NEURODEVELOPMENTAL TREATMENT

                     

                         NEURODEVELOPMENTAL TREATMENT

1.      THEORITICAL BASE:

·         The Bobath/neurodevelopmental treatment (Bobath/NDT) approach.

·         The way constructs related to theory and treatment are explained today reflects emerging knowledge of neurophysiology and nervous system functioning, as well as theories of motor control and learning (Bryce, 1991; Mayston, 1992, 2000a, 2000b, 2001; Bobath Centre, 1997; Mayston et al., 1997; Bly, 2000).

·         Approach involved the use of manual techniques to eliminate abnormal tone and dysfunctional movement and to retrain normal patterns of coordination in the affected trunk, arm, and leg.   goal was to restore normal movement and function.

·         The importance of the child’s active participation in meaningful occupation has become a central focus of treatment.

·         The Bobath concept continues to be a ‘way of thinking’ based on a problemsolving approach.

·         The importance of working towards functional goals, the importance of the child’s parents and caregivers in intervention (Bobath Centre, 1997), and the importance of the contexts that enfold each individual child’s life (Mayston, 2001).

·         Bobath’s clinical experimentation led to the discovery that abnormal degrees of postural (muscle) tone, which resulted in abnormal patterns of posture and movement, could be influenced and modified through the use of specialised techniques of handling. Furthermore, the change achieved in tonus, and subsequently patterns of movement, in turn assisted the client to move in a ‘more normal’ and thereby more functional way, despite the presence of spasticity. This, in turn, allowed the possibility for improved postural alignment and postural control – improved quality of functional movement.

·         Bobath found that the risk of contracture, asymmetry and deformity could also be influenced/ minimised by the handling techniques.

·         Bobath concept is articulated in terms of emerging neurophysiology and theories of motor control and motor learning (Mayston, 2001) in line with other contemporary models of practice.

·         Bodies of knowledge from different disciplines and theorists have influenced the evolution of the Bobath concept, including: Kabat, Knott and Voss (importance of providing proprioceptive information to build up/regulate tone); Rood and Goff (tactile stimulation techniques) (cited in Bobath Centre, 1997); and Petö (treatment of children with athetosis) (Bobath and Bobath, 1984).

·         The way that handling techniques are explained and applied (Mayston et al., 1997) has been modified: 

Ø  Recognition that the development of surviving extreme low birthweight and pre-term infants, and infants with severe asphyxiation, begins from a ‘different point of postural tone and control’ 

Ø  To accommodate the different combinations of hypotonia, hypertonia and secondary weakness now more commonly observed in the CP population

Ø  To increase the emphasis of sensory processing, sensation and perception on postural control (The Bobath Centre, London, 1996; Simmons Carlsson, 1999a, 1999b, 2000).

·         The term ‘inhibition’ was first introduced by Bobath to explain tone reduction commensurate with the idea that hypertonus was produced by abnormal tonic reflex activity – ‘a view which no longer can be supported’ (Mayston, 2001).

Ø  In treatment, the Bobath/NDT perspective of inhibition relates to the following: reducing hypertonus, ‘loosening’ up, adaptation, elongation, mobilisation, preparation for function.

Ø  Physiologically, inhibition is associated with counteraction of synaptic excitation, a shaping of a firing pattern of action potentials or depression of transmitter release.

·         The term ‘facilitation’ in treatment means to make possible, to make easier. Physiologically, it is associated with enhancement of synaptic transmission/transmitter release. This is more in keeping with the term ‘stimulation’ as used in the Bobath concept/NDT (Mayston, 1998, personal communication).

2.      KEY COCEPT:

·         Normal development

Ø  Principles of normal development

Ø  Sensory –motor sensory feedback system

Ø  Component of normal development

Ø  Sequences of motor development

·         Abnormal development

·         Sensory input as a means of bringing about changes 

3.      CONCEPT BOBATH:

·         Bobath concept (Mayston et al., 1997). Originally, Bobath explained the development of postural control against gravity in terms of the normal postural reflex mechanism (NPRM). This was based on a hierarchical theory of the nervous system, and handling techniques aimed at addressing postural reflexes and eliciting automatic righting and equilibrium reactions.

·         The Bobath concept is based on the recognition of two factors.

Ø  A lesion of the brain affects an immature, or rather a developing, central nervous system (CNS), leading to delay or arrest of motor development.

Ø  This results in the presence of abnormal patterns of posture and movement as a consequence of a disordered postural control mechanism – postural tone, reciprocal innervation and variety of movement are all affected to varying degrees and in various combinations.

4.      CURRENT THEORETICALFOUNDATIONS OF NDT

·         current theoretical foundations of NDT include:

Ø  Dynamic Systems Theory of Motor Control

Ø  The Neuronal Group Selection Theory

Ø  Sensory Contributions

Ø  Motor Learning.

5.      AIMS AND GOALS:

·         The approach is aimed at restoration of function through identifying and correcting underlying impairments that interfere with movement and participation in everyday activities.

·         The emphasis is on regaining normal movement and postural control, as well as quality of movement.

6.       ASSUMPTION:

·         NDT has listed the following ten assumptions posed by the Bobaths that are core to its theoretical base.

1.      Impaired patterns of postural control and movement coordination are the primary problems in clients with cerebral palsy.

2.      Identifiablesystemimpairmentsarechangeable,andoverallfunctionimproveswhen the problems of motor coordination are treated directly addressing neuromotor and postural control abnormalities in a task-specific context.

3.      Sensorimotorimpairmentsaffectthewholeindividual—theperson’sfunction,place in the family and community, independence, and overall quality of life. 

4.      A working knowledge of typical adaptive motor development and how it changes across the lifespan provides the framework for assessing functions and planning intervention.

5.      NDTfocusesonchangingmovementstrategiesasameanstoachievethebestenergyefficient performance for the individual within the context of age-appropriate tasks and in anticipation of future functional tasks.

6.      Movement is linked to sensory processing in two distinct ways (feedback and feedforward/anticipatory control).

7.       Intervention strategies involve the individual’s active initiation and participation, often combined with the therapist’s manual guidance and direct handling.

8.       NDT utilizes movement analysis to identify missing or atypical elements that link functional limitations to system impairments.

9.       Ongoing evaluation occurs throughout every treatment session.

10.  The aim of NDT is to optimize function.

·         Additional assumptions have been accepted. Howle (2002,)

1.      NDT accepts that human motor behavior and function emerge from ongoing interaction amongst the individual, the task characteristics, and the specific environmental context.

2.      Movement is organized around behavioral goals.

3.      All individuals have competencies and strengths in various systems. 

4.      A hallmark of efficient motor function is the ability of the individual to select and matchvariousglobalneuronalmapswiththepotentiallyinfinitenumberofmovement combinations that are attuned to the forces of gravity, forces generated by contracting muscles, and constraints posed by various environmental conditions.

5.      NDTusesamodelofenablement/disablementbasedontheInternationalClassification of Functioning, Disability and Health (World Health Organization, 2001) developed by the World Health Organization to categorize the individual’s health and disability.

6.      Clinicians can best design intervention by establishing functional outcomes in partnership with clients and caregivers.

7.      Intervention programs are designed to serve clients throughout their lifetime. 

8.      Learning or relearning motor skills and improving performance requires both practice and experience.

9.      Treatment is most effective during recovery or phase transition.

10.  NDT clinicians assume the responsibility to provide clients with the available evidence related to all intervention methods, outcomes, and service delivery systems.

7.      NORMAL POSTURAL CONTROL MECHANISM:

7.1  NPRM-Normal postural Reflex Mechanism

·         Normal postural tone

·         All degree of reciprocal innervation

·         All the pattern of movement (pattern of righting, equilibrium, postural reaction)

·         THEORY

Ø  Tonic reflex activity

Ø  Dynamic interaction systems

Ø  Feedback 

7.2  NPCM- Normal postural Control Mechanism

·         There are three components to the NPCM.

·         I-Components

Ø  To move efficiently and effectively, we need a degree of normal postural tone for maintaining posture and movement.

Ø   Postural tone needs to be high enough to withstand gravity, yet low enough to allow movement.

Ø  Postural tone provides the dynamic interplay between stability with mobility and mobility with stability – in association with other body systems and structures, e.g. the skeletal system – arousal and the action–perception system, and the functional task and environmental dimensions.

Ø  Neural aspects of tone include reflex activity, level of arousal, and feedback and feedforward mechanisms. Non-neural aspects include, for example, the passive–elastic properties of muscles, and the length–tension relationship of muscles and range of motion

·         II component of the NPCM relates to the normal reciprocal interactions of muscle groups.

Ø  This allows for synergic fixation proximally, which in turn allows for distal mobility, e.g. a stable trunk may serve as the point of reference for distal head/limb function, or head control as a basis for selective eye movements.

Ø  Alternatively, there may be situations where distal points of stability will provide for proximal mobility, e.g. moving the trunk over a weight-bearing arm, or using grasp as a point of fixation/stability for truncal activity.

Ø  Reciprocal interactions of muscle groups give us our automatic postural adaptations and graded control of agonist and antagonist to give normal co-contraction – timing, grading, force and direction of movements.

Ø  Disturbed patterns of movement as a result of the disturbance of reciprocal innervation may lead to a limited variety of movement patterns, difficulty in the organisation of movements with movement in more total/stereotypical patterns and reduced selectivity of movement (Bobath Centre, 1997).

·         III component of the NPCM relates to all the various movement patterns that are common to humans

Ø  Postural background adjustments encompass the many dynamic postural reactions that work together to maintain balance and adjust posture before (feed-forward), during and after (feedback mechanisms) movement, and include the righting reactions, equilibrium reactions and protective reactions.

Ø  Righting reactions work to assist with orientation in space via visual and vestibular mechanisms, as well as to restore normal alignment after rotation (derotation).

Ø  Equilibrium reactions help to maintain and restore balance during activities. They overlap and work in tandem with righting reactions.

Ø  Protective reactions form the link between righting and equilibrium reactions, and give the individual a last line of defence when the body is displaced beyond the capabilities of the first two mechanisms.

·         THEORY

Ø  Tone = neural + non neural

Ø  Dynamic interaction systems

Ø  Motor control theories: feedback and feed forward

Ø  Central and peripheral mechanism  

8.      NDT/BOBATH PRINCIPLES OF TREATMENT:

1.      The goal of treatment is to retrain normal movement responses on the patient’s hemiplegic side.

2.      The therapist should avoid activities and exercises that increase abnormal tone or strengthen abnormal movement responses and should use treatment techniques to suppress or eliminate these patterns.

3.      The therapist should use treatment activities and exercises that encourage or strengthen normal movement patterns in the patient’s trunk and extremities.

4.      The therapist should help the patient use existing motor control on the hemiplegic side for occupational performance.

5.      When the patient lacks adequate strength and control of the affected arm and leg for normal occupational performance, the therapist should develop compensations and adaptations that encourage use of the affected side and decrease the development of abnormal movements and asymmetrical postures.

                                                         or

1.      Estabilish a treatment plan with anticipated outcomes that include specific ,observable functions within a specific time frame under specific environmental condition

2.      Therapy utilizes client s strength ,recognizes that each individual has competences and disabilities

3.      Set anticipated outcome and impairment goals in partnership with the family the client and the interdisciplinary team 

4.      Treatment strategies often include preparation and stimulation of critical foundational elements as well as practice of the whole task

5.      NDT intervention includes planning and solving motor problem

6.      Repetition is an important component in motor learning

7.      Create an environment is conductive to cooperative  participation and support of the clients efforts

8.      Knowledge of the development of posture and movement components is use in designing treatment strategies

9.      A single treatment session progress from activities in which the client is most capable to activities that are more challenging

10.  NDT intervention methods include modifying the task or the environment and take into account the current level  of the clients performance and capacity for function

11.  Individual treatment session are designed to evaluate the effectiveness of treatment with the session

12.  Families receive information regarding the clients problems and management of those problems as they are able to understand and assimilate the information

13.  In an NDT approach suggestions to the family are as practical as possible

14.  NDT recommends an interdisciplinary model of service  

15.  Coordinate with the goals and activities of all other medical ,therapeutic, social, and educational to ensure a life-span approach to solving the clients problems

9.      NDT/BOBATH EVALUATION AND TREATMENT PLANNING:

·         Identify abilities and functional capabilities. Include:

Ø  Movements of both the arm and leg, postural patterns of the trunk, and functional independence in life skills.

Ø   How does the patient accomplish these functions?

·         Identify functional limitations, including:

Ø  Functions that the patient cannot perform that are necessary for improved independence and quality of life.

·         Determine what problems interfere with movement control and functional performance, such as:

Ø  Abnormal tone

Ø  Abnormal coordination

Ø  Loss of postural control

Ø  Loss of selective movement control

Ø  Loss of or changes in sensation

·         Establish functional goals and treatment goals.

Ø  Identify the functions that the patient will be able to learn to perform within an established time frame. Indicate whether performance will involve compensation or use of the involved side with normal coordination.

Ø  Identify the impairments that you will need to address to meet the functional goal. 

·         Based on the patient’s response to handling, determine where to begin treatment. What techniques of inhibition and facilitation will be used

10.  TREATMENT OUTCOMES:

·         Treatment outcomes focus on function:

Ø  To extend skills and improve the quality of functional ability

Ø  Retain skills and maintain function 

Ø  Make management easier and/or possible for parents/caregivers

·         NDT/Bobath treatment uses manual techniques to address the problems of tone and movement control and to provide sensory messages about how movement is organized and executed.

·         These techniques have the goals of preventing or eliminating abnormal tone and coordination, retraining normal movement responses, and increasing functional use

·         B. Bobath used her hands on the patient’s body to produce therapeutic changes in tone and movement. She called this treatment handling to reflect the hands-on quality of her treatment. Initially, handling was relatively static, requiring the use of reflexes and passive positioning to produce changes in muscle tone

·         The NDT therapist uses handling to provide specific tactile, proprioceptive, and kinesthetic messages that help organize the quality of the patient’s movement and influence the status of relevant impairments, such as spasticity and flaccidity.

·         B. Bobath found that certain hand placements, which she called key points of control, are most effective for controlling the patient’s movement. During treatment, the therapist selects key points that give maximal control over the patient’s problems and the movement pattern the therapist wishes to influence.

·         Proximal key points are used to influence posture and movement of the trunk, shoulder girdle, and hip, and distal key points are used to control the position of the distal extremities.

·         Handling incorporates two types of techniques: inhibition and facilitation.NDT Handling Techniques Inhibition techniques are used to:

Ø  Decrease abnormal muscle tone that interferes with passive and active movement.

Ø  Restore normal alignment in the trunk and extremities by lengthening spastic muscles.

Ø  Stop unwanted movements and associated reactions from occurring.

Ø  Teach methods for decreasing the abnormal posturing of the arm and leg during task performance.

·         Facilitation techniques are used to:

Ø  Provide the sensation of normal movement on the hemiplegic side.

Ø  Provide a system for relearning normal movements of the trunk, arm, and leg. 

Ø  Stimulate muscles directly to contract isometrically, eccentrically, or isotonically.

Ø  Allow practicing movements while the therapist maintains some constraints.

Ø   Teach ways to incorporate the involved side into functional tasks and occupations

11.  TECHNIQUES:

 

Handling techniques:

·          Reflex inhibiting postures (RIPs): Inhibition of tonic reflexes (Bobath and Bobath, 1940s)- Released tonic reflexes

·         Reflex inhibiting postures (RIPs): Simultaneous inhibition and  facilitation (and stimulation)- Abnormal tonic (postural)reflex activity

·         Tone influencing patterns (TIPs): Inhibition, facilitation, stimulation and biomechanical influence- Neural (reflex) and non -neural component

Facilitation of Weight Bearing

·         Wright bearing can be either facilitory or

·         inhibitory. Weight bearing also provides sensory input and to create or increase awareness of body

·         It can be used to maintain muscle length, normalize tone, and increase activity in the muscles of the trunk and arm

·         In the NDT/Bobath approach, weight bearing is a dynamic process.

·         The movements of the trunk cause muscles in the arm and hand to lengthen and shorten and contract to maintain the arm on the support surface.

·         Thus, weight bearing is used both to facilitate muscle activity in the hemiplegic arm and to increase functional use of that arm.

Facilitation of Arm Movement

·         Facilitation of arm movements is another important part of arm treatment.

·         Restore alignment of the segments to be moved using key points of control.

·         Assist the desired movement using light hands. 3. Proceed slowly and feel for the patient’s response.

·         The arm will feel lighter and movement easier when the patient is assisting.

·         Repeat movements until patient can actively assist and you feel the patient is active.

·         Lighten messages of your hands so that the patient moves with less assistance. Give verbal feedback during this phase.

·         Gradually withdraw control. The patient’s movement control may decline but should not produce an abnormal response.

·         Provide practice opportunities through use of activities (occupation-as-means) or home exercises.

Arm Treatment in Supine

·         The NDT therapist often begins to inhibit abnormal tone and facilitate normal patterns of arm movement with the patient lying supine.

·         Supine is the easiest position for patients with loss of postural control and weakness to practice moving their arms because the bed or mat provides postural stability.

·         The stable position of the patient’s trunk also makes it easier for the therapist to maintain normal scapulohumeral rhythm while lifting the hemiplegic arm into flexion and abduction.

·         To facilitate arm movements in supine, the therapist uses proximal and distal key points on the arm to extend the hemiplegic elbow and bring the patient’s shoulder into flexion.

·         The therapist should make sure that the scapula rotates easily before elevating the arm above 60°of shoulder flexion.

·         If spasticity or muscle tightness is blocking scapula movement, it is important to use inhibition to restore normal joint mechanics before bringing the arm into elevation.

·         B. Bobath called this technique “place and hold” because it is based on the normal placing response. Place and hold can be practiced with the shoulder and elbow in varying positions so that the patient develops control of proximal and distal arm movements as the patient develops the ability to place the arm and to move in small ranges without loss of control, handling is lightened or removed to allow opportunities for independent practice.

Arm Movement in Sitting

·         The therapist must reduce the subluxation before beginning facilitation and maintain this corrected position during arm treatment.

·         Initially, the therapist controls the position of the shoulder girdle during guided movements of the arm to strengthen

·         These activities help the patient learn to use the hemiplegic arm to provide support and assist balance.

·         Occupation-as-means also provides opportunities for practice moving the hemiplegic arm or coordinating use of both hands in bilateral patterns of coordination.

·         To practice control of elbow movements, the therapist may facilitate arm movements while the patient holds an object in the hemiplegic hand and practices bringing it to the body or face

·         Bilateral coordination is reinforced by tasks such as carrying a tray or pushing a vacuum cleaner.

·         The therapist selects tasks for occupation-as-means according to the movement components embedded in them.

·         The practice of these meaningful activities is expected to generalize to increased functional use of the hemiplegic arm in other tasks that use similar components

Weight bearing through the UE while sitting or standing Weight shifting

·         Helps to normalize tone throught them arm.preparations include scapular mobilization (gliding scapula into abduction, adduction, elevation, depression, and upward           rotation).        

·         During UE weight-bearing    activities, the   patient’s hand should be placed on a mat or bench several inches away from the hip to prevent wrist hyperextension.          

·         The humerus is placed in external     rotation, with  the elbow in extension.

                    Weight shifting

·         The guiding hand initiates weight shifts and provides stability to the body throughout a movement sequence (Bly & Whiteside, 1997).

·         The role of each hand may shift numerous times throughout a handling session, depending upon the varying conditions

Trunk rotation

·         To promote diassociation the clinician should introduce activities that  incorporates or facilitate trunk rotation

·         This activities trunk musculature and aids in trunk stability which will enhance UE movement trunk rotation performed in the sitting or standing position promotes weight shifting to affected side

·         Additional benefits from trunk rotation activities included increased sensory input and increased awareness of affected side .

Scapular protraction (scapular abduction)      

·         Benefits patients who display a flexor synergy of    the UE. Following the rule of working proximal to distal, the scapula should always be guided into forward protraction before the patient attempts to     raise the hemiplegic arm or     open the hand. 

·         The scapula can be     protracted if    the clinician     cradles the arm with one hand           while   placing the other hand along the scapula’s medial border and then           brings  the arm forward. Once            it is forward,   this position should be maintained     for a few seconds before        returning to the starting position.       

·         Pelvis in anterior pelvic tilt position is the optimal sitting position for patients           with hemiplegia. This position provides proper alignment     of the pelvis, shoulder, and head.

Slow, controlled movements                  

·         Facilitated in  patients with   high tone. Quick movements increase tone    and tend to trigger an associated reaction,            thus resulting in a        flexor   synergy of the UE; they should be avoided.        

·         Patients with  high muscle tone should be instructed to perform activities slowly and in a controlled manner.

·         Facilitation can be slow, moderate, or fast in speed. Slow movement is optimum when a child is fearful of movement in space or when sustained muscle contractions are required.

Proper positioning          

·         The patient in bed, sitting, or standing facilitates the development of normal movement throughout the recovery process.          

·         To normalize muscle tone and provide normal sensory input to the body.      

Incorporating the UE into activity        

·         Promoting functional    use of  the involved    UE.     

·         The involved UE can    be incorporated via weight bearing, bilateral activities, or guided use.      

·         Incorporating the involved UE into the activity will help develop selective use and bring NDT strategies into daily activities.

Key point control

·         Part of the body where the therapist can most effectively control and change patterns of posture and movement in the body parts

·         CKP {central key point} anterior –xiphoid process ,posterior – T7,T8

·         PKP{proximal key point} shoulder ,pelvis

·         DKP{distal key point} wrist, ankle

·         To help to align body parts, stabilise body parts, initiate movement and/or prevent movement in a part of the body (Bly and Whiteside, 1997).

·         Thus, handling via KPCs allows the therapist effectively to direct, guide and change the patterns of activity in other parts of the body.  

Quick movements

·         Facilitated in   patients with   high tone. Quick movements increase tone    and tend to trigger an associated reaction

Light Joint Approximation

·         Light joint compression, also called joint approximation, can be used to inhibit specific spastic muscles.

·          The method is to grasp the patient’s elbow and, while holding the humerus abducted to about 35–45°, gently move the head of the humerus into the glenoid fossa and hold it there until the spastic muscles relax.

Slow Rolling   

·         Slow rolling is done by the therapist holding the patient at the hip and shoulder and slowly rolling from supine to side-lying.

·         The patient should be lying comfortably, with a pillow under the head and between the knees if necessary for comfort.

·         A decrease in hypertonicity should be seen within minutes

Manual Resistance

·         Resistance to an ongoing movement or maintained posture is a form of stretch in which many or all of the spindles of a muscle are stimulated .

·         The muscle spindle, of course, cannot know whether the discrepancy between itself and the extrafusal muscle fibers is due to stretching by a moving force or by resistance that is preventing extrafusal muscle fibers from shortening as the spindle continues to shorten as programmed. The discrepancy causes the spindle to fire.

·         The electrical activity of the interneuronal pool is consequently high, and more and more motor units are more easily recruited to fire; this phenomenon is called overflow.

                    Scapula mobilization

·         Scapular mobilization is performed from side lying facing to therapist the index hold medial border of scapula ,thumb hold lateral border of scapula and web space hold inferior angle of scapula then perform mobilization in upward rotation and  down ward rotation, adduction the abduction of scapula

                   Deep compression                    

·         Deep compression to the large muscles of the trunk toward the weight-bearing surface is a specific facilitation technique enlisted to increase stability and postural control using ground force reactions to assist the initiation of muscle activation from the base of support.

·         Applying pressure downward to the child’s torso inward and downward potentially assists the child in holding his or her trunk more independently or in moving his or her limbs actively.

                   Quality of touch

·         The levels of touch provided during handling are direct and contoured, shaped to the body.

·         Depth of touch varies depending upon the type of sensory input required to elicit an active movement.

·         Light touch is best used when the child demonstrates greater degrees of independent motor control and deep touch provides increased support and direction.

                   Compression  

·         Compression and traction provide sensory data through both the touch and proprioceptive systems modifying tonal properties, alignment, and muscle activation. This touch cue adds a directional component to the cueing system signaling the direction of potential weight shifts.

·         Compression is often employed to create cocontraction of muscles to anchor created alignment of joint segments.

·         Compression can either relax or activate muscles depending upon their state of origination

                      Traction

·         Traction is often introduced to elongate stiff muscles, align joint segments, or facilitate the initiation of movement.

·         Together, these changing forces applied to joints and muscles create changes in alignment and activation of muscle synergies for function

12.  POSTULATES REGARDING CHANGE

                         General Postulates Relating Change

·         If movement achieved through handling is used in functional interaction within the environment, then the child has the greatest opportunity to develop functional skills.  

·         If the therapist adaptsthe environment to take into account the child’s developmental level, needs, and interests, then the maximum amount of stimulation will be provided to encourage motor skills.

·         If the therapist uses handling techniques when a child’s attention is focused on a play activity, then it is often easier for the child to respond with an automatic movement pattern.

·         If the occupational therapist is responsive to the child’s needs (i.e., sensitivity to movement, familiarity with situation or environment) and encourages the child to initiate movement during treatment, then therapeutic handling will be an interactive and meaningful process and the child will be more likely to initiate active movement to engage in purposeful activities.

·         If preventative measures such as adaptive equipment and orthotic devices are provided, then the child will receive consistent input to prevent or reduce the occurrence of secondary deformities and limitations (Schoen & Anderson, 1999).

                         Postulates Relating to Range of Motion and Dissociation of Movement

·         If the therapist prepares the client’s muscle length and joint ROM with various forms of handling, potential to increase muscle activation is facilitated. Traction combined with joint alignment into end ranges of joint mobility may potentially prepare the muscle length and soft tissue mobility for muscle recruitment. Speed, position of the child’s body, and direction of handling cues vary depending on the child’s conditions of stiffness, hypotonia, and soft tissue/bony restrictions.

·          If the therapist provides handling to promote weight shifts and transitional movements, alignment and dissociation of joint segments are supported as the child moves in and out of positions with proper alignment.

                      Postulates Relating to Postural Alignment and Patterns of Weight Bearing

·         If the therapist facilitates postural alignment in preparation for initiation of movement, then the child will have the potential to use appropriate muscle activation to maintain postural control during activities.

·         If the therapist maintains alignment throughout an active movement sequence within a functional task, the child will have the potential to sustain muscle activation for posture and movement with greater independence and energy efficiency.

·         If the therapist facilitates co contraction of musculature around a joint through aligned weight-bearing experiences, potential to develop proximal muscle strength timing, and sequencing of muscle contractions will be afforded. The therapist may add sensory input to the weight-bearing experience with deep pressure, joint compression, or weight shifts enhancing motor control in an aligned position.

·         If the therapist provides sensory input such as deep pressure down toward the child’s base of support when the body segments are aligned, this pattern of weight bearing will facilitate the initiation of movement from the base of support using the benefit of ground force reactions to aiding in muscle activation.

·         If the therapist provides weight bearing through an aligned body segment, sensory feedback from the weight-bearing experience potentially relaxes muscle activation and prepares the body segment for active engagement in task.

·         If the therapist provides handling to promote weight shifts and transitional movements to support alignment and dissociation of coupled joint segments, then the child will likely learn to move in and out of positions with proper alignment.

                           Postulates Relating to Muscle Tone/Postural Tone

·         If the therapist is able to feel the child’s muscle activation/relaxation and the therapist can grade his or her touch and directional cues accordingly, then the child will receive enhanced sensory input preparing the body for active participation in movement activity.  

·         If the therapist is able to monitor the child’s reactions to handling, then handling techniques may be modified in accordance to the child’s changing needs for sensory information.  

·         If the child has atypical muscle tone/postural tone, the therapist uses graded sensory input. This sensory input includes combinations of tactile, vestibular, and proprioceptive stimulation provided at different rates rhythms, speeds, positions, and directions. Distal and proximal key points of control are used with varying ranges to modulate tonal properties. The goal of this handling is to reduce the use of compensatory muscle synergies and ‘‘fixation’’ of muscle patterns for stability and reduced degrees of freedom.  

·         If the therapist is able to alter the impact of gravity through handling, positioning, or equipment, then the child will experience potential muscle activation under conditions of either reduced or increased resistive forces within a movement task.

                              Postulates Relating to Balance and Postural Control

·         If the therapist facilitates smooth interplay between agonist and antagonist muscles, then the child will potentially be able to achieve postural control in relationship to gravity.

·         If the therapist selects the appropriate position, equipment, and therapeutic handling techniques, facilitating opportunities for isometric, sustained holding of the trunk against gravity the potential to improve postural control is afforded.

·          If the therapist facilitates postural control during functional movement activities, and provides the child with repeated opportunity to experience these movement patterns in context, potentially the child will integrate these movement patterns into neuronal groups within the CNS.

·         If the therapist uses graded handling techniques combined with analysis of the child’s response to sensory input over time, the child will potentially develop greater strength, stability, and control during increasingly complex movement sequences.

·         If the therapist includes facilitation in all three planes of movement with specific facilitation of weight shifts into the transverse plane, then the child will experience the potential for axial rotation, elongation of multiple muscular systems simultaneously, dissociation of intra limb/inter limb couples, and activation of postural control synergies.

·          If the therapist provides concentric and eccentric muscle work throughout aligned joint range, motor strength and control are potentially increased and graded during functional movement tasks.

                        Postulates Regarding Coordination

·         If the therapist provides support to the performance of isolated movements requiring precision potentially increased dissociation and fractionated movements will be available to the child.

·          If the therapist facilitates bimanual coordination through the choice of appropriate tasks demanding coordination, the child will potentially develop patterns of integrated inter limb movements.

13.  FUNCTION – DYSFUNCTION:

·         Function–dysfunction continua provide therapists with descriptions of observable behaviors that are clinically relevant and identify the presence of function and dysfunction in children (Schoen & Anderson, 1999).

·         There are five key function–dysfunction continua, essential for the clinical assessment process that provides therapists with descriptions of observable behaviors.

Ø  The continua are ROM and dissociation of movement

Ø  Postural alignment and patterns of weight bearing

Ø  Muscle tone/postural tone

Ø  Balance and postural control, and coordination