April, 1966 P H Y S I O T H E R A P Y Page 5 MIRROR SYNKINESES (C O N T R A L A T E R A L IM IT A T IV E A S S O C IA T E D M O V E M E N T S ) A . M . K . O B H O L Z E R , D is k o b o lo s , K im b e rle y O ne o f th e m a n y “ n ice th in g s” in life is th e a b ility to m ove the extrem ities o f th e le ft a n d th e rig h t side in d ep e n d en tly . One can w rite w ith th e rig h t h a n d a n d , a t th e sa m e tim e, guide a sa n d w ic h to th e m o u th w ith th e left h a n d ; o n e c a n also c arry a su itca se w ith th e left h a n d a n d b e c k o n a p o rte r with th e rig h t one. I n th is w ay, o n e c a n d o m a n y m o re a n d some very difficult th in g s like p lay in g th e violin. I n th is case the left h a n d a n d th e rig h t h a n d p e rfo rm co m p le te ly differ­ ent difficult m o v em e n ts sim u lta n eo u sly . W hile d o in g a n y of these m o v em e n ts n o o n e d o e s b y a n y m e a n s feel lik e th e late a n d h e re to u n b e a te n k ing o f th e ju g g le rs, R astelli. One tak e s th e s e ab ilitie s fo r g ra n te d , a n d th e r e a d e r m ig h t w onder w hy he sh ould b e b o th e re d w ith su c h a n all to o natural fact. P eople w h o re m e m b e r th e ir p h y sio lo g y fro m g o o d old high school o r m a y b e fro m v a rsity d a y s will b e q u ic k to tell you w hy one is a b le to m ove th e lim bs in d e p e n d e n tly : “ T h e re are tw o b ra in h alv es— he m isp h e res— a rig h t a n d a left one. They c o n ta in , a m o n g s t o th e rs , c e n tre s fo r m o v em e n ts. T h e left hem isphere reigns o v e r th e rig h t side o f th e b o d y a n d Burns— C ontinued fr o m p a g e 4 All dressings a re d o n e in th e tre a tm e n t ro o m , b o th fo r aseptic re aso n s a n d b ecause th is is less tra u m a tic p sy c h o lo ­ gically fo r th e o th e r c h ild re n in th e w a rd . L a rg e b u rn s a re soaked in a m o b ile b a th c o n ta in in g a m ix tu re o f w a ter, Cetavlon, a n d R in g ers so lu tio n , a n d a th in p e rfo ra te d pipe circles the base o f th e b a th th ro u g h w h ic h oxygen is b u b b le d . This helps to lo o se n th e dressings a n d c leanse th e b u rn . Both b a th a n d tre a tm e n t ro o m a re d isin fected b etw een patients. P O S T O PER A TIV E O R F IN A L H E A L IN G ST A G E A fter th e dressings h a v e b e en re m o v e d a n d th e g ra ft has taken exercises a re s ta rte d a g a in , p ro g re s sin g fro m gentle to m ore vigorous m o v em e n ts. L a te r th e c h ild re n a re a b le to go to th e P h y s io th e ra p y D e p a rtm e n t w h e re b a ll g am es, pedal toys a n d o th e r a p p a ra tu s c a n b e u sed to g a in m o b ility and confidence. T he g rafted a re a is m assa g ed g e ntly w ith lan o lin , w hich is mixed w ith olive oil to a very so ft co n sisten c y as th e sk in is b oth d elicate a n d o f a re d u c e d se n sitivity a t th is stage. The grafted skin will te n d to c o n tra c t fo r a n y th in g u p to three m o n th s a fte r th e o p e ra tio n , p a rtic u la rly o v e r th e flexor aspects a n d th e p a lm o f th e h a n d , a n d it re q u ire s g re at supervision o n th e p a r t o f th e p h y s io th e ra p is t t o p re v en t deform ities developing w h ic h m ay re q u ire fu r th e r surgery. K eloid sc a rrin g m a y o c c u r, p a rtic u la rly in A fric a n p a tie n ts and this has to b e excised w h e n it h a s ceased b e in g active. Night splinting, a n d “ lively” h a n d sp lin tin g fo r d a y tim e use is o f g re at value, a n d lig h t p la s te r o f P a ris sp lin ts can be m ade w hich m a y be e asily a p p lie d by th e p a re n ts w h e n the child goes hom e. Unless th e p a tie n t lives fa r a w ay, h e a tte n d s th e h o sp ita l as an o u t-p a tie n t, b o th fo r p h y sio th e ra p y tre a tm e n t a n d check-up a t th e B u rn s F o llo w -U p C linic a t re g u la r in te rv als. M any o f these c h ild ren , a fte r su s ta in in g a severe b u rn , require a series o f c osm etic p la stic su rg e ry o p e ra tio n s w hich may have to be sp re ad o v e r a p e rio d o f several y ears. In conclusion, it c an b e seen th a t th e p h y sio th e ra p ist has a m ost im p o rta n t p a rt to p lay in th e g e n era l te a m w o rk of reh ab ilitatin g th e b u r n t child, a n d h e r w o rk is c o m p le ­ m entary to th a t o f th e s u rg e o n in re s to rin g th e p a tie n t to a norm al life. th e rig h t o n e o v e r th e left side. T h is is d u e t o th e fa ct th a t th e P y ra m id a l T ra c ts , w h ic h tra n s fe r th e in n e rv a tin g im ­ p ulses fro m th e m o to r c e n tre s o f th e b r a in to th e m uscles o f th e b o d y , c ro ss sides in th e D e c u s sa tio n . T h e tw o h em i­ sp h e re s a n d th e ir P y ra m id a l T ra c ts w o rk in d e p e n d e n tly . So, w h y sh o u ld th e r ig h t h a n d /a r m n o t b e a b le to c a rry o u t a m o v em e n t d iffere n t fro m t h a t o f th e le ft— ev en if these m o v em e n ts ta k e p lac e sim u lta n e o u s ly ? ” Y es, in d e e d , w h y n o t— if th e p re m ise t o th e c o n clu sio n is c o rre c t, i.e. if th e rig h t h e m isp h e re is re a lly o n ly re sp o n sib le f o r th e m o v e m e n ts o f th e left side o f th e b o d y a n d vice versa. T h e re is, h o w e v er, so m e r e a s o n fo r d o u b t c o n c e rn in g th e c o rre c tn e ss o f th is s ta te d p re m ise b e c a u se : Mirror Synkineses Associated with P athological Conditions T h e re a re p e o p le w h o a re in fa ct u n a b le to m o v e th e u p p e r e x tre m itie s in d e p e n d e n tly fro m e a c h o th e r. T h is p h e n o ­ m e n o n w e find n o t so ra re ly a m o n g s t sp a stic h e m iplegias. In th e s e cases a p a lsie d h a n d /a r m w h ich is o th erw ise u n a b le to m o v e a t all, m a y d o so if th e h e a lth y h a n d /a r m d oes a m o v e m e n t a g a in st s tro n g re sista n c e (O b h o lz e r)1. T h ese “ a sso c ia te d m o v e m e n ts” m ig h t b e so slight th a t th e y a re n o t re a lly a m o v e m e n t yet b u t o n ly a n in cre ase in m uscle to n e . B u t e v en th e n w e c a n re g a rd th is as a n a b o rtiv e co p y o f th e m o v e m e n t o f th e c o n tra la te ra l side. I f th e c o p ie d m o v e m e n t is well e x ec u te d th e n w e sp e a k o f a M ir r o r S ynkinesis (M .S .). T h e re is a lso a special c o n d itio n called K lip p el-F e il s y n d ro m e w h ic h show s M irro r S y nkineses (M .S .). H e re , m a in ly th e c ervical v e rte b ra e a re m isfo rm e d , cau sin g n e ck m o v em e n ts to b e re s tric te d . B a u m a n 2 stu d ie d six su c h cases, a n d fo u n d M .S . in f o u r o u t o f th e six cases. B efore B a u m a n , p a p e rs o n a b o u t 30 cases o f K lip p e l-F e il sy n d ro m e h a d b e e n p u b lis h e d , b u t n o th in g w as m e n tio n e d r e : M .S . I t is believed th a t M .S . w e re n o t n o tic e d in th e s e cases o n ly b e ca u se n o o n e w as o n th e lo o k o u t fo r th e m , th e c o n n e c tio n b etw een K lip p el-F e il sy n d ro m e a n d M .S . n o t b e in g k n o w n a t th a t tim e . M .S . c a n o fte n e asily be d isguised a n d th u s o v e rlo o k e d . T h e re is a lso a fam ilia l tre n d w h ic h is n o tic e a b le in M .S. A n e x a m p le : S m ith 3 re p o rtin g o f a 2 3-year old fa th e r a n d h is o n e -y e a r o ld so n , b o th sh o w in g M .S . A case w h e re M .S . w ere lin k e d w ith m e ta b o lic d istu rb a n c e s (p h e n y lp y ru v ic a c id u ria ) h a s b e e n r e p o rte d b y F rie d m a n a n d L e v in so h n 4. M .S . u su a lly exists fro m b irth , a n d sufferers “ le a rn ” to su p p re ss th e m in la te r life m o re a n d m o re . T h e in n a te c o n ­ d itio n , h o w e v er p e rsists th r o u g h o u t life. M .S . in NeurologicaUy Norm al Cases T h e re a re a ls o n e u ro lo g ic a lly n o rm a l p e rso n s w h o a re u n a b le to m o v e th e u p p e r e x tre m itie s in d ep e n d en tly . T h e re is th e case o f a rig h t-h a n d e d p e rs o n w h o w h e n h e w ro te w ith th e rig h t h a n d , c o p ie d th e m o v em e n t w ith th e le ft h a n d . W h e n h e trie d to sto p th e m o v e m e n t o f th e left h a n d by s ittin g o n it, h e w as u n a b le to c o n tin u e w ritin g w ith th e rig h t h a n d . If, h o w e v er, h e t o o k a p e n in th e le ft h a n d as well a n d s ta rte d w ritin g w ith th e rig h t h a n d , th e left h a n d c o p ie d w h a t th e r ig h t h a n d w ro te . . . b u t m irro rw ise, i.e. fro m rig h t to le ft a n d w ith in v e rte d le tte rs. A s o n e c a n re a d w h a t th e left h a n d h a d w ritte n o n ly w ith th e h e lp o f a m irro r, w e call th is ty p e o f w ritin g “ M ir r o r W ritin g ” (C ritc h le y 5, T h is m a n , I c a n a ssu re y ou w as n o t to o h a p p y a b o u t his “ g ift” . W h e n h e c a rrie d a b u c k e t o f w a te r in his le ft h a n d a n d w a n te d to o p e n a d o o r w ith th e rig h t h a n d , h e h a d to p u t th e b u c k e t d o w n first, o th e rw ise , h e w o u ld h a v e d ro p p e d th e b u c k e t w h e n tu r n in g th e h a n d le . W e a lso k n o w o f th e case o f a y o u n g m a n w ith th is ty p e o f M .S ., re p o rte d b y B u rr a n d C ro w 6. H e e n te re d th e n avy b u t p ro v e d to b e u n a b le to clim b a la d d e r, as every tim e h e re le ased a b a r w ith o n e h a n d in o rd e r to g ra b th e n ext h ig h e r o n e , th e o th e r h a n d a ls o o p e n e d . . . a n d h e fell d o w n . 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 6 P H Y S I O T H E R A P Y April, 1966 M .S. are, fo rtu n a te ly , as a ru le, lim ited to th e u p p e r extrem ities. Ju st im agine w h a t w o u ld h a p p e n to th e lo c o ­ m o tio n if th e left a n d th e right legs co u ld o nly m a k e id entical m ovem ents. W h a t th e re aso n fo r M .S. is, rem ain s u n k n o w n u p to d a te , as n o re p o rt o n an o b d u c tio n o f such a case h a s been p u b lished yet. All these types o f M .S. discussed a b o v e, c a rry , som ehow , th e sta m p o f “ p a th o lo g ic a l” . B ut, w h a t h a s th e really “ n o rm a l” Tiuman being g ot to d o w ith it ? M .S . with Every One H e re it can be sta te d th a t even th e “ really n o rm a l” h u m a n being show s M .S .— to a lesser o r g re a te r e x te n t— u n d e r c e rta in circ u m stan c es. T h is occu rs especially u n d e r stress, e.g. heav y re sistan c e to a m ovem ent (O b e rh o lz e r) 7 (A b e rcro m b ie et a / 8). As a m a tte r o f fa ct, th e tw o h alv es o f th e b o d y te n d to a c t in u n iso n a n d th e “ a b ility to sp lit” (L evin9), i.e. to m ove left a n d rig h t in d ep e n d en tly a n d a t th e sam e tim e, in o th e r w o rd s: to a tte n d to tw o o r m o re m a tte rs sim u lta n eo u sly , is re g ard e d as a “ m ea su re o f g ro w th a n d m a tu rity ” . T h is re m a rk a pplies to th e physical as well as to th e m en ta l developm ent. The Original Representation o f M ovement in the Brain is a Bilateral One T h e re is g o o d re a so n to believe th a t th e o rig in a l re p re ­ se n ta tio n o f m o v em e n t in th e b ra in is a b ila tera l one. T h e m ovem ents fo r th e left as well as fo r th e rig h t side a re rep re se n ted in each h em isphere. T h e n o rm a l c hild h a s the in clin atio n to m ove the left a n d rig h t sides sim u ltan eo u sly . L a te r, this ten d en cy subsides, w hen c o -o rd in a tio n a n d m uscle p o w e r has been a c q u ire d (D e J o n g 10). I n th e c o u rse o f this process side d o m in a n c e is e stablished. Side Dominance T h e e sta b lish m e n t o f side d o m in a n c e is o f g re a t im p o rta n c e fo r th e de v elo p m en t o f skill, speech, intelligence, re ad in g , w riting, a n d b e h av io u r. T h e b id o f som e physical e d u c a to rs to m a k e the c h ild ren “ a m b id e x tro u s” is in c o m p a tib le w ith th e d e v elo p m en t o f a well estab lish e d side dom in a n c e. S om e p a rts o f th e b o d y , especially th e facial m uscles, sh o w bila tera l a sso c ia te d m ovem ents fo r a m u ch longer tim e th a n th e e xtrem ities. If, in th e extre m itie s, M .S. are p e rsiste n t in la te r life to a n y m a rk e d degree, th ey are a cc o rd in g to C ritc h ley 11, re g ard e d as pathological.' T h a t M S .— in th e la te n t fo rm — a re p re se n t in n o rm a l a d u lts, can b e d e m o n s tra te d by th e follow ing e x p e rim e n t: T a k e a piece o f c h a lk in y o u r rig h t h a n d (if y ou a re right- h a n d e d ) a n d o n e piece in y o u r left h a n d . T h e n w rite on a b la c k b o a rd — sim u lta n eo u sly w ith left a n d rig h t— e.g. a bed w ith th e rig h t h a n d , a n d c o n c e n tra te o n th e w ritin g o f this h a n d . Y o u will th e n find— th e m a jo rity o f cases re ac t th u s — th a t th e left h a n d m irro r c o p ie d w h a t th e rig h t h a n d h a d w ritte n , th u s w ritin g fro m rig h t to left a n d in v ertin g th e letters. C ritc h ley 11 sta te s th a t— genuine— M irro r W ritin g is seen in all classes o f in d iv id u a ls ra n g in g fro m th e m en ta lly defective to in te lle ctu a ls o f th e h ighest o rd e r. T h e o u ts ta n d in g e xam ple fo r th e la tte r class is L e o n a rd o d a V inci, w h o at least since his 2 0 th year, w ro te all h is n o te s m irrorw ise. I u n d e rs ta n d th a t som e p ia n o tea ch e rs m a k e use o f M .S. by a sking th e ir p u p ils to p ra ctise m usic scales w ith th e right a n d th e left h a n d sim u lta n eo u sly — b u t in o p p o site direc tio n s, i.e. th e right p lay in g fro m left to rig h t a n d th e left fro m rig h t to left— b o th h a n d s m o ving cen trifu g a lly , th e re a fte r in th e o p p o site d irec tio n . T h is is su p p o sed to be m u ch easier fo r th e left h a n d th a n in d e p e n d e n t practice. A c co rd in g to E rle n m e y e r12 M .S. a re “ th e m o st n a tu ra l m ovem ents fo r th e h a n d s ” . H e th in k s th a t th e o u tw a rd , a b d u ctiv e o r cen trifu g a l m ov em e n ts a re th e easiest, th e best c o -o rd in a te d a n d best c o n tro lle d m ovem ents. T herefn “ M irro r W ritin g is th e m o st n a tu ra l m o d e fo r th e left a rm ”6 (O u r w ay o f w ritin g fro m left to rig h t is a w ritin g f0 r th right h a n d — cen trifu g a lly . L eft-h an d e rs sh o u ld , correT p o n d in g ly , a lso w rite c entrifugally, i.e. fro m rig h t’ to left--! in th e Sem itic w ay.) O nce y o u r a tte n tio n h a s been d ra w n to M .S. you will o b se rv e this p h e n o m e n o n in activities o f d aily living under v a rio u s c irc u m stan c es . . . on yourself, on y o u r frien d s and o n y o u r p a tie n ts. h O b e rh o lz e r, A . S o uth A fr. M e d . J., 25, 742, 13th Oct 2. B a u m a n , G . I. J, A m . M ed. A ssoc., 98, 2, pp. 1 2 9 -n ? 1 9 3 2 ,1 . 3. S m ith , C. A m . J. Dis. Child., 73, 2, pp. 175-177, 1947 4. F rie d m a n , A. a n d L ev in so h n , A. J. P ed., 4 4 , Dn' 553-557. J a n .-J u n e , 1954. P' 5. C ritchley, M . “ M irro r W ritin g ” . L o n d o n 1928, Kegan P a u l, T re n c h , T ru b n e r & C o. L td. 6 . B u rr, C . W ., C ro w , C. B. J. N erv. a nd M e n t. Dis 4 0, p p . 300-302, 1913. 7. O b e rh o lze r, A . A s p. 743. 8 . A b e rc ro m b ie , M . L. J., L in d o n , R . L ., T y so n , M .C. D evel. M e d . C hild N eurol., 6 , 6 p . 576. D e c., 1964. 9. L evin, M . J. N erv. a nd M e n t. D is., 119, p p . 61-66, 1954. 10. D e Jo n g , R . H . T h e N e u ro lo g ic al E x a m in a tio n . New Y o rk , 1950. P a u l B. H o e b e r In c ., p. 616. 11. C ritchley, M . As 5, p. 8 . 12. E elenm eyer, F . A. D ie S chrift. Grundzuge ihrer Physio- logie u nd ihrer Pathologie, S tu ttg a rt 1879. (C ited from C ritc h ley 4.) I wish to th a n k M iss F . S tra u ss, B.Sc. P h y s io th e ra p y for h e r interest a n d c o -o p era tiv e d iscussion w ith re g a rd to this article. For quality printing consult . INCE & SON (PTY.) LTD. • PRINTERS • STATIONERS • BOOKBINDERS • RULERS • LITHOGRAPHERS P r i n t e r s o f t h i s J o u r n a l P.O. Box 2 0 0 , B O O Y S E N S , Transvaal Telephone 834-420 1 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. )