A synthesis of therapy and management approaches is based on consideration of postural mechanisms, voluntary motion and perceptual-motor function intrinsic to function. It is particularly function that must draw on learning/teaching methods. Any synthesis for motor function development cannot be divorced from the emotional and social concerns of children, their parents and families. Synthesis also selects those methods which can enhance a child’s functional experiences in his daily life in home, school, playground and community.

Despite different terminologies and methods, the following aspects of motor function are fundamental to various approaches of treatment and management of motor disorders in cerebral palsy:

The postural mechanisms are neurological mechanisms which maintain posture and equilibrium and are included in locomotion. Sensory information from visual, proprioceptive, vestibular and tactile input are involved with the postural mechanisms. The importance of particular sensory systems varies during typical postural development. Young children until about age 3 years find vision more important than proprioception for postural control, whereas adults depend more on the proprioceptive input for postural control (Lee & Aronson 1974). Fully developed postural mechanisms, other than tilt reactions, are exhibited by adults who are blindfolded. Tilt reactions need vestibular and visual perception.

Postural mechanisms have been described by various neurological workers (Martin 1965, 1967; Belenkii et al. 1967; Foley 1977, 1998; Marsden et al. 1981; Shumway-Cook & Woollacott 2001; Visser & Bloem 2005; Hadders-Algra & Carlberg 2008; among others). Paediatric physiotherapists first need to focus on postural mechanisms of stability and related postural adjustment, and add training of righting, saving and tilt reactions in both active as well as reactive methods to develop motor function.

Purdon Martin’s presentation (Martin 1967; Foley 1998) has drawn on many neurological studies at the time and used their own observations or studies. Purdon Martin’s clear functional scheme originally provided me with a practical observational framework for clarifying many terminologies and methods in different treatment approaches. In this book there have been slight modifications related to children with cerebral palsies and in view of new research.

Whatever the terminologies and different viewpoints, there are methods to stimulate or train postural mechanisms within most treatment approaches. However, particular systems have emphasised some, but not all, of these postural mechanisms. Some assessments for therapy such as Chailey Levels of Ability (Pountney et al. 2004) and Gross Motor Function Measure (Russell et al. 1989) omit examination of the tilt and the saving postural mechanisms as their therapy emphasises other aspects. Children with cerebral palsy with severe visual impairments, severe intellectual problems or with perceptual-motor difficulties are among those individuals who cannot function safely and fully independently without all the postural mechanisms (Levitt 1984, Chapters 9 and 14; Butler & Major 1992; Hirschfeld 1992; Butler 1998; Foley 1998; Shumway-Cook & Wool-lacott 2001; Hadders-Algra & Carlberg 2008).

It is important to draw on all treatment approaches which have methods for postural mechanisms to make sure that none of an individual’s potential postural mechanisms are omitted. There need to be methods for a child’s active initiation as well as for automatic or reactive aspects of postural control. Hadders-Algra et al. (1996) have shown that increased experience improves postural control in the developing nervous system of normal babies. Training postural control in cerebral palsy provides positive results in sitting (Hadders-Algra & Carlberg 2008, Chapter 4) as well as in standing (Shumway-Cook et al. 2003). Those therapy approaches that have given attention to all the problems of postural mechanisms have not necessarily suggested methods to cover the needs of all children and older people. Therefore, methods need to be selected from different approaches and from eclectic clinicians so that dormant motor controls of postural mechanisms can be activated in an individual as much as is possible. Whenever possible, postural mechanisms are activated in the context of a function desired by an individual with cerebral palsy. Suggestions are given in Chapters 9, 10 and 12.

The postural mechanisms are given mainly in the terminology of the functional scheme of Martin (1967) and illustrated in the practical chapters. Other terminologies are mentioned when known.

In outline they consist of the following:

The antigravity mechanism or the mechanism which helps to support the weight of the body against gravity. This provides a pillar of the limb for support against gravity. This firm pillar becomes more flexible with development of the postural mechanisms discussed above.

This is also known as the supporting reaction in infants, leg straightening reflex or positive statzreaktion, and similar to infantile co-contraction.

The postural stabilisation (automatic fixation) of parts of the body, including head on trunk, trunk on pelvis, stabilisation of the shoulder girdles and pelvic girdles and the muscular activity of lower jaw, tongue and pharynx. Postural stabilisation of the body as a whole takes place in a variety of positions. In upright sitting and standing, there is vertical alignment of body parts and symmetry of both sides of the body. In able-bodied people, stability is achieved in many other postures. Although quiet stability results, there are subtle adjustments called ‘postural sway’.

Terminologies also used for this are stability, heavy work and tonic activity.

Counterpoising mechanisms are closely associated with postural stabilisation. They are postural adjustments of the trunk and other parts of the body so that a movement can be made whilst the person maintains posture or equilibrium. Movements are those of the limbs, head or trunk, which require these postural adjustments for equilibrium. Weight shift precedes limb movements and is minimal before any movement is started. Counterpoising or counterbalancing is an ‘anticipatory’ postural adjustment discussed below with voluntary motion. This is by proprioception and sometimes tactile as adults without labyrinthine function respond adequately.

Terminologies also used are balance during motion, load shift, weight shifts, and various balance exercises and movement superimposed on co-contraction.

Righting or rising reactions make it possible for the person to rise from lying to standing, or sitting to standing or for many other changes of position. It is not only rising into position but also returning to the original position. The rising involves a sequence of automatic ‘righting reactions’ or of intentional motor actions. The rising depends on turning over from supine to prone and later head and trunk raising which, in early development, include various head-on-body and body-on-body righting reactions. Intentional rising used by clinicians develops a child’s ability to focus on different ways he might use to get up from one posture to another.

Terminologies used are assumption of posture, moving into position and movement patterns. The latter is confusing as there are also movement patterns which are voluntary movements and different from these automatic changes of posture. The rising or righting reactions above depend on tactile and proprioceptive input but other terminologies of ‘righting reflexes’ use vestibular or labyrinthine input. They are righting reflexes that have been studied in relation to being tilted down. When a baby is suspended and passively tipped downwards (forwards, backwards or sideways), this elicits head adjustment to the upright and with further tilting the adjustments of the trunk. In this book the terms of righting/rising are integrated responses which are functionally more important for rising to standing and changing positions (Martin 1967; Foley 1998). Others consider righting reactions to be part of ‘equilibrium reactions’ stimulated on stationary or tilting surfaces (Bobath 1980; Aubert 2008). The response differs according to the difference of the surfaces (see below).

Tilt reactions occur when a person is tilted well off the horizontal plane and adjusts his trunk so that he preserves his balance. This is seen on a therapy roll or on a tilting board. Tilt adjustments are anteroposterior, lateral or diagonal to each side with equal response.

Reactions to falling or saving from falling are various responses in the limbs which try to prevent the person from falling over, if the perturbation of a child is so great that tilt reactions cannot preserve balance. These reactions may be excessive if a child has no tilt responses. Normally, they do not, on their own, stop falling over completely. For example, the arms may be thrown out to save the person from falling forwards, sideways, backwards and in more complicated patterns. Once a person has fallen, the saving response may result in propping on arms or hands. Should the person be falling over from the standing position, he may stagger, hop or quickly place a foot out to stop the fall.

When a less vigorous push is given to the front of the body, threatening a fall, the person’s reactions are ankle dorsiflexion or hip flexion. When a perturbation is particularly great, the person reacts with a forward leg placement to stop the fall (Shumway-Cook & Woollacott 2001). When the person is pushed from behind, he rises on toes. The arms may also be thrown out to stop falling. In sitting, kneeling and other positions, arms and legs also move in order to save a person from falling.

Terminology for these reactions is protective responses. Particular arm-saving reactions are also called parachute reactions, protective extension, arm balance responses, precipitation reaction or head protective response.

Equilibrium reactions or balance reactions are also terms used which mean a combination of tilt and the limb reactions. These terms are confusing as all the postural mechanisms above are involved with equilibrium or balance. Maintaining a stable posture alone or during movement is synonymous with maintaining balance even before equilibrium reactions develop. Also, limb-saving reactions need not be accompanied by tilt reaction, nor tilt reaction accompanied by limb-saving reactions. In children with cerebral palsy, either limb-saving or tilt reactions may only be present and then each is augmented, when on its own. This is seen particularly in athetoid and ataxic conditions. Perhaps the use of ‘equilibrium’ has led to the confusion that equilibrium reactions result in postural stabilisation and adjustment during limb and other intentional movements.

Besides the six main postural mechanisms above, there are also the following reactions:

Locomotive reactions, which serve to initiate, continue and stop stepping as well as enable turning in walking and running. They are also known as the mechanisms for propulsion or progression and control slow or faster locomotion. For stepping, locomotive mechanisms are initiated by slight forward lean, and for stopping by a slight backward lean. They operate with other postural control mechanisms in adaptation for human gait.

Visual postural reactions. Vision is of importance for babies and young children’s development of postural control. Vision initiates and monitors both posture and movements. Vision compensates for poor postural mechanisms, especially the tilt, and is important during locomotion and when avoiding obstacles. Severe visual impairment delays the development of postural control, particularly tilt reactions (Sykanda and Levitt 1982).

Some physiotherapists stimulate each of the postural mechanisms separately, which does not necessarily lead to their use in daily functions. All these postural mechanisms need to be stimulated within developmental functions and in different environments. Postural control in different tasks and in different environments involves adaptation or orientation (Shumway-Cook & Woollacott 2001). This is learned through experience using higher level integrative processes for adaptive and anticipatory mechanisms for postural control. It is helpful to be guided by motor developmental levels, for as the child acquires functional motor control he is acquiring these neurological mechanisms. However, the developmental sequences may vary in both able-bodied children and those with cerebral palsy. This is discussed below in the section on ‘Developmental training’.

Voluntary motion which is purposeful, conscious, willed motion is sometimes confused with the active automatic movements which occur in the postural mechanisms such as rising or saving from falling. Although some of the automatic movement synergies are also seen in voluntary movement, stimulation of the automatic patterns only corrects some abnormal movement synergies (patterns) but does not contribute much to the training of voluntary motion. Physiotherapists contribute techniques to strengthen and stretch muscles and increase joint ranges to minimise muscular–skeletal problems, which interfere with voluntary arm and leg motion. These physiotherapy methods can be drawn from many systems of treatment and, as in the past, may still be treated separately from the functional training. In such case, these methods need to be immediately activated in functions. When a child is able to carry out functions at his own developmental level, it is preferable to include active stretching out and strengthening within function.

Voluntary motion of the arm and hand is important for many daily tasks. There is some difference of opinion about the use of atypical grasps, though there are specific atypical functional patterns that are acceptable. The section on ‘Development of hand function’ in Chapter 9 discusses fundamental fine motor development, including neurological anticipatory control in hands. Both musculoskeletal and neuromuscular methods for hand function are not enough for the development of voluntary motion which is involved with sensory experience, perception, praxis (motor planning) and understanding. Voluntary motion in able-bodied children develops many different coordinated upper limb patterns and there may be a great variety of patterns (synergies) in any one child for the same task. Therapy in cerebral palsy needs to offer a variety of motor patterns so a child can have a choice for a task and use what he can manage and also avoid those deformities which may hamper function.

In Chapters 9, various methods from different approaches are suggested in play and daily care with more details on daily life in Chapters 10 and 12. Additional information needs to be gained from other disciplines, such as occupational therapy, psychology and special education.

Voluntary motion and postural control

Voluntary motion is intertwined with the postural mechanisms. Postural mechanisms allow voluntary movement to take place and any voluntary motion itself further activates the relevant postural mechanisms. When a child makes a voluntary movement, he has to maintain his balance as he does so. If his postural stability and counterpoising are inadequate, the child may not be able to initiate or carry out the movement. Should he manage to carry out an active movement on a background of unstable posture, the movement can be imprecise, clumsy, uncoordinated. There are weak limb movements due to disuse as the unstable person is fearful of using them in case of falls. To stabilise himself, the arms and hands are used as supports rather than for voluntary motion. Clinicians understandably want to train voluntary movements giving external support to an unstable child. However, there is a need to avoid overemphasising training of voluntary movement of arms, hands and legs in isolation from the postural control. This can happen if a child is firmly supported, most of the day in, say, special chairs and standing frames. Postural adjustments cannot be activated in firmly supportive equipment. On the other hand, isolated training of postural mechanisms without a variety of intentional hand and limb motions is not sufficient.

Since Martin’s work (1967), there have been many research studies to show that postural fixation (stabilisation) and counterpoising of limb movements are anticipatory postural responses (Marsden et al. 1981; Cordo & Nashner 1982). Nashner et al. (1983) found that in cerebral palsy, there is inability to activate postural muscles in anticipation of voluntary arm motion. Useful reviews by Mulder (1991), Hirschfeld (1992), Shumway-Cook and Woollacott (2001) and others quote many studies, including their own, showing that an anticipatory postural response takes place before an intended voluntary movement is begun. This is a ‘feed-forward’ mechanism among others which are activated before voluntary initiation of movement. For example, von Hofsten (1992), in his many research studies of infants’ visually directed reaching, had his infants fully supported as they did not have stability and anticipatory counterpoising under the age of 4 months. Amiel-Tison and Grenier (1986) manually stabilised an infant’s head on his trunk to reveal pre-reaching arm movements which were not seen without postural control. von Hofsten’s studies also showed that an infant’s reaching became more successful as his postural control developed from 4 months of age. Anticipatory postural responses of their trunks were observed at the normal age of 9 months. There are also ‘feedback’ mechanisms to grade the size of the muscle responses of postural responses, which develop with experience.

Postural control of the head and trunk helps eye–hand coordination in voluntary movement. Orofacial muscles function better with head control (Winstock 2005). Sugden (1992) and Van Vliet (1992) review vision, postural control and movement (see the section ‘Motor development and the child with severe visual impairment’ in Chapter 9).

The therapy systems explored in this book do not only mention the role of the physiotherapist but also emphasise the contributions of the occupational therapist and speech and language therapist to stimulation of all the senses, linking of sensations, sensory discrimination, developing body image, body scheme including identifying body parts, spatial relationships, and especially perceptual-motor abilities within self-care skills. Perceptual problems involve understanding concepts such as above, below, under and so on. There are also various dyspraxias which may be present with and without sensory integration problems. The psychologist, occupational therapist and teacher make specific structured contributions to these aspects. The neuromuscular techniques in the various therapy systems may be integrated with methods from one or more of the perceptual-motor approaches known to occupational therapists (Ayres 1979; Fisher et al. 1991) (see the section on ‘Motor function and perception’ in Chapter 10.)

The common ground between the different systems forms the basic principles of treatment. This is followed by my own additions from experience and from recent research studies. These common denominators will be discussed so that the therapist can understand where they exist and where differences are apparent or real.

General principles of management which are currently accepted by most practitioners: