Implementation of a strength training program for a 5-year-old child with poor body awareness and developmental coordination disorder.

School-based physical therapists often encounter children who move in an uncoordinated manner, appear unaware of their body positions in relation to themselves and others, and cause classroom disruption. These behaviors can frustrate teachers, who then reach out to therapists for assistance. A child displaying these behaviors may be exhibiting an underlying sensory processing deficit contributing to poor proprioception. (1) According to Buzzard, "Proprioception can be defined as the sense of the position and movement of the limbs and body in space. Proprioceptive information is transmitted from receptors found in muscles, joints, ligaments, skin, and other soft tissues to the central nervous system." (2(p528))

Children who display sensorimotor deficits, including impaired proprioception, also may fit into the classification of "developmental coordination disorder" (DCD). (3) The prevalence of DCD in children 5 to 11 years of age is estimated at 6% according to the American Psychiatric Association. (4) Criteria for DCD, as described in the Diagnostic and Statistical Manual of Mental Disorders, (4) assert that DCD is manifested by a marked impairment in the development of motor coordination that significantly interferes with academic achievement or activities of daily living. These impairments must not be associated with a general medical condition or a pervasive developmental disorder. If a child exhibits mental retardation, the motor skills should be delayed in excess of the child's mental age.

Although the etiology of DCD has yet to be specifically identified, (5) children with DCD often exhibit signs of minor neurological dysfunction such as dysftmctional muscle tone regulation, reflex abnormalities, choriform dyskinesia, coordination problems, poor fine motor manipulative ability, and miscellaneous rare disorders. (6) According to Hadders-Algra, (6) the percentage of cases of DCD that can be attributed to nervous system damage and whether these insults have occurred during prenatal, perinatal, or early postnatal development remain to be determined.

Controversy exists regarding the underlying deficits associated with DCD, including whether motor coordination deficits are the result of a physiological impairment or developmental delay. (7) Researchers debate whether the coordination difficulties seen in children with DCD are the result of a unisensory deficit or a multisensory deficit involving the visual, vestibular, and proprioceptive systems. (7) Even among the group of researchers who support the belief that coordination difficulties are the result of a unisensory problem, there is lack of agreement as to which sensory system is involved. (7)

According to Polatajko and Cantin, (8) the major treatment approaches that have been used for children with a diagnosis of DCD can be categorized into deficit-oriented and task-oriented interventions. Deficit-oriented approaches include sensory integration, sensorimotor, and process-oriented approaches. (8) Examples of deficit-oriented approaches promoted by Ayers (9) and Laszlo and colleagues (10) use sensory-based intervention and kinesthetic training, respectively, to facilitate skill acquisition. Deficit-oriented interventions focus on reducing impairments in sensory processing abilities or in performance components believed to be the cause of the motor coordination deficits (5,9-12) and place emphasis on foundation skills. (11) Research focusing on deficit-oriented approaches has shown their effectiveness to be nominal when addressing the needs of children with DCD. (8,11,13)

Task-oriented approaches include task-specific approaches, parent-teacher intervention programs, and the cognitive orientation to daily occupational performance program. (8) Examples of task-oriented approaches promoted by Schoemaker and colleagues, (12) Revie and Larkin, (14) and Missiuna and colleagues (15) use a problem-solving process to facilitate functional skill acquisition. Task-oriented interventions are based on the dynamical systems theory and place emphasis on motor learning principles and cognitive participation. (8,11,12) Research focusing on task-oriented interventions has shown their effectiveness to be more positive compared with deficit-oriented approaches when addressing the needs of children diagnosed with DCD. (8,11)

When selecting a treatment strategy, however, a therapist should be flexible enough to take into consideration individual differences in the presentation and progress of children with DCD. (16) Therefore, a multilevel approach to the treatment of children with DCD is recommended. (16) In addition, the results of a study by Cairney and colleagues (17) support the use of interventions designed to improve self-efficacy in a child diagnosed with DCD.

Interventions regarding remediation of proprioception deficits are discussed most frequently in the sensory integration and sensory processing literature. (1,18) Strategies regarding proprioception are placed into 2 categories: static or dynamic. Static strategies include the use of weighted items such as vests, beanbags, blankets, and cuff weights that can be worn during static as well as dynamic activities. Dynamic strategies require the child to actively participate in heavy muscle work such as pulling, pushing, or carrying heavy objects. Active heavy muscle work also can be generated via a person's own body weight through activities such as wheelbarrow walking, facilitating weight shifts, partner-pushing activities, and climbing.

Active heavy muscle work also can be achieved through structured strength training. According to sensory integration theory, active muscle contraction against resistance is considered an effective strategy to facilitate the development of proprioceptive awareness. (1) According to Guy and Micheli, (19) strength training refers to the use of progressive resistance to augment performance by using submaximal amounts of weight. Evidence indicates that, when guidelines for strength training regarding children are strictly followed, no detrimental effects occur. According to the American College of Sports Medicine (20) and many authors, (21-27) strength training in children is both safe and effective when delivered by a trained professional who adheres to published evidence-based guidelines.

Several studies (28-31) demonstrated that children with DCD produce significantly lower levels of maximum force and are less powerful when compared with peers who are normally coordinated. These studies provided evidence to support the theory that strength and power may be underlying deficits that contribute to motor difficulties in children with DCD. (28) However, it is not known whether variations in strength are primary or secondary in children with DCD. It is possible that strength deficits may be a result of the inactivity often seen in children with DCD.

Only a few studies have linked strength training to proprioception. (2,32-34) Limitations within these studies included small sample size as well as lack of generalization to the pediatric population because the samples were limited to patients with geriatric, hemophilia, or orthopedic diagnoses, (2,32-34) Despite the lack of literature involving strength training to facilitate proprioceptive awareness in children, some researchers suggest that proprioceprive sensations derived from active movement contribute to the development of body scheme, that is, the relationship of the body and its parts to enviromnental space. (1) In addition, some authors (35,36) have proposed that the increase in strength in children is not a result of muscle hypertrophy as in adults but is a result of increased neuromuscular activation with neural adaptations and coordination.

From a physiological viewpoint, evidence points to the role of the muscle spindle being involved in position sense and kinesthesia (37,38) as well as skin, which also contains stretch receptors that may convey information about movement. (39) Muscles provide information about joint position through the muscle spindle type I afferents that contribute to dynamic position sense and the muscle spindle type II afferents that detect static position sense. (37,38) Given this information, one might conclude that increased muscle activation through strength training may enhance proprioception via neural and muscle adaptations and therefore increase function in a child with poor proprioception, whether or not variations in strength and possible influences on proprioception are primary or secondary.

Review of the literature revealed a lack of evidence with respect to the use of a structured strength training program as an intervention for children who demonstrate poor body awareness or who are diagnosed with DCD. The purpose of this case report, therefore, is to describe how a program of strength training was associated with changes ha the muscle strength, gross motor function, and proprioccptive position sense in a 5-year-old pre-kindergarten child with poor body awareness and a diagnosis of DCD.

Case Description

At the time of the intervention, Andy (a pseudonym) was a 5-year-old boy enrolled in a half-day prekindergarten program. According to his legal guardians, although Andy was exposed to teratogens prenatally, he was carried to full term, weighed 3.3 kg (7 lb 6 oz) at birth, and as an infant displayed motor milestones that were within normal limits.

By age 5 years, Andy was classified as obese, as demonstrated by his height of 119.4 cm (47 in), weight of 41.5 kg (91.5 lb), and a body mass index of 29, placing him in the 97th percentile on the National Center for Health Statistics' Body Mass Index for Age Percentile chart. (40) He also developed multiple allergies for which he had been prescribed Claritin. (*)

His teacher initially referred him for physical therapy because of behaviors that seemed to be related to poor body awareness. Per protocol, a full evaluation was performed at 3.5 years of age, which included physical therapy, occupational therapy, cognitive, and speech and language assessments. The school psychologist and speech therapist reported Andy's cognitive and speech abilities to be within an age-appropriate range. However, his gross and fine motor skills were found to be significantly delayed.

The Peabody Developmental Gross Motor Scale, version 1, (41) which was still used in the school district at the time of this case, was administered and revealed a 19-month overall age equivalent or a 45% delay in overall gross motor skills. Notes from the assessment also indicated that Andy had muscle weakness, postural instability, coordination deficits, decreased endurance, and hyperextensibility. Motorically, Andy's major deficit appeared to be his lack of body awareness, which was demonstrated across various settings and activities such as appearing to unintentionally sit on children during circle time, stepping on objects and fellow classmates in his path, and walking with his arms outward and inadvertently swiping objects off the countertops while displaying no awareness of object destruction.

In addition, he displayed poor coordination and overall clumsiness, as exhibited by often missing his mouth with utensils during eating. He was unable to jump in place with feet together, to wheelbarrow walk, to pedal or steer a tricycle, or to ascend or descend steps safely. Andy could not coordinate self-propulsion of a Tumble Form scooter board ([dagger]) in a sitting or prone position. Following this assessment and observation, the major concern identified by the educational team was safety for Andy as well as his peers. As the result of his initial assessment, Andy received occupational therapy and physical therapy services twice a week while in prekindergarten. Goals focused on improving function and safety in the school setting.

Due to her strong motor learning background, the physical therapist (LBK) initially utilized a task-oriented approach focusing on dynamic strategies and a problem-solving perspective with Andy from 3.5 to 5.0 years of age in an attempt to increase his proprioception and body awareness. However, this approach produced minimal progress and was found to be laborious for this child. For example, Andy was nearly 5 years of age before he could pedal and steer a tricycle even a few feet.

At 5 years of age, testing was expanded to include a series of tests that were more age appropriate and focused on his individualized areas of concern. Andy's pediatrician assigned a diagnosis of DCD based on the following factors: a consultation with the physical therapist; review of the test results, including the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), (42) manual muscle testing, and position sense testing; and concerns of his guardians and teachers. At the time, Andy was diagnosed with DCD because his progress in therapy had been nominal; the implementation of a new intervention strategy consisting of a structured strength-training program was discussed with and approved by his pediatrician. Consent was obtained from Andy's legal guardians to implement the change in intervention.

In order to develop a family-oriented, child-centered program, Andy, his guardians, and his teachers were included in the planning process. The preintervention concerns of the teacher included Andy slouching in chairs, leaning against furniture and people for support, and stepping on toys and children sitting on the floor. Her goal was to eliminate these classroom behaviors. Andy's guardians' concerns included his difficulty balancing while dressing, climbing up and down stairs, and running slowly and sideways. His guardians wanted Andy to be more proficient in his gross motor abilities at home and in the community. Andy's only concern was that he wanted to keep up with his classmates.

Examination

The following tests and measures were administered as a component of the annual review prekindergarten meeting that was held prior to the new intervention: muscle testing, BOTMP, and proprioceptive tests (static and dynamic position sense testing of the upper and lower extremities). These tests were read-ministered for his Committee on School-Age Education meeting, which coincided with the end of his intervention, which was completed at the end of his prekindergarten year.

Muscle testing. Originally, manual muscle testing was attempted, but it was not continued due to Andy's inability to follow instructions, as demonstrated by inconsistency and repetitive muscle substitution. Muscle testing then was successfully performed using a handheld dynamometer (HHD) to establish baseline and posttraining strength measurements as well as data for the strength training protocol. Andy responded better to directions regarding movement using a dynamometer, and he appeared to have a decreased level of frustration and increased consistency in his performance. Measurements were taken the same time of day during his scheduled physical therapy sessions, and he was given the same rest periods between trims. Three HHD measurements obtained for each muscle tested were found to be similar and based on professional judgment were concluded to be more precise and reliable for this child.

Therefore, an HHD (Nicholas Manual Muscle Tester, model 01160 ([double dagger])) was used for both pretraining and posttraining measurements. Studies reporting on the use of the Nicholas Manual Muscle Tester with a pediatric population were not located; however, Trudelle-Jackson et al (43) demonstrated the Nicholas Manual Muscle Tester to be a highly valid and reliable instrument when measurements were examined between trials as well as between days using a sample of 30 women who were healthy. Intraclass correlations were used as test-retest reliability estimates, which ranged from .97 to .98 between trials and from .85 to .87 between days. (43)

Some studies that used the "break test" technique looked specifically at reference values for HHDs in children who were normally developing. (44,45) A break test requires the examiner to overcome a child's force and produces a measurement of eccentric muscle strength. (46) In the case of Andy, however, the make test was selected over the break test due to concerns about his low muscle tone and joint laxity. The make test requires a child to exert force against a dynamometer in a fixed position and requires a maximal isometric contraction. (46) Safety regarding joint integrity was the driving factor in this protocol decision. Stuberg and Metcalf (47) also used a make test with children with Duchenne muscular dystrophy, another population in which there are concerns regarding joint integrity, and compared them with children who were healthy. Focusing on knee and hip extension, elbow flexion, and shoulder abduction, Pearson product moment correlation coefficients for intratester and test-retest reliability were .83 to .99 for the children with Duchenne muscular dystrophy and .74 to .99 for the children who were healthy. Berry and colleagues (48) used the make test with a sample of children diagnosed with cerebral palsy.

No studies were found that used a sample of children with DCD for reliability studies. No reference values for HHDs were found for children with DCD. Likewise, make test values were unavailable for the pediatric population at large. This is a limitation of this case. The test positions used with Andy were those described by Daniels and Worthingham (49) with the following exceptions: abdominal muscle strength was tested with hips and knees flexed with feet on the mat, knee extension was performed in a sitting position with hip and knees positioned at 90 degrees, and plantar flexors were tested in a non-weight-bearing position because of Andy's level of understanding and performance. The preintervention muscle test scores for this case report are shown in Table 1.

Bruininks-Oseretsky Test of Motor Proficiency. The BOTMP (42) was selected to assess motor function because the Bruininks-Oseretsky Test of Motor Proficiency, second edition, was not available at the time the planning of this intervention was initiated. Additionally, the BOTMP was the test that was available and utilized by the school district at the time of this case. In a 2004 study by Gwynne and Blick, (50) the BOTMP, because of its strengths in validity and reliability, was considered to be the gold standard against which a motor checklist for children with DCD was evaluated. The BOTMP is one of the few standardized tests that examines subsets of gross and fine motor movements and can be administered over time from 4.5 to 14.5 years of age. The average test-retest reliability coefficients for gross motor subtests on the BOTMP in male children in grade 2 were .75 for running speed and agility, .73 for balance, .81 for bilateral coordination, .82 for strength, and .88 for upper-limb coordination. (42) This was computed using the Pearson r statistic, and the average was determined using the Fisher z transformation.

Duger et al (51) reported the validity of BOTMP scores for discerning aspects of motor development. The results of some studies, (52,53) however, did not support dividing the BOTMP into gross and fine motor composites because composite scores were found to be unreliable and invalid measures for which to observe change. Wilson et al (54) suggested that therapists should consider using the subtest point scores as a more accurate measure of change because they measure functional gains or deteriorations related to specific areas of motor control. Therefore, this case report utilized subtest point scores. The BOTMP sections tested included "Running Speed and Agility," "Balance," "Bilateral Coordination," "Strength," and "Upper-Limb Coordination" (42) because Andy demonstrated weaknesses in these areas. The preintervention BOTMP scores are shown in Table 2.

Proprioceptive tests. Static and dynamic position sense testing of the upper and lower extremities was performed to identify the level of proprioceptive deficit, which was the focus of concern. Limited information was available in the literature on static position sense testing. Bairstow and Laszlo (55,56) used a mechanical apparatus to test for kinesthetic sensitivity; however, this apparatus was not available or feasible in a school setting. Smyth and Mason (57,58) performed 2 studies using the matching arm posture task with children with DCD. Smyth and Mason (58) found a difference between children with DCD and control subjects in their ability to match a posture of one arm with the posture of the other arm. Even though position sense testing is an accepted practice, it is not standardized and no reliability or validity studies on non-apparatus-type testing procedures were found in the current literature. Therefore, static test positions were designed to assess Andy's proprioceptive deficits by keeping the test simple due to Andy's young age and for ease of replication for the examiner.

For the limb-matching test, Andy was instructed to keep his eyes closed while the therapist positioned one extremity, and he then was instructed to copy the position with his opposite extremity. He was asked to replicate 4 positions with his upper extremities and 4 positions with his lower extremities while positioned supine on a mat and sitting in a chair with no time constraints. The limb-matching test positions are described in Table 3.

A 3-point scale based on the scoring system developed by Korkman (59) and described by Smyth and Mason (57,58) was used to substantiate any changes in Andy's proprioceptive abilities. Even though no reliability or validity data were available for this scale, it was useful in denoting present status and changes. Table 4 describes Korkman's scoring criteria. The scoring for these tests was based on an ordinal scale. Based on Korkman's scoring system, Andy scored zeros for all limb-matching postures for both his upper and lower extremities during the preintervention examination.

According to Burgess et al, (60) the ability to sense limb position is independent from limb movement. Therefore, a limb movement position sense test was performed to address Andy's difficulty following movement patterns during classroom circle times. Thibault et al (61) examined the reliability of data for a limb movement sense test in a study in which the subjects' limbs were displaced 5 and 10 degrees following a specific velocity. High reliability was reported; however, the procedure as described was not replicable in a school setting and could not be used in this case report. Although limb movement sense tests have been used in practice and were cited in the literature, no studies of standardizing limb movements were found for any pediatric population; therefore, the movements chosen were individualized and related to Andy's specific proprioceptive difficulties.

For the limb movement sense test, Andy was asked to keep his eyes closed while the therapist passively moved one of his limbs. He then was asked to imitate the movement with his opposite limb with no time constraints. The movements done with Andy's upper extremities while he was sitting in a chair and with his lower extremities while he was positioned supine on a mat are described in Table 5. The scoring for this test was on a dichotomous scale (ie, either he could or could not do the movement).

Andy could not replicate any of the movement patterns in either his upper or lower extremities. He made an effort but aborted each attempt. Because Andy was unable to replicate any movements, the therapist explored the feasibility of whether performing these movements was an appropriate request. The therapist observed 5 of Andy's peers of the same age in a copy-the-movement game using the same movements being tested with Andy. None of Andy's peers demonstrated difficulty following instructions or completing the tasks during the copy-the-movement game.

Even though there is a lack of research using proprioceptive tests, for this child this type of testing appeared to be warranted and valuable in identifying changes in body awareness. The clinician can attempt to establish and maintain reliability following consistent procedural protocols, as was done in this case. Measurements were taken consistently with the child in the same positions, in the same chair, on the same mat, and at the same time of the day during his scheduled physical therapy sessions.

Evaluation

Andy demonstrated impairments in muscle force production, coordination, speed of movement, and both static and dynamic position sense. The therapist's hypothesis was that these impairments were responsible for his compromised function at home and school. Findings were consistent with Practice Pattern 5B: Impaired Neuromotor Development as described in the Guide to Physical Therapist Practice. (62)

Intervention

Because of Andy's slow response to the initial plan of therapy, the therapist explored the possibilities of different intervention strategies and considered a program of strength training. After procuring evidence to ensure that a resistance training program for preadolescent children with obesity would be safe and not contraindicated, (24-27) the therapist selected a program of strength training and developed it based on the best available evidence consistent with the Guide to Physical Therapist Practice. (19,21,63-65) Variables included in the program were muscle action, loading, exercise selection, exercise sequence, training volume, training frequency, rest intervals, repetition velocity, duration of session, duration of exercise program, and progression. (19,21,63-66) The therapist tailored Andy's program as follows.

Muscle Action

Because dynamic muscle strength is reported to be most improved when eccentric contractions are included in the training program, (63-66) Andy's program included dynamic repetitions with both concentric and eccentric contractions of full range of motion.

Loading

According to the American Academy of Pediatrics, (21) before a strength training exercise program is initiated, the specific exercises should be learned without resistance. Exercises should be executed using low resistance until the proper technique has been learned. Once an exercise is learned, as demonstrated by consistent performance and proper form, then incremental loads can be added. (21) Three weeks prior to using free weights, Andy performed the first set of exercises with just hands-on guidance.

The initial load is the amount of resistance with which a person begins exercising. (63) Different methods can be used to estimate the initial resistance with children. Faigenbaum et al (67) found that children could safely perform a 1-repetition maximum strength test using weight machines specifically designed for children. However, because Andy was unable to follow instructions or imitate movement patterns and because only free weights and cuff weights were available, the 1-repetition maximum test was not feasible. Load proportion also can be estimated by using a determined number of repetitions with weights until the performance deteriorates.

Because no studies, from which to estimate initial resistance, were found that used a strength training program to stimulate muscles to improve proprioception in children with decreased proprioception or DCD, the therapist determined the initial load for each exercise by Andy's ability to lift a weight through the full range of motion for at least 6 repetitions without deterioration of the performance. Because of Andy's substantially poor proprioceptive awareness, hands-on guidance was provided as necessary to ensure safety, as Andy risked hitting himself in the head with the weights. In Andy's case, the identified resistance load for each muscle was low, in some cases body weight only; however, this was not a concern because Anderson and Kearney (68) found that light loads may increase strength in previously untrained individuals. Similarly, Faigenbaum et al (23) found that muscle strength and endurance could be improved in childhood by using the prescription of higher repetitions with only moderate loads.

Exercise Selection

Hass et al (65) recommended that a minimum of one set of 8 to 10 exercises utilizing multijoint and single-joint workouts that involve major muscle groups should be incorporated in an exercise program for people who are healthy, including children. Single-joint exercises can target specific muscle groups and may cause less risk of injury because of the reduced skill level that is needed. (63) According to Kovaleski et al, (69) isotonic exercise imitates dynamic muscle function. This training approach, which includes the use of free weights, can facilitate contraction conditions similar to performing everyday tasks.

From the above information, the therapist chose 10 exercises aligning with these recommendations based on functional goals and safety needs, including use of individual body weight for resistance and use of free weights and cuff weights, depending on the exercise. Andy received hands-on guidance or stabilization as needed. The intervention focused on the antigravity muscles used to maintain a bipedal posture to facilitate the strength necessary for postural control and upper-extremity muscles to enhance his severely diminished upper-extremity position sense. The exercises used were those described in The American Physical Therapy Association Book of Body Maintenance and Repair, (70) except for the triceps muscle exercise described by Daniels and Worthingham. (49) The exercises, with any modifications included in the descriptions, are listed in Table 6.

Exercise Sequence

Kraemer and Ratamess (63) recommended large muscle group exercises prior to small muscle group exercises, multijoint exercises prior to single-joint exercises, and rotating opposing agonist and antagonist exercises. Table 6 shows the exercise sequence.

Training Volume

Training volume depends on the number of sets of each exercise performed and the number of repetitions performed in each set. According to Faigenbaum et al, (71) children should be able to perform at least 1 to 3 sets of 6 to 15 repetitions of a variety of isolated and multijoint upper- and lower-body exercises to build strength. Initially, Andy performed one set of 6 repetitions of each exercise.

Training Frequency

A twice-a-week training schedule was established as supported by the literature, (21,64,72) with one day of rest between training sessions. This schedule fit into Andy's preschool week acceptably and provided the day of rest required.

Rest Intervals

Andy's rest intervals (ie, the amount of time between exercise sets in his program) initially ranged from 30 to 120 seconds, as determined by his tolerance. Abdominal and back extension exercises required the maximum rest intervals.

Repetition Velocity

According to Kanehisa and Miyashita, (73) training at an intermediate velocity can develop muscular efficiency over a variety of contraction velocities. Therefore, the therapist chose the verbal rhythmic cue "one, one thousand" to set an intermediate repetition velocity during both concentric and eccentric phases of exercise.

Session Duration

The American Academy of Pediatrics (21) recommends the session duration for a child to be at least 20 to 40 minutes, including a warm-up component and a cool-down component. Accordingly, sessions for Andy were 20 to 30 minutes in duration, including a 5-minute warm-up period and a 5-minute cool-down period. Warm-up consisted of propelling a Tumble Form scooter board in prone and sitting positions to facilitate blood flow prior to the resistance training. The cool-down activities included flexibility exercises such as reaching for the toes in supine and standing positions, bending backward in a standing position while looking up toward the ceiling, and stretching in an all-fours position.

Program Duration

Hickson et al (74) investigated resistance training with adults and found that the majority of strength increases occurred within the first 6 to 8 weeks. Strength gains in children, however, result from increasing neuromuscular activation and improved coordination of the muscle groups being trained. (35,36) Because Andy demonstrated poor coordination, the therapist selected a 12-week program to give his neuromotor system time to adapt and allow for more practice.

Progression

For improvements to occur, an exercise program needs to be altered so that the human body is compelled to adapt to changing stimuli. This strategy is used to improve the body's exercise capacity by increasing resistance, repetitions, volume, and repetition velocity and by shortening rest periods. (63) Andy progressed according to his level of fatigue and tolerance because of his obesity and decreased endurance. Because he had difficulty following movement patterns, the therapist emphasized correct form of movement and varied the number of sets and repetitions more than the resistance, depending on the exercise. Every week, Andy's progression was reassessed to determine whether to increase the resistance or increase the number of sets for each muscle focused on. The exercises, with baseline levels and final outcome levels that he achieved by week 10 of the 12-week program, are shown in Table 7. Note that outcomes are reported for week 10 because no changes were noted for weeks 11 and 12 except for the deltoid muscles, which increased to 2 sets of 12 repetitions.

Outcomes

Intervention

Because Andy required hands-on guidance and verbal cueing to maintain correct alignment and avoid potential injury when performing exercises for the gluteus maximus, gluteus medius, deltoid, biceps, and triceps muscles throughout the duration of the program, he needed to be seen one-on-one instead of in a group strength training program. As the program progressed, his rest periods between sets decreased from a range of 30 to 120 seconds to a range of 10 to 30 seconds, which suggests that Andy improved his level of muscular endurance. Andy appeared to enjoy the exercises and said that he did not want to miss any sessions.

Muscle Testing

Andy's scores regarding his ability to exert force against an HHD before and after intervention demonstrated possible improvement. Progression in strength was seen at both the 6th and 12th weeks of muscle strength assessment, as shown in Table 1. The most substantial gains in strength were in the rectus abdominis and gluteus medius muscles. The rectus abdominis muscle demonstrated a 3-fold increase in strength, the right gluteus medius muscle demonstrated almost a 5-fold increase in strength, and the left gluteus medius muscle demonstrated a 3-fold increase in strength. Initially, the left gluteus maximus muscle tested weaker than the right gluteus maximus muscle, but at the conclusion of the program, the strength in the left gluteus maximus muscle surpassed the strength the right gluteus maximum muscle. Although gains were made in the upper extremities, they remained consistently weaker than the lower extremities. According to Berry et al, (48) many factors can affect a force outcome, including position of the patient, angle of the joint being tested, point of application of the force, amount and type of stabilization, muscle fatigue, and boredom from repetitive trials. This further supports the critical need for consistency in procedural protocols.

Bruininks-Oseretsky Test of Motor Proficiency

Although the BOTMP showed only minimal improvement in point scores in each subtest area, the functional gains were substantial, including Andy's ability to jump in place by the fifth week, raise his scapulas off the mat to perform an abdominal crunch, and maintain a wheelbarrow position supporting his upper body with his arms during the 10th week. At the conclusion of the program, Andy could wheelbarrow walk on his arms 3 steps forwards, jump 7.6 cm (3 in) off the ground with his feet together, and climb a horseshoe-shaped jungle gym all the way around--something he had never previously wanted to attempt. In the area of running speed and agility, Andy not only demonstrated a faster running time but also improved his running pattern from short choppy steps to an appropriate stride length for his body size. Andy's BOTMP strength subset score improved because of his new ability to perform a broad jump with his feet together. His guardians also observed changes and reported that Andy was now trying movement activities that were new for him such as swimming under water in his pool at home. His classroom teacher reported that his awareness improved, as he was no longer stepping on children and objects in his path. His teachers, guardians, and therapist observed that he challenged himself more and displayed increased confidence in his new motor abilities. Andy's preintervention and postintervention BOTMP scores are shown in Table 2.

Proprioceptive Tests

Andy demonstrated improvements in both static and dynamic limb position awareness. His static limb position awareness scores changed from 0's to 1's for all items listed in Table 3. A score of 1 denotes a position that is "approximately correct," with the joint angles incorrect up to 30 degrees. (57-59) Dynamic limb position awareness, as determined by the limb movement sense test, revealed that Andy was now able to replicate all test movements except for counterclockwise movements in both shoulders and hips. These findings should be regarded with caution because no reliability data are available for this type of testing.

Discussion

The subject of this case report was a 5-year-old child with poor body awareness who also was diagnosed with DCD. Andy's progress following a task-oriented program with problem-solving and dynamic strategies for about a year was minimal. The child appeared to need a different approach to enhance his proprioceptive and gross motor abilities.

The therapist turned to the literature to investigate an intervention strategy that would increase Andy's proprioception and function. Given the evidence from the literature concerning muscles and their relation to proprioceptive mechanisms and how children gain strength and evidence that strength training is safe for children, the therapist made a clinical decision to implement a strength training program to attempt to heighten Andy's proprioceptive sense and improve his body awareness and gross motor abilities. After a 12-week strength training program emphasizing correct form of movement and the number of sets and repetitions, Andy not only showed improvements in muscle strength but also demonstrated greater improvements in function and proprioceptive position sense compared with the previous year. The structured strength training program may have played a role in influencing proprioceptive changes in this child.

Andy's improvements may have been the result of an evidence-based approach to problem solving and design of a treatment program. Because Andy did not miss any exercise sessions, there was consistency in his program. Neuromuscular activation and neural adaptation could have occurred over the 12-week period because the program was so structured. Neuromotor learning may have occurred from the repetitions, which gave Andy input as to where his limbs were in space as he lifted resistance. As he started experiencing improvements, his motivation also appeared to increase.

There are other possible alternative explanations. Andy may have reached a plateau, which may have resulted from the 12 months of prior therapy. Combined with this program, there might have been a change in his functioning resulting from a combination of these interventions. Another explanation for the improved physical performance was Andy's new sense of self-esteem and confidence that was further fostered by his supportive guardians. This added enthusiasm and motivation may have resulted in an increase in Andy's dedication to the intervention, which created an intrinsic interest in changing his skill level. Andy's guardians reported an increase in his willingness to participate in novel gross motor activities at home. This increase in his activity level outside of therapy may have contributed to an increase in his abilities. It is not known whether Andy's initial reduction in strength was a result of having the diagnosis of DCD or was due to his initial lack of activity. Therefore, we cannot be sure whether the positive changes in strength demonstrated by Andy are the result of the strength training program or the increase in activity, or the combination of both. Finally, the large improvements in his muscle test scores with the HHD may have resulted from a learning effect from the repeated dynamometer usage.

This approach to treating children who demonstrate poor body awareness and who have a diagnosis of DCD does not appear to have been reported to date; however, caution is warranted about generalizing to other children with DCD because this case report concerns only one child and DCD is not a homogenous condition. Other limitations include lack of control regarding Andy's outside activities and the potential confounding variable of obesity. Additionally, there is a lack of standardization, reliability, and validity for the proprioceptive testing, the area in which Andy demonstrated the greatest improvement, and for the use of HHDs with children. Because of the lack of research, no established standard errors of measurement (SEMs) for proprioceptive testing and HHDs with children are available to determine measurement error from actual change. This is another limitation in this case report. Lastly, although the BOTMP manual lists SEMs, they were not appropriate for a 5-year-old child with the diagnosis of DCD because these standards were established on a sample of second-grade children. Unavailability of SEMs for younger children and children with the diagnosis of DCD is an additional limitation of this case report.

The outcomes of this case report suggest that pediatric physical therapists might further explore the use of strength training as an intervention strategy for the treatment of children with disabilities. Similarly, this case report suggests that strength training is a reasonable consideration for treatment of children with poor fitness levels, because no adverse outcomes were noted in either the literature or this case report.

Regarding clinical implications for tests and measures, the limb-matching test and the limb-movement sense test used in this case report are not commonly used in pediatric school-based assessment; however, both of these measures were easily administered and provided valuable information about how the child was functioning at a proprioceptive level. These tests provided quantitative information that could be used to document impairment and change. This case report suggests that the pediatric school-based community might further explore the utilization of these proprioceptive tests for use in pediatric practice settings. It is important to reiterate, however, that if clinicians want to utilize these measurements, they should go through testing to find their own intrarater and test-retest reliability, so they can calculate SEMs to be able to judge measurement error from actual change.

In conclusion, because the outcomes for this child were positive at both an impairment level and a functional level, this case report may foster further interest in formal research regarding the use of proprioceptive testing and strength training programs for increasing proprioception in children who show poor body awareness with and without a diagnosis of DCD.

Dr Kaufman provided concept/idea/project design, writing, data collection and analysis, project management, the patient, and consultation (including revisions and review of manuscript before submission). Dr Schilling provided consultation (including editing and review of manuscript before submission). The authors acknowledge Eleanor Caltabiano for consultation for review of grammar. Dr Kaufman acknowledges Dale Avers, PT, DPT, PhD, Director, Transitional Doctor of Physical Therapy Program, SUNY Upstate Medical University, and gives special thanks to Dr Schilling for her ongoing support.

This article was received June 17, 2006, and was accepted January 3, 2007.

DOI: 10.2522/ptj.20060170

References

(1) Bundy AC, Lane SJ, Murray EA. Sensory Integration: Theory and Practice. 2nd ed. Philadelphia, Pa: FA Davis Co; 2002:47, 86.

(2) Buzzard BM. Proprioceptive training in haemophilia. Haemophilia. 1998:4:528-531.

(3) Piek JP, Dyck MJ. Sensory-motor deficits in children with developmental coordination disorder, attention deficit hyperactivity disorder and autistic disorder. Hum Mov Sci. 2004;23:475-488.

(4) Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev ed. Washington, DC: American Psychiatric Association; 2000:56-57.

(5) Polatajko HJ, Macnab JJ, Anstett B, et al. A clinical trial of the process-oriented treatment approach for children with developmental co-ordination disorder. Dev Med Child Neurol. 1995;37:310-319.

(6) Hadders-Algra M. Developmental coordination disorder: Is clumsy motor behavior caused by a lesion of the brain at early age? Neural Plast. 2003;10:39-50.

(7) Willoughby C, Polatajko HJ. Motor problems in children with developmental coordination disorder: review of the literature. Am J Occup Ther. 1995;49:787-794.

(8) Polatajko HJ, Cantin N. Developmental coordination disorder (dyspraxia): an overview of the state of the art. Semin Pediatr Neurol. 2005; 12:250-258.

(9) Ayres AJ. Sensory Integration and Learning Disorders. Los Angeles, Calif: Western Psychological Services; 1972.

(10) Laszlo JI, Bairstow PJ, Bartrip J, Rolf VT. Clumsiness or perceptuo-motor dysfunction. In: Colley A, Beech J, eds. Cognition and Action in Skilled Behaviour. Amsterdam, the Netherlands: North Holland; 1988:293-316.

(11) Missiuna C, Rivard L, Bartlett D. Exploring assessment tools and the target of intervention for children with developmental disorder. Physical & Occupational Therapy in Pediatrics. 2006;26(1-2):71-89.

(12) Schoemaker MM, Niemeijer AS, Reynders K, Smits-Engelsman BC. Effectiveness of neuromotor task training for children with developmental coordination disorder: a pilot study. Neural Plast. 2003; 10:155-163.

(13) Mandich AD, Polatajko HJ, Macnab JJ, et al. Treatment of children with developmental coordination disorder: What is the evidence (CO-OP)? Part 1: theoretical foundations. Physical & Occupational Therapy in Pediatrics. 2001;20:51-68.

(14) Revie G, Larkin D. Task-specific intervention with children reduces movement problems. Adaptive Physical Activity Quarterly. 1993;10:29-41.

(15) Missiuna C, Mandich AD, Polatajko HJ, Malloy-Miller T. Cognitive orientation to daily occupational performance (CO-OP), part 1: theoretical foundations. Physical & Occupational Therapy in Pediatrics. 2001; 20:69-82.

(16) Wilson PH, Practitioner review: approaches to assessment and treatment of children with DCD: an evaluative review. J Child Psychol Pyschiatry. 2005;46:806-823.

(17) Cairney J, Hay JA, Faught BE, et al. Developmental coordination disorder, generalized self-efficacy toward physical activity, and participation in organized and free play activities. J Pediatr. 2005;147:515-520.

(18) Roley SS, Blanche EI, Schaaf RC, eds. Understanding the Nature of Sensory Integration With Diverse Populations. Albuquerque, NM: Therapy Skill Builders; 2001.

(19) Guy JA, Micheli LJ. Strength training for children and adolescents. J Am Acad Orthop Surg. 2001;9:29-36.

(20) Franklin BA, Whaley MH, Howley ET, eds. ACSM's Guidelines for Exercise Testing and Prescription. 6th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2000.

(21) Bernhardt DT, Gomez J, Johnson MD, et at. Strength training by children and adolescents. Pediatrics. 2001;107:1470-1472.

(22) Faigenbaum AD. Strength training for children and adolescents. Clin Sports Med. 2000;19:593-619.

(23) Faigenbaum AD, Westcott WL, Loud RL, Long C. The effects of different resistance training protocols on muscular strength and endurance development in children. Pediatrics. 1999;104:e5.

(24) Lillegard WA, Brown EW, Wilson DJ, et al. Efficacy of strength training in prepubescent to early postpubescent males and females: effects of gender and maturity. Pediatr Rehabil. 1997;1:147-157.

(25) Sothern MS, Loftin JM, Udall JN, et al. Safety, feasibility, and efficacy of a resistance training program in preadolescent obese children. Am J Med Sci. 2000;319: 370-375.

(26) Sothern MS, Loftin JM, Udall JN, et al. Inclusion of resistance exercise in a multidisciplinary outpatient treatment program for preadolescent obese children. South Med J. 1999;92:585-592.

(27) Stricker PR. Sports training issues for the pediatric athlete. Pediatr Clin North Am. 2002;49:793-802, vii.

(28) Raynor AJ. Strength, power, and coactivation in children with developmental coordination disorder. Dev Med Child Neurol. 2001;43:676-684.

(29) O'Beirne C, Larkin D, Cable T. Coordination problems and aerobic performance in children. Adaptive Physical Activity Quarterly. 1994;11:141-149.

(30) Larkin D, Hoare D, Phillips S, Smith K. Children with impaired coordination: kinematic profiles of jumping and hopping movements. In: Jones DE, Cuddihy T, eds. Progress Through Refinement and Innovation. Brisbane, Australia: Brisbane CAE Press; 1988:67-72.

(31) Raynor AJ. The Running Pattern of Seven Year Old Children: Coordination and Gender Differences [BPD honors thesis]. Nedlands, Australia: University of Western Australia; 1989.

(32) Swanik KA, Lephart SM, Swanik CB, et al. The effects of shoulder plyometric training on proprioception and selected muscle performance characteristics. J Shoulder Elbow Surg. 2002;11:579-586.

(33) Thompson KR. The Effects of Resistance Training on Proprioception and Function in Older Adults [PhD dissertation]. Bloomington, Ind: Indiana University; 2001.

(34) Hilberg T, Herbsleb M, Puta C, et al. Physical training increases isometric muscular strength and proprioceptive performance in haemophilic subjects. Haemophilia. 2003;9:86-93.

(35) Ozmun JC, Mikesky AE, Surburg PR. Neuromuscular adaptations following prepubescent strength training. Med Sci Sports Exerc. 1994;26:510-514.

(36) Ramsay JA, Blimkie CJ, Smith K, et al. Strength training effects in prepubescent boys. Med Sci Sports Exerc. 1990;22:605-614.

(37) Matthews PBC. Proprioceptors and their contribution to somatosensory mapping: complex messages require complex processing. Can J Physiol Pharmacol. 1988; 66:430-438.

(38) Clark FJ, Burgess RC, Chapin JW, Lipscomb WT. Role of intramuscular receptors in the awareness of limb position. J Neurophysiol. 1985;54:1529-1540.

(39) Edin B. Cutaneous afferents provide information about knee joint movements in humans. J Physiol. 2001;531(pt 1):289-297.

(40) National Center for Health Statistics. Growth charts. Available at: www.cdc. gov/growthcharts. Accessed August 2005.

(41) Folio MR, Fewer RR. Peabody Developmental Motor Scales and Activity Cards, Manual. Chicago, Ill: Riverside Publishing Co; 1983.

(42) Bruininks RH. Bruininks-Oseretsky Test of Motor Proficiency: Examiner's Manual. Circle Pines, Minn: American Guidance Service; 1978.

(43) Trudelle-Jackson E, Jackson AW, Frankowski CM, et al. Interdevice reliability and validity assessment of the Nicholas hand-held dynamometer. J Orthop Sports Phys Ther. 1994;20:302-306.

(44) Backman E, Odenrick P, Henriksson KG, Ledin T. Isometric muscle force and anthropometric values in normal children aged between 3.5 and 15 years. Scand J Rehabil Med. 1989;21:105-114.

(45) Beenakker EA, van der Hoeven JH, Fock JM, Maurits NM. Reference values of maximum isometric muscle force obtained in 270 children aged 4-16 years by handheld dynamometry. Neuromuscul Disord. 2001;11:441-446.

(46) Burns SP, Spanier DE. Break-technique handheld dynamometry: relation between angular velocity and strength measurements. Arch Phys Med Rehabil. 2005;86: 1420-1426.

(47) Stuberg WA, Metcalf WK. Reliability of quantitative muscle testing in healthy children and in children with Duchenne muscular dystrophy using a hand-held dynamometer. Phys Ther. 1988;68:977-982.

(48) Berry ET, Giuliani CA, Damiano DL. Intra-session and intersession reliability of handheld dynamometry in children with cerebral palsy. Pediatric Physical Therapy. 2004;16:191-198.

(49) Daniels L, Worthingham C. Muscle Testing: Techniques of Manual Examination. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1972.

(50) Gwynne K, Blick B. Motor performance checklist for 5-year-olds: a tool for identifying children at risk of developmental coordination disorder. J Paediatr Child Health. 2004;40:369-373.

(51) Duger T, Bumin G, Uyanik M, et al. The assessment of Bruininks-Oseretsky Test of Motor Proficiency in children. Pediatr Rehabil. 1999;3:125-131.

(52) MacCobb S, Greene S, Nugent K, O'Mahony P. Measurement and prediction of motor proficiency in children using Bayley Infant Scales and the Bruininks-Oseretsky Test. Physical & Occupational Therapy in Pediatrics. 2005;25:59-79.

(53) Tabatabainia MM, Ziviani J, Maas F. Construct validity of the Bruininks-Oseretsky Test of Motor Proficiency and the Peabody Developmental Motor Scales. Australian Occupational Therapy Journal. 1995;42: 3-13.

(54) Wilson BN, Polatajko HJ, Kaplan BJ, Faris P. Use of the Bruininks-Oseretsky Test of Motor Proficiency in occupational therapy. Am J Occup Ther. 1995;49:8-17.

(55) Bairstow PJ, Laszlo JI. Kinaesthetic sensitivity to passive movements and its relationship to motor development and motor control. Dev Med Child Neurol. 1981;23: 606-616.

(56) Laszlo JI, Bairstow PJ. The measurement of kinaesthetic sensitivity in children and adults. Dev Med Child Neurol. 1980;22: 454-464.

(57) Smyth MM, Mason UC. Use of proprioception in normal and clumsy children. Dev Med Child Neurol. 1998;40:672-681.

(58) Smyth MM, Mason UC. Planning and execution of action in children with and without developmental coordination disorder. J Child Psychol Psychiatry. 1997;38:1023-1037.

(59) Korkman M. NEPSY: A Proposed Neuropsychological Test Battery for Young Developmentally Disabled Children [PhD thesis]. Yllopistopaino, Finland: University of Helsinki; 1988.

(60) Burgess PR, Wei JY, Clark FJ, et al. Signaling of kinesthetic information by peripheral sensory receptors. Annu Rev Neurosci. 1982;5:171-185.

(61) Thibault A, Forget R, Lambert J. Evaluation of cutaneous and proprioceptive sensation in children: a reliability study. Dev Med Child Neurol. 1994;36:796-812.

(62) Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001:9-746.

(63) Kraemer WJ, Ratamess NA. Fundamentals of resistance training: progression and exercise prescription. Med Sci Sports Exerc. 2004;36:674-688.

(64) Faigenbaum AD, Milliken LA, Loud RL, et al. Comparison of 1 and 2 days per week of strength training in children. Res Q Exerc Sport. 2002;73:416-424.

(65) Hass CJ, Feigenbaum MS, Franklin BA. Prescription of resistance training for healthy populations. Sports Med. 2001;31:953-964.

(66) Dudley GA, Tesch PA, Miller BJ, Buchanan MD. Importance of eccentric actions in performance adaptations to resistance training. Aviat Space Environ Med. 1991; 62:543-550.

(67) Faigenbaum AD, Milliken LA, Westcott WL. Maximal strength testing in healthy children. J Strength Cond Res. 2003;17: 162-166.

(68) Anderson T, Kearney JT. Effects of three resistance training programs on muscular strength and absolute and relative endurance. Res Q Exerc Sport. 1982;53:1-7.

(69) Kovaleski JE, Heitman RH, Trundle TL, et al. Isotonic preload versus isokinetic knee extension resistance training. Med Sci Sports Exerc. 1995;26:895-899.

(70) Moffat M, Vickery S. The American Physical Therapy Association Book of Body Maintenance and Repair. New York, NY: Henry Holt and Company Inc; 1999: chapter 18.

(71) Faigenbaum AD, Kraemer WJ, Cahill B, et al. Youth resistance training: position statement paper and literature review. J Strength Cond Res. 1996;18:62-75.

(72) Faigenbaum AD, Zaichkowsky LD, Westcott WL, et al. The effects of a twice-a-week strength training program on children. Pediatr Exerc Sci. 1993;5:339-346.

(73) Kanehisa H, Miyashita M. Specificity of velocity in strength training. Eur J Appl Physiol. 1983;52:104-106.

(74) Hickson RC, Hidaka K, Foster C. Skeletal muscle fiber type resistance training, and strength-related performance. Med Sci Sports Exerc. 1994;26:593-598.

* Schering-Plough Corp, 2000 Galloping Hill Rd, Kenilworth, NJ 07033-0530.

([dagger]) Sammons Preston Rolyan, 4 Sammons Ct, Bolingbrook, IL 60440.

([double dagger]) Lafayette Instrument Co, PO Box 5729, 3700 Sagamore Pkwy, North Lafayette, IN 47903.

LB Kaufman, PT, DPT, MA, was a student in the Transitional Doctor of Physical Therapy Program, SUNY Upstate Medical University, Syracuse, NY 13210 (USA), at the time this case report was completed. Address all correspondence to Dr Kaufman at: lbkauf@ dreamscape.com.

DL Schilling, PT, PhD, is Rehabilitation Specialist, Cleveland Clinic, Cleveland, Ohio.

[Kaufman LB, Schilling DL. Implementation of a strength training program for a 5-year-old child with poor body awareness and developmental coordination disorder. Phys Ther. 2007;87:455-467.]

Table 1.
Muscle Testing Results: Before Intervention, at Midpoint of
Intervention, and After Intervention (a)

Muscles                    Before          Midpoint of
Tested                     Intervention    Intervention
                                           (at 6 wk)

Core Muscles
Rectus abdominis            2.0             4.65
Back extensors              7.2             9.6

Antigravity Muscles        Right   Left    Right   Left
Gluteus maximus             8.1     8.0     9.4     8.3
Gluteus medius              1.5     2.3     2.4     2.9
Quadriceps femoris          9.8     9.5    12.1    12.2
Gastrocnemius and soleus   13.3     9.3    14.7    11.85
Tibialis anterior           9.7     8.15   11.3     9.4

Upper Extremity            Right   Left    Right   Left
Deltoid                     3.1     2.5     4.2     3.3
Triceps                     5.2     4.2     6.1     6.7
Biceps                      5.0     5.2     6.5     5.8

Muscles                    After           Change
Tested                     Intervention
                           (at 12 wk)

Core Muscles
Rectus abdominis            8.4            +6.4
Back extensors             10.35           +3.15

Antigravity Muscles        Right   Left    Right   Left
Gluteus maximus            10.6    12.4    +2.5    +4.4
Gluteus medius              8.6     9.8    +7.1    +7.5
Quadriceps femoris         13.8    12.2    +4.0    +2.7
Gastrocnemius and soleus   16.4    13.1    +3.1    +3.8
Tibialis anterior          13.8    12.1    +4.1    +3.95

Upper Extremity            Right   Left    Right   Left
Deltoid                     6.2     5.2    +3.1    +2.7
Triceps                     9.8     7.5    +4.6    +3.3
Biceps                      7.1     6.7    +2.1    +1.5

(a) Muscle testing scores are recorded in kilograms. Scores reported
were the mean of the 2 highest scores of 3 attempts obtained during
testing.

Table 2.
Preintervention and Postintervention Scores on the Bruin
inks-Oseretsky Test of Motor Proficiency

Gross Motor Subtest         Maximum        Patient's Point Score
                            Point Score
                                           Before         After
                                           Intervention   Intervention
                                                          (at 12 wk)

Running speed and agility   15             0              3
Balance                     32             6              7
Bilateral coordination      20             0              1
Strength                    42             1              6
Upper-limb coordination     21             1              2

Table 3.
Limb Matching Test Positions

Upper Extremities

1. Shoulder at 90[degrees] of abduction with elbow fully extended,
palm down

2. Shoulder at 90[degrees] of abduction with elbow at 90[degrees],
palm facing forward

3. Shoulder at 180[degrees] of flexion with elbow fully extended, palm
facing forward

4. Shoulder at 135[degrees] of abduction with elbow fully extended,
palm facing forward

Lower Extremities

1. Hip abduction with full knee extension

2. Hip adduction in neutral

3. Hip flexion with knee flexion with foot on the mat

4. Hip and knee flexion at 90[degrees]

Table 4.
Korkman Scoring System for Static Position Sense Test (59)

Points    Observations
Awarded

2         No error noted in matched posture

1         Position is approximately correct, but the joint angles
            are incorrect up to 30([degrees])

0         One or more joint angles are in error by more than
            30([degrees])

Table 5.
Dynamic Position Sense Movements for Limb Movement Sense Test

Upper Extremities

1. Arm moved up to 180[degrees] of shoulder flexion with elbow fully
extended, palm facing forward, then brought to the side to 90[degrees]
of shoulder abduction, palm facing forward, and out in front to
90[degrees] of horizontal shoulder adduction, palm toward midline of
body

2. Shoulder circles forward

3. Shoulder circles backward

Tower Extremities

1. Hip circles counterclockwise

2. Hip circles clockwise

3. Active hip abduction and adduction with knee fully extended

Table 6.
Muscle Exercise Sequence

Order of      Patient      Muscles                 Exercise
Performance   Position

1             Supine       Rectus abdominis        Abdominal crunch
                                                     with arms at sides
2             Prone        Back extensors          Back lift with open
                                                     arms
3             Prone        Gluteus maximus         Horizontal hip
                                                     hitch with child
                                                     pushing leg toward
                                                     ceiling
4             Side lying   Gluteus medius          Lateral leg lift
5             Sitting      Quadriceps femoris      Seated knee
                                                     extension
6             Standing     Ankle plantar flexors   Standing calf lift
7             Standing     Ankle dorsiflexors      Standing toe raise
8             Standing/    Deltoid                 Side arm lift (one
                sitting                              arm at a time)
9             Standing/    Biceps                  Biceps curl (one
                sitting                              arm at a time)
10            Supine       Triceps                 Gravity-resisted
                                                     triceps exercise

Table 7.
Exercise Progression: Weeks 1 and 10

Muscles          Week 1                      Week 10

Abdominals       Arms in fair grade          Increased to 2 sets of 12
                   position, 1 set of 6        repetitions, able to
                   repetitions                 reach  for knees

Back extensors   Lifted up without any       Increased to 2 sets of 12
                   resistance, 1 set of 6      reps without resistance
                   repetitions

Gluteus          Use of 0.9-kg (2-lb) cuff   Increased to 2 sets of 12
  maximus          weights, 1 set of 6         repetitions with 0.9-kg
                   repetitions                 cuff weights

Gluteus medius   Needed active assistance"   Increased to 2 sets of 12
                   to raise legs, 1 set of     repetitions with 0.9-kg
                   6 repetitions               cuff weights, no active
                                               assistance

Quadriceps       Use of 0.9-kg cuff          2 sets of 12 reps with
  femoris          weights, 1 set of 6         2.3-kg (5-lb) cuff
                   repetitions                 weights

Ankle            Standing with 2 hands on    Changed to use of no
  dorsiflexors     table, 1 set of 6           hands on table for
                   repetitions                 support

Ankle plantar    Standing with 2 hands on    Changed to use of no
  flexors          table, 1 set of 6           hands on table for
                   repetitions                 support

Deltoid          Use of 0.45-kg (14b)        Increased to 1 set of 6
                   strap-on dumbbell in        repetitions, 1 set of
                   standing position, 1        12 repetitions, with
                   set of 6 repetitions        0.45-kg cuff weights

Biceps           Use of 0.9-kg (2-lb)        Increased to 2 sets of 12
                   strap-on dumbbell in        repetitions with
                   standing position, 1        1.36-kg (3-lb) cuff
                   set of 6 repetitions        weights

Triceps          Use of 0.9-kg strap on      Increased to 2 sets of 12
                   dumbbell, 1 set of 6        repetitions with
                   repetitions                 1.36-kg cuff weights

(a) Active assistance in this case report is defined as the limb
being physically guided through the range of motion of the particular
exercise.