j UNIE 1974 F I S I O T E R A P I E 3 be a b o v e. A n y o n e o f th e s e c o n d itio n s d o n o t give descrj he ad a ch e s in su b je c ts w h o h a v e n o p rim a ry rise . ]esion, o r w h o se lesio n is s u b -s y m p to m a tic . c erVthink th a t th e v a so -c o n s tric tio n a n d v a s o d ila ta tio n anial b lo o d vessels d e m o n s tra te d d u rin g a tta c k s of of m igraine” a re h o t c h e m ic a lly in d u c e d , b u t re s u lt trUe m e c h a n i c a l irrita tio n , a lte rn a tiv e ly a re a u to n o m ic fr0™nses to a lesion. 1 Question th e e x iste n ce o f a “ p sy c h o g e n ic ” h e a d a c h e until I am satisfied th a t it is n o t o f c erv ica l o rig in . T R E A T M E N T . I th in k t h a t su c c essfu l tre a tm e n t o f , nic h e ad a ch e s is p h y sic al a n d n o t p h a rm a c o lo g ic a l. 1 fm c u rre n tly tre a tin g a n y h e a d a c h e th a t p re sen ts, a n d i t h e sam e tim e a n a ly sin g th o se tre a te d a n d fo llo w in g Hi m up. I w o u ld b e g ra te fu l to a n y o n e c o n c u rre n tly w o r k in g o n h e a d a c h e s fo r c o m p a ra tiv e re su lts. 1 By m edical tre a tm e n t. 7 By p h ysical tre a tm e n t o th e r th a n m o b ilisin g e.g. ’ m an ip u latio n o r tre a tm e n t o f m u sc le spasm . 3 By a ny p h y s io th e ra p is t w h o w o u ld lik e to try a —' group u n d e r m y d irec tio n . E sp e c ia lly b y a n y o n e w h o m a y b e w o r k i n g a l o n g th e sa m e lin e s a n d is f o r m i n g s im i l a r o r d iv e r g e n t o p in io n s. B r e a k d o w n o f R e s u lts to d a te Of 105 re c o rd e d cases tre a te d by o u r staff o f th e p a st two years: 95 re sp o n d ed p ro m p tly w ith re lie f o f p a in a n d o th e r sy m p to m s; 10 did n o t re sp o n d fa v o u ra b ly o r a t all. Some of these w ere very ir r ita b le jo in ts a n d re sp o n d e d with increased p a in w h ic h se ttle d to its p re v io u s level. On F ollow -up o f 6-12 m o n th s la ter 37 have rep lied to d a te . O f th e s e :— 8 R e p o rt no im p ro v e m e n t; 17 re p o rt im p ro v e m e n t o f m o re th a n 6 0 % ; 12 no re c u rre n c e a t all. M y re su lts a re o p e n to in sp e c tio n a n d disc u ssio n . N o d o u b t th e r e is f a u lt to b e fo u n d w ith m y a sse ssm e n t a n d e v a lu a tio n o f re su lts — I a m a novice a t c o m p ilin g sta tistic s a n d w o u ld g re a tly v a lu e a d v ic e a n d /o r c o rre c ­ tio n — a n d h e lp . A b o v e reflects m y b e s t e ffo rt a t p re s e n tin g m y e x p e rie n c e in figures. A D V A N T A G E S O F P H Y S I C A L T R E A T M E N T 1. M o re effective th a n m edical tre a tm e n t. 2. I t is a g e n tle tre a tm e n t w ith n o c o n tra -in d ic a tio n s y e t c o m e a cro ss. 3. R e q u ire s n o h o s p ita lis a tio n . 4. N o d ru g s e m p lo y e d . 5. R e su lts in tre m e n d o u s re d u c tio n in d ru g -ta k in g — to m y m in d , th e m o s t sig n ific a n t a s p e c t— in sp ite o f th e fa c t t h a t I n e v e r suggest to th e p a tie n t t h a t th e y re d u c e th e ir se lf-m e d ic a tio n . 6 . N o b ra in w a s h in g o f p a tie n t. 7. N o “ e n v iro n m e n ta l m a n ip u la tio n ” . 8 . N o c o -o p e ra tio n ne ce ssa ry . 9. E a s ily ta u g h t te c h n iq u e . 10. C o s t — in sig n ific an t c o m p a re d to t h a t o f c o m ­ p lic a te d d ru g re g im es. 11. T h e p a tie n ts ’ in e v ita b le a n x ie tie s a b o u t m o re s in iste r c au se f o r u n su c c e ss fu lly tre a te d h e a d a c h e s a lla y e d . 12. N e u ro se s, w h ic h re s u lt fro m p ro lo n g e d u n a lle v ia te d p a in , re so lv e a n d p a tie n t g ra te fu lly re su m e s n o rm a l w o rk o r d o m e stic d u tie s a n d p e rs o n a l re la tio n s h ip s . A c k n o w le d g e m e n t. T h e a u th o r w o u ld lik e to th a n k th e M e d ic a l S u p e rin te n d e n t, K im b e rle y H o s p ita l f o r his h e lp a n d e n c o u ra g e m e n t in th e in v e s tig a tio n s a n d p r e ­ p a r a tio n o f th is a rtic le . A SHORT REAPPRAISAL OF THE PRINCIPLES OF TREATMENT IN CEREBRAL PALSY S. Irw in -C a rru th e rs , N a t. D ip . P h y sio . (P ta .), T e a c h in g D ip . P h y s io . (P ta .)* I I N T R O D U C T I O N In recent y e ars m u c h e m p h a sis rig h tly h as b e en placed on an a p p ro a c h to th e tr e a tm e n t o f c e re b ra l palsy based u p o n s o u n d n e u ro p h y s io lo g ic a l p rin cip les. Dr. and M rs. B o b a th h a v e c o n trib u te d th e m o s t fu lly developed a n d w ell d o c u m e n te d a p p r o a c h to th e tr e a t ­ ment of th e d is tu rb a n c e s o f m o to r f u n c tio n fo u n d in cerebral palsy a n d th e ir w o rk p ro v id e s a s o u n d a n d realistic o v e rall c o n c e p t o f tre a tm e n t. O th e r w o rk e rs in this field h a v e n o t a lw a y s fo llo w e d th e sa m e p r in ­ ciples, a lth o u g h so m e , su c h a s P r o fe s s o r R o o d , h a v e provided tec h n iq u es w h ic h in se lec te d in sta n c e s m a y b e of value in o b ta in in g specific re sp o n se s. W h ils t it is necessary to h a v e a k n o w le d g e o f th e v a rio u s a p ­ proaches to tre a tm e n t, th e d a n g e rs o f a n e le ctric a p ­ proach w hich u tiliz e s o p p o sin g p h ilo s o p h ie s o f tre a t- c an n o t t>e o v e r-stre sse d . W e a re d e a lin g w ith a Id w hose m o to r d e v e lo p m e n t, fo r a v a rie ty o f reasons, is going to b e a b n o r m a l — a n d th is a b n o rm a l Currently L e c tu re r in P h y s io th e ra p y , U n iv e rsity o f Stellenbosch. m o to r d e v e lo p m e n t is g o ing to ta k e p la c e a lo n g c e r­ ta in p r e d ic ta b le p a th w a y s . W e k n o w in a d v a n c e , to a g re a t e x te n t, w h a t a b n o r m a l p rim a ry a n d c o m p e n s a ­ to ry sy n e rg ies a re g o in g to a p p e a r a n d o u r tre a tm e n t is d ire c te d to w a rd s p re v e n tin g th e s e fro m th e m o m e n t o f th e c h ild ’s first asse ssm e n t. T o c h an g e fro m , say, B o b a th t o R o o d to p ro p rio c e p tiv e n e u ro m u s c u la r f a c ilita tio n to sp lin ta g e , a n d e v e n tu a lly su rg e ry d u rin g d iffe re n t sta g es o f a c h ild ’s d e v e lo p m e n t d isp lay s n o t o n ly a b re a k -d o w n in u n d e rs ta n d in g o f th e d isu rb a n c e s o f m o to r fu n c tio n in v o lv e d b u t a ls o a b re a k -d o w n in th e e x e c u tio n o f th e o rig in a l a p p r o a c h to tre a tm e n t. B e a rin g in m in d t h a t in S o u th A fric a w e u su a lly see th e s e c h ild re n w ith in th e first y e a r o f life w e a re in a p o s itio n to in fluence his m o to r d e v e lo p m e n t w h ilst s till a c k n o w le d g in g his lim its o f a tta in m e n t. T h e y o u n g c h ild d e v e lo p s his b o d y im a g e in th e first e ig h te e n m o n th s a n d his b a sic p o s tu r a l p a tte rn s d u rin g th e first th r e e y e a rs o f life, a n d by five y e a rs o f a g e h a s so p e rfe c te d h is m o v e m e n t p a tte rn s t h a t h e is re a d y fo r th e le a rn in g o f skills. F u r th e r p e rc e p tu a l d e v e lo p m e n t fo llo w s o n th e e sta b lis h m e n t o f b a sic s e n so ri-m o to r p a tte rn s — re q u irin g th e s e p a tte rn s fo r d e v e lo p m e n t R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 4 p h y s i o t h e r a p y JUNE, 1 9 7 4 a n d , in tu rn , b e ing a n e ce ssa ry p re -re q u isite fo r c o n ­ c e p tu a l d e v e lo p m e n t. . . . E a r ly tre a tm e n t o f th e c e re b ra l pa lsie d child (w itnin th e first e ig h te e n m o n th s of life, a n d preferably w ithin th e first n in e m o n th s ) a ffo rd s th e b e st p o tential fo r a d ­ ju s tm e n t to c e re b ra l d a m a g e th ro u g h the experience o f n o rm a ] se n s o ri-m o to r p a tte rn s a n d the c o n s e q u e n t d e v e lo p m e n t o f m o re n o rm a l m o to r skills. In o lder c h ild re n , w h o h a v e o n ly e x p e rie n c e d ab n o rm a l ,m 0; ° r p a tte rn s a n d h a v e th u s re in fo rc e d th e s e patterns in th e a tta in m e n t o f fu n c tio n — o fte n to th e extent of p ro ­ d u c in g fixed c o n tra c tu re s a n d d e fo rm itie s — the p o te n ­ tial f o r im p ro v e m e n t is m u c h less. E v en in th ese cases, h o w e v e r, s o m e th in g c a n be d o n e tow ards inhibition o f s p a stic ity a n d r e o rg a n is a tio n o f m o to r patterns, b ut it is im p o r ta n t to re co g n ize t h a t th e older child has s tru c tu re d h is re a c tio n s, h o w e v e r a b n o rm a l, in o rder to e n a b le h im to c o p e w ith th e d e m a n d s m ade upon him . T h e p sy c h o lo g ic a l effect o f in ju d ic io u s handling w hicn to o h a s tily b re a k s dow n his c a re fu lly stru c tu re d r e ­ sp o n ses a n d d isp la y s th e ir in a d e q u a c ie s can b e very d istu rb in g to th e c hild. , . W h a te v e r th e age o f th e c h ild w e can only help n im in d e v e lo p in g a n d e x p lo itin g h is pre-existing p o ten tiali­ ties, b o th p h y sic a l a n d in te lle c tu a l. T h e r e have, u n ­ fo rtu n a te ly , b een w o rk e rs o v e rse a s w hose extravagant c la im s on th e p h y sic a l a n d in te lle c tu a l responses to tre a tm e n t h a v e e n d a n g e re d th e re p u ta tio n of this a p ­ p ro a c h to tre a tm e n t. I n o rd e r to av o id any such wild c laim s a n d to g ive n e u ro d e v e lo p m e n ta l treatm ent th e re c o g n itio n it d e se rv e s, it is n e c e ssa ry to analyse th e u n d e rly in g p rin c ip le s a n d to e sta b lis h the aims of tre a t­ m en t. I I P H I L O S O P H Y O F T R E A T M E N T A s f a r b a c k as 1926 M a g n u s a tte m p ted to d irect a tte n tio n to th e u n d e rly in g a d a p tiv e changes of p osture w h ich p ro v id e th e c o n s ta n tly c h a n g in g background fo r m o v e m e n t. I t is th e s e p o s tu ra l p a tte rn s which provide th e k e y to th e tre a tm e n t o f c e re b ra l palsy, as well as o f o th e r d istu rb a n c e s o f m o to r fu n c tio n . T h e n o rm a l ch ild d e v e lo p s his postural reflex m e c h a n ism th ro u g h th e in te ra c tio n o f tw o sets of a u to ­ m a tic re a c tio n s: 1. T h e rig h tin g reactions: T h e rig h tin g re a c tio n s w e re first analysed by S c h a lte n b ra n d . T h e ir se q u e n c e of developm ent sta rts a t b ir th , a n d e n a b le s th e child to control th e p o s itio n o f h is h e ad in sp a c e as well as the alig n ­ m e n t o f th e v a rio u s b o d y p a r t s . ' T h ro u g h in *?r " a c tio n o f th e d iffe re n t rig h tin g reactions the child le a rn s to ro ll o v e r a n d sit u p in a typical p a tte rn o f r o ta tio n a r o u n d th e b o d y -a x is, which persists u n til th e d e v e lo p m e n t o f equilib riu m reactions se rv es to m o d ify th is se q u e n ce o f events. 2. T h e e q u ilib r u im reactions: A s first d e sc rib e d b y W eisz, th e equilibruim r e ­ a c tio n s a re h ig h ly se n sitiv e a d ju stm e n ts to p o stu ra l v a ria tio n s w h ic h o n ly s ta rt to m a k e an appearance a t a r o u n d 6 m o n th s o f age. T h e y are the m ost h ig h ly d e v e lo p e d o f th e a u to m a tic movement p a t­ te rn s a n d o n ly b e c o m e p e rfe c te d in the fifth y e ar o f life, b y w h ic h sta g e th e y h a v e already suppressed c e rta in o f th e e a rlie r rig h tin g reactions. I n t a c t rig h tin g a n d e q u ilib riu m reactions are the e s se n tia l p re re q u is ite fo r m o to r fu n c tio n . They can only o c c u r in th e p re se n c e o f “ n o r m a l” m uscle tone, i.e. th e to n e m u s t b e h ig h e n o u g h to p ro v id e a stable po stu ra l b a c k g ro u n d b u t lo w e n o u g h to a llo w movement to o c cu r. T h e c e re b ra l-p a lsie d c h ild d oes n o t h a v e the o p p o r­ tu n ity to d e v e lo p n o r m a l rig h tin g a n d e q u ilib riu m re ­ a ctio n s. T h e re a s o n is tw o fo ld , firstly his level or m o to r d e v e lo p m e n t is a rre s te d o r re ta rd e d , and secondly h e is s u b je c t to a b n o r m a l p o s tu r a l reflex a c tiv ity which c au ses a b n o rm a litie s o f m u sc le to n e a n d lim its his re­ a c tio n s to “ s e t” p a tte rn s o f m o v e m e n t. In a ssessing the ch ild it is im p o r ta n t to d istin g u ish b e tw ee n th e s e p rim i­ tive a n d p a th o lo g ic a l fa c to rs . I t is e sse n tia l to re a lis e t h a t th e n o rm a l b a b y de­ v e lo p s his first p o s tu ra l p a tte rn s in re sp o n se to the h a n d lin g h e re ce iv e d fro m his m o th e r. T h e s e early s e n s o ri-m o to r p a tte rn s fo rm th e b a sis o f a ll fu rth e r p o s tu ra l a d a p ta tio n s a n d sk ille d m o v e m e n t. T h ro u g h th e m th e b a b y le a rn s to c o n tro l first his h e a d , th e n his tr u n k , a n d la te r on to u se h is lim b s f o r s u p p o r t — w h ilst in a n sw e r to his p ro g re s siv e in d e p e n d e n c e the m o th e r a u to m a tic a lly re d u c e s th e d e g ree o f su p p o rt w h ic h she a ffo rd s h im . W h e re th e m u sc le to n e is too hig h (o r to o low ) to a llo w th e s e n o rm a l re sp o n se s to h a n d lin g , th e b a b y ex p erien c e s o n ly a b n o r m a l p ostures a n d m o v e m e n ts, a n d b e c a u se th e s e a re h is o n ly ex­ p e rie n c e he h a s to u tilise th e s e a b n o r m a l p a tte rn s to o b ta in v o lu n ta ry m o v e m e n t la te r on. T h r o u g h in h ib i­ tio n o f a b n o rm a l p o s tu ra l reflex a c tiv ity a n d fa c ilita ­ tio n o f n o rm a l rig h tin g a n d e q u ilib riu m re a c tio n s t Y , c h ild c a n b e given th e e x p e rie n c e o f n o rm a l posturV'V b a c k g ro u n d p a tte rn s w h ic h is so n e ce ssa ry f o r the d e v e lo p m e n t o f f u tu r e sk ille d m o v e m e n t. T h e fa c t t h a t th e n o rm a l in f a n t’s first re a c tio n s are a u to m a tic a n d n o t v o litio n a l lea d s us to a n o th e r im ­ p o r ta n t tr e a tm e n t p rin c ip le — t h a t o f a u to m a tic (B obath) o r s u b c o rtic a l (R o o d ) m o v e m e n ts o r p o s tu ra l pa tte rn s. V o litio n a l a c tiv ity w ill re s u lt in th e re p ro d u c tio n of a b n o r m a l p a tte rn s o f m o v e m e n ts a n d w ill th e re fo re stre n g th e n th e s e a b n o r m a l p a tte rn s . A u to m a tic m o v e ­ m e n ts, w h ic h a re n o less a c tiv e in n a tu re , a llo w n o rm al s e n s o ri-m o to r e x p e rie n c e a n d h a v e , th e a d d itio n a l a d ­ v a n ta g e o f n o t re q u irin g th e c h ild ’s activ e c o -o p era tio n . A s th e ch ild gains in c re a s in g c o n tro l o v e r his m o v em e n t p a tte rn s , a ll d e g ree s o f v o litio n a l a c tiv ity m a y be o b ­ ta in e d , fro m “ m o s t a u to m a tic ” to “ le a s t a u to m a tic ” , th e th e r a p is t’s c o n tro l b e in g g ra d u a lly w ith d raw n . I I I A I M S O F T R E A T M E N T T h e a im s o f tre a tm e n t a re : 1. T o p ro v id e n o r m a l s e n s o ri-m o to r e x p e rie n c e , and th e re fo re : 2. T o c o u n te ra c t th e d e v e lo p m e n t o f, o r to inhibit, a b n o r m a l p o s tu ra l reflex activ ity : T h is w ill in c lu d e in h ib itio n o f sp a stic ity in the sp a stic c h ild , w h e rea s o th e r c h ild re n m a y need p ro p rio c e p tiv e a n d e x te ro c e p tiv e te c h n iq u e s for se lective in cre ase o f m u sc le to n e in o rd e r to p rtr' v ide a sta b le p o s tu r a l b a c k g ro u n d f o r m ovem eiV l a n d c o -o rd in a tio n o f a g o n is ts a n d a n ta g o n ists. 3. T o fa c ilita te (a) basic p o s tu ra l m o v e m e n t p a tte rn s , a n d la te r: (b) sk illed m o to r p a tte rn s , o n th e b asis o f a m o re n o rm a l m u sc le to n e . 4. T o p re v e n t c o n tra c tu re s a n d d e fo rm itie s in y o ung c h ild re n a n d c o rre c t th e m , w h e re p o ss ib le , in older c h ild re n . I V P L A N N I N G O F T R E A T M E N T A d e ta ile d k n o w le d g e o f n o rm a l d e v e lo p m e n t and skill in h a n d lin g a n d a ssessing a re n e ed e d w h e n p lanning tre a tm e n t. T h e fo llo w in g a sp e c ts m u s t be e v a lu a te d : 1. H o w m u c h o f th e c h ild ’s d isa b ility is d u e t o each o f th e tw o basic d istu rb a n c e s o f m o t o r fu n c t i o n ? (a) a b n o r m a l p o s tu ra l p a tte rn s (p a th o lo g ic a l)? (b ) re ta rd e d m o to r d e v e lo p m e n t (p rim itiv e )? A lth o u g h th e re is a c e rta in d e g ree o f o v e rla p and d iffe re n tia tio n m a y be difficult, it is im p o r ta n t to a tte m p t th is d iffe re n tia tio n . Y o u n g in fa n ts m ay a p p e a r p rim a rily p rim itiv e b u t m a y sh o w “ so ft” signs w h ic h b e c o m e m o re defin itely p a th o lo g ic a l on R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) s tim u la tio n o r e x c ita tio n . I f th ese a re tru ly p a th o ­ logical th e y w ill b e c o m e definite a f te r a b o u t f o u r m o n th s o f age, as e x te n sio n d e v e lo p s. P rim itiv e p a tte rn s a re b a sic a lly n o rm a l a n d s h o u ld b e re c o g ­ nized in o r d e r to re ta in a n d b u ild u p o n th e m . It c a n n o t b e a s s u m e d t h a t a p rim itiv e p a tte rn w ill be re ta in e d a u to m a tic a lly — as th e c h ild gets o ld e r, p rim itiv e p a tte r n s a re o fte n e n tire ly re p la c e d by sp a stic p a tte rn s . I n o rd e r to re ta in th e m th e y m u s t be utilize d e a rly in tre a tm e n t. 2 . W h a t is th e ty p e a n d d egree o f m u s c le tone'} W h a t is th e c h ild ’s “ b a sic ” to n e w h e n h e is c o m ­ fo rta b ly a t re st? H o w d o e s s tim u la tio n a lte r h is b a sic s ta te ? D oes . h e sh o w c h an g e s o n fa s t m o v e m e n t, effort, loss o f b a la n c e , ta lk in g , etc.? 3. H o w d o h is a b n o r m a l p o s tu r a l p a tte r n s influ e n ce fu n c tio n a l a c tiv itie s in th e d e v e lo p m e n ta l se q u e n c e ? Is his p o s tu re b a sic a lly s y m m e tric a l o r a sy m m e tri­ cal? D oes h is a b n o r m a l a c tiv ity in te rfe re w ith sta tic ^ p o stu re s (p ro n e , su p in e , sittin g , k n e e lin g , sta n d in g )? 0 D oes his a b n o r m a l a ctiv ity in te rfe re w ith m o v e m e n t (lifting h e a d , ro llin g , s u p p o rtin g o n h a n d s , sitting u p , usin g h a n d s in m id lin e , c ra w lin g , s ta n d in g u p a n d w a lk in g )? W h a t is th e effect o n h e a d c o n tro l, b a la n c e a n d p ro te c tiv e re a c tio n s? W h a t a sso c ia te d re a c tio n s a re p re s e n t? 4 . W h a t is th e c h ild ’s le v e l o f m o to r d e v e lo p m e n t? Is h is le v e l o f a b ility c o n s is te n t a t o n e level o f d e v e lo p m e n t? o r D oes he sh o w a “ s c a tte r” o f a b ilitie s a t v a rio u s levels? I f so, w h a t a re th e m o s t im p o r ta n t gaps w hich n e ed filling in? A t w h a t le v e l s h o u ld tr e a tm e n t c o m m e n ce ? 5. W h a t is th e c h ild ’s c h ro n o lo g ic a l age'! Is th e re tim e (i.e. is th e ch ild y o u n g e n o u g h ) to pass th ro u g h a ll th e d e v e lo p m e n ta l stages? O r, in a n o ld e r c h ild , m u s t w e lim it o u r o b je c t to filling-in im p o r ta n t g aps? W h a t is th e lim it o f p o te n tia l? 6 . W h a t is th e d is tr ib u tio n o f e x te n t o f in v o lv e m e n t? C a n h e c o m p e n s a te v ia less a ffe c te d p a r ts o f th e b o d y ? O r, is o v e r -c o m p e n sa tio n p re v e n tin g h im fro m re a c h in g h is fu ll p o te n tia l? 7. A r e c o n tr a c tu re s o r d e fo r m itie s a lready p r e s e n t? W h a t a b n o r m a l p o s tu r a l p a tte rn s h a v e c a u s e d o r w ill te n d to c a u s e th e m ? C a n th e y b e p re v e n te d ? H o w m u c h is s t r u c tu r a l a n d h o w m u c h c a n b e c o r ­ re cted b y in h ib itin g sp a sticity ? F ro m th is a sse ss m e n t th e p ro g ra m a n d te c h n iq u e o f tre a tm e n t c a n b e d e te rm in e d . I n th e y o u n g c hild, w here stro n g to n ic p a tte rn s h a v e n o t y e t d e v e lo p e d , fa cilitation o f m o v e m e n t p ro g re s se s s im u lta n e o u s ly w ith inhibition o f a b n o r m a l p o s tu r a l p a tte rn s . I n th e o ld er child w ith fixed p o s tu r a l p a tte rn s o r e v en c o n tra c tu re s , m ore e m p h a sis m a y h a v e to b e la id on in h ib itio n — alth o u g h rig h tin g a n d e q u ilib riu m re a c tio n s a re fa c ili­ tated as s o o n a s p o ssib le . S ta tic re fle x -in h ib itin g p o s ­ tures sh o u ld b e a v o id e d . S tim u la tio n m u s t b e a d e q u a te to o b tain a re sp o n se , b u t c a re fu lly g ra d e d to p re v e n t unw anted a ctiv ity . G r a d in g o f s tim u la tio n is e sp e cially im p o rta n t w h e re to n e is lo w o r flu c tu a tin g . M o v e m e n t should n e v er b e d e m a n d e d a g a in s t th e re sista n c e o f h y p e rto n u s — th e th e ra p is t m u s t a s c e rta in t h a t th e m uscle to n e is n o rm a l b e fo re a tte m p tin g m o v e m e n t, and m u st c ease m o v e m e n t as s o o n as th e c h ild ceases to follow . A s w e l l , as p r e p a rin g th e c h ild f o r m o v e ­ m ent, th e p h y s io th e ra p is t m u s t a llo w h im sufficient tim e in w hich to re a c t, in o rd e r to e lic it a n a c tiv e a u to m a tic reaction a n d a v o id m e re p a ssiv e m o v e m e n t. A lth o u g h one stage in d e v e lo p m e n t le a d s to a n o th e r , it is a jUNlE 1974 5 m is ta k e to t h in k th a t o n e sta g e m u s t be p e rfe c te d b e ­ fo r e p ro g re s s in g to th e n ext. T h e r e is m u c h o v e rla p in th e n o r m a l d e v e lo p m e n ta l se q u e n c e , th is b e in g e sp e ­ c ia lly tr u e w ith re g a rd to b a la n c e a n d e q u ilib ru im r e ­ a c tio n s w h ic h a lw a y s la g o n e s ta g e b e h in d — f o r in ­ sta n c e th e c h ild beg in s to w a lk b e fo re h e h a s p e r ­ fe c te d h is e q u ilib ru im re a c tio n s in sittin g a n d k n e e lin g . M o re o v e r, fa c ilita tio n o f e q u ilib riu m re a c tio n s c a n b e ­ gin w h ilst a c e rta in d e g re e o f s u p p o r t is s till n e ce ssa ry f o r th e p o s itio n in w h ic h th e y a r e b e ing e licited. I t is, h o w e v e r, e sse n tia l th a t th e ch ild s h o u ld n o t be p u s h e d b e y o n d th e d e v e lo p m e n ta l lev e l f o r h is c h ro n o lo g ic a l age. A s a g e n e ra l ru le n o stage in th e d e v e lo p m e n ta l se q u e n c e s h o u ld b e c o m p le te ly o m itte d , b u t it is q u ite o fte n n e c e ssa ry to a v o id c e rta in (o th e rw is e n o rm a l) p o s tu r a l p a tte rn s in c h ild re n w h e re r e p e titio n o f th e s e p a tte rn s w o u ld lea d to re in fo rc e m e n t o f a b n o r m a l m o to r p a tte rn s , e.g. b rid g in g in a th e to id q u a d rip le g ia m a y r e ­ in fo rc e e x te n s o r sp a sm s, k ic k in g m a y c a u s e sc isso rin g a n d th e c o n s e q u e n t d e v e lo p m e n t o f a g ro ssly a b n o r m a l g a it, c ra w lin g o n a ll f o u r s m a y in c re a s e flexor sp a sticity , a n d fo rw a rd s u p p o rt o n e x te n d e d a rm s m a y in c re a s e flex o r sp a stic ity in th e s h o u ld e rs a n d tru n k u n le s s a b d u c ­ tio n a n d la te ra l ro ta tio n is e sta b lish e d first. V T H E A R G U M E N T A G A I N S T S P L I N T A G E A N D S U R G E R Y B ra c in g , sp lin tin g a n d e ven sp e c ia l b o o ts a re p r e f e r ­ a b ly a v o id e d in th e tr e a tm e n t o f c e re b ra l p a lsy . T h e d isa d v a n ta g e s in c lu d e in c re a s in g o r s h u n tin g o f sp a stic ity , a lte re d p ro p rio c e p tiv e in p u t, in c re a s e o f a s y m m e try a n d th e le a rn in g o f a d d itio n a l “ a b n o r m a l” p o s tu re s a n d p a tte rn s o f m o v e m e n t. C irc u la to ry c h an g e s a re a ls o a p ro b le m . In c re a s e o f sp a stic ity c a n o c c u r even w h e n th e s p lin t is m a in ta in in g th e lim b in a m o re “ f a v o u ra b le ” p o sitio n . T h is is b e c a u se , in c e re b ra l p a ls y , it is a lm o s t a lw a y s th e a c tio n o f flexors, a d d u c to rs a n d in te r n a l ro ta to r s w h ic h w e w ish to in h ib it — a n d th ese m u sc le s u n f o r ­ tu n a te ly f a ll in to th e g ro u p w h e re su s ta in e d stre tc h re su lts in a u to -fa c ilita tio n , a n d f u r th e r m o r e in in h ib i­ tio n o f th e a n ta g o n is ts o f th e s p a stic m u sc le g ro u p s. S h u n tin g o f sp a stic ity is a n e v e r-p re se n t d a n g e r w h e n ­ ev e r a lim b is h e ld fixed in o n e p o sitio n . E v e n sim p le sp lin ta g e o f th e h e m ip le g ic h a n d c a n re s u lt in in c re a s e d flex o r sp a stic ity a t e lb o w a n d s h o u ld e r w ith d e p re ss io n o f th e sh o u ld e r-g ird le , in c re a s e d flex o r sp a stic ity in th e tr u n k , r e tra c tio n o f th e p e lv is, in c re a s e d e x te n so r sp a stic ity in th e leg a n d c o n s e q u e n t d e te rio ra tio n o f th e w a lk in g p a tte rn . Since o u r p rim a ry a im in tre a tm e n t is to p ro v id e th e ch ild w ith m o re n o rm a l s e n so ri-m o to r e x p e rie n c e , th e d is a d v a n ta g e s o f th e a lte re d p r o p rio c e p tiv e a n d e x te r o ­ cep tiv e in p u t (u n a v o id a b le w ith a n y sp lin t) a re o b v io u s. T h e a rg u m e n t a g a in s t su rg e ry is th re e fo ld . F irs tly t h a t o f sh u n tin g o f sp a stic ity , se c o n d ly t h a t o f in ­ sta b ility a n d th ird ly t h a t o f a tte m p tin g a m e c h a n ic a l s o lu tio n to a n e u ro p h y s io lo g ic a l p ro b le m . I n a d d itio n , th e p o s t-o p e ra tiv e sp lin ta g e p o se s a ll th e p ro b le m s d is ­ c ussed a b o v e a n d th e p e rio d o f im m o b iliz a tio n re su lts in f u r th e r se n s o ri-m o to r d e p riv a tio n . S h u n tin g o f sp a stic ity is d u e to th e p re d e te rm in e d sy n e rg ies o f p a tte rn s o f sp a stic ity . M o v e m e n t can o n ly o c c u r w ith in th e s e p a tte rn s , a n d w h e n o n e c o m p o n e n t o f a p a tte r n is re m o v e d m e c h a n ic a lly as a re s u lt o f su rg e ry , sp a stic ity is lik e ly to b e s h u n te d to th e o p p o s ite m a s s p a tte rn . T h is is v ery o fte n e ven se e n fo llo w in g sim p le te n d o -A c h ille s le n g th e n in g , w h en th e re su ltin g in c re a s e d do rsiflex io n p ro d u c e s flexion a t k n e e a n d h ip , re tr a c tio n o f th e p e lv is, flex o r sp a stic ity in th e tru n k a n d in c re a s e d flexion in th e a rm . F o r th is re a s o n , w h e n e v e r a g a stro c n e m iu s re c e ssio n a n d /o r te n d o - A c h ille s le n g th e n in g d o e s a p p e a r to b e in d ic a te d , it is F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 6 P H Y S I O T H E R A P Y JUNE, i 9?1 THE p r e s e n t s - M i n i d y n e m k 111 TRANSISTORISED FARADIC UNIT Representing another advance in th e e v o lu tio n o f th e M in idyn e, the M a rk III version in c o rp o ra te s p rinted c irc u its w h ic h reduce th e size b u t also enhance the re lia b ility ; c o n tin u in g features are wide range of surge speed control with output sufficient for all forms of faradic techniques audible as well as visual indication of surge speed enabling the operator to anticipate a muscle reaction without having to watch the control panel fitted with Ever Ready PP9 batteries which will give up to six months' use without replacement and are obtainable worldwide W E IG H T reduced to: 4 lbs. (1,8 kg) SIZE reduced to 8 " x 5 i " x 2-J" ( 2 0 c m x 13,5 cm x 6 c m ) . M E D I C A L D I S T R I B U T O R S “CAPE YORK' I 252 JEPPE ST. | JOHANNESBURG | De Waal House, 172 V ic to ria Road | W oodstock, C.P. PLEASE ADDRESS ALL CORRESPONDENCE TO P.O. BOX I in u A M M P c m m r RIG ASSEBLIEF ALLE KORRESPONDENSIE AAN POSBUS | JUHANNbbBUHG TEL. ADD. 'D IS M E D ' PHONE | FOON 23-8106 TELEX: 43-7129 S.A. PRICE: R96.50 com p lete w ith accessories. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNIE 1974 F I S I O T E R A P I E 7 II to try p re lim in a ry p la s te rs to see w h e th e r th e aS- T will h e a b le to c o p e w ith th e in c re a s e d flexion, bility is a p a r tic u la r p ro b le m fo llo w in g o p e ra - * a r o u n d th e h ip jo in t. P e lv ic in sta b ility is a p ro b - ti°nS a m n io n to a lm o s t a ll c e re b ra l-p a ls ie d c h ild re n , lem cfgW 0 f th e m c a n tilt o r r o ta te th e ir pelvis or very . ex tend th e ir h ip s. H o w m u c h g re a te r th e p ro b - act tnen fo llo w in g tra n s fe r o r re le a s e o f m uscles 'cring u p o n th e h ip jo in t a n d pelvis. aCTh so iu tion w o u ld seem to be to p re v e n t th e need ex te n siv e su rg e ry , a n d th e o n ly in d ic a tio n f o r su r- f°r would seem to be e sta b lish e d d e fo rm itie s in the gfjp r u n tre a te d c h ild . C e rta in ly su rg e ry sh o u ld be ded in a y o u n g ch ild w h e re th e re is so m u c h p o te n - 3-V| for influencing th e p o s tu ra l to n e a n d m o v e m e n t tterns by m e a n s o f n e u ro d e v e lo p m e n ta l th e ra p y — A there a re c e rta in ly f a r b e tte r w ay s o f in h ib itin g a [V(oro re action th a n by le n g th e n in g th e h a m strin g s! S U M M A R Y : This article a tte m p ts a r e a p p ra is a l o f th e c o n c e p t o f A r o d e v e l o p m e n t a l th e ra p y in c e re b ra l p a ls y in th e Tope th a t th is a p p r o a c h to tre a tm e n t w ill be m o re c o n ­ sistently ap p lie d . R E F E R E N C E S : 1 B obath, K . a n d B.: T h e T r e a tm e n t o f M o to r D is­ orders o f P y ra m id a l a n d E x tr a p y r a m id a l O rig in by Reflex I n h ib itio n a n d F a c ilita tio n o f M o v e m en t, P h y sio th e r. (C .S.P .) 41, 5, M a y 1955. 2 . B obath, K. a n d B.: T h e N e u r o p a th o lo g y o f C e re ­ bral P a lsy a n d its Im p o rta n c e f o r T r e a tm e n t a n d D iagnosis, C e re b . P a lsy B ull., 1, 8 A u g u s t 1959. 3. B obath, K . a n d B.: A n A n a ly sis o f th e d e v e lo p ­ m en t o f s ta n d in g a n d w a lk in g p a tte rn s in p a tie n ts with c e re b ra l p a ls y , P h y s io th e r. (C .S .P .) 48, 6 , Ju n e 1962. 4. B obath, B.: M o to r d e v e lo p m e n t, its effect on g eneral d e v e lo p m e n t, a n d a p p lic a tio n to th e tr e a t­ m ent o f c e re b ra l p a lsy , Ib id . 5. B obath, K . a n d B.: T h e f a c ilita tio n o f n o r m a l p o s ­ tu ra l re a c tio n s a n d m o v e m e n ts in th e tre a tm e n t o f c e re b ra l p a lsy , P h y s io th e r. (C .S .P .), 50, 8 , A ugust 1964. 6 . B o b a th , B.: A b n o rm a l P o s tu r a l R eflex A c tiv ity c a u se d by B ra in L esions; L o n d o n , H e in e m a n n , 1965. 7. B o b a th , B.: T h e v e ry e a rly tre a tm e n t o f c e re b ra l p a ls y , D evel. m ed . c h ild n e u ro l., 9, 4, A u g u s t 1967. 8 . B o b a th , B.: T h e T r e a tm e n t o f N e u ro m u s c u la r D is ­ o rd e rs b y Im p ro v in g P a tte r n s o f C o -o rd in a tio n , P h y s io th e r. (C .S.P .), 55, 1, J a n u a r y 1969. 9. B o b a th , K .: T h e n o rm a l p o s tu r a l reflex m e c h a n ­ ism a n d its d e v ia tio n in c h ild re n w ith c e re b ra l p a ls y , P h y s io th e r. (C .S.P .), 57, 11, N o v e m b e r 1971. 10. B o b a th , K .: T h e M o to r D e fic it in P a tie n ts w ith C e re b ra l P a lsy , C lin ic s in D e v e l. M e d . N o . 23, L o n d o n , H e in e m a n n , 1972. 11. F in n ie , N ., H a n d lin g th e Y o u n g C e re b ra l P a lsie d C h ild a t H o m e , L o n d o n , H e in e m a n n , 1968. 12. M a g n u s, R .: C a m e ro n P riz e lec tu re s o n so m e r e ­ su lts o f stu d ies in th e p h y sio lo g y o f p o s tu re , L a n c e t, ii, 531 (p. 585) 1926. 13. R o o d , M . S.: T h e use o f S e n so ry R e c e p to r to A c tiv a te , F a c ilita te a n d In h ib it M o to r R e sp o n se , A u to n o m ic a n d S o m a tic , in D e v e lo p m e n ta l se q u e n c e ; in ; A p p ro a c h e s to th e T r e a tm e n t o f P a tie n ts w ith N e u ro m u s c u la r D y s fu n c tio n , S tu d y C o u rs e V I, 3rd O c cu p . T h e r. C o n fe re n c e , D u b u q u e , Io w a , W m . C. B ro w n & C o . 1964. 14. S c h a lte n b ra n d , G .: S o m e O b s e rv a tio n s o n D e v e lo p ­ m e n t o f H u m a n M o tility a n d on M o to r D is tu r b ­ a n c e s, B ull. N e w Y o r k A c a d . M ed ., 3, 534, 1927. 15. S to c k m e y e r, S. A .: A n In te r p r e ta tio n o f th e a p ­ p ro a c h o f R o o d to th e T re a tm e n t o f N e u ro m u s c u ­ la r D y s fu n c tio n , A m . J. P h y s. M e d ., 46, 1, F e b r u a ry 1967. 16. W eisz, S.: S tu d ie s in E q u ilib ru im R e a c tio n , J. N e rv . M e n t. D is., 8 8 , 150, 1938. A C K N O W L E D G E M E N T S : D r. a n d M rs. K . B o b a th , M rs. J. B ryce, P ro f. M . R o o d a n d M rs. E. R ic h a rd s o n — f o r p o s t-g ra d u a te c o u rs e n o te s a n d p e rs o n a l d iscussion. R ep o rt o f S ym p o siu m o f th e O b s te tric G ro u p o f S.A. S o c ie ty o f P h y s io th e ra p y PHYSIOTHERAPY and the PELVIS* P H I L L I P V . T O B IA S F.R.S.(S.A f.), F .L .S .(L o n d .), D .Sc., P h .D ., M .B .B .C h. H o n o r a r y V ic e -P re sid e n t, S o u th A fric a n S ociety o f P h y s io th e ra p y This S y m p o siu m a n d F irs t A n n u a l G e n e ra l M e eting of the S o u th A fric a n S o c iety o f P h y s io th e ra p y O b s te tric G roup re p re se n t a n im p o r ta n t ste p fo rw a rd in th e life and w ork o f y o u r S ociety. B nef a d d ress a t th e Official L u n c h e o n m a rk in g th e First S y m p o siu m o f th e F irs t S p e c ia liz ed G r o u p — the O bstetrics G r o u p — o f th e S o u th A fric a n S o ciety o f P h y s io th e ra p y , 2 3 rd M a rc h 1974. I n th e a b se n c e o f y o u r P re sid e n t, P ro fe s s o r B. B ro m ilo w -D o w n in g , le t m e e x p re ss m y p ra is e a n d c o n ­ g ra tu la tio n s to th e S o c iety on th e e sta b lis h m e n t o f this, t h e first o f its S pe c ia lised G ro u p s . T h e in c e p tio n o f th e O b s te tric G r o u p a y e a r a g o w as a n o th e r la n d m a rk — a n d th is m e e tin g is a n o th e r m ile ­ sto n e — in th e a d v a n c e o f P h y s io th e ra p y in S o u th e rn A fric a . In fa c t, sig n ific a n t d e v e lo p m e n ts in P h y s io ­ th e r a p y a re o c c u rrin g a t such a te m p o th e s e d a y s t h a t o n e sc a rc e ly h as tim e to c a tc h o n e ’s b re a th . O n ly la s t y e a r, th e P ro fe s s o ria l B o a rd f o r P h y s io th e ra p y c am e in to b e in g a n d o ne fo u n d o n e s e lf c o n g ra tu la tin g P r o ­ fe sso r J e a n B la ir on h e r e le c tio n as its first C h a irm a n . O n ly a y e a r o r tw o h a v e p a sse d since th e W itw a te rs- r a n d U n iv e rsity in a u g u ra te d a n e w degree, th e M a s te r o f S cience in P h y s io th e ra p y , a n d a lre a d y o u r first c a n ­ d id a te s a re c o m p le tin g th e ir d isse rta tio n s. I w o n d e r h o w lo n g it w ill be b e fo re w e find o u rse lv e s c o n sid erin g th e e s ta b lis h m e n t o f a S o u th A fric a n C o lle g e o f P h y s io th e ra p y ! R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )