a p p ro p ria te to c o n s id e r th e a im s of tr e a tm e n t o f c e re ­ b ra l p a ls y as d e sc rib e d by B o b a th (1967); “ I. T o d e v e lo p n o rm a l p o s tu ra l r e a c tio n s a n d p o s tu ra l to n e a g a in s t g ra v ity fo r s u p p o r t a n d c o n tro l o f m o v e ­ m e n ts. 2. T o c o u n te r a c t th e d e v e lo p m e n t o f a b n o rm a l p o s tu ­ ra l re a c tio n s a n d o f a b n o rm a l p o s tu ra l to n e . 3. T o g ive th e c h ild , b y m e a n s o f h a n d lin g a n d p lay , th e f u n c tio n a l p a tte rn s h e will u se la te r o n fo r fe ed in g , d re ssin g , w a sh in g e tc fo r se lf-h elp . 4. T o p r e v e n t th e d e v e lo p m e n t o f c o n tra c tu re s a n d d e fo rm itie s ” . I t is o b v io u s t h a t a c o m p re h e n s iv e a sse ss m e n t of e ac h c h ild , o u tlin in g b o th a b ilitie s a n d d isa b ilitie s, m u st p re c e e d th e ra p y . S im ila rly , p e rio d ic re a ss e s sm e n t fo rm s a n in te g ra l p a r t o f n e u ro d e v e lo p m e n ta l th e ra p y . M a n a g e m e n t o f th e fa m ily in clu d e s p a r e n t c o u n se llin g a n d e d u c a tio n , a n d a lso p ra c tic a l h e lp w ith d a y -to -d a y p ro b le m s. P a r e n t c o u n se llin g s h o u ld fo rm an in te g ra l p a r t o f th e m a n a g e m e n t o f e v ery h a n d ic a p p e d c h ild a n d sh o u ld b e o ffe re d as so o n as th e h a n d ic a p is d ia g ­ n o se d . I t m a y ta k e th e fo rm o f fo rm a l c o u n se llin g by a so c ial w o rk e r, o r p sy c h o lo g is t o r b e c o n d u c te d in ­ fo rm a lly b y th e th e r a p is t tre a tin g th e c h ild . M a c K e ith (1973) d e sc rib e s th e fe elin g s of a n g e r, g rie f, g u ilt a n d re v u ls io n f e lt b y p a re n ts fa c e d w ith th e sh o c k of le a rn in g t h a t t h e ir c h ild is h a n d ic a p p e d . P a r e n ts n e ed a n o p p o r tu n ity to disc u ss th e s e fe e lin g s in o r d e r to a d ju s t to w h a t h a s h a p p e n e d a n d c o m e to so m e so rt o r re a lis tic a c c e p ta n c e . W ith o u t a c c e p ta n c e th e p a re n ts w ill h a v e d iffic u lty fin d in g re so u rc e s w ith in th em se lv es to p ro v id e th e k in d o f lo v in g a n d se c u re e n v iro n m e n t th e ir ch ild n e e d s. 34 P a r e n ts sh o u ld b e g iven as m u c h in fo rm a tio n a b o u t th e ir c h ild ’s h a n d ic a p as th e y re q u e st. T h e d ia g n o s is a n d p ro g n o sis m u s t be in te rp re te d a n d d iscussed in te rm s w h ich th e y u n d e rs ta n d . T h e y a ls o n e ed to know w h a t fa c ilitie s a re a v a ila b le a n d h ow to use them T h e g re a te s t s o u rc e o f a n x ie ty in p a re n ts is u n c e rta in ty — n o t k n o w in g e x a c tly w h a t has h a p p e n e d n o r w hat c a n b e d o n e a b o u t it. P a re n ts a lso re q u ire p ra c tic a l h e lp w ith d a y -to -d a y p ro b le m s o f m a n a g e m e n t, e sp e c ia lly if th e ch ild is se v e re ly h a n d ic a p p e d . P ro b le m s o f fe ed in g , d iscipline, th e m o s t s u ita b le k in d o f p la y a n d toys, ho w to org a n ise the d a ily ro u tin e so th a t o th e r m e m b e rs o f th e fam ily a re n o t n e g le c te d , fre q u e n tly arise. T h e p re se n c e o f a h a n d ic a p p e d c hild in a fam ily re p re s e n ts a h u m a n tra g e d y . E v e ry e f fo r t sh o u ld be m a d e to p re v e n t such a situ a tio n fro m o c c u rrin g . H o w ­ e v er, w h e n it d o e s a ris e , e a rly d ia g n o s is a n d c o m p re ­ h e n siv e m a n a g e m e n t will lessen th e im p a c t, p ro v id e a m u c h n e e d e d s u p p o rt system a n d fa c ilita te a c c e p ta n c e b y th e p a re n ts a n d a lso p ro m o te th e d e v e lo p m e n t of th e c h ild . R e fe re n c e s B o b a th , B. (1967). T h e very e a rly tre a tm e n t of c ere b ral p a lsy . D e ve lo p . M e d . C h ild N e u r o l. 9, 373. H o lt, K. S. (1973). F u n c tio n a l a sse ss m e n t o f h a n d ic a p p e d c h ild re n : A n assessm ent. Proc. R o y . S o c . M e d . 66, 611. M a c K e ith , R . M . (1973). T h e feelin g s a n d b e h a v io u r of p a re n ts o f h a n d ic a p p e d c h ild ren . D e ve lo p . M e d C h ild N e u ro l. 4, 115. S h e rid a n . M . D . (1968). T h e d e v e lo p m e n ta l p ro g re s s of in fa n ts a n d y o u n g c h ild re n . M in istry o f H e a lth R e p o rt. 20. 102. L o n d o n . H .M .S .O . JUNIE 1981F I S I O T E R A P I E RESULTS OF EARLY INTERVENTION IN TH E BABY WITH CEREBRAL MOTOR DISTURBANCE S. H . IR W I N - C A R R U T H E R S , N a t. D ip . P h y sio . (P re t.), D ip . P h y sio . Ed. (P re t.)* S U M M A R Y T h e re su lts o f a stu d y c o m p a rin g the early a n d late tre a tm e n t o f b a b ies w ith cereb ra l m o to r d istu rb a n c e are d iscussed. C riteria f o r d ia g n o sis m u s t be e sta b lish e d b e fo r e tests can begin. I t w o u ld a ppear th a t early in te r­ v e n tio n re su lts in m a r k e d im p r o v e m e n t b u t m o r e su r v e y s are necessary to p r o v id e c o n v in c in g e vidence. In r e c e n t y e a rs m u c h h a s b e e n w ritte n on th e im ­ p o rta n c e o f e a rly in te rv e n tio n in th e tre a tm e n t o f c e re ­ b ra l m o to r d is tu rb a n c e s . T h e te rm “ c e re b ra l m o to r d is tu r b a n c e ” h a s re p la c e d c e re b ra l p a ls y a n d d e n o te s a m o v e m e n t d i s o rd e r w h ic h has d e v e lo p e d as a re su lt o f b r a in d a m a g e . B y “ e a rly in te r v e n tio n ” we m e a n t r e a t ­ m e n t s ta rte d as e a rly as p o ssib le w ith in th e firs t y e a r o f life a n d in a n y case a t less th a n six m o n th s o f age. I n th is c o u n try , w e h a v e n o t g o n e as f a r as in the U n ite d S ta te s w h e re n e u ro d e v e lo p m e n ta lly tra in e d * S e n io r le c tu re r a n d A c tin g H e a d o f D e p a rtm e n t, U n i­ v e rsity o f S te lle n b o sc h a n d T y g e rb e rg H o s p ita l, t P a p e r d e liv e re d a t S A S P C o n g re ss h e ld in P r e to r ia M a rc h 1981. R e ce iv e d 1 M a y 1981. O P S O M M IN G D ie resultate van ’n stu d ie w at vroe'e en laat b ehau- d e lin g van babas m e t sere b ra a l-m o to rie se v ersteu rin g £ v e rg elyk , w o rd b espreek. K rite r ia v ir d ia g n o se moet\^ vasgestel w o rd vo o r to etsin g begin. D it w il v o o r k o m d a t vroe'e beh a n d elin g d u id e lik e v e rb eterin g m e eb rin g , m a a r m e e r o n d e rso e k e is n o d ig o m o o rtu ig e n d e fe ite aan die lig te bring. th e ra p is ts a re in v a d in g th e in c u b a to rs in th e p re -te rm un its. E a rly in te rv e n tio n p re su p p o se s e a rly d ia g n o sis, w hich m a y b e e asy in th e se v e re ly a ffe c te d c h ild b u t very d iffic u lt in th e m o re m o d e ra te ly a ffe c te d y o u n g b a b y . S e v e ral w o rk e rs in th e field o f e a rly in te rv e n tio n h a v e b e e n c ritic ise d on th e g ro u n d s th a t th e ir c rite ria fo r d ia g n o s is m a y n o t e x c lu d e in fa n ts w hose sy m p to m s m ig h t h a v e c le a re d s p o n ta n e o u s ly . V o jta , in p a rtic u la r, h a s co m e u n d e r c ritic ism b e c a u se in h is c lin ic d ia g n o s is is m a d e o n th e g ro u n d s o f se v e n re fle x es, m o re th a n o n e o f w h ich b e a rs his n a m e a n d a ll ol' w h ic h a re assessed s u b je c tiv e ly fo r a d e g re e o f a b n o rm a lity . K o n g (1960, 1975) has su g g e ste d six in d ic a tio n s fo r e a rly tre a tm e n t: • A n o b lig a to ry a b n o rm a l p a tte rn — fro m b irth . • V e ry low to n e w ith n o h e a d c o n tro l b y th re e m o n th s . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNE 1981 P H Y S I O T H E R A P Y 35 • E v e n s l i g h t o p i s t h o t o n u s a f t e r t h r e e m o n th s . 0 O b lig a to ry a s y m m e try a f te r f o u r m o n th s . 0 S lig h t ( d o u b tf u l) a b n o r m a l i t i e s w h ic h b e c o m e m o r e p r o n o u n c e d in u p r i g h t p o s i t i o n s o r s u s p e n s io n . 0 S lig h t ( d o u b tf u l) a b n o r m a l i t i e s in t h e p r e s e n c e o f f e e d in g p r o b l e m s . E ven u sing th e s e c rite ria w e c a n n o t be c e rta in th a t w e a re n o t in c lu d in g in fa n ts w h o m a y d e v e lo p n o r ­ m ally w ith o u t in te rv e n tio n . E ven if we a re h a p p y w ith th e d ia g n o s tic c rite ria , can we c la im to h a v e p ro v e n th a t e a rly tre a tm e n t on n e u r o d e v e l o p m e n t a l lines is n e c e ssa ry o r t h a t it gives b e tte r re su lts? B o b a th (1967, 1972) p u ts fo rw a rd six reaso n s fo r e a rly in te rv e n tio n : • T h e a d a p ta b ilty o f th e in f a n t b ra in . • P r e v e n t i o n o f r e i n f o r c e m e n t o f a b n o r m a l p o s t u r a l p a t t e r n s . 0 P r e v e n t i o n o f s e c o n d a r y c o n t r a c t u r e s a n d d e f o r m i t i e s . 0 N e c e s s ity f o r n o r m a l s e n s o r i m o t o r e x p e r i e n c e in b u ild in g u p n o r m a l p o s t u r a l p a t t e r n s . 0 T h e e ffe c t o f n o rm a l s e n s o rim o to r e x p e rie n c e on th e 1 a c q u isitio n o f in te lle c tu a l skills. • T h e re la tiv e e ase o f im p le m e n tin g tr e a tm e n t te c h ­ niq u es in th e y o u n g b a b y . T o u w e n (1979) c o n sid e rs a ll th e s e fa c to rs to be v alid, b u t p o in ts o u t th e lack o f c o n v in c in g e v id e n c e o f th e b e n eficia l re su lts o f e a rly tre a tm e n t. T h e very few p u b lish e d stu d ie s (K o n g , 1966; W rig h t a n d N ic h o ls o n , 1973; S c h e rze r e t al., 1976; lr w in -C a rru th e rs , 1979) give c o n flic tin g e v id e n ce . W h y is th is? W h en o n e lo o k s a t th e p ro b le m s e n c o u n te re d in c o n ­ d u c tin g a c o n tro lle d tria l, th e d iffic u ltie s d o a p p e a r in ­ su rm o u n ta b le . PRO BLEM S O F E S T A B L IS H IN G C R IT E R IA FO R SE L EC TIO N In o rd e r to c o n d u c t a c o n tro lle d tria l o n e sh o u ld have tw o c o m p a ra b le g ro u p s o f c h ild re n , th e o n ly d iffe re n c e b e tw e e n th e g ro u p s b e in g th e age a t w hich tre a tm e n t w as in stitu te d . In v a ria b ly th e e a rly -tre a te d g ro u p c o n ta in s c o m p a ra tiv e ly m o re se v e re ly a ffe c te d c h ild re n , since c h ild re n sh o w in g o b v io u s signs a re likely to be d ia g n o s e d a t a n e a rlie r age. F ig u re 1 show s the d isc rep a n cy b e tw e e n th e tw o g ro u p s o f e a rly -tre a te d a nd la te -tre a te d c h ild re n fo r 43 W h ite c h ild re n seen a t T y g erb e rg H o s p ita l b e tw ee n J u ly a n d D e c e m b e r 1980. If ra n d o m sa m p lin g is u se d to d e te rm in e th e p o p u - (a tio n , th e b ia s b e tw e e n th e tw o g ro u p s w o u ld m o st iro b ab ly in cre ase.In o rd e r to re a c h s ta tis tic a l sig n ific a n c e it w o u ld be n ecessary to in c lu d e all th e c h ild re n o f o th e r ra ce g ro u p s, w hich w o u ld im m e d ia te ly re s u lt in la rg e n u m b e rs of e x clusions on g ro u n d s o f ir re g u la r a tte n d a n c e fo r tr e a t ­ m ent. S ig n ific a n t m e n ta l r e ta r d a tio n w o u ld a lso be g ro u n d s fo r e x c lu sio n , b u t th is is v e ry d iffic u lt to d e te rm in e in a y o u n g baby. P R O B L E M S O F E S T A B L IS H IN G C R IT E R IA FO R E V A L U A T IO N O F R E S U L T S T o u w e n (1979) m a k e s a p le a f o r th e ra p is ts to d o c u ­ m e n t th e ir c rite ria f o r d e te rm in in g re su lts o f tre a tm e n t. A lth o u g h s p a stic ity as su c h c a n b e m e a s u re d o b jec tiv e ly , the d e g re e o f sp a stic ity d o e s n o t n e c e ssa rily c o rre la te w ith f u n c tio n a l a b ility a n d , in a n y case, it w o u ld n o t b e a d v is a b le to su b je c t a y o u n g c h ild to th e te stin g p ro c e d u re s in v o lv e d . E sp o sito (1978) s ta te s t h a t th e a im o f e a rly in te rv e n tio n is to p r e p a r e th e c h ild fo r m a x im a l ph y sic al, in te lle c tu a l, e m o tio n a l a n d so c ial d e v e lo p m e n t to his fu ll p o te n tia l w ith in th e lim its o f h is h a n d ic a p . T h u s we a re try in g to assess fu n c tio n r a th e r th a n p o s ­ tu ral to n e. T h e m o s t o b v io u s re s u lt o f e a rly tre a tm e n t Spastic Diplegic Hemiplegic Athetoid Ataxic Mental Blind or quad. luad. Retardation Deaf Fig. 1. D egree o f in v o lv em e n t and associated handicaps. to ajl th o se o f us w h o a re a b le to im p le m e n t it is th e q u a lity o f m o v e m e n t o b ta in e d , n a m e ly th e p re se n c e o f m o re n o rm a l p a tte rn s o f m o v e m e n t a n d fe w ed a b ­ n o rm a l ones. I t is a lm o s t im p o s sib le to g ra d e q u a lity o n a q u a n tita tiv e sc a le ; e ven if su c h a sc a le coui~ be d e v ised , th e a ssig n m e n t o f a g ra d e c n th a t sc a le w . u i b e su b je c tiv e . T h e m o s t o b v io u s sign o f im p ro v e m e n t to b c th d o c to rs a n d p a re n ts is th e a c q u is itio n o f f u n c tio n a l a b ilitie s, su c h as th e a b ility to s it u n s u p p o rte d , g e t to sittin g u n ­ a id e d , c raw l, s ta n d up a n d w alk. T h is c a n b e c h a rte d , a lth o u g h som e p ro b le m s will be e n c o u n te re d : • B ias in p a r e n t- in te r p r e ta tio n . ® A v o id a n c e o f c e rta in d e v e lo p m e n ta l , u v it.e c ; c r th e r a p e u tic re aso n s. ® O m issio n s o f a n y a sse ss m e n t o f th e q u a L ty o r p : t t e r n o f m o v e m e n t in volved. In th e a b se n c e . n . .» c ritc rir ty p e o f e v a lu a tio n fo r re su lts o f o u r firs t c o m p a ra tiv e series. D IS C U S S IO N O F R E S U L T S D u rin g th e p e rio d A p ril 1975 to A p ril l i , o , 2 / j c h ild re n w ith p ro v e n o r su s p e c te d c e r e b r i m ^ t^ i tu rb a n c e s w ere re fe rre d to th e p h y s io th e ra p y o e p r.it- m e n t o f T y g e rb e rg H o s p ita l. O f these, 2 0 i ih ,l .. .e : i u . . _ fo u n d to h a v e a d e g re e o f m o to r im p a irm e n t s u ffic ie n t to w a r r a n t tre a tm e n t. O f these o n ly 93 h a v e b een . b e to a tte n d fo r r e g u la r tre a tm e n t. 'i lie rc . s^ n„ w h h a v e p re c lu d e d re g u la r tr e a tm e n t o ; th e le m .iiu .;. c h ild re n a re th e su b je c t o f a n o th e r s u r . e y n d v. I n o t b e d isc u sse d in d e ta il h e re b u t a p p ro im a te ly . ne th ird w e re c h ild re n w h o live a t a d is ta n c e . n d ;.c tre a te d by m e a n s o f a h o m e p ro g ra m m e ; n . p e n ; re a ss e s sm e n t, a p p ro x im a te ly o n e th ird w e re i e f e - . t fro m o th e r c e n tre s o r th e ra p is ts a n _ w ere , c ......... .o t r e a tm e n t u n d e r th e ir c a re , a n d th e re st o f th e c h ild re n w ere lo st to tre a tm e n t th ro u g h lo ca l c o n d itio n s. O f th e 93 c h ild re n w h o a tte n d e d re g u la rly , 23 w ere e x c lu d e d fro m th e p re s e n t stu d y b e c a u se th e y w ere u n d e r n in e m o n th s o f age a t th e tim e o f th e a n aly sis T h e s e w e re a ll C o lo u re d c h ild re n a n d a tte n d e ! i r r e u - la rly th e r e a f te r , so t h a t th e ir e x c lu sio n b e c a m e p e rm : - n e n t. T h is le ft 70 c h ild re n , 15 o f w h o m w e re re fe rre d fo r R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 36 F I S I O T E R A P I E JUNIE 1981 p h y s io th e ra p y a t six m o n th s o f age o r less (w ho will be d e sig n a te d th e e a rly -tre a te d g ro u p ) a n d 55 o f w hom w e re re fe rre d fo r th e ra p y a t m o re th a n six m o n th s of a ge (w ho will be d e sig n a te d th e la te -tre a te d g ro u p ). A f u r th e r 42 c h ild re n w ere e x c lu d e d Iro m th e la te -tre a te d g ro u p on g ro u n d s o f a sig n ific a n t m e n ta l h a n d ic a p w hich m ig h t h a v e a ffe c te d th e re su lts o f tre a tm e n t. N o sim ila r e x c lu sio n w as m a d e fro m th e e a rly -tre a te d g ro u p , th re e o f w h o m h a v e a sig n ific a n t m e n ta l h a n d ic a p . In th e e a rly -tre a te d g ro u p th e p re d o m in a n t in itia l sign w as r e tr a c tio n , i.e. in c re a s e d e x te n s o r to n e in th e n e ck a n d s h o u ld e r m u s c u la tu re , w h ich v a rie d in d e g ree f r o m a m o d e ra te h e a d -la g w ith in a b ility to e y e -tra c k d o w n w a rd s to to ta l o p is th o to n u s . Six c h ild re n p re se n te d w ith m o re th a n o n e sign; th e o th e r signs in c lu d e d a s y m m e try (w ith a p e rs is te n t a sy m m e tric a l to n ic n eck re fle x ), fiste d h a n d , “ flo p p in e s s ” a n d p o o r c o n ta c t w ith th e e n v iro n m e n t. In th e la te -tr e a te d g ro u p th e m ain c o m p la in t a t th e tim e o f re fe rra l w as o f d e la y in th e a c h ie v e m e n t o f gro ss m o to r m ile sto n e s , a lth o u g h all th e m o th e rs r e ­ c o u n te d se v e ra l signs w h ic h th e y h a d n o te d a t v a rio u s e a rlie r ages. F ig. 2. P red om in an t sign at tim e o f referral. In th e e a r ly -tre a te d g ro u p , th e m e a n age a t w hich signs w ere firs t n o tic e d w as 3,33 m o n th s o f a ge; th e m e a n age o f r e fe rra l w as 4 ,57 m o n th s o f age. A ll b u t five o f th e s e b a b ie s w ere, as a re s u lt o f th e ir p e rin a ta l h isto rie s, b e in g fo llo w e d up by th e D e p a r tm e n t of P a e d ia tric s a t T y g e rb e rg H o s p ita l a n d w e re re fe rre d im m e d ia te ly t h a t sig n s w e re n o te d . In 4 teases the m o th e r d e la y e d ta k in g th e in f a n t to a d o c to r a n d in o n e in sta n c e th e d e la y w as c a u se d by in itia l re fe rra l via a g e n e ra l p r a c titi o n e r a n d a p a e d ia tr ic ia n in p riv a te p ra c tic e . In a ll cases, h o w e v er, th e d e la y in re fe rra l w as m in im a l. W ith o u t e x c e p tio n , e v ery c h ild in th e la te -tre a te d g ro u p c o u ld be c la ssified as a n a t-risk in fa n t a n d 6 2 % o f th is g ro u p h a d b een seen re g u la rly by m e d ic a l p r a c ­ titio n e rs . A n a n a ly sis o f th e c h ild re n seen re g u la rly at T y g e rb e rg H o s p ita l sh o w ed 2 w h o a tte n d e d th e p re m a ­ tu r e fo llo w -u p c lin ic, 4 w h o a tte n d e d n e u ro s u rg ic a l fo llo w -u p a f te r in se rtio n o f a s h u n t a n d 2 w h o a tte n d e d re g u la rly fo r g e n e ra l h e a lth p ro b le m s. D e s p ite th is, in 9 2 % o f c ases it w as th e m o th e r w h o h a d p re sse d , u su a lly r e p e a te d ly , fo r f u r th e r in v e s tig a tio n a n d t r e a t ­ m e n t. T h e m e a n a g e a t w h ic h th e m o th e r h a d first n o te d signs w as 5,31 m o n th s a n d th e m e a n age by w hich sh e w as c o n v in c e d s o m e th in g w as w rong, d e sp ite a s s u ra n c e to th e c o n tra ry , w as 10,10 m o n th s ; d e sp ite th is th e m e a n age o f re fe rra l w as 21,15 m o n th s . It m u st, h o w e v e r, be p o in te d o u t th a t th is r a th e r high age o f re fe rra l w as d u e to th e e x tre m e ly la te a g e of re fe rra l o f o n e o r tw o c h ild re n ; in 3 8 % o f th e c h ild re n in th is g ro u p r e fe rra l w as in fa c t m a d e b e tw ee n eig h t a n d tw e lv e m o n th s of age. High ri9k Seen regularly at clinics Referred by doctor Treatment requested by mothar Age at referral: 0-12 months 13-18 monthg 19-2<* months 25-30 months 31-36 months > 3 6 months F ig . 3. R eferral o f late-treated group. T h e r e is a fa irly close c o rre la tio n b e tw e e n d ia g n o se s in th e tw o g ro u p s, w ith s p a stic d ip le g ia p re d o m in a tin g in b o th g ro u p s. In all cases th is sp a stic d ip le g ia w as re la te d to p re m a tu r ity w ith low b irth w eight. Quadriplegia Diplegia Hemiplegia F ig. 4. D ia g n o sis. Hypo- Athe- tanic toid F ig u re 5 c o m p a re s th e d a te s a t w h ic h g ro ss m o to r a c tiv itie s w ere a ch ie v e d in th e tw o g ro u p s o f c h ild re n . It is n e c e ssa ry to d e fin e th e s e gross m o to r a c tiv itie s if th e y a re to fo rm a d e q u a te c rite ria fo r ju d g in g re su lts. Sitting im p lies m a in ta in in g th e sittin g p o s itio n o n th e flo o r u n s u p p o rte d w hen p la c e d in a p o sitio n as close to lo n g -sittin g as p o ssib le , w ith o r w ith o u t a rm -s u p p o rt. Sitting up im p lie s g e ttin g fr o m p ro n e or s u p in e in to th e sittin g p o sitio n u n a id e d . Crawling im p lies re c ip ro c a l c ra w lin g on h a n d s a n d k n e e s (th e A m e ric a n e q u iv a le n t is c ree p in g ). Standing up im plies p u llin g to s ta n d in g a n d m a in ta in in g th e sta n d in g p o sitio n , w ith o r w ith o u t h o ld in g on. W alking im p lies w a lk in g u n a id e d , w ith o u t a n y fo rm o ^ su p p o rt. T h e e a rly -tre a te d g ro u p a c h ie v e d u n s u p p o rte d sittin g a t a m ea n age o f 8,53 m o n th s , w e re a b le to sit u p fro m p r o n e o r s u p in e a t 10,36 m o n th s , w e re c raw lin g ''a t a n a v e ra g e age o f 10,36 m o n th s , p u llin g u p to sta n d - ■ ing a t 12,15 m o n th s a n d w a lk in g in d e p e n d e n tly a t 15,03 m o n th s . T h e s e a c h ie v e m e n ts c o m p a re v ery fa v o u ra b ly w ith th o s e o f n o rm a l c h ild re n a n d c o n tra s t s tro n g ly w ith th e very d e la y e d a c q u is itio n o f gro ss m o to r a c tiv i­ ties in th e la te -tre a te d g ro u p . W h a t th e s e fig u re s c a n n o t c o n v e y is th e q u a lity o f m o to r p a tte rn s . T h e c h ild re n in th e la te -tr e a te d g ro u p sh o w f a r m o re m a rk e d ly a b n o rm a l p a tte rn s o f c o -o rd i- n a tio n th a n th o se in th e e a rly -tre a te d g ro u p . I t seem s lo gical to a ssu m e t h a t tr e a tm e n t f r o m a v ery e a rly a g e w ill give fa v o u ra b le re su lts. T h e y o u n g in fa n t se ld o m h a s very s tro n g sp a stic ity o r to n ic re fle x a c tiv ity a n d , sin c e his s e n s o rim o to r e x ­ p e rie n c e is lim ite d , he h a s n o t y e t le a rn t to u se a b ­ n o rm a l p a tte rn s fo r fu n c tio n . S in c e th e m o to r p a tte rn s w h ic h he re q u ire s a re , a t th is age, re la tiv e ly few a n d sim p le , it is e a s ie r to te a c h his m o th e r ho w to h a n d le him th r o u g h o u t 24 h o u rs o f th e d a y in su c h a w ay R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNE 1981 P H Y S I O T H E R A P Y 37 as to p ro v id e him w ith n o rm a l s e n s o rim o to r e x p e rie n c e a n d c o u n te r a c t th e d e v e lo p m e n t o f sp a stic ity a n d o f a b n o rm a l p o s tu ra l p a tte rn s . F ig u re 6 show s th e p r e s e n t m ile sto n e s a ch ie v e d by th e c h ild re n in th e tw o g ro u p s. A ll th e c h ild re n in th e j ^ e a r l y - t r e a t e d g ro u p a re a b le to sit u n s u p p o rte d , sit up u n a id e d , c raw l a n d p u ll to s ta n d in g . A ll b u t o n e can walk in d e p e n d e n tly . T h e o n e c h ild w h o c a n n o t w alk is a se v e re ly a ffe c te d q u a d rip le g ic w ith m e n ta l r e ta r d a ­ tio n a n d , a lth o u g h his a c h ie v e m e n ts to d a te h a v e b een re m a rk a b le it is u n lik e ly th a t he w ill e v er w a lk u n a id e d . T h e re h a s b e e n less c h a n g e in th e m o to r a b ilitie s o f th e la te -tre a te d g ro u p , all o f w h o m a re m u ch o ld er. T h e fa c t t h a t 3 8 % o f th is g ro u p w e re re fe rre d f o r tre a tm e n t b e tw e e n th e ages o f 8 a n d 12 m o n th s w ould seem to len d s u p p o r t to th e view th a t o p tim u m re su lts c an o n ly be o b ta in e d if tr e a tm e n t is in s titu e d w ith in th e first six m o n th s o f life. W ith e a rly tr e a tm e n t it a p p e a rs p o ss ib le to re d u c e se v e re sp a stic ity to m o d e ra te sp a stic ity a n d m o re m o d e ­ ra te signs to s lig h t d isa b ilitie s. T o d a te th e b e st re su lts have b e e n o b ta in e d w ith th e s p a stic d iplegics. G o o d re su lts h a v e a lso b e e n o b ta in e d w ith th e h e m i­ p legic c h ild re n b u t, o n c e th e y a re ru n n in g a ro u n d , th e ir a b n o rm a l p a tte rn s te n d to in c re a s e slig h tly as a re su lt o f a sso c ia te d re a c tio n s. It is in te re s tin g to n o te , on f u rth e r a n a ly sis, th a t th e m e a n a g e o f w a lk in g in d e p e n ­ d e n tly f o r th e h e m ip le g ic c h ild re n in th e e a rly -tre a te d g ro u p , w as a t 17,83 m o n th s , c o n s id e ra b ly la te r th a n th a t f o r th e g ro u p as a w hole. A sp a s tic q u a d rip le g ic w ith a th e to sis, o n th e o t h e r h a n d , w a lk e d a t 12 m o n th s . O f th e e a rly -tre a te d g ro u p 6 0 % a re in re g u la r n u rs e ry sc h o o l o r sc h o o l; m o st o f th e s e a re m ild dip le g ics. In th e e a rly -tre a te d g ro u p 3 3 % a re in c e re b ra l p a ls y sc h o o ls, w h e re a s 8 3 % o f th e la te -tre a te d g ro u p n e ed th e sp e c ia l c a re o f a c e re b ra l p a ls y sc h o o l. T w o o f th e la te -tr e a te d g ro u p d ied o f s h u n t c o m p lic a tio n s. A c c o rd in g to A re n s a n d c o -w o rk e rs (1978) as w e ll as fro m o u r o w n e x p e rie n c e th e re d o e s n o t a p p e a r to be a n y sig n ific a n t d e c re a s e in th e in c id e n c e o f c e re b ra l palsy in S o u th A fric a . In view o f th is e v e ry th in g p o s ­ sib le m u s t be d o n e to p r e p a r e th ese c h ild re n f o r an in d e p e n d e n t a n d p ro d u c tiv e ro le w ith in th e c o m m u n ity . I f w e b elieve th a t e a rly in te rv e n tio n p la y s a d e cisiv e ro le in th e e v e n tu a l re s u lt w e m u s t be a b le to sh o w p ro o f o f th e re su lts o f e a rly tre a tm e n t. A lth o u g h th e c o n tr a s t b e tw ee n th e a c h ie v e m e n ts o f th e e arly - a n d la te tre a te d g ro u p s in th e su rv e y is c le ar, th e n u m b e rs o f c h ild re n in v o lv e d a re to o s m a ll to c la im s ta tis tic a l sig n ific a n c e . F u r th e r su rv e y s o f c a re fu lly se lec te d c o m ­ p a ra b le g ro u p s a re n e c e ssa ry , th r o u g h o u t th e c o u n try , if w e a re to c o n v in c e o u rse lv e s as well a s th e m ed ic al p ro fe s s io n o f th e n e c e ssity f o r e a rly tre a tm e n t by p h y ­ s io th e ra p y . R eferen ces A re n s , L. I., M o lte n o , C . D ., M a rs h a ll, S. R ., R o b e rts o n , W . I. a n d R a b in , J. (1978). C e re b ra l P a lsy in C a p e T o w n — a c o m p a ra tiv e 1 2 -y e ar re tro s p e c tiv e stu d y . S. A fr . M e d . 53, 3 1 9 - 3 2 4 . B o b a th , B. (1967). T h e very e a rly tre a tm e n t o f c e re b ra l p a lsy . D ev. M e d . C h ild N e u r o l. 9, 373 - 390. B o b a th , B. a n d K . (1972) in: P h y s ic a l T h e ra p y services in th e d e v e lo p m e n ta l disa b ilitie s. E d. P e a rs o n , P H . a n d W illia m s, C. E . C h a rle s , C . T h o m a s . S p rin g field , p 101 - 112. C ro w , B. M . (1973): A b n o r m a l n e u ro lo g ic signs in th e f ir s t y e a r o f life (le tte r to th e e d ito r). D e v. M e d . C h ild N e u r o l., 15, 6 9 0 - 6 9 1 . D rillie n , C . M . (1972). A b n o r m a l n e u ro lo g ic signs in th e firs t y e a r o f life in low b irth w e ig h t in fa n ts: p o s ­ s ib le p ro g n o stic significance. D e v . M e d . C h ild N e u r o l., 14, 5 7 5 - 5 8 4 . E sp o sito , R . R . (1978). P h y s ic ia n ’s a ttitu d e s to w a rd s e a rly in te rv e n tio n . P h y s . T lier., 58, 1 6 0 - 167. lrw in -C a rru th e rs , S. H . (1979). A c o m p a ra tiv e stu d y o f e a rly - a n d la te -tre a te d c h ild re n w ith c e re b ra l m o to r d istu rb a n c e . N e w s le tte r o f th e S .A . N e u r o d e v e lo p - m e n ta l T lier. A ssn ., 3, (2) 6 - 10. K o n g , E . (1966). V e ry e a rly tre a tm e n t o f c e re b ra l p a lsy . D e v . M e d . C h ild N e u r o l., 8, 198 - 202. K o n g , E . (1975). P e rs o n a l c o m m u n ic a tio n . S c h e rz e r, A . L ., M a k e , V. a n d U son, J. (1976). P h y s ic a l th e ra p y as a d e te rm in a n t o f c h a n g e in th e c e re b ra l p a ls ie d in fa n t. P adieatrics, 58, 47 - 52. T o u w e n , B. C . L. (1979). W h a t a re w e a c tu a lly d oing? N e w s le tte r o f the S .A . N e u r o d e v e lo p m e n ta l T h e r. A ssn . 3, (2) 3 - 5 (tra n s la te d a n d re p rin te d fro m K e y - p o i n t — K o n ta k b la d van d ie s tu d ie g ro e p v o o r die B e h a n d e lin g v a n p a tie n te n m e t c e re b ra le p a re se n , 1979). W rig h t, T . a n d N ic h o ls o n , J. (1973). P h y s io th e ra p y fo r th e sp a stic c hild: a n e v a lu a tio n . D e v. M e d . C h ild N e u r o l. 15, 1 4 6 - 163.. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )