Temple Fay, a neurosurgeon in Philadelphia, recommended that the cerebral palsied be taught motion according to its development in evolution. He regarded ontogenetic development (in humans) as a recapitulation of phylogenetic development (in the evolution of the species). In general, he suggested building up motion from reptilian squirming to amphibian creeping, through mammalian reciprocal motion ‘on all fours’ to the primate erect walking. As lower animals carried out these early movements of progression with a simple nervous system, they can similarly be carried out in the human in the absence of a normal cerebral cortex. The midbrain, pons and medulla could be involved in the stimulation of primitive patterns of movement and primitive reflexes which activate the handicapped parts of the body. Fay also described ‘unlocking reflexes’ which reduce hypertonus. Based on these ideas, he developed progressive pattern movements which consist of five stages (Fay 1954a,b).

Stage 1. Prone lying. Head and trunk rotation from side to side.

Stage 2. Homolateral stage. Prone lying, head turned to side. Arm on the face side in abduction–external–rotation, elbow semi-flexed, hand open, thumb out towards the mouth. Leg on face side in abduction, knee flexion opposite stomach, foot dorsiflexion. Arm on the occiput side is extended, internally rotated, hand open at the side of the child or on the lumbar area of his back. Leg on the occiput side is extended. Movement involves head turning from side to side with the face, arm and leg sweeping down to the extended position and the opposite occiput arm and leg flexing up to the position near the face as the head turns round.

Stage 3. Contralateral stage. Prone lying. Head turned to side, arm on the face side as in stage 2.

The leg on the face side is, however, extended. The other leg on the side of the occiput is flexed. As the head turns, this contralateral pattern changes from side to side.

Stage 4. On hands and knees. Reciprocal crawling and reciprocal stepping on hands and feet in the bear walk or elephant walk.

Stage 5. Walking pattern. This is a sailor’s walk called by Fay ‘reciprocal progression on lower extremities synchronized with the contralateral swing of the arms and trunk’. A wide base is used and the child flexes one hip and knee into external rotation and then places his foot on the ground, still in external rotation. As the foot is being placed on the ground, the opposite arm and shoulder are rotating towards it. As weight is taken on the straight leg, the other leg flexes up.

The Doman-Delacato system or the Institute for the Achievement of Human Potential (IAHP) (Doman et al. 1960), which follows the basic tenets postulated by Fay, also recommends periods of inhalations of CO₂ from a breathing sack, restriction of fluid intake and development of cerebral hemispheric dominance. Cerebral dominance is attempted by principal use of dominant eye, hand, foot and arm, and other methods. Children are also hung upside down and whirled around to stimulate the vestibular apparatus. They are also asked to hang and ‘walk’ their hands along a horizontal ladder as observed in apes.

The progressive pattern movements called ‘patterning therapy’ are first practised passively at least five times daily. One person turns the head, another person moves the arms and leg on one side, and another person moves the arm and leg on the other side. Locomotion beyond the stage of the child’s patterning level is not permitted. A child who is not proficient in cross-pattern creeping is prevented from walking. There is a rigid and inaccurate view of development. ‘Neurological organisation’ is considered possible if each developmental level is established before going to the next level. This approach restricts itself to prone development and expects demanding daily regimes of treatment, amounting to 8–10 hours a day, 7 days a week in many cases.

Parents could not manage this without obtaining a number of volunteers. There was a high rate of inappropriate parental expectations with reports of excessive family stress as success or failure depended on the parents working intensively. Various medical organisations have made statements that there is no scientific evidence and that the theories are outdated and oversimplified. These organisations are American Academy of Paediatrics and American Academy of Neurology (1967), American Academy of Paediatrics (1999), American Academy of Physical Medicine and Rehabilitation (1968). Today, patterning therapy has almost disappeared in the United States (Miller 2007).

The British Institute for Brain Injured Children (BIBIC) and Brainwave originally acted in conjunction with the IAHP, but now function on their own. They use their developmental profile from Temple Fay (Fay 1954a,b). Play is notably absent and BIBIC’s educational programme is superficial, according to a multidisciplinary appraisal and independent review (Morton et al. 1999). They found that the Doman-Delacato influences are strong, and emotional, financial and other demands on the family are considerable.

Synergistic movement patterns

Signe Brunnstrom, a physical therapist who worked with adult hemiplegia, assessed the stages of recovery and compared them with normal sequential neu-romotor development in early childhood. Her studies consider flexion and extension limb synergies leading to isolated motion. She produced motion by stimulating primitive movement patterns or syn-ergistic movement patterns which are observed in fetal life or immediately after pyramidal tract damage. The main features of her work are as follows (Brunnstrom 1970):

Reflex responses are used initially which a patient could ‘capture’ and use later in voluntary control of these synergies to move. Later, the flexor and extensor synergies were modified (broken up), and voluntary function with more variety that was possible was elicited and practised.

Control of head and trunk is attempted with stimulation of attitudinal reflexes such as tonic neck reflexes, tonic lumbar reflexes and tonic labyrinthine reflexes. This is followed by stimulation of righting reflexes and later balance training.

Associated reactions are used as well as hand reactions; for example, hyperextension of the thumb produces relaxation of the finger flexors. Resisted action was used on the unaffected side to activate the affected side. The training of a patient’s voluntary control is developed later in the therapy programme.

Sensory stimulation. Brunnstrom uses proprio-ceptive and other stimuli in her training, such as tapping or stroking for adult hemiplegia. We see some of these methods in the early Bobath approach and in other neurophysiological approaches which used hierarchical theories and sensory input.

Herman Kabat, a neurophysiologist and psychiatrist in the United States, has discussed various neu-rophysiological mechanisms which could be used in therapeutic exercises. With Margaret Knott and Dorothy Voss, he developed a system of movement facilitation techniques and methods for the decrease of hypertonus, for strengthening, coordination and improving joint range (Kabat et al. 1959; Knott & Voss 1968; Voss 1972; Voss et al. 1985). The main features of these methods are the use of the following:

Movement patterns (called mass movement synergies) based on patterns observed within functional activities such as dressing, walking, playing tennis, golf or football. These patterns are spiral (rotational) and diagonal with a synergy or chain of muscle groups. Isolated muscle education was not used as a movement pattern could activate a muscle group within a chain of muscles. The movement patterns are therefore not the ‘mass movements’ seen after brain damage, but are functionally derived patterns. They consist of the following simultaneously activated components in hips, knees and feet or in shoulders, elbows, wrists and hands:

Sensory (afferent) stimuli are skilfully applied to facilitate movement. Stimuli used are touch and pressure, traction and compression, stretch or limb elongation and the proprioceptive effect of muscles contracting against resistance. Visual and verbal stimuli are included. All these stimuli provide clues for the direction of movement and are gradually reduced as the individual achieves the movement independently.

Resistance to motion is used to facilitate the action of the muscles which form the components of the movement patterns.

Special techniques

There are various combinations of techniques depending on the individual’s physical condition and the therapist’s goals. The use of stretch or traction and the optimal resistance needs careful use on unstable joints and level of muscle contraction.

Functional work or mat work involves the use of various methods mentioned above in training rolling, crawling, walking and various balance positions of sitting, kneeling and standing. As PNF is largely practised with adults, this was adapted for cerebral palsy using movement patterns within developmental motor functions (Levitt 1969, 1970b). PNF was also criticised for treating movement pattern in isolation from a whole function. Using them within developmental functions provided a better approach. Some examples of these are given in this book to use movements against resistance, which can simultaneously activate postural stability and counterpoising mechanisms in trunk, pelvic and shoulder girdles. Another example is the resistance to arm elevation which improves head control. In addition, the PNF patterns and resistance were used in combination with positioning other body parts to minimise activation of spasticity. This combined PNF with ideas from the Bobath approach (Levitt 1969). However, the Bobaths disagreed as they were against the use of manual resistance. Today, resisted actions have been accepted for weakness.

Adler et al. (2008), using PNF with adults, have added principles of motor control and motor learning from the work of Mulder and Hochstenbach (2002). There are additional functional activities using PNF and additional techniques in different positions. As individuals achieve the movements and stability, there is ‘hands-off’ by the therapist, so that patients can then detect any of their mistakes in their motor patterns. These mistakes give ‘feedback’, allowing the individuals to learn and correct themselves as much as they are able to do. Ideas from Mulder are used in this book and quoted in Chapter 6.

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). 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 level of development. If the child was, say, learning to roll, he was not allowed to crawl, or if crawling he 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 stimulate ‘normal tone’. Once postural security was obtained, achievements were facilitated and developmental sequences were followed throughout this training.

The CP therapist. Collis disliked the separation of treatment into physiotherapy, occupational therapy and speech therapy. She established the idea of the cerebral palsy therapist.

The developmental sequences became much more sophisticated and less strict. The idea of a cerebral palsy therapist has some appeal in the concept of a developmental therapist or primary interventionist. The worries of mothers were assumed to be helped by the treatment and by her willingness to be able to help her child. One hopes there is deeper understanding of parents’ predicaments and feelings today.

Karl Bobath, a neuropsychiatrist, and Berta Bobath, a physiotherapist, based assessment and treatment on the premise that the fundamental difficulty in cerebral palsy is lack of inhibition of reflex patterns of posture and movement (Bobath 1965, 1971a,b, 1980; Bobath & Bobath 1972, 1975). The Bobaths associated these abnormal patterns with abnormal tone due to overaction of tonic reflex activity. These tonic reflexes, such as the tonic labyrinthine reflex, symmetrical tonic neck reflexes and asymmetrical tonic neck reflexes, have to be inhibited in order to counteract ‘the abnormal patterns of released postural reflex activity, and at the same time facilitate normal reactions by special techniques of handling’. In time, the focus on reflexes was decreased (Bobath & Bobath 1984) but the Bobath system continues to focus on abnormal patterns and abnormal tone. The keystone of the approach still seems to be abnormal tone. There are many Bobath-trained physiotherapists who first spend time on reducing abnormal tone so that the child is ‘prepared’ for movement (Mayston 1992). Preparation involves stretching, handling and positioning by the therapist to improve quality of tone and therefore movement.

The practice of the Bobath approach or neurode-velopmental treatment (NDT) is different in different countries, in different parts of a country and in different centres. Physiotherapists have had to make modifications based on their clinical experiences and on the critical comments of others. As there is increasing scientific understanding of the brain and nervous system, the theories and concept of the Bo-bath system have been challenged by a number of therapists and other workers (Gordon 1987; Horak 1992; Shepherd 1995; Damiano 2004).

Howle (2002) suggests that contemporary theories developed by other approaches are now used for NDT. She quotes Mrs Bobath who maintained that the concept (or philosophy) had not changed through the years but the techniques have been developed and refined. A series of several photographs in Howle’s book show a skilful Bobath treatment with handling not only with hands but also with the therapist’s body and legs to position and treat a girl with cerebral palsy of a mild and moderate condition. These are familiar Bobath methods despite the ‘new theories’.

Mayston, a former Director of the original Bobath Centre in London, states that ‘little or no evidence is available to show that therapy offered by the “named approaches” is effective or that one approach is more beneficial than another’ (Mayston 2004). Mayston has provided new thinking and self-questioning by physiotherapists wedded to this system. She also says that ‘Bobath therapists’ should and have become more eclectic (Mayston 2004, 2008). This is reassuring as the Bobaths (Bobath & Bobath 1984), referring to earlier editions of this book, firmly stated that ‘Eclectic treatment, using a mixture of treatment techniques derived from various schools of thought which see the child’s problems from different viewpoints, cannot result in a cohesive treatment programme’. Mayston (2004) also points out that conductive education (which is a learning approach) places more emphasis on the child’s initiation, participation and practise ‘which is different to the Bobath approach’. This is also different to any motor learning approach. The dramatic changes in theories underlying NDT make it no longer clear what this approach consists of in theory and practice and how different it is from other therapists who have never been dedicated to this approach.

Features of the approach which can be usually observed are as follows:

Preparation for movement patterns specifically selected to treat abnormal tone associated with abnormal movement patterns and abnormal posture. Key components such as extension, rotation and symmetry often form the basis for motor skills and receive treatment methods.

Developmental sequences were more strictly followed in the past, but are now modified (Mayston 1992, 2004).

Sensorimotor experience. The reversal or ‘breakdown’ of the movement abnormalities is said to give the child the sensation of more normal tone and movements. This sensory experience, now called ‘feedback’, is provided by the therapist’s handling and is believed to gain more normal motion. ‘Learning to move is entirely dependent on sensory experience’ (Bobath & Bobath 1984).

Key points of control are used by many therapists to change the patterns of spasticity so that a child is prepared for movement and correct posture. The key points are usually head and neck, shoulder and pelvic girdles, as well as use of distal key points to aim to ‘normalise’ abnormal tone.

All-day management by parents supplements treatment sessions. Parents and others are advised on daily management and trained to treat the children. Nancie Finnie (1997) has written a book for parents on this all-day handling of the child in the home. This book is being updated.

Margaret Rood, a physiotherapist and occupational therapist, based her approach on many neurophys-iological theories and experiments (Rood 1962; Stockmeyer 1967, 1972). The main features of her approach are the following:

Afferent stimuli. Techniques of stimulation, such as stroking, brushing (tactile); icing, heating (temperature); pressure, bone pounding, slow and quick muscle stretch, joint retraction and approximation, muscle contractions (proprioception) are used to activate, facilitate or ‘inhibit’ motor response.

Muscles are classified according to various physiological data, including whether they are for ‘light work muscle action’ or ‘heavy work muscle action’. The appropriate stimuli for their actions are suggested.

Reflexes other than the above are used in therapy, for example tonic labyrinthine reflexes, tonic neck, vestibular reflexes, withdrawal patterns.

Ontogenetic developmental sequence is outlined and strictly followed in the application of stimuli.