In reviewing Toby's records, it appears that the primary concerns of rehabilitation are the limitations found in his upper extremities. Both arms are bent to 85 degrees of flexion and his hands show bilateral weakened grasp as well as decreased function and fine motor coordination. Secondary areas of concern are his balance impairment and regression of social skills ( ie. hesitation to speak or initiate play). We feel that painting will be an effective therapeutic activity as it will develop skills in his upper extremities, for example, strength, extension, coordination. As painting already exists as a form of play it will keep Toby's interest as well as offer an avenue for play. One requirement for Toby is an easel so his arms do not drag through his paintings.

With Toby's poor hand function and decreased fine motor control, finger painting would be a good starting point. In addition to accomodating his physical deficits finger painting is a fun and encouraging activity to commence treatment with. Using his fingers to spread the paint about will work to improve his hand functioning by exercising various finger and thumb muscles. Etching patterns in the paint with his fingertips may help to increase his fine motor coordination. As his fine motor coordination improves he will be able to include more detail in his pictures. This can be interspersed with sponge painting which will give him the opportunity to exercise his grasp as well as add variety.

As Toby's hand functioning and fine motor control improve, he can be graduated to painting with a brush. Due to weakened grasp the brush will be modified by starting him with a large handle circumference so that he can hold it with greater ease. As his grasp strengthens, he can be given brushes with progressively decreasing handle width. Toby will still be working on fine motor control as he works on adding detail with his brush (remember Toby is seven and detail may be a smile on a stick man).

In addition to increasing grip strength, another goal of brush painting is improving the extension at Toby's elbows. To work on increasing extension larger paper could be used so that he must use more extension and flexion to cover the increased surface area. We the therapists should encourage Toby to use the bottom corners of the canvas so he will unconsciously be working on elbow extension. We could also show Toby the brush stroke used when painting a wall- the constant rhythm of elbow flexion and extension- which may aid in increasing his elbow range of motion. We could get Toby using this stroke by asking him to paint the background of the picture before beginning his painting. We could monitor Toby to ensure proper technique of this stroke (ie: not just bending at the waist), but it is important to keep it fun and playful.

During his initial sessions Toby could begin by standing for a few minutes and then sit for the remaining time while finishing his painting. Standing at his easel, Toby will be leaning to the left and right to fill the width of the canvas and will be stepping to the side to reach his paints and different sized brushes. The duration of time that Toby spends on his feet could be progressively increased with an aim of decreasing his balance impairment. An adjustable easel is required for this combination of sitting and standing.

In order to reduce the chance of Toby becoming frustrated, he should initially paint for short periods of time (ie: 15 min-1/2 hour). The grading in skill should also help reduce frustration. We should talk with Toby during his painting and have him discuss his paintings, as this may help him to begin initiating conversations. As Toby gains confidence he could begin painting in small groups of children where he can contribute to ideas of what to paint and practice socializing with his peers.