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Review

The effectiveness
of passive stretching
in children with
cerebral palsy
Tamis Pin* MSc, Probationary PhD Candidate, University of
Melbourne, Victoria;
Paula Dyke MSc, Manager, School-aged Programme;
Michael Chan MSc, Senior Physiotherapist, Cerebral Palsy
Association of WA, Western Australia, Australia.

*Correspondence to first author at PO Box 143, North


Melbourne, VIC 3051 Australia.
E-mail: tamispin@hotmail.com

Passive stretching is widely used for individuals with Cerebral palsy (CP) is ‘an umbrella term covering a group of
spasticity in a belief that tightness or contracture of soft non-progressive, but often changing, motor impairment syn-
tissues can be corrected and lengthened. Evidence for the dromes secondary to lesions or anomalies of the brain aris-
efficacy of passive stretching on individuals with spasticity is ing in the early stages of its development’.1 This neurological
limited. The aim of this review was to evaluate the evidence disorder can cause secondary changes in the musculoskele-
on the effectiveness of passive stretching in children with tal system such as decreased muscle strength, tightness or
spastic cerebral palsy. Seven studies were selected according to contractures around joints, and abnormalities in both bony
the selection criteria and scored against the Physiotherapy structures and gait.2
Evidence Database scale. Effect size and 95% confidence Passive stretching is a common treatment to combat this
intervals were calculated for comparison. There was limited soft tissue tightness.3,4 The stretching can be done manually
evidence that manual stretching can increase range of by the therapist or the patient or by other external devices
movements, reduce spasticity, or improve walking efficiency such as splints, casts, or tilt-table.5 Despite the widespread
in children with spasticity. It appeared that sustained use of passive stretching, there is a lack of research evidence
stretching of longer duration was preferable to improve range demonstrating its effectiveness and the rationale behind the
of movements and to reduce spasticity of muscles around the stretch-based techniques in spastic human muscles.5,6
targeted joints. Methods of passive stretching were varied. Clinicians seek the ‘best evidence’ available from existing
Further research is required given the present lack of research studies to support their intervention procedures.7
knowledge about treatment outcomes and the wide use of this This review aims to investigate the current research evidence
treatment modality. on the effectiveness of passive stretching in children with spas-
tic CP by using the World Health Organization’s International
Classification of Impairment, Disability and Handicap (ICIDH-2)
to classify the outcomes described by different studies as rec-
ommended by the American Academy of Cerebral Palsy and
Developmental Medicine (AACPDM).7

Method
SEARCH STRATEGY
The clinical question of this review was: ‘Does passive stretch-
ing improve passive joint range of movements and reduce
spasticity more effectively in children with CP than no pas-
sive stretching?’ The inclusion criteria of this review were: (1)
studies on children under 18 years of age with spasticity due
to CP; (2) studies demonstrating the effects of passive stretch-
ing programmes with reported findings for analysis of its
effectiveness; (3) studies with all research designs except
expert opinions; and (4) fully published studies in peer-
reviewed journals. Studies that compared passive stretching
programmes with the effects of medications, surgery, or serial

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Table I: Methodology assessment of studies according to the Physiotherapy Evidence Database (PEDro) scale

Study Specified Random Concealed Similar Blinded Blinded Blinded More than
eligibility allocation of allocation prognosis participant therapists assessors 85% FU for
criteriaa participants at baseline at least one
key outcome

Fragala et al. (2003)20 Yes No No Yes No No No Yes


Lespargot et al. (1994)19 Yes No No Yes No No No Yes
McPherson et al. (1984)21 Yes No No Yes No No No Yes
Miedaner and Renander (1987)16 Yes Yes No Yes No No Yes Yes
O’Dwyer et al. (1994)14 Yes Yes No Yes Yes No Yes to Yes
half of
participants
Richards et al. (1991)17 Yes Yes No Yes No No No Yes
Tremblay et al. (1990)18 Yes Yes No Yes No No No Yes
aThis criteria is not counted for the total PEDro score; FU, follow-up.

casting were excluded as the area of interest was mainly on screened by the first author (TP) against the inclusion and
passive stretching without assistance from surgery and anti- exclusion criteria. When the title and abstract did not indi-
spasticity medications. cate clearly if an article should be included, the complete
Electronic databases (Medline, CINAHL, PsycINFO, Embase, article would be read to determine its suitability.
full Cochrane Library, and Physiotherapy Evidence Database
[PEDro]) were searched from the earliest date until April QUALITY ASSESSMENT OF METHODOLOGY
2006. The keywords used for the search were cerebral palsy, All the included studies were scored on their methodological
muscle spasticity, stretching, physical therapy, and range of rigour with the PEDro scale.8 The PEDro scale examines 11
movement. Subject headings, truncations, and thesaurus aspects of the quality of methodology: (1) specification of eli-
were used wherever possible. Reference lists in relevant stud- gibility of participants; (2) randomization of participants; (3)
ies and review articles were examined. The titles and abstracts allocation concealment of participants; (4) comparability of
of articles identified in the initial search were initially subject groups at baseline; (5) blinding of participants; (6)

Table II: Summary of study characteristics

Study Research design Level of Participant characteristics Nr of participants Age range


evidence Treatment Control
group group

Fragala et al. Multiple single-subject II Children with spasticity in 7 7a 4–18


(2003)20 ABAB design lower limbs with classification
of Levels IV and V by GMFCS
Lespargot et al. Before-and-after V Children with spastic CP 10 20 9–13
(1994)19 design with spasticity in hip adductors (median 10y
3mo)
McPherson et al. Multiple single-subject III Children with severe spastic 4 4a 10–18
(1984)21 design quadriplegic CP with knee
contracture
Miedaner and Renander Multiple single-subject I Children with severe physical 13 13a 6–20
(1987)16 with randomized and cognitive impairment (mean 10y 6mo)
cross-over design and decrease in joint ranges
of lower limbs
O’Dwyer et al. Randomized I Children with spastic CP 8 7 6–19
(1994)14 controlled trial with spastic triceps surae
Richards et al. Randomized I Children with spastic diplegia 8 11 3–13
(1991)17 controlled trial or hemiplegia (mean 7y [SD 3])
Tremblay et al. Randomized I Children with spastic CP 11 10 3–14
(1990)18 controlled trial (diplegia, hemiplegia, and Experimental group
quadriplegia) (mean 7y [SD 2y 7mo])
Control group
(mean 5y 11mo [SD 2y 5mo])
aParticipants acting as their own contols. GMFCS, Gross Motor Function Classification System; CP, cerebral palsy.

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Table I: continued of participants in the study). The averages of the standard devi-
ations of the group means and the numbers of participants
‘Intention Between group Point estimates PEDro score would be used if there were participant and control groups.11
to treat’ statistical analysis of variability
This formula for calculating the effect size with 95% CI was cho-
analysis for at least one for at least one
key outcome key outcome
sen as it has been deliberately simplified for clinicians who are
not experienced in complicated statistical calculations.11
Yes Yes No 4/10
Yes No No 3/10 Results
Yes Yes No 4/10 An electronic search on various databases and reference lists
Yes Yes Yes 7/10 identified 615 articles, among which 10 studies met the
Yes Yes Yes 8/10 inclusion criteria. The full articles of these 10 studies were
reviewed and three studies were further excluded because of
Yes Yes Yes 6/10
the following reasons. One study was a systematic review12
Yes Yes Yes 6/10 that evaluated studies on passive stretching of participants in
vegetative and minimally conscious states. As the partici-
pants had heterogeneous diagnoses and included both
adults and children, it was excluded from this report. Two
papers13,14 reported the data of the same study,14 and hence
they were treated as a single entity.14 One study15 did not have
any intervention but investigated the time that the soleus
blinding of therapists; (7) blinding of assessors; (8) more muscle was stretched during daily activities in a 24-hour peri-
than 85% follow-up of participants in at least one of key out- od in children with CP so as to deduce how long the muscle
comes; (9) ‘intention to treat’ analysis; (10) between group needed to be stretched to prevent contracture.15 Therefore,
statistical analysis of at least one of the key outcomes; and this report analyzed the results from seven research studies
(11) point estimate of at least one of the key outcomes. Acc- on the effects of passive stretching in children with CP.
ording to the PEDro guidelines, a positive answer to each of The scoring of each study with the PEDro scale is listed in
the criteria 2 to 11 will yield one point, obtaining a PEDro Table I. The median score of the seven studies was 6 (interquar-
score between 0 to 10.8 The details of the scoring criteria tile range is 4–6.5). According to the AACPDM evidence table
can be found in their weblink (http://www.pedro.fhs.usyd. of internal validity, four studies are level I randomized con-
edu.au/criteria.html). The PEDro scale has been shown to trolled trials (Table II).14, 16–18 There was no available infor-
have moderate interrater reliability (intraclass coefficient mation from these four studies to determine if the allocation
for the total score is 0.56, 95% confidence interval [CI] was concealed (criterion 3). The participants, therapists, and
0.47–0.65).9 assessors in most of the studies were not blinded (criteria
The AACPDM evidence table of internal validity was used 5–7). Most of the studies were able to follow up all the partic-
to grade the levels of evidence of each selected study.7 This ipants and all except one study19 used statistical comparison
classification of levels of evidence is a modification of Sackett’s of at least one key outcome measure between the study and
hierarchy of levels of evidence,10 but it includes and grades control groups (criteria 8–11). Hence, although more than
single subject research design, which is increasingly common half of the studies are of level I or II evidence, their method-
in research in the developmental disability domain.7 This ological quality is average.
grading procedure was done independently by the first (TP) Table II summarizes the characteristics of the research
and second (PD) authors. Any disagreements were resolved participants in these seven studies. The participants were
with discussion. aged from 3 to 20 years of age. As there was no raw data avail-
able in two studies including participants more than 18 years
DATA EXTRACTION of age,14,16 it was impossible to exclude the data relating to
Data from all the included studies were summarized in the for- those participants more than 18 years of age. These two stud-
mat as suggested by the AACPDM.7 The format includes: partic- ies were still included in this review of the effects of passive
ipants’ characteristics (number in each group, target stretching in children with CP.
population, diagnosis, numbers in each diagnostic subgroup, Table III summarizes the outcomes of interest of these
and ages), intervention used, control used, research design seven studies and codes the outcomes of interest according
and level of evidence for the study, and outcomes of interest. to the different dimensions of disablement. All the outcomes
of interest in these studies were at the level of impairment.7
DATA ANALYSIS
Effect sizes with 95% CIs were calculated if raw data were avail- CHANGE IN RANGE OF MOVEMENTS
able in the studies.11 The effect sizes give easy understanding of There are five studies investigating the effect of passive stretch-
how big the treatment effect is and the clinical significance of ing in improving the range of movement of identified joints.14,
these statistically significant treatment effects can also be justi- 16, 19–21 Two studies showed an increase in range of movement

fied. The effect size was the difference between the means of poststretching (of level III21 and level I16 evidence). The study
outcome measures of the participant and control groups. If by McPherson et al.21 of level III evidence showed that there
there was no control group, the difference of the pre- and post- was a significant reduction in knee flexion contracture in three
treatment means would be used as the participants were acting out of four treatment periods and a significant increase in
as their own controls. The 95% CI was approximated by the fol- knee flexion contracture in three out of four non-treatment
lowing formula: 3 x SD/√N (SD, standard deviation; N, number periods. The difference in means between treatment and

Review 857
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Table III: Summary of study results

Study Intervention Outcome of interest Measures Dimension of


disablement

Fragala et al. Manual stretch with hold for 40–60s, Passive range of hip flexion, hip Goniometer I
(2003)20 3 times for each movement, 1 or 2 times per week extension, hip abduction, popliteal
and routine positioning regime in classrooms angle, knee flexion, and knee extension

Lespargot Manual stretch for 15–20min in Passive hip abduction angle Specially I
et al. (1994)19 physiotherapy session and wedge-sitting designed
5–7h daily apparatusa

McPherson First year: manual stretch with hold for Range of knee flexor contractures Goniometer I
et al. (1984)21 60s, 5 repetitions for each joint,
3 times a day and 5 days a week
Second year: 30min on prone-stander Hypertonicity Specially I
per day, 30min on supine positioning designed
device per day, 5 days a week apparatusb

Miedaner and Manual stretch with 5 repetitions for each joint, Passive range of movement of hips, Goniometer I
Renander hold for 20–60s. One group having knees, ankles, and forefeet
(1987)16 5 days a week and one group having 2 days
a week. After 5 weeks, the groups were
switched for another 5 weeks

O’Dwyer et al. Sinusoidal stretch by specifically designed Spasticity of triceps surae Tonic stretch I
(1994)14 apparatus using stretch reflex as biofeedback, reflex
30min per session, 3 times per week for Contracture of triceps surae Ankle joint I
average 42 days passive torque

Richards et al. Standing in tilt-table with various ankle Muscle activation of tibialis anterior EMG I
(1991)17 positions for 30min each time and triceps surae
Gait analysis Video I
recording
EMG during walking Spastic I
Locomotion
Disorder Index

Tremblay et al. Standing in tilt-table with ankles in dorsiflexion Quality of passive movement of ankles Kin-Com I
(1990)18 for 30min dynamometer
and surface
electrodes
(in terms of
torque, ankle
angle, and EMG)

Quality of voluntary contraction Kin-Com I


of triceps surae dynamometer
and surface
electrodes
(in terms of
torque and EMG)
aThe reliability and validity of the apparatus not mentioned in the text; bInter- and intrareliability of this apparatus were reported in the text on

measuring tone over wrists; cfavours stretches. ND, no difference before and after stretches; I, impairment; PROM, passive range of
movements; CI, confidence interval; NS, non-significant results; NA, not applicable; EMG, surface electromyography; PF, plantarflexion; DF,
dorsiflexion; TS, triceps surae; TA, tibialis anterior.

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Table III: continued

Results Statistics Effect size (95% CI)

Statistically decrease in PROM Wilcoxon signed-rank test. No raw data provided for calculation. Authors
after the first non-stretch phasec Z-statistic=–1.999, p=0.046 defined changes >8° as real differences

No comparison of outcome of interest Not specified in text. Raw data provided Hip abduction with knee flexion, 6.13
before and after stretchesc for 4 participants. Calculation of effect size (–6.31 to 18.57) and –1.38 (–5.02 to 2.26).
shown no significant difference found Hip abduction with knee extension, 0.63
before and after stretching (–8.76 to 10.02) and 2 (–11.06 to 7.06)

3 out of 4 treatment periodsc Wilcoxon Match-paired, signed-rank Unable to calculate (see text under section
3 out of 4 non-treatment periodsc test p<0.05 and p<0.02 respectively ‘Change in range of movements’ for explanation)

1 out of 4 treatment periodsc Wilcoxon Match-paired, signed-rank test –1.56 (–3.1 to –0.02)
p<0.05

In right hip flexion and right Hip flexion: F=10.21, p< 0.01 Right hip flexion 12 (1.52 to 22.48)
straight-leg raising i.e. 2 out of 7 joints after Straight leg raising: F=5.71, p< 0.01 Right straight leg raising 8.2 (0.19 to 16.21)
5 days per week stretch.c
No significant difference between the 2
regimes of manual stretching except in right
straight-leg raising i.e. 1 out of 7 joints

Significant decrease in spasticity of triceps F(1, 12) >6.83, p<0.025 and No raw data provided for calculation
suraec F(1, 12) >5.61, p< 0.05
ND NS NA

Significant reduction in pre/post-ratio of p<0.01 No raw data provided for calculation


tibialis anterior in initial gait cyclec
ND NS NA

ND NS NA

Decreased resistance to passive p<0.05 At 30˚=–0.28 (–0.56 to 0)


movements of ankles immediately and At 60˚=–0.56 (–0.89 to –0.23)
up to 35min after stretchc At 60˚ after 25min=–0.67 (–1.26 to –0.19)
decreased EMG response during passive At 60˚ after 35min=–0.65 (–1.24 to –0.06)
movements of ankle immediately and TS EMG
up to 35min after stretchc 30˚DF=–0.23 (–0.39 to –0.07)
30˚PF=–0.2 (–0.37 to –0.03)
60˚PF=–0.41 (–0.71 to –0.11)
120˚PF=–0.26 (–0.47 to –0.05)
60˚PF after 25min=–0.42 (–0.73 to –0.11)
60˚PF after 35min=–0.33 (–0.65 to –0.01)
TA EMG
30˚DF=–0.33 (–0.59 to –0.07)
60˚DF=–0.48 (–0.85 to –0.11)
120˚DF=–0.35 (–0.61 to –0.07)
30˚PF=–0.44 (–0.73 to –0.15)
60˚PF=–0.46 (–0.86 to –0.06)
Increased torque during PFc p< 0.05 0.71 (0.28 to 1.14)

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non-treatment phases were <10˚ in general. The effect size available end range of movement by mechanical means such as
and 95% CI in this study were unable to be calculated due to standing table or position equipment.14,17,18 The other catego-
the small sample size (four participants) and the violation of ry is manual stretching, i.e. by holding the joint to the available
assumption of normal distribution of data. The study by end range of movement manually for a set amount of time and
Miedaner and Renander of level I evidence16 showed a statisti- then releasing it.16, 19–21 The latter, therefore describes a short
cally significant increase in two out of 14 joint measurements time limit for stretching (expressed as seconds), when com-
after stretching five times a week for 5 weeks. The effect sizes pared with the first category (expressed as minutes, or up to
of these two measurements were 8.2° and 12° respectively. 5–7h in some studies). Three studies combined sustained and
One study of level II evidence showed loss in range of move- manual stretching as their intervention procedures.19–21
ments in 28 motions after the cessation of passive stretching in It is of interest to compare the effects of manual and sus-
one out of four phases of study periods.20 No raw data was tained stretching. The study using manual stretching of short-
provided for the calculation of the effect sizes but the authors er duration by Miedaner and Renander16 (level I evidence)
defined that changes greater than 8° were considered not due showed some significant increases in range of movements
to measurement errors. Thus, it is believed that the difference but only in a small portion of total measurements taken. The
in these 28 motions should be greater than 8°. One level I evi- effect sizes were small (Table III). In studies using sustained
dence study, however, showed no difference in the range of stretching, the studies by O’Dwyer et al.14 (level I evidence)
movement of triceps surae poststretching.14 Although the and Tremblay et al.18 (level I evidence) demonstrated a statis-
level V study by Lespargot19 did not use statistical comparison tically significant decease in spasticity after stretching. The
in range of movements before and after stretching, raw data of study by Richards et al.17 (level I evidence) concluded there was
the four participants were available for the calculation of the no clinical significance in their statistically significant findings
effect size and the 95% CI. No statistical difference in the range in the reduction of spasticity following sustained stretching.
of hip abduction was demonstrated after passive stretching
(Table III). Discussion
CHANGE IN RANGE OF MOVEMENTS
CHANGE IN SPASTICITY There is conflicting evidence on whether passive stretching
In terms of changes in spasticity poststretching, there are four can increase the range of movement in a joint. One study14 of
studies (level III,21 level I,14 level I,17 and level I18 evidence) all high level of evidence and good methodological quality showed
showing a reduction in spasticity posttreatment. McPherson et no difference poststretching but three studies16,20,21 of mod-
al.21 reported that there was a statistically significant reduction erately poor to good methodological quality showed
in hypertonus over the knee joints in one out of four treatment improvements in the range of movement. For those studies
periods (effect size was –1.56 units in the torque of passive showing improvements in the range of movements, the effect
knee flexion; Table III). O’Dwyer et al.14 found a decrease in sizes were fairly small (in general less than 10°). One may
spasticity in the triceps surae after the stretching but no raw argue that some increase in range of movements can assist in
data provided for calculation of the effect sizes. Richards et al.17 positioning of these children. An increase in range of hand
demonstrated a significant reduction in the electromyography and hip movements is also important in hand and perineal
(EMG) pre/post-ratio for the tibialis anterior muscles only at hygiene respectively. However, these arguments can only be
the initial gait cycle after 30 minutes of stretching on a tilt-table. verified with more rigorous studies. As most of the authors in
The difference between the treatment and control groups was these studies did not declare their acceptable cut-off points
0.25 (no 95% CI calculated). The authors considered this for clinical significance, it is difficult to judge if those
reduction to be clinically non-significant17 as the reduction was improvements in range of movements were clinically rele-
not demonstrated in the other outcome measure used in the vant.11 Hence, there appears to be no conclusive evidence to
study (Spastic Locomotion Disorder Index). Tremblay et al.18 definitely state that passive stretching can increase the range
reported a significant reduction in resistance during passive of movement in a joint, although there is some evidence favour-
plantar flexion of the ankles after stretching and the effect last- ing passive stretching in an increasing range of movements in
ed up to 35 minutes poststretching on a tilt-table (effect sizes children with CP.
ranging from –0.28 to –0.67). In addition, there was a signifi-
cant reduction in the surface EMG post/pre-ratio during pas- CHANGE IN SPASTICITY
sive shortening in the ankle muscles (effect sizes ranging from There is some evidence to suggest that passive stretching can
–0.20 to –0.42 for triceps surae and –0.33 to –0.48 for tibialis reduce spasticity in children with CP as those studies show-
anterior muscles; Table III).18 ing favourable outcomes after passive stretching were mainly
of higher levels of evidence and had more rigorous method-
CHANGE IN GAIT ology. Similar to the range of movements, the effect sizes
Richards et al.17 (level I evidence) also examined the effects were fairly small and it was difficult to judge if the decrease
of passive stretching on children’s gait pattern. They did not was clinically significant. In addition, the reduction in spas-
find any significant changes in gait patterns as measured by ticity was unable to be carried over to more functional activi-
video recording after 30 minutes of stretching on a tilt-table. ty such as walking.

COMPARISON OF MANUAL AND SUSTAINED STRETCHING COMPARISON OF MANUAL AND SUSTAINED STRETCHING
The nature of the stretching intervention used in the studies From the reported studies, there appears to be some evidence
varied in method and dosage. The stretching regimes can be to indicate sustained stretching is preferable to improve range
roughly divided into two categories.5 The first category involves of movements and to reduce spasticity of targeted joints in chil-
sustained stretches by holding the targeted joint to the dren with spasticity. More studies of higher levels of evidence

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and better methodological quality showed improvements in ing the effects of passive stretching by including it in the daily
the range of movements and spasticity by means of sustained routine of patients. As there appears to be some evidence to
stretching, although the effect sizes were small. Among those show that sustained stretching is more effective than manual
studies using sustained stretching, there was no justification stretching of short duration in improving range of motion and
given by the authors14,17,18,21 regarding the duration of stretch- reducing spasticity, perhaps emphasis should be placed on the
ing chosen. A duration of 30 minutes stretching was the most optimum positioning of patients (both daytime and night-time
commonly chosen in the studies14,17,18,21 which may be based positioning) so as to maximize the effects of passive stretching.
on previous animal studies.5 Equipment such as orthoses, splinting, and serial casting can
be used as alternatives to sustained stretching. However, this
LIMITATIONS needs to be verified by studies of more rigorous methodologi-
The significant limiting factor of this review is that the selec- cal quality and of larger sample size.
tion of studies was done by one person. Two or more review- There are substantial gaps in this existing evidence related
ers should reduce the risk of selection bias in future. Another to passive stretching that need to be addressed by future
limitation of this body of evidence is the small number of par- research. More rigorous, well-controlled trials are required to
ticipants in each study and their heterogeneity, which has investigate the impact of passive stretching in children with
already been identified as a major barrier in research, partic- CP, particularly with regard to functional limitation/activity
ularly in children with CP.22 The children’s ages varied at the and participation. Studies that aim to investigate the optimal
point of investigation, implying variability in their growth rate duration and frequency of passive stretching to obtain the
and their stage of neuronal plasticity, which, in turn, affects desirable clinical changes in patients are necessary.
the influence of different interventions.22 None of the stud-
ies reported if the power of the sample size was calculated a DOI: 10.1017/S0012162206001836
priori. As the power of these studies was unknown, it is
suggested that readers interpret the statistically non-signifi- Accepted for publication 14th July 2006.
cant results as inconclusive, rather than indicative of there
being no effect from passive stretching.7 Most of the studies Acknowledgement
were in the middle range in the total PEDro score. It appears This review was an outcome of the Evidence-based Practice project
that there is a need to carry out well-designed trials for evalu- funded by the Community Development Services in the Cerebral
ation of the effects of passive stretching in children with CP. Palsy Association of Western Australia in Perth, Australia between
2000 and 2003.
Due to the limitations in the methodology of these studies, it
was difficult to make definite recommendations regarding References
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hypertonia. Phys Med Rehabil Clin N Am 12: 747–768.
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passive stretching may reduce spasticity in children with CP implications for muscle fibers. Phys Ther 81: 819–827.
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Classification of Mental and Behavioural disorders. Diag-


Book Review nostic Criteria for Research – 10th revision (1993). They
point out that a dimensional approach is far more appropri-
ate and emphasize that behaviour is inherently dimension-
Autism: A Neurological Disorder of Early Brain Development al, creating problems in defining subgroups within the
International Review of Child Neurology Series spectrum. Reliable and valid definitions of subgroups will
Edited by Roberto Tuchman and Isabelle Rapin be possible only when the underlying neuropathologies of
London: Mac Keith Press (for the International Child Neuro- different types of autism are understood. The editors also
logy Association), 2006, pp 354, £65.00, $US115.00 emphasize the overlap of autistic disorders with other
ISBN 1 898683 49 2 (Hardback) developmental and psychiatric conditions, especially as
manifested in more able individuals. The authors of the
The title of this book highlights the essence of the revolu- chapter on stereotypies do not agree with the currently
tion in ideas concerning the nature of autistic conditions. popular hypothesis that they are a form of self-stimulation.
In the 1940s and 50s, the prevailing view was that autism They consider that the movements are involuntary, due to
was due to the cold, distant, child-rearing practices of par- an immature and aberrant central nervous system. Yet
ents, especially mothers. From the 1960s onwards the another example of a willingness to take an unconventional
hypothesis that autistic conditions are developmental dis- view can be found in Martha Bridge Denckla’s preface. She
orders with a neurological basis has evolved and is now points out that the overly conventional approaches within
generally accepted. The editors and contributors agree neuropsychology, while emphasizing the neuropathologi-
with the concept of a spectrum of autistic conditions that cal basis of autism, have had the disadvantage of focusing
is much wider than Kanner’s original description of ‘early on cortical functions. This is not appropriate for a disorder
infantile autism’. The term autism is used in the book and starting early in life, probably in most cases before birth,
in this review to refer to the whole spectrum. with diverse developmental consequences which include,
There are chapters discussing each of the major clinical but are by no means limited to, functions affiliated with the
features – the social deficit, language and communication cerebral cortex. Dr Denckla notes that many of the chapters
problems, stereotypies and repetitive behaviour, unusual in the book indicate the need to investigate subcortical sys-
sensory responses, motor problems, and sleep disorders. tems that are basic to the development of the ‘social–emo-
Other chapters deal in detail with research in the neurobi- tional brain’.
ology of autistic spectrum disorders, including genetics In a book that is so comprehensive and detailed it is sur-
and the relationship of epilepsy with the basic neuro- prising that there is no mention of the catatonia-like prob-
pathology. The concepts underlying neuropsychological lems causing deterioration of movement and behaviour that
assessment, methods used, and the value of such assess- affect around 10% or more of adolescents and adults with
ments in clinical work have a chapter to themselves, as does autistic disorders.1 However, apart from this small criticism,
the epidemiology of autism. The editors focus the first cha- this book is to be recommended to researchers and profes-
pter on ‘Where are we now’ and the final one on ‘What we sional workers engaged in clinical work in the field. It would
have learned and where we need to go’, both of which are also be of interest to parents and carers who want to broad-
informative summaries. en their understanding of the fascinating and mysterious
The book provides a comprehensive overview of current conditions making up the autistic spectrum.
research and theoretical ideas on the neurological basis of
autistic spectrum disorders. It is refreshing to find that the Lorna Wing
contributors are able to criticise and look beyond conven-
tional views when they deem this to be necessary. For exam- DOI: 10.1017/S0012162206001848
ple, the editors, in their first chapter, discuss the dis-
advantages of the categorical nature of the diagnostic crite- Reference
ria laid down in the Diagnostic and Statistical Manual 1. Wing L, Shah A. (2000) Catatonia in autistic spectrum
of Mental Disorders, 4th edition (1994) and the ICD-10 disorders. Br J Psychiatry 176: 357–362.

862 Developmental Medicine & Child Neurology 2006, 48: 855–862


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https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0012162206001836