Indian J Pediatr 1992; 59 : 691-696

The Neurodevelopmental Approach in Early Physical Intervention for Motor Delay and Cerebral Palsy

Monica Hopkins

Department of Occupational Therapy, Christian Medical College & Hospital, Vellore

Cerebral palsy is estimated to be file second largest category of disabling conditions :unong children in India) World wide, 0.15% to 0.20% of the population are af- fected, which brings India's figure to ap- proximately 2 million.

In Europe and the United Kingdom Dr. & Mrs. Bobath had studied the wtrious mani- festations of cerebral palsy since the 1950's. Over many years they developed the form of treatment, now more commonly known as neurodevelopmental treatment (NDT). Mrs. Bobath, physiotherapist, and Dr. Bobath, be- lieved that though motor delay was evident, it was not possible to diagnose cerebral palsy adequately in the first 3 months of life, ex- cept in the more severe conditions, z How= ever, they also emphasised file importance of very early identification of motor delay and intervention, in the form of physical treat- ment to prevent the development of abnor- mal patterns of movement. This indicates that follow up screening and appropriate treatment should be given to any infant with established risk factors present at bir|h.

A baby with brain damage causing any sign of delay in development or change in muscle tone, should be identified and treated before wrong movement patterns develop. When such a baby is deprived of early treat-

Reprint requests : Ms. Monica Hopkins, Department of Occupational Therapy, Christian Medical College & Hospital, Vellore-632 004.

ment, there is a strong possibility that per- manent dysfunction in mental, physical and emotional factors will result, due to lack of the stimulation to develop normal responses. During the first years of life the child's brain is most amenable to learning perceptual con- cepts, thought processes, and movement pat- terns, and therefore great importance is placed on early stimulation. Emotional de- pendence and behavioral problems also tend to develop in the early years, due to frustra- tion caused by physical limitations. They cannot be covered in this article, but are an- other important reason for early treatment.

The Nature of Cerebral Palsy

Definition and manifestations. Cerebral palsy may be described as a persistent disor- der of movement and posture associated with a static lesion of the brain, occurring during early maturation of the central nervous sys- tem. It causes abnormal muscle tone and incoordinated muscle action, resulting in an inability to maintain posture and balance, and a lack of normal movements?

Changes in muscle tone and sensation of movements. Normal muscle tone is neces- sary for postural adjustment of the body in performing movements. From tile time of birth a normal baby develops motor abilities in a recognised sequence. Gradual develop- ment of postural reactions gives him head

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control and positions the head in relation to the body and limbs. The baby's first auto- matic movements, the righting and equilib- rium reactions, are initiated by the proprio- ceptive system, which helps to lay down sen- sory motor patterns of voluntary movements and functional skills. The sensation of a movement is what the baby learns, and therefore what he continues to repeat.

When muscle tone and postural reactions are abnormal, it is the sensation of abnormal posture and movement that is learnt and which becomes habitual. With these abnor- mal sensory experiences the infant cannot achieve normal motor patterns and postures. For this reason Dr. Bobath described cere- bral palsy as a sensorimotor disorder rather than a motor defect.

Pathological reflexes. The cerebral palsied child's nervous system does not mature in relation to his age, and primitive reflexes and reactions persist. Reflexes are a part of normal motor development. But if these nor- real reflexes persist beyond the appropriate age, they interfere with normal motor devel- opment and become pathological reflexes.

An awareness of each posturaI reflex is necessary in order to identify lhe movements of a cerebral palsied child, and the effect that each has on their postural reactions. Proprio- ceptive reflexes initiating in the neck muscles, such as the asymmetrical, labyrin- thine and symmetrical tonic neck reflexes, affect the whole body's reaction, e.g. when a spastic child sits on flexed knees with his head flexed, his arms will tend to flex. If his head is raised, he may automatically respond with extension of his arms due to the influ- ence of the symmetrical tonic neck reflex. If this reflex is very strong, and the tonic laby- rinthine reflex weaker, his legs will go into extension as his head and arms flex. This

primitive response prevents file development of crawling.

Neurodevelopmentai treatment, This aims first at normalising muscle tone by inhibiting the pathological tonic reflex activity. The unwanted reflex patterns are broken up by the use of reflex-inhibiting postures and pat- terns of movement. Normal postural reac- tions are potentially present, and can be acti- vated or facilitated, and established by repe- tition. The methods of handling the infant, to achieve this inhibition of unwanted reflex patterns, and facilitation of more normal movement and postures, are outlined briefly below.

NDT Methods for Early Treatment of Common Manifestations of Cerebral Palsy

The essence of neurodevelopmental treat- ment lies in an understanding of the various normal developmental patten~s of move- ment, and the identification of reasons for inability to achieve these patterns. 4 The common manifestations of cerebral palsy and their treatment are as follows :

The baby with motor delay-handling and positioning. The baby showing delay in de- velopment, belore neurological ,signs are apparent, benefits from handling techniques which facilitate the early movement patterns and positions? These may also be taught to the mother or caretaker in order to gain the most benefit:

(i) Lie the baby prone on a firm surface. This w i l l encourage movements of his head against gravity, pivoting sideways, leaning on his forearms and hands, pulling his knees up and reaching forward with his ,arms. All these strengthen him for precrawling activ- ity. Avoid lying him in supine, as this

!~IOPKINS : NEURODEVELOPMENT~-0 . A P P R O A C I t T O C E R E B R A L PALSY 093

~equires no attempt from him to move. (it) Place him prone over a wedge cushion, a roll, or across his mother 's leg, to raise him at chest level. This increases head raise, bearing weight on his arms, and widens vis- ual experience. (iii) Roll him, by turning his head to one side and waiting for his body to follow. Repeat this on each side. (iv) Support him sitting, legs flexed. Use a floor seat that can support him so that he can

' ' O observe the day s events gore= o~. (v) When ready, encourage sitting with the support of his own hands. This will increase protective responses and balance.

] 'he Infant with Increased Muscle Tone & Spastic Patterns

The damaged pyramidal system results in limited movements of stereotyped synergis- tic patterns. Tone is high in flexors of the upper limbs and extensors of the lower ex- tremities. Tonic neck and labyrinthine re- flexes pre-dominate. Stimulation of a short stretch reflex increases tone, while a pro- longed stretch decreases it. Contractures fornl easily, due to continual use of the pre- dominant reflex positions and lack of change in position. These must be prevented by con- stant use of dynmnic reflex inhibiting pos- tures (RIP's).

RIP's are postures which cause the proxi- mal joints to oppose tim pull of the abnormal reflex pattern, to file extent that they totally inhibit it. 6 From these postures file therapist can facilitate more normal movements. She uses her hands and body, the assistance of gravity and of appropriate equipment, to bring about this inhibition of the antagonists, in order that the agonists might be released to perform the movement required. At first file therapist assists this movement, and later only controls it until tile child learns to

*'take over" the action. Experiencing Ihe sensation of the new movement repeatedly will enable this more normal pattern to be learned, and then become automatic. The points of control used are over the proximal joints; the neck, trunk, shoulder girdle, and hips. Reinforcement of control in the muscle groups opposing the spastic pattern is achieved by tapping the opposing muscle groups, and by approximation or weight bearing over tile appropriate joints. Facilitation, or eliciting spontaneous active movement , is achieved by the therapist through skilled handling, in order to stimu- late normal righting reactions, while inhibit- ing the abnormal reflex, e.g. to facilitate head control in extension for an infant exhib- iting a total primitive flexor reflex pattern, die handling is as follows:-

RIP Facilitation

Place the infant prone over a roll, legs ext- ended, arms weight bearing forward (fle- xor reflex pattern inhibited by tim roll).

Raise file infant's arms forward in external rotation, with elbows ext- ended until a re- sponse of head raise and trunk extension is achieved. Rein force this with visual stimulation in this position.

When facilitating, a skilled therapist is al- ways aware of the child's part in the move- ment or activity, and will encourage his con- trol as much as possible. The more the thera- pist can remove her hands from tile child, the more effective tile facilitation has been. Handling requires sensitivity to file child's reactions, to ensure a controlled response. Over stimulation is counterproductive as it

694 TttE INDIAN JOURNAL OF PEDIATRICS Vol. 59, No. 6

can cause unwanted increase in tone. Facili- tation, in terms of range and speed of move- ment, should be adequate but not excessive, ensuring the child "takes over" the action himself.

Prevention of contractures - which develop in persisting reflex positions and patterns. This tendency occurs when RIP's are not used at all times, e.g. a persisting symmetri- cal tonic neck reflex (STNR) encourages "kneel-s i t t ing" and "bunny hopping", which lead to tightness of hip flexors, ham- strings and tendoachilles. The contractures that develop will prevent standing and crawling and the development of reciprocal leg movements.

Treatment includes :

-- Manual stretching and positioning of vulnerable joints regularly each day.

- Carrying the infant in the way that works best against the abnormal reflex patterns, e.g. with head and body flexed and arms in the midline, for the infant with a predominant extensor pattern,

-- Positioning the infant in the RiP's throughout the day. This may include use of appropriate aids or equipment such as a roll, floor seat, gaiters, or sandbags.

Dynamic weightbearing is required for ad- justment of trunk and limbs to maintain pos- ture. This is achieved through weight trans- fer-sideways, forwards, backwards and di- agonally-while manually giving pressure and resistance to control the action. This may be done with the infant prone over a roll, or us- ing a therapy ball. For a baby with hem- iparetic involvement, dynamic weight bear- ing with the affected limbs as a precrawling exercise is essential if one sidedness and bot- tom shuffling are to be avoided.

The Low Toned, Ataxic Infant

This baby has very little movement, but nor- mal passive range at all joints. He is usually happy when left supine by the mother, and becomes imtable when any attempt is made to change this secure position in which he has to play no active part.

Treatment consists of stimulating muscle contraction to maintain antigravity positions. Neurodevelopmental treatment techniques used are compression, blacing and cutaneous stimulation. 6

Compression of the neck to stimulate head control may be clone with the infant fully supported sitting upright. Slight trac- tion, lifting the head away from the~body, is followed by compressing it downwards, carefully maintaining the erect posture. This is repeated a few times, followed by a pause for the response of contraction in the neck muscles. The pattern is repeated.

Compression of shoulder, elbow and wrist may be clone in side-lying or supported sitting. The therapist holds the baby's right hand with her right hand, supports his elbow with her left palm, and gives a pull followed by a push in which weight is born through the wrist and extended elbow to the shoul- der. This is repeated, followed by pauses for response, and the action ends in weight bear- ing on the extended hand. The left arm is stimulated similarly, held by the therapist's left hand. Compression of the leg may be carried out in a similar way, the ankle being held at 90 ~ .

Placing and holding is the ability to maintain the position of a limb in any pos- ture in space. The position is the stimulus Ibr the muscles automatically to adapt to these changes. Toys are held in various positions for the infant to reach out and touch, topple or grasp. When this is impossible, the thera-

HOPKINS : NEURODEVELOPMENTAL APPROACtt TO CEREBRAL PALSY 695

pist takes the child's arm lightly between her palms, patting it from one to tile other in a movement sequence, and then leaving it momentarily to hold tile position. This en- courages normal co-ordination of move- ments.

Cutaneous st imul at ion - tapping. Tap- ping is often used in combination with plac- ing, as it increases postural tone by proprio- ceptive and tactile stimulation. When there is very low tone, it can take some minutes and a series of taps before a response can be elicited. Each tap is followed by tile next in quick succession initially, and as the re- sponse is elicited the speed is reduced. Tap- ping is not done directly on tile muscles to be stimulated, but towards the direction of tile desired functual pattern. Swee p tapping is done with a sharp sweeping stroke of the therapists extended fingers along the length of the muscles, towards a synergic pattern.

T h e Athetoid Chil d

The fluctuating tone of athetosis often devel- ops from the low tone of a " f loppy" baby. Treatment at file floppy stage is similar to that described for the ataxic infant. Fluctuat- ing postural tone causes exaggerated, assym- metrical movements, which increase on vol- untary action and on excitement. The thera- pist should maintain a calm and controlled atmosphere, using techniques for inhibiting exaggerated reflexes and facilitating postural stability, as follows :7 P rox ima l fixation can be facilitated through distal control, e.g. tile child's hands are tied to vertical or horizontal rods fixed to the table at almost ann 's length. While the therapist focuses the child's attention on something exciting, the child attempts to control his head, shoulders and trunk. In se- vere conditions special seating will also be needed with stabilizing straps over the

child's abducted thighs, to inhibit extensor spasm in tile hips pushing him forward out of the chair. Hand and eye coord inat ion can only be at- tempted while the child's body is stabilized. 8 In the position described above, one hand c,q-q, be encouraged to "p l ay" with suitable toys while the other is the stabilizer. Bila- taral play may later be attempted using an 18" rod, a large ball, or a bowl of water and toys, to facilitate file child's hands coming together in the midline, and to inhibit flexor reflex activity or the assymmetrical tonic neck reflex in the arms.

For file severely involved child, side- lying is an easier position (RIP) for tile use of both hands in play. A board with appro- priate straps may be used to inhibit file re- flexes mentioned above.

CONCLUSION

The success of neurodevelopmental treat- ment depends largely upon the continuous nature of file treatment and home exercise programme. It is the experience of occupa- tional therapists in C.M.C. Hospital that family involvement is vitally important, ill order that the neurodevelopmental treatment techniques may be regularly applied throughout the whole day. Each baby is unique, and needs a constant process of as- sessment during treatment, as the therapist looks for changes in movement patterns and behaviour.

As the baby becomes an infant, a child, and then an adolescent, the natural growfll of his body also tends to increase the abnormal movement patterns which he had to over- come, e.g. a young spastic diplegic, who has not achieved full extension in his walking pattern, will become more and more flexed at hips and knees as he grows up. He may then need surgical intervention and/or

696 THE INDIAN JOURNAL OF PEDIATRICS Vol. 59, No, 6

orthoses and therapy for the rest of his life. If, however the neurodevelopmental treat- ment approach had been started at or before 3 months, and continued without a break, it is possible that he could walk with only slight abnormality and without orthoses in adult life.

The purpose of this article is to outline early intervention and its value, and so the development of the neurodevelopmental treatment approach through all stages of the child's growth is not included. It is the view of the author that skilled use of the tech- niques of inhibition and facilitation initiated by Mrs. Bobath is basic to the development of more normal movement patterns in the cerebral palsied infant.

ACKNOWLEDGEMENTS

Thanks are due to the Departments of Child Health, Physical Medicine, Neurology, Orthopaedics and Psychiatry at C.M.C. Hospital, Vellore, where these methods_have been practised on children over the last 12 years.

REFERENCES

1. Spastics Society of Tamil Nadu. Spastics - A Part of Us. Madras : Spastin.

2. Bobath K. The neuropathology of cerebral palsy and its importance in treatment and diagnosis. Cerebral Palsy Bulletin 1959; 1 (8) : 13-33.

3. Bobatla B. A neurodevelopmental treat- ment of cerebral palsy. Physiotherapy 1963; 49 : 242-244.

4. Gillette HE. Systems of Therapy in Cere- bral Palsy. Denver, Colorado : University of Colorado Medical Centre, 1969 : 5-70.

5. Baker S. Helping the slow baby. London : National Society for Mentally Handi- capped Children.

6. Bobath B. Students Papers. (These are un- published papers, printed for their own students). London : Bobath Centre, 5 Netherhall Gardens, 1980.

7. Frances P, Connor G, Williamson GG. et al. Programme Guide for Infants and Tod- dlers with Neuromotor and other Develop- mental Disabilities. New York : Teacher's College, Columbia University, 1978 : 165- 172.