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Neurofacilitation techniques

Sensory input to the CNS produces reflex motor output. The various neurofacilitation techniques are based on this basic principle. All of the techniques aim to normalize muscle tone, to establish advanced postural reactions and to facilitate normal movement patterns.

Vojta method of therapy Vojta established 18 points in the body for stimulation and used the positions of reflex crawling and reflex rolling. He proposed that placing the child in these positions and stimulation of the key points in the body would enhance CNS development [A,B]. In this way the child is presumed to learn normal movement patterns in place of abnormal motion. Positioning and stimulation techniques are different from NDT. Vojta states that therapy should be applied by the primary caregiver at home at least 4-5 times daily and stopped after a year if there is no improvement.

Bobath neurodevelopmental therapy This is the most commonly used therapy method in CP worldwide. It aims to normalize muscle tone, inhibit abnormal primitive reflexes and stimulate normal movement. It uses the idea of reflex inhibitory positions to decrease spasticity and stimulation of key points of control to promote the development of advanced postural reactions [C]. It is believed that through positioning and stimulation, a sense of normal movement will develop. An important part of therapy of the infant is teaching the mother how to position the child at home during feeding and other activities [D]. The baby is held in the antispastic position to prevent contracture formation.

Benefits and limitations

Physiotherapy cannot correct the movement problem in CP. A few rare cases reach their full potential through physiotherapy alone, the majority of children need other interventions. The effect of physiotherapy in preventing contractures and deformities or improving balance and coordination [F,G] is also limited. Physiotherapy is beneficial in promoting the neurological development of the child and teaching the child to use his existing potential in the best possible way. By improving mobility, physiotherapy may also prevent secondary mental and psychosocial retardation. However, the success of treatment depends on the neurological capacity of the child. An allegory can be made with sports: even with the best coaching, an athlete cannot compete in the Olympics if he does not have the potential. Similarly, even with the best physiotherapy, the child with CP cannot walk [H,I] if he does not have the neurological capacity. The treatment team must be careful therefore not to raise any false hopes about the outcome of physiotherapy in children.

The efficacy of neurofacilitation techniques in improving the neurological impairment is controversial. Meta-analyses of neurodevelopmental therapy (Bobath) have shown that the functional status of the children at school age are the same regardless of having received therapy or not.

Long hours of intensive physiotherapy can harm the child in many ways. It interferes with play, schooling, family and peer relations. Organize therapy so as not to disturb normal childhood.

In the Vojta technique the therapist positions the baby to initiate crawling and rolling. The principle is to hold the head in a straight line with the body. Stimulating certain points in the body by applying pressure with the fi ngers causes refl ex movements. It is unclear whether these refl ex responses evolve into voluntary movement in the child.

Therapists try to elicit advanced postural reactions while preventing abnormal movements in the Bobath approach.

What can physiotherapy accomplish? Assist in the neurological development of the child.

Enable the child to use his existing potential in the best possible way. Improve mobility and prevent secondary psychosocial retardation. Prevent contractures and deformities in some cases.

Therapists try to develop balance in the kneeling position. Develop- ment of the control of pelvic muscles is an important step.

F

F

E

E

D

D

C

C

B

B

A

A

G

G

Work on ambulation in the parallel bars and with crutches. Use a wedge on the fl oor to keep the feet apart.

H

H

II

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Rehabilitation & Physiotherapy

H

H

OT aims to improve hand and upper extremity function in the child through play and purposeful activity. There are defined systematic treatment methods for occupational therapy. Ayres sensory integration therapy aims to enhance the child’s ability to organize and integrate sensory information. In response to sensory feedback, CNS perception and execution functions may improve and the motor planning capacity of the child may increase.

Begin therapy toward one year of age when the child can feed himself using a spoon and play with toys [A]. Teach the child age-appropriate self care activities such as dressing, bathing and brushing teeth [B]. Encourage the child to help with part of these activities even if he is unable to perform them independently. Always include play activities in the rehabilitation program. Play improves mental capacity and provides psychological satisfaction. Organized play can address specific gross and fine motor problems in the child and take the place of boring exercise protocols. This increases the child’s compliance with therapy. For example, riding a toy horse may improve weight shift over the pelvis, swinging may improve sensation of movement.

Sports and recreation

Disabled children need to be involved in sports and recreational activities just like their able bodied peers. Sports and recreational activities also form part of the rehabilitation program. Physical activity plays an important role in physical development, general fitness and health. It provides fun and recreation. Physical and occupational therapy combined with recreational activities or adapted physical education increases efficiency of rehabilitation and assist the disabled child to use his potential. It is difficult and time consuming for a child to continue physiotherapy once he is in school. If he does, he will be alienated from his friends. Sports and recreation benefit the child because they save him from going to long hours of physiotherapy and being apart from his friends, from loss of valuable time for lessons and play. In the meantime sports provides the only means of improving the child’s neuromotor abilities and preventing deformities when he is at school. Through sports and recreational activities, the child has the ability to participate in the world of normal children, will not feel left out because of hours of physiotherapy and will improve his neuromuscular functional status.

There are a variety of summer and wintertime sports that the disabled child can participate in [C,D]. The competitive aspects of involvement in sports and games is basic to human nature, however many physically handicapped individuals frequently do not have the physical attributes to participate fully in different sport activities. Therefore most of the modern games and sports are modified for handicapped persons. The rules of the sport or the game are modified to meet the needs of disabled person (wheelchair tennis), or specially designed adapted devices are used for physically disabled to compensate or substitute the loss of muscle strength or function (downhill skiing) [E]. Some modern sports require very high-technology equipment, but most adapted equipment and devices can be easily made or adjusted locally [F].

Sports scientifically shown to have significant therapeutic effects in CP are swimming [G,H] and horseback riding. They help to increase muscle strength and range of motion in the joints, improve sitting balance and body control and provide fun.

Children can learn simple tasks at home. They can learn how to look after themselves. They need coaching to master bath- ing, grooming and toileting skills.

Summertime sports Swimming Athletics Wheelchair basketball Tennis Table tennis Wheelchair racing Shooting Archery Canoeing Kayaking Sailing Weightlifting Football Wintertime sports Downhill Two track skiing Three track skiing Four track skiing Mono-and bi-skiing Sit-skiing Cross-country skiing

D

D

C

C

B

B

A

A

G

G

The child develops hand-eye coordination by playing with simple toys. She also experi- ences a sense of accomplish- ment, improving self image.

Most children love to swim, or at least be in the water. The buoyancy of water helps movement and inhibits muscle tone. Splashing about is a lot of fun. Prescribe aquatic exercises as therapy in the less severely involved child.

E

E

F

F