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Therapeutic Exercise in Developmental Disabilities

Leeds, Sheila

Departments: Book Review

Greensboro, NC

Therapeutic Exercise in Developmental Disabilities, 3rd Edition. B. H. Connolly, P. C. Montgomery (eds). Thorofare, NJ, Slack Incorporated, 2005, hardback, 547 pp, $80.

Therapeutic Exercise in Developmental Disabilities now in its third edition has been revised and expanded reflecting important changes in clinical practice: an increasing emphasis on evidence based practice and conformity with the Guide to Physical Therapist Practice. The book includes 18 chapters and is centered on five cases that represent common developmental disabilities seen in physical therapists' practice. The chapters have been written by a team of 15 well known pediatric physical therapists.

The first four chapters provide a solid background for the latter chapters. Chapter 1 written by VanSant presents basic background information on neural control of movement with a heavy dose of developmental theory. There is a brief discussion of dynamical systems theory, with a useful section on application of these newer theories to clinical practice. Chapter 2, authored by Connolly, discusses the concepts of examination and evaluation and defines these according to the Guide. The chapter then presents a helpful overview of the psychometric characteristics of tests and follows with a review of standardized assessments used commonly in pediatric physical therapy (PT). This section is extremely well organized, and the author has provided a very useful summary of each of our major examination tools, as well as introducing some that are less well known. The third chapter, contributed by Montgomery, is entitled "Establishing Functional Outcomes and Organizing Intervention." The chapter begins with discussions of the variables that influence the planning of intervention and provides a model used by the author in making sense of intrinsic variables that should be addressed in PT examinations, evaluations and interventions. The author walks us through the process of moving from examination to establishing therapeutic goals and functional outcomes, emphasizing the need to articulate functional outcomes in objective behavioral terms. Numerous examples are provided to illustrate the process. These examples are followed by discussions of long and short term functional outcomes and finally discharge planning. Sample discharge plans are included for six different children. A short but important section of the chapter discusses criteria for terminating PT services. This first part of the chapter is then followed by a discussion of motor learning, which although a very important and useful part of the book, appears misplaced within this chapter. The topic appears to deserve its own chapter. The discussion of motor learning includes a theoretical perspective, discussion of performance versus learning, transfer of learning, practice, feedback, and knowledge of results, concluding sections on the application of motor learning principles to clinical practice and the use of physical guidance to promote skill acquisition. Following the presentation on motor learning, a section on organizing treatment follows which presents ideas related to environmental context, the normal motor development sequence and suggestions for sequencing treatment both over the long term and within a treatment session. The chapter concludes with a brief section on documenting progress. The latter sections on organizing treatment seem to be more strongly linked with the first part of this chapter.

In Chapter 4 Connolly and Montgomery present the five cases that serve as examples to illustrate the application of information presented by authors of the later chapters of the book. Each case is anchored to a practice pattern from the Guide, and includes a comprehensive presentation of the examination history and systems review. The cases represent the medical conditions of right hemiparetic cerebral palsy, spastic quadriparesis, L1-2 myelomeningocele, Down syndrome, and developmental coordination disorder with attention deficit hyperactivity disorder. Each of the authors who provide perspectives on examination and intervention use these cases to illustrate application of the principles presented in their chapters.

Bohmert and Woods authored Chapter 5, which illustrates the application of the Guide to clinical practice. Beginning with a review of the history of the development of the Guide, the authors then describe the organization and concepts of the Guide before presenting its application to clinical practice. This part of the chapter requires readers to have the Guide available in order to follow along with the authors' explanations. They present the organizational framework within practice pattern 5C: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System—Congenital Origin or Acquired in Infancy or Childhood. They describe the organization of information within this aspect of the guide, review the diagnostic classification for patients who meet the inclusion classification for this pattern of care and then go on to discuss the processes of examination, evaluation, diagnosis and prognosis, intervention, reexamination, outcomes and criteria for termination of PT services. The authors then present the five case studies, three of which are classified in practice pattern 5C and two of which are classified in pattern 5B (Impaired Neuromotor Development). For each case the authors list the findings from the examination, systems review, tests and measures. They then provide an evaluation, diagnosis and prognosis followed by recommendations for interventions. This chapter sets the stage for the next 10 chapters that present more specific information on aspects of PT care.

Harris and Welch in Chapter 6 present information on PT in the Neonatal Intensive Care Unit (NICU); they discuss the variety of indications for NICU care and the role of physical therapists in the NICU, focusing on evaluation and therapeutic interventions. The chapter concludes with a brief presentation on the NICU course for each of the children presented in the case studies. A very helpful glossary concludes the chapter.

Chapter 7 by Chapman and Porter presents a discussion of Sensory Considerations in Therapeutic Interventions. The authors have included a succinct discussion of dynamic systems theory, a discussion of the sensory subsystem as it relates to motor behavior, the characteristics of sensory systems, and the selection of sensory input for use during interventions. The chapter continues with a discussion of examination and evaluation of sensory systems, and the interrelationship between examination and intervention strategies as it relates to cutaneous, vestibular, proprioceptive, visual and auditory inputs. The authors conclude with a discussion of each of the five cases, including both examinations and interventions.

Developing postural control is the topic of the eighth chapter authored by Montgomery and Effgen. The authors begin by defining postural control and then present both the reflex hierarchical and systems models of postural control. Greater emphasis is placed on the latter more contemporary model and this is followed by a discussion of reflex patterns which the authors propose are mediated by central pattern generators. They then discuss the use of reflexes in making medical diagnoses, particularly as it relates to children with CNS pathology. The authors conclude with a discussion of nature versus nurture in the development of postural control before presenting principles of examination and evaluation followed by considerations for intervention. These principles are illustrated in their discussion of each of the five cases.

The ninth chapter, written by Sternat discusses the development of head and trunk control. Beginning with a discussion of the importance and complexity of head and trunk control, Sternat then presents seven principles of motor control before presenting an approach to examination and evaluation that includes four methods involving observation, handling, and eliciting skills and the continued examination of the child during intervention. Intervention strategies are presented and illustrated prior to presenting a protocol for intervention and the concluding discussion of the case studies.

Respiratory and oral motor functioning is the topic of Alexander's chapter. A brief discussion of oral motor, feeding/swallowing and respiratory and phonation functions precedes a section on impairments of oral motor and respiratory function. An intervention framework is presented, followed by discussion of clinical examination, evaluation and treatment programming. The author emphasizes proper body positioning in treatment programming and illustrates this concept with a series of illustrations. The chapter concludes with a discussion of each of the five cases.

Bierman is the author of the 10th chapter on the development of ambulation skills. Beginning with a differentiation between locomotion, walking, and gait/ambulation the author then discusses each in turn. A section is included that describes the growth and development of the musculoskeletal, neuromuscular and sensory systems and their interaction in the development of gait. Various pathologies are presented along with the implications of each on the parameters of gait. These pathologies include myelodysplasia, cerebral palsy and mental retardation. A comprehensive outline of an examination of gait is included along with a discussion of the systems analysis that explores the relationship of the various body systems to the abnormalities of gait. Principles of intervention are discussed with reference to Levels of the Gross Motor Function Classification System. The information presented in this discussion is well illustrated with photos of children. The chapter concludes with a discussion of the ambulation function for each of the five cases.

Chapter 12 by Boehme presents the development of hand function. The author begins her chapter with a discussion of postural alignment that is then illustrated with a case study. Although the purpose of this presentation is to demonstrate the link between postural alignment and hand function, the author's discussion of this relationship could have been stronger. The nature of postural control is then presented as a lead in to the discussion of the shoulder girdle and its constituent bones and joints, followed by a review of scapular movements. The functional roles of the humerus, elbow, forearm, wrist, and hand are then presented. The author then discusses typical development of the upper limb, followed by an overview of developmental delay as it related to hand function and fine motor skills. The author advocates the use of task analysis prior to her discussion of examination and evaluation. Intervention strategies are then presented followed by brief discussions of practice, and carry over. Each of the five case studies is discussed at the end of the chapter.

Bierman and Wilson Howle present a discussion of the selection and use of assisted technology devises in Chapter 13. After presenting five purposes of using adaptive equipment, they discuss each in turn including facilitation participation, increasing functional independence, improving postural control, alignment and movements, managing impairments, and preventing secondary impairments or pathologies. These introductory sections are concluded with a discussion of environmental constraints and a suggestion that therapists consider the environments in which children function when selecting equipment. A section on examination, evaluation and intervention in the context of assistive technology precedes the authors' discussions of the case studies. An appendix provides contact information for manufacturers of assistive technology.

Chapter 14 by Bohmert presents information on PT in the educational environment. Beginning with an overview of educational law, the author then discusses current educational laws including No Child Left Behind, Individuals with Disabilities Education Act, and other laws that affect individuals with disabilities. A discussion of the roles and functions of physical therapists in schools precedes the author's comments on each of the five cases.

In Chapter 15 the editors, Montgomery and Connolly, emphasize the focus of this text on functional limitations and related impairments. They briefly summarize for each of the children presented in their five case studies the primary functional limitations, impairments, goals and functional outcomes and a rich discussion in each case of the child's prognosis. This summary information is extremely helpful in tying together the many presentations and perspectives on the cases. The chapter concludes with an important message about episodic care and the goal of enabling independence and self management.

Chapters 16 and 17 by Michaels and Harris respectively, present information on evidenced based practice (Michaels) and single subject case designs (Harris) for clinical research. Michaels presents scenarios in which the therapist in each case study goes beyond routine documentation. In one instance a case report is prepared; in three others clinical questions are defined and evidence is gathered to answer the questions. In a fourth case, a single subject research study is carried out by the clinician in collaboration with a faculty member at a local university. These examples linked to the cases are both instructive and motivating for the reader. In Harris' chapter on single subject design, she begins with a section on the importance of clinical research with subsections on reliability, validity, and research terminology. Then the author presents issues related to measurement, and types of experimental designs included within the general class of single subject research designs. The case studies at the end of the chapter are used to illustrate these designs.

The final chapter by Connolly presents issues of aging for individuals with lifelong disabilities. This informative and interesting chapter provides important information about general aspects of aging and their effect on individuals with disabilities. Topics include the senses, the neuromusculoskeletal system, and the cardio-respiratory system. A brief discussion of cognitive changes with age in individuals with Down syndrome concludes the chapter.

In summary, the editors and authors of the chapters are well-known and respected pediatric therapists. Overall the organization of the text is good and the application of the Guide practice patterns are both timely and useful aspects of the book. The inclusion of discussions of evidence based research and single subject designs is also very relevant and helpful, particularly the application of the information to the cases. This text, which previously was primarily used as supplemental reading for physical therapist students, is now what I would consider a strong stand-alone text. The use of the case studies is a very compelling aspect of this edition of the book, one that should be very helpful for students. I would recommend all pediatric physical therapists add this book to their libraries and would expect that faculty would find the text useful for students in their educational programs.

Sheila Leeds

Greensboro, NC

© 2005 Lippincott Williams & Wilkins, Inc.