APPLICATION OF FACILITATORY APPROACHES IN

DEVELOPMENTAL DYSARTHRIA

 NEURODEVELOPMENTAL APPROACH , NEUROMUSCULAR AND REFLEX

BASED TECHNIQUES
Facilitation is the process of stimulating a structure through neuromuscular physical
techniques. All these facilitation approaches believe in improving posture, tone and strength
of the structures before correcting speech. The older and more conventional types of
treatment for cerebral palsy were based on the belief that the lesion has caused static brain
damage, the effects of which cannot be influenced in anyway.

A growing range of therapeutic methods is available for managing CP in children.

Neurodevelopmental treatment (NDT) as well as a number of other treatments, such as Vojta
therapy, sensory integration, Temple-Fay, Rood, and Kabat can be classified as
neurophysiological approaches (also referred to as neurofacilitation approaches or
neuromaturational approaches) and were developed decades ago.

More recently, action system approaches have provided a new way of conceptualizing
motor development and control. Proponents of the ecological approach and the dynamical
systems approach favour the view that motor development and coordination emerge from a
dynamic interaction of many subsystems in a task-specific context. Law and colleagues and
Ketelaar and co-workers provide good examples of applying the action system approach.
Other frequently evaluated therapeutic methods are conductive education and biofeedback
with a central role for motor learning theories, electrical stimulation, and hippotherapy.

In treatment the process of normal motor development is not followed but the child is trained
to sit, stand, and walk and to perform functional skills that are possible by the child.

In order to achieve this he may be given special devises and hence the environment is
adjusted to the child’s abnormal motor patterns whereas newer therapies focus on training the
child to adjust to his environment.

Some of neuromuscular approaches are as follows:

 BOBATH’s APPROACH (Neurodevelopment therapy (NDT) approach)
 VACLAV VOJTO’S APPROACH (Reflex Creeping and other Reflex Reactions)
 TEMPLE FAY’s METHOD (Progressive patterning movements)
 WINTHROP PHELP’s APPROACH (Modality Training Approach)
 MARGERET ROOD’S APPROACH (Rood, 1954)
 Brunnstron’s Approach (“Synergistic movement Pattern”)
 KABAT, K. and VOSS APPROACH (Proprioceptive Neuromuscular Facilitation)
 EIRENE COLLIS APPROACH (Neuromotor Developmental Approach)
 ANDREAS PETO’s APPROACH (Conductive Education)
 LE METAYER'S METHOD
 AYERS APPROACH (Sensory integration)
 GEORGE DEAVER’s APPROACH
 DOMAN-DALACATO'S METHOD
VACLAV VOJTO’S APPROACH (Reflex Creeping and other Reflex Reactions)

 Vaclav Vojta a German neurologist developed this approach from the work of Temple
Fay and Kabat (Vojta, 1984, 1989; Von Aufsschaniter, 1992).
 Used in Europe.
 Reflex creeping and reflex rolling are present in the new born but persist in cerebral palsy
children.
 The main features of this approach include:
1. Reflex Creeping - Reflex creeping is a movement sequence that includes the most
fundamental components of locomotion:
a) Specific postural control,
b) Uprighting or extension against gravity and,
c) goal-directed stepping movements of the arms and legs.
The main position is prone lying with the head resting on the bed rotated to one
side. These creeping patterns involving head, trunk, and limbs are facilitated at various
trigger points or reflex zones (totally 9 zones) via sensory stimuli.

In new-born babies, reflex creeping can be fully activated from one zone; in older
children and in adults, a combination of several pressure points is necessary. Movement
predominantly ensues in the so-called cross pattern, in which the right leg and the left arm, or
vice versa, move simultaneously. A leg and its contralateral arm support the body and move
the trunk forwards (As shown in the below picture).

In therapy, the therapist sets up an adequate resistance against the patient’s incipient
head rotation. This strengthens the activation of the overall body musculature, thus creating
the pre-conditions for uprighting.

This reflex creeping phase goals include the following:

- Activation of the muscular support and uprighting mechanisms necessary for supporting
and grasping, rising and walking, as well as stepping movements of the arms and legs 
- Activation of the respiratory, abdominal, and pelvic floor musculature, as well as the
sphincters of the bladder and bowel 
- Swallowing (important for mastication) 
- Eye movements.
2. Reflex Rolling  Reflex rolling transitions from supine to side lying and leads to
crawling. In a healthy new-born baby, part of this movement sequence is spontaneous,
and can be observed in approximately the sixth month of life, with a further part of the
sequence observable in the eighth/ninth month. With Vojta therapy, it can even be
obtained in new-born babies. Therapeutically, reflex rolling is used in different phases of
supine and side lying.
Activation of supine lying leads to following reactions:

- Extension of the spine 

- Flexion of the legs in hip, knee, and ankle joints 
- Maintenance of the legs in this position against gravity, outside the support base
of the back.
- Preparation of the arms for the following support function 
- Lateral eye movements 
- Initiation of swallowing 
- Increase in the depth of breathing 
- Coordinated, differentiated activation of the abdominal muscles

Activation of side lying leads to the following reactions:

- Contrary flexion and extension movements of the over- and underlying arms and
legs with increase in support function on the underlying shoulder progressing to the
hand, and on the underlying pelvis progressing to the leg 
- Extension of the spine during the entire rolling sequence 
- Maintenance of the head in side lying, against gravity

3. Sensory Stimulation: Touch, pressure, stretch muscle action against resistance is used in
making of the triggering mechanisms or in facilitation of creeping.

4. Resistance: This is recommended for action of muscles. Specific techniques are used to
apply the resistance so that either a tonic or phase muscle action is provoked. For example
the phasic action may be provoked on a movement of the limb creeping up and
downwards. The tonic action can be obtained if a phasic movement is prevented by full
resistance given by the therapist.
So, over all, the treatment based on the reflex locomotion (reflex creeping and reflex rolling)
contributes to (3):
− Modification of the reflex activity of the young child and orientation of the neuromotor
development in a more physiological direction, by induction of a different central
neurological activity that supplies to the patient a new corporal perception. The muscular
proprioception plays a very important part.
− Modification of the spinal automatisms in lesion to the spinal cord;
− Control of breathing in order to increase the vital capacity; and
− Control of the neuro-vegetative reactions and promotion of a harmonious growth of the
locomotor anatomical system.
Vojta suggests that very early treatment with this method could cure babies-at risk. But he did
not see that there are limits to the results with more severely impaired children.

Limitations:
 Created stress in children and parents.
 More number of practices were needed in the same day.
 There is omission of sensory, perceptual, and cognition with excessive focus on the
movements.

EIRENE COLLIS APPROACH (Neuromotor Developmental Approach)

Eirene Collis, a therapist and pioneer in cerebral palsy in Britain, stressed neuromotor
development as a basis for assessment and treatment (Collis 1947; Collis et al. 1956).
Assessment of neuromotor developmental sequence was the basis of this approach. Her main
points were as follows:

 The mental capacity of the child would determine the results.

 Early treatment was advocated before abnormal patterns could be established.
 Management: The word ‘treatment’ was considered misleading in that besides the
physiotherapy session there should be ‘management’ of the child throughout the day. The
feeding, dressing, toileting and other activities of the day should be planned.
 Strict developmental sequence: The child was not permitted to use motor skills beyond
his/her level of development. If the child was learning to “roll”, he/she was not allowed to
crawl, or if crawling he/she was not allowed to walk. At all times the child was given a
‘picture of normal movement’ and, as posture and tone are interwoven, Collis placed the
child in normal postures’ in order to stimulus ‘normal tone’. Once postural security was
obtained, achievements were facilitated and developmental sequences were followed
throughout this training. Collin promoted the idea of “CP therapist” and disapproved the
separation of treatment into PT, OT and ST.

ANDREAS PETO’s APPROACH (Conductive Education)

It was developed in Budapest, Hungary, in the 1940s and 1950s by Andreas Peto as
an educational technique for children with cerebral palsy. In North America and the rest of
Europe, this has come to be viewed as a physical therapy approach. The children were treated
by conductors in a facility where they lived full time. It is used for conditioning technique
and group dynamics for some children to help them to participate more adequately in the
work of the group.

The treatment was based on educational principles in which motor skills that children
could just barely perform were identified, and then they were assisted over and over again
until the skill was learned. A planned programmed which includes getting out of bed in the
morning, dressing, feeding, toileting, movement training, speech, reading, writing, and other
social work. This approach is the same as is typically used to teach the multiplication tables.
 Conductive education also includes a great emphasis on instilling a sense of self-
worth and a sense of accomplishment in the children. The motor skill were performed with a
series of simple ladder- type devices that can be used to assist standing, stepping, walking,
and even sitting activities, and is applicable to individuals with some useful motor function,
but not such a high level of function that they are essentially independent ambulators.

Conductor works with a group of children of similar handicap and age, which teaches
children all tasks of daily living as well as speech, language and academic subjects,
Understands all the mental and physical problems of the children in her group so that is able
to guide the work of each child according to his capacity. Studies of the efficacy of
conductive education suggest that it is equal to standard therapy programs, or may be slightly
better at teaching motor skills. It is within the structure of one conductor, one group, and a
planned programme that the children overcome their greatest handicap and lack of
motivation.

Advantages: The child may be treated by highly skilled personal and that his progress may be
carefully discussed by a team.

Disadvantages:

 An insecure child must adapt himself to a large number of adults.

 The therapist must struggle for the attention of the child in order “to get the best out of
him” in the limited time at her disposal, stimulated by toys and other incentives, the child
is the centre of attraction. He will be spoiled- not motivated.
 The teachers and therapists may have received different types of training and therefore,
disagree about the best method of treatment.
 Symptoms are treated in isolation, this is not only confusing for the child but also
physiologically wrong.

AYERS APPROACH (Sensory integration)

Introduction and history: Sensory integration, the neurobehavioral theory developed by Dr.
Ayres, stressed the CNS’s ability to organize and interpret sensory information.

 In Ayres’ original theory, higher level processes of perception and cognition were
considered dependent on brainstem and midbrain processing of sensory input
(hierarchical).

 SI theory was developed to explain an observed relationship between deficits in

sensory processing and deficits in academic or neuromotor learning.

 The principles of SI theory are used by occupational therapists in developing

treatment approaches for children with sensory processing difficulties, including CP.

Assumptions:

The basic assumptions put forward by Ayres included the following:

 1. Plasticity exists within the CNS.

2. SI processes occur in a developmental sequence.

3. The brain functions as an integrated whole, but is compromised of systems that are
hierarchically organised.

4. Eliciting an adaptive behaviour promotes SI and, in turn, the ability to produce an

adaptive behaviour reflects SI.

5. People have an inner drive to develop SI through participation in sensorimotor

activities.

6. The person and the nervous system are open systems. The open system is viewed as
one in which the person and the nervous system are capable of self-regulating and
self-organising through a spiral process of self actualisation.

7. It is based on the hypothesis that in order to develop and execute a normal adaptive
behavioural response, the child must be able to optimally receive, modulate, integrate,
and process the sensory information.

Evaluation using Sensory integration approach:

She developed some standardised tests to identify and measure symptoms of sensory
dysfunction. Through the use of these tests, supplemented by clinical observations,
children are identified as having sensory integrative disorders in the following:

1. Postural-ocular movement.

2. Tactile discrimination

3. Sensory modulation

4. Bilateral integration and sequencing

5. Somatodyspraxia

LE METAYER'S METHOD

It is based on the theories started by Tardieu. Meticulously analyzes the child

functional level, posture, reflexes, etc... And here is educated and trained using motivation
and orthotic support for seats pelvic abduction splints. The treatment is to motivate the child
to go stringing the different postures and movements. According to this method education
and training are possible only to the extent that the areas of partnership are able to function.
Based on the normal child's neuromotor reactions, trying to provoke in the child with cerebral
palsy neuromotor patterns normal.

The technique can be realized on these points:

• Assessment of level of neurological development of the cerebral motor ill child, defining,
for each child, the scheme predominantly neurological disease.

• Factor analysis as one of the motor assessment and examination to determine stiffness,
control of the reactions to external stimuli, observation and resting kinetic period.

• Review of postural maintenance, which will detail the weaknesses and defects of motor
organization, mobilization maneuvering leading to a state of complete decontraction.

• Try to lead the child to travel to different levels of motor development essential to the
acquisition of normal motor schemes, combined with the different reactions static righting
and equilibrium reactions in order of difficulty.

  • Biomechanical assessment for possible contractures, deformity installed or possible, as

well as the preparation and placement of adaptive systems to help the child improve function
in daily life activities and to prevent musculoskeletal disorders arising from muscle forces
abnormal.

• Functional examination of locomotion, play, grooming, food, clothing and seated, should
determine the level of autonomy in various activities.

• Assessment of associated disorders: sight, hearing, sensitivity, feeding disorders Gnostics,

organization and understanding gestures, etc.

DOMAN-DALACATO'S METHOD

It is based on the principles established by Temple-Fay.  It is based on the child with brain

injury should aprenderr movements of amphibians, reptiles, and then standing cuadrúpedeos
(following the phylogenetic development of the species)

- Is to encourage the child with cerebral palsy as possible, through reflection and, above all,

making passive movement patterns and repeated several times throughout
the day: reptationscheme ipsilateral heterolateral scheme creeping, creeping or scheme up 
on all fours. Messages are transmitted to the brain by increasing the motor stimulus,
visual, auditory and tactile frequency and duration with an always increasing.

- Parents are highly involved in the treatment of their children, for the execution of several

people need treatment and the child has to have, in many cases, a passive role
in treatment.
 Winthrop Phelps approach:

- The Winthrop Phelps approach believes that the time and effort should be spent
on eliminating the effects of cerebral palsy. The form of treatment depends on
upon the patient’s motor disability and particular needs.
- Fifteen procedures are used in addition to bracing, drugs and surgery. They are
summarized in the following table.

1. Massage for hypotonic muscles (For children with spasticity and athetoids). And
is specially recommended for flaccid group of muscles.
2. Passive Motion is provided by the therapists through mobilization of joints and
groups of muscles. Speed of the movement is slower for spasticity and increased
for rigidity.
3. Active Assisted Motion is the next step or modality wherein the patient is expected
to show some voluntary control over the movements with assistance of therapist.
4. Active Motion, where in the patients voluntarily execute the movements without
any assistance provided by the therapists.
From 1 to 4 modalities, it is expected that the tone of the muscle increases in flaccid,
reduces in spastics and stabilizes in dyskinetics. Once all these four are achieved,
move to the next modality.
5. Resisted motion, where the therapists offer resistance to the voluntary movement
exhibited by the patients thereby improving the strength of the muscle groups. If
this activity is sustained for a longer time, it builds up endurance. Once this is
achieved, move to the next modality.
6. Condition Motion is recommended for babies, young children and mentally
retarded children. In this, the learnt movements in the previous modalities is
taught to be executed when a visual or auditory or tactile stimuli is provided.
7. Confused Motion or Synergistic Motion which involves resistance to a muscle group
in order to contract an inactive muscle group in the same synergy. Mass
movements such as extensor thrust or the flexion withdrawal reflex were usually
used.
For example, using the hip-knee flexion and dorsiflexion synergy, to stimulate
inactive dorsiflexors by giving resistance to the hip flexors.

Confused motion is used by the children when the selective isolated

movements are not possible.
8. Combined Modality where the patients are trained to combine two learnt motor
behaviours, either simultaneously or in a co-ordinated fashion.
9. Relaxation Techniques used are those of conscious “letting go” of the body and its
parts (Levitt, 1962), tensing and relaxing of the parts of the body. These methods
are mainly used with the athetoids.
10. Movement from relaxation is conscious control of movements once relaxation ahs
been achieved. It was mainly used for the children to consciously control
involuntary movements.
11. Rest periods are suggested for children with athetosis and spasticity.
12. Reciprocation is training movement of one leg after the other in a bicycling
manner in lying, crawling, knee walking and stepping.
13. Balance training of sitting and standing in braces which are very important with
ataxic group of muscles.
14. Reach, grasp and release used for training fine motor skill of the forearm.
15. Skills of Daily Living such as feeding, dressing, washing and toileting are tackled.

Advantages:
 Does not use complex procedures.
 Modalities are simple and in hierarchy.
 Helps in improving the posture, tone and strength of the muscle

TREATMENT SPASTICITY ATHETOSIS TREMOR ATAXIA RIGIDITY

Massage For weaker In some cases Rarely Important Rarely used

antagonists, for weak used for power
for zero muscles and tone
cerebral
muscles

Passive Teaches Follows Same as Teaches Faster

motion smooth relaxation athetosis kinaesthetic speed used
motion, done training sense
slowly,
without
stretch reflex

Active Follows If Same as Teaches Same as

assisted passive involuntary athetosis direction, spasticity
motion motion. motion or speed and
 Precaution: overflow range of
slow down if occurs, motion
stretch reflex treatment is
is obtained too advanced

Active Advanced Concluding Same as Direction Same as

motion form of treatment athetosis and timing spasticity
treatment, prior to ADL of motions
stressing stressed
range of with and
motion and without use
speed of eyes

Resisted To strengthen For muscle Rarely Important Same as

motion antagonists of weakened by used for spasticity
spastic and non-use increasing
zero cerebral muscle
muscles power

Conditioned Watch for Stop if Same as Beginning Same as

motion stretch reflex involuntary athetosis treatment spasticity
and overflow motion
appears after
relaxation

Automatic, For zero Not indicated Not Not Not

confused cerebral indicated indicated indicated
motion muscles

Combined Advanced: for Same as Same as Stress eye- Same as

motion speed and spasticity spasticity hand spasticity
accuracy coordination

Rest Lying down, Same as Same as Same as Same as

braces, spasticity spasticity spasticity spasticity
splints,
adapted
equipment
and diet

Relaxation For part Beginning Same as Not Same as

worked upon treatment, athetosis indicated spasticity
only and basic training
proceed to
 total slowly

Motion from Not indicated Maintain Same as Not Not

relaxed relaxation athetosis indicated indicated
position during
passive
motion

Balance Difficult: from Diminish Same as Make aware Same as

head to athetosis athetosis of balance spasticity
sitting, knee before change and
standing, starting correlations;
standing repetition is
important

Reciprocal From hips Same as Same as Same as Same as

motion and spasticity spasticity spasticity spasticity
shoulders;
later all parts
of body

Reach and Sitting Same as Same as Same as Same as

grasp position; spasticity spasticity spasticity spasticity
passive, then
active from
simple joint
motion to
skills

Skills The final step in all treatment for every type of disability. Motor
activities are grouped as specific skills under the headings of feeding,
reading, writing, manual work etc. This depends upon the occupation/
vocation or scholastic activity that an adult or child may have to be
subjected to. This requires a complex integration of learnt behaviours
carried out in previous modalities.

- According to Phelps, the cerebral palsied children lack many automatic functions
found in normal children such as reciprocal kicking, reach and grasp which will
be established by advocating physical, occupational and speech therapy.

Neurodevelopment approach/ Bobath’s approach:

This approach is given by Karl Bobath and Berta Bobath based on their personal
observations working with children with cerebral palsy.
The basis of the NDT approach as conceptualized by Bobath is that the motor
abnormalities in children with CP are due to the failure of normal development of
postural control and reflexes because of underlying dysfunction of the CNS. The aim
of the NDT approach is to facilitate normal development and function and to
prevent development of secondary impairments due to muscle contractures and
joint and limb deformities.

The Bobath treatment approach used to inhibit pathologic tonic reflexes, first
continuing with facilitation of righting reflexes and balance reactions.

Bobath therapy is a problem solving neurodevelopmental approach for the

assessment and treatment of individuals with cerebral palsy and other allied
neurological conditions. It addresses the problems that occur as a result of
impairment of the developing central nervous system that affects the individual’s
sensory-motor, cognitive, perceptual, social and emotional development.

Principle:

 Motor development in CP is comparable with typically developing children.

 Normal development in motor skills will be followed by sequential
development of primitive reflexes which are gradually overtaken by postural
control (righting and equilibrium reactions)
 Thus, treatment of CP should also follow this sequence
 Otherwise motor abnormalities such as contractures and orthopaedic
deformities may occur
 Should not encourage movement patterns of later stages before controlling
the earlier stages

Correction of speech in NDT approach

 Assessment of speech adequacy includes:

1) Assessment of body movements that is associated with speech mechanism,
such as head, neck and shoulder.

 Assessment of non speech skills includes:

a) Assessment of vegetative activities such as sucking, swallowing, biting and
chewing ( Because NDT approach believes that these are the prerequisite for
speech or speech is a overlaid function)
b) Evaluation of breathing ( at rest and during speech)
c) Evaluation of child’s ability to move and manipulate the organs of speech
such as jaw, lips and tongue.
d) Evaluation of the child’s ability to vocalize and speak.

 Assessment of the above is carried out in terms of

 a) normal b) primitive and c) pathological reactions
 in voluntary act ( with and without emotion)
 in involuntary or reflexive acts
 Assessment is continued in RIPs
  Assessment before therapy and during therapy.

 Assessment of head, neck and shoulder movements:

 See if he patient allows a passive upward movement of one shoulder without
an associated movement of the other.
 See if patients head can move without an associated movement of the
shoulder.

 Turn the head to right/left (if ATNR present, then the child is not ready for
speech therapy.
 Supine position—flex patients shoulders forward – (i) if the head extends or
falls back, then he is ready for speech therapy because there is dissociation of
movements
(ii) if the head also flexes forward (due to the influence of total
extension or flexion reflex) then the child is not ready for speech
therapy because there is no dissociation of movement.
 Prone position – repeat tests as above

 Assessment of language, crying and coughing – as these involve

unconscious vocalization
 Assessment of sucking- find if the sucking reflex is positive, primitive or
inhibited. If positive, and is present beyond the expected age, it affects
chewing.
 Assessment of swallowing reflex- normal or abnormal, prolonged use of
bottle feeding, presence of tongue thrust
 Assessment of biting reflex-its existence assesses the strength of this stimulus
and what evokes it.
 Assessment of chewing- chewing is a coordinated activity which helps in
speech development.
 All the vegetative skills are assessed to check primitivity. If primitive, they are
inhibited. If they are absent, they are facilitated. The vegetative skills are
established in the order that is same as the development patterns in normals.

 Assessment of articulators:
Jaw movements: in quiet (jaw thrust, open mouth etc), passive movements, for the
isolated movements of jaw when there is associated head movement.

Teeth: occlusion and related problems

Soft palate: activities to assess nasality

Lips: in quiet (eg: spastic grin) and during activity

Tongue: Various movements

 Assess for sensitivity and desensitize: start with parts of the body which are
furthest away from the mouth and then work towards mouth.
 Assess breathing: assess for rate of breathing, breath per minute, type, speech
breathing etc
  Assess for vocalization pattern: voluntary production, involuntary
production, quality etc
Principles of speech therapy in NDT

Stages in speech therapy are:

1. Inhibition of patient’s pathological and abnormal reflex behaviour

2. Facilitation of more developmentally mature movements
3. Performance of movements under the voluntary control of the patient

Steps:

1. Normalize muscle tone – i.e., work hand in hand with physiotherapist to

improve general muscle tone
2. Inhibition of abnormal reflex behaviours: work from gross movements such
as movements of head, neck and shoulders to movements of jaws, lips and
tongue.

e.g.: To control drooling

Marie Crickmay (1966) recommends teaching the patient to keep the teeth
closed and the tongue tip up against the alveolar ridge as he/she swallows. The
clinician then inhibits any extraneous movements of cheeks and lips.

To teach a normal mouth position,

Crickmay suggests the following:

Help the patient close his/her teeth in a normal jaw position. Place one hand
under the patient's chin and hold that position for him/her. Use the other hand to
stroke the patient’s lips and cheeks forward in order to relax the face. Chin pressure
must be released gradually in order to permit the patient to assume control and to
experience a closed mouth. Help the patient gradually increase the time the mouth
remains closed.

To reinforce the closed mouth position negative practice may be used. The
clinician asks the patient to go back the original open mouth position and then to
deliberately assume the new closed mouth one. Repeated practice will enable the
patient to feel the difference between positions. Using a mirror during practice will
provide visual reinforcement.

In order to inhibit the infantile sucking reflex,

Crickmay recommends the following:

Put the patient in an RIP. Gently stimulate the lips by touching them with a
straw or finger. Use the other hand to prevent them from moving into a sucking
position. The clinician will have to control the patient's lips by keeping them in a
relaxed position despite the stimulation. Finally the therapist should help the child
assume control. This can be done by the clinician removing his/her hand
occasionally-gradually increasing the length of time until the patient can inhibit the
reflex without assistance.

To facilitate the chewing reflex

(A normal reflex, which with sucking and swallowing is a prerequisite for speech)
the clinician can give hard licorice or chocolate (absent dietary or swallowing
restrictions). It should be pressed against the hard palate in order to stimulate
chewing. Rubbing the gums and teeth, front, back and sides, in a rotary motion with
a finger will also help.

To facilitate independent tongue movement,

Crickmay suggests holding the patient's jaws apart while having him/her
raise the tongue to the alveolar ridge. Next, encourage him/her to produce /t/, /d/,
/l/, and /n/ sounds. Make sure the jaw doesn’t become fixed. It should be
immobilized, but given some freedom of movement. Finally, permit the patient to
take control.

Differentiation of lip movements may be necessary for many patients. The

techniques described above can be used with patients who have difficulty
differentiating lip, tongue, and jaw movements. That is they cannot make the /r/
sound without moving both lips and tongue or are unable to make /t/, /l/, or /n/
sounds without also moving the jaw.

3. Select suitable RIPs- specifically focusing on the head, neck and shoulders and
then work on the oral structures

Reflex inhibiting posture (RIP)

In order to normalize muscle tone the patient is placed in a reflex inhibiting
posture (RIP) which he/she has become accustomed to while in physical therapy.
Two postures that tend to have normalizing effects are the prone (extended spine
and flexed elbows-lying on your stomach while leaning on your elbows), and the
supine (hips and knees extended, shoulders flexed -held by therapist, and head
back-chin held.

In inhibiting abnormal speech reflexes, the therapist should go from gross to

fine. Head control, the ability to lift and turn the head is a prerequisite for speech.
Crickmay suggests that the individual be in a supine position with legs and arms at
his/her sides and hips and legs flexed. This is a good time to work on desensitize the
face/articulators. Remember we are talking about desensitizing the speech
mechanism because when you manipulate the tongue and lips the child may react
with spasms. Crickmay suggests that you help the patient build up tolerance by
holding him/her in the RIP while gently and carefully touching and moving the
hypersensitive face. Since the mouth is the most sensitive he/she should start with
facial areas furthest from the mouth and work in towards the mouth. The patient
will resist and try to break out of the RIP. He/she should be held gently but firmly
so that he/she can build up a tolerance and permit the speech pathologist to
manipulate the speech mechanism. The time taken for this to happen is quite
variable-from a few days to several weeks.

The patient learns to lie quietly in an RIP keeping the face free of abnormal
movement. When facial grimacing occurs it can be usually controlled by the
fingertips. Those with spasticity often have an open mouth, lips drawn back grin.
Crickmay suggests flexing the head forward to inhibit the extensor spasm, and close
the patient’s mouth.

4. Desensitize the oral structures

5. Correct abnormalities such as:
a. Open mouth
b. Abnormal swallow
c. Tongue thrust
d. Drooling
6. Provide external feedback (auditory and visual) and encourage the child to
feel the movements (proprioceptive)- in order to improve and encourage self
learning of active or voluntary movements
7. Where ever possible, use negative practise – help the child to perform the old
patterns of movements and compare them with the established ones.
8. Vocalization training:
a. Vowel training – sustaining and changing vowels
b. Loose jaw- Froeschels chewing technique to relax
c. Rhythmic pattern of voice
d. Learning to listen
9. After the previous step is learnt, facilitate babbling- that is syllables and
sounds, introduce consonants which are easy to difficult. Teach voiced –
voiceless contrast.
10. For back consonants- eg: /g/ sound- RIP in prone position- therapist provides
series of gentle pressure under the chin, then pushes up the back of the
tongue to the palate, provides simultaneously the model of /g/ and
encourages the production of /g/. In supine RIP- put a little water in the
mouth. As a reflective action, the back of the tongue will move up against
velum to prevent choking.

Then generalize to different body positions and stabilize.

 Facilitation of lip sounds- supine RIP and the manipulation
 Tongue tip sounds- any RIP with head flexed forward position and
push up the chin
 Facilitating the sibilants- place straw between the lips and ask the child
to hiss.
For all the steps used to facilitate articulation, Bobath use motor kinaesthetic method
in RIPs.

Language training follows simultaneously. The major steps emphasized include:

  Percept training (feedback and feed forward)
 Egocentric speech
 Socialized speech

Temple Fay’s approach:

Its central hypothesis is that primitive motor patterns can be trained in brain-injured
patients when motor centres in the lower part of the brain have been left
undamaged. By utilizing the normal and latent reflex activity of the spinal cord,
medulla, pons, and midbrain, forms of movement may be conditioned or
reawakened, if properly sought, and through them an otherwise apparently
paralyzed extremity may be utilized. Hellebrandt’s research also suggest this
possibility. For example, the tonic neck reflex may be elicited in prone position by
turning the head to one side, whereupon forward movement of the arm occurs on
the side to which the face is turned. According to Fay this may be used in later
training to establish self-feeding responses not otherwise possible. Covalt et al. have
also applied tonic neck reflex positions when retraining the hemiplegic arm in cases
of acquired spasticity in adults, while Reynolds and Brunstrom call attention to the
positive effect of the tonic neck reflex on the associated reaction seen in most cases
followed in Brunstrom’s study.

Fay claims that the spastic man is a reflex robot as evidenced by reactions from the
tonic neck reflex to the mass patterns of defence or postural reflex. He believes this
reflex response can be made to work for the patient, and he applies the term
“unlocking reflexes” to the positions and movements of the neck or extremities,
which cause automatic release or relaxation of hypertonic muscle groups. Following
this regime, crude “patterns of movement” can be trained to enlist the voluntary
coordination of the patient, even where there is loss of higher cortical levels of response.
These patterns are likened to the ambulatory mechanisms of amphibians and
reptiles, and Fay believes they are a natural sequence in motility which the therapist
might well borrow from nature’s hints in evolution. Hence this approach believes in
delocking the system i.e, facilitating the higher centres by providing physical
exercises in hierarchies. This includes-homolateral movements, homologous
movements, quadruped creeping position, contralateral movement like walking.
Such a training is presumed to facilitate mature motor movements in a given child
and help in unlocking/delocking the primitive, immature motor movements.

Herman Kabat approach:

He has developed a system of neuromuscular re-education based upon the fact that
proprioception plays an important role in conscious activity. It is his contention that
in either upper or lower motor neuron lesions where no regeneration of nervous
tissue is possible, there are still opportunities to improve function by developing the
potentialities of dormant structures.

The receptor mechanisms for kinaesthetic sense and the vestibular apparatus of the
middle ear (which are called the proprioceptors) may be excited so that summation
of stimulation occurs, more motor units are fired and voluntary motion is thereby
affected. Kabat calls this as ‘proprioceptive facilitation’. Proprioceptors can be
influenced by the following methods: (1) rapid stretch; (2) resistance- a method more
powerful than stretch eliciting a large proportion of motor units, but dependent
upon the afferent or sensory conductors being intact; (3) mass movement patterns
employing synergistic contraction of a group of muscles; if these synergists are
resisted, an even greater response is obtained from allied components; (4) reversal of
antagonists, which is more applicable to lower motor neuron disabilities, since
stronger the contraction of the antagonist, the greater the will be the facilitation of
the agonist; (5) rhythmic stabilization which, because of its use of cerebellar
mechanisms, is diagnostic of cerebellar involvement when it cannot be elicited, as
well as useless in cases of cerebellar ataxia.

Margaret Rood’s approach:

Main features are:

-Afferent stimuli

-Light/heavy work muscle action

-Reflex inhibitory techniques

-Ontogenic developmental sequence

-Vital function.

1. Afferent stimuli: The various nerves and sensory receptors are described and
classified into types, location, effect, responses and indicators. Hence the techniques
of stimulation such as the following are advocated to facilitate or inhibit motor
responses.

 Stroking, brushing(tactile)
 Icing, heating( temperature)
 Pressure, muscle contraction( proprioception)
2. The muscles are classified according to various physiological data, including
whether they are light work muscle action or heavy work muscle action. The
appropriate stimuli for their actions are suggested.

3. Reflex inhibiting techniques: are also used in therapy.

4. Ontogenic developmental sequence is outlined and strictly followed in the

application of stimuli.-total flexion, roll over, prone with hyper extension of head,
trunk and legs, prone head over edge or co-contraction of vertebral muscles, on
elbows( prone & push backwards),all the four limbs(Crawl, shift), standing
upright(weight shift), walking.

5. Vital functions: A developmental sequence of respiration, sucking, swallowing,

phonation, chewing and speech is followed. Techniques of brushing, icing pressure
are used.
5. Brunstrom approach/movement therapy:

Basic Principles

 Uses primitive synergistic patterns in training in attempting to improve motor

control through central facilitation
 Based on concept that damaged CNS regressed to older patterns of
movements (limb synergies and primitive reflexes);
 Thus, synergies, primitive reflexes, and other abnormal movements are
considered normal processes of recovery before normal patterns of
movements are attained
 Patients are taught to use and voluntarily control the motor patterns available
to them at a particular point during their recovery process (e.g., limb
synergies)
 Enhances specific synergies through use of cutaneous/proprioceptive stimuli
 Encourages abnormal patterns of movement

Brunstrom Stages of Recovery (assesscurrent stage and progress to the next)

1. Flaccidity (immediately after the onset)

 No voluntary movement on the affected side can be initiated
2. Spasicity appears
 Basic synergy patterns appear
 Minimal voluntary movements may be present
3. Patient gains voluntary control over synergies
 Increase in spasticity
 Semi-voluntary stage (patient able to initiate movement, but is
unable to control the result)
4. Some movement patterns out of synergy are mastered (synergy
patterns still predominate)
 Decrease in spasticity
5. If progress continues, more complex movement combinations are
learned as the basic synergies lose their dominance over motor acts
 Further decrease in spasticity
6. Disappearance of spasticity
 Individual joint movements become possible and coordination
approaches normal
7. Normal function is restored

Treatment Techniques (vary according to stage of recovery)

 Stages 1, 2, and 3 (synergy stages)

o Affected arm serves as an aid to normal arm
o Range of Motion in synergistic pattern
o Resistance to facilitate synergy
* To progress from stage 3 to stage 4, movement combinations must be introduced
that deviate from the paths of the basic limb synergies.
  Stages 4and 5
o Move out of synergy
o Don’t resist synergy pattern
o Combine movement patterns
o Isolation control/skill

George Deaver’s approach:

The goal of this approach is to make the child as independent as his chronologic
and mental age and according to his type of cerebral palsy, the extent of involvement
of parts of his body, and also how much the severity of his overall disability will
allow. The major sub-divisions of this central aim are to teach self care activities, to
teach ambulation, to obtain maximum use of hands, to have adequate speech and to
have, in so far as possible, a normal appearance.

All the programs of exercises are designed for the purpose of maintaining the
normal range of motion at the joints and of preparing the child to perform voluntary
coordinated movements essential to the demands of daily living. This is further
accompanied by the use of prosthetic appliances to restrict undesirable movements
and to convert obtainable motion into functional activity.

The following are the special methods in Deaver’s approach to tackle the
different type of problems in cerebral palsy.

a. Spasticity: Problem – Tightness of muscles producing contractures and

deformities.
Remedial procedures – Passive stretching of all joints to prevent contractures
in tight muscles. Heel cord stretching and stretching the adductor muscles
of the lower extremity are important in almost all spastics. A child cannot
be expected to benefit from muscle education if there is limitation of
motion at the joints. Bracing is used in these cases to prevent deformities
and to teach ambulatory activities. Motion in braces is started by
restricting all but two movements of an extremity and utilizing these to
perform a functional activity. As the child progresses, he is given new
movements to control until, after years of practice, he may be able to walk
with fairly normal gait, without braces of crutches.

b. Athetosis: Problem – Uncoordinated, involuntary movements.

Remedial procedures – Training to obtain relaxation and coordination,
combined with bracing to control involuntary movements can be used in
these types of cases. Here also, active motion is restricted in the beginning.
The athetoid quadriplegic starts ambulation with all the movements
controlled except flexion and extension of the shoulder and hip joints. As
the child progresses, the restraining bars for the arms may be removed or
the weight on the crutches may be lessened. Training the hands of athetoid
patients to perform voluntary functions is a difficult task in view of the
seven movements at the shoulder, the four movements of the elbow and
 the many movements of the thumb and fingers which must be
synchronized.

c. Ataxia: Remedial procedures – The improvement of most ataxics can be

accelerated by using weighted shoes or other appliances on the shoes.
Deaver suggests for a carefully selected combination of outpatient and
inpatient service. Deaver believes it is possible to accomplish more in 1
month of inpatient care than in 6 months on an outpatient basis. Short
periods of inpatient care are also recommended when the child is ready
for toilet training, dressing and eating activities which he is not attempting
or using in his home life. These inpatient services not only serve as
therapeutic services but also give the rehabilitation team an opportunity to
study the reactions of the child and the parents when they are separated.

References:

Denhoff, E. & Robinault, I. (1960). Cerebral palsy and Related disorders.

Dworkin. (1991). Motor Speech Disorders: A Treatment Guide.