Dr. Winthrop Phelps developed an approach to cerebral palsy treatment in 1932 in Baltimore. His goals were economic independence and self-care ability. His approach involved accurate diagnosis, mental assessment, and a multidisciplinary rehabilitation team. Fifteen treatment modalities were used, including passive range of motion, active assisted motion, muscle education, relaxation techniques, and braces. Movement progressed from simple to complex patterns based on a child's abilities.

1. Phelp’s approach
Dr. Winthrop Phelps
Work started from 1932 at USA,
Baltimore
Purpose of treatment is :
(1) economic independency,
(2) able to self-care and be socially presentable.

2. 1. An accurate diagnosis of the condition
Specific diagnostic classification
5 major categories of cerebral palsy with,
• Spasticity
• athetosis, with tension and without tension
• Rigidity
• Tremor
• ataxia
2. A careful mental assessment
3. A wide, comprehensive and intensive approach. Make
a rehabilitation team of PTs, OTs,ASTs orthopedicians
pediatricians and neurologists, teachers.

3. PRINCIPLES
Fifteen modalities were described and specific
combinations of these modalities were used for the
specific type of cerebral palsy.
1) Passive motion through joint range for mobilizing
joints and demonstrating to the child ,the movement
required.
Speed of movement –
slower for spasticity
increased for rigidity.
2) Active assisted motion.
3) Active motion.
4) Resisted motion (according to the child’s capability)

4.  Muscle education. Children with spasticity are given muscle
education based on an analysis of whether muscles are
spastic, weak, normal or zero, cerebral – being unable to
act. Muscles antagonistic to spastic muscles are activated.
This is to obtain muscle balance between spastic muscles and
their weak antagonists.
Spastics - need muscle re-education
Ataxics - may be given strengthening exercises.
Athetoids – need to control simple joint motion and do not have
muscle education in their therapy.

5. Which patterns to use?
5) Confused motion: Mass movements such as the
extensor thrust or the flexion withdrawal reflex were
usually used. Confused motion is used by children
when selective isolated movement is not possible.

6. 6) Combined motion is training motion of more than one joint,
such as a shoulder and elbow flexion.
7) Reciprocation is training movement of one leg after the other
in a bicycling pattern in lying, crawling, knee walking and
stepping.
8)Balance: Training of sitting balance and standing in braces.
9) Reach and grasp and release used for training of hand
function.
10) Conditioned motion is recommended for babies, young
children and mentally retarded children. This included a
routine and the use of the same song or jingle for the same
movement modality.

7. 11)Periods of rest are suggested for athetoids and children with
spasticity.
12)Relaxation techniques used - (Jacobson’s method). Used mainly
in - athetoids. This is practiced in various functional positions.
13)Movement that happen from a state of relaxation is conscious
control of movements, once relaxation has been achieved. It was
mainly used to consciously control involuntary movements.
14) Massage for hypotonic muscles, but contraindicated in children
with spasticity and athetoids.
15) Skills of daily living such as feeding, dressing, washing and
toileting should be achieved by modified appliances and aids.
Many aids were devised by the occupational therapists.

8.  Braces or calipers.
 Maintain a corrected deformity,
 to obtain the upright position
 to control athetosis.
• Children wore long leg braces depending on their level of
control and gradually as they gained control over joints, the
braces are slowly weaned off by unlocking the orthotic joints
and then removing the orthotic joint.

9. • upright standing frame to provide
weight bearing was used early in
rehab to prevent hip dislocation.

10. Temple Fay’s Approach
pic
Dr. Temple Fay
America, Philadelphia
1895-1963

11. PHILOSOPHY
• He stated that animals carried out these early
movements of progression with a simple
nervous system, these movements can
similarly be carried out in human in the
absence of a normal cortex.
• The mid brain, pons and medulla could be
involved in the stimulation of primitive
patterns of movement and primitive reflexes.

12. PRINCIPLES
• " Neurological organization" occurs if each developmental
level is established before going to the next level.
• If any one stage is not achieved it will adversely affected all
subsequent stages.
• The development of a child who had a neurological injury
could be improved by making him or her undergo normal
sequences in a frequent, repetitious fashion.
• These movements are taught initially with passive movements
known as patterning. The child is later encouraged to perform
them actively.

13. • He said that movement sequences should be built up from-
Reptilian squirming -> amphibian creeping -> mammalian
quadripedal reciprocal crawling-> erect walking of the
primates.
• The movement patterns are developmental and Fay suggested
that they should be followed in strict sequence of :
1) Prone Lying – Head and trunk rotation

14. 2, 3) Primitive homolateral and Contralateral creeping

15. 4Crawling
5 Elephant walk on hands and feet
6 Walking pattern.