FACILITATION IN PRONE

→ tone normalization→ sensory accod. to weight bearing surface→ elongation in spinal extension→ weight shift across central axis→ head righting reaction

Decreased tone; increased integration between upper and lower trunk.

REACTION: elongation weight bearing sideinternal and external rotation – UE & LEpelvic and spinal alignmentweight shift – weight bearing surfaces – hands/feetforming midline

If increased tone, grade stimulus slow; small excursions; deep pressure to elongate weight bearing surface.

PREPARATION SCAPULA:Prone → preparation for sidelying → to sitting H.R.

weight shift, elongation, H.R.labyrinthine R – prepare before taking to sidelying

Sidelying:Reinforce elongation through pressure Align pelvis and shoulder around axis

Facilitate weight shift GRADEToward prone → increased ext. BEWAREToward supine → increased flexion (chin tuck → supine E.R.)

May need to work specific pelvis: Mod

Hips

Shoulder: Shoulder

head/abd

SUPINE DANGERS: Neck hyperextension→ inactive trunk – abdominals

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→ overstretched neck, lumbar spine→ fixed posterior tilt

SOME PURPOSES:

A. elongation neck extension – preparation UE and reaching.B. alignment of spine – activation of flexion and extension

THOUGHOUT spineC. activation of abdominalD. preparation pelvic movement for sitting.

DON’Ts:

Legs Resting (Inactive) Too Much Hip Ext (No Activation) Anterior Tilt

Approx. into Flexed hips Duplicates sitting position in chair.Collapsed lumbar spine or P.P.T. overstretched Neck Extensors

Always maintain good alignment

Recognize difference between BABIES ↔ OLDER CHILDREN

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A. ELONGATION NECK:

Key Points: scapula/shoulderstrunkupper extremities

Weight Bearing on Scapula Action: tractionLateral weight shiftAlignment – balance flex/ext

B. ALIGNMENT SPINE:

Key Points: sternumabdominals/pelvis --OR--lateral trunk

weight bearing/pelvis Action: subtle weight shift

deep pressure

Key Points: ant/post surface trunksides of trunkpelvic areathoracic area

weight bearing/scapula Action: tractionlateral weight shiftapprox - ONLY once aligned

C. ACTIVATION ABDOMINALS:

Key Points: Pelvis

Weight bearing Action: tractionlateral weight shift(prepare for rolling, etc)

D. PELVIC MOBILITY

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MUST HAVE ADEQUATE NECK MOBILITYKey Points: thighs insideAction: lower pelvis – cue lift

Up/down usinf abd. & glutes (B)Weight bearing neck (A)

SUMMARY OF NEURODEVELOPMENTAL TREATMENT TECNIQUES – BOBATH

I. KEY POINTS OF CONTROL:

Both inhibition and facilitation are usually performed at key points of control; however, your handling is not necessarily limited to these points.

Proximally: Head, shoulders, and pelvisDistally: Thenar eminence, wrist, toes, ankle, and jaw

Any one or combination of the key points of control can be used.

II. INHIBITION:

Purpose:To increase the potential for a wide variety of differentiated (highly selective) patterns of movement.

Method:

Inhibition techniques are used only as needed and are interplayed with facilitation techniques. Reflex inhibitory patterns (RIPs) are not static and are rarely used in isolation. Tonic postural dominance is inhibited peripherally (initially by the therapists) while higher level righting and equilibrium reactions are facilitated. The goal is central inhibition by the patient.

Normalization of increased postural tone is often achieved by:

A. Movement:1. slow, rhythmic rocking – reduces spasticity2. shaking – counteracts fixation

B. Weight bearing in moving patterns:1. inhibits hypertonus - it is a type of elongation when used on the

involved area and is used with slow movement to prevent build-up of tone.

2. increases tone (depends on how it is used).

C. Elongation:

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1. slow sustained lengthening to break up stereotyped movement patterns.

2. naturally occurs on the weight bearing side.

D. Rotation: 1. elongation and rotation = dissociation2. VERY effective in breaking up total synergies.3. extremely important component of righting and equilibrium reactions.

***It is essential to note that inhibition will only carryover during and after treatment if automatic postural reactions (righting, equilibrium, protective) are facilitated.

III. FACTILITATION:

Purpose:

The righting and equilibrium reactions are stimulated to provide the patient with experience in a wide range of controlled, graded movement patterns. The spontaneous achievement of these postural reactions means the abnormal reactions (including primitive reflexes) have been successfully integrated.

Methods:

A. Inhibition of mass movement patterns immediately allows for normal, differentiated movement and is, therefore, a facilitation technique.

B. Facilitation of Automatic Movement Sequences:

Carefully selected portions of the development sequence are facilitated through use of righting, equilibrium, and protective reactions. A directional cue is used. The significance parts of sensory motor development are the transitions between positions, not the position itself (i.e. moving in and out of sitting, not sitting per se). The following points are important to remember:

1. Respect the child – don’t impose yourself:a. Let the child lead the movement if possibleb. Use child’s own tempo – not yoursc. Give child the feeling that he can do somethingd. Your hand guide – not dominate

2. Repeat- repeat – repeat, but don’t go too far:a. Use millimeters and micromillimeters of movementb. Don’t always repeat in one way

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c. Repeat until child takes over – and it is automatic but not stereotyped

3. Give normal feeling of normal movement:a. You don’t want static positions but movement in and out of

positionsb. Or minimal movements with control in positionsc. You want ACTIVE REACTIONS from babiesd. They give more normal sensorimotor experiences

4. Stop when quality goes wrong. Don’t paint in the wrong quality or wrong body image.

- Never do anything that doesn’t work. Find out why it doesn’t work and prepare more or try a different way.

5. Key to treatment = preparation. Positions need to be prepared for.

6. Find most difficult points and play with it.7. Watch for fixes.

8. The child must WORK under your hands and learn to take over:a. First under our hands. We must gradually move away.b. Must not be passive or child will only depend on you.c. We must give the child the possibility to take over.

9. Our aim is FUNCTIONAL REACTION:a. Example: hands to midline, hands to feet.

Inhibition techniques continue to be used as needed but must be with drawn as central control is increasing.

ENHANCEMENT TECHNIQUES OF PRIMARY FACILITATION:

The following are used to enhance “B”:

1. Weight Bearing, Pressure, Compression and Resistance:a. Joint approximation used frequently but almost always

during a sequence of movement.b. Proximal most common; distal when combined with

tapping.c. Antigravity weight bearing is most common.d. Not always through joints; often through trunk in a

downward diagonal direction.e. Alignment should be as near normal as possible.

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2. Placing and Holding, Both Automatic and Voluntary:a. Placing: the ability to arrest a movement at any given

stage. It is the automatic adaptation of muscles to a change in movement or posture.

b. Often used to help break up a pattern of fixation; i.e. place arm back in a normal position or inhibitory pattern if it is pulling into an abnormal pattern.

3. Tapping:a. Increases postural time of trunk or limbs by proprioceptive

and tactile stimulation.b. Almost always combined with holding against gravity in

some way.c. Never use when spasticity is present because it will

increase spasticity – normalize tone first.d. Use within framework of a movement pattern and never for

a specific muscle.e. Performed quickly and arrhytmically to avoid

accommodation to stimulation.f. Patient is now allowed to relax in between tapping – want

to heighten or active tone.g. Four types of tapping:

1. Inhibitory Tappinga. Increases function of muscles which are weak

secondary to opposition by spasticity.b. Direction due into the movement pattern; i.e.

wrist extension desired: tap palmar surface of fingers toward wrist extension.

2. Pressure Tappinga. Increases postural tone against gravityb. Stimulate contraction of agonists and

antagonists togetherc. Often used with ataxics and athetoids to get

stability in midrangesd. Done arrhythmically – this is the difference

between pressure tapping and joint compression

3. Alternate Tappinga. Follows pressure tapping – a light tapping using

fingertips in an effort to facilitate balance reactions usually in a midposition.

b. Obtains proper grading of reciprocal innervation and stimulates balance reactions

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through recruitment. The resulting movement is inhibitory to spasticity.

4. Sweep Tappinga. The only type of tapping that is applied to a

muscle group. The prime mover is activated with broad sweeps and some pressure.

b. Usually for distal movement.c. Use when tone is normalized – a more

sophisticated facilitation technique.

4. Push – Pull:

a. Really a variation of #1 (compression) combined with directional cueing or joint traction.

b. Usually used with low tone, either primary hypotonia or with fluctuating tone as in athetosis or ataxia, BUT only after increased tone and clocks are NORMALIZED

c. Enhances tone and provides strong propriception and kinesthetic

Insert tables here

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Treatment Principles for the Cerebral Palsied Child

Children with Spasticity

Reduce hypertonus. Movement reduces hypertonus; therefore, move the patient and make him move. Aim at wide –ranged movements. Treat primary proximally (trunk, shoulders, hips). This will indirectly give reduced tonus distally.

Facilitate AUTOMATIC motor responses such as righting, equilibrium, & protective reactions & use them for sequential movements against gravity.

Introduce such movements in the normal neurodevelopmental sequence.

Counteract deformities with correct therapeutic handling & positioning. Don’t treat functionally too early – prepare for function.

Children with Fluctuating Tone (Athetosis)

Normalize tonus. Use weight bearing & tapping techniques when tonus is too low. Reduce tonus as when treating spastics when tonus is too high. Aim at getting SUSTAINED tonus for postural control.

Emphasize symmetrical alignment of head & trunk and have patient’s ACTIVE COOPERATION in so doing.

Facilitate (rather: organize) righting, equilibrium & protective reactions.

Teach control of intermediate range of movement, grading, holding and timing.

Treat functionally earlier than spastics and emphasize volitional involvement more than with spastics.

Children with Ataxia

Normalize tonus. Work for sustained contractions ( without effort) and grading of movement.

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Use it for maintaining positions while placing limbs. Be aware of abnormal FIXATION.

Incorporate lots of graded trunk rotation. Use techniques of intermittent holding (move – hold) If needed, use weights proximally but aim at decreasing weights and

removing them. Refine righting and equilibrium functions.

Children with Low Tone (flaccidity)

Build up tonus with various tapping techniques, but be aware of the potential danger of eliciting spasticity or athetosis.

Teach head control, engagement of hands (and feet) in midline. Emphasize breathing, especially in prone and sidelying. Eye contact and general response to environment is important to

obtain.

Applied Uses

1. Development of head and trunk extensionA. To stimulate head extension, arm

extension, hip extension and knee flexion, place the child in prone on appropriate size roll.

B. To stimulate head and trunk extension,

place the child in “knee standing” position with weight bearing on

knees, hips and extended arms.

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C. Place a child in sitting position straddled over the roll and position yourself behind him. Place child’s head and trunk face down on roll and then ask child to slowly extend segmentally beginning with the head and neck. Caution should be taken to prevent hyperextension of head and trunk which could elicit abnormal movement patterns. To help prevent this, therapist should hug child from behind, holding child’s arms above the wrist.

2. Development of forearm and hand controlA. “Prone Prop” the child on an appropriate

size roll. Encourage reaching, grasping and releasing.

3. Development of upper extremity weight bearingA. Place child prone on an appropriate size roll shifting

weight bearing from knees to upper arms.

B. Position child on all fours (creep position) with rollGiving moderate support.

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4. Balance activitiesA. Place the child in a sitting position on the roll straddling it. The roll

should be of a diameter that permits child’s feet to rest flat on the floor. The thigh and lower leg should be at right angles to each other. Trunk is leaning slightly forward from the hips. The hands are placed flat against the top surface of the roll between the knees. See illustrations below:

The child pushes up with first one foot then the other to stimulate a rocking motion. As the motion continues, the child should be able to compensate for the shifting position of the roll and maintain his original postural attitude.

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B. A variation of the above activity is to have the child hold his arms straight out in front of his body while “rocking”, thus maintaining his balance with trunk and legs only.

C. Have child lie down on the roll in a prone position (he lies lengthwise – not across it). His legs should be extended straight out from the hips with knees slightly bent to allow him to “hug” the roll with his legs. The arms will “hug” the roll as illustrated below:

Gently rock the roll from side to side asking the child to maintain his original position on the roll and compensating for the shifting center of gravity.

Or repeat exercises in 4C, but place the child in a supine position on the roll, with arm hugging sides and legs extended.

D. A variant of this activity is to have child extend his arms to the sides of his body and try to maintain his balance using only legs and shifting body weight as the roll is rocked side to side.

E. One a large roll, sit the child over the edge and rock the roll back and forth to stimulate full equilibrium reaction in upper and lower extremities.

5. Develop lower extremitiesA. Straddle roll in sitting position and gently rock left to right to reduce

muscle tone in legs and feet. Staying balanced on the roll, position legs out front to stretch hamstrings and abductors. To stretch heel cords, place hips, knees and ankles at 90 degrees or greater.

B. From a sitting position on an appropriate size roll with hands staying on the roll, bring the child to standing position to facilitate stretching hamstrings while controlling knee extension and hyperextension.

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C. Straddle appropriate size roll in kneeling position to provide moderate knee pressure with left – to – right balancing.

6. Develop trunk rotationA. Sit the child astride an appropriate

size roll and rotate trunk left and right.

B. Build on rotation by gradually leaning sideways to the point of touching the floor on either side.

7. Develop perceptual skillsA. The longer rolls make excellent seats

for the teacher and child for one-to-oneinstructional or sensory stimulationexercises. Working with flash cardsor other instructional aids whileteacher and child face each otheron the roll permits a more “private”atmosphere while encouraging balancecontrol for the child.

B. Two children can sit together on a roll for games such as “train ride” or “Simon Says”

C. Use rolls in an obstacle course to develop“over and under” concept. Roll can be crawled over or walked over, and crawled under when bridged between two chairs.

Wedges

Application: A wedge is primarily used as an alternative to sitting when a child lacks head control, lacks sitting balance and lacks the ability to adjust the trunk from poor posture.

Construction: Tumble Forms incline wedges are made of firm but flexible foam with durable Tumble Form covering bonded to the foam.

Sizes: Wedges are available in the following eight sizes (including five heights).

PC 2795A Wedge 4x20x22 in (10x51x56 cm)PC 2795B Wedge 6x20x22 in (15x51x56 cm)PC 2795D Wedge 6x20x26 in (15x51x66 cm)

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PC 2795C Wedge 8x20x22 in (20x51x56 cm)PC 2795E Wedge 8x24x26 in (20x61x66 cm)PC 2795J Wedge 10x20x22 in (25x51x56 cm)PC 2795F Wedge 10x24x26 in (25x61x66 cm)PC 2795L Wedge 12x24x26 in (30x61x66 cm)PC 4768B Add-on leg abductor wedge, 4 in (10 cm) high. Attaches with Velcro strip.

Selection of a particular wedge will depend to a great extent on the size of the child who is going to use it. In general the ideal size wedge for a child will be one whose surface is long enough to accommodate the child’s body (in the prone position) form sternum (breastbone) to the feet or at least to the knees.

Applied Uses:

1. Provide weight bearing on upper extremities

Position child in prone position on appropriate size wedge to accomplish:a. Favored weight bearing on shouldersb. Favored weight bearing on elbowsc. Favored weight bearing on extended forearms

2. Facilitate head raising and controlled movement

Position child in prone symmetrically with upper extremities extended over the upper edge allowing head to be unsupported.

3. Promote extension of hips and knees

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Place child in prone position symmetrically so that weight bearing is felt on trunk, helping the hips to extend and bear weight. In turn the knees will be freed to extend and bear weight.

4. Incline positioning while supine

a. Lay the child symmetrically on the wedge so that the head is in a down position (at the low end) to reduce tone. Maintain this for whort attended periods.

b. This position is also useful for postural drainage.

5. Facilitate normal pre-crawl development

a. Place child in prone position on a moderately inclined wedge so weight bearing is favored first on upper extremities as the lower extremities are positioned higher.

b. Conversely, if the weight bearing is favored on lower extremities, turn child around, positioning upper extremities higher. Proceed with gentle flexing to provide movement.

6. Facilitate rolling skills

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The child is placed crosswise on a moderately sloping wedge. The incline is used to assist the child in trunk rotation.

7. Reaching and grasping activities

a. Position the child symmetrically prone. The wedge should be of a height that permits the elbows and forearms to rest lightly on the floor. If the wedge is too low, the child will be weight bearing excessively on the forearms, preventing reaching or grasping.

b. The child may, for other reasons, need a wedge that is too high for reaching and grasping, leaving the play area too low. Since this condition will increase flexor spasticity, simply raise the play area on a board, stool or block. Of course, if the wedge is too low, place another wedge on top or prop the front of the wedge with blocks, towels, or sandbags.

c. Reaching and grasping activities also will help increase range of motion.

8. Therapist bracing

As you work with the child you will find wedges comfortable for you to lean against, prop against and brace yourself.

9. Side lying positioning

The wedge provides an ideal shape for relaxed side lying positioning on a slight incline.

10. Develop balance reactions

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Place two wedges butted together at the highest end providing an up and down ramp. The child has to adjust to balancing on the soft foam for left to right response, and to compensate for front to back changes while ascending and descending.

Balls

Application: The 16 inch and 22 inch balls are used for developing vestibular responses, balance, spatial orientation, body awareness and muscle strength. The smallest (11 inch) ball is primarily designed for rolling, pushing, throwing, catching and may also be used for adapted kickball.

Construction: Soft, yet firm foam, with colorful, cleanable, sealed upholstery. Tumble Forms’ unique coating helps to prevent the balls from sliding. The 22 inch (56 cm) ball is built with solid structural core with an outer layer of firm foam to prevent “bottoming out”.

Sizes:PC 2769C Neuro Developmental Training Balls Set

Contains all three sizes

PC 2769L Neuro Developmental Training Ball22 in (56 cm) has rigid core for adapted support

PC 2769M Neuro Developmental Training Ball16 in (41 cm)

PC 2769S Neuro Developmental Training Ball11in (28 cm)

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Applied Uses:

1. The 22 inch or 16 inch Balls; (16 in ball may be used with infants and small children for the gross motor activities described).

a. Balance activities

1. Lay child prone on surface of appropriate size ball; child’s arms should “hug” the sides of the ball while his legs are extended straight from the hips; hold the child at the hips with both hands and gentlybegin rolling from side to side, gradually increasing the distance of the rolling motion.

2. Sitting on the 22” ball; have child stand with the back of his legs against one side of the ball; have him sit on the ball while you roll it back until child is centered on top of the ball; move ball in different directions to stimulate balance reactions.

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b. Develop head righting and trunk extension

Give prone activities at a suitable working height while the child is prone on the ball as illustrated.

c. Develop trunk and upper extremities

1. Have child lie prone on the top ball with head, trunk and arms totally relaxed and hanging down against the sides of the balls; encourage child to raise his entire upper body from the ball’s surface to “fly like a bird” while giving him support with both hands on his hips or legs.

2. Use as a “push” ball

d. Elicit protective extension reflex: Lay child prone on appropriate size ball with arms in front of ball giving child support at hips, roll the ball forward and elicit the protective extension reflex.

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e. Develop supine flexion

Lay child supine on the ball with legs and knees flexed. Arms should be flexed as shown. Encourage child to flex head to elicit total flexion pattern.

f. Elicit trunk equilibrium response

1. Lay child prone on an appropriate size ball; again giving child support at the hips, gently rock ball forward/ backward and sideways.

2. Child sitting on ball with support at the hips. Do the same as above.

g. Stimulate trunk rotation

On the ball place child on his side using firm steady pressure push shoulders away from you and hip toward you, alternately pulling and pushing.

h. Facilitate relaxation

Especially appropriate for spastic children; decrease muscle tone by quietly rocking while child is in prone position on ball. The child’s reaction to this activity should be carefully monitored so that over – inhibition does not occur. It is especially important that this particular activity be supervised by

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a therapist.

i. Provide vestibular stimulation in different planes

j. Promote weight bearing on knees and ankle

For example: knee walking hugging the appropriate size ball.

k. Sensory Integration

1. “Sandwich” – begin with two children of approximately the same size. Have one lie supine on the floor with the 11” or 16” ball on is abdomen. Have the second child lie prone over the ball. Move the top child back and forth so that the ball rolls on the bottom child’s chest, abdomen and legs. This provides a “heavy touch” pressure to the child on the floor, eliciting prone extension and automatic equilibrium reaction from the top child.

2. Balance reactions, vestibular input, and prone extension can also be created by holding hands with the child while he is prone on the appropriate ball, thereby creating the required movement.

The 11” ball is primarily designed for rolling, pushing, throwing, catching and may also be used for adapted kickball.

It can be used to facilitate equilibrium reactions, in pre-K or younger children by having the child sit on the ball feet flat on the floor, while engaging in various activities. The more advanced child can be asked to rotate on the ball with his arms outstretched to the side while maintaining good balance.

Tumble Forms Scooter Boards

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Two scooter boards are available. One is a circular board, 24” in diameter square. Both are coated with Tumble Forms’ unique material for protection and easy cleaning.

The PC 4814B Round Scooter Board, with its Shepard casters, helps develop a child’s neuro-motor control as he propels himself in any direction, or swivels and rotates. The convenient handles on the sides prevent injury to his hands and help to support the child. The child may also be pulled or pushed or rotated by a therapist, teacher or playmate.

As the Scooter Board moves, he learns to orient his body to shifting space and to reorient his balance. The Round Scooter may also be used like the Jettmobile to rotate the child, first in a clockwise, then a counter-clockwise direction.

It should be emphasized that for reasons of safety, the child should never stand on the Scooter Boards, and all activities should be supervised.

As for the PC 2780A Gym Scooter, this smaller square unit may be used for the same types of mobile activities and spatial orientation. However, the smaller size of the board and the lack of handholds limit its use to the child able to propel himself and to control his balance. It may, of course, be pulled by a second child or teacher if the child on the scooter holds on to a rope, but this type of activity also requires a measure of control.

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Russell Sage CollegeDepartment of Physical Therapy

PTH 417

Let’s get on the ball

(The Swiss Ballgymnastik Technik)A handout presented to participants at a workshop on Swiss Ball Gymnastics

Rationale:

Mature coordinate movement (1) is achieved through the interaction and integration of several developmental components. Rights and equilibrium reactions are vital to normal sensorimotor development (2), and to attaining and maintaining an upright posture.

Posture is almost continuously mobile (3) and, when in motion, postural influences are needed to maintain stability. In mature coordinate movement, these adjustments are provided automatically. Martin (3) states that “associated with every voluntary movement which significantly changes the shape of the body there is a postural adjustment which has the effect of protecting the equilibrium.” Most postural adjustments affect the entire body through a chain of reactions (4). In the rehabilitation of the individual with disturbances of muscular control, postural adjustments and righting and equilibrium reactions should be understood in order that adequate assessment and treatment can be accomplished. To aid in this understanding, rationale for one component of coordinate movement – development of a normal postural reflex mechanism is proposed as follows.

In the normal development of the child, equilibrium reactions in sitting and quadriped positions are integrated before the child will be able to independently come to standing or take his first steps alone (5). In attempting these higher level functions, primitive reflexes or postures are often demonstrated (as in the high guard position of the arms due to the influence of the parachute reaction) (6). When an individual with an level of development, the nervous system reacts to the stressful situation and the release of more primitive mechanisms can be seen in movement and posture (4,7,8,9). When the stressful situation is removed, the primitive reflexes no longer dominate, and the individual can once again control his movements and posture.

According to R. Magnus (10) in his 1924 publication, “korperstellung”, postural reflexes play a fundamental role in the formation of normal animal postures. He also suspected the presence of similar reflex activity in normal

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healthy adults, but failed to observe these reflexes in adults as basic patterns of movement due, in part, to the action from higher nervous system centers. He demonstrated that the postural reflexes were manifested in the human in certain clinical cases of cerebral dysfunction (as in Cerebral Palsy, brain tumor, etc.). Once such postural reflex, the righting reflex, refers to the reflex movements which occur to recover the normal position of the head and / or body when they are changed in relation to the earth or to the horizon. In explanation of this reflex, Fukuda (11) stated that with elicitation of the reflex, the vestibular organ mainly participates along with visual and proprioceptive senses. Fukuda also studied two other postural reflexes in normal, healthy adults: the tonic neck and tonic labyrinthine reflexes. He concluded from his research that the postural reflexes exist in the human “extrapyramidal system” as reflex patterns and their manifestations in normal healthy adults usually are inhibited by impulses arising from the cortex or higher centers in the brain stem. However, with maximal neuromuscular effort, these higher centers “actively connect with the extrapyramidal system” and manifestations of those reflex patterns may occur in daily movements. Fukuda’s studies were done with normal, healthy adults engaged in athletic or recreational activities. He concluded that many such activities will include movements which can be more efficient or forceful if a postural reflex is incorporated with the volitional dynamic movement.

It is suggested from the research of Magnus and Fukuda that when the human nervous system is under stress, such as in strenuous neuromuscular activity or cerebral dysfunction, postural reflexes are either excited or not inhibited to the usual degree. When the postural reflex mechanism is impaired, normal coordinate movement is no longer possible. The fine adaptations necessary for maintaining an upright posture or making the fine adaptations necessary for postural stability upon which coordinate mobility can be superimposed is difficult (12, 9).

In the case of individuals who demonstrate some type of cerebral dysfunction, higher levels of function are difficult to coordinate. For example, the person who has incurred a hemiplegia secondary to a CVA may not be able to walk without the use of a brace and crutch or cane. He is unable to make normal postural adjustments due to the varying degrees of loss of proprioceptive and sensory motor function (13).

Following an insult to the human nervous system, the reappearance of primitive reflexes may interfere with coordinated functioning in the upright posture. Removing the stress on the nervous system by allowing the individual to first develop postural control in prone, supine, sitting and quadriped positions will facilitate the development of normal coordinate movement. Rehabilitation therapists attempt to improve postural adjustments in patients with disturbances of neuromuscular control through the use of many varied techniques, almost all of which are based on certain

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common denominators, the nervous system and normal coordinate movement. One such therapeutic technique, or tool, for attempting to activate more normal postural adjustments is the use of the Swiss Gymnastic Ball as an adjunct to the treatment program.

The Swiss Gymnastic Ball seems to be more effective than a chair or stool due to it’s narrow base of support and dynamic qualities. The patient or participant must, of necessity, make fine postural adjustments in order to stay on the ball. As long as righting reflexes are present so that the individual can maintain an upright sitting posture with minimal assistance, the Swiss Gymnastic Ball can be an adjunct to the treatment program.

An imaginative and skilled therapist can adapt Swiss Ball Gymnastics for use in many varied treatment programs, ranging from those designed for persons with severe neuromuscular disorders to conditioning exercises for normal healthy adults.

The technique must be continually adapted to the individual needs of the patient in order to be effective. Consequently, the therapist who uses Swiss Ball Gymnastics as a part of a treatment program must be alert to the responses of the patient, skilled in evaluating the patient’s needs and creative in developing and adjusting the techniques.

Assessment:

The primary use of Swiss Ball Gymnastics is an adjunct to the treatment programs for persons with problems of neuromuscular control, although in selected cases, it may be the comprehensive treatment program. The criteria for including Ball Gymnastics in a treatment program will, therefore, be determined by the results of an initial and continuous patient assessment.

In a goal-oriented treatment program, the assessment determines and continually influences the treatment (14); if, for example, the patient’s diagnosis is hemiplegia secondary to CVA, depending upon your experience and training. Many approaches to hemiplegia emphasize the importance of initial and continuous assessment based on the identifiable stages of recovery. If you are skilled in the use of Brunnstrom’s (13) “Movement Therapy in Hemiplegia”, you have an existing assessment form and procedure at your disposal. Your own assessment or those for other therapeutic approaches to hemiplegia with which you feel comfortable could also be used effectively. The important thing is to ascertain a baseline measurement of the patient’s abilities and needs. After determining the goals of treatment in this manner, your approach to treatment will be influenced by your experience and training. Skilled use of the Swiss Ball

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Gymnastic Technique will give you an additional tool in attaining the treatment goals you have established.

Assessments are available with which you can establish a baseline measurement for your patients, whether the problem deals with neurologic disorders, decreased range of motion, functional muscle function, or any of a myriad of difficulties. Whatever type of assessment is used, if the patient demonstrates a problem with balance and equilibrium reactions, or in strength and coordination, the Gymnastic Ball can be useful in the treatment program provided that the following minimal readiness criteria are met.

Readiness Criteria:

1. Off the Ball

A. Be sure the patient is medically stable (consult a physician before using Ball Gymnastics).

Review and/or check the patient’s status, including:1. Cardiopulmonary function2. Seizure activity which may be stimulated by ball gymnastics3. Tendencies toward dizziness and/or nausea4. Hemorrhagic tendencies5. Blood pressure

B. The patient should be able to sit on a chair or mat table independently. This suggests that:

1. Head righting reflexes are present (righting reactions should be assessed in prone, supine, and sitting).

2. Protective extension responses of upper and lower extremities may be absent or delayed, but the potential should be considered good for an increase in functional neuromuscular control.

3. Trunk stability and lower extremity function are sufficient to maintain a midline sitting posture provided the base of support is stable.

2. On the Ball

A. In a guarded situation (giving the patient assistance if necessary by providing external support at the hips or knees and feet), can he/she:

1. Stay seated on the ball, maintaining approximately a 90 degree angle at the hip, knee, and ankle, and anterior-posterior stability.

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2. Maintain a midline position (lateral stability).

The above will require fair abdominal function and co-contraction of trunk musculature, as well as poor to fair lower extremity muscle function.

B. If pain or spasticity increase, reassess, adapt your treatment program, or discontinue Swiss Ball Gymnastics.

Remember that the above are minimal readiness criteria. Any regression in function is indication for critical re-evaluation of the patient’s abilities and your treatment program.

3. Additional Precautions

A. Contractures, calcification, posture disorders, and surgery must be noted, as their presence will influence the treatment program.

B. Be sure to safeguard the patient at all times, particularly during the initial treatment sessions.

References

1. Oogler, C: Self-Instructional Package on Differentiation of Human Skeletal Muscle. Physical Therapy Dept., School of Allied Health, Georgia State University, 1974.

2. Gunsolus, P., Welsh, C., Houser, C: Equilibrium Reactions in the Feet of Children with Spastic Cerebral Palsy and of Normal Children. Develop. Med. Child. Neurol., 1975, 17, 580-591.

3. Martin, J.P. The Basal Ganglia and Posture. J.P. Lippincott, Co., Philadelphia, 1967.

4. Gilfoyle, E. & Grady, A. A Developmental Theory of Somatosensory Perception. Published in The Body Senses and Perceptual Dificit, edited by Anne Henderson & Jane Coryell. From Proceedings of the Occupational Therapy Symposium on Somatosensory Aspects of Perceptual Deficit, Boston University, Boston, MA, 1972.

5. Milani-Comparetti, A. and Gidoni, E. Routine Developmetal Examination in Normal and Retarded Children. Develop. Med. Child. Neurol., 1967, 9, 631-638.

6. McGraw, M.B. The Neuromuscular Maturation of the Human Infant. New York: Hafner, 1966.

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7. Bobath, K. The motor Deficit in Patients with Cerebral Palsy. Clinics in Developmental Medicine., No. 23, 1966.

8. Hellebrandt, F.A., Houtz, S.J., Partridge, M.J., Walters, C.E.: Tonic Neck Reflexes in Exercises of Stress in Man. Amer. J. Phys. Med., 35:144-159, 1956.

9. Fiorentino, M.R., Normal and Abnormal Development. Charles C. Thomas Publisher. Springfield, IL. 1972.

10. Magnus, R., Korperstellung. Berlin, Springer. 1924.

11. Fukuda, T. Studies in Human Dynamic Postures From the Viewpoint of Postural Reflexes. Acta Oto-Laryngologica Karlavagen 41, Stockholm, 1961.

12. Stockmeyer, S.A. A Sensorimotor Approach to Treatment. Physical Therapy Services in the Developmental Disabilities. Leila Green, Ed.

13. Brunnstrom, S. Movement Therapy in Hemiplegia. Medical Dept., Harper & Row Publishers, New York, 1970.

14. Stockmeyer, S. A Pattern for Evaluation in the Assessment of Motor Performance. In The Child with Central Nervous System Deficit. A report of two symposium. U.S. Dept. of HEW, 1975.

Sporthaus-Brinckmann44 Munster/westf.

Prinzipalmarkt 22/23

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Postfach 1528Germany

The “Hippity Hop” can be used for simple exercises.

B. Techniques:

A good spotting technique is for the therapist to sit on another ball or rolling stool behind the patient while facing a mirror. The patient feels safe with this arrangement. The therapist can shift to facing the patient when both feel more secure. From this position, it’s possible to correct postures, give resistance when indicated, and still be close enough for safety. Dental dam can be placed around the thighs just above the knees to facilitate hip abductors even more, and it seems to also facilitate dorsiflexors in some exercises. Music helps rhythm, increases motivation, and tends to decrease inhibition in some patients.

C. Precautions:

Ball gymnastics require much cortical effort in the beginning, and it is exhausting. Work totally within your patient’s tolerance. At first, give minutes may be too much! Be extremely cautious with CVA patients due to hemorrhage or whenever there is a possibility of hemorrhage. If low back pain is experienced, recheck posture, test abdominal strength, and if necessary, discontinue the ball. The quick stretch given the biceps when bouncing, especially in the upper extremities, may cause an increase in spasticity.

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Part II: The Basic RoutineAdapt According to Individual Needs

The Warm-Up

1. Sitting Posture

Chest high!

2. Stretch & Bouncea. Stretch to extreme & then relax into a slow bounceb. Swing both arms in an alternating pattern

Rotation Patterns:a. Alternate sidesb. Do first without bouncec. Use the basic technique of PNF diag. patterning

3. Trunk Rotationa. Alternate sides without bounceb. With bounce

4. Lateral Bendinga. Alternate sidesb. Try without bounce and then with a bounce

Maintain “plumb-line” posture: shoulders relaxed & level, weight equally distributed over both feet in a comfortable base of support. Knees should be directly over feet. DO NOT allow anterior pelvic tilt.

PNF patterns may be added to this exercise.

Stretch to the extremes of this exercise. Straighten the leg to which the arms are directed.

Stretch as far as possible; do this slowly. Depress shoulder, Adduct scapula. Keep knees apart and feet flat on floor. Stress rhythm. Keep eyes on the hand which is “behind”.

Attempt to touch the floor on each side. Allow basic righting and equilibrium reactions to “happen”.

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The Gymnastic Routine (Beginning Balance)

1. Basic Sitting Posture

a. without bounceb. with bounce

2. Reciprocal Arm Swing

3. Pelvic Mobility(for stability)a. Anterior-Posterior pelvic tiltb. Lateral pelvic tilt

(both sides)c. Combined Circles

4. Walking Rhythma. Alternate feet onlyb. Add reciprocal arm swing

5. Marching Rhythma. Alternate legs only

b. Add reciprocal arm swing

These techniques should be attempted first without a bounce & then with a bounce. Try each component of the more complex techniques individually before combining them. Resistance may be given at the hips.

Watch that knees remain “over the feet”.

The pelvis is to be motion & not the legs or upper trunk. Pelvis stability is essential for successful performance of the exercises which follow. This is more difficult than it appears & most patients need careful instruction & practice to develop this skill.

Constantly check on maintenance of good posture. Feet may be brought closer together to maintain balance.

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Check that lumbar curve is not lost. Hamstring or low back tightness

will prevent maintenance of correct posture. Do not sacrifice correct posture for a straight leg.

These Exercises Require Fair-to-Good Balance/ Equilibrium Reactions

6. “Hippity-Hop”a. Bounce around in one

direction & then the other, allowing feet to rise.

b. Bounce around as in “a” but keep always in contact with the floor.

7. Leg Abductiona. Alternate legsb. Increase timing

8. Leg Extensiona. Alternate legs

9. Slow Side Rolla. Pelvic hike

b. Rotate trunk to face straight leg

The footwork on this exercise is beneficial. Weak abductors will be obvious in this exercise.

Bounce leg out to side in short hops at first. Progress to bouncing it out in 1 hop. For coordination, bounce out & in change legs in rhythm to bouncing on the ball. Finally, bounce from one side to the other without a center stop position.

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Bounce each leg out to the side and around to the back. Stretch hip flexors & return by bouncing the leg. At extreme extension, the ball should be under the thigh of the “forward” leg.

This exercise is good also for teaching one leg kneel for coming to standing.

Maintain abduction of the “bent” leg at all times. Sit forward on the ball.

More Difficult Exercises

10. Sit to Supinea. Toe touch

b. Roll backward

c. In supine, ball should be between scapulae-hips high

d. When a,b,c are done easily in position, roll ball slowly to the side alternating sides.

Keep the ball at midscapular level; do not let it go too high.

Weak abdominals, hamstrings or gluteus maximus may prevent this exercise from being performed correctly.

Keep hips high and level (see arrow)

Rotation should be accomplished in the upper trunk while pelvis stabilizes.

11. Sit to Pronea. Bend and straighten elbows

in prone; kick both straight legs high.

b. “Flutter-kick”

c. One arm stand; check to see that scapula is well stabilized.

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Rotate pelvis, abduct “upper” leg. Look over the shoulder at abducted leg. This exercise should be performed slowly and with control. Alternate sides.

12. Prone to Kneesa. and return

b. rotate

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Become proficient at ball gymnastics before attempting to teach them to your patient. This will give you an appreciation of how fatiguing it is and, also of the degree of cortical input necessary in the beginning.

Children’s Rehabilitation Hospital

Department of Physical Therapy

Incorporating Therapeutic Handling into Daily Care Activities

Therapeutic handling can be defined as holding, positioning and moving the baby in such a manner as to inhibit/ discourage primitive, and/or abnormal postures and movements and facilitate or encourage more desirable postures and movements. This handling can be incorporated into the daily care of the babies while in the nursery and later, at home.

Babies become comfortable in postures in which they are placed and with movements which they have already used. This frequently will be to the exclusion of more normal ones. The baby learns and perceived these postures/ movements as “normal”. For example, a premature baby becomes very comfortable lying in supping with the neck hyper-extended and rotated to the side, scapular adduction, shoulder extension and elbow flexion and the lower extremities in a frogged-like position (flexed, widely abducted and externally rotated). This posture, if continued will delay the baby in acquiring a midline head position with a chin tuck in supine, engaging hands in midline and engaging in hands to knees and hands to feet play, (all important movement components and building blocks for later gross motor skills). Some babies will arch their hips, trunk and head into extension while in their cribs or when being handled. This, too will prevent the normal

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acquisition of anti-gravity flexor control (head midline, hands engaging, etc.) needed for normal movement.

The more the baby is allowed to lie and move in primitive/ abnormal postures, the stronger and more habitual they will become. Through handling we can prevent, or at least minimize their strength and frequency.

The baby who is relaxed with limbs “collected” in flexion is less irritable and better able to accept visual and auditory stimuli, feeding and general movement.

In the intensive care and transitional nurseries, the nurse is with the baby frequently. She is in an ideal position to handle the baby therapeutically during feeding, diapering and positioning while monitoring his physiologic responses to this handling. The handling need not add more time to the daily care program.

Some suggestions for therapeutic handling are as follows:

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