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→ tone normalization
→ sensory accod. to weight bearing surface
→ elongation in spinal extension
→ weight shift across central axis
→ head righting reaction
PREPARATION SCAPULA:
Prone → preparation for sidelying → to sitting H.R.
Sidelying:
Reinforce elongation through pressure
Align pelvis and shoulder around axis
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:
DON’Ts:
Legs Resting (Inactive) Too Much Hip Ext (No Activation) Anterior Tilt
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A. ELONGATION NECK:
B. ALIGNMENT SPINE:
C. ACTIVATION ABDOMINALS:
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Up/down usinf abd. & glutes (B)
Weight bearing neck (A)
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.
A. Movement:
1. slow, rhythmic rocking – reduces spasticity
2. shaking – counteracts fixation
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:
Methods:
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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.
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.
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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:
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Treatment Principles for the Cerebral Palsied Child
• 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.
Applied Uses
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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.
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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.
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.
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C. Straddle appropriate size roll in kneeling position to provide moderate
knee pressure with left – to – right balancing.
Wedges
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.
Applied Uses:
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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.
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7. Reaching and grasping activities
8. Therapist bracing
As you work with the child you will find wedges comfortable for you to lean
against, prop against and brace yourself.
The wedge provides an ideal shape for relaxed side lying positioning on a
slight incline.
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
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Applied Uses:
a. Balance activities
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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.
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e. Develop supine flexion
h. Facilitate relaxation
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j. Promote weight bearing on knees and ankle
k. Sensory Integration
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.
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Let’s get on the ball
Rationale:
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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).
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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.
Assessment:
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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:
2. On the Ball
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B. If pain or spasticity increase, reassess, adapt your treatment
program, or discontinue Swiss Ball Gymnastics.
3. Additional Precautions
References
3. Martin, J.P. The Basal Ganglia and Posture. J.P. Lippincott, Co.,
Philadelphia, 1967.
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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.
Sporthaus-Brinckmann
44 Munster/westf.
Prinzipalmarkt 22/23
Postfach 1528
Germany
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B. Techniques:
C. Precautions:
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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.
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”.
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The Gymnastic Routine (Beginning Balance)
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.
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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
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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.
b. “Flutter-kick”
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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.
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
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.
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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.
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