sway is

dependent on optimal alignment. It has been found by Wollacott et al (1998) that older typically

developing children who imitate the crouch stance of children with cerebral palsy show disorganised

and tonic postural sway responses similar to that of typically developing children at the time of initial

PTS.

6
Mechanoreception of the hand has been found to assist with attenuating postural sway. Rapidly

adapting cutaneous mechanoreceptors, sensitive to local vibration and the detection of localised

movement of the skin against a support surface and slowly adapting cutaneous mechanoreceptors

detect body sway through skin surface deformation. Critical components of the CHOR (Jeka and

Lackner 1995). Interestingly there have been studies which have demonstrated that when balance is

challenged, adults will automatically chose a light touch force contact where LL postural muscles are

most active and hand receptor sensitivity is at its greatest and provides the highest resolution of

directional change despite being and able to use as much force as they wish on a support surface

(Jeka and Lackner 1994 and 1995).

A study by Barela et al (1999) found infants had attenuated postural sway when they had an open

extended hand contacting a round surface precluding grasp. Similarly, studies of adults and children

have found the use of single finger contact attenuates postural sway via anticipatory and feed

forward mechanisms (Dickstein 2005, Jeka and Lackner 1994, Jeka et al 1997, Krishnamoorthy et al,

2002) and that bilateral touch is more effective at attenuating sway than unilateral touch and

unilateral touch anterior to the body is more effective than lateral unilateral touch (Dickstein 2005).

Midline orientation

Cutaneous information coupled with muscle spindle afferents of arm musculature when in contact

with a support surface provide information for the position sense representation of the body and

about body orientation relative to the support surface (Jeka & Lackner 1995). This has been

suggested by Barela et al (1999) to be of use in the newly standing infant who, although well before

they PTS have sufficient extensor strength in their LL’s to support their weight in standing, use the

support surface with large forces initially not to support their weight but to assist with vertical

orientation. With more experience and orientation of upright stance the infant can then begin to

lessen their support and develop standing balance with variable UL use and trunk rotation (Barela,

Jeka and Clark; 1999).

7
Limb loading

Whilst there are no studies which directly demonstrate that the use of an extended hand on a

support surface facilitates lower limb extensor musculature it may be extrapolated from adult gait

studies. Buurke et al (2005) have found that when using flexed grasp on a walking stick, there is

reduced activity of anti-gravity extensor muscles such as gluteus maximus and medius, erector

spinae and vastus lateralis when compared to walking unaided. The use of grasp has also been

implicated in the activity of lower limb postural muscles. Esposti & Baldissera (2011) found that an

increase in grasp on a handle decreased LL postural muscle activation.

8
 Case analysis – FB

Initial Assessment

Prior to initial assessment, consent was obtained from FB’s mother for case study use, internal and

external presentation and for de-identified photos to be used (Appendix 2). The details of FB’s initial

assessment are presented in Appendix 3. FB presented as an alert and healthy almost 14 month old

boy of insignificant pre, peri and post natal history who was tolerant of handling and able to be

engaged in a variety of toys. FB was crawling and interested in objects on higher surfaces. FB’s

mother acknowledged that he was behind the motor development his peers and the development of

his siblings at 14 months and expressed the desire for FB to achieve timely independent walking.

On assessment there were a number of functional skills that FB was unable to complete

independently which should be in the repertoire of a typically developing 14 month old (Atun-Einy et

al 2012, Bly 1983); the first of which was that FB was unable to independently PTS. He would reach

up to higher surfaces from a four point kneel (4PN) but did so with his LL’s over 40 cm from the

support surface so that his LL’s were posterior to his trunk (Figure 1); an alignment not conducive for

active lower limb extension to stand (Shumway-Cook and Woollacott, 2012). From this position, FB’s

mother would provide a light de-weighting of his trunk which would assist him to stand at support

(Figure 2).

9
Figure 1. FB independent positioning when Figure 2- FB’s mother de-weighting the trunk to
encouraged to stand on initial assessment assist FB into standing in initial assessment

Once assisted into standing, FB was unable to stand with light or nil upper limb support, instead

weight bearing (WB) heavily through at least one UL, generally through the forearm (Figure 3).

Figure 3. FB weight bearing heavily through forearm

It was also noted that FB displayed an asymmetry with decreased WB, grounding and active

extension through the left (L) LL and a decreased ability to elongate through the L trunk in standing

in comparison to the right (R) side of his body (Figures 4 and 5).

10
 Decreased L trunk
Decreased extension and
extension elongation
through L
hip Heavy upper limb weight
bearing

Flexed L LL
with minimal
active
extension
Minimal L LL WB
-Poor L foot Weight shift with
grounding pelvic shunting and
-Ankle decreased
plantarflexion/inver associated trunk
sion and lateral > extension and
medial mid-forefoot elongation
WB

Figure 4- Asymmetrical stance Figure 5- Asymmetrical stance

FB did not initiate cruising. The initiation of cruising requires control of the pelvis and trunk to shift

weight laterally to create a stance leg (Haehl et al 2000). Figure 5 demonstrates the difficulty in the

control of this lateral weight shift. Contributing factors to these aforementioned functional

limitations are presented in Table 1.

Table 1. Contributing factors to functional limitations of FB

Problem Evidenced by Implications for PTS/standing

Global hypotonia - Sits in large degree of passive Decreased sense of de-

flexion with wide base of weighting of trunk via
support (BOS) and use of UL’s extension to assist LL’s to
for stability more than would extend against gravity during
be expected for a typically PTS or whilst standing
developing 14 month old with
poor variability of sitting
postures (Bly 1983)

- Minimal tonal resistance to

passive range of movement of
all limbs

11
Problem
Decreased postural/core
control :
- Decreased active motor
control of lumber > thoracic
trunk extensors
-Decreased coordinated co-
contraction of
abdominals/trunk extensors
- Decreased control of lateral
weight shift and associated
ipsilateral trunk elongation
Asymmetrical stance and
asymmetrical WB in stance
Evidenced by
- Observations in sitting as
above
- Lumber lordosis and some
bilateral LL abduction in crawl
- Decreased exploration of
weight shift in kneel
- Heavy UL WB in stand
-Nil attempts at trunk rotation
or cruising in stand
- Delayed postural responses
when on Swiss ball with
external perturbations
(Shumway-Cook and Wollacott
2012)
Placement of L > R LL outside of
linear alignment under trunk in
stand
R LL held more actively
extended under trunk in stand
Implications for PTS/standing
- Decreased control of lateral
weight shift in high kneel to
enable half kneel to be
obtained
- Increased need to rely on UL
for mechanical support in stand
rather than a proprioceptive
support to develop postural
sway and the development of
independent stand (Barela et al
1999)
- Decreased control of lateral
weight shift and trunk
elongation to create stance leg
from which cruising can be
initiated (Haehl et al 2000)
- Negatively impacting length-
tension relationship of extensor
musculature to achieve
independent stance (Shumway-
Cook and Wollacott 2012)
- Decreased ground reaction
force through L > R lower limb
decreasing proprioceptive drive
for extensor musculature
activation (Prochazka et al
1997)
Loss of symmetry in standing
through which
postural/extensor musculature
can experience and respond to
postural sway therefore
inhibiting independent stand
attainment (Marigold and Eng
2006)
12
Problem Evidenced by Implications for PTS/standing

Decreased proprioceptive Delayed postural responses Decreased ability to respond to

awareness of : when on Swiss ball with and therefore control postural
external perturbations sway in stance or for weight
-Trunk globally (Shumway-Cook and Wollacott, shift for cruising
-L LL 2012)

- potentially of UL’s as used for Placement of L LL in relative Decreased placement of L LL in

fixation/heavy weight bearing
instead of being able to be used
for propriceptive role
abduction and flexion with
minimal WB in stance in
absence of range restrictions
alignment with full contact on
ground optimise the ground
reaction forces through the
lower limb to drive extension
for the attainment of extension
in PTS or in stance (Prochazka
et al 1997)

Outcome measures

In addition to observations of improvements in posture, alignment, symmetry and control of

postures and transitions, it was decided to use the Goal Attainment Scale (GAS) to measure potential

improvement post treatment of FB. The GAS is an individualised criterion-referenced measure

shown to be a valid measure of motor change in infants with and without motor delays (Pallsano et

al 1992). The GAS requires development of goals that are observable, repeatable and measurable

(Pallsano et al 1992). Ideally these goals should be developed with the child’s family as this is an

important component of Family Centred Practice (FCP); an approach to service delivery which is

considered best practice in paediatric rehabilitation and has been shown improve the psycho-social

well-being of children and their families and result in greater functional improvements (King et al

1998 and 2004). The pre-walking skills of PTS, cruising and independent stance were explained to

FB’s mother; as was the impact asymmetries could have on the attainment of these skills (Marigold

and Eng 2006).With this in mind, a block of therapy to assist in the attainment of these goals and

promotion of symmetry was agreed upon and the goals utilising the GAS were formulated to

measure FB’s progress (Appendix 4)

13
The use of the Alberta Infant Motor Scale (AIMS) was considered for use as it measures global motor

development in children from birth to independent walking (Darrah et al 1998). It was however

decided that it would not be used in the case of FB as at almost 14 months of age, FB was far outside

the range of four to eight months where the AIMS has its highest sensitivity and specificity for

measuring motor development and motor delays (Darrah et al 1998). Additionally, the AIMS,

although including PTS and independent stance as items for assessment do not measure them in

isolation and therefore would not provide a specific measure of improvement specific to the goals

formulated with FB’s mother.

Treatment

FB attended seven sessions of physiotherapy with weekly to fortnightly breaks between sessions.

Each session generally lasted 40-60 minutes depending on FB’s mood, engagement and tolerance of

handling. Details of key subjective and objective findings in each session are outlined in Appendix 5.

For each session; the treatments completed, home exercise program (HEP) prescribed and within

session changes are recorded in Table 2. Further description of key treatments are presented in

Appendix 6.

Following a number of treatment sessions and discussions with speech pathology colleagues it was

evident that FB may have delays in speech and language. This was educated to FB’s mother and she

consented to a referral to a speech pathologist. It was also suggested to FB’s mother that

investigation into FB’s asymmetries and motor delays by a paediatrician may be indicated. Although

yet to consent to this referral, FB’s mother is considering the implications of this.

14
Table 2. Treatment record

Session 1 – initial 2 3 4 5 6 7
Treatment assessment
Facilitation of grounding  whilst sitting
of foot through with foot
pronation and extension grounded
of mid foot to forefoot
and great toe via
intrinsic input
Dynamic core control in   with CHOR on  unsupported  on foam step  on foam step
sitting on exercise mirror with reach with foot with foot
ball/therapist anterior/posterior grounding with grounding with
knee/bench/chair/step and laterally reach reach
with gentle bouncing anterior/posterior anterior/posterior
up/down or sway and laterally and laterally
anterior/posterior/
laterally
Lateral pelvic tilt with   
reach sitting on foam
block

Sit to stand from  with CHOR  with CHOR and  with with +/- CHOR and +/- CHOR and
physiotherapist (PT) and downwards downwards and CHOR and CHOR and +/-downwards +/-downwards
knee and anterior anterior pressure downwards +/- and anterior and anterior
pressure through and downwards pressure through pressure through
Appendix 6 (a) through quadriceps anterior and quadriceps quadriceps. Also
quadriceps pressure anterior performed form
through pressure sitting on foam
quadriceps through step
quadriceps

15
 Session 1 – initial 2 3 4 5 6 7
Treatment assessment
Alignment of LLs in    with CHOR on  with  with +/- CHOR +/- CHOR
standing vertical mirror CHOR on CHOR on on Swiss on Swiss
and abdominal Swiss ball Swiss ball/foam steps ball/foam steps
and gluteal input ball/foam
to encourage steps
neutral pelvis
Supported standing  with CHOR at  with CHOR at  with CHOR on  with  with  with CHOR on  with CHOR on
foam steps and foam steps and vertical mirror CHOR on CHOR on Swiss ball/foam Swiss ball/foam
Appendix 6 (b) compression compression and abdominal Swiss ball in Swiss steps in bilateral, steps in bilateral,
through pelvis through pelvis for and gluteal input bilateral, L ball/foam L bias stride L bias stride
for grounding grounding/stability to encourage bias stride steps in stance and L SLS stance and L SLS
and stability neutral pelvis stance and bilateral, L with gluteal and with gluteal and
L single leg bias stride quadriceps input quadriceps input
stance (SLS) stance and
with gluteal L SLS with
and gluteal and
quadriceps quadriceps
input input
Unsupported standing  with  +/- reach +/-
reach with input to
input to abdominals and
abdominals gluteals
and
quadriceps
Standing with external  with  with CHOR on  with CHOR on
perturbation CHOR on Swiss ball with Swiss ball with
Swiss ball gluteal and gluteal and
Appendix 6(c) with gluteal quadriceps input quadriceps input
and
quadriceps
input

16
 Session 1 – initial 2 3 4 5 6 7
Treatment assessment
Rotation between two  with  with CHOR +/-
surfaces in standing CHOR. input to gluteals
Bilateral, L and abdominals
Appendix 6(d) stride for control of
stance rotation over
stance leg
Stop standing  with CHOR  with  nil CHOR  nil CHOR
CHOR on
Appendix 6(e) play table

Low to high kneel  with CHOR and  with CHOR and

LL alignment LL alignment
Appendix 6(f)
Weight shift  with  with CHOR on
laterally/obliquely in CHOR on foam step.
kneel foam step. Rotation over L
Rotation support limb in
over L half kneel
support
limb in half
kneel
Facilitation into half  of left and of left for climb
kneel playing at foam
steps in L half
Appendix 6(g) kneel with CHOR

Half kneel to stand  through L with  through L  through L with  through L with
CHOR with CHOR CHOR CHOR

17
 Session 1 – initial 2 3 4 5 6 7
Treatment assessment
Climbing  over boso on foam steps on foam steps
(semi-circle Swiss and input lateral and input lateral
ball) and cushion gluteal for pelvic gluteal for pelvic
with stability with stability with
encouragement weight shift weight shift
of initiation via R
LL for L lateral
weight shift
Cruising  with  with CHOR on
CHOR on plinth with
plinth with facilitation of
facilitation controlled weight
of shift through
controlled pelvis for creation
weight of SLS
shift encourage of
through independent
pelvis for between surfaces
creation of
SLS

18
 Session 1 – initial 2 3 4 5 6 7
Treatment assessment
-Gentle - Unsupported - Climbing over - Climbing -Encourage -Encourage Walk with push
bouncing on sitting on adult cushions - High kneel cruising to cruising between cart
HEP exercise ball chair/bench with -Facilitating into L play with LL R furniture, - Unsupported
-Sit to stand feet unsupported half kneel for PTS alignment -Standing gradually stand +/- light
from mothers when dressing with L increasing external
knee with upper body reach for distance perturbation with
gentle elongation light support from
compression of L trunk toy and
through knees gluteal/abdominal
-Alignment of input
LL’s under trunk
when standing

19
 Session 1 – initial 2 3 4 5 6 7
Treatment assessment
Within session changes Increased Increased bilateral Increased time (2- Increased Minimal Improved active Unsupported
midrange gluteal activation 3 seconds)spent active within control of truck in stand with close
gluteal and mid-terminal sit to independently extension in session L stride stance s/v for 2 seconds.
quadriceps stand from PT maintaining L LL in L changes Some
activation with thigh neural pelvic tilt stride noted STS from PT thigh disorganised
sit to stand in stand stance and with close s/v and ankle response to
(STS) from PT Slightly increased near nil support on 2 correct anterior
thigh control of lateral Initiate climb over symmetrical occasions displacement.
weight shift over L boso with L half WB in Flickers of tibialis
leg for R half kneel kneel bilateral Improved control anterior
stance of lateral weight activation to
Increased speed of shift and posterior
anterior/posterior STS from PT elongation displacement but
postural trunk thigh with through L trunk minimal attempts
corrections in close with lateral and to correct
response to supervision extended reach displacement
external (s/v) and nil
perturbation in support on Independent STS from PT
sitting 2 occasions initiation from sit knee/foam step
to 4PN over L with close s/v > 5
stance leg from occasions
foam step
Cruise between
furniture and
around corner for
first time

Mid-range
eccentric control
of stand to half
kneel with CHOR

20
Evaluation of therapy

FB achieved the expected level of outcome on the GAS (0) in relation to the PTS goal (highlighted in

Appendix 4). In comparison to the assistance required to stand at initial assessment (Figure 6), FB

was able to independently PTS with the use of bilateral UL’s (Figure 7).

6(a) 6(b)

Figure 6 (a and b) - FB’s mother assisting FB to stand on initial assessment

7(a) 7(b) 7(C)

Figures 7 (a-c) – FB independently pulling himself to stand in sequence

FB was also able to stand from a seated position with close supervision (Figure 8) or PT knee with

very minimal assistance (Figure 9). Although this does not indicate achievement of the highest PTS

goal predicted (+2) on the GAS as per Appendix 4 as it could not be completed independently it was

21
felt to be a significant achievement nonetheless given the significant control of weight shift,

antigravity extension and postural control required for the transition.

8(a) 8(b) 8(c)

Figure 8 (a- c) – FB sitting to stand from step with close supervision in sequence

9(a) 9(b) 9(c)

Figure 9 (a- c) – FB sitting to stand from PT thigh with very minimal assistance in sequence

The attainment of independent stance was less than was predicted (-1) on the GAS (highlighted in

Appendix 4). In comparison to being completley unable to stand without assistance on initial

assessment, FB was able to stand for approximatly 2 seconds with close supervision and nil UL

support (Figure 10a). Encouragingly whilst unsupported, FB also maintained momentary balance

with reaching (Figure 10b)and self initiated trunk rotation whilst standing (Figure 10c).

22
10(a) 10(b) 10(c)

Figure 10 (a-c) – FB standing unsupported statically and whilst initating reach and rotation

The symmetry of stance and the degree of UL WB was also positivley changed with therapy. In

comparison to the greatly assymmetrical stand (Figure 11a) and heavy UL WB (Figure 12a) on initial

assessment, FB’s stand was significantly more symmetrical, aligned and grounded (Figure 11b) and

he required only the use of a light hand for support (Figure 12b).

11(a) 11(b)

Figure 11 – FB standing supported with poor L weight bearing on initial assessment (11a) and with a
greater degree of symmetry, alignment and L foot grounding at end of therapy sessions (11b)

23
12(a) 12(b)

Figure 12 – FB utilising heavy UL support on initial assessment (12a) and one light hand at end of
therapy sessions (12b)

Additionally, FB was now able to independently maintain unsupported mid to high kneel for 3-5

seconds, albiet in a wide base of support (Figure 13), climb up onto his mother unassisted (Figure

14), climb with initiation of L stance limb (Figure 15), sit to stand with a self initiated bias over his L

leg with minimal support (Figure 16), cruise around corners (Figure 17) and between two surfaces

(Figure 18) and walk with moderate support of two UL’s (Figure 19).

Figure 13 – Unsupported kneel

24
14(a) 14(b)

14(c) 14(d) 14(e)

Figure 14 (a –e) FB climbing onto his mother with nil assistance

Figure 15 – FB initiating climb with L stance

25
16(a) 16(b)

16(c)

Figure 16 (a –c) FB sitting to stand with L LL bias with minimal assistance

Figure 17 – FB cruising around a corner Figure 18 – FB cruising between two surfaces

26
Figure 19 – FB walking with light support of two contactual hands

27
 Reflections

Key components of the Bobath concept and the role that they play in motor development and skill

acquisition were exemplified through working with FB. In particular the role that postural tone and

control, alignment, symmetry and sensorimotor integration play became evident and were used in

the observation, hypothesis, and development, execution and evaluation of treatment of FB. Lessons

that will be used in future patient contacts. Encouragingly there were significant changes in the

alignment, symmetry, independence and control of PTS and stance in FB. The role however that the

CHOR played in the development of PTS and independent stance in the case of FB remains

inconclusive.

Firstly whether or not the promotion of an open and extended hand contact with a surface in the

treatment of FB represented a true CHOR is unclear. Barela et al (1999) have found that the time at

which a contact source is used at a force indicative of light touch somatosensory support (key

component of the CHOR) rather than mechanical support is approximately one to two months post

the attainment of independent walking, a skill FB was yet to achieve at the conclusion of therapy.

Furthermore the challenging nature of working with a paediatric client who has limitations in how

long they will stay engaged in an activity or tolerate handling meant that it was very difficult to

completely optimise a CHOR with scapula setting, external rotation and placement via a straight line

pathway.

However on reflection had more attention been paid to sensory stimulation of the hand in therapy

and as part of the HEP, FB’s hand placement in therapy may have been closer to a true active CHOR.

This consideration would be particularly pertinent when working with any person who has an upper

limb impairment limiting the hand from performing it’s functional role but particularly with children

with cerebral palsy who often demonstrate sensory impairments and excessive grip force to

compensate for decreased sensory input (Majnemer et al 2009); forces which are not conducive to a

CHOR and the haptic feedback the CHOR provides.

28
Nevertheless, improvements were seen. Whether this was due to a true CHOR, promoting the

experience of verticality through sitting to stand and standing, providing sensory feedback through

facilitation in standing, stop standing or kneeling to promote active alignment, symmetry, postural

control and antigravity muscle activity (Marigold and Eng 2006, Prochazka et al 1997), through

activating the reticular system with variable, short, unpredictable bouncing of FB on a Swiss ball to

increase his global muscle tone (IBITA, 2014) or merely through setting up the environment in an

engaging way that encouraged repetitive use of musculature in a functional context is largely

unclear. The pertinent message that all of these approaches were likely effective in combination and

that the experiences will assist in guiding the treatment of any future patient with movement

dysfunction; be they paediatric or adult.

Another consideration in the case of FB was the frequency with which FB was treated. No literature

was able to be sourced that guided the development of a regime with the optimal frequency,

duration or intensity. The decision for when FB was treated was therefore modelled on FCP in that

frequency of treatment was determined by how often FB’s mother felt she could realistically commit

to coming to the hospital for therapy in the context of her family and their busy lifestyle. The

development of a HEP which was altered each session in response to improvements in FB was also

instructed and encouraged to be completed as often as practically possible with FB’s mother in the

context of FB’s natural environment and daily routines (Hanft and Pilkington 2000). Context that

ensures that FB can PTS by himself on the coffee table in his lounge room so that he can play cars

with his sisters. This is surely what matters most to FB and his family, not that he can PTS on a plinth

in a therapy room.

29
 References

Angelaki DE and Cullen KE (2008): Vestibular system: the many facets of a multimodal sense. Annual

Review of Neuroscience 31:125-150.

Atun-Einy O, Berger S and Scher A (2012): Pulling to stand: common trajectories and individual

differences in development. Developmental Psychobiology 54: 187-198.

Barela JA, Jeka J and Clark JE (1999): The use of somatosensory information during the acquisition of

independent upright stance. Infant Behaviour & Development 22: 87-102.

Bly L (1983): Components of typical and atypical motor development. California: Neuro-

Developmental Treatment Association Inc.

Buurke JH, Hermens HJ, Erren-Wolters CV and Nene AV (2005): The effect of walking aids on muscle

activation pattern during walking in stroke patients. Gait & Posture 22: 164-170.

Darrah J, Piper M and Watt MJ (1998): Assessment of gross motor skills of at-risk infants: predictive

validity of the Alberta Infant Motor Scale. Developmental Medicine and Child Neurology 40:

485-491.

Denny-Brown D (1966): The cerebral control of movement. Liverpool: Liverpool University Press,

p145.

Dickstein R (2005): Stance stability with unilateral and bilateral light touch of an external stationary

support. Somatosensory and Motor Research 22: 319-325.

Esposti R and Baldissera FG (2011): Combined recruitment of two fixation chains during cyclic

movements of one arm. Human Movement Science 30: 213-226.

Gjelsvik BE (2008): The Bobath concept in adult neurology. Stuttgart: Theime

30
Haehl V, Vardaxis V and Ulrich B (2000): Learning to cruise: Bernstein’s theory applied to skill

acquisition during infancy. Human Movement Science 19:685-715.

Hanft BE and Pilkington KO (2000): Therapy in natural environments: the means or end goal for early

intervention? Infants and Young Children 12:1-13.

International Bobath Instructors Training Association (IBITA) (2014): The assessment and treatment

of adults with neurological conditions- the Bobath concept: basic bobath course manual.

IBITA.

Jeka JJ and Lackner JR (1994): Fingertip contact influences human postural control. Experimental

Brain Research 100:495-502.

Jeka JJ and Lackner JR (1995): The role of haptic cues from rough and slippery surfaces in human

postural control. Experimental Brain Research 103:267-276.

Jeka JJ, Schöner G, Dijkstra T, Ribeiro P and Lackner JR (1997): Coupling of fingertip somatosensory

information to head and body sway. Experimental Brain Research 113:475-483.

Karnarth H, Ferber S, Dichgans J (2000): The neural representation of postural control in humans.

Proceedings of the National Academy of Science USA 97: 13931-6.

Krishnamoorthy V, Slijper H and Latash M (2002): Effects of different types of touch on postural sway

Experimental Brain Research 147:71-79.

King G, Law M, King S and Rosenbaum P (1998): Parents and service providers perceptions of the

family centeredness of children’s rehabilitation services. Physical and Occupational Therapy

in Pediatrics 18: 21-40.

King S, Teplikey R, King G and Rosenbaum P (2004): Family-centred service for children with cerebral

palsy and their families: a review of the literature. Seminars in Pediatric Neurology 11: 78-86.

31
Marigold DS and Eng JJ (2006): The relationship of asymmetric weight-bearing with postural sway

and visual reliance in stroke. Gait and Posture 23:249-255.

Majnemer A, Bourbonnais D and Frak V (2009). The role of sensation for hand function in children

with cerebral palsy. Archive de publications électroniques de I’Université du Québec á

Montréal. Accessed from archipel.uqam.ca on 12/5/14.

Pallsano RJ, Haley SM and Brown DA (1992): Goal Attainment Scaling as a measure of change in

infants with motor delays. Physical Therapy 72: 432-437.

Porter R and Lemon R (1993): Corticospinal function and voluntary movement. Oxford: Clarendon

Press

Prochazka A, Gillard D and Bennett DJ (1997): Positive force feedback control of muscles. Journal of

Neurophysiology 77:3226-3236.

Raine S, Meadows L, Lynch-Ellerington M (2009): Bobath concept: theory and clinical practice in

neurological rehabilitation. Oxford: Wiley, pp 97, 101, 173

Ring HA and Serra-Mestres J (2002): Neuropsychiatry of Basal Ganglia. Journal of Neurology,

Neurosurgery and Psychiatry 72: 12-21.

Rothwell J (1994): Control of human voluntary movement. (2nd ed.) London: Chapman & Hall: p

459.

Shumway-Cook A and Woollacott A (2012): Motor control – translating research into clinical

practice. (4th ed.) Baltimore: Lippincott Williams & Wilkins, pp 247-249, 343.

Sheridan MD (1998): From Birth to Five Years – Children’s Developmental Progress. Camberwell:

ACER Press, pp 20-25

Snell RS (2010): Clinical Neuroanatomy. (7th ed.)Philadelphia: Lippincott Williams & Wilkins.

32
Vaughan-Graham J, Eustace C, Brock K, Swain E and Irwin-Carruthers S (2009): The Bobath concept

in contemporary clinical practice (grand rounds) (report). Topics in Stroke Rehabilitation

16:57-68.

Woollacott MH and Burtner P (1996): Neural and musculoskeletal contributions to the development

of stance balance control in typical children and in children with cerebral palsy. Acta

Paediatrica Supplement 416: 58-62.

Wollacott MH, Burtner P, Jensen J, Jasiewicz J, Roncesvalles N and Sveistrup H (1998): Development

of postural responses during standing in healthy children and children with spastic diplegia.

Neuroscience and Biobehavioural Reviews 22: 583-589.

33
 Appendices

Appendix 1 – Schematic drawing of (A) two-leg and (B) half-kneel strategies for pulling to stand

Figure from: Atun-Einy O, Berger S and Scher A (2012): Pulling to stand: common trajectories and

individual differences in development. Developmental Psychobiology 54: 187-198.

34
Appendix 2 - Consent

35
 Appendix 3 - Initial assessment of FB

Referral: Referred by maternal child health nurse at 9.5 months of age as although sitting, not rolling

much from supine to prone and not initiating a lot of movement in prone

Date of assessment: 17/2/14

Age of FB: 13months, 28 days

Subjective assessment

Birth History: Gestational diabetes throughout pregnancy, 3rd pregnancy. Born at term (39 + 3/40).

Normal vaginal delivery, Mother needed to be induced. APGARS 8 at 1 minute and 9 at 5 minute.

Weighed 3070g at birth.

Past medical history: nil significant

Investigations: nil

Social History: Lives with Mother, Father and 2 older sisters (12 and 8 years old). Not attending

playgroup, mothers group or gymbaroo

General Health: Nil significant. Eating soft solids and bottle formula. Wakes once during night and

has one two hour sleep throughout the day.

Behaviour, communication and play: Disliked tummy time. Enjoys company. Enjoys cars, wheel, and

balls. Babbling, can say “mumma”, “dada”, and “ball”.

Developmental milestones:

 Rolled supine to prone at five months, prone to supine at six months

 Independent sit at seven months

 Crawled at 11 months

36
  Not yet pulling to stand or standing, independently. Mother offers gentle lift through

upper thorax to assist to pull to stand.

 Not yet walking. FB’s Older sisters walked at 12-13 months old

Parental concerns: Realises FB is a little slower physically than other children his, reports would like

to see FB achieve timely independent walking. Reports he has “3 mothers” and his sisters do a lot for

him whom she feels may have contributed somewhat to his motor delays

Objective assessment

General: Happy, easy to engage in cause and effect and noisy toys such as ocean drum and fish bowl.

Good eye contact especially with song. Smiles but minimal laughter or sounds voiced. Tolerant of

handling.

Neurodevelopmental screen

 Hips, spine, feet: NAD for signs of developmental hip dysplasia (DDH), scoliosis, spina

bifida, metatarsus adductus, talipes

 Head/neck: Mild R plagiocephaly, nil torticollis

 Tone: Mild UL/LL bilateral hypotonia, nil clonus or catch and release

 Tendon reflexes: Nil abnormality detected (NAD) in elbow and knee

 Oculomotor: NAD, follows full range

 Auditory-motor: NAD, turns bilaterally to sound

 Sensory-motor:

- Tactile - Normal response to tactile stimuli; grasps and manipulates

- Proprioception- Delayed response to change of body position

- Vestibular – Nil nystagmus with rotation

37
Gross motor

 4PN: Transitions into 4PN through walking back hands rather than initiating with

lateral weight shift and hip flexion under trunk. Flexed throughout lumbar spine in

4PN, abdomen towards ground, bilateral LL abduction L >R

 Crawl: Preferred method of locomotion. Significant lumbar lordosis. Bilateral hip

abduction L > R. Able to weight shift and support in three point kneel to reach for

toy.

 Rolling: not observed despite encouragement

 Supine to sit: Effortful via trunk flexion and rotation over L or R pelvis, significant use

of UL’s to assist

 Sit to 4PN: Effortful via R or L side sit. Significant use of UL’s and upper trunk to pull

into position

 Sitting: Posterior pelvic tilt with global flexion throughout trunk. Preferences ring sit

as opposed to long and half long sit. Able to maintain balance and play with toy in

midline however preference for UL support.

 Appropriate but slowed balance reactions when sat and moved on Swiss ball

anteriorly/posteriorly and laterally

 Pull to stand: Attempts made to compete independently via 4PN to high kneel at

support with bilateral UL. Minimal experimentation of lateral weight shift in position,

nil initiation into half kneel. Mother assists into stand from high kneel with gentle lift

through upper thorax – some active foot placement and WB R > L LL. When assisted

into L or R half kneel or sit to stand from therapist knee with LLs placed in alignment

38
 able to isolate good active and reasonably symmetrical LL extension to stand

however once in stand will adopt asymmetrical stand with WB R > L

 Standing: Supervision required in standing, decreased WB through L LL. L LL in

degree of hip flexion, abduction and internal rotation. L ankle plantarflexed. Variable

inversion/eversion. Majority of L WB through lateral border of mid-forefoot.

Requires one UL for support often through forearm and hand with significant

associated lateral trunk flexion to WB side. Nil UL preferences demonstrated.

Minimal active trunk rotation in standing. Nil balance reactions observed.

 Cruising/walking: Nil attempts made despite encouragement

Fine Motor

Casting toys with L and R hand (nil hand preference observed). Pincer grip and gross grasp observed

L and R. Some isolated finger use observed bilaterally

39
 Appendix 4 – GAS for FB

Pull to Stand Stand

+2 (much more than
expected outcome)
+ 1 (more than expected
outcome)
0 (expected level of
outcome)
-1 (less than expected
outcome)
-2 (much less than expected
outcome)
Independent symmetrical sit Independent symmetrical
to stand from chair/therapist stand nil UL use > 5 seconds
leg or via half kneel with nil
UL use
Independent pull to stand via Independent symmetrical
half kneel with use of 1 UL stand nil UL use for 3-5
seconds
Independent pull to stand via Independent symmetrical
half kneel with 2 UL use stand nil upper limb use for 3
seconds
s/v pull to stand via half Supervision stand nil upper
kneel with 2 UL use limb use < 3 seconds
Assistance required to pull to Assisted stand nil upper limb
stand via half kneel with 2 UL use > 3 seconds

= level of function prior to therapy

= level of attainment following therapy

40
 Appendix 5- Session Record

Session 1 – initial assessment 2 3 4 5 6 7

Date 17/2/14 25/2/14 7/3/14 18/3/14 24/3/14 1/4/14 8/4/14
Age 13 months, 28 days 14 months, 5 days 14 months, 15 14 months, 26 15 months, 4 15 months, 12 15 months, 19
days days days days days
Subjective reports Crawling but not able PTS without Notice R LL Nil Nil Cruising bilaterally, Increased
from Mother to PTS. FB well. assistance. More preference for improvements improvements yet to cruise confidence in
grounding of L PTS. Attempting noted since last noted since last between furniture. climb and
foot in stand. Has cruising. Unable session. Limited session. Noted Enjoyed bilateral cruise.
cold and slept to control time in past preference for attendance at FB well.
poorly overnight descent once week for HEP. FB cruise to L. FB toddler gym
standing, falling well. well. program which
posteriorly. FB included
has a cold jumping/climbing
activities. FB well
Major new objective As per initial PTS independently Decreasing use of Nil change to PTS PTS with Asymmetrical STS 3 repetitions of
findings assessment (Appendix exclusively via R UL to PTS via R greater control from PT knee R>L sit to stand from
2) half kneel half kneel Initiating high of weight shift with very close s/v PT knee/step
exclusively kneel but poor when with close s/v
Significantly more endurance positioning into
straight line Cruising 3-4 steps R half kneel Unsupported
alignment in bilaterally with Able to rotate in stand 2 second
standing with bilateral heavy stance bilaterally Increased with large degree
improved UL support with distance of of postural sway,
grounding of L LL encouragement bilateral cruise attempting to
with preference rotate in
to cruise to L unsupported
stand
Behaviour/tolerance in Happy, easily Poor tolerance of Tolerant of Tolerant of Poor tolerance Tolerant of Happy, easily
session engaged, tolerant of handling. Grizzly handling. handling. of handling, handling. engaged, tolerant
handling at times Generally happy Generally happy seeking Generally happy of handling
reassurance
from mother

41
 Appendix 6 – Key treatment descriptions

a) Sit to stand from PT knee

This picture shows the use of downwards compression and anterior translation of

quadriceps during a STS to promote symmetrical loading and antigravity extension to

promote independent PTS. In this picture a contactual hand is not used, however on other

occasions a unilateral or bilateral contactual hand with the foam steps to the side or in front

of FB respectively was also used to facilitate a STS.

PT follow STS by coming

into high kneel to give Downwards pressure with anterior
sense of forward translation through bilateral quadriceps to
progression and give sense of loading and extension
extension

FB engaged in activity that promotes

desire to stand. In this picture that is
standing to pop a bubble

LL’s placed in as optimal

alignment as possible under trunk

42
 b) Supported standing with contactual hand

This picture shows supported standing with FB in stride stance with contactual hand on a

plinth. Stability and extension are promoted through the L weight bearing hip with an

upwards and medially directed compression through the gluteals to encourage stability

through the pelvis for PTS and standing. On other occasions this treatment was conducted

in bilateral, and L SLS. At other times a Swiss ball, vertical mirror or foam steps were used as

a surface for the contactual hand.

FB engaged in activity to promote global extension. In

this case reaching up to pop the pop up men

Contactual hand

Compression to gluteal and upper

quadriceps to give sense of stability
and extension through L hip to support
extension through L LL and trunk

43
c) Standing with external perturbation

This picture shows the use of a Swiss ball to provide small external perturbations to

develop muscle activation patterns to correct postural sway in unsupported stand. In

this case a unilateral contactual hand is used with the added complexity of trunk

rotation.

On other occasions FB had bilateral contactual hands and was facing forward. Often in

this situation his mother was gently moving the ball back and forth whilst singing “row

row row your boat” whilst hip extension was promoted by PT by giving sense of de-

weighting of the trunk with upwards and inwards pressure through abdominals and

extension and compression through gluteals.

Gentle rocking of ball back and forth for

external perturbations

Contactual hand

44
 d) Rotation between two surfaces in standing

This picture shows FB rotating over his right leg to a toy that has just been moved from the

foam steps on his left to the plinth on his right. The toy was repeatedly moved between the

plinth and the foam steps to encourage rotational control in standing. Compression and

extension facilitation was provided through the gluteals and lateral thigh especially on the

ipsilateral side to which FB was rotating towards to encourage hip extension and stability

during weight shift and rotation; key skills to assist in the attainment of half kneel for

efficient and controlled PTS and for early walking.

Compression and extension of gluteals and

lateral quadriceps especially on stance leg
during rotation
Contactual hand

45
e) Stop standing

This picture depicts the facilitation of stop standing. In this case an upwards and anterior

distraction is provided to hamstrings to unlock the knees in standing with distraction

through quadriceps to control lowering to a squat. From here, FB was encouraged to stand

from squat though upwards and inwards compression through hamstrings. FB was

encouraged by his mother in an engaging toy which she moved up when FB was extending

and down when FB was lowering. On other occasions stop standing was performed with

contactual hands at a play table or foam steps.

Upwards and inwards

Anterior distraction
compression through
through quadriceps to
hamstrings to unlock knees
encourage eccentric
to initiate stand to sit
control to lower into sit

46
 f) Low to high kneel with contactual hand

This picture depicts the promotion of antigravity extension necessary for the attainment of

independent PTS and for control of standing. The contactual hand is being developed though

promotion of placing and use for sense of stability with light contact on dorsum. Antigravity

extension of hips through low to high kneel is promoted through light upwards tapping/compression

through the gluteals whilst eccentric lowering and control from high to low kneel is provided

through light resistance to body lowering against PT hand.

Developing a contactual hand

Light resistance to
body lowering

Use of toy that promotes repetitive

extension and lowering. In this case a
car ramp.

PT thighs used to promote LL

alignment under trunk through
lateral compression of LL’s

47
g) Left half kneel to stand

This picture shows the promotion of PTS through assisting antigravity extension following

positioning into L half kneel. Once positioned into L half kneel, FB was provided downward

compression and anterior distraction of quadriceps to promote loading and extension through L to

stand. A toy which encouraged repetitive standing and lowering was chosen to encourage this.

Contactual hand

Downwards pressure
through quadriceps to
Ball run used in which FB
give sense of loading and
picked up ball from
extension
ground and had to extend
to put into top of ball run

48