Page Two P H Y S I O T H E R A P Y A p ril 1953 PH YSIO TH ERAPY IN THE CEREBRAL PALSY TEAM A T TH E F O R E S T T O W N S C H O O L , JO H A N N E S B U R G . By S o p h i e L e v i t t , B.Sc. (Physiotherapy) R and. PH Y S IO T H E R A PY is one o f the cogs in the great wheel o f rehabilitation which is turning w ith increasing m om entum at the Forest Town School for Cerebral Palsy. It is often said th at physiotherapy is actually the axle round which this wheel rotates. Physiotherapy educates physical movement, and it is through physical movem ent th a t the developing child learns and acquires self-help, locomotion and experience o f his environm ent. I always maintain, however, th a t th e physical stim ulus alone is inadequate, and correlated stimuli from the mental, em otional and social aspects is needed as well. This is available in the integrated habilitation program m e carried out at the F orest Town School. Cerebral Palsy This is defined by M. Perlstein as a condition characterized by paralysis, weakness, inco-ordination or any other aberration o f m otor function, due to pathology in the m otor control centres o f the brain. I t must be differentiated from spinal palsy, peripheral nerve palsy and mental deficiency. Approach' to Case One often hears how difficult and complex it is to treat cerebral palsy cases, and as a result many therapists are discouraged from w ork in this field. We realise however, th a t any problem can be complex if one does not approach it scientifically and analyse exactly w hat the basic diffi­ culties are before trying to overcome them . The complexity diminishes if one applies the following questions ; (1) What is the normal ? The physiotherapist applies her kpowledge o f kines­ iology (body mechanics and muscle work) and a study of neuro-m otor development as investigated by D r. A rnold Gesell and others. (2) How is the pathological movement different ? This is analysed by examination. (3) Why is there a difference ? Basically the neuropathology and mechanical distor­ tions are responsible. A n example o f the latter is an equino- varus foot, secondary to spasticity o f the internal rotators at the hip with deformity, o r it m ay be due to a tight Tendo- Achilles only. Examination We have compiled an annual exam ination form, to record the abilities and disabilities, and the progress o f each case. The main headings include (1) Posture and perform ance (Ability) o f basic posi­ tions e.g. lying, prone-lying, sitting, kneeling, standing. (2) (a) M od e of locom otion o f patient. 1 (b) Developmental m otor skills in the broad sequence—rolling, crawling, walking, running and jumping. (3) Exam ination o f Individual M ovem ents and the m usculature under the sub-headings passive and active. The range, spasticity and strength o f movem ent is recorded as applicable to each case. U nlike o th er w orkers in this field, we do no t m ake an examination o f individual muscles. I base this on neuro-physiological experiments which suggest th a t representation in the m otor cortex is th at o f foci of movem ent, and not o f individual muscles. (4) Tests for balance and co-ordination. (5) Photographs and summary. H aving completed this evaluation, the obvious question is—W hat can be done ? Therapy We are trying to build up m otor patterns which the norm al child develops autom atically—probably beginning w ith its foetal kicks. T he cerebral palsied child also in­ stinctively tries to m ake contact with its environment, but, with abnorm al m otor patterns. T hus the older the child, the m ore difficult it is to break down incorrect m otor habits', or alleviate the inevitable contractures, before we can begin building up the desirable movements. T hus therapy should be commenced as soon as the deviation from the normal is diagnosed. T herapy is planned according to the above evaluation form. Besides therapy o f the individual disabilities, all children receive training o f basic postures and m otor skills in the developmental sequence as outlined. Techniques are adapted to each individual and type. The Spastic In this case the cortical m otor area 4S, situated in front o f prem otor area 4, has a lesion. I t does not convey its inhibitory impulses through the corticobulbar reticulo­ spinal tract to control over-action o f the spinal reflexes and their related muscle contractions and tone. Therefore Sherrington’s law of reciprocal innervation is upset, e.g. when the spastic attem pts elbow flexion he encounters a sim ultaneous contraction o f the stretched extensors. This is antagonistic to the movem ent and tension, blocking or the stretch reflex occurs. W ith involvement o f area 4 as well, paralysis is also present, which m ay be flaccid if 4S is still intact. The spastic is taught voluntary relaxation, followed by relaxed rhythm ic passive movement, given with, care not to elicit the stretch reflex. The simple fundam entals o f motion are passively dem onstrated to the child. T his stimulates kinaesthetic images o f the correct movements, which the child will attem pt through assisted active and active move­ ment. Then simple movements are built up to the complex. F o r example, when Willie learns to walk, he will begin from the back-lying position and combine the simple movements for reciprocal hip and knee flexion and extension. H e pro­ gresses this reciprocal leg m otion in crawling, knee-walking, tricycling to markinig time assisted, unassisted and finally education o f w alking itself. Obvioilsly m uch balance and postural training is im portant. The latter includes specific and general strengthening and mobilising exercises. Resisted exercise is often used for the weak antagonists to the more spastic groups. Passive stretchings and the use o f night splints form a large p a rt o f our- treatm ent o f the spastic muscle groups. M anipulations o f the feet and arches are constantly used as well. The Athetoid The lesion here is thought to be extra-pyram idal and within the basal ganglia: T hus the body receives too many 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. ) P H Y S I O T H E R A P Y Page Three .kes to move, owing to the lack of the filtering action i t h e basal ganglia. These unpatterned, involuntary move- 0 k distort the voluntary action and there is an upset in H ^ n c e lack o f co-ordination and muscular weakness. There are tension athetoids and m ore com m only no n ­ tension athetoids. Therapy emphasizes relaxation progressed through n basic body positions—increasing the length o f the miired period o f relaxation. T he methods o f building ntor patterns for the spastic and the athetoid show m°jiarities The athetoid is first taught passively the H rection range and uninterrupted movement which he liter performs as voluntary controlled action. Balance and r-n o r d i n a t i o n are trained with particular attention to t h e Control o f the disrupting influence o f the athetotic head nd neck movements. Resisted movem ents are often used for focussing attention, educating directional sense and diminishing athetosis. The Ataxic I The balance co-ordination and muscle tone are a b ­ normal due to a cerebellar lesion. Proprioception is stimulated by passive movements which are soon followed bv simple directional movements. Balance is trained in all fundamental starting positions and advanced to derived oositions, such as four-foot kneeling, half-kneeling, step- standing and eventually to balance in walking forward, backward, sideways, on foot-prints and on a line. C o­ ordination exercises o f arm s, legs, both combined and further with head and trunk are practised in the pro­ gressive positions o f medical gymnastics. Fraenkel’s exercises and the introduction o f K lapp’s Crawls have proved useful. Remedial exercises incorporating strengthening and co-ordination are used in a postural training table. The Tremor and Rigid Types These are rare and we have neither a t the School. The rigid type is similar to the spastic in therapy, but more severe in pathology. The trem or resembles the athetoid in these respects. There are 10 spastic quadriplegias, 5 paraplegias, 9 hemiplegias, 16 athetoids, 4 ataxies and two with a com­ bination o f spasticity and ataxia undergoing physiotherapy at the school. For all types we employ varied apparatus to counleract. the deficiencies o f balance, co-ordination, reciprocal move­ ment, strength and spastic deformities. Parallel bars with an abduction board, foot placement ladder, reciprocal walking skis, inclined plane for walking heel first, stairs, wallbars and mirrors are all used a great deal. Nevertheless in therapy it is careful observation and intelligent use of exercises that m atter rather than impressive apparatus. Attitudes to Therapy The everyday actions o f the norm al child are acquired as skills to the crebral palsied. T he cerebral palsied child learns to walk in the sam e way as the norm al child learns to play the piano, and needs constant, practice and special training. Continued activity is essential to m aintain the power, endurance, and co-ordination o f the neuro-muscular mechanism. Therefore it is m p ortant that they have pleasant associations with therapy, and move confidently and with enjoyment. As a result we have to use our ingenuity and imagination continually to develop m otivations. Early head control is encouraged by following a moving toy with the eyes. Singing rhymes are used with the exercises as well as finger plays, action songs and interesting apparatus. 1 roup work supplements the individual treatm ents o f the less excitable children. The group situation provides m oti: vation and the inspiration of confidence. We are trying “ daring ” corrective exercises which prom ote the thrill o f achievement an d confidence. These exercises include assisted som ersaults, climbing wallbars, hanging, horizontal bar-w ork, baby gymnastics an d swinging by the arm s or upside-down by the legs. A freedom o f movem ent is enjoyed th a t has never really been known. However we are still sceptical o f the relaxing effect o f swinging by the limbs, which, is perhaps more effective for the norm al child. Correlation within the Cerebral Palsy Programme F o r an efficient campaign against cerebral palsy, it is essential th a t a co-ordinated program m e of habilitation be carried ou t by skilled personnel working as a team . The team includes the different therapists an d educationalists as well as an advisory panel o f specialists in pediatrics, ortho- tpaedics, neurology, psychology and otolaryngology. The integration o f physio-therapy with the other therapies and education is described below. (1) Speech Therapy The sam e underlying principles, progression from gross m ovem ent and basic function to finer, m ore complex m ovem ents exist. In other words as we teach reciprocal kicking before walking, the speech therapist teaches basic tongue and lip exercises before sounds and speech. R elaxa­ tio n and breathing present jo in t problem s for physiotherapy and speech therapy. We have also to provide incentives to encourage the children to speak, sing and count. T his superimposes speech on a large moving mechanism. The focus o f treatm ent on the affected arm o f a hemiplegia may result in speech and behavioural difficulties, and thus we have close association w ith the speech therapist in dealing w ith these cases. (2) Occupational Therapy C o-operation is obviously necessary in this field, for together we must build up the movements o f functional activities and skills o f everyday life for the independance of the cerebral palsied child.- (3) Education It has been noticed that rapid im provem ent in muscle control occurs when a cerebral palsied child goes to school, even if there has been no definite emphasis on muscle training itself, and also vice-versa. E ducation increases the child’s lim ited experiences and therefore checks the fear factors. Education also helps him compensate for his disabilities and adjust to his handicap. M any o f the special teaching methods adapt equipm ent and incorporate training in co-ordination, proprioception and concentration. The N ursery School activities become largely th era­ peutic, a p art from their psychological and socialising influences. M anual dexterity and sensory education o f shape, size and texture are developed through the use of special apparatus, such as the peg-board, threading large beads o f various'shapes, as well as crafts such as finger-painting, clay modelling, project work, egg-shell w ork and o th er interests as created by the teacher’s ingenuity. F u rn itu re in the classroom m ust be supervised by the medical officer and physiotherapists. We have special tables and chairs, built to the measurements and disabilities o f each child in order to prevent contractures, prom ote sitting balance, and a good relaxed posture. Standing tables are recommended according to the needs o f the case. Owing to the inter-relationship between movement and learning, physiotherapy helps the child acquire know ­ ledge in a broad sense, besides the simple necessity for the use o f hands to write o r turn pages o f a book. 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. ) Page Four P H Y S I O T H E R A P Y April, 1953 A ID S TO W A L K IN G . (1) A th e to id in R eciprocal Skis. (2) S pastic P araplegia in knee corsets, using trip o d crutches. Play Therapy This is in valua ble in o u r tr ea tm e nt . C h a ir swings, ju ng le gym, bean bag a n d ball games, pedal-cars, push carts, tricycles, h o b b y horses a re used u nd e r supervision to e n co u r a g e balance, co- ord in ati on , stren gthe nin g a n d rh yt hm ic sense. This is supp le me nt ed by musical an d rh y th mi c activities which a p p ea l to the personality o f the child as a whole. Percussion ban d, e ur hy thm ies a n d modified da nci ng are being developed. We are at present also o b ­ serving the effects o f swim ming instruction a n d working on a pian for developing hy d rot her ap y. Parent Education T h e progression o r retrogression o f the c hil d’s habili- tation de p en ds greatly on the parents. W e help them ac qui re con str uctive a tt itu d e s a nd carry ou t h o m e exercises, passive stretchings, a n d if indicated the app lication o f appliances. Th ey are advised on any p ro bl em s a n d e nco ur ag ed to allow their children to develop their potentialities as no rm al individuals, within the limits o f their conditions. Experiments and Research T h e school is the first o f its kind in So ut h Africa, a nd has been run ni ng for fou r years. The n e ur om u s cu l ar tec hniques have been learnt fro m o u r own experience an d knowledge a d a p t e d from overseas person nel a n d all available literature. Exp eri men ts a r e small a n d consist o f :— ( I ) Bracing : We a r e f o r tu n at e in having the tech ­ nical advice o f Mr. J. D. Ball a n d Mr. W. D. R ob er tso n. A “ For es t T o wn ” night splint has been developed an d proved itself useful for spastics. It has also received fav o ur ­ able co m m e n t fro m various o r t h o p a e d ic specialists. D a y knee co rsets from thigh to cal f have been i n tr o ­ duced for the o l d e r child with knee contr act ure s, a n d weight bearing on flexed knees. D u c k -b o o t s with wide base an d pull on the plant ar- fiexors are being used at the m om e nt . Shoes with raised soles a n d d r o p p e d heels for stretching tight Tendo-Achilles have so far prov ed themselves worthwhile. T E A M W O R K IN THE O R TH O P A E DIC DEPARTMENT. N o te : D o c to r is h o ld in g n ig h t-s p lin t d e v e lo p e d at th e Forest Town School fo r Spastics. We ho pe to wor k o ut a " lively ” type o f splintage during the day, which resists unde sir abl e mov eme nt pa tte rn s but assists the childs vol un tar y correc tio n o f mo vement. (2) Pulleys : I a m a d a p t i n g a system o f pulleys for resistance, assistance, c o -o rd in a tio n a nd interest o f these children. (3) Sandbags : filled with lead shot o r metal dust are being m ad e up in the shape o f dolls a n d an im a ls for weighting limbs in relaxation o r in g r a d u at ed resistive exercises. These a r e m o re att rac tiv e sa nd ba gs a n d pr ovo ke en joy m en t o f the exercise. (4) Breathing : It is being recognised that m a n y o f the cerebral palsied have “ difficulties in b re at h in g .” Ther e seems to be little investigation into this, however. T h e mechanics o f breathing, air flow, p u l m o n a r y function a n d co rre lat io n with the neurological features o f the cerebral palsied interest me. At present I a m in the pr eliminary stages o f a research investigation into the respiration, kn owl ed ge o f which is invaluable for speech therapy, physical p e r fo r m a nc e and c on ce nt r a tio n at school. SUM M ARY T he ph ysi ot her ap y o f the different types o f cerebral palsy as described, is carri ed ou t at the Forest T o w n School for Ce reb ra l Palsy (Spastics). It is shown h ow the ph ysi o­ th erapist guides the child's devel opm ent a n d p r o m o te s a positive a tti tu de to the enjoym en t o f mo vement. T h e t e a m ­ wo rk o f therapists a n d ed uca tionalists is stressed an d described, a n d also the progressive and co nst ructive o u t ­ look o f the school. In conclusion may I ack nowl edge how m uch 1 a p p r e ­ ciate being a m em b e r o f a team o f such excellent workers, led by Mrs. F. M. T r ag o t t Vorweg, a nd Dr. M. Medalie. Phy sio th e ra py at the Forest T o w n School is indeed a challenge wort h accepting. It is re warding a nd pioneering work, de m a n d i n g ap pli cat ion o f on e 's specific a n d general knowledge, experience a n d personality. I personally feel privileged to play a small pa rt in helping these children help themselves avoid the sh ad o w o f a h a n d ic a p a n d live the fullest life possible. F o r indeed we do no t believe in the phi lo so p hy that only the fit sho ul d survive. 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. )