THE PHYSIOTHERAPEUTIC TREATMENT OF 

CEREBRAL PALSIED CHILDREN
By A. OBHOLZER, M.D., Ph.D.

Page Two P H Y S I O T H E R A P Y  October, 195]

1 A  L e c t u r e  d e l i v e r e d  a t  t h e  M e e t i n g  o f  t h e  K i m b e r l e y  B ra n c h  o f t h e  S o u th  A f r ic a n  S o c ie t y  o f  P h y s io th e ra p is ts  

a t  t h e  H e le n  B is h o p  H o m e  in K i m b e r l e y  o n  2 5 t h  A u g u s t , 1 9 5 1 .

A T  last the ■ Infantile-Cerebral Palsied Children have 

“  caught the eye of the health authorities in South 
A frica. They have been brought out of —  as W . M. 
Phelps says —  the farthest and darkest corner of our. 

national conscience, where they' have been stowed 
away, neglected and forgotten. Y et they are still 
fa r fro m  attaining all the publicity and —  in connec­
tion w ith it — 1 all the funds which their more popular 
brothers and sisters, the polio children, get. A n d  this 
although the incidence of Cerebral Palsy is about as 

high as polio.

U n til the present day three government schools —  
the schools for physically handicapped children in 
Kimberley —  embarked, among other projects, upon 

the treatment of and research on In fa ntile  Cerebral 
Palsy. Besides these three schools there exist two 
private schools for cerebral palsied children, one in 
Johannesburg and one in Pretoria. Cerebral Palsy 
cases are also accepted and schooling is provided for 

them by the M eerhof Children’s Hospital and by the 
open-air school in D urban. Further it is this home, 
the Helen Bishop H om e, and the “H ope Convalescent 
H om e fo r Children” at Johannesburg which accept, 
treat and at the same time school these children.

I f  we speak of the treatment of Cerebral Palsy, then 
we refer only to rehabilitation —  if possible, and as 
far as possible —  but not to cure. F o r a cure does 
not exist. A n d  in the treatment the m ain thing is the 
patient and perseverant work of the physiotherapist 
for years and years. For although many specialists 
w ork in the field of Cerebral Palsy it is the unanimous 
opinion of the leading cerepalsists of the w orld that 
concerning the rehabilitation of cerebral palsied children 

one profession stands right in the centre, and this is 
physiotherapy —  physiotherapy inasfar as it under­
takes neurom uscular education, or re-education by 
remedial exercises. A ll the other special fields like 
orthopaedic surgery, neurosurgery, bracing, drugs, etc., 

are only adjuvants.

S o : Cerebral P alsy is the field o f the Physiotherapist.

One of the outstanding figures in physiotherapy for 
the cerebral palsied is Miss P au la Egel fro m  the 
Children’s Hospital, Buffalo, N ew  Y ork. She is a 
pupil of D r. W . M . Phelps who is one of the greatest 
pioneers in the treatment of Cerebral Palsy. Miss 
Egel wrote an excellent book, titled, “Technique and 
Treatm ent for the Cerebral Palsy Child. * I t  is 
most clearly and concisely written and should be 
studied by every physiotherapist. U nder the guidance 
of Miss Egel and M r. M o ir P. Tanner of the said 
hospital, a film on Cerebral Palsy treatment has also 
been composed. This film was first kindly lent to us

* S t. Louis, 1948.

by the Cerebral Palsy Association of Western New 
Y ork, and later when we asked for prolongation of 

tim e wc received the best and shortest reply we ever 
got to a request: Keep it !

(T he film , " Pioneering fo r  A m erica’s Children," lent 

by the P rincipal o f the School fo r  Physically Handi­
capped Boys, M r. V. Vaughan, zvas shown by Dr. 

Obhoteer).

The impression given by this film is that 
physiotherapeutic treatment of cerebral palsied 
children is very difficult, as all eases differ 
widely. So one certainly needs a sound know­
ledge of remedial exercises. B lit what one needs 
above all is constant study of each single case in order 
to adapt one’s personal knowledge to the given 
circumstances. One must experiment and carefully 
observe. Moreover, one needs patience, perseverance 
and a good deal of horse-sense. One has to keep 
in touch w ith modern development in Cerebral Palsy, 
and study new publications, for Cerebral Palsy is 
rapidly gaining field overseas and considerable re­

search is being carried out.

Let me now discuss one of our cases, just an 
average spastic one, but rather typical for how problem 
after problem arises w ith each single patient.

X . 7 years 11 months. H e  came to our school 
l i  years ago. In  terms of the 1937 Act he was “a 
child in need of care” ; his fam ily circumstances were 
most unfortunate. H e  arrived at our school barefoot, 
dirty, neglected and very shy. H e  walked with some ' 

difficulty, having a spastic gait and bearing his we'£^4j| 
on the lateral dorsum of the right foot,' where a n  
thick callus could be seen. The right arm was kept 
bent at the elbow and wrist and carried in front ot 
the body. The right hand was h a lf clenched to a 
fist. H e  m ainly used the left hand, and could 
not dress himself. H e  stuttered badly, and often 
showed inspirational ilitonation. A p a rt from this, X 
showed no abnormality in the initial medical examina­
tion carried out by the senior medical officer of our 

school, D r. H . G. Pretorius. The diagnosis made 
was Spastic Cerebral H em iplegia. A fter that lie was 
screened by our dental doctor and our psychologist 

who fo un d  his I.Q . to be 98 (individual scale) ; thus 
the boy was of norm al intelligence, although his 
behaviour was difficult and he was very disobedient. 

H e  showed emotional instability.

H e  appeared to be quite a good case, being still 

rather young —  as young as our school can accept 

children at the present time —  and thus still mould- 

able. However, the treatment of Cerebral Palsied 

children should begin much earlier —  as soon as their

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0 <tober-j95^ P H Y S I O T H E R A P Y Page Three

■ becomes apparent —  and this is often the 
f oiiditio children reach one year of age, which 
case tic im po rtant and generally accepted
bring* ^ us

treatm ent as early as possible.

ihe little chap was enrolled fo r a trial period
b<' lonths, and when he showed signs of improve-

° t h o w e v e r slight they were, he was accepted for
11,11 I One should think twice before rejecting a child
^  il ■ result of the first medical exam ination. It is

'Cm  cive him  a chance bv allow ing a trial period 
wiser fe
()f j  months.

W . know very little about the history o f this 
i t '  O nly that he was a breech b irth and that 

I’- lb was long and difficult. Y et whether this accounts 
f his Cerebral Palsy we cannot say. It is some- 

hat strange that his condition was not noticed before, 
-"•'his mother wrote to us: “he could w alk well.” 
This remark resembles closely the statement of a re- 
orter on the results of the B ikini island atom 

bombing- He said that although the goats survived 
they “would rem ain sterile for some generations.” 

liVlore observant mothers notice such a condition much 
earlier. They usually soon see the difference in 
kicking between the right and the left leg, and the 
difference in gripping between the right and the left 
hand. In our patient we mus't assume that it had 
existed since birth as in the first year we hear of no 
sickness —  whooping cough was contracted later.

He now got good clothes and boots and was. proud 
of them, and he went to the gymnasium and to kinder­
garten school. H e  received treatment by the 
occupational therapist as well as the speech therapist, 
and he also enjoyed spending some of his spare time 
in our leisure department. X  had had 110 treatment 
whatsoever before he came to our school.

An accurate muscle test was carried out (using the 
muscle test chart fo r spastics of the Phelps school). 
Hereby it was determined which muscles were spastic, 
normal, weak cerebral, or even zero cerebral. F o r­
tunately there were no permanent contractures yet as 
with older children, where an operation is then re- 
(|iiircd. The muscle test took some weeks as this 
little man was not very co-operative. H e  soon tired 
and could not concentrate for more than about IS 
minutes at a time. A n d  this brings me to another 
principle:

It is essential to secure the co-operation o f the 
patient.

We also tried to carry out a faradic muscle test, 
but this frightened the little boy and had to be aban­
doned for good. W e  were not dismayed for we are not 
convinced of the value o f either faradic muscle testing 
or faradic treatment for spastics and I  am pleased to 
say that our chairm an, M r. F. H . Henry, confirms this 
opinion.

At the same time X  became acquainted w ith remedial 
exercises. These consisted —  at least in the beginning 
— mainly of playing,- clone or w ith others. Thereby 
lie was carefully observed to determine future treat­
ment. Being allowed to play, he came to like' the 
place, and this is very im portant for everybody, still 
more for children and above all for spastic children, 
the little boy then had his daily treatment period of 

minutes in the gymnasium, partly individual and 
Partly with a few other children of the same age. X  
Slowed among other shortcomings, zero cerebral 
orsmexors at the right foot which promptly responded

0 the “Confused M otion” treatment found by Phelps 
l ia l ’ res'stance to hip-bending dorsiflexes ankle). X  

to walk fro m  his living quarters to the school­

room about a quarter o f a mile away — . or rather, he 
was usually transported by car. This was very un ­
satisfactory. So we succeeded in m aking him  like 
tricycling. A  broad safe tricycle, which could not 
tumble over easily .was given to him  and after a few 
days he mastered it all right. Thus he was self- 
mobile, and at the same time, had some excellent 
exercise for his spastic foot. Tricycles have been re­
commended for the treatment o f spastic children over 
and over again —  so e.g., by M rs. Fischel and Mrs. 
Gratke * W h a t makes tricycling so valuable is not 
only that reciprocal movement o f feet, etc., helps in 
the neurom uscular education o f certain spastic child­
ren, but that tricycling is not boring; moreover it is 
great fu n  and thus used extensively. I t  is a complex 
movement and has a definite practical purpose. I  must 
adm it that of all the special muscle exercises we could 
offer this boy 011 the plinth or even in the gymnasium,, 
tricycling was by far the best. In  spasticity psychic 
tensions grossly inhibit freedom o f movement. Thus 
it is of param ount importance that exercises are made 
enjoyable. A nd here we have another p rin c ip le :

llxcrcises should be enjoyable.

This is generally recognised although difficult to 
bring into practice.

The additional principle that

Exercises should be made up o f complex movements 
zvith a practical purpose

is still the centre o f some controversy.

I 11 connection w ith this, tricycling experiments have 
been carried out in order to determine . how the 
position of the spastic foot is influenced tjy cycling 
straight forw ard, circling to the right and to the 
left. The results have been used for training.

L a ter X  also got a scooter w hich he likes to ride in 
the big gymnasium. H is  spastic foot stands on the 
scooter and is prevented from  the usual inverted 
position by a box keeping his foot straight. H e be­
came quite a scooter-expert and developed very good 
balance.

I have already mentioned that this little boy was 
treated by our speech therapist. In  connection with his 
speech a special round table conference was called, 
i t  was attended by the principal of our school, the 
doctor, the two vice-principals, the psychologist, his 
remedial instructor, his hostel fathers and mothers, 
the occupational therapist,- the speech therapist, the 
head o f the leisure department, his teachers and a 
nurse to whom he is especially attached. The main 
question was whether .im m obilization o f the boy’s 
healthy (le ft) hand should not be tried fo r a while. 
W h y  this? Because an occasionally found mirror- 
w riting w ith the left hand had awakened our sus­
picion that he was innately right-handed and that his 
handedness had been violently, changed by Cerebral 
Palsy. So there was the possibility that this change 
of handedness m ight have caused the speech disturb­
ance. Consequently im m obilization o f the left hand 
and the resultant increased practice by the affected 
hand m ight cause improvement o f speech, which could 
be measured by m aking recordings. The idea behind 
this im m obilization o f the left hand was thus not an 
attempt to change his handedness prim arily —  a very 
doubtful thing —  but ju s t to find out what effect such 
a transitory change o f handedness w ould have on 
his speech. This problem, involved as it was by 
itself, became still more complicated by psychological

* Fischel, U .K . “ The Spastic C hild  “ St. Louis, 1937. 
M cIn to sh Gratke, Juliette, “H e lp Them H elp 
Themselves,” D allas, 1947.

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