2. Interdisciplinary Approach
Treatment Team Members
Physical and
Occupational
Therapists
Neurosurgeon
Orthopedist
Orthotist
Seating
Specialist
Nurse
Social Worker
Speech
Therapist
Family and
Caregiver
Physiatrist
Neurologist
Primary Care
and Family
Physician
Children with
Cerebral Palsy
3.
4. Treatment Options for Patients
with Cerebral Palsy
CP Child
Intrathecal
Baclofen
(ITB™)
Therapy
Oral
Medications
Rehabilitation
Therapy
Orthopedic
Surgery
Neurosurgery
Injection
Therapy
6. Upper Motor Neuron
Syndrome (UMNS)
Positive Signs
( being in excess of the
normal resting state)
• Spasticity
• Rigidity
• Hyperreflexia
• Primitive reflexes
• Clonus
Negative Signs
( being less than the
normal resting state)
• Lack of strength
• Lack of motor
control
• Lack of
coordination
22. • Injections can be an effective
treatment for focal spasticity.
• Injection therapies are often used in
combination with other interventions,
such as orthoses, serial casting,
stretching, strengthening, and
rehabilitation to improve motor
control.
23. • Anesthetic/Diagnostic Nerve
Blocks
• Useful in identifying presence and
extent of contracture
• May help predict effect of subsequent
neurolytic procedure
24. • Neurolytic Blocks
• Injected into motor points of
involved muscle
• Decrease spasticity by damaging
nerve, blocking efferent (and
sometimes afferent) muscle
stimulation
• Agents used in neurolytic blocks
include phenol (3-7%) and ethanol
25. Injection Therapy: Considerations
Decrease positive signs
• Focal spasticity or dystonia
• Contracture
Improve negative signs
• Lack of Motor Control (use rehab to
address)
• Lack of Strength (use rehab to
address)
– opportunity to work on strength and
better alignment
Consider other negative signs
• Lack of Strength (consider whether
decreasing hypertonia would be
detrimental to posture and function)
26. Injections
Advantages
• Not permanent
• Evidence to support efficacy in reducing
spasticity and improving function
• Effects are localized - not systemic
Disadvantages
• Not permanent - may need to repeat
injections
• Ethanol and Phenol: require greater skill
to inject, increased risk of paresthesias,
dysesthesias
• Botulinum toxin: more expensive than
other injections, may develop antibodies
28. Botulinum Toxin
• Produced by the bacterium, Clostridium
botulinum
• Seven serotypes (A-G); only “A” and “B”
approved for clinical use
• Trade names of BTX-A:
– BOTOX® (Allergan)
– DYSPORT® (Ipsen, Ltd.)
• Conversion ratio: 1 Unit BOTOX~3-5 Units
Dysport
• Trade name of BTX-B, from Elan:
– MyoblocTM in USA
– NeuroBloc® in Europe
www.wemove.org
30. Intrathecal Delivery of Baclofen
• Acts as GABAb – receptor agonist
– GABA (gamma-amino butyric acid) is an inhibitory
CNS neurotransmitter
– Two receptor types (GABAa and GABAb)
• Mechanism of action is probably presynaptic
inhibition
– Inhibits release of calcium into presynaptic terminals
– Thereby impedes release of excitatory
neurotransmitters
• Baclofen is delivered directly into CSF in
intrathecal space
31. SynchroMed® Infusion System
Components
Pump
• infuses drug at programmed
rate
Catheter
• delivers drug to the
intrathecal (subarachnoid)
space of the spinal cord
Programmer
• allows for precise dosing
• easily adjustable dosing
32. Indications for ITB™ Therapy
• Patients must demonstrate a positive
response to the screening test
• Patients with spasticity of spinal origin:
– unresponsive to oral antispasmodics
– and/or experience unacceptable side effects
at effective doses of oral baclofen
• Patients with spasticity of cerebral origin
must be one year post brain injury to be
considered for ITB Therapy
33. Therapist Role Post-Implant
• Determine appropriate therapy
venue
• Propose treatment plan
• Provide input regarding dosing
34. Neurosurgical Treatments
• Neurectomy (cutting of peripheral nerves
to permanently reduce spasticity).
• Myelotomy (dividing or cutting of the
anterior and posterior horns of the spinal
cord).
• Anterior Rhizotomy (cutting of a spinal
nerve root which interrupts motor output
from the spinal cord).
35. • Selective Dorsal Rhizotomy
(Selecting cutting of dorsal sensory
nerve roots).
• Cordectomy (removal of part of the
spinal cord).
•
• Thalamotomy (Thalamotomy –
lesioning the thalamus to reduce
involuntary movements, usually
used in patients with dystonia to
treat contralateral dystonia).
37. Orthopedic Surgery
• Soft-tissue operations
– Lengthening (lengthens tendons
and/or muscles to correct
contractures).
– Releases (cutting the tendon or
muscle to release muscle
contractures and improve passive
joint movement)
– Tendon transfers (tendons are moved
to alternate places on the bones to
provide better joint alignment and
muscle control).
38. • Bony operations
– Osteotomies (realignment of bones . Most
common in the femur in children for hip
joint integrity or to maintain the lower
extremities in a neutral position when there
are significant rotational deformities.
– Fusions (joints in the spine, wrist, hip and
ankle may be fused to provide stability and
maintain a functional position for patients
with severe bony deformities).
39. Orthopedic Surgery: Considerations
• Decrease positive signs
– Contracture
– Abnormal Bony Alignmet
• Improve negative signs
– Lack of Motor Control (may improve
with rehab)
– Lack of Strength (may improve with
better biomechanical alignment, may
require rehab)
– Lack of Balance (may improve if better
base of support)
40. Orthopedic Surgery
• Advantages
– Effects usually last a few years
• Disadvantages
– Anesthesia risks
– Non-weightbearing after bony
procedures
– Risk of weakness, decreased function
41.
42. Management
• Aim
– Keep function
– Optimise development
• Multidisciplinary team
• Initial thorough evaluation
• Re-evaluation
ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 42
43. Principles of Treatment:
• Numerous philosophies can be adapted for
use in the treatment of both neurological and
non-neurological disorders of childhood.
• The concepts and objectives are wide-
ranging.
• Some are common and complementary to
each other, whilst others appear to conflict.
ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 43
44. General principles
1. Careful assessment and recording should be
an ongoing process, not an isolated event.
2. Realistically planned therapeutic measures
should be derived from the assessment.
3. Early treatment should be incorporated into
the daily management of the child.
4. Repetition and reinforcement are essential for
learning and for the establishment of modified
motor patterns.
ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 44
45. 5. Maximise sensorimotor experience .
6. Involvement of the child as an active
participant.
7. Motivation of the child is essential.
8.Teamwork.
The multidisciplinary approach is invaluable
and must include the child and his or her
family. Conflicts and confusions should be
minimized by discussion and demonstration.
ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 45
46. Specific principles
1. A consideration of developmental training.
Philosophies differ as to whether sequences
should be strictly followed or modified.
(Compare Rood, Fay, Doman, Bobath,
Vojta, for example.)
2. A modification of abnormal tone. Some
schools of thought give much less emphasis
to this aspect and more to functional
independence.
3. The use of afferent stimuli.
ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 46
47. 4. The facilitation of purposeful, active
movement (although some use
passive movement also).
5. Minimizing and preventing
deformity.
6. Functional independence.
The levels at which the use of
compensatory movements and aids are
introduced vary greatly between the
philosophies.
ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 47
48. ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 48
Treatment Guidelines
The efficacy of rehabilitation Program
depends on:
1- Early diagnosis.
2- Early intervention.
3- Careful evaluation &accurately detection of
the child abilities and disabilities .
4- Determination of the problems in the form
of functional terms.
5- Arrange the problems according to the
priorities.
6- Identification of the underlying causes of
each problems.
.
48
49. ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 49
Treatment Guidelines
The efficacy of rehabilitation Program
depends on:
7- Finding the appropriate solutions for each
sub-cause of the problem.
8- Setting the short & long term goals according
to the child abilities and disabilities.
9- Using functional model of treatment.
10- Task analysis.
11- Involvement of the child's family and
caregivers in the rehabilitation.
49
50. ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 50
12- Home routine.
13- Co-operative Rehabilitation team.
14- Preparation the most suitable healthy
rehabilitation environment during training.
(Dressing of the child and trainer , Emotional
stress, examination tables, treatment room,
aeration, distractabilities, warmth &cold
,light ,presence of caregivers, medical status
of the child , drugs, and the relationship
between the trainer and the child).
15- The importance of periodical re-evaluation.
16- The individualization of each case.
50
51. The Postural Mechanisms
• The postural mechanisms are
neurological mechanisms which maintain
posture and equilibrium and are
involved in locomotion.
• They have been described by various
neurological workers (Belenkii et at.
1967; Martin 1965,1967; Roberts 1978;
Foley 1977a,1998;Marsden et at.1981; Cordo
&Nashner 1982;Shumway-Cook & Woollacott
2001).
ehabkafy@yahoo.com dr.ehab.abdelkafi@facebook.com 00966531698541 51
60. • The Bobath concept is arguably the most
familiar and widely used approach
known to British physiotherapists
working with children with neurological
disorders.
• It originated in the 1940s and early 1950s
and has subsequently been developed and
modified by herself, Dr K. Bobath and
the staff of the Bobath Centre.
61. Philosophy
The approach was originally based on
neurodevelopmental principles which
view development as:
• Dynamic
• Sequential
• Cephalocaudal
• Proximal to Distal
• Automatic before conscious
• Responsive and Adaptive.
62. • The basic premise is that a child in the
first few months of life undergoes a
maturation of the central nervous system.
• At first the child is dominated by reflex,
unconscious movement patterns, but
gradually these involuntary movements
become part of conscious experience,
they become controlled, rhythmical and
coordinated.
• Once the child is able to control
movement at a particular level of
maturation, the developmental process
then moves on to the next level.
63. • For the child with a neurological
disorder, however, the maturation of his
or her central nervous system has been
arrested at a particular level and the child
is unable to progress beyond it.
• This means that stereotypical primitive
reactions and responses become
obligatory and the adaptive coordinated
development of more skilled movements
does not take place.
64. Basic principles
• The Bobaths outlined a number of basic
principles which should be incorporated
into any treatment approach intended to
overcome the above problems.
• These principles are:
• Patterns of movement
• Use of handling
• Prerequisites for movement.
65. 1-Patterns of movement.
• Movements work in patterns, and it is
patterns which are represented at cortical
level rather than isolated muscle activity.
• It is therefore essential that all activities
designed to increase movement skills
should be based on developmentally
appropriate movement patterns.
66. The child with cerebral palsy may acquire
movement patterns (abnormal) in a
number of ways:
• By retaining primitive reflexes and
reactions.
• By developing abnormal patterns of
movement because of restricted
movement possibilities.
• By compensating or adapting to
abnormal movements.
67. • These restricted movement patterns may
themselves become limiting and prevent
the acquisition of more skilled,
responsive movements.
• The more the child uses an abnormal
pattern the more it becomes part of the
child's movement vocabulary.
• In this way a pattern of walking on the
toes with inwardly rotated hips and
flexed knees becomes the only way of
walking which feels right to the child.
68. • Correct walking is therefore not just a
matter of learning a new way, but of also
unlearning the incorrect way.
• When using the Bobath approach the
physiotherapist would aim to ensure that
all movement patterns are learned in a
more normal manner.
• The quality of the movement is as
important as its performance.
69. • As movement is created in patterns ,the action
of any one muscle group will result in an
adaptive response from all other muscle
groups in the body (associated movement).
• In this way the act of opening the mouth to
speak may result in a loss of control over the
pelvic girdle; reaching for a toy may cause
plantar flexion in the ankle of the opposite
leg.
• The greater the effort required to perform any
individual movement the greater these
responses will be.
70. • It is therefore important that abnormal
inappropriate movement patterns are
recognized and that therapy programs are
designed to overcome them.
• Normal responsive and effective patterns
are then encouraged and developed.
71. 2-Use of handling.
• These responsive and effective patterns
of movement are developed through the
use of special handling techniques.
• During treatment sessions the
physiotherapist becomes part of the
sensory input system of the child, and
handling is a constant interplay between
the therapist and the reactions of the
child.
72. The Bobath concept of handling aims to :
• Normalize tone,
• Improve co-ordination of posture and
movement, and
• Develop skilled, adaptive responses.
In this way the child is helped and guided to
improve the quality of movement rather
than being left to struggle on his or her
own.
The child responding to skilled handling
more easily than to spoken requests.
73. 3-Prerequisites for movement.
The Bobaths listed three factors, or prerequisites, for
efficient movement
1. Normal postural tone is necessary to resist gravity whilst
at the same time allowing movement to take place.
(Independent upright sitting balance).
2. Reciprocal innervation to muscle groups enables the
action of agonists and antagonists to be coordinated and
balanced.
1- Finger flexors and extensors enable movement of
pencil to form letters or shapes
2-Shoulder abductors and adductors enable movement
of pencil across page).
3. Postural fixation is necessary so that central muscle
groups can give stability whilst dynamic movement takes
place in more distal parts of the body. ( Shoulder girdle
stability Wrist and elbow stability)
74. Bobath concepts
• A dynamic management concept has been
developed from these basic principles in which
the responses of the child are guided through
handling towards the achievement of
consistent sensorimotor goals.
• These special techniques of handling also
counteract the abnormal patterns of tonic reflex
activity (Bobath 1983).
• The treatment pattern described below could be
incorporated into any therapy session
77. • By passively rotating or rocking the body
in a range of sequences the normalization
of tone is promoted.
• These sequences are constantly
developed through therapy practice and
frequently:
- The least affected part is worked on
first
- Handling begins proximally.
• Thus, the reduction of spasticity in the
hand might first be encouraged by
working on the movements of the
shoulder girdle.
78. • It is neither necessary nor desirable for
therapists to use static reflex inhibiting postures
by passively reversing the abnormal patterns
and controlling and holding every part of the
patient's body.
• Though this reduces spasticity, it makes active
and more normal movements impossible
(Bobath 1983).
• Instead the RIP is used throughout the
performance of an activity to inhibit :
– an inappropriate return of altered muscle
tone,
– associated reactions and
– abnormal movement patterns.
79. • In this way RIPs are incorporated into
therapy both as
- A preparation for active movement.
and as
- A support for control of its performance.
80. Examples of Reflex Inhibiting Patterns
All of the above patterns can usefully be combined with rotation of
the shoulder girdle against the pelvic girdle.
Pattern of Increased
Tone
Reflex Inhibiting Patterns Supplementary
RIP
Flexor Spasticity
Shoulder & Arm
- Neck Extension.
- Spinal Extension.
- External Rotation Shoulder
- Extended Elbow.
- Wrist Extension.
- Forearm Supination.
- Abduction Thumb.
Extensor Spasticity
Trunk & Neck
- Hip Flexion.
- Protraction Shoulder Girdle
- Hip Abduction.
- Internal R Shoulder.
-Trunk Flexion.
- Neck Flexion.
- Jaw Retraction.
Extensor Spasticity
Trunk & Legs
- Retraction Shoulder Girdle.
- Hip Flexion.
- Hip Abduction.
- External R Hip.
- Flexion Trunk.
- Flexion Knees.
- Dorsiflexion toes &
Knees
81. Key points of control.
• Key points of control are those parts of the body
at which handling by the therapist normalize
tone and guides normal active movement.
• As with RIPs the key points of control are
frequently proximal.
82. Facilitation.
Facilitation is used to enable the child to:
1. Achieve a more normal postural background
for movement.
2. Develop righting and equilibrium reactions .
3. Develop fundamental movement patterns on
which more skilled activities can be built.
4. Adapt to movement during its performance.
83. • The input from the therapist is carefully
graded and is based on a careful and
detailed assessment of the motor
responses of the child.
• Treatment becomes an ongoing and
reciprocal interchange between the
actions of the therapist and the response
of the child.
• The therapist must be guided by the
child's reaction (Bobath & Bobath 1964).
84. • This assessment will have led to a choice
of RIP and appropriate key points of
control for the performance of
movement.
• The motor support and sensory stimuli
given by the therapist must be sufficient
to gain a response but must not prevent
the child's active participation in the
movement.
85. The therapists must also take into
account:
1. The child's developmental level (without
adhering rigidly to it, e.g. early standing may
be promoted to encourage back extension and
head control).
2. The way in which a child without a disability
would perform that movement.
3. A sound knowledge of normal movement is very
important to the therapist.
86. Proprioceptive stimulation .
• Proprioceptive stimulation can be used as an
adjunct to facilitation where the child has low
muscle tone, where weak muscles underly
spasticity, or where the child has a lack of
sensorimotor experience.
• The techniques of pressure and/or tapping can
be used in combination with the techniques of
facilitation.
• In the example given above, pressure through
the pelvic girdle in sitting can be used to achieve
Postural stability prior to and during movement.
87. Tapping
• is used to give intermittent input to enable the
child to maintain a position.
• By tapping the posterior aspect of the shoulder
and the triceps muscle the child may be
stimulated to maintain weight-bearing on the
supporting arm.
• The stimulus is given at a speed which is rapid
enough to prevent loss of control, but slow
enough to allow the child to react.
88. • As control increases the stimulus
can decrease in frequency.
• As with all techniques of facilitation
the balance between support and
independence must be achieved.
89. Movement sequences and
functional skills.
• All techniques of inhibition and
facilitation are used to develop
purposeful movement sequences and
functional skills.
• Movement sequences are varied and
flexible and should not be followed
rigidly. However, the following form a
basis for consideration:
90. • Rolling
• Lying to sitting
• Prone lying to forearm support to all
fours
• All fours to high kneel
• High kneel to stand
• Sitting to standing.
• Transfer of weight on all fours
• Arm support in sitting
• Trunk balance in sitting
• Transfer of weight in high kneel
• Transfer of weight in standing
• Protective leg extension in standing.
91. • As with all activities the child must understand
the reason for achieving these basic skills and be
motivated through play and purposeful activity.
• Discussions with parents and caregivers can
lead to practical and relevant objectives being
included where inhibitory and facilitatory
techniques have a direct impact on :
– dressing,
– undressing and
– toileting.
• It is essential that children are “managed”
throughout the day and everyone involved
should ideally be taught appropriate handling
for each child.
92. Equipment
• The Bobath approach is one which first and
foremost uses direct handling of the child.
• However, some items of equipment may
sometimes be used as additional tools to achieve
movement skills,
• The equipment is only used as an adjunct to
handling,
For example,
- As a means of maintaining central
stability so that more skilled distal movements
can take place, or to
- Promote automatic balance reactions.
• Examples of Equipment : The large therapy
ball - The “sausage” roll - The wedge.
93.
94. This approach is based upon the work of
Margaret Rood, an American physiotherapist
and occupational therapist.
She originated her theory in the 1940s and
revised it many times.
Rood did not write extensively; she seemed to
prefer clinical teaching for the dissemination
of her ideas.
Most of the literature that describes the Rood
approach is based on interpretations by
accomplished occupational and physical
therapists such as Ayres, Farber, Heininger
Randolph, Huss, and Stockmeyer.
95. Rood spent many years studying and clinically
testing treatment methods that she devised based
on her readings.
Rood described and classified sensory receptors
and nerves according to their types, location,
effect, response, distribution and indication.
Muscles are also classified according to whether
they are light or heavy work muscle action.
96. Reflexes are used in therapy .eg, TLR, TNR,
vestibular reflex ,withdrawal R.
She interpreted the data derived from basic
neuro-physiological and movement-development
research and attempted to bridge between what
she learned from this basic research to the
treatment of brain-injured patients.
Her treatment was originally designed for
cerebral palsy, but she believed it was applicable
to any patient with motor control problems.
97. Rood's basic premise was
Motor patterns
They are developed from fundamental reflex
patterns present at birth which are utilized and
gradually modified through sensory stimuli
until the highest control is gained on the
conscious cortical level.
It seemed that, if it were possible to apply the
proper sensory stimuli to the appropriate
sensory receptor as it is utilized in normal
sequential development, it might be possible to
elicit motor responses reflexly and by following
neuro-physiological principles, establish proper
motor engrams.
98. If the correct sensory stimulus is applied
using the appropriate sensory receptor
(as it is used in normal sequential
development), it should be possible to
elicit motor responses reflexly and, by
repetition, gain correct movement
patterns.
99. The major components of the theory
are:
1. The prerequisite for movement is the
normalization of tone and stimulation of
normal motor responses, achieved reflexly by
using appropriate sensory stimuli .
2. Sensorimotor control is developmentally based
and thus therapy begins at the child's current
level of development and progresses in
sequence to higher levels.
3. The movements should be purposeful, with the
child's attention being directed towards the
end goal (not the pattern of movement)
100. 4. Repetition of sensorimotor responses is
essential for learning. Reeducation of muscular
responses occurs through repetition .
5. Facilitatory and inhibitory techniques are
carried out within the movement sequences.
6. Approximation of real life context increases
treatment effectiveness and generalization.
101. ROOD'S FOUR COMPONENTS OF MOTOR
CONTROL
An important contribution of Margaret Rood's
concepts is the emphasis she placed on
components of motor control.
She was a forerunner of current motor control
theories in that she was among the first to
identify and articulate the importance of
components of motor control in the therapeutic
context.
Therapists can apply these same concepts today
in physical therapy & occupation-based
practice.
Accordingly, the four components of motor
control Rood emphasized are summarized
below.
102. 1-Reciprocal Inhibition (Innervation)
(Mobility)
It is a phasic (quick) type of movement that
requires contraction of the agonist muscle as
the antagonist muscle relaxes.
The stimulus for this type of response is
quick, light stretch or stroking of the distal
parts or other low-threshold, A-fiber type of
stimulation.
103. 2- Co-contraction (Co-innervation)
(Stability)
Cocontraction is the simultaneous contraction
of the agonist muscle and antagonist muscle,
with the antagonist, supreme.
It is the foundation of postural control, which
provides the stability needed for engaging in
occupation.
The stimuli for stability responses are high-
threshold stimulation: joint compression;
stretch, especially of the intrinsic muscles of
the hands and feet; fast brushing and other C-
fiber stimulation; as well as resistance.
104. 3- Heavy work:
Is described by Stockmeyer as "mobility
superimposed stability" .
In this postural pattern the proximal muscles
contract and move, whereas the distal segment
is fixed.
This phase is used to develop controlled
mobility of the proximal joints.
Sensory stimuli from high-threshold spindle
and joint receptors are involved in this
response.
105. 4- skill
Skill is the highest level of motor control and
combines the effort of mobility and stability.
In the execution of a skilled pattern the
proximal segment is stabilized while the distal
segment moves freely.
Skill is associated with many of the functions
needed in the in any age, such as typing and
fine eye-hand coordination for computer
work.
(Skill: It is the ability to produce highly
coordinated movement characterized by
precise timing and direction movement. e.g.
feeding, writing and walking)
106. These four levels of motor control are
developed as the patient is placed
through the skeletal developmental
sequences which Rood referred to as
ontogenetic motor patterns.
107. Treatment Programming:
Rood evaluated the patient to determine:
what the distribution of muscle tone was and
what level of motor control, according to her
developmental sequences, the patient had
achieved.
She started therapy by facilitating the patient's
muscles needed to affect the pattern desired.
Stimulation involved use of the appropriate
type of stimuli to facilitate the desired response
(tonic or phasic).
108. If necessary, the patient was assisted into the
desired pattern, and a purposeful activity that
demanded the movement and/or position and
was within the capability of the patient, was
immediately presented.
The motor pattern chosen to be worked on was
the one that the patient could do, but not easily.
Then the patient was progressed through the
sequences as he mastered each new level.
The point at which the patient was easily able
to do the task represented his highest level of
development.
Treatment started at the point where the patient
had to struggle to do the pattern.
109. ROOD TREATMENT TECHNIQUES
Summary of rood facilitatory and inhibitory
techniques
Cuteaneous facilitatory techniques:
Light Touch
Fast brushing
Icing
113. Inhibition Facilitation
1- Rate of stimulation is generally slow
even and rhythmic, perhaps affecting
inhibitory region of the reticular
formation
1- Rate of stimulation is generally fast
uneven and intermittent.
2- Stimulation may be processed in
peripheral and CNS regions. Both central
and peripheral processing serve to direct
excitation and produce localized
responses.
2- Stimulus cause a condition of critical
change in the body or specific body part
stimulated. The spatial or temporal
discharge pattern may change.
3- Following inhibitory input, either
generalized or specific calming can be
measured.
3- Following stimulation , a state of
arousal can be measured in various body
systems.
117. Definition
• The Spider Cage is a unique and
dynamic device consisting of metal
walls, pulleys, bungees (rubber band),
straps ,splints and belts utilized to
perform a variety of exercise.
• The UEU can be used to perform a
variety of strengthening exercises or it
can be used for “Spider Therapy”.
ehabkafy@yahoo.com Spider Cage 117
