Indian J Pediatr 1992; 59 : 37-51
VOJTA Neurophysiologic Therapy H. Bauer, G. Appaji* and D. Mundt**
hzstitute of Social Pediatrics and Medicine for Adolescents, University of Munich, Germany *Thalatr Hari Prasad bzstitute of Rehabilitation for the Mentally Handicapped, Hyderabad **Kinderklinik an der Amsterdamer Strabe, Universitiite Kbeh~. Ki~eln The reflexlocomotion acc. to VOJTA is a neurophysiologic facilitation system for the whole CNS and neuromuscular apparatus. It consists of all components, in a reciprocal manner of locomotion: (i) automatic control of posture, (ii) uprighting, (iii) aimed movements. Consequently the indications for this type of kinesiologic facilitation are really extensive. In this article the following complete list of indications is described: CCD (central coordination disorder), CP (cerebral palsy), peripheral paresis, Spina bifida (MMC), Myopathies, congenital malformations, orthopaedic problems, traumatic cross sections, neuromuscular dysfunctions etc. Further the experiences of the treatment in each disease are discussed. Even EMG-detections have shown the effect of the therapy in peripheral and central damage. Therefore a good prognosis for improvement and rehabilitation can be given in a large number of disorders, irrespective of age.
Key words: Neurophysiologic therapy acc. to VOJTA; Rehabilitation; Kinesio-logic EMG; Cerebral palsy; CCD (central coordination disorder); Spina bifida.
Physiotherapy based on neurophysiology was developed by VOJTA during 1954 to 1969 and has since then been constantly, improved. A large number of disorders relating to the central and peripheral nervous
Wrong Concepts About Indication
Reprint requests : Dr. reed. Hartmut Bauer, Head of the Physiotherapeutic Department, Institute of Social Pediatrics and Medicine for Adolescents, University of Munich, Children's Centre, Heiglhofstr, 63, D-8000 Munich 70, Germany.
Until now, VOJTA-therapy has only been applied in a limited manner. It was believed that: the therapy was suitable only for infants with central coordination disorders and/or spastic movement 37
system as well as to structural disorders of the muscles and joints can now be effectively treated by this method. 1-~
38
THE INDIANJOURNALOF PEDIATRICS disorders, this therapy is indicated only in the first few years of life, this therapy is not suited for older children or adults in bringing about any change of their condition, the affliction of muscles, bones and joints is the exclusive domain of orthopaedic surgeons, VOJTA's therapy is also contra-indicated in many disorders.
Vol. 59, No. 1 according to the principles of ontogenetic development, it is seen that all basic conditions for a change in motor functions are included. It is evident from the introductory descriptions of the therapeutic concept that the range of indications is very wide.
Absolute indications. The following disor-
ders demand an absolute indication for early therapy in infancy: 1.
Concept of the Method The therapeutic method developed by VOJTA was first applied to adolescents with fixed cerebral palsy; only later it was introduced in the treatment of infants with coordination disorders. Basically, the principles of the locomotion complex developed by VOJTA are not only a treatment for motor development but also have an effect on the whole body, including the vegetative and sensory-nervous system. Therefore, one can see during therapy changes in blood pressure, breathing and peripheral blood circulation, besides the effects on motor functions. 77ze motor-kinesiological content (locomotion content) of reflex creeping and reflex turning-developed by VOJTA - consists, like any other form of locomotion, of three inseparable components: (i)
The automatic control of body posture (postural stability/reactibility), (ii) the uprighting of the body, (iii) aimed movements, in its widest sense. Citation of M A G N U S : Every accurate movement starts from a definite posture and ends in a posture. More than this, reflex posture accompanies every movement "like a shadow". ~ By analysing these three main components
2. 3. 4. 5. 6. 7.
Moderate severe/severe central coordination disorders (CCD) (1. and 2. with a possible threat of CP), Mild asymmetric central coordination disorders, Muscular and neurogenic torticoilis, Peripheral paresis, Spina bifida, Congenital myopathies, Congenital malformations (e.g. Osseous scoliosis, arthrogryposis)
Moderate/Severe Central Coordination Disorders (CCD) The central coordination disorder describes, in fact, only a condition of a movement disorder or a general developmental disorder, and not yet a cerebral palsy. In case of moderate and severe central coordination disorders, it is established that 45% to 87% of the children develop pathologically in the sense of a movement disorder and/or mental disorder, and hence, have no chance of spontaneous normalisation. 6 The results of studies by different authors show that this "diagnosis" can achieve a far better prognosis if an early therapy according to Vojta's method is carried out, compared to untreated children. It was shown that treatment should begin at the latest by the 5th month of life in order to achieve favourable results, and with change
B A U E R E T A L : VOJTA NI-UROP! IYSIOLOGIC T i l E R A P Y
in the spectrum of cerebral palsy (incidence 0.730/00). `.7 Many children who receive an early physiotherapy show a normal gross motor development, even if primarily these children are mentally retarded (Figures 1-3). It is important to state here that the number of children with a moderate and severe central coordination disorder forms a very small percentage (2% to 4%) of the total population. Therefore, a qualified neurological examination of all children is necessary in order to start physiotherapy wilh the affected children) 9,~~ Asymmetric Central Coordination Disordrrs
Therapy is indicated even in very light or light CCD when there is either a posturai or neurological asymmetry. Wrong postures lead to a large number of secondary complications, like torticollis, C-scoliosis in infants and severe hip dysplasia (Figures 4 and 5).. Muscular Tortieollis Muscular torticoUis has multiple effects on the entire motor functions as described in "Seven-syndrome". Consequences: Birth
Fig. l. Moderate central coordination disorder, age 3 months.
39
Fig. 2. Signs of normalisation of motor development under treatment. Age 9 months, duration of treatment 7 months. traumatic injuries of the sternocleidomastold muscle result in a bending of the head towards the shortened side, and a turning of the head to the opposite side as well as a faulty posture of the cervical vertebral column. Therefore, in its further development the child is not able to assume a symmetrical elbow support in the prone position. In supine position the slanting posture is further accentuated leading to an asymmetric bone development of the skull and the face. Because of the constant slanting posture, an uneven development of the hands can occur. While the coordination between hand, eye and mouth can develop on one facial side, it can be stunted on the other. As a result, there is a progressively abnormal rotating posture of the cervical vertebral columnn (scoliosis) and a movement disorder in the pelvic area which leads to an oblique posture and to an asymmetry of the legs. This, in turn, causes a one-sided limitation of the abduction of the hip, a delayed maturation of the hip joint, and finally, a faulty posture of the foot (Figures 6-9 show the prevention of the deformities described).
40
"HIE INDIAN JOURNAl. OF PEDIATRICS
Vol. 59, No. 1
Fig. 4. Mild central asymmetric coordination disorder, age 10 weeks.
Fig. 3. Free coordinated walking, age 16 months. Therapy is ended (duration of therapy 14 months).
Peripheral Paresis (plexus paresis) In infants, various forms of paresis of the peripheral ncrvous system can occur. Here, especially a brachial plcxus paresis is an indication for Vojta's thcrapy. Because in most cases there is no complete division of the nerves, an improvement in the muscular activity of the affected arm can bc achieved by by a well defined stimulation of affcrcnt nerve impulses. Plexus paresis of the leg or diaphragm are much rarer. These, as well as facial paresis, can, however, also be effcctively treated. At first the activation is not perfect, but expresses itself in uncoordinated muscle group activations, later in coordinated muscle group patterns, and finally, in iso-
Fig. 5. Normali~tion of motor development under thcrapy. Age 13 months, duration of treatment one year. metric contractions. If it is only the question of a functional disorder, the activation of the muscle groups Ls soon achieved so that there is a
BAUER El" AL : VOJTA NEUROP!IYSIOLOGICTI IERAPY
41
Fig. 6.
Fig. 8. Still a scoliotic posture (age 13 months). integration of the arm can be achieved. H.z2 The duration of treatment of a plexus paresis lasts one and a half to four years. Every child should be treated irrespective of the extent and degree of paresis in order to avoid the effects on the entire body posture as has been described in the case of torticolIts (Figures 10 and 11). A normalisation can not be achieved in every case of the so-called lower plexus paresis. In such cases we can expect difficulties in scapular movements, in extension and rotational movements of the hand and fingers (Figures 12 and 13).
Fig. 6 and 7. Severe torticoUis with facial asymmetry, in supine position deformity of skull visible (age 6 t/z months).
The final defect syndrome can be clinically and electromyographically confirmed only from the 6th month of life, at a time when a spontaneous re-inncrvation can and may not be expected any more. ~3
complete recovery in 40% of the cases. In further 45% a partial recovery with a good
77ze aim of the treatment is an improvement of the regenerative process: at least,
42
I'HE INDIANJOURNALOF PEDIATRICS
Vol. 59. No. 1
?. ".'i
Fig. 10. Plexus paresis right with typical rotational movement. No use of hand, age 5 weeks.
"Ai.~
.'.;.
,.-
'~':
,~
Fig. 9. The developmcnt of scoliosis is stopped (age 16 89months). however, a functional improvement to use the arms and hands better in daily life.
Spina bifida With spina bifida there is, as a rule, a cross scctional damagc of the spinal cord in very differcnt degrees, with incomplete deficits of the peripheral ncrvcs affecting the sensory-motor and vegetative functions. In most cases there is also a hydrocephalus with a central coordination disordcr or even a spastic cerebral palsy. Therefore, widely differing limitations of movemcnt can occur proportional to the severity of the palsy.
Fig. It. After 14 months of therapy the paralysis is cured. The extent of the paralysis again will be determined by application of the therapeutic concept according to Vojta. Hereby, the still existing activities of different muscle groups can be clearly identified and distinguished from reflex automatisms. There are also abnormalities in the ver-
B A U E R Eq" A L : VOYFA N E U R O P I IYSIOI.OGIC T | IERAPY
43
Fig. 12. Defective condition of the right hand, age 7 months, improvements still possible. tebral column, in hip, knee and ankle joints as well as functional disorders of the bladder and rectum or disturbances in blood circulation and growth of the affected segments. As long as there is a residual nervous connection between the legs and spinal cord, there is a possibility of activating these connections to improve the various functions of the child (Figures 14 to 16). A large number of clinical studies prove that the following changes can be achieved in a child with splna bifida by applying Vojta's therapy:. an improvement in blood circulation which also has a positive effect on growth and development of the bones, a reduction in sensory disturbances, a reduction of muscular atrophy, an improvement in spontaneous motor functions in the partly paralysed muscle groups as well as the respiratory and abdominal musculature, - a possible improvement in joints witout completely fixed contraetures, an improvement in the bladder and bowel functions by reduction of the residual urine, a more regular emptying -
Fig. 13. Minimal residual defect of the right hand and arm and in posture, age 22 months. of the bowels and reduction of the frequency of urinary tract infections, and improvement in C.S.F. circulation, particularly with shunted hydrocephalus. Due to these positive influences, the number of operations required earlier can be reduced and the utility of orthopaedic aids can be improved. 14"~6 Congenital Myopathies Congenital myopathies-contrary to progressive muscle diseases-are characterised by a severe hypotonia already in the neonatal period. Disorders in the construction of muscle fibres belong to this group, which, as a rule, are not progressive. An exact diaguo-
44
TI IE INDIAN JOURNAL OF PEDIATRICS
Vol. 59, No. 1
(~:a'~':. ' ~ .
"
.,
Fig. 15. Creeping, age 2 years. Fig. 14. Spina bif/~a, age 16 months, level of paralysis lumbar incomplete (L2-IA).
sis can only be made at the end of the first year of life by a muscle biopsy and, if needed, by electronmicroscopy. However, these children must be treated at the earliest possible time after birth in order to improve their abilities like breathing, sucking, drinking etc. Congenitalmalformations. Many malformations have effects on parts of the bony, muscular and nervous locomotion apparatus. This, for example includes: the bony malformations of the vertebral column (scoliosis) which often is associated with other disorders of the neck and face, e.g. KlippelFeil-syndrome (Figures 17 and 18). Arthrogryposis multiplex congenita is also a disorder which is characterised by severe changes in the joints, muscles and other organs. The aim of treatment is to prevent secondary atrophies of the muscles and the development of contractions as well as to improve the coordination between individual muscles (Figures 19-24)) 7a~ Further indications for Vojta's therapy. In the following cases there is a relative indication for early therapy in infancy: 1. Down's Syndrome and other syndromes (genetic disorders), 2. Motor retardations, 3. Posture disorders and defective up-
e'r
Fig. 16. Verticalisation with 4 years (marked area: no sensibility), supply with "Ferrari orthesis" is now possible.
.
righting mechanisms (e.g. C-scoliosis, lordosis), Dysplasia of the hip,
BAUER ET AL : VOJTA NEUROPHYSIOLOGIC"I7tERAPY
45
Fig. 17. Congenital malformation of spinal column, scoliosis, blockade of motor development, age 21 months. 5. Foot deformities Motor Retardations and Posture Disorders (e.g. Down's Syndrome)
The developmental rehabilitation of children with chromosomal anomalies, e.g. Down's Syndrome, is a task that requires a multi-disciplinary approach. In infancy, there is a severe muscular hypotonia which is mainly caused by a lack of motivation and mental retardation. As a result, in later childhood a severe postural disorder may develop. Therefore, the treatrnent should aim at an early improvement 0fmotor abilities and an early improvement of the mental condition. Besides, it is important to prevent secondary posture disorders due to muscular w~akness. Thus, Vojta's therapy also has beneficial effects on the orofacial muscles of children with Down's Syndrome. Our experiences
Fig. 18. Functional correcuon after 1 year therapy, dcliveration of motor functions, age 32 months. show that these children achieve a considerable confidence in the uprighting of the trunk. The same holds true for all children who, due to different causes, have disorders of motor development, particularly in uprighting. This is probably the key to the prevention of later postural disorders of the vertebral column. Defective Positions of the Joints
Frequent congenital disorders are hip joint dysplasias and malformations of the feet, like club foot. These occur mostly in combination with other disorders of the peripheral and central nervous system or intrauterine movement disorders, like e.g. breech position.
46
TIlE INDIANJOURNAL OF PEDIATRICS
In cases of clear hip dysplasias, Vojta's therapy is an altenaativ9 to conventional orthopaedic treatments, i.e. a separating cast between the thighs. The same holds true for the treatment of the club foot, at least pre-operatively) 92~ Indications for Vojta-therapy with Older Children and Adults In later childhood and adolescence, the following indications are prcdominant: 1. 2. 3. 4.
infantile cerebral palsy, Acquired cerebral syndromes, Cross section syndromes (paraplegia), Congenital and acquired peripheral paresis, 5. Myopathies, 6. Scoliosis and kyphosis, 7. Joint contractures,
vol. 59, No. I 8. Functional limitations of the movement apparatus Infantile Cerebral Palsy Infantile Cerebral Palsy is subdivided into the following groups: (i) Spastic syndromes, (ii) Dyskinesias (e.g. athetotic syndromes), (iii) Ataxia, (iv) Other rare mixed forms. Vojta's therapy has proved to be effective in all of these cases. It can be said that thc earlier the therapy is started, the better the results. But also in case of a coordination disorder, which was detected late, and where C.P. is already fixed, Vojtathcrapy is suitable for enabling the child to
Fig. 19 and 20 Arthrogryposis, Severe contractions in almos~ all joints, age 3 months.
BAUER ET AL : VOYI'A NI~UROI'IIYSIOI.OGICTIIERAPY achieve motor indepcndcnce (as long as additional handicaps are not existing) (Figurcs 25 to 27).
Improvement of tile Prognosis Depending on the child's motivation, i.e. its mental situation and its social environmcnt, it is possiblc to make an carly prognosis about the child's furthcr development. For example, one can say that a child with a spastic diparesis which creeps at the age of one and a half can probably walk indcpcndently or at least with some walking aids at school age. 21z3 The influence on motor coordination was proved by EMG. ~ 2 On the other hand, a treatment started later can also achieve improvement in many areas, e.g. blood circulation or growth disorders or disorders of
47
vcrticalisation of the trunk. Also secondary changes such as scoliosis, hip joint disordcrs, knee and ankle joint contractures as wcll as functional disordcrs of the hands can bc rcduced. Surgical hzterventions without a preparatory physiotherapy arc especially with cerebral palsies of no use. But, even aflcr an opcration, a physiotherapy is absolutely necessary to stabilise the effects of the operation. Acquired Cerebral Disorders This tcrm includes all disorders of brain functions, particularly post-traumatic and post-infectious sequelae and disturbances due to other basic disorders, like circulation disorders or metabolic degenerative disordcrs of the nervous system. The technique of Vojta's therapy can also be applied for rehabilitation of adolescents and adults. Although mainly movement disorders are treated here, various other functions can be
J Fig. 21. Sitting.
Fig. 22. Crawling on all four extremities.
Fig. 23. First steps.
48
TI IE INDIANJOURNALOF PEDIATRICS
Fig. 24. Standing. Fig. 21 to 24. Arthrogryposis. "Functional release" of almost all joints, club foot operation, age 2 88years.
Vol. 59, No. l
Fig. 26. Pathological uprighting, pulling-up, age 5 89years (stage 6 of locomotion), that means tetrapedal gait in venicalisation. Cross Section Syndromes in Childhood and Adulthood
Fig. 25. Spastic diparesis in its first uprighting, starting position of pathological hopping, age 3 88 years (stage 4 of locomotion). influenced, same as in infancy and early childhood.
In case of damage to the spinal cord, e.g. due to accidents, there is normally an incomplete disorder, i.e. the facilitation systems of the spinal cord mostly retain connection to the corresponding spinal segments. It is not always possible to detect this clinically so that it has to be confirmed with the help of electromyography or other electro-physiological methods. Often muscle functions are seen under therapy inspite of clinical paraplegia. One can expect improvements with Vojta's physiotherapy as long as such connections can be demonstrated. The integration of the patient in daily life can be eased by the improvement of certain functions even if a complete recovery cannot be
BAUER l~l"AI. : VO.ITANEUROi'I IYSIOI.OGICT! IERAPY
49
Fig. 28. Scwcre traumatic spinal lesion, age 14 months.
Fig. 27. Independent walking in a pathological pattern, age 12 ycars (stage 7 of locomotion). achicvcd (Figures 28 to 30). Muscle Diseases In childhood and adolesccnce, genetically dctcrmined and clinically progressive muscular dystrophies are more frequent. By a purposeful facilitation, e.g. by reflex creeping, the patient's abilities can be maintained for a longer period, ttowcver, a substantial improvement or even an arrest of the progression of the disease, same as in other ncurodcgenerativc disorders, can certainly not be achieved.
Fig. 29. Uprighting into heel position, age 3 V2 years. Contractures of tile joints and functional limitations of the movement (scoliosis, kyphosis). Vojta-thcrapy can bring about an improvement of functional limitations of the movements in various joints, with the exccption of rheumatic diseases, in all ages. Evcry active treatment is preferable to a treatment with passive movements because of its better effects on the disturbed muscle function. Here, naturally, the Vojta-thcrapy can bc combined with other methods. Examples arc the treatment of joints after a long period of immobilisation, e.g. after
50
Vol. 59, No. 1
Tl II" INDIAN JOURNAL OF PI'DIATRICS
large number of disorders and brings about improvcmcnt in the patients, irrespective of age. P,~rE~CES 1.
Fig. 30. Inspire of severe high cross sectional symptomatic: quatropcdal uprighting, age 4 89 years (murked area: no sensibility). fiacturcs c~r .ic~int dis~rdcrs caused by sp~rt activities.
2.
3.
Limits of the Therapy However, V O J T A ' s therapy also has limits in its indications and its efficacy. These dcpend on the extent and degree of the basic affliction and the resultant functional disorders, e.g. the combination of infantilc ccrcbral palsy with epilepsy, mental retardation or disorders of sense organs. Often, the primary limits of a therapeutic success are already seen in infancy, and it is surely necessary to consider early, about how long an intensive therapy, i.e. three to four therapeutic scssi
VOJTA Neurophysiologic Therapy H. Bauer, G. Appaji* and D. Mundt**
hzstitute of Social Pediatrics and Medicine for Adolescents, University of Munich, Germany *Thalatr Hari Prasad bzstitute of Rehabilitation for the Mentally Handicapped, Hyderabad **Kinderklinik an der Amsterdamer Strabe, Universitiite Kbeh~. Ki~eln The reflexlocomotion acc. to VOJTA is a neurophysiologic facilitation system for the whole CNS and neuromuscular apparatus. It consists of all components, in a reciprocal manner of locomotion: (i) automatic control of posture, (ii) uprighting, (iii) aimed movements. Consequently the indications for this type of kinesiologic facilitation are really extensive. In this article the following complete list of indications is described: CCD (central coordination disorder), CP (cerebral palsy), peripheral paresis, Spina bifida (MMC), Myopathies, congenital malformations, orthopaedic problems, traumatic cross sections, neuromuscular dysfunctions etc. Further the experiences of the treatment in each disease are discussed. Even EMG-detections have shown the effect of the therapy in peripheral and central damage. Therefore a good prognosis for improvement and rehabilitation can be given in a large number of disorders, irrespective of age.
Key words: Neurophysiologic therapy acc. to VOJTA; Rehabilitation; Kinesio-logic EMG; Cerebral palsy; CCD (central coordination disorder); Spina bifida.
Physiotherapy based on neurophysiology was developed by VOJTA during 1954 to 1969 and has since then been constantly, improved. A large number of disorders relating to the central and peripheral nervous
Wrong Concepts About Indication
Reprint requests : Dr. reed. Hartmut Bauer, Head of the Physiotherapeutic Department, Institute of Social Pediatrics and Medicine for Adolescents, University of Munich, Children's Centre, Heiglhofstr, 63, D-8000 Munich 70, Germany.
Until now, VOJTA-therapy has only been applied in a limited manner. It was believed that: the therapy was suitable only for infants with central coordination disorders and/or spastic movement 37
system as well as to structural disorders of the muscles and joints can now be effectively treated by this method. 1-~
38
THE INDIANJOURNALOF PEDIATRICS disorders, this therapy is indicated only in the first few years of life, this therapy is not suited for older children or adults in bringing about any change of their condition, the affliction of muscles, bones and joints is the exclusive domain of orthopaedic surgeons, VOJTA's therapy is also contra-indicated in many disorders.
Vol. 59, No. 1 according to the principles of ontogenetic development, it is seen that all basic conditions for a change in motor functions are included. It is evident from the introductory descriptions of the therapeutic concept that the range of indications is very wide.
Absolute indications. The following disor-
ders demand an absolute indication for early therapy in infancy: 1.
Concept of the Method The therapeutic method developed by VOJTA was first applied to adolescents with fixed cerebral palsy; only later it was introduced in the treatment of infants with coordination disorders. Basically, the principles of the locomotion complex developed by VOJTA are not only a treatment for motor development but also have an effect on the whole body, including the vegetative and sensory-nervous system. Therefore, one can see during therapy changes in blood pressure, breathing and peripheral blood circulation, besides the effects on motor functions. 77ze motor-kinesiological content (locomotion content) of reflex creeping and reflex turning-developed by VOJTA - consists, like any other form of locomotion, of three inseparable components: (i)
The automatic control of body posture (postural stability/reactibility), (ii) the uprighting of the body, (iii) aimed movements, in its widest sense. Citation of M A G N U S : Every accurate movement starts from a definite posture and ends in a posture. More than this, reflex posture accompanies every movement "like a shadow". ~ By analysing these three main components
2. 3. 4. 5. 6. 7.
Moderate severe/severe central coordination disorders (CCD) (1. and 2. with a possible threat of CP), Mild asymmetric central coordination disorders, Muscular and neurogenic torticoilis, Peripheral paresis, Spina bifida, Congenital myopathies, Congenital malformations (e.g. Osseous scoliosis, arthrogryposis)
Moderate/Severe Central Coordination Disorders (CCD) The central coordination disorder describes, in fact, only a condition of a movement disorder or a general developmental disorder, and not yet a cerebral palsy. In case of moderate and severe central coordination disorders, it is established that 45% to 87% of the children develop pathologically in the sense of a movement disorder and/or mental disorder, and hence, have no chance of spontaneous normalisation. 6 The results of studies by different authors show that this "diagnosis" can achieve a far better prognosis if an early therapy according to Vojta's method is carried out, compared to untreated children. It was shown that treatment should begin at the latest by the 5th month of life in order to achieve favourable results, and with change
B A U E R E T A L : VOJTA NI-UROP! IYSIOLOGIC T i l E R A P Y
in the spectrum of cerebral palsy (incidence 0.730/00). `.7 Many children who receive an early physiotherapy show a normal gross motor development, even if primarily these children are mentally retarded (Figures 1-3). It is important to state here that the number of children with a moderate and severe central coordination disorder forms a very small percentage (2% to 4%) of the total population. Therefore, a qualified neurological examination of all children is necessary in order to start physiotherapy wilh the affected children) 9,~~ Asymmetric Central Coordination Disordrrs
Therapy is indicated even in very light or light CCD when there is either a posturai or neurological asymmetry. Wrong postures lead to a large number of secondary complications, like torticollis, C-scoliosis in infants and severe hip dysplasia (Figures 4 and 5).. Muscular Tortieollis Muscular torticoUis has multiple effects on the entire motor functions as described in "Seven-syndrome". Consequences: Birth
Fig. l. Moderate central coordination disorder, age 3 months.
39
Fig. 2. Signs of normalisation of motor development under treatment. Age 9 months, duration of treatment 7 months. traumatic injuries of the sternocleidomastold muscle result in a bending of the head towards the shortened side, and a turning of the head to the opposite side as well as a faulty posture of the cervical vertebral column. Therefore, in its further development the child is not able to assume a symmetrical elbow support in the prone position. In supine position the slanting posture is further accentuated leading to an asymmetric bone development of the skull and the face. Because of the constant slanting posture, an uneven development of the hands can occur. While the coordination between hand, eye and mouth can develop on one facial side, it can be stunted on the other. As a result, there is a progressively abnormal rotating posture of the cervical vertebral columnn (scoliosis) and a movement disorder in the pelvic area which leads to an oblique posture and to an asymmetry of the legs. This, in turn, causes a one-sided limitation of the abduction of the hip, a delayed maturation of the hip joint, and finally, a faulty posture of the foot (Figures 6-9 show the prevention of the deformities described).
40
"HIE INDIAN JOURNAl. OF PEDIATRICS
Vol. 59, No. 1
Fig. 4. Mild central asymmetric coordination disorder, age 10 weeks.
Fig. 3. Free coordinated walking, age 16 months. Therapy is ended (duration of therapy 14 months).
Peripheral Paresis (plexus paresis) In infants, various forms of paresis of the peripheral ncrvous system can occur. Here, especially a brachial plcxus paresis is an indication for Vojta's thcrapy. Because in most cases there is no complete division of the nerves, an improvement in the muscular activity of the affected arm can bc achieved by by a well defined stimulation of affcrcnt nerve impulses. Plexus paresis of the leg or diaphragm are much rarer. These, as well as facial paresis, can, however, also be effcctively treated. At first the activation is not perfect, but expresses itself in uncoordinated muscle group activations, later in coordinated muscle group patterns, and finally, in iso-
Fig. 5. Normali~tion of motor development under thcrapy. Age 13 months, duration of treatment one year. metric contractions. If it is only the question of a functional disorder, the activation of the muscle groups Ls soon achieved so that there is a
BAUER El" AL : VOJTA NEUROP!IYSIOLOGICTI IERAPY
41
Fig. 6.
Fig. 8. Still a scoliotic posture (age 13 months). integration of the arm can be achieved. H.z2 The duration of treatment of a plexus paresis lasts one and a half to four years. Every child should be treated irrespective of the extent and degree of paresis in order to avoid the effects on the entire body posture as has been described in the case of torticolIts (Figures 10 and 11). A normalisation can not be achieved in every case of the so-called lower plexus paresis. In such cases we can expect difficulties in scapular movements, in extension and rotational movements of the hand and fingers (Figures 12 and 13).
Fig. 6 and 7. Severe torticoUis with facial asymmetry, in supine position deformity of skull visible (age 6 t/z months).
The final defect syndrome can be clinically and electromyographically confirmed only from the 6th month of life, at a time when a spontaneous re-inncrvation can and may not be expected any more. ~3
complete recovery in 40% of the cases. In further 45% a partial recovery with a good
77ze aim of the treatment is an improvement of the regenerative process: at least,
42
I'HE INDIANJOURNALOF PEDIATRICS
Vol. 59. No. 1
?. ".'i
Fig. 10. Plexus paresis right with typical rotational movement. No use of hand, age 5 weeks.
"Ai.~
.'.;.
,.-
'~':
,~
Fig. 9. The developmcnt of scoliosis is stopped (age 16 89months). however, a functional improvement to use the arms and hands better in daily life.
Spina bifida With spina bifida there is, as a rule, a cross scctional damagc of the spinal cord in very differcnt degrees, with incomplete deficits of the peripheral ncrvcs affecting the sensory-motor and vegetative functions. In most cases there is also a hydrocephalus with a central coordination disordcr or even a spastic cerebral palsy. Therefore, widely differing limitations of movemcnt can occur proportional to the severity of the palsy.
Fig. It. After 14 months of therapy the paralysis is cured. The extent of the paralysis again will be determined by application of the therapeutic concept according to Vojta. Hereby, the still existing activities of different muscle groups can be clearly identified and distinguished from reflex automatisms. There are also abnormalities in the ver-
B A U E R Eq" A L : VOYFA N E U R O P I IYSIOI.OGIC T | IERAPY
43
Fig. 12. Defective condition of the right hand, age 7 months, improvements still possible. tebral column, in hip, knee and ankle joints as well as functional disorders of the bladder and rectum or disturbances in blood circulation and growth of the affected segments. As long as there is a residual nervous connection between the legs and spinal cord, there is a possibility of activating these connections to improve the various functions of the child (Figures 14 to 16). A large number of clinical studies prove that the following changes can be achieved in a child with splna bifida by applying Vojta's therapy:. an improvement in blood circulation which also has a positive effect on growth and development of the bones, a reduction in sensory disturbances, a reduction of muscular atrophy, an improvement in spontaneous motor functions in the partly paralysed muscle groups as well as the respiratory and abdominal musculature, - a possible improvement in joints witout completely fixed contraetures, an improvement in the bladder and bowel functions by reduction of the residual urine, a more regular emptying -
Fig. 13. Minimal residual defect of the right hand and arm and in posture, age 22 months. of the bowels and reduction of the frequency of urinary tract infections, and improvement in C.S.F. circulation, particularly with shunted hydrocephalus. Due to these positive influences, the number of operations required earlier can be reduced and the utility of orthopaedic aids can be improved. 14"~6 Congenital Myopathies Congenital myopathies-contrary to progressive muscle diseases-are characterised by a severe hypotonia already in the neonatal period. Disorders in the construction of muscle fibres belong to this group, which, as a rule, are not progressive. An exact diaguo-
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(~:a'~':. ' ~ .
"
.,
Fig. 15. Creeping, age 2 years. Fig. 14. Spina bif/~a, age 16 months, level of paralysis lumbar incomplete (L2-IA).
sis can only be made at the end of the first year of life by a muscle biopsy and, if needed, by electronmicroscopy. However, these children must be treated at the earliest possible time after birth in order to improve their abilities like breathing, sucking, drinking etc. Congenitalmalformations. Many malformations have effects on parts of the bony, muscular and nervous locomotion apparatus. This, for example includes: the bony malformations of the vertebral column (scoliosis) which often is associated with other disorders of the neck and face, e.g. KlippelFeil-syndrome (Figures 17 and 18). Arthrogryposis multiplex congenita is also a disorder which is characterised by severe changes in the joints, muscles and other organs. The aim of treatment is to prevent secondary atrophies of the muscles and the development of contractions as well as to improve the coordination between individual muscles (Figures 19-24)) 7a~ Further indications for Vojta's therapy. In the following cases there is a relative indication for early therapy in infancy: 1. Down's Syndrome and other syndromes (genetic disorders), 2. Motor retardations, 3. Posture disorders and defective up-
e'r
Fig. 16. Verticalisation with 4 years (marked area: no sensibility), supply with "Ferrari orthesis" is now possible.
.
righting mechanisms (e.g. C-scoliosis, lordosis), Dysplasia of the hip,
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Fig. 17. Congenital malformation of spinal column, scoliosis, blockade of motor development, age 21 months. 5. Foot deformities Motor Retardations and Posture Disorders (e.g. Down's Syndrome)
The developmental rehabilitation of children with chromosomal anomalies, e.g. Down's Syndrome, is a task that requires a multi-disciplinary approach. In infancy, there is a severe muscular hypotonia which is mainly caused by a lack of motivation and mental retardation. As a result, in later childhood a severe postural disorder may develop. Therefore, the treatrnent should aim at an early improvement 0fmotor abilities and an early improvement of the mental condition. Besides, it is important to prevent secondary posture disorders due to muscular w~akness. Thus, Vojta's therapy also has beneficial effects on the orofacial muscles of children with Down's Syndrome. Our experiences
Fig. 18. Functional correcuon after 1 year therapy, dcliveration of motor functions, age 32 months. show that these children achieve a considerable confidence in the uprighting of the trunk. The same holds true for all children who, due to different causes, have disorders of motor development, particularly in uprighting. This is probably the key to the prevention of later postural disorders of the vertebral column. Defective Positions of the Joints
Frequent congenital disorders are hip joint dysplasias and malformations of the feet, like club foot. These occur mostly in combination with other disorders of the peripheral and central nervous system or intrauterine movement disorders, like e.g. breech position.
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In cases of clear hip dysplasias, Vojta's therapy is an altenaativ9 to conventional orthopaedic treatments, i.e. a separating cast between the thighs. The same holds true for the treatment of the club foot, at least pre-operatively) 92~ Indications for Vojta-therapy with Older Children and Adults In later childhood and adolescence, the following indications are prcdominant: 1. 2. 3. 4.
infantile cerebral palsy, Acquired cerebral syndromes, Cross section syndromes (paraplegia), Congenital and acquired peripheral paresis, 5. Myopathies, 6. Scoliosis and kyphosis, 7. Joint contractures,
vol. 59, No. I 8. Functional limitations of the movement apparatus Infantile Cerebral Palsy Infantile Cerebral Palsy is subdivided into the following groups: (i) Spastic syndromes, (ii) Dyskinesias (e.g. athetotic syndromes), (iii) Ataxia, (iv) Other rare mixed forms. Vojta's therapy has proved to be effective in all of these cases. It can be said that thc earlier the therapy is started, the better the results. But also in case of a coordination disorder, which was detected late, and where C.P. is already fixed, Vojtathcrapy is suitable for enabling the child to
Fig. 19 and 20 Arthrogryposis, Severe contractions in almos~ all joints, age 3 months.
BAUER ET AL : VOYI'A NI~UROI'IIYSIOI.OGICTIIERAPY achieve motor indepcndcnce (as long as additional handicaps are not existing) (Figurcs 25 to 27).
Improvement of tile Prognosis Depending on the child's motivation, i.e. its mental situation and its social environmcnt, it is possiblc to make an carly prognosis about the child's furthcr development. For example, one can say that a child with a spastic diparesis which creeps at the age of one and a half can probably walk indcpcndently or at least with some walking aids at school age. 21z3 The influence on motor coordination was proved by EMG. ~ 2 On the other hand, a treatment started later can also achieve improvement in many areas, e.g. blood circulation or growth disorders or disorders of
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vcrticalisation of the trunk. Also secondary changes such as scoliosis, hip joint disordcrs, knee and ankle joint contractures as wcll as functional disordcrs of the hands can bc rcduced. Surgical hzterventions without a preparatory physiotherapy arc especially with cerebral palsies of no use. But, even aflcr an opcration, a physiotherapy is absolutely necessary to stabilise the effects of the operation. Acquired Cerebral Disorders This tcrm includes all disorders of brain functions, particularly post-traumatic and post-infectious sequelae and disturbances due to other basic disorders, like circulation disorders or metabolic degenerative disordcrs of the nervous system. The technique of Vojta's therapy can also be applied for rehabilitation of adolescents and adults. Although mainly movement disorders are treated here, various other functions can be
J Fig. 21. Sitting.
Fig. 22. Crawling on all four extremities.
Fig. 23. First steps.
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Fig. 24. Standing. Fig. 21 to 24. Arthrogryposis. "Functional release" of almost all joints, club foot operation, age 2 88years.
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Fig. 26. Pathological uprighting, pulling-up, age 5 89years (stage 6 of locomotion), that means tetrapedal gait in venicalisation. Cross Section Syndromes in Childhood and Adulthood
Fig. 25. Spastic diparesis in its first uprighting, starting position of pathological hopping, age 3 88 years (stage 4 of locomotion). influenced, same as in infancy and early childhood.
In case of damage to the spinal cord, e.g. due to accidents, there is normally an incomplete disorder, i.e. the facilitation systems of the spinal cord mostly retain connection to the corresponding spinal segments. It is not always possible to detect this clinically so that it has to be confirmed with the help of electromyography or other electro-physiological methods. Often muscle functions are seen under therapy inspite of clinical paraplegia. One can expect improvements with Vojta's physiotherapy as long as such connections can be demonstrated. The integration of the patient in daily life can be eased by the improvement of certain functions even if a complete recovery cannot be
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Fig. 28. Scwcre traumatic spinal lesion, age 14 months.
Fig. 27. Independent walking in a pathological pattern, age 12 ycars (stage 7 of locomotion). achicvcd (Figures 28 to 30). Muscle Diseases In childhood and adolesccnce, genetically dctcrmined and clinically progressive muscular dystrophies are more frequent. By a purposeful facilitation, e.g. by reflex creeping, the patient's abilities can be maintained for a longer period, ttowcver, a substantial improvement or even an arrest of the progression of the disease, same as in other ncurodcgenerativc disorders, can certainly not be achieved.
Fig. 29. Uprighting into heel position, age 3 V2 years. Contractures of tile joints and functional limitations of the movement (scoliosis, kyphosis). Vojta-thcrapy can bring about an improvement of functional limitations of the movements in various joints, with the exccption of rheumatic diseases, in all ages. Evcry active treatment is preferable to a treatment with passive movements because of its better effects on the disturbed muscle function. Here, naturally, the Vojta-thcrapy can bc combined with other methods. Examples arc the treatment of joints after a long period of immobilisation, e.g. after
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large number of disorders and brings about improvcmcnt in the patients, irrespective of age. P,~rE~CES 1.
Fig. 30. Inspire of severe high cross sectional symptomatic: quatropcdal uprighting, age 4 89 years (murked area: no sensibility). fiacturcs c~r .ic~int dis~rdcrs caused by sp~rt activities.
2.
3.
Limits of the Therapy However, V O J T A ' s therapy also has limits in its indications and its efficacy. These dcpend on the extent and degree of the basic affliction and the resultant functional disorders, e.g. the combination of infantilc ccrcbral palsy with epilepsy, mental retardation or disorders of sense organs. Often, the primary limits of a therapeutic success are already seen in infancy, and it is surely necessary to consider early, about how long an intensive therapy, i.e. three to four therapeutic scssi
