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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 side


internal and external rotation – UE & LE
pelvic and spinal alignment
weight shift – weight bearing surfaces – hands/feet
forming 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 GRADE


Toward prone → increased ext. BEWARE
Toward 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 spine
C. activation of abdominal
D. 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/shoulders


trunk
upper extremities

Weight Bearing on Scapula Action: traction


Lateral weight shift
Alignment – balance flex/ext

B. ALIGNMENT SPINE:

Key Points: sternum


abdominals/pelvis
--OR--
lateral trunk

weight bearing/pelvis Action: subtle weight


shift
deep pressure

Key Points: ant/post surface trunk


sides of trunk
pelvic area
thoracic area

weight bearing/scapula Action: traction


lateral weight shift
approx - ONLY once aligned

C. ACTIVATION ABDOMINALS:

Key Points: Pelvis

Weight bearing Action: traction


lateral weight shift
(prepare for rolling, etc)
D. PELVIC MOBILITY

MUST HAVE ADEQUATE NECK MOBILITY


Key Points: thighs inside
Action: lower pelvis – cue lift

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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 pelvis


Distally: 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 spasticity
2. 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:
1. slow sustained lengthening to break up stereotyped movement patterns.
2. naturally occurs on the weight bearing side.

D. Rotation:

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1. elongation and rotation = dissociation
2. 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 possible
b. Use child’s own tempo – not yours
c. Give child the feeling that he can do something
d. Your hand guide – not dominate

2. Repeat- repeat – repeat, but don’t go too far:


a. Use millimeters and micromillimeters of movement
b. Don’t always repeat in one way
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
positions

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b. Or minimal movements with control in positions
c. You want ACTIVE REACTIONS from babies
d. 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.

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.

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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 Tapping
a. 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 Tapping
a. Increases postural tone against gravity
b. Stimulate contraction of agonists and
antagonists together
c. Often used with ataxics and athetoids to get
stability in midranges
d. Done arrhythmically – this is the difference
between pressure tapping and joint
compression

3. Alternate Tapping
a. 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
through recruitment. The resulting movement
is inhibitory to spasticity.

4. Sweep Tapping

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a. 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.
• Use it for maintaining positions while placing limbs. Be aware of
abnormal FIXATION.
• Incorporate lots of graded trunk rotation.
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• 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 extension


A. 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 control


A. “Prone Prop” the child on an appropriate
size roll. Encourage reaching, grasping
and releasing.

3. Development of upper extremity weight bearing


A. 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 roll


Giving moderate support.

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4. Balance activities
A. 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 extremities


A. 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 rotation


A. 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 skills


A. The longer rolls make excellent seats
for the teacher and child for one-to-one
instructional or sensory stimulation
exercises. Working with flash cards
or other instructional aids while
teacher and child face each other
on the roll permits a more “private”
atmosphere while encouraging balance
control 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)
PC 2795C Wedge 8x20x22 in (20x51x56 cm)

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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 shoulders
b. Favored weight bearing on elbows
c. 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

Place child in prone position


symmetrically so that weight

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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

The child is placed crosswise on a moderately sloping wedge. The incline is


used to assist the child in trunk rotation.

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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

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.

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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 Ball


22 in (56 cm) has rigid core for adapted support

PC 2769M Neuro Developmental Training Ball


16 in (41 cm)

PC 2769S Neuro Developmental Training Ball


11in (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 gently
begin 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.

b. Develop head righting and trunk extension

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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
a therapist.

i. Provide vestibular stimulation in different planes

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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

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

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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.

Russell Sage College


Department of Physical Therapy
PTH 417

23
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
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

24
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
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.

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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
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

26
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 function
2. Seizure activity which may be stimulated by ball gymnastics
3. Tendencies toward dizziness and/or nausea
4. Hemorrhagic tendencies
5. 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.
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.

27
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.

7. Bobath, K. The motor Deficit in Patients with Cerebral Palsy. Clinics in


Developmental Medicine., No. 23, 1966.

28
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-Brinckmann
44 Munster/westf.
Prinzipalmarkt 22/23
Postfach 1528
Germany

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

29
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.

Part II: The Basic Routine


Adapt According to Individual Needs

30
The Warm-Up
Maintain “plumb-line” posture:
1. Sitting Posture shoulders relaxed & level, weight
equally distributed over both feet
Chest high! in a comfortable base of support.
Knees should be directly over feet.
DO NOT allow anterior pelvic tilt.

2. Stretch & Bounce PNF patterns may be added to this


a. Stretch to extreme & then exercise.
relax into a slow bounce
b. Swing both arms in an
alternating pattern
Rotation Patterns:
a. Alternate sides
b. Do first without bounce
c. Use the basic technique of Stretch to the extremes of this
PNF diag. patterning exercise. Straighten the leg to
which the arms are directed.

3. Trunk Rotation
a. Alternate sides without
bounce Stretch as far as possible; do this
b. With bounce slowly. Depress shoulder, Adduct
scapula. Keep knees apart and
feet flat on floor. Stress rhythm.
Keep eyes on the hand which is
“behind”.
4. Lateral Bending
a. Alternate sides
b. Try without bounce and Attempt to touch the floor on each
then with a bounce side. Allow basic righting and
equilibrium reactions to “happen”.

31
The Gymnastic Routine (Beginning Balance)

1. Basic Sitting Posture


These techniques should be
a. without bounce attempted first without a bounce &
b. with bounce then with a bounce. Try each
component of the more complex
techniques individually before
combining them. Resistance may
be given at the hips.
2. Reciprocal Arm Swing
Watch that knees remain “over the
feet”.

3. Pelvic Mobility
(for stability) The pelvis is to be motion & not the
a. Anterior-Posterior legs or upper trunk. Pelvis stability
pelvic tilt is essential for successful
b. Lateral pelvic tilt performance of the exercises which
(both sides) follow. This is more difficult than it
c. Combined Circles appears & most patients need
careful instruction & practice to
develop this skill.

4. Walking Rhythm
a. Alternate feet only Constantly check on maintenance
b. Add reciprocal arm of good posture. Feet may be
swing brought closer together to maintain
balance.

5. Marching Rhythm Check that lumbar curve is not lost.


a. Alternate legs only Hamstring or low back tightness
b. Add reciprocal arm will prevent maintenance of correct
swing posture. Do not sacrifice correct
posture for a straight leg.

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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. The footwork on this exercise is
b. Bounce around as in beneficial. Weak abductors will be
“a” but keep always in obvious in this exercise.
contact with the floor.

7. Leg Abduction
a. Alternate legs
b. Increase timing

Bounce leg out to side in short


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

Bounce each leg out to the side


and around to the back. Stretch
9. Slow Side Roll hip flexors & return by bouncing
a. Pelvic hike the leg. At extreme extension, the
b. Rotate trunk to face ball should be under the thigh of
straight leg the “forward” leg.

33
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 Supine


a. Toe touch Keep the ball at midscapular level;
do not let it go too high.
b. Roll backward
Weak abdominals, hamstrings or
gluteus maximus may prevent this
c. In supine, ball should exercise from being performed
be between scapulae- correctly.
hips high
Keep hips high and level (see
d. When a,b,c are done arrow)
easily in position, roll
ball slowly to the side Rotation should be accomplished in
alternating sides. the upper trunk while pelvis
stabilizes.

11. Sit to Prone


a. 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.

34
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 Knees


a. and return

b. rotate

35
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
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.

36
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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