CONTROL OF MOTOR FUNCTION IN THE TREATMENTOF CEREBRAL PALSYl

By KAREL BOBATH, lVI.D. (Prague), D.P.lVl.,Assistant Physician, Brookwood Hospital, Knaphill, Surrey,

AND

BERTA BOBATH, F.e.S.p.,Principal, The Cerebral Palsy Centre, London

The treatment to be discussed in thispaper is based on neurophysiology, forcerebral palsy is not an orthopo=dic but aneurological problem. Damage to the brain(the cause of cerebral palsy) leads to adisorder of tlluscular coordlnation and notto paralysis or paresis of muscles, as, forinstance, tn lovver lllotor neurone lesions.We find dIsordered motor function in allpatients, and often there are associateddefects of vision, hearing, and speech. Themotor 5ystem is affected centrally and there­fore we do not confine ourselves to treatingany particular lTIuscle group but treat thebody as a \vhole. The usual treatrnent con­sists of exercises used for orthopaedic casesas though the patient could control hismuscle function in the normal way_ Anorinal central nervous system allows thepatient to direct his nervous impulses sothat he can contract or relax specific musclegroups in order to move, say, an elbow, ahand, or a foot. In such a person we canstrengthen weak muscles and teach the

1 SpecIal contrIbution for the SIxth SeSSIon ofCongress of the AustralIan PhysIot11erapy AssocIa­tion. held at AdelaIde from September 23 toSeptember 30, 1956

patient to correct faulty postures and move­ment patterns. The patient with cerebralpalsy has all the lTIuscle power he needs formovements and his perIpheral nerve supplyis Intact, but he cannot direct the impulsesto his n1uscles in the norinal way so as toproduce separate movements. SometilneshIS posture becomes completely fixed andhe cannot move at all. When he does move,however, the movement is widespread andthere is no fixation. He cannot direct hismovements either and often flexes a limbwhen he wants to extend and vice versa"fhe patient cannot contract or relax indivi­dual muscle groups or move parts of thebody Independently of each other. Hiscoordination of posture and movements isabnormal and this involves all the affectedparts of the body.

Patterns of Coordination.The muscles of a normal person are

coordinated in patterns. We never useIsolated muscles for any movement, evenIf we only move one arm or hand. TheSll1aller and finer the intended movementfor instance, movement of the fingers, th~more we have to inhibit or suppress move-

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ments of the wrist, elbow, or other partsof the body. As far as the nervousmechanism of coordination is concerned,this inhibition or suppression of unwantedactivity is as much a part of the action­pattern of the movement as is the movementitself. A movement of any part of thebody calls not only for synergic action ofmuscle groups which give fixatIon, but alsofor a constantly changing postural adjust­ment of the rest of the body to changesof the equilibrium produced by the move­ment. For movements and the changingposture which they require, the musculatureof the body is activated in quickly changingpatterns. All this happens in the normalcentral nervous system automatically. Thepatterns of muscle action and the changesof muscle tone for the adjustinent of pos­ture of the rest of the body are sub­cortically controlled. We think of walking,but we do not say to ourselves: "Now wemust bend our knee, swing our arms, putour foot down." We initiate the actIon butleave the detaIls of its execution to sub­cortical centres. Kinnler Wilson has saidthat a large part of our so-called voluntarymovements is automatic and outside ourconsciousness.

The posture and movements of a spasticpatient are also coordinated in patterns, butIn abnormal patterns. They are not asvaried and selective as ours, but are wide­spread and stereotyped. The patIent hasonly a few patterns of motor activity at hisdIsposal. The more severe the case, the lessvariety of posture and movement we find.This accounts for the typical postures of thehemiplegic and diplegic patients and for thelimitation of their movements in range andvariety. The whole body in the diplegic orthe whole affected side in the hemiplegIcpatient becomes involved in a movement offoot or hand.

Release Symptoms.These "mass patterns" of coordInation

are due to release of lower reflex activityfrom higher control of the brain. Damageto the upper motor neurone produces twotypes of symptoms, which HughlingsJackson has called negative and positIvesigns. The negative signs are caused bythe destruction of cells in the brain and

they manifest themselves in the absence offunction, such as loss of SUplnatlon of theforearn1, abduction or opposition of thethumb, and indivIdual movements of thefingers. The positIve signs are seen in thehyperactivity of those parts of the centralnervouS systelTI which have lost the con­trolling Influence of the damaged parts.They are called "release SY1TIptoms". Thefew prin11tlve postural and lTIOVement pat­terns which are integrated at these"released" lower centres appear becausethey are unchecked and are so powerfulthat they dominate the ITIotor behaviour ofthe patIent. They prevent the appearanceof a hIgher integrated and more selectIvemotor actIvIty. Physiotherapists usuallytry to improve lost function by concen­trating on the negative signs. In our treat­ment we concentrate first on the suppression~f "re~ease symptoms", that is, on the posi­tIve sIgns. Suppression or 1nhibition ofabnormal reflex activity is the first step toa more normal inotor function,. Althoughdamaged brain cells cannot recover thereis ~lways higher actlvity than one 'thinks.ThIs can be freed by a treatment whichgives the patient control over hIS releasedabnofll1al reflex actIvity.

Spinal and Tonic Reflexes.The patterns of released reflex actIvity

are those of the spinal and tonic reflexes.They have been described in detail informer papers (Bobath, B., and Bobath,1(., 1954, 1955), and only a few exampleswill be given here.

The spinal reflexes coordinate the musclesof the limbs in patterns of either totalflexion or extension. For instance theflex?r withdra,":,a~ reflex of the leg producesflexion at all JOlnts by contraction of allflexor lTIuscles with inhibition of theextensor muscles. The extensor thrust pro­duces extension at all joints with inhibitionof the flexor muscles. Spinal reflexes are"phasic" or movement reflexes and theiraction is not sustained. '

The tonic or static postural reflexes areintegrated at the level of the brain stem.They produce sustained tonic contractionsof muscles, especially of the antigravitymuscles. They are not seen in normal mansave for the waning influence of the asym-

CONTROL OF MOTOR FUNCTION IN CEREBRAL PALSY 77

metrical tonic neck reflexes which can beseen during the first sixteen weeks afterbirth. Tonic reflexes effect changes in thedistribution of muscle tone throughout thebody in response to a change of the positionof head and body in space (by stimulationof the labyrinths) or of the head in relationto the body (by stimulation of the pro­prioceptors of the neck muscles). The toniclabyrinthine reflexes produce maximalextensor tone in the supine, and maxilnalflexor tone in the prone position. TheaSyll1nletrical tonIC neck reflexes produce111axinlal extensor tone in the art11 and legof the sIde to which the face is turned andInaximal flexor tone in the arm and leg ofthe other side. The symmetrical tonic neckreflexes produce extension of both armsand flexion of the legs when the head israised, and flexion of the arms ,vith exten­sion of the legs when the head is lowered.All these reflexes interact very closely, sothat the pattern of each one alone can rarelybe seen by itself in a patient.

In the spastic patIent, released tonicreflexes produce both an abnorinal increaseand distribution of muscle tone. Abnormalincrease of lTIuscle tone lnakes the patientstiff and prevents movements. The distribu­tion of muscle tone resulting from the inter­action of the various ton1C reflexes causesthe well-kno\ivn typical postures of thepatient.

The severely spastic child is completelydOlllinated by these reflexes. He can neithersit without support nor can he stand, walk,or use his hands.. Patients with moremoderate or slight spasticity, and those inwhom some parts of the body are lessaffected than others, may learn to sit andto use one or both hands and even to walk.The legs may be more affected than thearms, as in the diplegic, or the arms morethan the legs, as in the quadraplegic, or oneside only may be affected, as in the hemi­plegic child. These chl1dren show, inaddition to the abnormal patterns ofreleased reflex activity, compensatoryabnormal patterns of movement. Theseare caused by the child's attempt to com­pensate with the more normal parts for theinadequate reflex patterns of the moreaffected ones. For instance, in walking, achild will move his head and trunk exces-

'lIvely in order to lift his stiff leg off theground to make a step. When trying tofeed hlmself, a child who cannot lift hisarm to bring his hand to his mouth willflex the head and spine. We see, therefore,a 111ixture of both abnormal reflex andfaulty voluntary activity.

Most cases of athetosis seen by us showedthe influence of tonic reflexes in the formof intermittent spasms. These Inake thepatIent assume stiff postures which aresimilar to those of the spastic, but they areof short duration.

Basic Motor Patterns and SkilledMovements.

The everyday activities of a normal adultare highly skilled. The patterns of postureand movement which enable us to keep ourbalance in sitting, standing, and walking, touse our hands freely for such purposes asdressing, feeding, or writing, are complexand varied. We are not born wIth all theseachievements, but acquire them graduallyover a long perIod of time; in fact, theprocess of learning skills continues intoadult life. Fr0111 birth onwards, as thecentral nervous system matures, the earlyand primitive movement patterns becomemore varied and selective. The changesfrom the more primitive to the higher andlTIOre individualized patterns are producednot only by the addition of new activitiesbut by the suppression of unwanted activity.For Instance, a baby at first picks up anobject with the whole hand but later on helearns to do so with thumb and forefingeronly. The movement becomes confinedto thumb and forefinger, while theactivity of the other fingers is inhibited.I t takes a normal child five years toperfect his movement patterns so that theyare adequate for the learning of skillslike writing or those needed for playinggames. The original primitive patterns ofsucking, kicking, grasping, and releasing,are modified in a proper sequence, eachactivity preparing for the next one. Gesellhas described the successive stages of motordevelopment in normal children and he hasshown that certain activities appear in achronological order at definite times. Thebaby first learns to turn to his side and, atabout two months of age, he can hold his

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head up when placed on his abdomen. Hesoon supports himself in this position onhis forearms and, later, on his extendedarms. At this stage, that is at about sixmonths of age, he gets on hands and knees.At about the same time he lifts his headwhen lying on his back and pulls himselfup to the sitting position. At about eightmonths of age he turns by himself onto hisabdomen. He passes from crawhng towalking on hands and feet and from thereto standing up. Walking is a highly skilledactivity, and it takes the chIld at leasttwelve months to achieve it.

The fundamental movement patterns\i\lhich enable the child to turn over, lift hishead, get on hands and knees, and to situp, are automatic at first. The child gradu­ally uses them voluntarily; he tnOdlfies andchanges them. These automatic movementsare the "righting reflexes" described byMagnus (1926) and Schaltenbrand (1927)and the higher organized and lTIOre conlplex"equilibrium reactions" descrlbed by Weisz(1938).

The righting reflexes are integrated atthe level of the lnid-brain. The neckrighting reflex secures the norinal alignmentof trunk and head. It enables the child toturn over to his side. This reflex makes thebody follow the movement of the head.The labyrinth righting reflex on the headis responsible for Inaintaining and regainingthe normal position of the head in space,that is, face vertical, mouth horizontal. Itenable~ the infant to raise his head in proneand ~upine lying, and it helps the child tocontrol the position of the head whenmoving the body. The body righting reflexon the head secures the normal positionof the head by touch of the body surfacewith the support. For instance, the headand body right thelTISelves in walkingthrough contact of the foot with the ground.The righting reflexes interact with eachother and work to the same end of securingthe normal position of head and body inspace and in relation to each other. Theircombined action enables the child to rollover, to sit up, to get on hands and knees,and to stand up. The righting reflexesdevelop in a definite sequence from birthonwards. Their appearance coincides withthe recognized milestones of the child's

motor development. As cortical controlincreases they are gradually inhibited anddisappear around the age of three to fiveyears. Schaltenbrand (1925) has describedhow the motor patterns of the growing childchange as the righting reflexes becomeinhibited. He tested the way of getting upfrotTI lyIng supine at different ages. Up tothree years of age, when the rightingreflexes are still active, the child turns overto his abdomen and gets on his hands andknees before sItting and standing up.Between three and five years of age, whenthe rightIng reflexes are waning, he rotatesthe body but he does not get on hands andknees any more, and only at about five yearsof age, when the righting reflexes areinhibited, does he get up symmetrically likean adult

Equilibrium reactIons are responsIble forthe autolnatic adj ustment of balance in allour activIties. They also develop in adefinite sequence from the age of sixmonths onwards, and their appearance over­laps with that of the righting reflexes. Theyappear first In prone and supine lying, laterin sitting and in kneeling, and, still later,in standIng and walking. Balance in stand­ing depends on the proper development ofequIlibrium reactIons III sitting, and balancein walking is preceded by established equili­brium reactions in standing.

Righting reflexes and equilibriumreactions require normal n1uscle tone fortheir proper function. They are absent inthe severely spastic, and incompletelydeveloped in the less severely affectedpatients. In an athetoid patient they maybe present, but their execution will beabnormal because of inconsistent muscletone.

The learning of skilled movements inpatients with cerebral palsy depends, there­fore, on the presence of these basic auto­lnatic movement patterns. The teaching ofskills by making the patient use his abnor­mal and inadequate motor patterns cannotresult in a normal performance. Thepatient, in trying to feed or dress himself,to write, to stand, or to walk, uses excessiveeffort Because of this a spastic patientbecomes more spastic, and an athetoidpatient shows more involuntary movements.The repetition of abnormal activities may

CONTROL OF MOTOR FUNCTION IN CEREBRAL PALSY 79

lead in time to deformities" These are notusually seen in young children with cerebralpalsy who have not yet tried to performskills with inadequate movement patterns.

Treatment.We have to prepare the patient for skilled

movements. First we have to suppressreleased lower reflex activity, especially thetonic reflexes. This produces more normalmuscle tone, that is} reduction of spasticity.The basic automatic movement patterns canthen be developpd In their proper order.The treatlllent, therefore, consists of theinhibition of abnorn1aI reflex activity andthe facilitation of normal automatic move­ments. Both are used together. In a severecase successful reflex inhibition is immedi­ately followed by facilitation of movement.If the movement deteriorates because of thereappearance of tonic reflex activity, reflexinhibition is used again unttl muscle tone issufficiently normal to allow for furthermovelnent. In the moderate case of cerebralpalsy) and in young babies, both reflexinhibition and facilitation of ITIovemen1 areused simultaneously. Here facilitation tech­niques play the main part lil treatment, andreflex inhibition is llsed only to preventabnormal reflex activity during lTIOVelnent.

Reflex Inhibiting Postures.The abnormal postural patterns of the

patient can be regarded as the expressionof his released reflex activity.. We have tochange these abnorlnal postural patterns. Ifwe leave them intact and unchanged wecannot hope for better motor function. Wecannot superimpose norlnal patterns ofposture and movelnent on abnormal ones.The patient cannot control his abnormalreflex activity without our help. Releasedpostural reflexes can be controlled byplacing the child into postures which breakup the abnormal patterns. We call them"reflex inhibiting postures". For instance,in the supine position the child usuallyshows retraction of head, neck andshoulder, the arms are abducted, the elbowsflexed. The legs are usually extended atthe hips and the knees, inwardly rotated andabducted, and the feet are plantiflexed"(Extensor pattern, due to the influence oftonic labyrinthine reflexes, Figure I.) One

of the reflex inhibiting postures counter­acting this postural pattern is the following:The head is flexed and supported, the armsare moved forward and crossed over thechest, the forearms are supinated so thatthe palm of each hand touches the back ofthe opposite shoulder. The legs are fullyflexed at the hips and the knees, and areabducted.

The proximal parts of the body, that is,the head, neck, and spine, and, to a lesserdegree, the shoulders and hips, are the mostin1portant "key-points" for this positioning.The degree and distribution of muscletone throughout the whole body can beinfluenc.ed by the position of the head, neck,and spIne, and, to a lesser degree, by

FIGURE I ExtensIon pattern In SUpIne(TonIC labyrInthine reflex) Nate exten­sion of spIne, crossIng of legs, planh­flexIon of feet Head turned to left, fIghtarm flexed, left arn1 extended (asym-

metrIcal tonIC neck reflex)

positioning the shoulders and hips. Westart the positioning with the head, thespine, and the shoulder girdle, thus reducingspasticity in the limbs. This makes it pos­sible to position the limbs without unduestretch of spastic muscles. Frequently,positioning of the proximal parts, the "key­points", is sufficient to reduce spasticity inthe limbs to such an extent that the patientcan move them freely. We can thus oftenconfine our assistance to the proximal parts,the "key-points", and from there reduceand control spasticity and abnormal pos­tural reactions. In this way we can makethe child use his hands in sitting, makehim crawl, stand, and walk, without inter­ference, that is by guiding and controllinghim only from the key-points.. The severelyspastic child, who can hardly move, is notjust held in a reflex inhibiting posture but

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is being moved until he begins to move byhimself. For instance, in the above­mentioned reflex inhibiting posture insupine lying, he is rolled from side to sideand into sitting and back again. Theathetoid child, who moves too much, ismade to hold a reflex inhibiting posturesteadily for a long time. Here we combinethe reflex inhibiting posture with weight­bearing and the giving of resistance toincrease and steady postural tone.

In order to devise suitable reflexinhibiting postures for the individual child,his postural reactions are studied in variouspositions and activities, such as supine andprone lying, in sitting, crawling, standing,and walking. Although the basic posturalpatterns are similar in most patients, thereis a great variety of patterns in the indivi­dual child arising out of the various com­binations of the primary tonic reflexes andthe individual compensatory patterns.Therefore, the reflex inhibiting postureshave to be different for every patient andthey have to be changed as the child's lTIotorpatterns change in treatment.

In analysing the child's postural patternswe ask ourselves:

I. What patterns does the ch\ld shavvwhen placed into a position?

2. What degree of resistance do thevarious parts of the body offer whenwe try to move them out of theabnormal position?

For instance, a child in the prone positionwill lie with his face on the support andthe arms flexed and adducted under hischest; the spine is flexed, and the legs areadducted with either flexed or extendedhips and knees. (Flexor pattern due to theinfluence of tonic labyrinthine reflexes,Figure 2.) We note the degree of resist­ance to raising the head, and to extensionof the spine, to abduction of the legs, andto extension of the hips and knees. Thedegree of resistance gives us a good indica­tion of the difficulties the child is likelyto have when trying to do any of thesemovements actively~ If the resistance isstrong the child cannot be expected to per­form any of these movements at all, norwill he be able to hold any of these positionswhen put into them-for instance, to hold

up the passively rai~ed head. If resistanceis moderate, the child may not be able tomove into the reflex inhibiting posture, buthe may be able to hold it. If resistance isslight, he may be able to assume the newposition but with undue effort, in a jerkymanner and not to its full extent.

In patients who can move about but showabnormal coordination, we have to find outat which stage of a movelnent abnormalreflex activity interferes and distorts orprevents the performance. For instance, achild may be able to put his heels down inwall(ing as long as his head is flexed. Butwhen he looks up he gets on his toes and

FIGURE 2 FlexIon pattern in prone(ToniC labyrInthIne reflex) Note facerestIng on support, arn1S flexed underchest, spIne, hlpS, knees and ankles flexed

easily loses his balance. Another child maybe able to sit and use his hands fairl}T wellas long as he does not turn his head too farto one side, when an asymmetrical tonicneck reflex will interfere and upset hisbalance. The cause of abnormal coordina­tion in lnovelnent is often discovered by ananalysis of the patient's reactions in variousreflex inhibiting postures. For instance, apatient who walks with flexed trunk andlegs is usually unable to lie prone sup­porting himself on his extended arms whilekeeping his hips on the support.

Resistance to a reflex inhibiting postureexplains more than the inability to changefrom one posture to another. It means thatthe patient cannot perform the most essen­tial movements. For instance, in pronelying, resistance to extension of the head,spine, and hips means that the child cannotraise his head and shoulders to bring his

CONTROL OF MOTOR FUNCTION IN CEREBRAL PALSY 81

arms forward from underneath his body.Resistance to extension of the arms meansthat he cannot support his weight on hisextended arms to get on hands and knees.In supine lying, resistance to flexion of thehead and the spine means that the childcannot raise his head to initiate sitting up.Resistance to flexion of the arms at theshoulders means the inability to bring thehands forward to hold on to a support.Resistance to flexion of the hips enhancesthe difficulty of sitting up. Resistance toreflex inhibiting postures explains thepatient's difficulties in moving. However, apatient's adj llstment to a reflex inhibitingposture, his learning to hold it unaided andto move into it without help, means thathe has acquired a whole range of newactivities. The inhibition of abnormal pos­tural pattern in one position enables thepatient to perform all those movementswhich before were made impossible by thatone abnormal postural pattern. We do not,therefore, have to teach the patient anyoneof these activities separately.

As has been tnentioned before, thepatient has to adjust himself to the newpostures, that is, he has to cease resisting.The reflex inhibiting posture as such is nota guarantee of successful inhibitIon. 1f thechIld cannot adjust hImself to a reflexinhibiting posture and continues to resist,nothing is gained and the patIent is asspastic as before; he may even become morespastic. The reflex inhibiting posture hasbeen too dIfficult and the child unable toadjust himself. The adjustment of thepatient to a reflex inhibiting posturedepends on the skill and the knowledge ofthe physiotherapist.. The postures have tobe graded very carefully, progressing fromeasier to more difficult ones. They shouldneither be too easy for the child nor shouldthey be so difficult that he continues 1.0 givestrong resistance. If the reflex inhibitingposture is too easy, the patient will notgain sufficient control over his abnortualreactions and will not progress; if it istoo difficult, he will becolne more spastic.We can help the patient to adjust himselfby moving his trunk, shoulder girdle, orhips while, on the whole, maintaining theposition. Movements of rotation are ofgreat help in reducing spasticity. However,

our assistance is only the first step towardsthe control of spasticity or of intermittentspasms. The patient has to learn activelyto inhIbit his abnormal reactions, that is, togive up resistance. He has to take overcontrol. For that reason we reduce ourhelp gradually as resistance decreases, forthis is the moment when the patient has achance to take over control. We releaseour hold gradually, and give less and lesspressure, moving our hands about from onepart to another, until the child can controlthe position with the help of only one fingerheld lightly on the most important key­point. When the child has full control wecan take our hand away. However, we haveto be ready to give assistance again atany moment, for spasticity may recurunexpectedly and suddenly after a periodof adjustlnent, especially when the childstarts to move or moves further than hecan control.

Facilitation of Movements.Movelnents are encouraged during every

stage of treatment whenever muscle tonehas become sufficiently reduced to ensuretheir normal performance. In the youngchild, movement patterns are developed inthe same sequence as they are acquired bythe norlnal child. In the older patient, whohas already learned to sit, stand, or walk,with abnormal coordination, we go back tothe early and more primitive activitieswhich should have preceded these skills. Apatient who has never acquired the normalpatterns of rolling over to side-lying andto prone-lying, of sitting up, kneeling, andstanding up, cannot be expected to stand and,valk normally. Proper balance in four-footkneeling and sitting prepares for balance instanding, and balance in standing preparesfor balance in walking" In order to improvethe quality of these activities in the olderchild we have to "fill in the gaps", that is,we have to prepare the child for the higherand lTIOre complex functions by gettingmore normal coordination of the patternspreceding them. It is, however, a muchmore djfficult task to eradicate abnormalpatterns of long standing than to help theyoung child to start movements in thenormal way. The difficulty is enhancedsince we cannot prevent the older child

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using what he has achieved, abnormalthough it is. We can cut down, however,on too much abnormal activity, such aswalking or sitting et cetera, until the childcan move in a more normal way.

The fundamental movement patternswhich have to be developed are those of therighting and equilibrium reactions. Theseautomatic reactions are not taught lIkeexercises; that is, we do not ask the patient

FIGURI: 3 FacilItatIon of tUl nlng overHead flexed forward, turned to side, bodyfollows the head (Neck fIghtIng reflex)

to perform these movements voluntarilyand on request. As in the developlnent ofthe normal child, automatic motor activityshould precede willed movements, and thishappens when the basic patterns of auto­matic activity have been safely established.We "facilitate" these movements; that is,we stimulate the appearance of rightingreflexes and equilIbrium reactions. Thepat1ent is moved in a way which necessitatesautomatic reactions of protection againstfalling9 We may move him into an unCOll1­fortable position which induces him to moveinto a more comfortable one, to right hishead and to restore the normal alignmentof the head, body, and limbs. There aremany ways of facilitating movements, andonly a few exan1ples \viII be given here.We may move the head of the patient andmake the body follow it, thus using neckrighting and body righting reflexes. Insupine lying, for instance, we flex the headforward, counteracting extensor spasticity,and, at the same time, turn the face to oneside. The patient will then turn over tothe side to which the face is turned (Figure3). By turning the head further in the

same direction and lifting it up at the sametime in order to extend the neck and thespine, the patient will roll over onto hisabdomen. The patient can be made to situp from prOl1e lying by raising the headand fully extending the spine while turningthe head gently around 180 degrees (Figure4). From sitting we can lead the body bythe head to kneeling, and, by lifting the headand spine, to kneel-standing. The timingand speed of the movements of the headhave to be very accurate to ensure that thebody can follow easily into the desireddirection. The sequence of these Inove­ments and their patterns should be smoothand without interference by spasticity;otherwise the body will not follow the headin the normal way. The labyrinthinerighting reflexes on the head are made useof by moving the patient's body while hehas to control his head and keep it in thenormal position. For instance, when movingthe patient in sitting, head control can bemade easier by holding his arms adductedand extended against his trunk with theshoulder girdle raised. In this way welower the patient slowly backward, but onlyas far as he keeps his head in the norma]positjon. A'3 he is moved backwards, he

FIGURE 4 FIrst stage of facIlItatIon ofSittIng up from prone lying Head ISraIsed, spIne extended, arms extend andsupport body weIght The head thenturned and the body follows Into SIttIng.

(Neck and body fighting reflexes.)

has to flex his neck and spine more andmore to keep his face vertical. If this is toodifficult for a child, it can be made easierby moving the trunk a little to the sideor rotating it instead of lowering himstraight backwards. A righting movement

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of the head in the opposite direction can beobtained by moving the patient's body for­ward in sitting. The normal movement ofraising the head can be assisted by holdingthe arms extended and in external rotationbackwards. As the head is raised the spineextends while the hips flex further.

Equilibrium reactions are facilitated atthe earliest possIble moment in all reflexinhibIting postures. In kneeling, forinstance, the patient is swayed from sideto side j and forwards and backwards, toget him used to weight transfer and tostin1ulate protective reactions agaInstfalling. In four-foot kneehng he is madeto SIt to one side of his feet. He has touse his arms to maintain his balance whilewe move his hips from one side to the other.In sitting we lnay hold him by one arm andtransfer his weight frOlTI one buttock to

FIGURE 5A EquIlIbrIum reactions ofnOl mal chtld In sIttIng ChIld IS pushedto rIght sIde The head has moved toleft towards normal POStbon Lef t legabducts, fIght arm shows protective

extensIon.

the other. This will encourage abductionof the arm and leg freed from weight anda righting movement of the head towardsthe midline. We may also push the childto one side to encourage the automaticextension of the arm to protect himself

from falling (Figures SA and SB). Equili­brium reactions in standing are preparedfor in kneel-standing by transferring thepatient's weight from one knee to the other.He is held by the arm of the side to whichthe weight is transferred, and the arm israised to elongate the trunk on this side.In this way we encourage the automaticreaction of abduction of the free leg - a

FIGURe 5B Absence of equilIbrlumreactIons In spastIc chIld

very important pattern for balance instanding and walking" In standing, equili­brium reactions can be obtained by trans­ferring the weight of the body to the out­side of one leg, producing abduction of theother leg (Figure 6A and 6B). This is veryimportant for the patient with adductorspasm and iu\\'ard rotation of the legs, whonever fully transfers his weight from oneleg to the other and, therefore, does not setone leg free to make a step. Other equili­brium reactions can be obtained by makingthe legs follow the movement of the body.For instance, the patient is held under thearmpits from behind. The therapist moveswith him a few steps forwards, backwards,and sideways, quickly changing the direc­tion. The patient's feet have then to followautomatically the changing centre ofgravity. Equilibrium reactions of head,trunk, and arms, can be obtained in thefollowing manner: The patient stands withhis feet firmly on the ground in a good

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position. He is held by his extended kneesand swayed in every direction (Figure 7).Equilibrium reactions are also practisedwhile the patient stands on one leg only.All this is a preparation for walking. Asfor the facilitation of righting reflexes, thetime and speed of our handling of the childhave to be adequate to get normal reactions.

FIGURI: 6A EquIlIbrium reactions ofnormal child in standIng ChIld IS movedto ~eft) rlght leg abducts, head has lTIovedto lIght towards n01 mal posItion Body

weIght on outsIde of left foot

The speed and range of our movementsshould not interfere with the patient'sattempts at adjusting his balance; that is,we must do the right movement at theright time. If the movement is too quickor of too wide a range, the patient willbecome spastic again and equilibriumreactions cannot occur; if he is too wellsupported, he will rely on the therapistand no reactions will take place.

During all facilitation of movements thechild must be guarded against the recur­rence of abnormal reflex activity by thereflex inhibiting postures at the most

important key-points. From the key-pointsboth the child's movements and his abnor­mal reactions have to be controlled. Weinhibit and facilitate at the same time.

Use of Afferent Pathways.Both the inhibition of abnormal reflex

activity and the facilitation of movementsis effected by our handling of the patient.In treatment the patient experiences agreat variety of new sensations, sensationsof posture which he has never been able tomaintain, and of movements which he hasnever been able to perform. The patientnever felt anything else but tension andexcessive effort when moving, and he wasused to restricted ranges of movement andabnormal postures. However, when muscletone is reduced the patient receives different

FIGURE 6B Absence of equiltbriumreactions in spastic child.

and more normal proprioceptive messagesfrom his muscles and joints. He can thenrespond to these new sensations with morenormal movement patterns, and these canbe laid down for the first time. We do notlearn movements, but the sensations of

MOVEMENT EDUCATION

movements; and only normal sensationswill give the patient the possibility ofnormal movements. The fundamental auto-

FIGURE 7. FacIlItation of equIlibriumreactIons 0 f trunk and head In standtngNote outward rotatIon of legs, extensIonof knees, heels on ground The child 15swayed from sIde to sIde and forward

and backward

matic movement patterns, which the patientacquires in treatment, can then be used byhim for voluntary skilled movements.

Summary.A treatment of cerebral palsy based on

the inhibition of abnormal reflex activityand the facIlitation of normal automaticmovement patterns has been described andan attelupt has been n1ade to expla1n itstheoretical background.

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SCHALTENBRANDJ G (1927), "The Developmentof Human MotilIty and Motol DIsturbances",Arch of Ner and Psyc, XVIII

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