Occup. Ther. Int. 17 (2010) 159167 2010 John Wiley & Sons, Ltd.

159
RESEARCH ARTICLE
Clinical Changes During an Intervention Based on
Constraint-Induced Movement Therapy Principles on
Use of the Affected Arm of a Child with Obstetric
Brachial Plexus Injury: A Case Report
Daniela Virgnia Vaz
1
, Marisa Cotta Mancini
2
*

, Mara Ferreira do Amaral

3
,
Marina de Brito Brando
3
, Adriana de Frana Drummond
2
& Srgio Teixeira da Fonseca
1
1
Physical Therapy Department, Universidade Federal de Minas Gerais, Brazil
2
Occupational Therapy Department, Universidade Federal de Minas Gerais, Brazil
3
Graduate Program in Rehabilitation Sciences, Universidade Federal de Minas Gerais, Brazil
Abstract
The objective of this study was to test the feasibility of a treatment programme based on the elements of constraint-
induced movement therapy (CIMT) to encourage use of the affected arm of a child with obstetric brachial plexus
injury (OBP), as well as to document clinical changes observed with this intervention. A 2-year-old female child
with Erbs palsy had 14 weeks of daily home-based treatment with 30-minute sessions planned according to the
principles of CIMT. The child was assessed every 2 weeks with the Toddler Arm Use Test. Test scores throughout
the intervention period demonstrated improvements in quality of movement, amount of use and willingness to use
the affected extremity. The childs mother reported improved ability to perform bimanual activities at home. The
results suggest that treatment based on CIMT principles has potential to promote functional gains for children with
OBP. Experimental studies should test the effects of this kind of intervention for children with OBP. Copyright
2010 John Wiley & Sons, Ltd.
Received 25 February 2010; Revised 21 April 2010; Accepted 22 April 2010
Keywords
obstetric brachial palsy; constraint induced movement therapy; upper extremity function; toddler; pediatric occupational therapy
*Correspondence
Marisa Cotta Mancini, Departamento de Terapia Ocupacional, Programa de Ps-Graduao em Cincias da Reabilitao, Universidade
Federal de Minas Gerais, Av. Antnio Carlos, 6627, Campus Universitrio UFMG, Pampulha, Belo Horizonte MG, Brasil. CEP
31270-010.

Email: mcmancini@pib.com.br
Published online 19 July 2010 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.295
(Heise and Gherpelli, 2006). OBP incidence is compa-
rable with that of other important health conditions in
infancy, such as Down syndrome and cerebral palsy
(Bialocerkowiski et al., 2006). The literature points to
several risk factors for OBP, including increased weight
at birth, prolonged labour, perinatal asphyxia and
forceps delivery. Although the relation between these
factors and OBP is well established in the literature,
Introduction
Obstetric brachial plexus injury (OBP) causes partial or
total paralysis of the upper limb because of trauma to
the brachial plexus during delivery (Evans-Jones et al.,
2003). Despite the signicant improvements in obstet-
ric techniques, the incidence of this condition may
reach 1.5 cases per 1,000 births in developed countries
CIMT-Based Intervention for a Child with OBP Vaz et al.
160 Occup. Ther. Int. 17 (2010) 159167 2010 John Wiley & Sons, Ltd.
factors related to the functional prognosis of the condi-
tion are still under investigation (Evans-Jones et al.,
2003) and include injury site and severity (Strmbeck
et al., 2007).
OBP has important repercussion for the child as
structural decits that interfere with the use of the
upper extremity can result in limitations to the perfor-
mance of activities of daily living and restrict participa-
tion of the child at school and community (Strmbeck
et al., 2007). In addition to conservative treatments,
several surgical techniques are used with the aim of
improving the childs clinical status. Nevertheless, the
literature regarding the functional rehabilitation of
children with OBP is remarkably scarce.
Among the most promising rehabilitation treat-
ments aimed at improving upper extremity function in
individuals with neurological dysfunctions is the tech-
nique named constraint-induced movement therapy
(CIMT) (Liepert et al., 2000; Boyd et al., 2001; Sterr
et al., 2002). This technique consists of constraint of the
non-affected extremity associated with intensive task-
related training of the affected extremity. Development
of CIMT was based on studies with monkeys that
exhibited a behaviour called learned non-use after deaf-
ferentiation of one upper limb. The animals learned not
to use the affected limb because they could perform
satisfactorily with the other limbs. This habitual
non-use persisted so that even after recovery of the
affected limb, the animals did not seem aware of the
new functional possibilities (Taub et al., 1999). Experi-
ments with animals demonstrated that CIMT could
minimize this behaviour. Subsequently, CIMT has been
shown to increase the use of the affected extremity of
adults with cerebrovascular accidents (Taub et al., 1994,
1999; Kunkel et al., 1999; Miltner et al., 1999; Liepert
et al., 2000; Eliasson et al., 2003) and children with
hemiparesis because of cerebral palsy (Eliasson et al.,
2003, 2005; Taub et al., 2004, 2007; Gordon et al., 2005;
Naylor and Bower 2005; Charles et al., 2006; Deluca
et al., 2006; Cope et al., 2008; Brady and Garcia 2009;
Coker et al., 2009). The proposed mechanism of
improvement after CIMT is attributed to the over-
coming of learned non-use and the effects of task train-
ing on neural plasticity (Kim et al., 2004; Taub et al.,
2004).
A process analogous to learned non-use, termed
developmental disregard by Gordon et al. (2005), is
likely to occur in infants with OBP and may contribute
to the failure to develop functional use of the affected
extremity. Repeated failure after initial attempts to use
the affected extremity may lead the infant to stop trying.
Developmental disregard may also prevent recovery of
function that could have occurred as a result of nerve
regeneration (Shepherd, 1999). Clinical observation
indicates that some infants with good return of muscle
function nevertheless ignore the arm and refuse to use
it. Because of such observations, Shepherd suggests the
treatment of children with OBP should be based on
CIMT principles (Shepherd, 1999).
The objective of this study was to test the feasibility
of using elements of CIMT in the treatment of a child
with OBP as well as to document clinical changes on
the use of the affected arm after this intervention.
Results from this case report may suggest alternative
mechanisms as possible explanations for the effects
underlying this intervention.
Methods
The child
AC, a female child, was diagnosed with Erbs palsy of
the right arm after a forceps delivery. She received
physical therapy sessions twice a week until the age of
2 years, when she no longer demonstrated functional
improvements. Although she demonstrated ability to
use the affected upper extremity to reach and hold
objects during treatment sessions, her mother com-
plained she demonstrated little spontaneous use of the
arm at home. The family was then invited to take part
in a course of treatment planned according some of the
principles of CIMT. According to the specic com-
plaints related to limitations in activities at home and
difculty in attending daily sessions of treatment at the
outpatient clinic, a home-based intervention was
chosen. In addition, the familiar physical and social
environments at home could facilitate engagement in
the activities and lead to better results. The University
Ethics Review Board approved this case study
and informed consent was obtained from the childs
mother.
The main concern expressed by the mother in the
beginning of the intervention was related to perfor-
mance of daily life activities. The child had difculties
at combing, detangling her hair, donning shirts, sweat-
ers or dresses without a front opening, and donning
trousers without an elastic waistband. The mothers
identication of the functional activities that were not
performed by the child according to expectations was
Occup. Ther. Int. 17 (2010) 159167 2010 John Wiley & Sons, Ltd. 161
Vaz et al. CIMT-Based Intervention for a Child with OBP
important to help guide the functional context of
intervention.
Physical examination revealed that the child was
capable of actively moving the shoulder, as well as wrist
and ngers, but not throughout the complete range of
motion. She did not have active elbow movement and
was capable of raising the arm only by associating
shoulder abduction with trunk extension and lateral
exion. She could grasp small objects, but they would
easily slip off her hands because of the decit in prehen-
sion strength.
Intervention protocol
According to the original model proposed by Taub
(Taub et al., 1999), CIMT involves the restriction of
the non-affected upper extremity for approximately
90% of waking hours, during 23 weeks, with intensive
and repetitive training of arm and hand function
everyday for 6 hours. Nevertheless, some studies con-
ducted with children propose adapted child-friendly
models with decreased dosage of daily training
compensated by increased protocol duration (Eliasson
et al., 2005; Gordon et al., 2005; Naylor and Bower
2005).
Daily training sessions for AC lasted 30 minutes.
Duration of sessions was decided in collaboration with
the mother and took into consideration the tolerance
and level of frustration of the child, and the time the
mother had available in her daily routine to implement
the training at home. During all sessions, movement of
the non-affected arm was supposed to be restricted. By
suggestion of the mother, restriction was attained by
dressing the child with a jumper, closing the opening
of the left sleeve and tying it on the childs back with
and elastic band. The initial frustration and irritability
of child because of the restriction were soon minimized
as she received verbal encouragement and rewards from
her mother and learned the sessions were short in dura-
tion. The constraint was not used any other time of the
day.
A schedule of three tasks, each to be practised for 10
minutes every day (summing a total session time of 30
minutes) was dened for each 2-week period. The tasks
were chosen according to their suitability to the childs
age and interests, and focused on abilities needed for
play, self-care and school activities. Mothers indica-
tions of childs functional limitations guided the choices
of activities to be used in the adapted CIMT protocol,
in each occupational area. The abilities trained included
reaching, prehension and manipulation with the
affected hand. Task difculty was increased progres-
sively during weekdays and with every schedule change,
by manipulations in the demands for velocity, move-
ment amplitude and versatility. Table I lists all activities
recommended in the seven schedules used during the
fourteen weeks of intervention.
For example, in one of the tasks of the fourth sched-
ule, the child was encouraged to play with her mothers
clown nose, by reaching it and taking it off. The mother
received instructions to position her face right in front
of her childs right shoulder at a distance equivalent to
arm length in the rst day and to progress to higher
positions along the days of practice. As another example
of progression, in one schedule, the child should reach
and grasp foam rubber gures stuck to a wet mirror,
and in the next schedule, she should remove gures
stuck with Velcro to a vertical surface, which offered
greater resistance and thus demanded greater pre-
hension strength in order to detach the gures. The
Table I. Tasks scheduled for each 2-week period
Schedule
number
Recommended tasks
1 Finger painting
Tear paper towels (single thickness)
Make something with play-dough
2 Remove foam rubber gures stuck to a mirror with
water
Throw party balloons to the mother
Tear magazine pages
3 Remove foam rubber gures stuck with Velcro to a
vertical surface
Without looking, nd candies inside a box lled with
shredded paper
Color a drawing with crayons
4 Spread moisturizing cream on mothers body
Pick-up and eat biscuits
Reach and grasps mothers clown nose
5 Build a tower with toy bricks
Make soap bubbles using a bubble blower
Remove big puzzle pieces stuck with Velcro to a
background
6 Throw a ball to the mother
Remove medium puzzle pieces stuck with Velcro to a
background
Stick foam rubber gures a wet mirror
7 Assemble a foam puzzle
Remove small puzzle pieces stuck with Velcro to a
background
Pick-up and eat breakfast cereal
CIMT-Based Intervention for a Child with OBP Vaz et al.
162 Occup. Ther. Int. 17 (2010) 159167 2010 John Wiley & Sons, Ltd.
therapist provided all materials necessary for home
activities.
All schedules contained descriptions of the tasks in
simple language, as well as instructions on how to
increase task difculty as the child demonstrated
improvements in performance. At the end of
each session, the mother should rate her childs per-
formance as very good, good or poor by marking
the corresponding smiley face in the schedule
(Figure 1).
Figure 1 Example of a schedule for task training
SCHEDULE NUMBER 4

TASK 1:Spread moisturizing cream on mothers body

TIME: 10 minutes.

DESCRIPTION: The child should spread the cream on a doll or on her mothers body. In the first day, the
doll or body part should be positioned at the height of the childs hips. Height should be increased every
day until childs shoulder level is reached.

SUNDAY

SUNDAY

MONDAY

MONDAY

TUESDAY

TUESDAY

WEDNESDAY

WEDNESDAY

THURSDAY

THURSDAY

FRIDAY

FRIDAY

SATURDAY


SATURDAY


TAKS 2: eat biscuits

TIME: 10 minutes.

DESCRIPTION: The child should pick-up and eat biscuits placed in a plate in front of her. Big biscuits
should be offered in the first day. Size of biscuits should be decreased every day.

SUNDAY

SUNDAY

MONDAY

MONDAY

TUESDAY

TUESDAY

WEDNESDAY

WEDNESDAY

THURSDAY

THURSDAY

FRIDAY

FRIDAY

SATURDAY


SATURDAY



TASK 3: remove clown nose

TIME: 10 minutes.

DESCRIPTION: the child should try to reach and remove her mothers clown nose. In the first day, the
nose should be right in front of the childs right shoulder at an easily reachable distance. Height and
distance of the nose should be increased every day.

SUNDAY

SUNDAY

MONDAY

MONDAY

TUESDAY

TUESDAY

WEDNESDAY

WEDNESDAY

THURSDAY

THURSDAY

FRIDAY

FRIDAY

SATURDAY


SATURDAY

Occup. Ther. Int. 17 (2010) 159167 2010 John Wiley & Sons, Ltd. 163
Vaz et al. CIMT-Based Intervention for a Child with OBP
Assessments
An adapted version of the Toddler Arm Use Test
(TAUT) was used to assess arm function throughout
the course of intervention. The TAUT is a standardized
observational test in which 21 functional tasks and play
activities are scored in respect to the functional use of
the affected extremity (Taub et al., 2004). During
assessment, the examiner tries to elicit the childs best
effort to perform each task. If the child does not dem-
onstrate any use of the affected extremity in the rst
attempt, she is requested to perform the task again
using the affected arm. Separate scales are used to score
performance in relation to amount of participation of
the affected arm, how well the arm is used, and willing-
ness to use it. In the participation scale, scores vary
from 0 to 2. Score 0 is given if the child does not attempt
to use the affected arm, 1 if the child moves the affected
arm during the task, but it does not contribute to task
completion, and 2 if the child uses the affected arm to
carry out the task, regardless of whether the task was
performed in an age-typical manner. The how-well
scale is scored from 0 to 5, with 0 indicating that the
child does not use the arm during the task and 5 indi-
cating that the ability to use the weaker arm for that
activity was typical for age. Intermediate scores indicate
very poor, poor, fair and almost normal performance.
Willingness scores vary from 0, indicating that the child
never attempted activity with the affected arm, to 3,
indicating that the child demonstrated no resistance to
use the affected arm and attempted activity with it with
minimal prompting. Intermediate scores indicate con-
siderable and some resistance to use the affected arm
(Taub et al., 2004).
The TAUT has been used to document the efcacy
of interventions aimed at improving function of the
less-involved upper extremity in children with hemi-
plegic cerebral palsy (Taub et al., 2004). In the reported
course of intervention, 15 of the 21 tasks were consid-
ered appropriate to the age of the child and were there-
fore used in assessments (Table II).
The rst assessment was conducted before initiation
of intervention, and subsequent assessments were per-
formed at every 2 weeks, when task schedules were
changed and new recommendations were given to the
mother. Intervention lasted 14 weeks, and thus included
seven schedule changes and eight assessments sessions,
carried out in a university paediatric laboratory facility
and videotaped to be scored by the therapist after the
end of treatment. After the intervention protocol, the
mother was interviewed about her perceptions and
opinions regarding treatment.
Results
Figure 2 demonstrates the changes in the scores of the
three TAUT scales. In the amount of participation
scale, the percentages of each possible score among the
15 tasks were approximately similar in the initial evalu-
ations. From the fth assessment session on, no 0 scores
were observed anymore for any of the 15 tasks, and the
percentage of scores 1 decreased gradually while there
was a concomitant increase in the percentage of scores
2. In the last assessment, the child received the
maximum score of 2 in 93% of the 15 tasks. These
results indicate that in the beginning of intervention,
the child did not move the affected arm or the move-
ment she demonstrated was not sufcient to complete
most of the tasks. After 14 weeks, however, the arm was
used to perform most of the 15 tasks.
The how-well scale scores, presented in Figure 2,
demonstrate improvement in movement quality during
the course of intervention. From the fth assessment
on, no 0 scores were attributed to any task, and the
frequency of scores 1 and 2 decreased while there was
a general increase in the percentage of scores 3 and 4.
In the rst assessment, the child did not use the affected
arm (score 0) or had very poor (score 1) or poor arm
performance (score 2) in most of the tasks (67%) In the
Table II. TAUT tasks used in assessments
TAUT tasks used in assessments
1 Strike a toy with hammer
2 Use markers for scribbling
3 Pick up snack
4 Pull lever
5 Push button
6 Remove puzzle pieces with large knob
7 Remove puzzle pieces with small knob
8 Squeeze horn
9 Remove ball
10 Place or throw ball
11 Remove phone (vertical orientation)
12 Remove phone (horizontal orientation)
13 Unclip clothes pin (weak spring) from the edge of vertical
surface
14 Unclip clothes pin (moderate spring) from edge of vertical
surface
15 Unclip clothes pin (strong spring) from edge of horizontal
surface
CIMT-Based Intervention for a Child with OBP Vaz et al.
164 Occup. Ther. Int. 17 (2010) 159167 2010 John Wiley & Sons, Ltd.
last assessment, performance of the affected arm was
considered fair (score 3) or almost normal (score 4) for
58% of the tasks.
The willingness to use scores (Figure 2) also demon-
strated improvement. There was a general decrease in
the frequency of scores 0 (no attempt to use the affected
arm) throughout the assessment sessions and this score
was no longer observed from the fth assessment on.
There was also a general decrease in the number of tasks
for which the child demonstrated considerable resis-
tance to use the arm (score 1), and an increase in the
number of tasks for which there was only some resis-
tance (score 2). In the last assessment, no scores 0 or 1
were observed; 92% of the tasks were scored 2 and 8%
of the tasks were scored 3 for the rst time, indicating
the child demonstrated no resistance to use the affected
arm during those tasks.
Figure 2 also illustrates how the childs mother rated
her performance in the tasks practised each day through-
out the intervention period (according to the mother,
all activities were practised in all scheduled days) In the
rst assessment, performance of the child was consid-
ered poor for 10%, good for 57% and very good for
33% of the days in the 2-week period. From the fourth
task schedule on, the childs daily performance was
never again considered poor. In the last assessment,
performance was considered good in 2% and very good
in 98% and of the days of the last 2-week period.
The interview at the end of treatment revealed the
mother had perceived improvements in manual perfor-
mance. She reported positive gains in her childs abili-
ties to perform bimanual activities such as combing the
hair, eating and dressing up. The child performed these
activities with more consistent and efcient assistance
from the affected arm. As a strong point of treatment,
the mother mentioned that the task training moments
stimulated stronger motherchild bonds, since she
could be closer to her daughter, playing with her and
witnessing her development. As a weakness of the pro-
tocol, the mother mentioned she initially thought the
restrictive elastic band to be somewhat aggressive to the
child because her daughter demonstrated irritation
when using it. However, both mother and child got
used to the restriction as they played and performed the
scheduled tasks.
Discussion
Explanations about the mechanisms involved in recov-
ery of function after CIMT are discussed for cases of
Figure 2 Percentage distribution of Amount of Participation, How-well and Willingness scores for the 15 Toddler Arm Use Test tasks
tested in each assessment and percentage distribution of the daily ratings given by the childs mother to her performance during training
in each 2-week period
Occup. Ther. Int. 17 (2010) 159167 2010 John Wiley & Sons, Ltd. 165
Vaz et al. CIMT-Based Intervention for a Child with OBP
central nervous system injuries. Different authors
suggest that the positive effects of this technique on
upper extremity function are related to two possible
mechanisms, the use-dependent plasticity of the central
nervous system (Liepert et al., 2000; Wittenberg et al.,
2003; Kim et al., 2004) and the overcoming of learned
non-use, or in the context of child development, devel-
opmental disregard (Taub et al., 1994, 2004). Evidence
demonstrated increased activation of cortical areas
related to movement of the affected extremity after
CIMT in patients with central nervous system injuries
(Liepert et al., 2000). Long-lasting cortical reorganiza-
tion has also been shown to occur after a peripheral
nerve injury and there is some evidence of peripheral
plasticity involved in early functional recovery after
OBP (Lundborg 2000; Vredeveld et al., 2000). Whether
training can inuence mechanisms of peripheral and
central plasticity in OBP is not yet known and should
be investigated.
Developmental disregard, the decreased functional
use of the extremity in relation to its motor potential,
may be present in children with OBP. Before treatment,
the childs mother expressed concern on the fact that
she thought her daughter had potential to use the
affected arm more frequently and effectively than she
usually did. The therapist had similar perceptions, and
the hypothetical negative role of learned non-use on
functional performance was a reason to indicate a treat-
ment schedule based on CIMT principles. In young
infants, under the perspective of motor learning, the
early implementation of the technique could minimize
developmental disregard and prevent the appearance of
non-use behaviours, directing the infants attention to
the affected arm and consequently, promoting the use
of the affected extremity. The infant may realize that
the incorporation of the affected limb into daily tasks
may bring on improvements in functional abilities
(Glover et al., 2002; Coker et al., 2009). The perception
of the possible use of the affected extremity in daily
manual activities would lead to the overcoming of
developmental disregard.
The progress demonstrated by the child throughout
the 14 weeks of intervention is coherent with these
positive expectations and indicates that effects of CIMT
protocols for children with OBP should be further
investigated. According to scores in 15 TAUT tasks, the
child became more willing to move the affected arm
and it participated more consistently in the perfor-
mance of the analysed tasks, with better movement
quality. These results are similar to those reported for
children with hemiplegic cerebral palsy submitted to
CIMT (Eliasson, et al., 2003, 2005; Taub et al., 2004;
Gordon et al., 2005; Naylor and Bower, 2005). The
effects observed in this clinical case may however be not
entirely attributed to treatment effects on developmen-
tal disregard, but to a learning effect of repeated testing.
This factor should be accounted for in controlled
experimental investigations. Nevertheless, even in case
learned non-use is not a limiting factor for functional
performance of children with OBP, systematic task
training during intervention sessions or repeated testing
might be able to produce functional gains for these
children, as was suggested by the positive perceptions
of the mother regarding to her childs abilities.
Adhesion to the treatment protocol was excellent.
Despite the young age of the child and the initial con-
cerns about frustration and irritability, mother and
child soon adapted to the routine of training. The fact
that the mother administered the training in short ses-
sions at home may have favoured such adaptation.
Also, the functional relevance of the tasks and activities
selected for intervention, which were identied by the
mother, certainly contributed to the improvement. The
greater grades attributed by the mother to the childs
performance during sessions from the fourth task
schedule on might also reect decreased irritability and
decreased resistance to take part in the proposed activi-
ties. Nevertheless, this kind of intervention may not be
adequate for all children, as some might not tolerate the
frustration of having movement of the non-affected
arm restricted. Therefore, intervention demands must
be nely adjusted to the level of performance presented
by each child in order to avoid excessive frustration.
Children presenting a very low level of active control
over the affected upper extremity may thus not benet
from this approach. Guidelines to the minimal perfor-
mance requirements for eligibility to this kind of inter-
vention will need to be determined with more systematic
group studies. Additionally, not all parents have the
necessary resources to conduct home-based treatment.
Intervention conducted in the clinical environment
might be more appropriate to some families.
A limitation of the present study regards the meth-
odological design. Although studies such as an A-B-A
single case design could offer stronger support to the
claim of clinical changes during treatment, a less strong
study design based on a case study was used. Consider-
ing the specic functional complaints and the busy
CIMT-Based Intervention for a Child with OBP Vaz et al.
166 Occup. Ther. Int. 17 (2010) 159167 2010 John Wiley & Sons, Ltd.
family routine, we concluded it would be clinically
most appropriate to have 30-minute daily sessions
conducted at home by the childs mother. Given the
short duration of sessions, treatment had to be
extended in time and was conducted for 14 weeks. The
mother was trained and systematically monitored to
comply with and meet the interventions principles
and procedures. We believe that this arrangement
maximized the implementation of CIMT principles
into the daily routine of the child. Given the recom-
mendation of similar lengths for each phase of a single
case design (Portney and Watkins, 2009) an A-B-A
study would require 11 months of repeated assess-
ments every other week. The feasibility of taking part
in such a study would be very limited for any of the
families attending our outpatient clinic, because of dif-
culties with both nancial and time resources. A case
study reporting the clinical changes that accompany an
intervention based in CIMT principles for a young
child with OBP can provide relevant contributions to
the eld as evidence regarding the effects of CIMT-
based interventions is promising for children with
upper extremity functional decits because of cerebral
palsy but very limited for children with OBP (Buesch
et al., 2009).
Conclusion
The results from this study suggest that intervention
based on CIMT principles has potential to promote
functional gains for children with OBP and suggest
further investigations regarding the application of
CIMT for peripheral nervous system injuries as well as
the neurophysiological and behavioural mechanisms
related to functional improvement. Controlled experi-
mental studies should test the effects of this kind of
intervention specically for children with OBP.
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