Page 8 P H Y S I O T H E R A P Y December, 1966

Talking to Leading Orthopaedic Surgeons and 

Paediatrician about Child Physiotherapy

By A G N E S W E N H A M , M .C .S.P., A .G .I..N .N .

In order to prom ote child physiotherapy I w rote to 
Professor J. T ru eta in 1964. T he idea occurred to me as I 
read his F o u n d er’s Lecture to the A nnual N ational Congress 
of Physiotherapists in L ondon, 1963. Its title was “ R ehabili­
tation, Past and F u tu re” and contained a brilliant account 
o f the early beginnings o f rehabilitation, a t the daw n of 
civilisation, its status in ancient times, its condition through 
the M iddle Ages right up to  m odern times and to  Professor 
T ru eta’s own efforts to throw  scientific light on our vague 
notions ab o u t body reactions to  physical stimuli. F o r 
example, he conducted experim ents with electrically stim u­
lated muscles on an  anaethetised dog which showed increased 
interosseus fluid pressure during muscle contraction and 
decreased pressure during relaxation. T his led to  the dis­
covery th a t th e nourishm ent an d  health o f bone and o f 
articular cartilage depended on activity o f nearby muscles. 
In  the same way skeletal grow th and health o f the em bryo, 
the child and th e  adult were dependent on th e close inter­
action o f circulation and muscle action. O steoarthritis 
could be shown to  develop from  such parts o f the hip joints 
where cartilage nourishm ent had become p o o r due to absence 
o f sufficient use o f th a t section o f th e jo in t. It was no co­
incidence th a t am ong people with the hab it o f squatting on 
the floor osteoarthritis o f th e hip did not occur. The influence 
o f muscle contraction upon bone could also be shown to be 
greater in th e young o r pre-osseus skeleton th a n  in the more 
developed bone structure. Professor T ru eta visualized 
systematic exam ination o f the newly b o rn  child and at least 
one annual assessment of the grow th and developm ent. In th is 
way, he th o u g h t, we m ight, one day, be in th e position “ to 
correct or reduce m ost of the defects o f the body at a stage 
w hen we consider them  postural or functional” . H e con­
cludes: “ Now we understand why rehabilitation, to  be 
scientifically based, should begin as early in life as a defective 
tendency is detected.”

t
I t was this sentence which electrified me into action. I t put 

into a nutshell w hat D etleff N eum ann-N eurode had preached 
and practised w ith u tter dedication. I asked myself w hether 
Professor T ru eta knew o f N eum ann-N eurode’s m ethod o f 
systematic rem edial exercises for babies an d  children. O r 
did he have o ther m ethods in m ind for early correction? 
W ithout do u b t I had to  find out. I  w rote a long letter enclos­
ing m y translation o f N eum ann-N eurode’s booklet and my 
articles on baby gymnastics and orthopaedic gymnastic 
equipm ent for children. In  his answer P rofessor T rueta, 
th e Nuffield Professor O rthopaedic Surgery in Oxford, 
said: “T he subject in your letter is one th a t interests me 
greatly . . .  I  w ould be m ost interested in personally meeting 
you and seeing som e o f your w ork with children.” Now 
reality had to  be faced. T he struggle began to  arrange my 
practice an d  to  find th e substantial m eans for a journey 
overseas. F o r a tim e it looked as if I could get the necessary 
professional and financial support. W hen it was refused in 
the end I  had no other choice but to  ab an d o n  th e project. 
M y father then realized th a t, perhaps, a rare opportunity 
was going to be lost and decided to  help the cause by paying 
for my journey.

O n 14th Septem ber, 1965 I found myself waiting for Prof. 
T ru eta am ongst his patients from  all over the world. W hen 
he h ad  finished his surgery we arranged a date for the

following week when he w anted to  hear my talk  and see rhy 
film w ith some o f his colleagues and the physiotherapists 
on his staff. T he arrangem ent allowed me a few days to get 
an impression o f th e C entre and to  find one o r tw o babies 
fo r a practical dem onstration. M y task was m ade easy 
through the helpfulness o f M r. B. T. O ’C onnor, Assistant 
O rthopaedic Surgeon to  th e Professor. H e soon found a 
baby who was n o t to o  ill fo r exercises. As I went along to 
see little Paul, he turned out to be deaf, blind and slightly 
spastic. Still, he liked exercises an d  I agreed to  have him 
for the practical dem onstration on the day o f my lecture.

T o  introduce my subject, P rof. T ru eta m ade a speech on 
th e reasons why he considered rem edial exercises for babies 
o f great im portance. H e explained th at, as a young m an, he 
had know n o f baby gymnastics. I assume it was at th e time 
when N eum ann-N eurode him self was spreading the idea 
am ongst medical men. Since then Prof. T rueta had gained 
the im pression th a t the a rt o f giving rem edial exercises to 
infants had been lost, until, out o f th e blue, I had written 
to  him  ab o u t it. In  order to  show how im portant it was to 
carry out treatm ent as early as possible, he pointed out that 
only the still growing bone can regain its norm al shape. In 
osteomyelitis, he explained, th e disease norm ally leaves 
horrible scars an d  loss o f bony tissue. In  children under nine 
years o f age, however, it will heal w ithout leaving the slightest 
m ark on the bone. It needed to  be m ore widely know n that 
the skeletal plasticity o f th e to d d ler begins to  disappear at 
six o r seven years and is lost alm ost completely at twelve. 
C ongenital dislocation o f the hip and club feet were two 
typical examples to  show how treatm ent during th e first 
year o f life brings excellent results, results th a t can never be 
achieved when treatm ent is started after tw o years o f age. 
Prof. T rueta then referred to  the idea o f Sir D ennis Browne 
who had so clearly pointed out the param ount im portance 
o f a correct muscle pull on the cartilagenous bones o f the 
foetus. N orm al shape and grow th o f th e foetal skeleton 
were largely dependent on the existence o f norm al and 
balanced muscle activity. O veraction o f one muscle group 
w ould cause m ore serious deform ities in very young bones 
th a n  in those already ossified. T he infantile hip jo in t was a 
good example. Insufficient contraction o f the abductors 
w ould cause the form ation o f a shallow acetabulum , also 
the wrong angle between shaft and neck o f the fem ur and an 
unstable jo in t w ith the danger o f dislocation o r osteo­
arthritis late in life. W eak and under-active muscle groups 
o f infants had to  be over-developed and over-active ones 
had to  be discouraged in order to  norm alize the shape of 
jo in ts and bones.

T he dem onstration o f baby P au l’s exercises followed, and 
then my talk and film. I gave a short history o f the develop­
m ent o f N eum ann-N eurode’s baby exercises and m entioned 
the opening o f th e State R egistered N eum ann-N eurode 
School for Remedial Exercises for Babies and C hildren in 
Berlin, following a previous testing period at the famous 
C hildrens’ H ospital in B erlin-C harlottem burg. I pointed out 
th at, since the closing of th a t School, proper training in 
N eum ann-N eurode’s exercises had dwindled dow n to  alm ost 
zero. I  stressed the need for m edical support. W ithout the 
active interest o f medical m en no progress could be expected. 
Even N eum ann-N eurode had needed recognition and sup-

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f outstanding doctors o f his time such as Prof. Bier, 
£°of K lapp and later Prof. Schede.

w hen I  had finished, as the lights came on after the film, 
f T rueta said: “ Very, very good. Y our plea shall not 

^  n h e e d e d ! ”  A fterw ards he asked me to  hand him 
8° “ nn_Neurode’s booklet. I to ld  him  th a t the Pergam on
0 «<! in Oxford had shown interest in publishing my trans-
1 tinn Would he consider writing a new introduction for the 
c  d ish  edition? A n em phatic “ Y es” and the offer to  con- 
tart the editors was his reply. W hen afterw ards the film was 
h a n d e d  back to  me, Prof. T ru eta gave me good advice: 
‘■rut the running time dow n to  30 minutes, speak for 15

d leave the rest for discussion. I f  on top o f it you can 
efve the lecture in French, you have som ething you can 
take with confidence ro u n d  the w orld.”

Since not many doctors had attended the film show, a 
fact openly regretted by P rof. T rueta, I tried to  win the 
interest o f a few m ore whilst I was staying at the Nuffield 
Orthopaedic C entre. Visits to  the O rthopaedic O ut-Patients’ 
D epartm ent gave me some welcome opportunities. I  could 
show a father how he could m ake a foot-stool in o rder to 
stretch his son’s contracted heel-band. A m other did not 
know how to  stretch her baby’s sterno-m astoid muscle 
without provoking th e child’s protective resistance. I 
showed her how she could gently tilt th e baby’s whole body 
upside-down, resting for a few seconds his shoulder and 
head on a soft surface. A fter a few attem pts and a few 
mistakes, the m other m astered th e “ trick” sufficiently well 
for the doctor to  be pleased w ith the procedure.

At the C lub-F oot Clinic the d octor to o k  kindly to  the 
“foam rubber wings” I  had brou gh t fo r th e very young 
baby w ith club-foot, and w anted to  know where I  had 
developed them .

A sister tu to r asked M r. B. T. O ’C onnor w hether he 
would give up his lecture time in o rd er to  let the student 
nurses see w hat could be done to  hospitalized babies in 
need o f physiotherapy. H e agreed and requested th a t I 
should notify a Miss Chiw andim ira, a rem edial gymast 
from R usape in R hodesia, who was in L o n d o n  on a study 
tour sponsored by the African D evelopm ent F u n d . W hen the 
young an d  very pleasant A frican therapist arrived she also 
had a short film. I t showed her caring for a host o f crippled 
children in a village treatm ent centre, all o f them  performing 
corrective exercises on N eum ann-N eurode’s apparatus. It 
was an amazing coincidence.

M r. O ’C onnor found the approach to  rem edial exercises 
“unusually sensible and refreshingly new an d  suggested 
another film show to  the entire medical staff. A short report 
of this meeting reached our South A frican Journal from  Miss 
A. M. Symons, H ead Physiotherapist at the nearby Churchill 
Hospital. She happened to  hear o f the occasion and I was 
delighted to  have a colleague sharing th e experience with me. 
Mr. O ’C onnor explained why he had w anted his colleagues 
to see the film. T his was followed by a lively discussion. A 
medicine specialist thought this kind o f physiotherapy 
desirable for all his child patients, including those after 
fractures and operations. A surgeon considered it im portant 
that strenghtening exercises were given to  babies with 
deformities o f th e spine. N o  harm , only good could come 
from  this active approach, whilst plaster beds had their bad 
and sad side. H e welcomed the possibility o f active participa­
tion by instructed parents.

In  L ondon I  m et the new C.S.P. Secretary at Tavistock 
house. M r. Jack Rose gave me the impression o f a m an with 
great strength, integrity and friendliness. H is approach was 
straightforw ard: “ This is com m on sense and very much 
needed” was his em phatic com m ent as he looked at the last 
photo in my album  o f orthotoys. The question o f getting

pecember, 1966 Page 9

orthopaedic play apparatus know n and produced followed 
quite naturally.

F ro m  the C hartered Society I  went to  D r. and Mrs. 
B obath at their Private Clinic at St. Jo h n ’s W ood, L ondon. 
I m et them  treating spastic children w ith m any therapists 
aro u n d  them . “ L et me show you O U R  orth o to y s” M rs. 
Bobath said when th e m om ent came for m y introduction. 
She dem onstrated to  m e her huge beach ball w ith a small 
child learning to  relax over it. A lso her low, padded benches 
which m ade many suitable positions possible. W hilst Mrs. 
Bobath was still busy teaching a group o f students, D r. 
Bobath to o k  me aside to  show me the newest sound film on 
cerebral palsy he had m ade in America. W hen M rs. B obath 
and a few teachers on her staff joined us, I  showed my film. 
Its message was nothing new to  them . T hey knew much 
about the late N eum ann-N eurode’s w ork a n d  I  noticed his 
booklet on a desk. W hat m ade them  so thrilled ab o u t the 
babies at w ork in my film, I  do no t know . I  ju st heard 
delighted rem arks by M rs. B obath about certain points 
and then a final: “I  can see this must be learned properly. 
We need it for our atonic babies. You m ust let me know 
when you give a first course on baby gymnastics in L o n d o n .” 
D r. B obath quietly added th at, if I ever contem plated 
an o th er film on babies, he would gladly m ake it. I was over­
whelmed by such acknow ledgem ent and support. W hat is 
m ore, I was moved th a t the wish to  learn th e exercises came 
from  a person who was already know n th roughout the world 
fo r her skill in handling notoriously difficult spastic babies. 
A t a later visit, M rs. B obath rem arked how difficult it was to 
make therapists see th a t a technique cannot be acquired in a 
week o r tw o w ithout running th e risk o f seeing it degenerate 
into superficial gestures bringing weak results and conse­
quent lack o f confidence o f medical men and physiotherapists 
alike.

W hen I showed the film at G reat O rm ond Street, D r. Basil 
K iernander, D irector o f Physical Medicine, said th a t his 
hospital had already started to  use remedial exercises for 
babies, at th e tu rn  o f the century, long before anybody else 
in the world. H e com plim ented m e on the designs o f o rth o ­
toys and believed th a t the teaching o f the subject o f “ Infantile 
Physiotherapy” was badly needed.

A m ong th e spectators at G reat Orm ond Street was M r.
G . F . B utler from  th e N ational Research D evelopm ent 
C orporation. W ith him  I  discussed the subject o f royalties 
for the designs o f orthotoys. H e inform ed me th a t no 
personal gain could come from  medical designs. R oyalties 
paid were ethically b o u n d  to  go to  some benevolent institu­
tio n  o r into a fund fo r further developm ent o f orthotoys. 
T his state o f affairs explains, perhaps, why comparatively 
few aids are developed in medical departm ents, whilst 
m otor cars and aeroplanes soar ahead w ith one invention 
following the next, bringing maximum com fort to  the 
com m and of our toes and fingertips.

A refreshing note o f hope rang in my ear when I  heard 
th e opening lecture by Sir H erb ert Seddon a t the annual 
C.S.P. Congress in L ondon. H is inspired call to  physio­
therapists to  accept the every day need for rethinking and 
fo r new attem pts at better solutions, were a delight to 
hear from  a m an who was know n for a lifetime o f creative 
service to  medical science. W hen later I was introduced to 
him at a dinner at th e Cafe R oyal he told me th a t he con­
sidered baby gymnastics to  be one o f th e im portant new 
branches o f physiotherapy. H e suggested my contacting 
Miss Lois D yer at th e R oyal N atio n al O rthopaedic H ospital. 
As it happened I  was in close touch w ith her already.

M y next step was to  contact Professor Illingw orth at the 
D epartm ent o f Child H ealth who had agreed to  see me a t the 
Children’s H ospital in Sheffield. T he interview w ith him 
consisted mainly o f searching questions: W hat particular 
conditions did I  believe I  could beneficially influence ? W hy 
chronic bronchitis? W hat could I  do fo r spinal deform ities?

P H Y S I O T H E R A P Y

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Page 10 P H Y S I O

How much did physiotherapy achieve with spastic babies? 
H ow  could I prove th at knock-knees did better with th an  
w ithout specific exercises? W hat ab o u t valgus ankles? 
H ad I thought o f the need o f proving my points by experi­
ments with controls? I was happy to  have the opportunity 
o f providing inform ation on these points. Prof. Illingworth 
took me round his m odern departm ents and let me watch 
his own clinic for baby consultation. H e was proud o f an 
exceptionally low rate o f baby m ortality in Sheffield.

I was also given a chance to  witness an afternoon session 
at the Spina Bifida Clinic under the charge o f M r. W. J. W. 
C harrard. H e was especially interested to  close the gap in 
the coverings o f the spinal cord within 24 hours o f the baby’s 
birth. A t th at m om ent the skin stretched m ore easily over 
the gap, less bulging o f cerebral fluid occurred; conse­
quently there was less strain on the nerve ro o ts with less 
paresis and paralysis developing. H is patients were given 
intensive physiotherapy as soon as they were old enough to 
understand w hat was expected o f them . I asked him w hether 
he would welcome it if systematic exercises could be given 
already at the baby stage. H e had no d o u b t about the 
advisability o f very early exercise to  the inactive m asculature. 
U nfortunately, there was no time to  show photographs or 
film.

A nother, most gratifying appointm ent was with the P ro ­
fessor for Preventive M edicine and Public H ealth in Sheffield. 
Professor K now elden told me th at what I showed and 
explained was entirely new to  him. “ Y ou m ust try and talk 
to  leading orthopaedic surgeons and paediatricians. Only 
w ith their support can you hope to  become effective and 
spread the news what early physiotherapy can do.” This, 
o f course, had been the very purpose of my journey. I was 
also interested in his rem ark on what he called “ woolly 
thinking about children’s valgus ankles and flat feet” . H e 
felt completely confused about what to think o f the con­
dition. H e had heard the most diverging opinions. Some 
doctors considered valgus ankles and flat feet a definite 
weakness, hard to  cure, perhaps incurable, often giving 
rise to  pain, particularly at middle age; others thought that 
the majority o f children grew out o f them , contradicted by 
another group who considered them  norm al for all ages 
because o f their frequency. I said th at I thought it was a 
m atter o f preventing the condition from  developing at 
the baby and toddler stage. F urtherm ore, the N ursery 
School could do a lot to help the child to  gain really strong 
and healthy feet. W ith this in mind I had started designing 
and laying out an orthopaedic playground where nursery 
school children could train their feet and generally posture 
as they played.

F rom  Sheffield I travelled to  M anchester. H ere I visited 
D r. Ben Epstein, the paediatrician, form erly o f Pretoria. 
T o my surprise he had arranged a program m e o f hospital 
visits and a film show. W ith him I had the pleasure to  witness 
the opening o f a wing for mothers which enabled them  to 
stay with their children who had been operated on. This was 
a heartening example o f progress I saw in hospitals and clinics. 
I also saw some retrogression. A t G artside Street O ut-Patient 
D epartm ent, where I had w orked fo r several years during the 
last war, I learned th at only one physiotherapist was now 
employed instead o f the form er three. Even at the M ain 
H ospital, the R oyal M anchester C hildren’s H ospital, a 
single physiotherapist was doing all the w ork in a cram ped 
room  th at did not even have the appearance o f a treatm ent 
room  or gymnasium. Baby gymnastics had long disappeared. 
Elsewhere, I was inform ed th a t remedial exercises fo r p re ­
school children had been discontinued in practically all 
English Child W elfare Centres. Such retrogressive develop­
m ent appeared to  be somehow related to  the apparently very 
sm all am ount o f teaching Paediatric Physiotherapy at 
training schools. However, I found an exception in the slow 
ra te  o f developm ent concerning physiotherapy for children 
in the field o f cerebral palsy. H ere, the value o f early treat­
m ent with suitable baby exercises has been grasped and in 
m any places pu t into practice. A good example o f enterprise

T H E R A P Y  December, 1966

was show n at th e “ H orse Show o f the Y ear” at Wembley. 
H ere, for the first time, a group o f about 20 spastic children 
on their ponies entered the floodlit arena. They gave a 
dem onstration o f th e exercises they had been taught with the 
aim o f improving their condition and self-confidence. Those 
physiotherapists and organizers who had the courage to 
place the children into this brilliant show certainly deserve 
congratulations.

Back in L ondon, my last days were crowded w ith showing 
the film to doctors, medical students and occupational 
therapists. Professor Bowden’s medical students at the Royal 
Free School o f M edicine gave the film the loudest an d  longest 
applause it ever received, perhaps, because the subject had 
taken them  completely by surprise and displayed a welcome 
simplicity o f concept. Lively interest was also shown at the 
O ccupational T herapy C entre and T raining School in 
H am pstead. H ere I had a m ost welcome surprise. The 
Secretary of Sir D ennis Browne telephoned th a t Sir Dennis 
would like to come. I felt im mensely grateful for this response 
to  m y recent letter. I t seemed m ost im portant to  me that 
som ebody who had been the first paediatric surgeon for 29 
years at the L ondon H ospital fo r Sick C hildren in G reat 
O rm ond Street, and who had been knighted for his services 
to  orthopaedics, should form  his opinion on N eum ann- 
N eurode’s baby gymnastics and the orthopaedic gymnast 
equipm ent. Sir D ennis w holeheartedly agreed w ith the prin­
ciple o f early correction. H e liked the way in which remedial 
exercises were m ade interesting to  the child w ith the help of 
apparatus. On the way out he asked me to come and see him 
next day. At this occasion he showed me photographic slides 
o f orthopaedic conditions o f babies, m entioning the advan­
tage o f passive as well as active correction in cases o f infantile 
scoliosis and valgus ankles. I was also shown som e recent 
correspondence in which his theories were strongly attacked 
and defended. H is explanations about the causes o f some 
infantile deformities fascinated me. T he idea th at they 
frequently stemmed from  a m alposition in utero fitted 
singularly well with my experience o f overcom ing limitations 
o f movement in babies and o f coaxing into action muscle 
groups th at must have been inactive fo r a considerable 
time. A ccording to  Sir D ennis B row ne’s own experience, 
m any early mild m alform ations do not cure themselves but 
often persist and frequently develop into worse deformities 
as th e child grows into school age, teenage and adulthood.

O ne m ore experience deserves mentioning. T he visit to 
the C hildren’s O rthopaedic H ospital in C arshalton. The 
physiotherapist in charge had m anaged to  arouse the interest 
o f his doctors and colleagues. A t the end o f the film on 
a pparatus, he ju st burst o u t: “ I w ant them all!” A few days 
later he called me back to  present my them e to  the other 
section o f the huge hospital, th at is for retarded children. 
T he doctors understood immediately the advantage of 
orthopaedic play equipm ent fo r these mentally deficient 
children. Such children often suffer from  a num ber o f smaller 
and larger physical defects, for which individual correction 
is m ade problem atic by their lack o f understanding and 
limited conscious co-operation. T he doctors felt th at an 
in- and ou td o o r gymnasium , properly fitted ou t w ith o rth o ­
toys, could contribute a great deal to  norm alize weight­
bearing and the general physical developm ent o f these 
children.

In conclusion, I wish to  say gratefully th at my hopes to 
find support for the early treatm ent and early prevention 
o f orthopaedic conditions with the help of infantile remedial 
exercises and special gymnastic equipm ent were richly 
fulfilled.

Footnote: “ I am pleased to report th at, thanks to  the active 
interest o f Professor J. T rueta, Nuffield Professor o f O rth o ­
paedic Surgery in O xford, the Pergam on Press, Oxford, has 
now agreed to publish my translation o f M rs. K aiser’s 
booklet on ‘N eum ann-N eurode Baby Gym nastics’.

T he publishers intend printing the booklet in time for the 
W .C .P.T. conference in M elbourne, 1967.”

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