F ro m t he n or mal d e v e l op me nt

Cerebral Palsy

PAC-CENTERED STRATEGIES
POSTURAL TONE | AXIS | CORTICAL LEVEL OF MOVEMENT

JUNG SUN HONG

PREFACE
It is my happiest moment to share my knowledge and clinical experiences
regarding how to treat children with neurological conditions. First of all, I pray
to God to give my deepest appreciation for the immeasurable mercy and grace
in opening my eyes to help these children.
I would also like to give my appreciation to all the children with cerebral
palsy who guided me and helped me comprehend human movement and
normal development and ideas of treatment.
It was quite a long time ago when I met children with cerebral palsy but it
was like destiny. Nobody wanted to treat them then. We were scared of these
children because there were no knowledge and ideas on how to handle and
treat them.
Ignorance leads to my effort and motivation for comprehension who they
are, how to treat them.
I was incredibly lucky to get scholarships and opportunities to take courses
and workshops. I was able to observe the clinical practice of Bobath in the
United States, London and Osaka under great teachers. I specifically
appreciate Mr. Kii Katsumasa who opened my 140 billions brain cells to see the
children adequately.
It is my pleasure and responsibility to pay back to the entire family of
Bobath and colleagues. Moreover, I wish to help others who are in a similar
situation as I was when I started my practice and who lack ideas in handling
children with cerebral palsy
Thus, I am willing to donate this book to all medical professionals.
Hopefully, this can be a good prototype of the books for children with cerebral
palsy.
Lastly, I want to give my appreciation to the Korean and Philippine Bobath
Pediatric Groups for their encouragement and camaraderie. They will always
be my family. They encourage my spirit to go further as they try to brush up
my knowledge.

November 2, 2019
Jung Sun Hong

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 ABOUT THE AUTHOR
Jung Sun Hong, PT, MPH, is a physiotherapist and Bobath senior instructor of
the Asian Bobath Pediatric Association (ABPIA). He now works as the president of
Hong’s Children Center for Cerebral Palsy in Manila, Philippines. He has been
working for children with cerebral palsy since 1980, first in Korea University
Hospital, then, Korea Bobath Memorial Hospital and currently in Hong’s Children
Center for Cerebral Palsy.
He has finished an eight-week Bobath Pediatric Course in Houston, Texas,
U.S.A. Since 1991, he has also completed refresher and advanced courses in
London Bobath Center and in Japan Memorial Hospital.
In 1994, he had finished and qualified for the second training course by
Jennifer Bryce in London Bobath Center. There he was qualified as an Instructor.
He was then certified as a Bobath Pediatric International Instructor in 1997. In
2005, he was certified as a Senior Instructor of ABPIA.
The first eight-week Basic Course in Korea was held in 1993, and he had
worked as a course organizer and assistant. Since then, he has been working for
Basic Courses, Advanced Courses and many other courses such as Introductory
Courses and Normal Development Courses, for nurses, medical doctors, and
special teachers who work for children with cerebral palsy.
From 2000 to the present, he has been holding Introductory Courses and
Workshops in Asian countries, namely, the Philippines, Indonesia, Sri Lanka,
India and Malaysia.
Moreover, he has finished the 5th eight-week Pediatric Basic Course in the
Philippines, with the first one in 2014. The courses’ participants were from
different countries. In addition, he has finished the 23rd eight-week Pediatric
Basic Course in Korea.
He graduated from the Department of Physiotherapy in Korea University and
went to receive Master’s Degree in Public Health from Seoul National University.
bobathhong2@naver.com

Appreciation to:
Hong’s Children Center for Cerebral Palsy, and the staff, namely, Ms. Araceli
Soccoro S. Estose, Ms. Ayra Mae Dayao, Ms. Angelica S. Pineda,, Ms. Faye Ann
DL. Medina, Ms. Jeanne Karol T. Reyes, Ms. Janelle Ira Campos, And Ms. Thea
Alipio, for their contribution in writing this book; as colleagues and assistants and
for their great endeavors in spreading the Bobath approach to the professionals in
the Philippines.

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INTRODUCTION

There are many types of children with cerebral palsy and majority of these
children are born premature. (Volpe, 2009) The clinical picture of children with
cerebral palsy spastic quadriplegia or with cerebral palsy spastic diplegia, born
premature, is different from those born full term. Preterm children present with
problems of low muscle tone of the eye, face, neck and body, whereas those born
full term present with strong hypertonus on the head and body.
The low muscle tone of the preterm child with cerebral palsy is especially
evident when they sit or are placed in sitting. They present with low tone on the
facial muscles with hyperextended or collapsed neck, elevated scapula, and
internally rotated arm and hand. The child also shows low tone on the proximal
part of the body, with rounding of the back and tendency to do sacral sitting. In
general, the problems of the preterm child with cerebral palsy can be described as
low tone on the eye and face, weak or absent capital flexion, altered axis of the
arm, poor movement of the spine and limited movement of the scapula and pelvis
(Fig. A.1).

Figure A.1 General feature of premature diplegia

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 All of these children show twisted midline axis of the joints and muscles from
the eye, head and neck to the upper and lower extremities, hand and foot.
The altered axis of the legs and feet of the preterm child with diplegia is
already evident even when they are sitting. The movement and the posture of the
foot show that the ankle is immobile or ‘frozen’ and the calcaneus is small, fixed
and elevated.
In standing and walking, they present with low tone of the neck. The neck
and trunk sway in walking. They show asymmetric and anteriorly tilted pelvis
with altered axis of the legs, tiptoeing with elevated and small size of the
calcaneus, either with or without broken axis of the talocalcaneal joint (Fig. A.2).

Figure A.2 Walking pattern of premature diplegia

The altered axis of the legs is due to the low postural tone from the low
muscle tone of the eye, neck, trunk and around the pelvis. Other contributing
problems include poor eye location, poor or no capital flexion, less or stiff spine
movements including scapula and pelvis, and poor movements of the arm and leg,
hand and foot.

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 When the muscles of the face, neck and body are located out of midline (axis),

they can only reach 30 – 50% of their maximum function. For instance, the human

being can strongly contract the gluteus maximus when we stand with the pelvis in

neutral rotation. This is the middle (axis) of the pelvis. When we put the pelvis in

anterior tilt, we are unable to contract the gluteus maximus at all. All 600 of the

muscles of the human body can activate maximally when they are in the right

location.

Furthermore, when the muscles of the eye, face and neck are not in the right

location and they do not activate properly, postural tone of whole body falls into

low tone. (Hong, 2017)

Another important matter of movement is capital flexion of the neck.

Through capital flexion, the cervical spine is elongated and straightened. When

the cervical spine is straightened, movements of the head creates consequent

movement of the cervical spine, then the thoracic spine and finally, the lumbar

spine. This can be termed as connective movement of the head to the cervical

spine, thoracic spine and lumbar spine.

Lack of capital flexion decreases the muscle tone of the neck and results to

poor movement of the whole spine. It lowers the tone of the proximal part of the

body. In the case of premature children, they show neck collapsed to

hyperextension. This means that the neck muscles are weak, thus, they have poor

capital flexion.

The poor movement of the spine and the weak activation of the spinal

muscles not only drive the body to low tone, but also cause poor scapular and

pelvic movement, as the scapula and pelvis move with spinal movement. The

scapula and the pelvis as bases of movement for the arms and legs, respectively,

then become ineffective.

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 One of most important areas to focus on for children with cerebral palsy is

the foot. The foot serves as base of support (BOS) in standing and walking. Deeper

consideration must be particularly given to the calcaneus. Most of them have a

small and elevated calcaneus caused by poor weight bearing from a shortened

Achilles tendon. The foot pronates excessively and the medial arch collapses

resulting to a broken talocalcaneal joint.

The apparent role of the calcaneal bone when the foot is the BOS is to allow

for the muscles of the foot to activate correctly, consequently increasing the

postural tone.

When we consider proper alignment in normal human movement, firstly, the

calcaneal bone bears 60% of weight when we stand. (Cavanagh, 1987) The

calcaneal bone acts as a stable BOS for standing. Secondly, during standing, the

muscles of the leg activate 100% with the ankle joint in neutral position (Fujii,

2005) and with the calcaneus in the right location. Thus, it makes sense that the

leg weakens when the calcaneus is elevated even to a certain degree.

The most important role of the calcaneus for base of support is that it acts as

the fulcrum of the pelvic movement. The pelvis moves forward and backward with

diagonal movement onto the calcaneus.

When the foot is in neutral poistion with the leg and the calcaneus in the

correct location, all of the muscles of the leg activate more than 100% including all

of the toe muscles. If the calcaneus is elevated, twisted and small, all the muscles

of the leg including the foot become weak.

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 All medical professionals should take this knowledge into consideration,

otherwise, they may make a great mistake in treatment. When the professional

treats with just any functional movement without changing the main problem, it

would be classified as very low quality of treatment.

This book shares in-depth analysis of normal movement of human, the

problems seen in children with cerebral palsy, and the gaps between normal and

atypical pattern. Moreover, it offers new ideas of treatment of children with

cerebral palsy.

CITED REFERENCES:
Cavanagh, P.R., Rodgers, M.M., Iiboshi, A. (1987). Pressure distribution under symptom-free feet during
barefoot standing. Foot Ankle, 262. In: Shumway-Cook A., Wollacott M.H. (2001). Motor Control:
theory and practical applications. 2nd Ed. Philadelphia: Lippincott Williams & Wilkins.
Fujii T., Kitaoka H.B., Luo Z.P., et al. (2005). Analysis of ankle-hindfoot stability in multiple planes: An in
vitro study. Foot Ankle Int, , 633.
Hong, J. S. (2017). New Ideas of Treatment for Cerebral Palsy, Capital Flexion of the Neck: The Key Link
in Prematury Treatment. Journal of Health Science, 56-72.
Volpe, J. (2009). Brain injury in premature infants: a complex amalgam of destructive and developmental
disturbances. Lancet Neurol, 110-124.

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VESTIBULAR INFORMATION
P.A.C.
Postural tone
Cranial Nerve
Postural Tone vs Muscle Tone
Capital Flexion
Package of Capital Flexion
Base of Support
Axis
Correct Axis
Altered Axis
The Eye
The Neck (Capital Flexion)
The Scapula
The Pelvis
The Foot
Ankle Joint
Toe Muscles
Calcaneus
Sensation of the foot
Cortical Level of Movement
NORMAL MOVEMENT
Normal postural control mechanism

Although it works together, human movement can be separated into two

mechanisms. These are: (1) automatic mechanism or subcortical level of
movement, and the (2) voluntary movement or cortical level of movement.
Subcortical level of movement is generated subconsciously which consists of
coordinated activation of the whole body to maintain the head in space. All parts of
the body fall on the same line which is called axis. Within this axis, all or special
groups of muscles are activate in order to maintain the head upright at any static
posture, or while moving.
When we move into standing, we never put our attention to maintain the
head and body upright. The muscles work automatically. We only put our
attention to it when we watch or when we manipulate with our hands. When we
walk, our stride and speed are automatic, using the central pattern generator of
the spinocerebellar circuit. We pay attention to walking only when we need to
adjust our walking rhythm, stride or direction in relation to environment
(Fig. A.3).

Figure A.3 Human movements

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 In order to generate proper activation of muscle groups, it is necessary to

get information on where the head is, if the axis of the head and body falls in the

same axis and if all muscles are located on the right axis (midline).

This information is provided by the vestibular system, integrating

information from the eyes, inner ear, neck and trunk. The basic generator of

postural tone is the neck. If a human is not able to raise the head, the muscles of

trunk do not work consequently. There is no information or demand to activate the

muscles of the trunk to maintain the head in space.

In relation to vestibular information as initiator of movement from the eye,

head and neck, premature children commonly show weakness of these parts. This

is why they commonly show low postural tone, altered axis and poor cortical level

of movement.

VESTIBULAR INFORMATION
This important apparatus of humans contributes in maintaining the head

and body on the same line, and in the automatic modulation of postural tone

regarding to the location of the head and body.

The vestibular neural network works to maintain the same line from top to

bottom in response to any displacement from the reference axis.

Modulation of the degree of postural tone happens with fast activation of

certain muscle groups supporting the head and body in each posture or movement.

Sensory receptors from the vestibular apparatus located in the inner ear send

vestibular information or feedback to the vestibular nuclei (Fig. A.4).

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 Figure A.4 Vestibular system

In normal development, as the central nervous system (CNS) matures,

specifically the vestibular system, the child becomes driven to move to higher
positions. (Caplan, 1971; Alexander, 1993) Consequently, as the head rises from
the ground, the vestibular system activates the muscles of the body to maintain
the head in space in a much higher location. This describes the modulation of
postural tone regarding the head position. This is made possible with the
integration of the neural network of sensory and motor channels for the execution
of body movements.

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 A special contributory function of the vestibular system to human
movement is to provide an idea of a central line from the head to the feet with the
head as the keystone of movement. As guided by the vestibular system, all parts of
the brain contribute to directing human movements in maintaining the head in
the same line with the body, and in adjusting the line of the body as related to the
displacement of the head. All neural systems and the postural muscles involved
activate independently in an interrelated manner to recover displacements
automatically. A person in sacral sitting or upright sitting position, for example,
can move his legs freely without activating muscles for weight bearing. But with
attempts to go to standing, the forward displacement of the head from upright
sitting produces vestibular information that may send signals to the muscles of the
legs to bear weight on the feet and support the head and the body while
maintaining the axis (Fig. A.5).

Figure A.5 Vestibular contribution in sitting to standing

Humans stand from sitting given adequate vestibular information

from the head. This includes integration of information from the head, eyes,
and neck. In other words, if the head is not located at the middle or if it
dfsdfs
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shows altered vestibular system, the sequence of movements for standing up will
be atypical. Thus, the apparatus most responsible for providing information of the
head’s location in relation to the axis (midline) and for activating parts of the body
to preserve this axis is the vestibular system.
In human movement, the head moves in various directions (forward,
backward, lateral elongation and rotation) in order for the eyes to watch
something. This act of watching generates adequate postural tone and activates
special muscle groups in the body in relation to the location of the head.
(Rossignol, 1996) However, children with cerebral palsy commonly present with
altered axis (midline) of the eye, head, and neck which leads to alteration of the
trunk axis. This altered information may be the direct cause of their asymmetric
posture and movement.
Children with premature diplegia with hyperextended neck, with upward
gaze, and with poor ability to watch, present with a different standing pattern.
They initiate movement with hyperextended neck and trunk, followed by
anteriorly tilted pelvis and hyperextended, adducted and internally rotated legs.
This is referred to as altered vestibular system in extension. Additionally, children
with severe spastic quadriplegia can also be observed to move with asymmetric
and hyperextended body. They present with hyperextended neck and upward gaze.
This type of posturing is an evidence of altered vestibular information.

POSTURAL TONE
Postural tone is an automatic mechanism consisting of the dynamic
activation of the muscles of the entire body working together to maintain
the head at the middle, in the context of any posture or movement.
(Ivaneko, 2018)

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 In standing, people generally activate 100% of their postural tone to
maintain the head position in midline. (Vuillerme, 2005) Soldiers who are
standing at attention generate about 120% activation of postural tone (although an
accurate score cannot be given and the percentage mentioned is only an
assumption of illustration of the varied quality of postural tone). Postures that do
not require any kind of movement, such as lying down in bed, generate low
postural tone. During sleep, as when dreaming or in REM (rapid eye movement)
state, about 10% of postural tone normally is activated. Upon initial transition to
an awakened state while opening eyes signaling all body parts to orient towards
the midline, 20% of postural tone starts to work. (Hong, 2017) As the person starts
to raise his head to go from mat position to sitting, postural tone further increases
until the person assumes upright sitting and standing. And the postural tone
generated is at 100% (Johnson, 2012) (Fig. A.6).

Figure A.6 Modulation of postural tone

Postural tone is also generated by the level of arousal and the muscle tone
of the neck. In humans, if muscle tone of the neck is low, muscle tone of the eyes
and face are also low. Consequently, low postural tone of the body follows. If a
person is not able to raise head, the muscle tone of the proximal muscles is
absolutely low. This causes decreased lower extremity muscle activation as well.

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Cranial Nerve
We can identify the important factors of modulating postural tone through
observation of premature children with cerebral palsy. Although there are many
variations and different clinical presentations of premature children, they
generally present with low muscle tone on the eye, face and neck, and with poor
capital flexion. They also show weak sucking and swallowing, with weak
sternocleidomastoid and trapezius muscle activation. All these things are
generated by the 12 cranial nerves which indicates the early development of the
lower cerebrum and the brain stem during fetal development (Alexander, 2019)
(Table. 1).
NAME FUNCTION ACTIVITY

I Olfactory Sensory Sense of smell.

II Optic Sensory Vision.

III Oculomotor Motor Pupillary reflex, extrinsic muscle movement of the eye.
IV Trochlear Motor Eye muscle movement.
V Trigeminal Mixed Opthalmic branch: Sensory impulses from scalp, upper eyelid, nose, cornea, and
lacrimal gland.
Maxillary banch: Sensory impulses from lower eyelid, nasal cavity, upper teeth,
upper lip, palate.
Mandibular branch: Sensory impulses from tongue, lower teeth, skin of chin, and
lower lip.
Motor action includes teeth clenching, movement of mandible
VI Abducens Mixed Extrinsic muscle movement of eye.
VII Facial Mixed Taste (anterior two-thirds of tongue). Facial movements such as smiling, closing of
eyes, frowning. Production of tears and salivary stimulation.
VII Vestibulocochlear Sensory Vestibular branch: Sense of balance or equilibrium. Cochlear branch: Sense of
I hearing.
IX Glossopharyngeal Mixed Produces the gag and swallowing reflexes

X Vagus Mixed Innervates muscles of throat and mouth for swallowing and talking. Other branches
responsible for pressoreceptors and chemoreceptor activity.
XI Accessory Motor Movement of the trapezius and sternocleidomastoid muscles. Some movement of
larynx, pharynx, and soft palate.
XII Hypoglossal Motor Movement of tongue for swallowing, movement of food during chewing, and
speech.

Table. 1 12 Cranial nerves

Table retrieved from Health & Physical Assessment in Nursing, 2nd Ed. (2012)

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 Underdeveloped cranial nerves are a clear evidence of immature
development of the brain. Poor sensory and motor functions of cranial nerves on
the eyes and face may manifest as low muscle tone. This contributes to low level of
alertness and low neck tone as well. Poor attention, poor watching, and altered
axis of the eye muscles influence the lowering of postural tone of the body. The
package of poor activation and low tone of the eyes, face and neck muscles causes
low postural tone of the body.

Postural tone vs. Muscle tone

Postural tone is the whole-body mechanism for maintaining the posture
and movement, whereas muscle tone refers to the specific activity of muscles.
(Shumway-Cook & Wollacott, 2001) Muscle tone is the tension of each muscle but
if the postural tone is low, the tone of each muscle also decreases. Normally, we
can feel the tension of muscles in typically developing children when they are
awake. We can feel the normal tension of the muscle as the muscle moves when we
mobilize the joint.
There are various ranges of muscle tension depending on the demand of the
activity or exercise. In the case of typical humans, the tension of the muscle can
easily be palpated because the muscles are located in the normal axis of the body.
With hypertonus, low postural tone, altered axis of the eye, neck, spine, hand and
pelvis, and with small and elevated calcaneus, it is difficult to feel the muscle tone
of the arm and leg muscles. The muscle tone is low or absent with altered axis.
An increase in muscle tone is a good indicator that the muscle is in the
right axis and can be the initial target of treatment. When we manage to change
the altered axis, thereafter, we can see the movement of the target muscle and feel
its tension.

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Capital flexion
Capital flexion is a small movement of the C1-C2 suboccipital component. It
is generated by small muscles such as the longitudinal oblique, superior and
inferior longus colli at the anterior part of the neck. The motion also involves the
activity of the rectus capitis anterior, posterior major, rectus capitis lateralis from
the lateral part of the neck. The extension, flexion, lateral elongation or rotation of
the neck requires a clear initial movement (Fig. A.7). The movement is referred to
as capital flexion which is the primary movement of the neck relative to the
construction of the cervical spine to head (Hong, 2017) (Fig. A.7).

Figure A.7 Capital flexors: anterior and posterior part

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 There are two steps in activating capital flexion. First, the head is pulled
down by the longitudinal oblique, superior and inferior longus colli accompanied
by mouth closure and eyes looking down. Second, the suboccipital segment of the
cervical spine straightens, which will connect the head movement to thoracic spine
movement. The second movement generates various ranges of locking of the
cervical spine depending on the required power and speed of the movement
(Fig. A.8).

Figure A.8 Capital flexion – straightening of the neck

The most important movement modulating dynamic postural tone is the

capital flexion of the neck. This connects the head movement with the whole spine
in various movement of the body.
Connection means activation of the muscles of the neck and proximal part
simultaneously to allow for many kinds of movement. Movement that requires
power and faster speed requires stronger neck activation, which is called chin
tuck. If there is no capital flexion, the muscle tone of the neck does not increase.
Thus, the postural tone of the whole body falls into low tone. Consequently,
weakness or no capital flexion leads to poor movement of spine. Stiff and immobile
spine causes low tone of the whole body.

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 Another important consideration is the function of the upper extremities
and of the hand. An altered axis of the neck makes the spine immobile, thus,
causing poor dissociation of the scapula and the humerus. The scapula and the
humerus are the bases of hand movement.
Weak or no capital flexion strongly leads to poor movement of the hand. A
weak neck drives the body to low tone and weakness. A straightened neck with the
presence of two posterior columns formed by the upper trapezius muscle implies a
symmetrical activation of both sides of the neck and proximal muscles. However, if
a person shows disappearance or a smaller bulk of the column on one side, low
tone can be observed, with poor activation of proximals and extremities, on that
side. Similarly, if the eye and face muscles are weak, meaning there is no strong
axis of the head, neck muscle activation and postural tone of the body will not
increase as well.

Package of capital flexion

Capital flexion occurs with downward movement of the eye and closing of
the mouth. Many children with cerebral palsy show upward gaze of the eyes and
open mouth. This is the major cause of difficulty in capital flexion, and
consequently, of low postural tone of the body.

Base of support
Another important factor in generating postural tone against gravity is the
base of support. Positions such as prone on elbows, quadruped, sitting on an
upright pelvis and standing with weight on the calcaneus provide for the
development of the extensor muscles. Infants initially develop flexor muscles in
the first stage of development, and they develop extensor muscles through a base
of support (BOS). (Bly, 1994)

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 As they learn to bring the head up against gravity, postural tone starts to
increase and develop, like in prone on elbows. Prone on elbows emerge when the
infant start to raise his head in prone but still has insufficient postural tone to
maintain the head in the space. This is the first weight bearing position against
gravity and with the elbows as BOS (Fig. A.9).

Figure A.9 Prone on elbow

Prone on elbows develops extensors of the arm to support the head against
gravity with the elbows as BOS. The same development occurs when they start to
crawl or go into quadruped. Weight bearing on the hand is developed, as all
extensor muscles of the arm and hand are also developed (Fig. A.10).

Figure A.10 Quadruped

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 Trunk muscles develop when the infant sits on an upright pelvis. Extensors
of the trunk develop completely in sitting when they sit on an upright pelvis. This
enables the infant to move the arms lightly and the hands freely at this time.
(Angsupaisal, 2017) (Fig. A.11).

Figure A.11 Sitting with upright pelvis

Activation of the trunk extensor muscles increase when the BOS is on the
ischial tuberosity of the pelvis. Likewise, activation of the extensor muscle of the
whole body increase with the BOS on the calcaneus in standing (Fig.A.12).

Figure A.12 Standing on foot: BOS

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 Modulation of postural tone in any kind of posture and movement involves
the use of BOS. Postural tone increases in relation to the head location over a
stable BOS, whether in sitting, standing, or walking. The BOS is not stable and
strong when the muscles surrounding the BOS change properties and activation
due to dislocations, subluxations and contractures. When this happens, postural
tone will also not be properly increased and sustained. The presence of limited or
smaller bases of support will confuse the body in terms of alignment and influence
the concomitant increase in postural tone.

AXIS (MIDLINE)

Correct axis
There is a clear but imaginary line in the midline of the human body
running from head to feet. The position of the midline of the head is between the
two eyes. This invisible line is oriented and adjusted relative to the displacement
of the head and body, based on the vestibular information. It is important to note
that, based on the anatomical position, the axis (midline) does not only exist at the
center of the body or trunk but also in each extremity.
The right location of the axis of the head is the basis of vestibular
information for the eye. Also, the right location of each muscle correctly activates
the specific muscle movement to produce power and speed.
The tone of the muscles is easy to distinguish from examination and
palpation. If the muscles are in the correct axis, there is sufficient muscle tone
and power. The opposite finding is observed from altered axis.
The axis of all muscles is not only related to muscle tone and power but also
to various sensory signals. Low muscle tone means slower sensory conduction.
(Ivaneko, 2018)

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Altered axis
When the axis of an extremity is altered or displaced, the muscle tone
changes. This is the result of the displacement of the origin and insertion site of
the muscles. The efficiency of the muscles that are lengthened or shortened is
changed. A resultant low muscle tone and decrease in muscle bulk can be
observed. (Kisner & Colby, 2012)
As aforementioned, the axis of the eye and head influences the axis of the
whole body. When the spine is not in the correct axis, the scapula’s location is out
of axis as well. Consequently, an out of axis scapula and shoulder location
influences the axis of the arm and hand.
Likewise, when the pelvis is not in midline, the leg and foot is out of axis.
Lastly, altered axis of the foot causes all toe muscles to be inactive, which in turn
would influence the postural tone of whole body to become low.

THE EYE.When the eyes are in midline, correct axis of the body can be
observed. The eyes, the vestibular system in the ears, and the influence of the
vestibular system on the neck and the trunk through the vestibulocollic and the
vestibulospinal reflexes, respectively, collaborate to maintain the head in the
middle. In contrast, the vestibulooccular reflex maintains the eyes in the middle
while the head and body sways. All these apparatuses contribute to maintain the
head in the middle and in the same axis.
Many premature children with spastic diplegia present with weak muscles
of the eye and weak vestibuloocular reflex (Jeon, 2019). This is the reason they
sway the eyes, head and trunk when they walk (Fig. A.13).
In some children with cerebral palsy, one eye is not located in the same
horizontal plane with the other. (Koeda, 1997) One eye is lower, thus the muscle
tone on one side of the neck is also weaker.

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 Figure A.13 Swaying head and trunk of premature diplegia

Consequently, they show lower postural tone on one side of the body. If the
eye of the child is out of axis and have very weak movement, an urgent matter of
treatment is to change the axis and build up the muscles of the eye. Ideas specific
to this principle will be described in the chapter on treatment.

THE NECK (CAPITAL FLEXION). The weak muscles of the eyes

and face are connected to weak muscles of the neck, specifically to the weakness or
absence of capital flexion. Premature children with cerebral palsy, usually present
a hyperextended neck such that there is shortness or limitation of movement at
the C1-C2 suboccipital component. If these segments of the neck are extremely
shortened and fixed for a long time, the C7 spinous process is not easily observed
or palpated. Muscle tone activation of the sternocleidomastoid and upper
trapezius muscles will weaken or cause disappearance of the muscle bulk on the
anterior or posterior sides of the neck. Thus, when capital flexion of the neck does
not occur, the construction or the full elongation of the neck and connection of
movement of the whole spine will not occur.

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 A hyperextended neck results to altered axis or altered vestibular system.
The position drives the eye to move to an upward location and the mouth to an
open posture. If a child shows higher than normal location of the eyes, it
influences the neck and body to have an altered axis towards extension. They
usually use the extensors more than the flexors when they move because the axes
of the eye and neck are altered to extension. Thus, the body follows this vestibular
information.

THE SCAPULA. When the child presents with poor capital flexion of
the neck, the spine is flexed and immobile. The scapulae are out of axis, and all
muscles of the shoulder and arms weaken. The scapula and clavicle are mostly
elevated and fixed because of poor movement of the thoracic spine. Limitation of
thoracic spinal movement is due to poor capital flexion.
If the scapula is elevated and fixed, the muscles of the upper back are tight,
specifically, the three parts of the trapezius, rhomboids and muscles of the
shoulder girdle. The longest and biggest muscle of the arm is the biceps brachii.
When the shoulder and scapula are adducted and internally rotated, this muscle
naturally goes into internal rotation as well and goes out of axis. The biceps
brachii muscle acts to internally rotate the arm rather than its original function
for elbow flexion. Its muscle tone becomes low and its muscle bulk becomes
smaller.
According to Norkin (1992), maximal active force of a muscle can be
generated when it is at its resting length which can be achieved when the joint is
in its anatomical alignment. Thus, complete activation of the involved body parts
and the overall postural tone will not occur when there is an altered axis (midline).

24
 THE PELVIS. The pelvis moves in the same axis as the head and the
foot when they are located in the midline of the body. It moves onto both hip
joints, moving anteriorly, posteriorly, as well as diagonally and laterally to either
side. This is termed as 3-dimensional movement of the pelvis because it moves
along the three planes.
Children with cerebral palsy commonly present with the pelvis anteriorly
tilted. This makes it difficult to move the pelvis towards the diagonal direction.
Diagonal movement of the pelvis is similar to the pelvic movement observed in
creeping, wherein one leg is in extension and the other leg is in flexion with
diagonal movement of the pelvis (Fig. A.14).

Figure A.14 Diagonal movement ( 3D ) of the pelvis

The side of the pelvis that goes downward is the side with extended leg
while the opposite side is the side with the flexed leg. The pelvis performs the
same movement in standing and walking.
In the beginning of walking, the first movement is weight transfer to one
side, which is also called the stance phase. On the weight bearing side, the pelvis
moves diagonally and downward on the weight bearing leg. This is the side of
stability. The leg muscle tone is higher than the opposite side, which is in flexion
and positioned to step forward.

25
 Walking involves continuous pelvic diagonal movements. Therefore, it is
called dynamic 3-dimensional pelvic movement. If there is an out of axis hip joint
caused by dislocation or subluxation or strong adduction and internal rotation,
the pelvis does not move at all or moves incompletely. Children with cerebral
palsy walk without sufficient 3-dimensional pelvic movement. Thus, there is no
clear delineation of the roles of stability and mobility in walking. They usually
walk with swaying of trunk side to side.
In treatment, the most important aspect to manage is location and
dynamic 3-dimensional movement of the pelvis. Moreover, if the pelvis is located
out of midline or fixed in anterior tilt with asymmetry, the muscles of the lower
extremities weaken including the gluteus maximus.

THE FOOT.
Ankle joint. The foot is the most important BOS of human beings. It
develops with strong ankle movements in connection with the neck to protect the
head in space until the head and trunk fully develops stability in sitting. From
birth, the ankle moves to maintain the head in space for safety. In the womb, the
fetus already starts to move ankle towards dorsiflexion within a flexed posture in
the mother’s womb. Toe movements can already be observed as well.
It is observed that when the ankle is plantar flexed with hypertonus, the
increased tone of the leg and whole body is reinforced. On the other hand, low tone
of the ankle and toe leads to low postural tone of the body. When the foot forms a
90-degree angle with the leg and with the calcaneus in a stable position, all
muscles of the leg activate to more than 100% including the toe muscles. This
activation is crucial as the foot is an important BOS. Inversely, when the ankle is
plantar flexed, with elevated calcaneus, all muscles of the leg and toe becomes
weak.

26
 Toe muscles.Strong ankle movement comes with the primary muscles,
tibialis anterior and peroneus longus, while toe muscle movement comes from the
peroneus brevis. Specifically, strong flexion of the toes enhances strong ankle
dorsiflexion. When this occurs, standing posture can be maintained with good
stability. Therefore, all toe flexors are posture keeper. If these are weak, they
influence the intensity of postural tone and maintenance of postural alignment
(Fig. A.15).

Figure A.15 Toe curling with dorsiflexion of the ankle

From this discussion, we can see that the most important focus of
treatment is more than 100 percent activation of the toe flexors. This must be
done with the the calcaneus in the correct location and optimal age-appropriate
size.

Calcaneus. The calcaneus is the most important part of the body to

generate postural tone or to maintain the muscle tone of the leg. When we put
weight on the calcaneus in sitting or standing, we feel the contraction of leg
muscles. Also, we feel the strong contraction of the muscles of the leg when the
calcaneus moves downward to its maximal range. If the calcaneus is fixed and
elevated, all muscles of the leg weaken. When palpated, contraction of the leg
muscles is weaker (Fig. A.16).

27
 Figure A.16 Elevated calcaneus

Another important consideration is the calcaneus as the correct BOS to

generate 3-dimensional pelvic movement in standing or walking.
If the calcaneus is small, collapsed or elevated, the pelvis does not move.
This lack of mobility also increases anterior tilting of the pelvis. Moreover, the
ankle positioned in 90 degrees is the basis of activity of all toe muscles. The right
location of the calcaneus contributes in maintaining 90 degrees angle of the ankle.
An elevated calcaneus could be a major contributing factor to the weakness of leg
and foot muscles.

Sensation of the foot. The foot is the most sensitive part of the body for
somatosensory input. It responds intensely to tactile, temperature and deep sense
proprioception and pain. (Kars, 2009) Somatosensatory information from the foot
is quickly sent to the higher centers for weight shifting and displacement of the
foot to facilitate maintenance of standing and walking. (Cavanagh, 1987) This
indicates that the sensory pathway on the foot is huge and faster than any other
part of the body. As foot movement in the upright posture occurs with less input
from the visual system, the somatosensory system is relied more.
One of most sensitive sensations for the human being is tickling of the foot.
This can be used as a basic strategy of treatment to activate body scheme of the
foot.

28
 In prematurity, the white matter damage is seen more on the
thalamocortical tract than the corticospinal tract. (Hoon, 2009) Generally, many
premature children with spastic diplegia are not aware of their own legs and feet.
Because of the damage to the sensory channel and in relation to the altered axis of
the foot, they have weak sensory afferent system of the muscles of the foot.
The higher sensitivity of the foot can be an advantage in treatment as it
can be used to activate the foot with correct axis of the pelvis and leg. Also, all foot
muscles arise from the tibia and fibula. Hence, it is quite necessary to recover the
right axis of the tibia and fibula to activate the sensory and motor channels of the
foot.

CORTICAL LEVEL OF MOVEMENT

The eyes, head and neck are located and move in the correct axis through
the appropriate vestibular information. Also, displacement of these standpoint
initially generates proper postural tone and movements of the body in response to
the displacement. When the axis of the standpoint and body are altered, all
muscles are weak because of weak sensory information. (Bove, 2009)
The appropriate intensity of postural control mechanism is modulated by
the cortical level of movement through intention, judgment and adjustment.
There is awareness of movement with the right information from correct muscle
and joint axes. This allows for more accurate intentional adjustments and
guidance from feedforward control. (Ivaneko, 2018) All mechanisms contribute to
the formation of new neural networks for the proper execution of movement.
Volitional movement is related to the neurological processes that involve
intention, judgment, and processing. (Bobath & Bobath, 1997) Axis (midline) and
postural tone are bases for human movement but there is a need to match these
not only to the functional level of movement but also to the functions of the brain.

29
 Cortical level of movement refers to purposeful movement in the context of
a functional activity like rolling over, sitting, standing, and walking. This type of
movement increases the neural activity of the neocortex. Cortical level of
movement utilizes and requires motivation to perform in a specific functional
level.

CITED REFERENCES:
Alexander B., Kelly C.E., Adamson C., et. al. (2019). Changes in neonatal regional brain volume
associated with preterm birth and perinatal factors. Neuroimage, 654-663.
Alexander R., Boehme R., Barbara C. (1993). Normal Development of Functional Motor Skills.
Tucson: Therapy Skill Builders.
Angsupaisal M, Dijkstra LJ, la Bastide-van Gemert S, van Hoorn JF, Burger K, Maathuis CGB, Hadders-
Algra M. (2017). Best seating condition in children with spastic cerebral palsy: One type does
not fit all. Res Dev Disabil, 42-52.
Bobath B., Bobath K. (1997). Student Course Notes to Accompany the 8-Week Course in Cerebral Palsy.
London, UK: The Bobath Centre.
Bove M, F. C. (2009). Interaction between vision and neck proprioception in the control of stance.
Cognitive Neuroscience, Elsevier, 1601-1608.
Caplan, F. (1971). The first twelve months of life. New York: Grosset and Dunlap.
D'Amico, Donita T., Barbarito, Colleen. (2012). Health & Physical Assessment in Nursing, 2nd
Ed. Pearson.
Hong, J. S. (2017). New Ideas of Treatment for Cerebral Palsy, Capital Flexion of the Neck: The Key Link
in Prematury Treatment. Journal of Health Science, 56-72.
Hoon AH, Stashinko EE, Nagae LM, Lin DD, et al. (2009). Sensory and motor deficits in children with
cerebral palsy born preterm correlate with diffusion tensor imaging abnormalities in
thalamocortical pathways. Developmental Medicine & Child Neurology.
Ivaneko Y., a. G. (2018). Human Postural Control. Frontiers of Neuroscience.
Jeon H., Jung J.H., Yoon J.A., Choi H. (2019). Strabismus Is Correlated with Gross Motor
Function in Children with Spastic Cerebral Palsy. Curr. Eye Res., 1-6.
Johnson M.B., Van Emmerik R.E.A. (2012). Effect of Head Orientation on Postural Control during Upright
Stance and Forward Lean. Motor Control, 81-93.
Kars HJJ, Hijmans JM, Geertzen JHB, Zijlstra W. (2009). The Effect of Reduced Somatosensation on
Standing Balance: A Systematic Review. J Diabetes Sci Technol., 931-943.
Kisner C., Colby L.A. (2012). Therapeutic Exercise: Foundations and Techniques, 6th Ed. F.A. Davis
Company.
Koeda T, Inoue M., Takeshita K. . (1997). Constructional dyspraxia in preterm diplegia: isolation from
visual and visual perceptual impairments. Acta Paediatr., 1068-73.
Norkin, C., White J. (1985). Measurement of Joint Motion: A Guide to Goniometry. F.A. Davis Company.
Rossignol, S. (1996). Visuomotor regulation of locomotion. . Canadian Journal of Physiology and
Pharmacology, 418-425.
Shumway-Cook A., Wollacott M.H. (2001). Motor Control: theory and practical applications. 2nd Ed.
Philadelphia: Lippincott Williams & Wilkins.
Vuillerme, N., Pinsault, N., Vaillant, J. (2005). Postural Control During Quiet Standing Following Cervical
Muscular Fatigue: Effects of Changes in Sensory Inputs. Neuroscience Letters, 135-9.

30
NORMAL DEVELOPMENT
Fetal Stage
General Growth
General Picture of Prematurity
Neonatal Intensive Care Unit (NICU)
Environment in the Incubator
Consideration of Treatment in the NICU
First Stage
First Period
Second Period
Second Stage
Third Stage
Fourth Stage
FETAL STAGE

General growth
The development at this stage is marked by the increase in body size and
the integration of sensory and motor systems of the brain’s neural network.
When the fetus is 20 weeks old, the body weight is at 500-800 grams. It
represents an increasing amount of muscles, bones, subcutaneous fat including
internal organs. On the 28th week of gestation, there is a sudden increase in body
weight to 1300 grams. In the second half of intrauterine life, particularly during
the last 2 1/2 months, approximately 3200 grams or 50% of the full-term weight is
added (Sadler, 1995). This significant increase in body weight has important
implications in the development of movement (Fig. B.1).

Figure B.1 Fetal growth

The increase in the fetus’ body structures cannot be accommodated within

the womb, driving the body into flexion. As the fetus further increase in body size,
it enhances the flexed posture. Thus, all movements promote the development of
flexor pattern of movement until the fetus goes out from the uterus.

32
Development of sensory and movement
Around 16 - 20 weeks of gestation, the mother feels the fetus move in her
womb. Fetal movement is possible because of the development of the neural system
of the brain leading to the development of the sensory organs namely, vision,
auditory, and olfactory system. Thus, in this stage, the development of sensory
channel enables the fetus to respond to stimuli which activate movements. As the
sensory systems develop, the fetus is able to respond to the environment and this
influence to initiate movement. At this stage, the fetus is able to smell what his
mother ate and the smell of the food cooking in the kitchen. He is able to listen to
sounds and respond to them by kicking the wall of his mother’s uterus.
As part of the development of neural network as cranial nerves, specifically
the trigeminal nerve, the face gets innervated and begins to move. It contributes to
basic survival functions such as swallowing, sucking and breathing. The fetus'
movement is fidgety, and purposeless, and their small size allows them a lot of
movement in a spacious uterus. The fetal movement increases development of
muscles and bones. With the increase in body weight at 24 weeks, the fetus is
developing a more flexed position and moves in a more compact space. This
encourages development of the body concept (Fig. B.2).

Figure B.2 24 weeks gestational week of the fetus

33
 At around 19 weeks, the fetus starts to respond to sounds. At this time, 96%
of fetuses respond to 250HZ and 500HZ but none respond to 1000HZ. They start to
respond to 3000 Hz tones at 27weeks. At 33 and 35 weeks, tones respond
respectively (Hepper .1994)
The transmission speed of sound in the amniotic fluid is four times faster
than in the air. So, the fetus can listen to a variety of sounds, especially the sounds
made by the mother. This helps him to identify his mother and therefore helps
establish the relationship between the fetus and the mother
Around 28 weeks, one of the turning points of fetal development is the
increase in body size and weight. This involves development of the musculoskeletal
system, and the increase in the amount of subcutaneous fat and muscle. This
increase in physical development is directly influenced by the development of
movement and the sensory channels. With the increase in size and body weight, the
space inside the mother’s uterus becomes smaller. And so the fetus has no choice
but to move in a flexed posture. This flexed posture is crucial for the development of
sensory systems, cognition, and postural control which are very important when the
infant moves against gravity after birth (Fig. B.3).

Figure B.3. Development of flexed posture

34
 On the aspect of body concept, with the development of vision, movement
(kicking, pushing, rolling), and sucking, the fetus gradually becomes aware of his
body parts and how they are related to each other. The coming together of the
infant's body parts in flexion reinforces this idea. Sucking the fingers and pushing
against the uterine wall make the fetus realize that his hand is located below the
shoulder, and consequently where the elbow is located. The development of body
scheme is derived from tactile experiences and sensations arising from the body.
Kicking movements give the idea of the weight and length of the lower extremities.
Rolling movements in the uterus and the sensation of the mother's movements
give the fetus the idea about his body and its relation to space.
Realization of body scheme and body awareness develops midline
orientation. All movement experiences contribute so that everything comes to
midline and this develops a sense of safety in the fetus. Coming to midline gives
the fetus psychological and emotional security (Nemire and Cohen, 1993).
Moreover, fetal movement is characterized by non-selective movements of
the limbs. But this moving together is important to make a connection from the
head to the feet while in the flexed position. This flexion activity eventually
develops extension and combination of movements through activities in prone,
supine, sitting, and standing.
Around 32- 38 weeks, increasing body size further drives the body into
more flexion against the same compact size of the uterine. It develops more
patterned movement of flexion than the previous weeks.
Moreover, the brain has grown approximately one hundred billion nerve cells with
10 trillion connections. The brain and head have grown as big as they can be in the
womb (Asim Kurjak, 2005).

35
Development in the flexed posture

Movements of flexion
Flexor pattern is an unchangeable posture at this moment. The fetus moves
with capital flexion of the neck and trunk which enhances flexor movement of the
leg with posterior tilted pelvis.
All parts of the body move into flexion within an axis. Also, it is capital
flexion, otherwise called chin tuck, which enables a person to produce power and
speed for sports activity such as throwing or kicking a ball farther through the
increase of neck stability. This gives an advantage to activate connective movement
of the body which is a basis of human movement (Fig. B.4).

Figure B.4 Flexed posture with capital flexion

In capital flexion of the neck, not only does it lead to activation of individual
muscles towards all kinds of movement but also it contributes to more concentrated
co-activation of the neck and trunk. Consequently, it contributes to the development
of the muscles of the neck and proximal as well as the neural network of the body.
It is a key feature of this stage because it builds up neck and proximal muscles in
preparation for head movements against gravity after birth.

36
 As the fetus kick or pushes the wall of uterine, a special environment with a
small compact space, more concentrated and stronger co-activation of the neck and
trunk is activated. It is comparable to isometric exercise. It also drives the whole
part of the body in the same pattern, which is termed as mass pattern of movement.
Moreover, the neck and trunk are naturally flexed and the shoulders are in
protraction. With this, the infant easily brings his hands to the mouth and is able to
suck his fingers. This makes the fetus perceive the existence of his hand. And when
he pushes and kicks against the wall of the uterus, he can perceive that his hand is
connected to the elbow and that the elbow is connected to the shoulder. This
experience is very important in the development of the perceptual process and body
scheme (Fig. B.5).

Figure B.5 Flexed posture and sucking the finger

This is the same process with the development of hand use with vision,
which eventually leads to the development of forearm and hand support.
At 36 to 40 weeks, the fetus prepares for delivery by turning and changing
his position so that the head is near the mother’s cervix. This posture gives the
fetus information about a new direction and so he perceives a stronger connection of
his body parts and learns about body scheme.

37
 One other important aspect of the flexed posture is the posterior tilting of
the pelvis. This pelvic position allows easier leg movements specifically flexion.
Kicking develops the abdominal muscles of the lower proximal and the muscles
around the hip and ankle joints; including the development of hip joint structures
such as the acetabulum, ligaments, and joint capsule.

Capital flexion, muscle tone of the neck

The most important feature in the fetal stage is the development of the neck
such as in the increase of neck muscle tone and capital flexion. The neck is
essential for the maintenance of the head in space. It works with the vestibular
inputs from the head, eyes, and muscles in order to maintain all parts of the body in
the same axis regarding the position of the head. Moreover, muscles located around
the neck are the most important muscle groups necessary for modulation of
postural tone. This is because the neck muscles, although smaller and shorter than
other muscles of the body, contain the highest density of muscle spindles. (Gordon
& Ghez, 1991). These muscles work in collaboration with the neural network that
mediate various reflexes (vestibulospinal, vestibulocolic, and vestibuloocular
reflexes) to ensure good alignment of the head and trunk, as well as its appropriate
adjustment as one moves.
Inside the womb, the infant’s movements such as sucking, swallowing,
breathing, turning the head in various directions, pushing the arms and kicking the
legs against the uterine wall while in the flexed posture, all reinforce development
of the muscle of the neck and trunk. As mentioned earlier, these activities not only
cause the development of each utilized muscle fibers but also promote proximal co-
activation through isometric contractions.
Of special concern of development in this flexed posture is capital flexion.
The tiny muscles of capital flexion is basis of muscle tone of the neck and also it
contributes connective movement of the spine from head to cervical and cervical to
thoracic as well.

38
 All the infant’s flexor movements seen in the womb continue to develop after
birth with the physiological flexion. These movements are important and necessary
for the development of head movement in space.

Development of facial and oromotor

In the flexed posture, the fetus sucks his hand, swallows amniotic fluid and
practices breathing. These activities, which are all vital functions, are all easier in
the flexed posture. While flexed, contraction and relaxation of the face muscles is
more easily done when the fetus is sucking. The flexed posture also reinforces
increasing negative pressure. It is easier to close the mouth while in the flexed
position which makes nasal breathing easier. The amniotic fluid can go into the
deeper lung structures. These facilitate development of the structure of the lungs
and diaphragm, thus enhancing pulmonary function.
After birth, the infant’s breathing pattern changes with the development of
the abdominal muscles. At 5 to 6 months, with the emergence of the Landau
pattern, the breathing pattern of the infant shifts from abdominal breathing to
thoracic breathing. This change is very much related to the development of shoulder
girdle, rib cage, lower trunk and abdominal muscles. Even before the development
of thoracic breathing, the infant is already able to get air into the lungs because of
the practice of deep nasal breathing of amniotic fluid while in the mother’s womb.
Another aspect of development is oculomotor development. A stable neck
with capital flexion allows for development of oculomotor muscles. All these
activities which involve the development of oromotor, oculomotor, and breathing
help develop neck stability. Consequently, these contribute to the development of
head and trunk movement.
Activity of the facial and oculomotor muscles play an important role in
increasing motivation to move, adaptation to different stimuli, and the level of
arousal towards movement especially at the beginning of anti-gravity movement.
Also these muscles work for modulation of postural tone.

39
Counterbalance of extensor activity
Movement in the flexed posture continues to develop as physiological
flexion until 2 months after birth. When the leg is extended it flexes back like a
spring. This is the recoil phenomenon, a mechanism that prevents too much
extension after birth. Human beings have a tendency to move up against gravity
with extension and the recoil phenomenon counterbalances too much extension.

Emotional stability/ psychological stability

In the flexed posture, the fetus moves with a flexor pattern and easily
comes to midline. This posture can be a protective response giving the infant the
security and emotional stability as he adjusts and adapts to a lot of sensory
stimulation from the environment such as visual, auditory, olfactory, and
movement stimuli.

Self-regulation
After 40 weeks in the mother’s uterus, the fetus recognizes many different
sounds such as the mother’s biological rhythms and the mother’s daily routine —
sleeping, eating, toileting, and other activities. This helps the fetus recognize his
mother and the environmental cues (day, night). This also serves as the foundation
for their relationship (Fig. B.6).

Figure B.6 Sleeping in mother's womb

40
 The developing fetus hears more and more sound variation as the pregnancy
proceeds, and the brain also learns how to interpret them. These sounds include the
rumblings of the mother’s stomach and intestines, the sounds of blood flowing
through the mother’s blood vessels, and the beating of the heart (Nilsson, 1990).
The fetus’ favorite sound is that of his mother’s urination. This explains why the
shushing sound resembling that of the sound during urination calms an infant
down (Harvey, 2002).

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Amy Nagorski johnson, DNSc, RNC: Kangaroo Holding Beyond the NICU. Pediatric Nursing. 2005; 31: 53-
56.
Alexander, R., Boehme, R. & Cupps, B. Normal Development of Functional Motor Skills: The first Year of
Life. Tucson: Therapy Skill Builders; 1993.
Bobath B. Hemiplegia 3rd edition, 1990 Heineman.
Bremmer P, Byers JF, Kiehl E. Noise and the Premature infant: Physiological effects and practice
implications. J obstet Gynecol Neonatal Nurs. 2003; 32: 447-454.
DiFiore J.W., Wilson JM.: Lung development. Semin Pediatr Surg 1994; 3 (4): 221-232.
Fuchs E: Epidermal differentiation: the bare essential. J cell Biol 111: 2807, 1990.
Guyton A.C. Hall J.E. Textbook of Medical physiology. W.B. Sauders Company, London Newyork, 2000
Harvey Karp, M.D.: The Happiest baby on the block. 2002.
Jean Massion.: Postural control system current Opinion in Neurobiology. 1994; 4: 877-887.
Jill Anderson, MS, OTR; Sensory Intervention with the Preterm Infant in the Neonatal Intensive Care Unit:
A.J.O.T 1986; 40: 19-2.
Walker JM. PhD, PT: Musculoskeletal Development, A Review. Phys Ther. 1991; 71: 878-889.
Marla C. Mahoney, MPT, MS PT: Effectiveness of Developmental Intervention in the Neonatal intensive
care unit: Implications for neonatal Physical therapy, Pediatric Phys Ther. 2005; 17: 194-208.
Nemire K. Cohen MM. Visual and somesthetic influences on postural orientation in median plance
Perception & psychophysics. 1993; 53: 106-116.
Nilsson, Lennart. A child is Born. New york: Dell Publishing, 1990.
Sadler T.W., Denno KM, Hunter ES 111: Effects of altered maternal metabolism during gastrulation and
neurulation stages of development. Ann NY Acad Sci. 1993: 48-678.
Sadler T.W: Langman’s medical Embryology. Seventh Edition. Lippincott williams & wilkins. 1995.
Schweigart G, Heimbrand S, Merger T, Becker W: Perception of horizontal head and trunk rotation:
modification of neck following loss of vestibular function. Exp Brain Res. 1993; 95: 553-546.
Snell R.S.: The fate of epidermal desmosomes in mammalian skin. Cell and Tissue Research. 1965; 66 (4):
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Stevenson D.K. et al.: Very low birth weight outcomes of the National Institute of Child Health and Human
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Gynecol. 1998; 179 (6pt 1): 1632-1639.
Sue Angus: The premature baby charity, 2005.
Shumway-cook A, Wollawtt M.H.: Motor control. Therapy and practical Applications. Williams and Wilkins,
1995.
Veit Witzemann: Development of the neuromuscular Junction. Cell Tissue Res. 2006; 326: 263-271
Whitsett J.A.: Molecular aspect of the pulmonary Surfactant system in the newborn. In chernick V, Mellins
RB (eds): Basic Mechanism of Pediatric Respiratory Disease: cellular and Integrative.
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Foundation of Pediatrics. Baltimore, Md: University Park press; 1981: 330-342.

42
GENERAL PICTURE OF PREMATURITY

General picture of movement

The presentation of the premature infant depends on the degree of damage
to the brain, with corticospinal and corticothalamic tracts usually affected. (Hoon,
2009) Therefore, there are many problems in the neural pathway of the motor and
sensory components, in the development of joints and muscles and in the innate
movement which is the basis of normal development.

THE EYE
Low muscle tone of the eye
There are many muscles of the eye that generate various eye movements.
Many children with cerebral palsy have insufficient eye and facial movement,
associated with low muscle tone of the neck and low alertness. Consequently, the
postural tone they generate is low.

Altered axis of the eye

There are many cases of children with altered axis of the eyes. Most
children with cerebral palsy have their eyes located higher than the middle, such
as in upward gaze, which indicates an altered vestibular system. It leads to an
extended neck and extended body.
Also, the two eyes may not be equally located at the middle, one being lower
than the other eye. Consequently, postural tone generated on the side with the
lower eye is lower than the side with the eye in the middle.

43
In the case of children with severe brain damage (spastic
quadriplegia or premature dystonia)
These children present with hypertonus of the eye and neck muscles. The
eyes go strongly to one side which enhances asymmetry and promotes total pattern
movement.

THE FACE
When the child has low level of arousal or alertness, the face usually
presents with low muscle tone. This also contributes to low postural tone and
limited movement of the eye. In addition, this promotes low muscle tone of the
neck and especially causes insufficient activation of capital flexor muscles of the
neck. Thus, when the orofacial muscle tone is low, the postural tone generated is
lower.

THE NECK
Altered vestibular system of the neck
Higher axis of the eye, such as in upward gaze, presents with shortened
neck muscles, including the rectus capitis anterior, rectus capitis posterior major,
and rectus capitis lateralis in the lateral part. These are the capital flexors acting
on the suboccipital segment.
For children born prematurely, the higher axis of the eye with shortened
muscles is caused by the insufficient period of having the neck fully flexed in the
mother’s womb during the third trimester. This contributes to the altered
vestibular information; thus, the neck and body are extended.

44
Poor capital flexion
The package for capital flexion consists of downward movement of the eye,
closed mouth with strong, maximal masseter activity and movement of the face
muscles. Capital flexor muscles do not get activated when this package is weak or
with low muscle tone. Lack of capital flexion produces low neck muscle tone and
insufficient or absent movement of the spine. Consequently, the lack of capital
flexion generates low postural tone of the body.

THE IMMOBILE SPINE, INSUFFICIENT SPINAL MOVEMENT

Capital flexion is the connective movement of the head and cervical spine.
If capital flexion does not occur, the spine becomes totally fixed or immobile.

THE ELEVATED AND FIXED SCAPULA

As previously mentioned, the spine naturally does not move if there is no
capital flexion of the neck. Moreover, if the thoracic spine does not go into flexion,
it leads to higher clavicle and rib cage.
This results to scapular elevation with upward rotation. This fixed scapula
also enhances the altered axis of the muscles and joints of the arm. Wrist and
hand alignment also follow this altered axis.

THE PELVIS
The pelvis moves onto both hip joints. The construction of the hip joint is
insufficient with children born premature. Hypertonus of the muscles surrounding
the hip joints promotes hip subluxation or dislocation, while low muscle tone may
cause hip subluxation due to the lack of stabilization from the muscles
surrounding the joint.
The pelvis is commonly fixed in anterior tilt in relation to the altered axis of
the head and stiff spine.

45
In walking, they have insufficient 3-dimensional pelvic movements, causing
difficulty to perform dissociated movement of the lower extremities for their
distinct roles of stability and mobility. Another consideration is the
aforementioned immobile spine caused by absence or weakness of capital flexion.

THE LEG
There is a clearly limited or absence of movements of the leg because of
damage of the neural pathway of the motor and sensory systems in the lower
extremities of premature children. In addition to that, low postural tone of the eye,
face and neck leads to insufficient movement of the spine and lower extremities.
Hypertonus alters the axis of the entire lower extremities. It changes the
alignment of the femur, tibia and fibula, consequently influencing the ankle and
foot as well. The calcaneus becomes elevated, the talocalcaneal joint collapses, and
toe movements become limited.

THE ANKLE
In the flexed posture, the fetus has many movements in the mother’s womb.
Typically, the infant moves the head, ankle and foot simultaneously. This
movement can be defined as mass pattern of flexion.
The ankle and foot are strongly linked with the location and movement of
the head. These help to stabilize and to maintain the head in space for safety,
thus, strong head stability is associated with strong ankle and foot. Weak neck
muscle activity leads to limited movement of ankle and toe.

46
 Another consideration is the location of the tibia and fibula. When these are
located in the correct axis, all the muscles of the ankle are activated with 100% of
muscle tone and are able to produce maximum power. If the axis of the tibia and
fibula is altered, muscles tone and power disappear or become weak.
Another important effect of an altered axis of tibia and fibula is the
resultant alteration of the axis of the ankle. The ankle with an altered axis
commonly has a collapsed talocalcaneal joint, elevated calcaneus, or broken arch of
the foot. A foot that is fixed in plantar flexion also has shortened Achilles tendon
and elevated calcaneus. Thus, muscle tone of the leg falls low.

THE FOOT AND TOES

When the foot has an altered axis, it allows for limited ranges of foot and
toe movement. An elevated calcaneus and altered axis of the ankle eventually
causes poor movement of the toes.
Somatosensation of the foot decreases with altered axis and with lack of
foot and toe movement. Consequently, it leads to poor body scheme of the foot and
toes.
Weak toe muscles lead to low postural tone. With lack of toe activation for
stability and for appropriate ankle strategies, the foot with poor toe movements
serve as a weak BOS for standing.

47
NEONATAL INTENSIVE CARE UNIT (NICU)

Environment in the incubator

The NICU environment should provide an environment similar to the
uterus to avoid "sensory impact" (Fig. B.7).

Figure B.7 Incubator care for premature infant

The quality of light and sound, and other stimuli in the NICU are sources
of "sensory impact" that comprise the stressful elements of the NICU environment
that increases developmental delay and a variety of neuromuscular problems
(Allen, 1995).

AUDITORY STIMULATION
The noise level in the NICU is potentially harmful to the neonate. The
sources of noise in the NICU include loud talking, laughter, telephone ringing,
doors slamming, and incubator and monitor alarms. Signs of infant distress
include startle and motor arousal, worried expression, poppy eyes, and
disturbance of sleep. Physiological changes include decrease in blood oxygenation,
increase in intracranial pressure, and increase in heart rate and respiratory rate
(Bremmer, 2003).

48
LIGHT
Disturbance in homeostasis can also come from the continuous bright
fluorescent lighting. There is a 30% increase in incidence of retinopathy of
prematurity (ROP) in extremely low birth weight infants exposed to bright light.
Other physiological changes, including endocrine changes, are disturbances in
sleep and biological rhythms which have grave implications for healing, brain
development, and weight gain (Allen, 1995).

TACTILE AND VESTIBULAR STIMULATION

Immaturity of skin structures which cause hypersensitivity and pain
makes it difficult for the child to adapt to tactile stimulation such as touch, weight
bearing on hard surfaces, or thermal sensations such as when being bathed.
Providing vestibular stimulation can be a source of great stimulation. This
can be done by rocking and holding the infant in different postures in space. NICU
care should include giving premature infants the chance to carefully develop
adaptation to various sensory channels.

CONTRACTURES
Altered head posture, extended body, extensor pattern of movement, and
limited amount of available movement all lead the child to develop atypical
pattern of movement. Consequently, there is a great possibility for the child to
develop contractures around the joints. Thus, consideration of activation of
adequate movement is really important.

49
POSITIONING
Positioning is very important. The medical professional should ensure that
the infant is placed in a flexed posture. This promotes sensory channel and motor
development similar to the development achieved by a fetus who completed his
development inside the mother’s womb (Fig. B.8).

Figure B.8 Positioning for providing flexed posture

In the NICU, the infant may be wrapped in a towel and held tight against
the therapist. The therapist should move her body and provide the gentle,
rhythmic movements that are similar to the movement experience in the mother's
uterus. These movements stabilize the infant's internal rhythms (Sue, 2005).

50
CONSIDERATION OF TREATMENT in the NICU or
EARLY TREATMENT

We, medical professionals, should comprehend the problems of children

with cerebral palsy through our knowledge of normal and abnormal movement and
sensory development. Providing an early treatment as soon as possible is
important in reducing the huge gaps in the development of premature children in
comparison with normal infants.

Enforcement of flexed posture

In treatment in the NICU, the medical professional holds the infant in a
flexed posture to produce capital flexion of the neck. To gain this, the professional
should mobilize the neck muscles and lengthen the C1-C2 suboccipital segment
with the eyes in neutral or in downward gaze and to elongate the whole part of the
back with a posteriorly tilted pelvis. Also, this flexed posture promotes connective
movement and neural network from the head to foot such as the mass pattern of
flexed posture (Fig. B.9).

Figure B.9 Activation of capital flexion in flexed posture

51
1). Activate the facial muscles with closed mouth. The frontalis muscle can be
used to activate movement of the eye. Move the eye downward through the face
muscles which enhances increased muscle tone, movement and alertness
(Fig. B.10).

Figure B.10 Activate muscles of the face and eye

2). While keeping the mouth closed, put deep pressure around mouth. This
increases nasal breathing (Fig. B.11).

Figure B.11 Activate mouth closure and deep breathing

52
3). Activate the capital flexor muscles through mobilization of C1-C2 suboccipital
segment. The C1-C2 suboccipital segment should be mobile like a compass.
Activate downward movement of the anterior part of the capital flexors, and then
make an elongated cervical spine through the lateral part of capital flexors
(Fig. B.12). Capital flexion is a prerequisite movement of the spine and it corrects
the altered vestibular system of the neck.

Figure B.12 Elongation and mobilization of C1,C2 segment with lowering the eye

53
4). Put the hand of the infant to the mouth to increase the body scheme of the
hand. Activate sucking fingers while holding the cheeks together (Fig. B.13).

Figure B.13 Activation of body scheme of the hand

5.) As a preparation, pay attention to mobile spine to make a dynamic movement

of the spine and pelvis which is 3 dimensional pelvic movement.

6). Put both legs in midline with the pelvis in posterior tilt to generate higher
postural tone with flexor pattern. The important thing to do is to correct the axis
of the tibia and fibula. Then, mobilize the foot and gently stimulate the foot by
applying tactile stimulation and pressure such as touching or tickling which
activates somatosensation of the foot (Fig. B.14).

Figure B.14 Stimulate the foot

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Sensory adaptation

Tactile system
The medical professional provides gentle massage on the whole body of the
infant to settle him down or to increase adaptation of the tactile receptors in the
skin which were underdeveloped due to prematurity.

Vestibular system
The medical professional holds the infant firmly, while moving side to side
or up and down rhythmically like a tide. This generates adaptation to being
moved as it imitates the movements of the mother while the infant was still inside
the uterus.

Mobilization of the joint.

Although this is a passive movement, this is necessary especially when the
child’s arms, hand, legs, or feet are already fixed. The therapist should mobilize
the affected parts of the body to prevent the infant from developing contractures.

55
Establishment of emotional attachment and
relationship between the mother and the infant

Provide Kangaroo posture. This provides the infant with emotional

security and a sense of belongingness to the mother (Fig. B.15).

Figure B.15 Kangaroo postures

CITED REFERENCES:
Allen, A.M.: Stressors to Neonates in the Neonatal Unit. Midwives-May 1995.
Bremmer P., Byers JF, Kiehl E. (2003). Noise and the premature infant: physiological effects and practice
implications. J Obstet Gynecol Neonatal Nurs. , 447-54.
Hoon AH, Stashinko EE, Nagae LM, Lin DD, et al. (2009). Sensory and motor deficits in children with
cerebral palsy born preterm correlate with diffusion tensor imaging abnormalities in
thalamocortical pathways. Developmental Medicine & Child Neurology.
Sue Angus: The premature baby charity, 2005.

56
NORMAL DEVELOPMENT

It is important to understand how an infant develops inside the womb until

he is able to sit, stand and walk. Comprehension of normal development will help
you figure out the gaps between normal and abnormal movement. There are many
key words that can lead to the right concepts for strategy of treatment.

Key Words
- Postural tone and muscle tone of the neck and body
- Sensory development: vestibular information, vision, visual perception,
somatosensation
- Axis of the eye, head and neck
- Capital flexion, spine movement
- Whole dynamic movements of the spine: flexion, extension, rotation, lateral
elongation
- Whole connection of posterior muscles:
Trapezius – rhomboideus – erector spinae – gluteus maximus – leg muscles
- Dynamic movement of the scapula: right axis of the arm and hand
- Dynamic 3-dimensional movement of the pelvis: right axis of the leg and foot
- Calcaneus, toe muscles
- Base of support: elbow, hand, upright pelvis, foot (calcaneus)
- Cortical level of movement:
~watching, hand and foot movement, any voluntary movement
~Adjustment, correction, purposeful movement

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STAGES OF NORMAL DEVELOPMENT

A. Fetal development

B. First stage (after birth)

Physiological flexion
Midline (axis) of the eye and head, capital flexion with spine movement,
Shoulder construction with scapula through prone on elbow: extensor
muscles of the arm develops through prone on elbow
Sensory development: vestibular, vision, visual perception

C. Second stage
Capital flexion with whole spine movements, development of scapular
movement
Transference of base of support from elbow to hand
Locomotion: Creeping, pivoting
Weight transfer by dynamic movement of the spine with scapula and pelvis in
prone
Pivoting, Landau reaction: hand being a strong base of support, connection of
extensors
Landau reaction generate posterior muscles trunk in prone
Trapezius – Erector spinae – Gluteus maximus – Muscles of the leg

D. Third stage
Correct sitting with upright pelvis: strong base of support in sitting
It develops strong erector spinae muscles which signifies connection of the
posterior trunk muscles.
Development of trunk extensors in sitting with upright pelvis: lighter arm and
hand
Construction of pelvis and hip joint, dynamic 3-dimensional movement of the
pelvis
Locomotion: crawling, kneeling, squatting, Right axis of leg muscles with right
location of the calcaneus

E. Fourth stage
Maximal extensor muscle connection against the base of support in standing
Dynamic 3-dimensional pelvic movement in standing: dissociation of both legs
Strong leg with foot, Development of Toe muscles: flexor muscles
Complete somatosensation of the foot

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FIRST STAGE

First period (Neonatal)

Phase and completion of Physiological flexion
Immature movements and survival reflexes

Physiological flexion as a protective mechanism

The physiological flexion is a continuation of the flexor posture pattern
inside the womb and the similar experience provides comfort to the infant. It is the
strongest protective mechanism designed for self-preservation and survival as the
brain is still developing. Of special consideration is that, if the head is not in the
middle, then all survival functions are difficult to perform. Thus, physiologic
flexion happens as automatic maintenance of the axis of the head and body.
(Aucott, 2002)
After birth, the infant is faced with a different situation from the warm,
comfortable, and stable environment inside the mother’s womb. He is faced with
new challenges and the most significant of which are new stimuli such as light, the
force of gravity, and many different sounds. These stimuli may initially cause
discomfort and the infant usually cries because of the inability to adapt to the new
stimulation. Physiological flexion, wherein the head and trunk are flexed, and the
recoil phenomenon, which helps the infant come to midline automatically, places
the head and trunk in good alignment even before development of head movement
against gravity (Fig. B.16).
After birth, the infant is challenged to move against gravity. Immaturity of
the CNS, presence of reflexes, and weakness of the eye and neck muscles make it
more difficult to maintain the head in midline against gravity.

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 Figure B.16 Physiological flexion after birth

Basic survival functions such as sucking, swallowing, and breathing are

difficult, but physiological flexion is a continuity of the flexor posture in the womb
that makes alignment easier. Its protective function provides the basic mechanism
for development of head control for the child to learn basic survival functions.
Survival functions such as breathing, sucking, and swallowing require good
alignment of the head and trunk. In the absence of good head and trunk control,
physiological flexion makes it easy to come to midline while the infant is
breathing, sucking, and swallowing. This sensorimotor experience is very
important because it is similar to what the infant experienced in the mother’s
womb.
At this stage, the infant tries to move the head and other parts of the body
together as a unit. They present reflexive and innate movements that are similar
to the flexor movements in the mother’s womb. It is considered as an innate
movement, but this experience is the foundation for making a strong connection of
the whole body and is the basis for development of postural control.
Physiological flexion acts to counterbalance the anti-gravity extensor
movement appropriately. If the counterbalance mechanism of physiological flexion
does not work, extension of the whole body will not develop within the normal
range. The stronger muscle groups such as the adductors and internal rotators will
dominate, limiting development of the extensor muscle groups while in the correct
alignment.

60
 Gradually, physiological flexion and reflexive and innate movements
decrease. Since the infant cannot hold his head in space yet and has no midline,
the head drops to gravity and the child’s posture and movement may be
asymmetrical. The infant moves with reflexive and random patterns. When he
sucks, the head may turn to one side and the whole body follows. With this
experience, the infant learns about head and trunk alignment. Without this
experience of head turning generating connective movement of spinal rotation
with the body, the child only learns flexion and extension of the spine consequently
generating undissociated movement of the scapula and the arms. There is less
chance for development of variety of movement.
In supine, the infant places his hands to his mouth but this is not yet done
in midline. His head may fall towards either side. This is the process of developing
midline orientation against gravity. The experience of hand to mouth in midline is
the basis for eye-hand coordination, forearm support, and later development of
hand support and protective extension. Finally, the infant develops arm reaching
and hand grasping.
As the vestibular system develops, the eyes move towards the middle which
is the first contribution of the vestibular system to allow raising and maintaining
the head in midline while in space. As the child develops the vestibular neural
network for midline alignment, he begins to lift the head against gravity. This
development is necessary for further enhancement of head movement and is the
precursor for the developmental process of using the eyes as an axis, which then
allows the head to move in midline (Fig. B.17).
In the flexed posture in the mother’s womb, the muscles of the neck and
trunk are developed. The flexed posture is the basis for development of muscle
tone specifically the capital flexors of the neck including the muscles of the eye and
face, as well as development of a strong mass pattern of movement, signifying the
connective movement from the head and body. This position in the mother’s womb
is a prerequisite for development of the neck and sensorimotor experience for
midline.
61
.
 Figure B.17 Development of head movement.

In supine, the infant cannot maintain the head in midline yet, which makes
breathing difficult. And so, the infant tries to align the head and trunk to midline.
When the infant sucks his fingers, it makes the hands come to midline. It
contributes to a continuation of this midline sensorimotor experience in the
mother’s womb (Fig. B.18).

Figure B.18 Sucking finger

While in physiological flexion, the head, arms, and legs move together with
the shoulders in protraction, trunk in flexion, and the pelvis in posterior tilt. The
parts of the body always move together in this posture. The leg mirrors the
movement of the arms reflexively. The posterior tilting of the pelvis allows for
greater flexion of the legs for kicking. Kicking helps in the co-activation of the
trunk and therefore contributes to neck and proximal dynamic stability.
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 The posterior tilt of the pelvis and the flexion of the legs also facilitate neck
elongation, which is necessary for development of neck stability. With the neck
elongated and acting as the fulcrum, pelvic movement is increased. This
interaction between the neck and the pelvis contributes to development of trunk
control.
With the neck as the fulcrum, movement and control in the sagittal plane is
developed. Gradually, the infant develops control in all planes of movement.
Development of control in all planes is needed for dynamic stability. With the neck
as the fulcrum, scapular movement and arm movement is also developed.
Moreover, a stable neck allows for development of capital flexion which
straightens the cervical spine in order to connect the head to spine. When an
infant has good capital flexion of the neck, the neck as fulcrum is enhanced. And
so, neck stability with capital flexion facilitates eye and face muscle activation that
modulates postural tone of the body (Fig. B.19).

Figure B.19 Development of capital flexion of the neck in supine

Kicking is another experience that is a continuation of the sensorimotor

experience in the womb. Kicking gives input that helps in the development of the
articulation between the acetabulum and the femoral head. Kicking also
stimulates muscle development around the hip joint. When the infant kicks with
his legs, neck and proximal muscle dynamic stability develops. Pelvic band
muscles also develop as it moves in coordination with the core muscles.

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Second period
Development of vestibular system
-Head and eye establish midline/ right axis of standpoint
Eye begin to watch / cortical level of movement
Head and neck work as an axis of the body
Capital flexion phases
-Cervical spine starts to move into flexion, extension and rotation
-Gradually connecting to thoracic which is initiation of connective
movement of the spine
Prone on elbow
-Construction of shoulder joint with scapula
-Extensors develop against base of support (BOS)

Development of the vestibular system

PRONE
Around 2-3 months after birth following the development of the brain, or
more specifically the central nervous system (CNS), the infant develops eye and
head movement in the midline axis. At this time, the infant starts to watch an
object and play with the hand, both of which show brain activation at the cortical
level.
This is the start of the development of midline orientation. During this
stage in the prone position, the head goes into space which generates an increase
in postural tone in order to maintain the head up (Fig. B.20).

Figure B.20 The head is going to space in prone

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 In the normal movement as bipedal human beings, the basic connective
neural network is the activation of postural tone regarding the head's location in
space. Head movement develops with the maturation of the CNS as head
movements become integrated with body movements. This is the beginning of body
movement along the right axis. This is not only important for the development of
head movement but also for the establishment of the head and neck as the axis for
the movement of the body (Fig. B.21).

Figure B.21 Development of an axis

Head moves more dynamically because capital flexion of the neck connects
the head with the cervical spine. Inputs from the vestibular system as well as
good neck muscles are required to have neck dynamic stability. Head control
signifies the development of neck muscles. It is also ultimately essential for vision
and for spreading signals from the vestibular network which enhances the
connective movement of the body from top to bottom.
When the infant rotates his head to watch something, the rotation of the
head and neck activates the vestibular networks, which in turn sends signals from
the neck to alert the body with the change of axis. This results to the rotation of
the body as it follows the rotation of the head and neck. Head rotation is improved
by capital flexion of the neck which in turn enhances stronger connective

65
movement of the whole spine, from cervical to lumbar spine. Thus, the
development of vestibular networks contributes to the activation of the body's
mechanism to recover its axis whenever altered, as well as to the anatomical
connection of the whole spine to move within the same axis (Fig. B.22).

Figure B.22 Correct axis with vestibular information

When the infant wants to touch the toy on his side, the cervical spine
rotates. With further movement of the cervical spine, rotation of the thoracic spine
follows. This rotation of the thoracic spine then results to movement of scapula on
that side to go further towards the toy. If the hand has to reach farther, thoracic
and lumbar spine rotation is activated. This demonstrates connective movement of
the whole spine and is the basis of weight transfer. It is at this stage that the
extension and segmental rotation of the spine develops, which results from the
development of spine movement with capital flexion of the neck.
As the child plays in prone, the infant tries to lift the head to look at an
object. This is only possible with the development of neck muscles with movement
of the spine and the development of the vestibular system on both sides of the
head. The development of the vestibular system enables head raise which
generates an increase in postural tone. Also, the desire to raise the head leads to
elbow support in order to maintain the head in space. It is the natural process of
development of activation of the muscles of the body, including the proximals.

66
Muscle tone of the eye, face and neck are developed which activate to modulate the
postural tone in relation to the location of the head.
When the head raises, three parts of the trapezius develop and initiate
rhomboideus activity. These muscles generate scapular movements and establish
the right location of the scapula. While the scapula moves in the right axis, the
humeral head constructs into the scapular fossa which is the basis of
glenohumeral rhythm. The shoulder joint (clavicle, scapula, humerus) moves in
the right axis which enables the arm and the hand to move in the right axis as
well.
Prone on elbows makes a triangle where two corners are made up of the
elbows and the fulcrum is at the abdomen. When the fulcrum in prone is at the
abdomen, not only does the abdominal muscles increase in activation but also it is
elongated and takes weight. These are very important for the development of
proximal dynamic stability (Fig. B.23).

Figure B.23 Prone on elbow

In this position, the weight is taken by the elbows. Initially, as the infant
tries to lift the head, weight is transferred to the arm and shoulder. Eventually,
the infant puts the weight on the elbow but there is yet no movement of the
scapula. As construction of the head of humerus with the scapular fossa continue
to develop, better alignment and weight on the elbow is promoted which indicates
good activation of the shoulder joint.

67
 In this posture, the most important consideration is the development of the
extensor muscles of the arm. Basically, the infant starts to move using stronger
flexors than extensors in the flexed posture inside the mother’s womb. Strong
flexor development continues even during physiological flexion.
Prone on elbow is the beginning of extensor muscle development in the
infant’s life. It enhances development of various directions of the arm muscles
against the BOS. It forms the right length, arrangement and direction of the arm
muscles. In prone on elbows, the scapula goes into adduction and downward
rotation, which is the basis for harmonized extension of the back. In addition, in
prone on elbows, there is lowering of the pelvis and positioning of the legs into
extension which change their direction from proximal to distal (Fig. B.24).

Figure B.24 changing direction of the arm and leg to BOS

Of special consideration is taking weight on the hands which leads to the

development of body scheme. Moving on the hands as BOS leads to the
development of taking weight on the feet as BOS in standing.

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SUPINE
During the development of the vestibular system and cortical level of
movement in supine, the eyes start to enjoy watching mother and toys. Gradually,
the eyes can watch a wider range and more specifically, the downward gaze with
capital flexion of the neck. It naturally increases head flexion which in turn,
activates flexor muscles of the neck and proximals. It also strengthens the head
and neck as axis which further develops the proximal muscles (Fig. B.25).

Figure B.25 Downward watching with capital flexion of the neck

There are two types of neck movement with capital flexion: One is simply
neck rotation which is generated by rotation of the cervical and thoracic spine. The
other is with the neck as a fulcrum where it serves as an axis for various
movements of the proximals.
When the infant rotates the head and the trunk follows, there is connective
movement of the spine. This means activation of the proximal muscle groups. This
connective activity of the trunk muscles is possible because of capital flexion of the
neck, or what we call chin tuck. If there is poor or no capital flexion, it is
impossible to rotate the head.
The other movement is the neck as a fulcrum. Chin tuck generates power of
the body in various activities like in lifting the leg or during trunk rotation. It
requires stronger muscles of the neck which activates muscles of the proximal.

69
 In continuation of the flexor movement, when the infant raises the head
and the trunk muscles start to work, the gluteus maximus also starts to work.
This is the posterior tilting of the pelvis that is immediately activated through the
connectivity of the whole spine as generated by capital flexion. This connective
flexor movement is related to vestibular information to maintain the same axis of
the head and the body.
This development is the beginning of the strong automatic connection
between the head and the gluteus maximus. The connection happens in any kind
of posture such as upright pelvis in sitting and standing when the pelvis is in the
right axis. The two gluteus maximus work together to make posterior tilting of the
pelvis. However, when the pelvis rotates, only one side of the gluteus maximus
works to make a rotatory movement of the pelvis.
Also, as a contrast movement in this posture, the harmonized extension of
the back starts with the neck straightening with capital flexion that acts as a
fulcrum. This extended neck with capital flexion brings the thoracic spine in
extension and the scapula adducted towards midline (Fig. B.26).

Figure B.26 Trunk extension in supine

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CREEPING
As the infant develops muscles from the neck to the proximals, connective
movement develops with dynamic movement of the spine through the neural
network of the CNS, particularly, the vestibular system.
When the infant rotates the head in prone on elbow, although not fully
developed at this stage, a slight rotation of the spine activates elongation of one
side of the trunk and 3-dimensional movement of the pelvis. At this time, we
should pay attention to the different movements of the leg. One leg goes into
flexion and the other leg into extension. This difference in movement of the legs
develops creeping. Creeping begins because of the 3-dimensional movement of the
pelvis, or in the other words, diagonal movement of the pelvis. Diagonal movement
of the pelvis is the downward movement or the lowering of the elongated side of
the pelvis.
The side of the lowered pelvis is the extensor part. As the pelvis moves in
dynamic diagonal movement, the lowered or extensor part serves as the stability
part while the other becomes the mobility part where the leg can move more.
This dynamic movement of the pelvis happens rhythmically and
automatically like in the central pattern generator of walking. Mobility with
central pattern generator occurs in creeping, crawling and walking.
The infant, at this stage, however, starts to creep or roll over like a log
because connective movement of the spine and 3-dimensional movement of the
pelvis are not yet completely developed (Fig. B.27).

Figure B. 27 Creeping
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Differences between the environment in the mother’s womb and
the environment after birth

GRAVITY
In the uterus, the fetus moves while suspended in the amniotic fluid, as if
swimming in water. The fetus is very comfortable in this environment. After birth,
the force of gravity acts on the infant and it may be perceived as a strong and
different stimulation. The recoil phenomenon of physiological flexion helps the
infant move against gravity. When the recoil phenomenon is diminished, the
infant moves against gravity by himself.

DIFFERENT SENSORY INPUT

Light
Sound
Different degrees of pressure from base of support
Air into the lungs
Temperature of environment
Vestibular system

BODY SCHEME
As the fetus moves while suspended in the amniotic fluid, he is unable to
identify the direction of his movement. After birth, the infant gradually develops a
sense of direction and body scheme due to gravity and the experience of being
carried by the mother. He learns about this further when he observes and touches
his mother and other people.
Dressing the infant is another experience where he learns about body
awareness and body scheme. The infant experiences tactile input as he is being
dressed. The learning process is further enriched when the infant observes others
getting dressed. He also learns through imitation.

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GETTING BASE OF SUPPORT
For 40 weeks, the fetus is suspended in the amniotic fluid without any
experience of support. After birth, the infant moves with a BOS when he is placed
in supine or prone. With a BOS to provide stability, the direction of the muscles is
established. From this stable BOS, the infant gains stability which enhances
movement against gravity. This interaction between stability and mobility
develops body scheme. As the infant moves against different surfaces, his learning
about his body scheme is enriched. This is similar to the experience of pushing and
kicking against the walls of the uterus in fetal development.

DEVELOPMENT OF CENTRAL NERVOUS SYSTEM

The development of the CNS is influenced by environmental and cultural
factors. The adaptation of the CNS is determined by factors such as climate and
temperature, way of life, manner of carrying, etc. Differences in the rate of CNS
development are largely determined by these factors. (Stiles, 2010)

TAKING IN FOOD
In the mother’s womb, the fetus is nourished passively through the
umbilical cord. After birth, the infant has to take in food through the mouth,
initially mediated by automatic reflexes and eventually more actively. When the
infant takes in food, he starts to differentiate flavors.

DAY AND NIGHT

The mother’s womb is a dark place. The newborn baby encounters light for
the first time at birth. This may be initially strange for the infant, but he
gradually realizes the difference between light and dark and eventually relates the
differences with the functions of sleeping and being awake. The infant also
observes others as they go through the routines of the day and this strengthens his

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understanding of daytime and nighttime activities. The infant’s observations of
the differences in the characteristics of visual and auditory stimuli, as well as
temperature differences of day and night strengthen this understanding further.
All these help develop self-regulation in the infant.

IMMATURE REFLEXIVE MOVEMENT

There may be differences because of developmental and environmental
factors, but immature and reflexive movements are generally observed until 2
months after birth. At this time, the CNS is also immature, and so inhibitory
control is still just emerging.
Although these reflexes are present until the infant develops head control,
these are important because they provide sensorimotor experience in preparation
for eating and other survival functions. They also stimulate the development of the
muscles of the head and trunk, and especially of the face muscles for maintaining
arousal and alertness. Furthermore, they contribute to the development of the axis
of the neck.

Reflexes

ROOTING REFLEX
When the infant is stimulated in the area around the mouth, the head
turns in the same direction. This is rooting, a reflexive movement that is related to
the infant’s need to feed. The rooting reflex disappears around the time that head
control is developing. Rooting is a very important sensorimotor experience for
development of head control and survival.

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GAG REFLEX
In the infant, the gag reflex occurs when the anterior part of the mouth is
stimulated while in the adult, the gag reflex is elicited when the posterior part of
the mouth is stimulated. This is a very important reflex for survival because this
prevents aspiration of food.

SUCK AND SWALLOW REFLEX

Suck and swallow is an automatic and reflexive manner of swallowing.
Initially, sucking and swallowing occur together but at the time when the infant
starts to control the head, the two activities are dissociated from each other.

AUTOMATIC BITING REFLEX

Stimulation of the gums and the inside of the mouth of the infant results in
the continuous biting activity called the automatic biting reflex. This disappears
around the time head control is developed.

NECK RIGHTING REACTION

When the infant turns the head to one side, the trunk rotates toward the
same side automatically. This reaction is eventually integrated with head righting
reaction with the development of good head control. This is the basis of
development of the connection between the head and trunk and is important in
maintaining alignment. This reaction contributes to the alignment needed in
eating, sucking and swallowing, and breathing.

MORO REFLEX
When the infant’s head is suddenly extended, the mouth opens, and the
arms go into abduction and flexion. This reflex disappears at 2 months. The main
difference between the startle reaction and the Moro reflex is that with adaptation,
the startle reflex is not repeated whereas the response to the Moro reflex is elicited
repeatedly due to lack of head control.
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PRIMARY WALKING AND PRIMARY STANDING
Primary standing is observed when the newborn infant takes weight on the
feet when placed in standing with or without full extension of the leg.
Primary walking is observed when the child steps forward. These reflexes
are observed until about 2 months. Primary walking emerges from the immature
inhibitory control mechanism for locomotion, the so-called central pattern
generator (CPG). This manner of walking is a reflexive movement that provides
the initial sensorimotor experience of walking. The locomotor centers in the
midbrain mediate these stepping movements. The CPG may be elicited in the child
because of the lack of integrative control but in the adult, this is not possible
because it is integrated with voluntary movement (Mccrea, 2008). Control of
quadripedal locomotion involves control from the cervical to the lumbar spine
whereas bipedal locomotion involves control from the lumbar spine only. Creeping
and walking are locomotive patterns that are mediated by the CPG.

Development of Vision
With continuous development of the brain, the vestibular system enhances
the development of the right axis of the head and neck. When the eye moves in the
middle or in its right axis, the muscle tone and the movement of the eye muscles
increases as well, which is the basis of watching.

MONOCULAR VISION
Before midline control of the head is developed, the infant uses one eye to
look at objects. With the eyes not yet in the midline axis, different visual
information is received in each eye. The CNS has an automatic inhibition system
which blocks information from one eye and allows the use of one eye. Monocular
vision is developed before binocular vision. However, in the development of vision,
voluntary control of one eye is possible only after binocular control is achieved, as
such after development of symmetry.

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BINOCULAR VISION
With the development of arm support in prone and control at midline in
supine with chin tuck, the child can look at objects using both eyes (binocular
vision). The vestibuloocular reflex (VOR), which is mediated by the vestibular
system, helps develop midline positioning of the eye to facilitate binocular vision.
The VOR also facilitates voluntary eye-head dissociation since the reflex involves
separate movements of the eyes from the head. The difference between monocular
and binocular vision is primarily related to the perception of spatiotemporal
relationships of objects and a sense of distance. Amphibians and reptiles are
unable to perceive depth and distance because they use only monocular vision. In
mammals such as monkeys and lions, binocular vision affords them a more
developed perception of space to move about and catch prey (Fig. B.28).

Figure B.28 Development of binocular vision

Development of the sensory channel

Before development of vision, the infant uses other sensory channels such
as the auditory, olfactory, tactile, and vestibular. At this time, the infant learns
about object characteristics primarily through touch. When vision develops around
5-6 weeks, the infant learns about other characteristics such as size and shape.
Initially, the child perceives light and with maturation of the visual system, the
infant is able to observe and learn about objects in three-dimensional space.

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 With all sensory channels receiving input from the environment, the body
scheme becomes fully developed and the infant learns about his body parts, their
relationship to each other and with the environment. All these sensory channels
are necessary for the development of postural control which allows the child to
make good alignment and good movement.

CITED REFERENCES:
Alexander, R., Boehme, R & Cupps, B.: Normal Development of Functional Motor Skills: The first Year of
Life. Tucson: Therapy Skill Builders; 1993.
Asim Kurjak, Milan Stanojevic et al: Fetal behavior assessed in all three trimesters of normal pregnancy
by four-dimensional ultrasonography. Croat Med J 2005;46(5):772-780.
David A. McCrea, Ilya A. Rybak, Organization of mammalian locomotor rhythm and pattern generation :
Brain Res Rev.2008 January ; 57(1): 134-146.
Dietz V. Human neural control of automatic functional movements:interaction between control problems
and afferent input.physio Rev 1992;72:33-69.
Gordon J, Ghez C. Mucles receptors and spinal reflexes: he stretch reflex. In: Kandal E, Schwartz JH,
Jessell TM, eds. Principles of neuroscience. 2rd ed. New York: Elcvier, 1991:564-580.
Gurkinkel VS, Kots Y, Paltsev Y, Feldman A. 1971. The compensation of respiratory disturbances of the
erect posture of man as an example of the organization of interarticular interaction. In:Gelfand J,
Gerkinkel, VS, Formin S, Tsetlin M, eds, Models of the Structural-Functional Organization of Certain
Biological Systems. Cambridge, Massachusettes, USA:MIT Press;382-395.
Hans Forssberg : Neural control of human motor development. Current Opinion in Neurobiology
1999;9:676-682.
John D. Willson, Christopher P. Dougherty et al: Core stability and its relationship to lower
extremity function and injury. Journal of the American Academy of Orthopedic Surgeons
2005;13:316-325.
Massion J. 1992. Movement, Posture and Equilibrium : Interaction and coordination. Progr Neurobio
38:35-56.
Naitional Geography. Mystery of a birth, 10 month. 2005
Sadler T.W: Langman's medical Embryology. Seventh Edition. Lippincott williams & wilkins. 1995.
Shumway-cook A, Woollacott M.H.: Motor control. Therapy and practical Applications. Williams and
Willkins, 1995.

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SECOND STAGE

Development of symmetrical movement in extension with abduction

- Develops at 4-6 months
- Transference of base of support from elbow to hand
- increasing muscle tone and power of head and arm through base of
support

Landau reaction
- Develops at 5-6 months
- Mass extensor pattern develops the whole spine extensors in prone
- Erector spinae, Glutues Maximus enhances voluntary movement of the
foot
- The pelvis is going to the right location (middle) into both hip joints
- Legs come to and move in midline increasing connection between proximal and
both legs
Locomotion: creeping, pivoting

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Development of proximal dynamic (core) stability
Stronger muscle tone and axis of the neck enhances the development of
proximal dynamic stability. With good stability of the head and development of
proximal dynamic stability, the rib cage descends with increase in range of
movement which allows for greater volume of air in the lungs during respiration.
This includes movement of the spine and trunk in various directions because of the
stronger neck axis and muscles that provide stable fulcrum. As much as proximal
dynamic stability develops, the neck movement becomes efficient and lighter while
proximal becomes stronger and heavier.
At this stage, because of more dynamic movements of the spine, there is
more development as this is the basis of human movement. With this interaction,
the head and arms move more freely in space. This allows for development of
better control of the arm and hand for reaching with visual guidance, of better
reaching control for distant objects and of better prehension.
However, if there is incomplete development of proximal dynamic stability,
the legs move out of midline. As the pelvis is not yet stable and mobile, the infant
cannot move the legs freely.

SUPINE
Development of the head movement increases postural tone continuously
because of the connective movement of the spine. We can imagine how many
muscles originate and insert on the spine; thus, dynamic movement of the spine
leads to increasing muscle tone and power of the proximal part of the body.
Development of spine movement in extension and rotation of the thoracic spine
enhances development of the muscles located in the upper back. Thus, dynamic
thoracic spine movement, which activates the muscles of the upper back, brings
the scapula on the right axis.

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 On the other hand, neck dynamic stability allows for scapular adduction
with extension of the spine. This is connected to the harmonized extension of the
back. But still, like in the prone posture, because of incomplete development of
proximal dynamic stability, the infant cannot place the legs and pelvis in the
middle and they are usually in flexion, abduction and external rotation (Fig. B.29).
The right axis of the spine and scapula including the clavicle will result to the arm
and hand located in the right axis.

Figure B.29 The legs moving out of midline

With the cervical spine elongated with capital flexion, vision is developed.
Midline stability of the neck allows for other movements to occur, such as spine
extension and axial rotation. Thus, the infant can lift both legs to place his foot
on his mouth, can kick both legs, and in the process, can develop proximal dynamic
stability and movement of the pelvis (Fig. B.30).

Figure B.30 Foot to mouth

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 Log rolling is observed at this stage, because the vestibular system and
connective movement between the cervical and lumbar spine are not yet
developed. Moreover, the 3-dimensional movement of the pelvis as activated by
proximal dynamic stability is not yet developed along with the dissociated pattern
wherein the lower leg is extended and the upper leg and pelvis rolls and flexes
over it (Fig. B.31).

Figure B.31 Log rolling

PRONE
Dynamic proximal stability starts to develop when the infant takes weight
on the elbows in prone. This develops further as the child supports himself on his
hands. The change of the BOS clearly presents development of the power of the
extensor muscles of the arm as well as the flexors.
With the arm in its right axis and with 100% muscle tone, the sensory
pathway of the hand develops. The infant uses the hand more strongly than in the
previous stage because of the higher and stronger sensory pathway. This drives
the child to use the hand in manipulation and more importantly, to use it with
intention and adjustment. Watching and hand manipulation like in play increase
the intensity of neural signal in the brain (Fig. B.32).

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 Figure B.32 Playing using both hands: cortical level of movement

The infant can also maintain the head, arms, and legs in space for longer
periods of time. This means that compared to the previous stages, the infant’s
postural tone is higher and his visual field wider. Because the child can now use
higher arm support and has greater ability to lift his body and arms from the
ground, he now sees more of the environment, leading to greater variety of head
and trunk movements, as well as the development of vision and visual perceptual
skills. Also, trunk extension with co-activation of the flexor muscles is utilized
whenever the infant lifts himself up, resulting to further development of proximal
dynamic stability (Fig. B.33).

Figure B.33 Development of proximal dynamic stability in prone

Whereas the infant is able to move the upper extremity dynamically, he can
only move the legs passively until this time because spine mobility is not enough.
Proximal dynamic stability is also not yet fully developed.

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 The sensorimotor experiences of the infant in the previous stage such as
weight transfer, axial rotation, and hand support allows for a variable, changeable
and wide range of movement at this stage. The repetitive movement of raising the
arms in space and then using them to support the body in prone is the beginning
of protective extension (Fig. B.34).

Figure B.34 Development of protective extension of the arm

But still, like in the supine posture, because of the incomplete development
of proximal dynamic stability, the infant cannot maintain the legs and pelvis in
midline. The legs cannot move together or with selective movement such as in
walking.

WEIGHT TRANSFER
Weight transfer to one side further develops more dynamic movement of
the scapula. With this, 3-dimensional movement of the pelvis also starts as
dissociated movement of the legs happen.
Dynamic changes of stability and mobility generate locomotion of human.
While one side of the scapula moves in abduction and upward rotation with
diagonal downward movement of the pelvis, the other side of scapula goes to
adduction and downward rotation with diagonal upward movement of the pelvis.
This is the basis of walking which requires dynamic 3-dimensional pelvic
movement.

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 Weight transfer also develops the lateral wall of the trunk. With elongation
of one side, the connection between the trunk, pelvis and leg are reinforced for
stability, while the other side is for mobility (Fig. B.35).

Figure B.35 Weight transfer from side to side

In prone on hands with weight transfer to one side, one hand receives more
weight, and this develops the clavicular, shoulder, arm, and forearm movements.
It enhances weight bearing on the wrist and elongation of the hand muscles. This
is the beginning of one hand support and movement of the unloaded arm in space
which will be used for independent transition from supine to sitting and sitting to
standing.
Hand support is not just for security but also for psychological stability,
motivation to move in different directions using sequences of movement, and
movement of the body against the BOS such as in sitting and standing.

PIVOTING AND CREEPING

The development of head movement increases the postural tone that results
to using hand support with concurrent trunk extension and good proximal
dynamic stability. The child’s center of gravity goes higher and the child’s
motivation further increases.

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 Development of muscles of the neck and proximals, connective movement of
the spine, and the vestibular system allow the child to perform dynamic weight
transfer and rotation of the body.
The child enjoys walking with the hands in pivoting. With repeated
movements to the side, upward and downward, proximal dynamic stability is
further enhanced, and the infant's legs gradually come to midline (Fig. B.36).

Figure B.36 Pivoting

In the beginning, the creeping pattern involves mainly arm movement. The
infant initially uses extension to creep backwards with scapular adduction. This
develops selective arm movement which the infant eventually uses to propel
himself forward. Gradually, with better connection between the pelvis and the
trunk, the infant uses his legs to creep (Fig. B.37).

Figure B.37 Creeping with voluntary leg movement

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 A symmetric creeping pattern is seen before complete development of
postural tone and neck and proximal dynamic stability which generates
dissociated movement of each side of the body.

SITTING WITH HAND SUPPORT

At this stage, although head development is achieved and postural tone can
be increased regarding the location and movement of the head in space, movement
of the spine and extensor muscles are not yet complete.
In other consideration, the trunk muscles are not fully developed to activate
completely with regards to the vestibular information of the head and neck. Thus,
the gluteus maximus does not develop yet. The infant still has to stabilize his
trunk using his arms and hands. Generally, this incomplete proximal development
is demonstrated by slouched or sacral sitting. Incomplete proximal activation
causes insufficient activation of 3-dimensional pelvic movement, which makes it
difficult to generate leg movements. Thus, the child’s legs still move out of midline
and with incomplete extension (Fig. B.38).

Figure B.38 Sitting with hand support

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Landau reaction
Develops at 5-6 months
Mass pattern of extension with adduction
- Mass extensor pattern develops the whole spine extensors in prone
such as the erector spinae and gluteus maximus which enhances
voluntary movement of the foot
- The pelvis is going to the right location (middle) onto both hip joint
- The legs come to and move in midline
- connection between proximals and both legs

Figure B.39 Landau reaction- extension with adduction.

Landau reaction is the stage of maximum development of head extension in

prone. This extensor pattern activity is produced by the complete development of
the vestibular system of the body in prone. The maximum development of head
extension enhances trunk extension. This provides the maximum activation of the
spinal muscles developing the dynamic spine movement. It then brings the pelvis
and legs in midline since head raise in landau sends signals to the proximal
muscles to activate.

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 Strong extensor connection of the core muscle group composed of the
trapezius, rhomboideus, erector spine, gluteus maximus, rectus femoris, biceps
femoris develops. This extensor connection of the trunk is however, not yet enough.
Maximally, it will develop when it works against the BOS such as sitting on
upright pelvis.
Moreover, although leg muscles on this stage are already connected with
the head and trunk, they still do not have enough power for standing and walking.
It will completely develop 100% when the leg takes weight on the foot.
This stage is very important in infant development as it is in this stage that
the midline alignment of the head, trunk, pelvis, and legs and the axis for postural
control are established. This stage is also the prerequisite for standing and
walking. The head, trunk, pelvis and legs are connected in midline, and most
especially, the pelvis and the joints of the legs move separately and voluntarily.
The legs positioned at the middle means that the femur, tibia, fibula and the bones
of the feet are aligned.
At 5-6 months of age, the infant shows development of a strong extensor
pattern of movement on the floor. This movement is necessary for development of
the proximal part, as well as connection from the neck to the feet. This connection,
which develops with the neural networks, will eventually make the activity
automatic. After this stage, the trunk begins to have dynamic stability for other
movement. This strong extensor movement pattern also develops coordination of
the muscle groups and strong neural networks for anti-gravity movement, which is
an important precursor for standing and walking.

SUPINE
At this stage, proximal dynamic stability is fully developed making arm
and leg movement in space possible. Of special consideration is the complete
development of the proximals allowing the head to move freely as the proximals
can now take over in stabilizing the body dynamically.

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 In supine, the infant is able to move the legs in midline with a posterior
tilted pelvis, which enhances adequate ankle movements. Development of
proximal dynamic stability allows for strong kicking and strong flexion in midline
(Fig. B.40).

Figure B.40 Connection of proximal part of the body and legs

Development of proximal dynamic stability requires activity from the

transverse and oblique abdominals and the rectus abdominis. Good activation of
the obliques allows for a variety of pelvic movement as well as an improved
breathing pattern. Because of the active movement of the legs, creeping is
gradually modified into crawling pattern. The development of proximal dynamic
stability and the leg muscles makes forward propulsion more powerful. The infant
can now creep, crawl, and play in four-point kneeling or quadruped. The infant is
able to do transition from one activity to another by himself (Fig. B.41).

Figure B.41 Development from creeping to crawling

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PRONE
The Landau reaction is a strong extension-adduction response against
gravity. Development of proximal dynamic stability allows for maintenance of the
arms and legs in space. Stronger connections are made in mass patterns such as
the flexor activity in the mother's womb and later, anti-gravity extension in
Landau. The Landau is a prerequisite for automatic extensor anti-gravity
activities, such as standing and walking (Fig. B.42).

Figure B.42 Mass pattern. Physiological flexion - Landau reaction

Up until this stage, head and trunk dynamic stability is the focus of
development. However, at this stage, the important aspects concern the
development of spine, pelvic and leg movements. This is similar to attaching the
legs of a robot to its body; like adding a new part to an already working set of
parts. In another point of view, postural dynamic stability eventually becomes an
automatic component of dynamic movement of the legs. The muscles around the
hip joint, the pelvis and the proximal part of the thighs work with the core muscles
to provide proximal dynamic stability and connection between the pelvis and legs.
This connection between the legs allows for greater variety of movement of the
pelvis and legs. Before this stage, the leg moves with the arms automatically and
passively, but at this time, the legs have greater voluntary movement. The two

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legs coming to midline due to proximal dynamic stability allows for the
selective movement of the hip, knee and ankle joints.

QUADRUPED
Within the right axis, the arm and hand develops in many postures and
movement, but it is only when weight is given on the hand that the muscles of the
arm and hand develop completely. Shoulder and arm muscles including its
extensors and rotators develop while they stabilize the body or move against the
BOS.
The most important factor for quadruped is the full pelvic construction onto
the hip joint. This leads to dynamic movements of the lumbar spine and 3-
dimensional movement of the pelvis. Because of this, dynamic locomotion and
transitional movements happen in sequence like half-kneeling, kneeling and
sitting. Complete axial rotation is not only observed in the trunk but also in the
pelvis and especially the legs (Fig. B.43).

Figure B.43 Qaudruped

The infant perceives the BOS from weight bearing on the hands with the
element of vision. Rocking in quadruped involves selective movement of the joints.

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SEGMENTAL ROLL OVER
At this stage, more selective movement of the legs can be seen as the infant
rolls over, where one leg extends as the other leg flexes over it. This is only
possible with the complete development of neck and proximal dynamic stability as
well as the diagonal movement or 3-dimensional movement of the pelvis with
spine dynamic movements. The neck and proximal stability allow for good pelvic
mobility as the neck stabilizes the body’s axis. Proximal dynamic stability allows
3-dimensional movement of the pelvis. This pelvic inclination generates
alternating activation of the legs with one leg in extension and the other leg in
flexion (Fig. B.44).

Figure B.44 Segmental rolling over

SITTING
At this stage, the infant needs the arm support because the vestibular
system and muscles around the head are not yet completely developed for upright
sitting. The infant is not yet able to activate gluteus maximus regarding to the
location of the head and thus trunk extension is also not yet developed (Fig. B.45).
Because there is still insufficient activity of the trunk in sitting, the ankles
are in dorsiflexion in order to provide more stability (Fig. B.46).

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 Figure B.45 Sitting with arm support

Figure B.46 Sitting with ankle dorsiflexion

Because of distal stability through ankle dorsiflexion, the infant is able to

use the hands in space. At times, the infant uses the hands for support. These
changing positions are preparation for protective extension in sitting.

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THIRD STAGE

Develops 7-9 month after birth

Correct sitting with upright pelvis: strong base of support in sitting/ upright pelvis
- It develops strong erector spinae muscles for connective back muscles
Development of trunk extensors: lighter arm and hand
Dynamic 3-Dimensional movement of the pelvis against base of support
Development of leg muscles through lower center of gravity in many kinds of
locomotion: crawling, kneeling, half kneeling, squatting
Increasing foot movement, somatosensation and development of toe muscles

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 In this stage, the remarkable development of the connective movement on a
strong axis enables more dynamic voluntary movement of the body.
The development of proximal dynamic stability enabled 3-dimensional
movement of the pelvis which is needed for selective movement of the lower
extremity joints to occur (Fig. B.47). The development of postural control, vision,
and cognitive function increases the child’s curiosity. This drives him to use
locomotion in order to explore the environment.

Figure B.47 Selective movement of each joint of the leg

The infant’s muscle power and speed increases due to his desire to move to
explore his environment; this also serves as preparation for future standing and
walking. To compare with the previous stages, the infant now prefers playing in
higher postures relative to the ground. This is possible because his body can
already move with good connective movement made possible by good neck and
proximal dynamic stability, which improved as a result of CNS development.
At this stage, better dynamic proximal stability does not only generate
selective extremity movement but also allows 3-dimensional pelvic movement
against BOS which is a requirement for the child’s locomotion in higher postures.

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 In quadruped, the pelvis moves dynamically in the horizontal plane onto
the hip joint. While in half kneeling, the pelvis goes to the vertical plane against
both knee joints. Half-kneeling is the first upright posture against gravity and
BOS. It provides the right location of the pelvis and development of quadriceps
and hamstring against BOS. It is in relation to 3-dimensional pelvic movement.
When the infant begins to move forward such as in walking, the first
movement is weight transfer to one side. Pelvis moves in diagonal movement with
the weight-bearing side descending to form the stability side. And once one leg
becomes stable, the other steps forward. This also happens when one assumes
standing from half-kneeling. All movements happen accidentally or coincidentally.
Dynamic spine and 3-dimensional movement of the pelvis against the BOS is the
basis of walking.
Through repetition of these movements, the muscle of the gluteus,
quadriceps and hamstring become stronger continuously. Moreover, development
of selective movements of the knee and ankle joints are a prerequisite for
combination movements, such as knee extension with ankle dorsiflexion, which is
used in walking. Proximal dynamic stability acts automatically as the pelvis and
legs are connected in movement.
At this stage, the infant already has the sensorimotor experiences of
transitioning from one position to another. This increases the power and volition of
leg movements. The infant can use the arms for either support or prehension,
which increases upper extremity muscle power and speed. The development of
trunk, pelvic, and leg control enables the infant greater anti-gravity movement
and increases the child's curiosity and motivation for locomotion and exploration.

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SUPINE
At this stage, supine is a transient posture which the infant uses as he
changes positions. With the development of proximal dynamic stability, the child
lifts his head and his legs with knees extended (Fig. B.48).

Figure B.48 Development of combination movement on the leg

This activity involves knee extension with ankle dorsiflexion in supine,

which is a practice activity for standing. When the infant flexes and extends his
legs, the legs now control pelvic movement. Before this stage, the reverse is true
(Fig. B.49).

Figure B.49 Knee extension with ankle dorsiflexion

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 When the infant goes to standing, the pelvis is pulled backward in an
anteriorly tilted position hindering it to go over the ankle. Because standing is a
high posture, activation of 3-dimensional movement of the pelvis in the vertical
plane is still really difficult. The foot is required to be strong as BOS. At this stage,
the foot is not fully developed. All muscles of the foot develop with muscle of the
ankle. Thus, toe curling occurs to counterbalance the backward pelvic movement
to maintain standing (Fig. B.50).

Figure B.50 Pelvis is pulled back and toe curling

In pelvic bridging, the infant pushes down with both feet as the pelvis goes
into extension. With weight on the feet, it is easier to push the pelvis forward.
Pelvic bridging is one activity wherein the feet control the movement of the pelvis.
Moreover, development of somatosensation on the foot generates volitional control
of the foot. Through this movement, the infant realizes about the foot as a BOS
and tries to move the foot with toe. It is basis of development of toe muscles.
Bridging, upon analysis, activates 3-dimensional movement of the pelvis
against BOS in the same pattern and movement as standing. Thus, the infant
utilizes this position as a preparation for movements necessary for standing. In
addition, this posture activates connective movement of the body (Fig. B.51).

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 Figure B.51 3-dimensional movement of the pelvis in bridging

In standing, when the infant pushes himself backwards in order to turn to

one side, the foot and ankle functions as the BOS while pelvic movement elicits
trunk extension with axial rotation. This dynamic interaction between the trunk,
pelvis, ankles and feet prepares the child for standing and walking.
When the pelvis is lowered and raised in bridging, it contributes to
development for selective movements of hip and knee joint as well as development
of toe movement. This bridging provides the development of ankle and toe
movement to be the key workers for maintaining balance with a small BOS.
Furthermore, in pelvic bridging, the toes play an essential role in the grading of
pelvic movement. This interaction of movement between the ankle and the pelvis
is established. When the toes work, there is deeper dorsiflexion which makes for
more pelvic movement. Activity from the toes therefore determines the amount of
pelvic movement. Toe movement is essential for pelvic control. In standing,
movement of the ankle with the toes is a component of good forward and backward
pelvic movement. Toe activity with ankle movement is the key in the strategy for
balance reactions in standing. If there is only ankle movement the balance
response is inadequate and weak (Fig. B.52)

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 Figure B.52 Dynamic ankle and toe movement in standing

PRONE
At this stage, the infant only stays in prone to take a break from his other
activities. As in supine, it is also a transient position.
In prone, the infant's pelvis is lowered, promoting extension of the gluteus
maximus. In the Landau reaction, the pelvis is extended with the legs. But at this
stage, the infant moves higher to quadruped which has advantages to take weight
on the distal part.
When the infant moves forward and backward or moves to side sitting or
sitting and then go back to quadruped again, 3-dimensional pelvic movement
against the BOS is activated. Precisely, this is the kind of practice with same
pattern of movement of standing and walking (Fig. B.53).

Figure B.53 Selective movement of the leg including ankle joint

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PIVOTING
This is a continuation of the development of combination movements of the
legs. Pivoting basically involves extension, but there is stronger extension of the
legs and plantarflexion or dorsiflexion of the ankles. This develops not just from
proximal dynamic stability but also from increased hip muscle strength (Fig. B.54)

Figure B.54 Strengthen the muscles with combination of leg movements

CRAWLING AND CREEPING

Enhancement of postural diagonal dynamic stability in other positions
makes creeping and crawling stronger and easier. The infant's motivation to move
faster and the more selective movement of the legs are two reasons why the infant
prefers crawling over creeping. Crawling involves 3-dimensional movement of the
pelvis against the BOS which also generates reciprocal movement of the arms and
legs. Although the infant practices a lot of axial rotation in transitioning from
supine to quadruped, the reciprocal movement becomes the child's patterns when
diagonal dynamic stability is developed (Fig. B.55). When the infant crawls, strong
muscles of the arm, legs and feet activate vertical transference to go to bear
position and walking on the ground.

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 Figure B.55 Development of axial rotation for transitioning from supine to quadruped

KNEELING AND HALF-KNEELING

Taking weight on the knee is a shorter lever arm than taking weight on the
ankle and foot. Thus, kneeling is a prerequisite activity for standing where the
child experiences taking weight on the distal part of the body as BOS. When the
knees flex, selective ankle movement with hip extension occurs. This ankle
mobility increases pelvic and foot movement making kneeling a good activity to
practice 3-dimensional movement of the pelvis against BOS. Also, toe activity
enhances dorsiflexion of the ankle, and vice versa.
In kneeling it is easier to bring the pelvis forward, as compared to standing
which imposes challenges to higher anti-gravity extension. Half-kneeling is a
component of the movement of transition to standing. Half-kneeling is a good
position to develop dynamic stability of the hip joint and foot. Before this stage, hip
joint stability is developed in creeping, crawling, quadruped, and transition
activities that involve axial rotation. All these make the foot at midline possible in
half-kneeling. In turn, half kneeling with dynamic hip joint and foot stability
enhances activities in creeping, crawling, quadruped, and movement transitions
(Fig. B.56).

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Figure B.56 Development of kneeling and half kneeling

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FOURTH STAGE
Last mission of connection of extensors to the base of support in standing
Dynamic 3-dimensional pelvic movement on the calcaneal bone in standing:
dissociation of both legs
Strong leg with the foot
Development of toe muscles with the ankle
Complete somatosensation of the foot

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The Foot
Compared with other skills, the infant takes longer to achieve independent
standing and walking at this stage. This is especially because the ability to
maintain the head within the axis over a small foot as a BOS is not yet developed
completely. In other words, the connection of the erect muscles of trunk and lower
extremity appropriately activating altogether in the same axis against the BOS is
not yet developed even if the infant had already developed neck and proximal
dynamic stability, dynamic movement of the spine and 3-dimensional pelvic
movements with or without BOS. It is still difficult because of his weak foot. This
is why the child stands with arm support in the beginning (Fig. B.57).

Figure B.57 Standing with hand support

At this stage, the infant attempts to stand and walk using mass patterns in
the effort to connect all parts of the body. In upright posture, it is difficult to put
all parts of the body onto the weak foot and to maintain balance with weak ankle
movement. Thus, all upper extremities go higher to maintain balance instead of
ankle movement. The arm posturing is also necessary to increase postural tone in
order to maintain standing on a weak and small foot.

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 Examples of mass patterns employed by the infant are strong adduction of
scapulae and tiptoe gait to get more extension. When the infant begins to walk
using mass patterns, he transfers weight of the pelvis forward on tip toe instead of
using dynamic ankle strategy.

Figure B.58 Mass pattern in Standing

On the other hand, ankle and toe movements help the pelvis move forward
when it is displaced in standing. In the beginning of standing, it is difficult to
maintain upright posture because of weak toe muscles. Therefore, there is toe
curling until taking weight on the feet becomes successful. Toe muscles act
initially for distal dynamic stability and eventually become a component of
responses to maintain balance in standing. (Fig. B.59) Toe muscles develop and
work together with 90-degree location of the ankle.

Figure B.59 Ankle and toe movement in standing.

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 Most important development for bone growth and joint mobility of the foot
is the completion of the foot arch. It is composed of 3-point weight bearing areas.
The most important of the 3-point BOS is the calcaneus. (Fig. B.60)

Figure B.60 standing on foot (focus on calcaneus)

The Calcaneus
When we stand with 100% of postural tone, we take weight on the foot. 60%
of the weight borne by the calcaneus is in the talocalcaneal joint. (Cavanagh, 1987)
When we walk, the pelvis moves dynamically onto the spot where the calcaneus
receives the weight.
On 90 degrees of ankle joint, it is possible to push the calcaneus more into a
deeper dorsiflexion. It generates stronger activation of extension of the leg. The
calcaneus is mobile upward and downward, and side to side during weight
transference in standing or walking. This contributes in the activation of muscles
of the leg. The muscle tone is made higher through a final range of pushing
movement or downward movement of the calcaneus, which is the same movement
of pushing against ground. Proper size of the calcaneus in relation to age is the
basis of the arch of the foot. (Carreiro, 2009) It moves dynamically depending on
the displacement of the body.

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SITTING
The infant prefers to play in the sitting position than in the previous
stages. Development of postural tone and muscles of erector spinae and gluteus
maximus enhances upright pelvis. The upright pelvis is generated by the gluteus
maximus through activation of the vestibular connection from the head. Strong
neural connection assists to maintain the head in the space automatically. Good
information of the head activates upright pelvis and erector spinae completely, a
normal sequence of sitting.
Stable trunk extension on an upright pelvis and legs all provide the needed
support to allow free arm use in space. Therefore, the child can sit for long periods
of time without the need of hands for support.
Proximal dynamic stability and 3-dimensional pelvic movements against
the leg in sitting also permit different movements of the hips and legs. Full
development of the hip joint, which is a ball and socket joint, is made possible by
the variety of movement of the hips and legs in many different sitting positions.
(Fig. B.61)

Figure B.61 Dynamic sitting posture

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LONG SITTING
At this stage, long sitting is possible because the upright pelvis puts the
legs in the middle axis with proper muscle activity. Also, side to side dynamic 3-
dimensional pelvic movement is possible. This generates dissociated movement on
each side of the body with leg. Thus, like a transient posture, the infant is able to
stay or move to other postures easier. The child changes positions dynamically and
in the process, he may fall. And when the child falls towards different directions,
this develops protective extension sideward and backward. (Fig. B.62)

Figure B.62 Long sitting and development of protective extension

STAIR CLIMBING
Because of development of cognition, vision, visual perception, and body
scheme, the infant can determine the height and width of a step. With appropriate
postural tone and dynamic 3-dimensional pelvic movement, reciprocal dissociated
movement of the leg is enhanced. The child enjoys ascending and descending stairs
with this increased ability and curiosity. Initially, climbing up is difficult because
movement is not yet selective, but with practice, the infant performs it with more
selective movement of the arms and legs. (Fig. B.63)

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 Figure B.63 Stair climbing

BEAR STANDING AND BEAR WALKING

Before the child learns how to use toe and ankle strategies and before
achieving appropriate postural tone and proximal dynamic stability against BOS
in standing, he first performs bear standing with full extension of the extremities,
resembling a mass pattern. This position does not require dynamic 3-dimensonal
movement of pelvis against the ankles and feet but is only a practice activity for
taking weight on the feet accompanied with strong leg extension. As the infant
feels stable with his feet, he starts to step forward with his arms. (Fig. B.64)

Figure B.64 Bear standing and walking

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SQUATTING
While cruising or bear walking, the infant may then try to sit down in the
squatting position and try to stand up again. This component requires graded
movement of the legs within an adequate axis and it develops mobile weight-
bearing of the ankle and toe in walking. Moreover, it enables the tibia to move
forward over the foot which develops mobile weight transfer of the foot in walking.
(Fig. B.65)

Figure B.65 Squatting

STANDING
A child who stands for the first time exhibits insufficient postural tone
because of their difficulty to activate good head movement in the higher position
(increase in height). It demands the child to maintain the whole body within the
same axis.
Also, the infant is faced with the most difficult task of taking weight on the
small BOS provided by the foot. The foot is not yet developed as a BOS because of
the weak muscles of the ankles and toes. The BOS of standing requires stable foot.
Although it is small, it must be strong enough to take the weight of the body. It
needs higher and stronger muscle activation.

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 Before this stage of developing mobile distal stability on the feet, the child
takes weight on the hands and knees such as in quadruped and kneeling. These
are all practice activities where mobile distal stability is developed, which
eventually is transferred to walking. (Fig. B.66)

Figure B.66 Mobile distal stability with 3-D movement of the pelvis

Before going into standing, the child goes into bear walking. This is because
standing requires pelvic extension and mobile dynamic stability of the ankle and
foot. Strong toe muscles have to bear the body weight independently. Also, the
child should have sufficient proximal dynamic stability to allow standing upon a
small BOS, the foot. It causes the child to resort to using the hands for support.
This is the reason why children who are newly practicing their standing exhibit
high guarding position of the hands.
During standing with support, the child practices neck and proximal
dynamic stability as well as dynamic pelvic movement against a small foot while
the body is aligned at the midline. This initial attempt of standing is essentially
similar to bear walking where the child demonstrates good trunk extension that is
aligned with the pelvis. (Fig. B.67)

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 Figure B.67 Start to stand with hand support

When they begin to stand, the mass pattern used by the child is useful in
connecting all the parts of the body and in making aligned axis of all parts. With
development of good proximal dynamic stability of the trunk and 3-dimensional
movement of the pelvis against BOS, selective leg movement and adequate
extension of the trunk and the whole body with the axis occur. Toe and ankle
activity contribute to dynamic distal stability and eventually balance reactions
develop and the child stands by himself. (Fig. B.68)

Figure B.68 Standing with toe curling at 90 degree of the ankle

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 As described before, the high guard posture is a picture of the mass pattern
to get higher postural tone for adaptation of higher height and maintaining the
head. But also, the head and trunk works to maintain balance of the whole body
instead of the weak ankle joint, (Fig. B.69) because we generally use ankle
strategy to maintain balance in standing.

Figure B.69 Standing and Walking with High Guard

CRUISING
Generally, the infant starts to stand while supporting on the furniture or
wall because of difficulties still to maintain the axis from the head to bottom
against gravity. Standing on the feet is an especially most difficult activity for the
infant. The feet are not yet stable and mobile to maintain the axis.
In order to make a step, it requires not only to maintain the axis on a small
BOS but also dynamic 3-dimensional pelvic movement against the feet. It is really
difficult for the infant at the beginning of walking. Thus, the infant holds the
posture by using the arm and hand and then start to make a step sideways which
does not require dynamic 3-dimensional pelvic movement. It generates steps by
abduction and adduction of the hip without pelvic movement. (Fig. B.70)

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 Figure B.70 Cruising

WALKING
Walking is the highlight of achievement for postural control such as head in
the correct axis which leads to sufficient postural tone and proximal activation,
and dynamic 3-dimensional pelvic and leg movements on the feet. All these
movements are activated automatically.
In the early stage of walking, if the infant is incapable of maintaining the
head, neck and proximals on the feet with sufficient postural tone, the infant
presents with raising of the arm higher and tip toeing utilizing mass pattern to
move against gravity. Gradually, there is adaptation to the highest posture
against gravity and development of movement and dynamic displacement against
the small feet. Thereafter, the infant starts to walk.
The most important consideration is diagonal movement of the pelvis with
a clear distinct role of stability and mobility. If the pelvis moves out of axis, the
pelvis does not participate in the lower extremity movement.
Many children with cerebral palsy walk with anterior tilted pelvis. They
walk without movement of the pelvis, thus, walking with undissociated movement
of the legs.

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 At this stage, the infant recognizes the function of the feet due to the
development of the brain. The infant moves the ankles and toes in the same way
as voluntary control of the hand. Thus, the infant is able to control walking using
strategies for step length or width regarding to environment. (Fig. B.71)

Figure B.71 Walking

CITED REFERENCES:
Aucott S., D. P. (2002). Neurodevelopmental care in NICU. Mental Retardaion and Developmental
Disabilities Research Reviews.
Carreiro, J. E. (2009). Pediatric Manual Medicine. Churchill Livingston: Elsevier Ltd.
Cavanagh, P.R., Rodgers, M.M., Iiboshi, A. (1987). Pressure distribution under symptom-free feet during
barefoot standing. Foot Ankle, 262. In: Shumway-Cook A., Wollacott M.H. (2001). Motor Control:
theory and practical applications. 2nd Ed. Philadelphia: Lippincott Williams & Wilkins.
McCrea, David A., Rybak, Ilya A. Organization of mammalian locomotor rhythm and pattern generation :
Brain Res Rev.2008 January ; 57(1): 134-146.
Stiles J., a. J. (2010). The Basics of Brain Development. Neuropsychology Review.

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POSTURAL TONE AND AXIS
The Eye
The Neck
The Spine
The Pelvis
The Leg

CORTICAL LEVEL OF MOVEMENT

The Foot
The Hand
Watching
TREATMENT IDEAS FROM BASIS OF
HUMAN MOVEMENT

In order to treat children with cerebral palsy correctly, medical professionals

should understand normal development in relation to normal movement of humans.
Thereafter, you are able to distinguish the gaps between normal and abnormal
movements of children.
Although there are a lot of problems in children with cerebral palsy, we can
group them into three common components which are based on human movement,
namely:
1. Different postural tone
-Hypertonus, hypotonus, low muscle tone from altered axis
2. Altered (changed) axis
-Axis of the eye, neck, extremities with scapula and pelvis, hand and
foot, specifically calcaneus
3. Limited or no cortical level of movement
-Purposeful movement for function
-Watching, hand manipulation, adjustment of the foot
-Rolling over, sitting up, transitions, locomotion, standing and
walking
If you pay attention to these three components when you treat, it is easy to
figure out the gaps of the abnormal pictures of children with cerebral palsy from the
normal pattern of human movement.
For example, when a medical professional treats a child with spastic diplegia
by making them stand and walk without considering the low postural tone and the
altered axis with immobile ankles and toes, the medical professional makes the
child’s movement problems worse. In this case, the child will only stand and walk
using only 40-50% of muscle activity in the body and the child will not use his foot
volitionally.
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 If the three components are considered during assessment, the child with
prematurity will show low postural tone with altered axis of the eye, neck and
body with or without hypertonus on the distal part of the body. The low postural
tone is linked with low muscle tone and movements of the eyes, face and neck.
These are standpoints of postural tone of the body. The low muscle tone also
directly correlates to low alertness level.
Thus, we may surmise that along with prematurity, there is immature
development of the brain particularly the cranial nerves which innervate the eye,
face and neck region. The cranial nerves start to develop in the early fetal stage
just as the motor and sensory channels develop.
In order to increase alertness and postural tone, the first thing that we
consider is building up the normal muscle tone and activation with the right axis
of the eye and face muscles including the body and foot. Through this, we can
improve capital flexion and the connection of the neck elongation and activation to
the dynamic movement of the spine.
This chapter presents the adjustment of axis with postural tone build-up
and the importance of activating the muscles of the eye and face together with the
neck in the initial phase of treatment. The chapter will describe how to change the
biomechanical problems from analysis and proper execution of movement namely:
(1) activation of postural tone by neutralization of vestibular system and building
up of neck muscle tone with capital flexion, (2) connective movements of the spine
with capital flexion, (3) scapular movement on the right axis with thoracic spine,
(4) arm movement with correct axis of the scapula and (5) 3-dimensional pelvic
movement with lumbar spine. The scapular and pelvic movement is necessary for
the voluntary movement of the hand and foot which will be the bases for functional
human movement.
Moreover, the chapter will describe how to recover the muscle tone and
movements of the leg within the right axis, how to facilitate the movements of the
pelvis from the hip to foot, and how to the build-up the muscle tone and movement
of the ankle and toe through the right axis of the tibia and fibular bone.
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 The activation of the foot in terms of sensory stimulation within the correct
axis of joints and muscles of the toe will be emphasized specifically. The
characteristic of the foot as highly sensitive in terms of somatosensation will be
utilized in the strategies of treatment. Sensory information can be given such as
displacement and pressure on specific parts as to build the idea of the foot BOS.
All of these are basis of functional movement. The medical professionals
should emphasize on these to improve the child’s own function especially in the
cortical level of movement. All of these should be targeted during treatment by
adjusting and activating the three components: postural tone, right axis, and
cortical level of movement.
This chapter shows the process of treatment to activate the basis of human
movement regarding to these three components. The frequency of better quality
movements of the child enables them to move more normally. This enhances
reduction of hypertonus, contractures and deformities.

POSTURAL TONE AND AXIS

Postural tone and axis are deeply linked and influence each other. It is
difficult to separate these two components in normal movement and in the
strategy of treatment.

THE EYE
We cannot facilitate eye movement directly. However, we can control and
build up specific eye muscles through its connection to the face muscles. The
easiest to activate is the frontalis muscle for opening and closing of the eyes (Fig.
C.1).

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 Figure C.1 Activation of eye movement with Frontalis

The first target of treatment is to bring the eye to the correct axis. The eye
muscles can be adjusted through the face muscles by adjusting the position of the
head with the neck in the right axis.
In the case of a child showing a different axis on one eye, this different axis
can lead to monocular vision. An effective treatment strategy is to cover the
predominant eye with an eye patch to train the other eye. If the axis is regained,
gradually encourage the use of two eyes for watching.
Bringing the eyes to the right axis or in the middle is the most important
first target. If it is located out of axis, eye muscles weaken resulting to increased
alteration of the neck axis. The second target of treatment is to build up muscle
tone and movement of the eye.
If the cognition of the child is normal, the therapist may give resistance to
the facial muscle opposite the direction of the weak ocular muscle while the child
keeps watching a target. In this way, the muscle tone of the eye builds up.
(Fig. C.2)
As mentioned previously, the muscle tone of the eye and face is the basis of
postural tone and level of alertness of human.

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Figure C.2 Building-up muscle tone of the eye by resistive exercise of face muscles

1. Activate all face muscles with capital flexion

- Activation or stimulation of face muscles moves and activates
movements of the eye. It also increases the level of alertness. (Fig.
C.3).

Figure C.3 Stimulation of face muscles

- Capital flexion generates connective maximum power of movement
from the eye, face, neck and proximal part of the body. Thus, it
basically increases muscle tone of the face.
2. Right axis of the eye
3. Activate eye movement with face muscles
4. Build up muscle tone of the eye by resistance

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THE NECK

Children with spastic quadriplegia and dystonic athetosis who present with
typical hypertonic pattern exhibit an extremely hyperextended and asymmetric
posture (Fig. C.4).

Figure C.4 Typical hypertonic pattern of children with cerebral palsy

There is an efficient way of reducing the hypertonus of these children.

First, correct the altered axis of the eye and neck, then release the higher muscle
tone of the eye, face and neck gently. The higher muscle activity of the eyes and/ or
neck is a standpoint in human as it influences all part of the body to go to
hypertonic pattern.
There is hyperlordosis of the cervical spine when the neck is
hyperextended. This is common with premature children with spastic diplegia. In
this posture, upon palpation, there is a seeming disappearance of the C7 spinous
process, sternocleidomastoid and upper trapezius, and stiffness around the C1-C2
segment. Because of this, the spinal rotation from cervical to thoracic to lumbar
spine cannot happen. Cervical spine movement is not connected with the other
spinal segments.

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 The therapist should next change the altered axis of the eye and neck then
build up the muscle tone of the neck. Connective spine movement through the
right axis of capital flexion should also be targeted.

CAPITAL FLEXION OF THE NECK

Capital flexion is accomplished by activity from two muscle groups, the
anterior group composed of the longitudinal oblique, superior and inferior longus
colli and lateral group composed of the rectus capitis anterior, posterior major,
rectus capitis lateralis. Initially, the anterior group pulls down the chin. In
continuation, the lateral group pushes the suboccipital part up which results to
upright and locking movement of the head and spine. The action of the lateral
group increases muscle tone of the neck and its connection with the whole spine.
This generates increase in postural tone. Therefore, it is quite important to
establish normal movement for capital flexion, especially its lateral group.

Supine with posteriorly tilted pelvis

The therapist must change the posture and bring the arm, body and head
towards the middle.
In the beginning of treatment, the therapist should encourage watching
through utilizing entertaining visual targets to develop voluntary stabilization of
the axis. This is the most important strategy of treatment because intentional
watching is the best stabilizer of the neck while the therapist handles the head
and neck (Fig. C.5).

Figure C.5 Preliminary posture for capital flexion

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1. Lowering eyes with mobilization of pulled face muscles

- First, mobilize the scalp by lowering it. Then mobilize the face by pulling
downwards. This activates the eyes to go downward (Fig. C.6)

Figure C.6 Full range of capital flexion with lowering of eyes

- Encourage mouth closing to activate nasal breathing (Fig. C.7)

Figure C.7 Deep nasal breathing with mouth closed

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2. Lowering rib cage with downward rotation of clavicle

- Clavicle is elevated with upward rotation whenever the rib cage is high
(Fig. C.8)

Figure C.8 Downward rotation of clavicle and ribcage

- Downwardly move the rib cage with flexion of thoracic spine. If there is no
capital flexion, it will not be possible (Fig. C.9)

Figure C.9 Ribcage movement with flexion of thoracic spine

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- Also mobilize both shoulders. If there is a strong protraction and internal
rotation of the shoulder, the rib cage is unable to move (Fig. C.10)

Figure C.10 Shoulder mobilization

- Flexion of the neck and proximal generates connective flexor movement.

This requires lowering the rib cage, posterior tilting the pelvis and flexing
the leg with dorsiflexion in the middle (Fig. C.11)

Figure C.11 Connective flexor movement

- Pay more attention in bringing the rib cage downward and mobilizing it.

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3. Gently palpate and mobilize C1-C2 segment which should move like a
compass (Fig. C.12)

Figure C.12 Mobilization of C1-C2

4. It is important to consider the head and the two eyes in the middle which
signifies the intact function of the vestibular system. The therapist must
first check the function of the vestibulooccular reflex (VOR) because real
midline involves the eyes positioned in the middle. Then use this to
facilitate head movement. The therapist must assess the movement of the
eyes while eliciting the VOR (Fig. C.13)

Figure C.13 Building up VOR for right axis of the head

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5. The eye always moves towards the side with higher tone. Slow rotation of
the head activates two eyes in the middle. Therapist must not only bring
the eyes towards the other side but should facilitate movement freely in
all directions. This will change the axis of the eye and activate eye
movement.

6. Try to lengthen the back of the neck until capital flexion of the neck is
achieved (Fig. C.14)

Figure C.14 Neck Elongation

7. If it is difficult to achieve capital flexion of the neck because of

hyperlordosis of the neck, hold both sides of the neck, then gently move it
downward (Fig. C.15)

Figure C.15 Downward movement of both sides of the neck

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8. Increase movements such as nasal breathing, watching the hand and
touching the face
- First, activate connective rotation of the cervical and thoracic spine. The
therapist must stabilize the neck with capital flexion, then rotate the head
to the side until the end of range of cervical spine and then rotate the neck
more. The thoracic spine will automatically follow because it is the
natural connective movement between cervical and thoracic spines (Fig.
C.16)

Figure C.16 Connective movement between cervical and thoracic spines

9. Rotate the head to one side and give resistance when the therapist asks
the child to rotate the head. This builds up the neck muscles with capital
flexors through isometric exercise of neck, eyes and face muscles (Fig. C.17)

Figure C.17 Isometric exercise of neck, eyes, and face muscles

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Sitting
Sitting is the same flexed posture as in supine with a posteriorly tilted
pelvis used to achieve capital flexion. In the case of younger children, the therapist
may start treatment on the therapist’s lap (Fig. C.18)

Figure C.18 Flexed posture on therapist’s lap

There are many advantages of sitting with flexed neck, trunk and
posteriorly tilted pelvis. This is the flexed posture in supine but with involvement
of gravity. Nonetheless, it is easier to mobilize and achieve capital flexion with
gravity.

1. The therapist elongates head and all the back side of the trunk. Mobilize
C1-C2 segments to reduce lordosis of the cervical spine (Fig. C.19)

Figure C.19 C1-C2 mobilization to reduce cervical spine lordosis

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As mentioned before, the therapist should assess the location of the C7
spinous process. If lordosis of cervical spine has reduced, the therapist is
able to touch it clearly.

2. In this posture, it is also easier to make connective rotation of the spine.

(Fig. C.20)

Figure C.20 Spinal mobilization towards rotation

3. To mobilize the pelvis side to side or forward/backward, the therapist

should stabilize the neck. (Fig. C.21) This is to awaken the sleeping gluteus
maximus, which is the basis of upright pelvis.

Figure C.21 Pelvic mobilization in sitting

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 4. The therapist activates rotation of the head with rotation of the spine.
- Diagonal movement of the pelvis may be achieved through direct activation
of one side of gluteus maximus. If one side of gluteus maximus is
stimulated, this would cause rotation of the spine (Fig. C.22)

Figure C.22 Rotation of the spine influenced by diagonal movement of the pelvis

Aid of capital flexion

If the child shows low postural tone because of low muscle tone and poor
capital flexion of the neck, it is called collapsed neck. The child has difficulty
maintaining upright cervical spine against gravity. In order to prevent the child
from low postural tone and low alertness level, put the neck brace to maintain
upright cervical spine and capital flexion of the neck (Fig. C.23)

Figure C.23 Use of neck brace for upright cervical spine

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THE SPINE
The spine is part of the proximals. It maintains the posture by regulating
the muscle tone of the proximal muscles for the overall balanced postural tone. It
also serves as support to the head and a bridge between the upper and lower parts
of the body in general.
The most important consideration is the erector muscles of the spine. It
functions connectively as antigravity extensors of the trunk during sitting and
standing. If one part of the spinal muscles especially the cervical to thoracic does
not connect, all erector muscles do not work effectively.
In all children with cerebral palsy, the spine is stiff. There is no dynamic
and connective movement because there is weak or no capital flexion. If the spine
is inactive, it means that there is an altered axis on the neck and upper trunk
areas. If there is no dynamic movement of the spine, the muscle tone of each part
of the body becomes low. Thus, enough postural tone cannot be generated.

Creeping posture in prone

To activate more diagonal inclination of the pelvis, the legs should move
separately in flexion and extension (Fig. C.24)

Figure C.24 Diagonal inclination of the pelvis

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This posture has a lot of advantages to adjust and activate normal movements.

1. Easy to get capital flexion (Fig. C.25)

Figure C.25 Capital Flexion in creeping posture

2. Mobilization of the spine to get extension and rotation (Fig. C.26)

Figure C.26 Spinal mobilization towards extension and rotation

3. Easy to get connective movement of the spine (Fig. C.27)

Figure C.27 Connective movement of the spine

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4. Easy to get movement of scapular with thoracic rotation (Fig. C.28)

Figure C.28 Scapular movement with thoracic rotation

5. Easy to get movement of pelvis with lumbar spine (Fig. C.29)

Figure C.29 Pelvic movement with lumbar spine

6. 3-dimensional pelvic movement (Fig. C.30)

Figure C.30 3D Pelvic Movement

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7. Adjustment of altered axis of arm as well as restoration of muscle tone in
the extremities (Fig. C.31)

Figure C.31 Restoration of muscle tone in the extremities

8. Easy to get extension of the knee joint, specifically, rotation of the knee
joint (Fig. C.32)

Figure C.32 Extension and rotation of the knee joint

9. Easy to activate ankle dorsiflexion and flexion of toe muscles in flexed leg
(Fig. C.33)

Figure C.33 Ankle dorsiflexion and flexion of toe muscles in flexed leg

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 10. Activate toe muscles with adjustment of tibia and fibular axis (Fig. C.34)

Figure C.34 Toe muscle activation by adjusting tibia and fibular axis

To activate automatic segmental rotation of the body, rotate each spinous

process of the thoracic spine on the same axis as the cervical spine. Then rotate
the pelvis within the same axis. It activates not only rotation of spine but also
scapular movements such as abduction and external rotation of the same side
while adduction and internal rotation of the other side. Connective spinal
movement activates variety of arm and leg movements.
Any of these postures: turning the head, rotating the spine, making 3-
dimensional movement of the pelvis or putting one leg flexion with ankle
dorsiflexion with the opposite leg in extension, generates head turning with trunk
rotation and 3-dimensional movement of the pelvis. These are all normal postural
control of the body.

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Sidelying
Sidelying is a good posture to separate the mobility and the stability side
through diagonal 3-dimensional movement of the pelvis. The lower side is the
stability side. The strength of this posture depends on the degree of diagonal
movement of the pelvis.

There are many advantages of this posture.

a. Increasing muscle tone of the neck
b. Easy to get downward movement of shoulder and rib cage on the upper
side
c. Bring the scapula on right axis and movement of the scapula with
thoracic spine
d. Easy to mobilize the spine with adduction of the scapula
e. Change altered axis of the arm, specifically, biceps brachii. This
muscle contributes to shoulder internal rotation rather than elbow
flexion and supination when it is in an altered axis with the shoulder.

1. Pull the shoulder downward and just press further until there is a space
for the glenoid fossa (Fig. C.35)

Figure C.35 Downward pulling of the shoulder

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2. Bring the arm to the middle and change the axis of the biceps brachii,
externally rotate this muscle (Fig. C.36)

Figure C.36 Changing the axis of the biceps brachii

3. Bring the arm backward and put the scapula into adduction and
downward rotation (Fig. C.37) If it does not go downward, press the inferior
angle of the scapula to get adduction and downward rotation

Figure C.37 Scapular adduction and downward rotation

4. When the scapula can stay in the full range of adduction, mobilize the
spinous process of the entire thoracic spine to get extension with rotation
(Fig. C.38)

Figure C.38 Extension with rotation of the entire thoracic spine

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Sitting
Sitting with upright pelvis is an important posture to develop the extensors
of the trunk. It connects the extensors from the neck to the pelvis.
The upright pelvis stimulates connection of the vestibular system from the
head to the gluteus maximus. It helps to strongly maintain the posture on the
same line of the head in sitting. It also contributes in maintaining the pelvis on
the same line of the head in standing and walking. When the head goes up, the
pelvis goes upright automatically and then the trunk goes into extension.
Many children sit on the sacrum because of weak neck, weak gluteus
maximus and erector spinae muscles and because of stiff spine.

1. If the child is not able to sit, the therapist places the child in propped
sitting to get more extension of the spine (Fig. C.39)

Figure C.39 Sitting with upright pelvis and extension of the spine

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2. Try to make an upright pelvis within midline. If it is difficult because of
the small size of the gluteus maximus, put a thin layer of towel under the
pelvis (Fig. C.40)

Figure C.40 Supported pelvis with thin layer of towel

3. If the child leans forward, it is easy to get extension of the spine. Mobilize
the pelvis side to side to get diagonal movement of the pelvis (Fig. C.41)

Figure.C.41 Diagonal movement of pelvis

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4. If the therapist gets 3-dimensional pelvic movement with upright pelvis,
it is easy to weight transfer to one side. Facilitate stability and mobility on
each side of the body which is an important movement for walking (Fig.
C.42)

Figure.C.42 Transferring weight to one side with upright pelvis

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Sidesitting
It requires dynamic spine mobility and 3-dimensional movement of the
pelvis.
1. The therapist makes a diagonal movement of the pelvis for transferring
weight to one side. Rotate thoracic spine and then lumbar spine towards
the table (Fig. C.43)

Figure C.43 Rotation of thoracic and lumbar spines

2. In this posture, it is easy to make scapular movement and pelvis 3-

dimensional movement (Fig. C.44)

Figure D.44 Scapular and 3D pelvic movement

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 3. Through this posture and rotation of the spine, activate extension of the
spine (Fig. C.45)

Figure C.45 Extension of the spine

Scapular, arm and hand axis

When the scapula moves in the right axis with the thoracic spine, adjust
the altered axis of the arm one by one.

1. When the therapist gets the right axis of the scapula and glenohumeral
dissociation, bring the arm forward like in prone on elbow. This is the
right construction of the shoulder joint and arm. (Fig. C.46)

Figure C.46 Construction of the shoulder joint and arm

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2. When the therapist changes the altered axis of biceps brachii, there must
be a clear change in the muscle tone and muscle bulk. (Fig. C.47)

Figure C.47 Changing the axis of the biceps brachii

3. Encourage end-range elbow extension with the forearm in supination.

This can be termed as double lock of the elbow joint which indicates the
right axis of the muscles and joint. Then, activate movement of the
brachioradialis which generates supination of the hand (Fig. C.48).

Figure C.48 Brachioradialis activation with double locking of elbow

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4. Bring the arm in neutral rotation which enhances neutral position of the wrist.
Mobilize the wrist for extension of the hand (Fig. C.49)

Figure C.49 Extension of the hand

5. Mobilize the fingers with the wrist to reduce proximal contraction and stiffness
of the adductors and internal rotators of the shoulders.

6. When the forearm is in the right axis of joints and muscles, the therapist
should check for the restoration of muscle tone and muscle bulk. This is the
outcome when the muscles are in the right axis. (Fig. C.50)

Figure C.50 Restoration of the muscle tone and bulk of the forearm

7. Another important treatment idea is increasing somatosensation of the

hand. The therapist should change the altered axis of the arm and hand.
When the muscle and joint are in the right axis, the sensory information is
conducted at a faster velocity.
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8. Bring the arms forward and activate movement of the arm by having the
child hold a bar (Fig. C.51)

Figure C.51 Activation of the movement of the arm

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THE PELVIS
At any posture and locomotion, 3-dimensional pelvic movements generate
automatic reciprocal movement of the leg. Also, the pelvis has separate and
different roles on each side: stability and mobility. It is required in walking, which
includes additional movements: diagonal and posterior tilting. Thus, it is named,
3-dimensional movements.
In the case of children with spastic diplegia, the pelvis is out of axis,
anteriorly tilted and has almost limited movement. This is because of an
adducted, internally rotated hip joint that is possibly subluxated or dislocated and
presents with hypertonus.
In order to get dynamic 3-dimensional pelvic movements, the therapist has
to get the right axis of the pelvis and hip joints with the pelvis in neutral rotation
or in the middle. This recovery of the pelvic axis can best be achieved in prone.

1. In prone, the therapist bends both knee joint while putting both legs in
midline (Fig. C.52)

Figure C.52 Putting legs in midline

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2. The therapist touches the great trochanter of both sides. These are
elevated because of adduction and internal rotation of the hip joints (Fig.
C.53)

Figure C.53 Elevated Greater Trochanter

3. The therapist presses both sides of the greater trochanter until the pelvis
touches the surface. (Fig. C.53)

Figure C.53 Elevated Greater Trochanter

4. If the therapist is confident he has already placed the pelvis and the leg
in the right location, the therapist can start diagonally moving the pelvis
side to side or with rotation (Fig. C.54). Many children with cerebral palsy,
whether spastic diplegia or hemiplegia, walk without movement of the
pelvis. For instance, at the moment of weight transfer to one side, the
diagonal movement does not come to generate stability on that side and
allow the opposite side to step forward.

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 Figure C.54 Diagonal side to side movement of the pelvis with rotation

THE LEG
The ability of the child to completely move the leg by himself depends on
the muscle tone of the legs and the pelvic and spine mobility. It is also affected by
the postural tone and the presence of capital flexion.
In the case of the child presenting low muscle tone and small muscle bulk
on quadriceps with bigger adductors of hip joint or hypertonus, poor or no
voluntary foot movement can be observed. At this altered axis, the quadriceps
work for adduction rather than extension of the knee joint.
In treatment, the therapist should build up muscles of the neck by capital
flexion, activate movement of the spine and 3-dimensional pelvic movements.
Thereafter, adjust the altered axis of quadriceps. Also, with any muscles of the
body, the therapist should be certain in recovering the altered axis before
increasing the muscle tone and muscle bulk.
After recovery, the child gradually recognizes the activation of quadriceps.
If there is a great feedback from somatosensory channels, the child will start
moving the leg by himself.

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CORTICAL LEVEL OF MOVEMENT

THE FOOT
The foot moves with the ankle joint and the muscles of the ankle and toes
altogether. When they work together, the foot can be moved with intentional
cortical level of control necessary for adjustment and strategies used in walking.
If the therapist tries to activate the foot, he should consider the postural
tone from the head which implies muscle tone of the eye and neck including
capital flexion in the beginning of treatment. Moreover, the therapist should
consider 3-dimensional pelvic movements with movement of the spine and the
right axis of leg muscles around the hip joints. Thereafter, adjust the axis of tibia
and fibula to connect with the muscles of the ankles and toes. Furthermore, the
therapist should pay attention to activate the foot with ankle movement. The foot
should move in the right axis with the calcaneus in the right axis, size and
mobility because all flexors of toe muscle pass through it.

SOMATOSENSATION OF THE FOOT

The foot is an important part for the cortical level of movement or
voluntary control for standing and walking. It serves as a strong BOS for dynamic
walking and running of human movements. But many of children with cerebral
palsy are not able to move and control the foot due to various reasons. Many of the
medical professionals are aware of this but ignore how the foot is important for
human movement.
In human movement, the ankle and the foot start to move after birth to
protect the head in space because the neural network of the vestibular system and
muscles of the eye and neck have not yet completely developed. The ankle and the
foot always move and react to protect the head. These automatic movements of the
ankle and foot only disappear when the head and the trunk move completely

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upright in sitting. Thus, if there is no movement of the foot with the ankle, the
child will present with weak capital flexion and weak postural tone of the body.
In cases of children with severe spastic quadriplegia who present with
hypertonic extensor pattern where the eye and head rotate to one side, their body
follows the asymmetrical line, by fixing the posture through hypertonus in the
hand and foot. The foot contributes to the locking of this asymmetrical hypertonic
posture and movements.
The picture of the foot in the case of spastic quadriplega and diplegia
typically relates to the asymmetric anterior tilted pelvis and adduction and
internal rotation of the hip joint. This is because of hypertonus on adductor and
internal rotators. The internal rotation of the tibia and fibula finally invert and
plantar flex the ankle with the foot and toes flexed.
All the joints are rotated inside. The foot contributes to this rotation and
this inverted foot collaborates with strong adductor and internal rotator of the hip
joint. The foot is the strongest locker of this posture and the tonic pattern of
movement. In order to reduce hypertonus of the hip joint, release the foot or
activate voluntary movement of the foot. That is why the activation of the foot is
the most important task for treatment of children with cerebral palsy.
In the treatment of the foot, there is a great advantage of the foot in the
aspect of structure. It is the part of the body used for stable BOS that has the
higher somatosensory information. The foot sends huge sensory information on
displacement of the body without help from the major sensory organ, vision. The
foot is designed to have a higher density of somatosensation such as tactile,
pressure, temperature, pain and proprioception in general.
One indicator that the foot has the one of the highest sensations is its
sensitivity with sensory input such as tactile or pressure. By stimulating the
somatosensory channel of the foot in the right axis, the foot registers on the brain.
This is the way of increasing awareness or body scheme of the foot into the brain.
It enhances movement of the foot with volition.

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ACTIVATION OF THE FOOT

Creep posture
This posture has a great advantage to activate higher responses with
diagonal movement of the pelvis. This reinforces pattern of movement, flexion or
extension on each side.

1. This posture has a great advantage to activate higher responses with

diagonal movement of the pelvis. This reinforces the patterns of movement,
flexion or extension on each side.

- On the side of the flexed leg, adjust axis of tibia, fibula and foot. In order
to stimulate the foot, the therapist must mobilize the ankle to 90 degrees
with the right axis. The most important thing for the treatment of the
foot is the restoration of the right location and dynamic movement of
calcaneus with the full length of Achilles tendon. This is because all toe
muscles activate on the right axis and location of the calcaneus (Fig.
C.55)

Figure C.55 Restoration of right location and dynamic movement of calcaneus

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2. When the therapist puts the lower leg and foot, specifically the calcaneus
in the right axis, the therapist should be aware of the gradual increase in
muscle tone and compare this with the tone when the axis was altered (Fig.
C.56)

Figure C.56 Monitoring muscle tone

3. For increasing body scheme of the foot, the therapist provides sensory
stimulation such as tactile, tickling, sweeping, or a poke to the bottom of the
foot. This is to activate responses of the child. The sensory information
activates the part of the brain specific to the foot in the right axis (Fig. C.57)

Figure.C.57 Stimulation of the foot to increase body scheme

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 4. Thereafter, stimulate the flexor muscles of the toe. Toe flexion activates
automatically with ankle dorsiflexion. The point of stimulation is to create a
pathway of the flexor digitorum longus and brevis in the arch of the foot
which is an adjacent point of the calcaneus (Fig. C.58)

Figure C.58 Activation of the flexor muscles of the toes for the arch of the foot

5. If the child can flex the toes voluntarily, you can use this in a strategy to
strengthen the toe and foot being a BOS. Put the paper between any toe
then ask the child to grip the paper by flexion and adduction of the toes.
The strong flexion of the toe is one of strong posture keeper of human (Fig.
C.59)

Figure C.59 Strengthening the toes and foot for BOS

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Supported sitting with posterior tilted pelvis
This program is for high cognitive children who are able to comprehend. It
must be enjoyable. The cortical level of movement is adjustment with volition
whenever it is needed by the child.

1. In supported sitting, the therapist should make the right axis of muscles
located on lower leg such as the tibialis anterior and posterior, peroneus
longus and brevis, extensor hallucis longus and brevis. Be certain of
changing the axis and muscle tone including muscle bulk (Fig. C.60)

Figure.C.60 Monitoring muscle tone and bulk in the lower leg

If it is difficult to awaken the muscles, it could be useful to facilitate

individual movement of each muscle and give a pressure on muscles for
activation.

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 2. Stimulation can be done similar to the previous approach in the creeping
posture. It requires that the calcaneus be of bigger size to act like a
fulcrum. Thus, if it is small, the therapist puts an aid to reserve the height
of the calcaneus (Fig. C.61)

Figure.C.61 Calcaneal pad to aid reservation of the height of the calcaneus

3. Stimulate the flexor muscles of the toe. Activate flexion of the toe with
dorsiflexion of the ankle, and then the therapist asks the child for the foot
and toe to move together. (Fig. C.62)

Figure.C.62 Combine activation of the toe muscles and dorsiflexion of the ankle

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4. Also, it is necessary to strengthen flexion of the toe by gripping a paper
placed between the toes.

5. The child will get confidence in making movements by himself even if the
movements are still small and weak. When the child moves the foot in each
direction, the therapist help and assist the movement with guidance and
stimulation.

6. The final goal of movement for the foot is to move the foot in a circle. This
presents activation of all muscles of the foot by himself (Fig. C.63)

Figure C.63 Circular movement of the foot

7. If the foot starts to move, the therapist can feel reduction of the
hypertonus around the hip joint.

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Aid for calcaneus
Many children with cerebral palsy have a small, immobile and elevated
calcaneus. If there is a small calcaneus, it is difficult to have a stable and strong
BOS. This is a reason why the pelvis does not move dynamically. In the upright
position, the pelvis moves onto the calcaneus. Thus, medical professionals have to
make a normal size calcaneus by using a pad whenever the child stands or walks
(Fig. C.64)

Figure C.64 A child standing with use of calcaneal pad

THE HAND
Similar to the activation of the foot, the important consideration is the
dynamic postural tone from the eye and neck with capital flexion. In addition,
another consideration is the dynamic connective spine movement, specifically, the
thoracic spine which is the basis of scapular movement and connective movement
of all the extensor antigravity muscles such as the trapezius, rhomboideus and
erector spinae.

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1. In sidelying, it is almost the same program mentioned in the part of the
spine. With the right axis of muscles of the arm, the therapist must be
certain of increasing muscle tone and muscle bulk while moving the hand
(Fig. C.65)

Figure.C.65 Monitoring muscle tone and bulk of the arm

2. An additional feedback during voluntary hand movement compared with

the foot movement comes from the visual system

3. The therapist helps and guides the direction of the muscles while asking
voluntary movement of the hand. The first step of hand movement is to
move side to side with the fist, then up and down, then finally make a circle
towards all direction. (Fig. C.66)

Figure.C.66 Mobilization of hand

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 4. The next step of voluntary movement of the hand is to open the hand
with assistance from the therapist, then close the hand with flexion and
extension of the fingers.

5. Although it is hard for the child, it increases the intensity of brain

connection. The final goal for the hand is to control adjustment.

WATCHING
Watching is the first cortical level of movement of the human. Upon
waking up, watching influences modulation of postural tone in relation to
alertness.
It requires normal level of alertness, right axis, muscle tone and movement
of the eyes as well as normal muscle tone of the face and neck, specifically capital
flexion. All these factors are prerequisite for treatment.
Another important focus of watching is the vestibulooccular reflex (VOR).
It provides stability and gaze stabilization while head is moving. Many of the
prematurity cases present with difficulty to watch the toy continuously. They
manifest swaying of head in walking. Weak VOR is caused by altered axis
and weak muscles of the eyes. The therapist should help the child to get stronger
watching in order to modulate postural tone.

1. In supine or half sitting with posterior tilted pelvis, the therapist should
build up muscles of the eye the same way as the previous chapter.
2. Then, while child is watching the toy or pictures, the therapist moves the
head in various directions with control of range and speed.
3. Also, the therapist should change the posture by going to up to upright
sitting. This generates higher and stronger VOR which is basis of
continuous watching.

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164
Table of Fetal Development (National Geographic, 2005)
WEEK FEATURE
3weeks * Confirmation of pregnancy by hormonal changes
* The kidney bean-sized embryo
4weeks * Beginning of eye formation
* Formation of buds on the body: The buds become the arms and legs
*The skin is made up of three layers
: the epidermis, the dermis, and subcutaneous layer. Initially the embryo is covered by a single layer of ectodermal
5weeks
cells
* The skin covering of the fetus is composed of the ectoderm and the mesenchyme

7weeks * The periderm, a layer of flattened cells forms on the surface

*The length: about an inch long

* No eyelids
• Eyes set widely apart

8weeks

* The embryo looks more like a tiny human and becomes known as a fetus
* The body weight is at 10-45 grams
9weeks * The fetus starts to get nutrition from the placenta as the ovum supplying nutrients to the fetus shrinks
* The nervous system is developing fast, spreading connections throughout the body
* Autonomic beat, not controlled by heart or brain, increase of the heart rate
* The length of the fetus is 7cm
• The fetus is the size of a human fist
* There is low risk of miscarriage
* Kicking and pushing out with their legs
: stepping reflex
(preprogrammed biological impulse)
: promotion of further development of muscle and
11~12
co-activation of proximal muscles.
weeks
• The movements of the fetus arms and hands
against the uterine wall give the "idea" of body
awareness.
* At this age, there is so much space in the uterus.
The fetus bounces and leaps around using the wall of the womb like a trampoline.
* At 5-12 weeks of gestation, the lungs do not yet have respiratory bronchioles or alveoli.
: Pseudoglandular period of the maturation of the lungs

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WEEK FEATURE
* The length of the fetus is five and a half inches.
• During the 12th-16th week, the dermis has papillae that contains nerve organs and the deep layer,
the subcorium, contains large amounts of fatty tissue.
* Movements are increasingly controlled by her brain.
* The muscles are flexible, and the fingers and toes are separated.
* The hand is developing earlier than foot
* Bones are hardening; decreased distances between eyes
* CNS extending to part of fetus's body that connects and controls the body.
Heart is controlled (140~150 beats per minute)
* The fetus is becoming sensitive to touch and prods through the mother's abdomen.
• As the fetus explores her body, she spends a lot of time practicing the grasping reflex, grabbing hold her hands,
feet, fingers, toes and even her umbilical cord.
16weeks
: the "idea" of body awareness

* The epidermis is composed of the following layers

The basal layer further differentiates into an intermediate zone. At the end of the 16th week, there are four layers
① The basal layer or the germinative layer
: produces new cells and forms ridges and hollows reflected on the surface of the skin and the fingerprints
② Spinous layer
: has polyhedral cells that contain fine tonofibrils and melanocytes
③ Granular layer
: contains keratohyaline granules
④ The horny layer
: The tough protective layer which contains keratin
* Begins to swallow amniotic fluid through the digestive system
* Mother feels the baby's movement
18weeks * Some fetuses are opening their eyes at 18 weeks
* The eyes do not work this early at 18 weeks. It is just the first sign of blinking reflex
* The fetus develops her fingerprints
* The movement of fetus is fidgety, purposeless
* Their small size allows them a lot of movement
in a spacious uterus.
• The fetal movement increases development of
muscle and bone.
20weeks

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WEEK FEATURE
* The size of the fetus is longer than the father's hand
* With increase in size and weight of the body, flexed posture develops more and there is more movement in a mor
e compact space: development of body concept
* It is possible that the fetus could survive outside the womb, but she is likely to suffer brain damage and learning di
sability
* The fetus' lungs can't supply oxygen yet
* There is increased fetal movement
* Growth is the main job for this little girl. with all her organs in place, they need time
to develop and maturate.
* Sensation: this is the time when the fetus receives her first stimulation from the world beyond as her senses flicke
r to life.
* Most sensory organs, ears, nose, taste buds and the nerve that respond to touch, are mature. The brain is bombar
ded by signals from the sensory cells, and she must begin to interpret this overload of sensations.
* These will allow her to develop a sense of self, a means to interact with others, to explore and to learn.
* Taste, Smell
: A twenty-four-week-old the fetus is able to stick out her tongue. It is known that her mouth is full of taste buds so
she could be tasting the amniotic fluid.
The fetus's mouth and nose are permanently filled with amniotic fluid that can carry the tastes and smells of the mo
ther's food.
A well-developed sense of taste and smell could help the baby take her first sips of breast milk when she is born.
* Vision
24~25
: At twenty-four week-old fetus can open and close her eyes.
weeks
It is too dark in the womb, so the fetus still can't see anything.
The fetus learns the blinking reflex from these responses.
* Formation of detailed structures (like eyebrows)
* The most developed sense is hearing.
* The fetus is completely surrounded by amniotic fluid.
Because sound travels through fluid about 4 times faster than it does in air, the fetus has plenty to hear.
* The sounds the fetus hears as her ears start picking up vibration at 13 weeks are the gurgles and rumbles made by
her mother's body (hiccups, burps, bubbles, slurps, slashes).
* The fetus also makes her own noises as she kicks and swishes in the amniotic fluid.
* She can also hear the competing heart beat, her own beat is rising at twice the speed of her mother's.
* The fetus can also hear sounds from the world outside; conversations, loud noises, music.
* The wall of the womb together with abdomen acts to filter out high frequencies
* All sounds that reach the fetus are distorted
* The lower bass notes of the piece of music and vowels have much more impact
* The sound of mother's voice is different from any other since it travels directly through the fluids in the body
* This may help the baby develop a unique relationship with her mother
* Other voices like father's must pass through the air and then fluid, and may not cut through the general backgroun
d noise
* The loudest sound the fetus ever hears may come during an ultrasound scan
* At six months of gestation, type two alveolar epithelial cells start producing surfactant which is important in loweri
ng surface tension that prevents collapse of the air sacs

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WEEK FEATURE
* The size of the fetus is ten inches from head to toe, growing fast
* The fetus spends about 90% of her time sleeping. When sleeping, nothing can wake her up
* For the other 10% of time, they are awake and alert, ready for whatever might happen next
• They may react to sudden sounds with the startle reflex, flinging their arms and legs out to the side (for self
preservation)
• The fetus swallows about 500ml of amniotic fluid daily. By drinking the fluid, the fetus helps maintain liquid
balance in the womb; it also helps the new digestive system develop properly. From the moment she is born
and the cord is cut, she learns to take food from her mouth to her stomach
* Sucking- the fetus attempts to suck anything close to her mouth : the sucking reflex begins to develop a lifelong
preference for one hand or the other
* The brain and nervous system will continue to grow dramatically
* It is possible to hear a fetus' heart beat just by putting an ear to mother's abdomen
The fetus's heart beat is about twice as fast as her mother's
• The mother's heart rate and blood pressure are directly affected by her emotional state. Although the fetus
has her own blood supply, the increased heart rate and blood pressure of the mother are easily passed
through the placenta and have a direct impact on the baby.
26weeks
Stress in the mother can lead to low birth weight or premature birth, and development of chronic health
problems such as heart disease, diabetes and even have harmful effects on child's mental development
* The mother can feel her kick and push everyday
* Sometimes, the mother may feel regular twitches- her baby's hiccups
A hiccup is a reflex that may help baby latch onto a nipple to feed
In the fetal lung, there is no air and therefore no hiccup sound
• During the canalicular period at 16-26 weeks the terminal bronchioles divide into respiratory bronchioles and
alveolar ducts
• From 26 weeks to birth primitive alveoli form and capillaries establish close contact during the terminal sac
period
• Inside the fetus’ lung, the branching network of tubes is filled with amniotic fluid, but the tiny air sacs remain
closed
* The fetus still makes breathing movements with the lungs and diaphragm.
This strengthens chest muscles so they are ready to expend and fill the lung with air the moment the baby is born

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WEEK FEATURE
* The baby gains weight fast and lays down a layer of fat under her skin
* A sudden increase in body weight to 1300 grams
* Her senses are buzzing
* The cerebral cortex is maturing enough to support consciousness.
Over the next four weeks, the nervous system will become as dense as a
newborn baby's.
* She is becoming aware of the world around her and for the first time, her
brain is beginning to
create memory
* The fetus has spent so much time listening to her mother's voice that
she is familiar with its rhythms.
28weeks She absorbs enough of these patterns to recognize and even respond to it
Researchers analyzing the cries of newborn have found out that they already contain some of the rhythms and
patterns of their mother's speech.
* The fetus can now hear, taste, smell and touch.
* The fetus is likely to be turned head down in the womb, getting ready for born.
* The type of music the baby is exposed to can alter her movement.
Fast music stimulates excitement. Music that is closest to the natural sounds and rhythms of human voice, such as cla
ssical or choral music, has a calming effect.
If she hears the same music over and over again, she may even be able to remember it.
* The eyes of the mid-term fetus is sensitive to light and it has been observed that a fetus tries to shield her eyes from
the light.
* The fetus also has the ability to see her hands.
• From the 32nd week until before birth the body weight will increase to
more than 3000g.
: It will develop more compact space to move in the womb which promotes
increasing flexed posture with capital flexion of the neck
* This flexed posture of the body causes elongation of the neck and back
muscles, including the muscles of the leg
32weeks * The head of the fetus is oriented to the cervix.
* The fetus now feels the weight of the head.
This stimulates the vestibular system
* Type one alveolar epithelial cells become thinner starting the last two months of prenatal life, and this promotes
intimate contact between the epithelial and endothelial cells. This structure makes up the blood-brain barrier.
* During the alveolar period, from eight months of gestation to childhood, the alveoli mature and develop capillary
contacts for gas exchange.

* Many women feel uncomfortable during the last couple of months because of the weight of the baby, pressure on t
he spine, pain on the back and legs, and anxiety.
* The mother is often short of breath as her lungs struggles to absorb 20% more oxygen than normal.
33weeks * The fetus has rapid eye movement in sleep. This is an indication of dreaming.
* The brain has grown approximately one hundred billion nerve cells with 10 trillion connections. The brain and head
have grown as big as they can be in the womb.
* The fetus can survive and can be born anytime from about 35 weeks without much medical help.

169
WEEK FEATURE
* Amount of surfactant increases during the last two weeks
before birth.
* Sign of birth : The first contraction of the uterus or the
breaking of water (the amniotic sac ruptures).
* The baby's lung together with placenta determine the
timing of birth.
* When the lungs are mature, they secrete protein into the
amniotic fluid which alters the percentage of production of
hormones. This slowly releases progesterone and triggers
the release of the new hormone, oxytocin, which initiates
contraction of the uterine wall.
* The first stage of labor: the baby's head is locked in the bottom of the uterus and is bearing down on the cervix,
38weeks
the barrier between the uterus and the vagina.
* Squashing of the umbilical cord can easily constrict the supply of oxygen.
The baby releases large quantities of adrenaline to keep her heart pumping fast enough. Adrenaline also help
prepare the lungs.
* As soon as the baby is delivered, the fluid leaks from lungs and air rushes in, expanding the air sacs to keep the
baby alive.
* The surfactant remains on the alveolar cell membranes and prevents collapse (atelectasis) during the first intake
of breath.
* All life support systems are now working independently and the umbilical cord can be cut.
* The baby finally comes face-to-face with her mother.
* The baby is thrust into a noisy, bright world and starts to feel uncomfortable sensations like cold and hunger.
* Her smile would not be seen again until she is at least four weeks old.

170
Journal of Health Science 5 (2017) 56-72
doi: 10.17265/2328-7136/2017.02.002
D DAVID PUBLISHING

New Ideas of Treatment for Cerebral Palsy I Capital

Flexion of the Neck: the Key Link in Prematurity
Treatment

Hong, Jung Sun, PT, MPH, Bobath Pediatric Senior International Instructor of ABPIA
Hong’s Children Center for Cerebral Palsy, Corp. Pasig City, Philippines

Abstract: In a human, the head and spine work together in any kind of posture and movement. Any movement starts from the head
through neck flexion and specifically capital flexion. Capital flexion initiates the straightening of the cervical spine which causes the
connection of the head on the C1-C2 suboccipital part to the thoracic and lumbar parts. With this, the spine starts to move and
postural tone increases. Without construction of the neck or alteration of the axis, as seen with cases of prematurity, postural tone
becomes low. Typical features of children with prematurity include low postural tone, altered axis of the head and neck which
generates incorrect or ineffective vestibular information and poor cortical movement caused by poor development of capital flexion.
Therefore, the most important aspect to consider is the lack of capital flexion causing the absence of some initiation of movements of
the spine which leads to further weakness of the neck and trunk.

Key Words: Eyes, capital flexion, neck, postural tone, axis, spine movement.

1. Introduction spasticity, premature cases are noted to have moderate

or lower than moderate levels.
During the last two decades medical professionals
Both spastic quadriplegia and diplegia cases caused
face new types of children including those with
by damaged on the cortex show strong typical
cerebral palsy due to prematurity.
hypertonic pattern with poor head control while
According to reports, prematurity now represents
present premature cases show low tone on the
40-50% of children with cerebral palsy [1]; 6% has
proximal part while hypertonus exists on the distal
birth weight lower than 1,500 g or 1,000 g [2]; and 11%
parts of the body. The quantity and quality of their
is from short gestational age lower than 28 weeks [3].
movements are different as they are seen with better
In addition, research from Korea which reportedly
head control, level of cognition, and speech, which are
presents a statistically realistic set of data due to a big
all necessary for development of functional movement.
number of respondents (i.e. 700 respondent mothers),
Many of those affected are able to sit and walk
relates that 53% of prematurity cases have cerebral
although these may develop slowly.
palsy [4].
Clinical picture of older cases of spastic diplegia
Among the cases of children with cerebral palsy
from prematurity include inability to assume upright
from prematurity, findings show that the damage to
posture and difficulty in staying still in sitting or
the brain is around the lateral ventricle [5]. This group
standing. As they walk, neck and trunk sway either
shows a different picture as children with cerebral
with or without a certain degree of hypertonus on the
palsy, as previously reported, obtained damage on the
feet. These findings are brought about by low tone of
cortex. As such, with respect to the degree of
the neck and trunk (Figure 1).
Corresponding author: Hong, Jung Sun, Ms.C, research
One way of assessing the postural tone of the child
field: pediatrics. can be done by asking him to come to the sitting
 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
Fig. 1 Walking of Child with Spastic Diplegia.
position from supine. A child with prematurity cannot
flex and raise their head completely. This can be
described as weak neck, or weak muscle tone of the
neck. This weak neck consequently contributes to the
low tone on the trunk. Most of them will prefer to go
into prone first; then, come to sitting using extension
pattern instead of using neck flexion. Therefore, it is
evident that the limited frequency of using neck
flexion may lead to missing some components in
relation to normal human movement.
Human movement, in any situation, is governed by
the person’s ability to modulate postural tone in order
to sustain head upright against the base of support. His
repertoire of movement depends on alignment and
balanced activation of the intrinsic muscles of the
neck especially those used for capital flexion. Capital
Flexion initiates increase postural tone by connecting
the whole cervical spine to thoracic and lumbar with
lowered ribcage and posteriorly tilted pelvis,
respectively. Constructing the neck’s C1-C2
suboccipital component or getting capital flexion
straightens the whole cervical spine which makes the
whole spine move consequently. Capital Flexion
increases neck muscle tone and together with spinal
movement, postural tone as a general also increases.
Another way Capital flexion increase postural tone
is by serving as the axis (midline) of vestibular system.
With neck in the middle, this means eyes are also in
57
the midline and oriented together with the inner ear to
get all the vestibular information needed to increase
postural tone and perform any kind of movement
against gravity.
To illustrate this, let us use rising from the bed as
an example. When lying down, postural tone is mostly
low. As soon as the head comes to midline with sent
information of the vestibular system to eyes and inner
ear regarding the environment and situation, capital
flexion initiates increase in postural tone.
Simultaneously, capital flexion straightens and moves
the cervical spine as a whole and connects it to
thoracic spine as ribcage lowers down and to lumbar
spine as pelvis posteriorly tilted. Further increase in
the position of the head to a more upright position
then orientes the child’s vestibular information and the
muscles of the trunk to increase activation of the
postural tone as to support and sustain the head on its
axis against the base of support available.
All muscles of the body works towards maintaining
the head aligned at any posture or in any movement
contexts with just the right modulation of tone of
individual muscles. However, when the neck axis is
compromised which is often seen in cases with
prematurity as hyperextension, the role of the capital
flexion will not be maximized. There is unequal
activation of the muscles of the neck causing immobility
of the spine and poor orientation in vestibular system,
thus low postural tone becomes evident.
Therefore, in order to cope with the need to move,
maintain the head up and increase the postural tone, a
child with prematurity compensates by using an
atypical pattern.
Considering these ideas, we can surmise that a child
with prematurity who moves with low tone and with
an atypical manner is brought about by weakness or
poor development of the neck especially capital
flexion. Thus, the presence of weak neck causing low
tone of the trunk or low postural tone, in general,
should not be taken for granted. Vestibular
information (as neural component) and spinal
58 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
movement (as non-neural component) to effectively
increase postural tone should be well assessed and
managed. As medical professionals, strategies to
promote correct patterns of movement with modulated
postural tone should be included when treating
children with prematurity.
The skills and repertoire of movement of the child
with prematurity also deviate from typical ones due to
missed events during the latter part of gestation.
Events inside the womb that should have been
experienced must be given importance as bases to
explain the missed components of development.
Promoting missed experiences, especially capital
flexion which serve as reference or key to stronger
and more fluid human movement repertoire, should be
done in cases with prematurity.
When analyzing the clinical picture of children with
prematurity, the following important and common
difficulties are expected:
(1) With or without issues related to low arousal
level
(2) Poor eye movement with weak facial muscles
(3) Weak neck and poor Capital Flexion
(4) Poor spinal movement or immobile spine
(5) Low tone on trunk or low postural tone of the
body with hypertonus on distal parts of the body
(6) Poor body scheme
To understand the difficulties of children with
prematurity, it is vital to clinically assess the
components of their movements, compare it to normal
human movement, and link these observations to
events missed in the latter part of gestation.
This paper will, therefore, describe important
factors in fetal development commonly missed by
children with prematurity, especially capital flexion as
a key reference to normal human movement, and
foundations of normal movement including
relationship of vestibular information, postural tone,
axis and cortical level of movements. At the latter part,
ideas of treatment which can help in filling in the gaps
and in making a child’s movement as close to normal
as possible will be described.
2. Fetal Development: Development in and
Importance of the Flexed Posture
2.1 Movements of Flexion
At the fetal stage, flexor components fully develop.
The physical changes in the developing fetus happen
while experiencing flexed posture in a very limited
space. This gives the whole body a chance for
connective movement from head to feet through
passive elongation, making the initial development of
capital flexion as a key feature and basis of normal
human movement possible.
At around 28-34 weeks of gestational age, all parts
of the body move into flexion within an axis [6]. As
the fetus becomes more confined and as he assumes a
more flexed posture, the neck goes into deeper capital
flexion (Figure 2).
As such, when the fetus moves with flexed neck
and spine, movement of the legs towards flexion with
posteriorly tilted pelvis is also reinforced. This
manner of moving all the parts of the body in the same
direction can also be described as mass pattern of
movements. Kicking at this stage develops muscles of
the lower proximals, hips and ankles, and joint
structures such as the acetabulum, ligaments, and joint
capsule. This state of the neck is actually similar to
chin tuck in adults when power and speed can be
Fig. 2 Flexed Posture.
 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
produced by increasing neck stability (i.e. when
throwing or kicking a ball farther in sports activities).
This important posture activates isolated muscles
on the body and contributes to a stronger and more
concentrated co-activation of the neck and trunk. This is
comparable to isometric exercises of the target muscles.
At this stage, then, primarily assists in building up
neck and proximal muscles in preparation for head
and trunk movements against gravity after birth.
Since the neck and trunk are naturally flexed, all
segments of the spine from cervical to lumbar,
simultaneously move into flexion. Flexion also makes
the shoulders and scapulae go down and forward.
Because of this, the fetus can easily bring his hands to
mouth and suck his fingers. This helps the fetus
perceive the existence of his hand. Moreover, as he
pushes with his hands against the wall of the uterus,
he could learn that his hand is connected to the elbow
and that the elbow is connected to the shoulder. This
experience is very important in the development of
body scheme and the perceptual process, in general.
When outside the womb, this idea of the hand will be
further supported by vision. The use of the forearm
and hand for support and play will then develop
consequently.
At 36 to 40 weeks, the fetus prepares for delivery
by turning and changing his head’s position towards
the mother’s cervix. This posture gives the fetus
information about change in direction as he tries to
relate this with his body. As such, the development of
body scheme is further enhanced.
Alongside the development of capital flexion of the
neck comes the development of the neural network of
the body. Connectively moving in a fully flexed posture
prepares the child for movement against gravity.
Immediately upon birth, various movements that may
go along and/or through physiologic flexion are noted
until a more stable head control is developed.
2.2 Neck Dynamic Stability
Inside the womb, the infant’s movements such as
59
sucking, swallowing, breathing, turning the head in
various directions, pushing the arms and kicking the
legs against the uterine wall while in the flexed
posture all reinforce development of the muscles of
the neck and trunk, especially capital flexion. The
recoil of all the movements of the fetus against the
wall of the uterus while in fully flexed and elongated
neck sends signal to the intrinsic muscles of the neck,
thus strengthening the development of capital flexion.
As mentioned above, these activities not only cause
development of each utilized muscle fiber but also
promote connective neck and proximal co-activation
through isometric contractions.
All of the infant’s flexor movements seen in the
womb continue to develop with physiological flexion
after birth. These movements are essential for the
development of head movement and stability in space.
However, with the absence of the rigorous
development of the flexor components in the womb,
as in cases of prematurity, the development of neck
stability is hampered given the lack of passive capital
flexion.
As previously mentioned, muscles located around
the neck are the most important muscle groups
necessary for postural control. This is because the
neck muscles, although smaller and shorter than other
muscles of the body, contain the highest density of
muscle spindles [7].
The neck modulates postural tone to enable the
infant to move against gravity after birth. Neck
muscles work in collaboration with the neural network
that mediates various reflexes (vestibulospinal,
vestibulocollic, and vestibulo-ocular reflexes) to
ensure good alignment of the head and trunk, and to
facilitate appropriate adjustments as one moves.
Vestibular inputs from the head, eyes, and postural
muscles are integrated with the information from the
stable neck, maintaining all parts of the body in the
same axis with regards to the position of the head.
Therefore, if the neck is unstable and out of axis,
insufficient postural tone will be generated. This
60 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
causes inactivity of the truncal muscles which is one
of the main problems associated with prematurity [8].
Thus, neck dynamic stability is essential not just for
maintaining head in space but also as a basis for
postural control.
It is logical, therefore, to state that the most
important feature of the fetal stage is the development
of neck stability.
2.3 Development of Breathing Pattern, Oromotor
Control, and Oculomotor Skills
When in the flexed posture during the fetal stage,
the fetus sucks his hand, swallows amniotic fluid, and
practices breathing. These activities, which are all
vital functions, are easily done in flexed posture. In
this posture, contraction and relaxation of the face
muscles are practiced with sucking and swallowing.
The flexed posture also reinforces increase in negative
pressure. It is easier to close the mouth while in the
flexed position which makes nasal breathing easier
and deeper: amniotic fluid can then go into deeper
lung structures [9]. These facilitate the development of
the structure of the lungs and diaphragm; thus,
enhancing pulmonary function.
After birth, the infant continues to develop his
breathing pattern with the development of the
abdominal muscles. At 5 to 6 months, with the
emergence of the Landau pattern, the breathing pattern
of the infant shifts from abdominal breathing to
thoracic breathing [10]. This change is very much
related to the development and shaping of the shoulder
girdle, rib cage, lower trunk and abdominal muscles.
While the baby practices breathing in midline (axis)
and as he uses his mouth, oculomotor control also
develops simultaneously [10]. Neck maintained in
midline and in flexed position allows for the
development of oculomotor muscles. Conversely, all
these activities which involve the development of oral
movements, eye movements, and breathing help
develop neck dynamic stability. As such, these also
contribute to the development of stable and connected
head and trunk movement.
Activity of the facial, oral and oculomotor muscles
plays an important role in facilitating adaptation to
different stimuli, increasing level of arousal and
promoting motivation to move especially at the
beginning of anti-gravity movement. As such,
prematurity not only compromises the activity of the
aforementioned muscle and movement developments
but also affects emotional and sensory adaptation,
cognition, and arousal level.
2.4 Counterbalance of Extensor Activity
Movements in the flexed posture continue until 2
months after birth. When the leg is extended it flexes
back like a spring. This is the recoil phenomenon, a
mechanism that prevents too much extension after
birth [10]. At this stage, human beings have a
tendency to move following the direction of gravity
with extension and the recoil phenomenon
counterbalances too much extension. With increased
development of neck stability and its connection to the
trunk, co-contraction of the flexor and extensor group
matures and stabilizes further; thus, promoting the use
of more dynamic movement.
2.5 Emotional Stability / Psychological Stability
In the flexed posture, the fetus moves to midline in
mass flexor pattern. This posture develops as a
protective response and can be related to promoting
security for emotional stability and survival in
response to various sensory stimulation from the
environment such as visual, auditory, olfactory, and
movement.
2.6 Self-regulation
After 20 weeks in the mother’s uterus, the fetus
recognizes many different sounds: his mother’s
biological rhythms, as well as his mother’s daily
routine—sleeping, eating, toileting, and other
activities. This helps the fetus recognize his mother
and learn from environmental cues (e.g. day, night)
 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
which are some of the bases for socio-emotional and
cognitive development. This also serves as the
foundation for the development of attachment or
relationship between the mother and the baby [11].
Thus, cases with prematurity often experience
difficulty recognizing and adapting to changes in the
environment given the shorter length of time in the
womb.
3. Foundations of Normal Movement
To understand the problems of children in terms of
movement, medical professionals have to recognize
the importance of postural axis (midline) in relation to
how postural tone should be modulated based on
vestibular information and cortical level of movement.
3.1 Vestibular Information
The vestibular neural network contributes to
providing information about the location of the head
and body in order to maintain the same line from top
to bottom with regard to any displacement.
Modulation of the degree of postural tone happens
with fast activation of certain muscle groups
supporting the head and body in a given posture or
movement. Sensory receptors from the vestibular
apparatus located in the inner ear send vestibular
information or feedback to the vestibular nuclei. The
vestibular nuclei functions for two different reflex
systems [12].
The lateral vestibular nucleus (LVN) projects down
to the ipsilateral cervical and lumbar levels of the
spinal cord where they excite antigravity motor
neurons that control slow extensor muscle fibers for
antigravity posture. The very fast conducting lateral
vestibulospinal tract travels through the ventromedial
white matter of the cord explaining its preferential
access to the axial and proximal limb musculature and
intermediate zone circuits which determine postural
support. Thus, it is responsible for labyrinthine
righting reflexes involving the limbs. The medial
vestibular nucleus (MVN), on the other hand, sends
61
bilateral and partly inhibitory projections to the neck
motor neurons and intermediary circuits in the upper
cervical cord. Thus, it subserves vestibulocollic
reflexes for maintaining head stability.
Projections from the vestibular nuclei contribute to
sensory information about head movement and
position relative to gravity, gaze stabilization (control
of eye movement when the head moves), postural
adjustments, autonomic functions, and consciousness
[12].
In normal development, as the central nervous
system (CNS) matures, specifically the vestibular
system, the child becomes driven to move to higher
positions. Consequently, as the head goes in space
from the ground, the vestibular system activates
muscles of the body to maintain the head in space in a
much higher location. This describes modulation of
postural tone with regard to head position which
essentially happens with the integration the neural
network of sensory and motor channels for the
execution of body movements.
A special contributory function of vestibular system
to human movement is to provide an idea of a central
line from the head, as the keystone, to bottom. As
guided by the vestibular system, all parts of the brain
contribute to directing human movements in
maintaining the head in the same line with the body,
and in adjusting the line of the body as related to the
displacement of the head. All neural systems and the
postural muscles involved activate independently in
an interrelated manner to recover displacements
automatically. A person in sitting position, for
example, moves his legs freely without activating all
muscles to take weight. But with attempts to go to
standing, the displacement of the head forward
produces vestibular information that may send signals
to the muscles of the legs to keep the weight on the
feet and support the head and the body while
maintaining the axis. Therefore, humans are able to
stand from sitting with adequate vestibular
information from the head. This includes integration
62 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
of information from the head, eyes, and neck. In other
words, if the head is not located at the middle or it
shows altered vestibular system, the sequence of
movements for standing up will be atypical.
Thus, the apparatus most responsible for providing
information of the head’s location in relation to the
axis (midline) and for activating parts of the body to
preserve this axis is the vestibular system.
In human movement, the head moves in various
directions (forward, backward, lateral elongation and
rotation) in order to watch something. This act of
watching generates adequate postural tone and
activates special muscle groups in the body in relation
to the location of the head.
For instance, when a person rests on a sofa, his
head is flexed and his body leans backward, making
all muscles of the body relaxed; thus, lowering his
total postural tone. Generally, in this situation,
humans sit on the sacrum. But when he intends to do
something, which is mostly triggered by watching, the
head goes to a higher position and the pelvis
automatically goes upright. This movement is
generated by the gluteus maximus with the pelvis
acting as the base of support. The back muscle
extensors will then work to extend the body and
maintain the axis of the head against the pelvis. The
gluteus maximus, however, can only do its work as
the initiator of the sequence of movements and as the
axis keeper for upright sitting if the head location is
correct. If, in any case, the axis of the head and the
pelvis is altered, there will be consequent alteration of
the vestibular information. Gluteal muscles will be
incapable of responding to change; thus, the child
assumes sacral sitting.
In the same way, cases of premature diplegia with
hyperextended neck and with poor ability to watch can
be observed with a different pattern of standing up.
They start to move with hyperextended neck and
proximal, followed by anteriorly tilted pelvis and
hyperextended, adducted, internally rotated legs. This
is referred to as altered vestibular system in extension.
In summary, the location and movements of the
head in any posture, in relation to vestibular
information, activate specific group of muscles to
immediately maintain the head in space. Similarly, as
the trunk or the pelvis rotates, the head rotates
immediately to maintain the axis from head to bottom
which illustrates how the body changes direction in
relation to the initiating part. A person’s head which
stays in extension to watch something at or above
eye-level will lead to the activation of extensor groups
of muscles rather than flexors.
3.2 Postural Tone
Postural tone is an automatic mechanism for
dynamic activation of body muscles to maintain the
head at the middle in the context of any posture or
movement.
In standing, people generally activate 100% of their
postural tone to maintain the head position in midline.
Soldiers who are standing at attention generate about
120% activation of postural tone through capital
flexion (chin tuck) and connective activation of the
proximal muscles. (An accurate score cannot be given
and the percentage mentioned is only an assumption
and illustration of the varied quality of postural tone).
Postures that do not require any kind of movement,
such as lying down in bed, generates little postural
tone. At rest, as when dreaming or in REM (rapid eye
movement) a state of about 10% of postural tone is
activated. Upon initial transition to an awakened state
while opening eyes (which signals all body parts to
orient towards the midline), 20% of postural tone
starts to work. As the person starts to raise his head to
go to sitting, postural tone further increases until the
person assumes upright sitting and standing, where the
postural tone generated is at 100%.
A child who has yet to develop the brain and
muscle bulk will use different mechanisms to increase
tone compared to an adult.
In normal development, postural tone of the infant
is initially low until the vestibular neural network
 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
develops. Sensory channels especially vision and
auditory peak in development during the latter part of
the 1st stage of normal development. Vision and
vestibular apparatus in the inner ear help in orientation
and exploration of the environment, thus vestibular
information becomes clearer. This vestibular neural
network urges the child to keep pace with the
surrounding and be encouraged to lift the head against
gravity. As they learn to bring the head up, postural
tone starts to increase and develop, like in rolling over
and prone on elbows. The infant simultaneously learns
to bring his center of gravity higher and move or keep
his head in that position by adjusting the postural tone
relative to the position. This is the neural part of
increasing the postural tone.
Non-neural factor of increasing postural tone, on
the other hand is capital flexion as axis of construction
of the spine and development of the muscles of the
neck and trunk. C1-C2 sub occipital component of the
neck should be constructed, especially to cases with
prematurity so as to connect spinal movement and
proximal muscles activation. Capital flexion serves as
the axis of the whole cervical spine from which spinal
movement starts to happen. As capital flexion
develops together with more established vestibular
information, postural tone starts to increase.
Thus a poorly constructed neck drives the neck and
trunk to low tone and weakness due to poor axis of
the neck for vestibular information and spinal
movement. A good postural tone in sitting, for
example, includes two columns formed by the upper
trapezius muscles implying a symmetrical activation
of both sides of the neck and proximal muscles.
Disappearance of or a smaller bulk of the column on
one side is caused by poor connective movement of
the neck and trunk muscles secondary to poor
capital flexion and disconnected spinal movement.
Similarly, if the eye and face muscles are weak
meaning there is no strong axis of the head, neck
muscle activation and postural tone of the body will
not increase as well.
63
As such, modulation of postural tone happens in
relation to the head location relative to construction of
capital flexion for vestibular information and spinal
movement, movement against gravity, and base of
support. To sum up, both neural and non-neural
factors for increasing postural tone depend on
development of Capital Flexion.
However, because all the neural network and
muscles are fully developed in a typical adult, postural
tone automatically increases as related to voluntary
movement of the hands, feet, or any specific part of
the body even when lying down.
Modulation of postural tone in any kind of posture
and movement involves use of base of support.
Postural tone increases in relation to head location
over a stable base of support, whether in sitting,
standing, or walking. When the base of support is not
stable and strong as noted when the muscles
surrounding the base of support have changed due to
dislocations, subluxations and contractures, postural
tone will also not be properly increased and sustained.
The presence of limited or smaller bases of stability
will confuse the body in terms of alignment and the
supposed concomitant increase in postural tone.
3.3 Axis (Midline)
Basically, there is a clear but imaginary line at the
middle of the human body from head to feet. The
position of the midline at the center of the head and
body is between the two eyes. This invisible line is
oriented and adjusted relative to the displacement of
the head and body based on the vestibular information.
But it is important to note that based on the
anatomical position, the axis (midline) does not only
exist at the center of the body or trunk but also in each
extremity.
When axis of an extremity is altered or displaced,
the body moves along the same line of displacement
immediately. And when the body is moved away from
the midline, the head goes in the same line as the
body.
64 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
According to Norkin [13], maximal active force of
a muscle can be generated when it is at its resting
length which can be achieved when the joint is in its
accurate alignment. Thus, complete activation of the
involved parts of the body and generally the overall
postural tone will not happen if there is an altered axis
(midline).
In the case of premature children with CP, they
usually show a hyperextended neck such that there is
shortness or limitation of movement at the C1-C2
suboccipital component. If these segments of the neck
are extremely shortened and fixed for a long time, the
C7 spinous process at the back disappears. Muscle
tone activation of the sternocleidomastoid and upper
trapezius muscles will weaken or cause disappearance
of the anterior or posterior side of the neck. Thus,
when capital flexion of the neck does not occur, the
construction of head and whole spine connection will
not happen. Usual presentation of hyperextended neck
causes altered axis or altered vestibular system. This
position drives the eye to move to an upward location
and the mouth to an open posture.
3.4 Cortical Level of Movement
Volitional movement is related to the neurological
process that requires intention, judgement, and
processing. Axis (midline) and postural tone are bases
for human movement but there is a need to match
these not only to the functional level of movement but
also to the functions of the brain.
Cortical level of movement refers to purposeful
movement in the context of a functional activity like
rolling over, sitting, standing, and walking. This type
of movement increases the neural activity of the
neocortex. It utilizes and requires motivation to
perform in a specific functional level.
Compared to cortical level, the subcortical level of
movement focuses on postural control and more
automatic types of movement while providing and
preserving the correct axis of the body, and while
activating the right quality of postural tone.
Important activities to increase cortical level of
movement are engagement in watching, grasping and
manipulation of hands, and foot movement as related
to function.
4. Basic Knowledge for Treatment
4.1 The neck
4.1.1 Capital flexion
The head moves dynamically for watching and
directing any kind of movement. Capital flexion refers
to straightening of C1, C2 cervical spine to get
appropriate extension of whole cervical. It later
connects to thoracic spine, and thereafter, to the
lumbar level of the spine. Thus, we may name it as
construction of the whole spine through capital
flexion.
The C1, C2 sub-occipital component is quite
mobile just like a compass and is involved in all kinds
of human postures and movements. The spine, when
moved with capital flexion, serves as the axis or
stability point to where the distal parts of the body
depend its quality of movement. Thus, if the spine is
twisted and immobile, all kinds of movements of the
arms and hands will be difficult because of the
changed axis of the bone structure as well as the
changed direction of all muscles. Therapists should
recognize this general concept related to spinal
movement and apply this in children with prematurity
or Cerebral Palsy.
Capital flexion is a small movement of the C1-C2
sub-occipital component. This is generated by small
muscles such as the longitudinal oblique, superior &
inferior longus colli from the anterior part of the neck.
There is also activity of the rectus capitis anterior,
posterior major, rectus capitis lateralis during
activation of capital flexion. The extension, flexion,
lateral elongation or rotation of the neck requires a
clear initial movement. This movement refers to
capital flexion which is the primary movement of the
neck relative to the construction of the cervical spine
to the head.
 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
When analyzing the case of premature children with
poor or no flexor movements, take specific
consideration of this principle: if capital flexion does
not get initiated, neck flexion cannot be executed
because the cervical spine does not get completely
flexed. Complete sequence of neck flexion includes
the eyes going downward, mouth closing with deeper
capital flexion and then finally the neck goes to
flexion.
Downward movement of the ocular muscles and
closing of mouth are packaged together as initiators of
active capital flexion of the neck. When there are
many problems related to the movements of ocular
muscles or the eyes are fixed and located high in
relation to the Frontalis and Masseter, there will be
consequent difficulty in closing the mouth. There will
be poor deep nasal breathing experience. Premature
cases, though, may present with poor movement of
eyes and facial muscles as related to low arousal level
and missed flexion experience.
Comparing the development of the neck during the
fetal stage which is more passive and isometric
because of the given elongation from physiologic
flexion, neck construction during the first stage of
normal development is more active. The mass pattern
decreases as physiologic flexion decreases and
specific components of capital flexion develop against
gravity one at a time. At around 3-4 months [14] as
active capital flexion develops, spinal connection
between head and cervical spine is established,
consequently, connecting all parts of the spine more
precisely.
4.1.2 Connective movement of the spine
Capital flexion facilitates the construction of all
parts or levels of the spine from its connection to the
head. It is the primary connective movement of the
head to the cervical spine. At the beginning of neck
flexion, capital flexion illustrates the articulation or
connection of the head and the cervical spine by
generating or activating tone of certain parts of muscle
groups. If capital flexion does not occur before neck
65
flexion, it is clearly disconnected to other levels of the
spine. Poor connective activation of the cervical spine
movement with capital flexion cannot provide signals
to switch on the flexor group of muscles because of
limited vestibular information related to location of
the head.
Similarly, capital flexion activation maximizes
cervical extension, which eventually moves with the
thoracic spine as well as the lumbar spine. A strong
neck extension includes capital flexion as initial
movement. This demonstrates that connective
movement of the spine from top to bottom occurs with
any kind of movement of the neck.
If only cervical spine moves without connection to
thoracic spine, i.e. capital flexion of the neck does not
occur, it will be similar to moving the head of a doll
without movement of the body. There is also no
connective movement from the head and trunk
causing low postural tone as what happens to cases of
prematurity with neck in hyperextension or poor
construction of capital flexion. Their spine remains
immobile and stiff evident in all movement patterns.
In normal human movement, when the head flexes
with executed capital flexion, the thoracic spine
connectively goes to flexion generating some small
downward movements of the clavicle and ribcage.
Therefore, the absence or limitation of active capital
flexion in the majority of children with CP results in
the higher location of the rib cage. Consequently, the
shoulder joints and arms become fixed.
Poor movement of the spine causes weak activation
of the trunk as well as difficulties of arm and hand,
and leg and foot movements. The movement of
thoracic spine contributes to movement of the arm and
hand. When the arm goes forward, there should be
smooth movement of the scapula and the shoulder
joint. But the lack of rotation from the cervical to
thoracic spine prevents dissociated scapular
movement, which leads to insufficient construction of
the shoulder joint. Poor construction, on the other
hand, impedes the full range of motion of the humerus
66 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
on the glenoid fossa. Thus, children with no
connective movement show poor scapular dissociation
causing their arms to move together.
Along the same line of rationalization, limitation in
the mobility of the lumbar spine limits the variable
movements of the leg and foot since dynamic pelvic
movements, i.e. 3- dimensional pelvic movement, are
also limited. The pelvis executes complex and
multi-directional movements with the extension and
rotation of the lumbar spine onto the both hip joint. If
poor extension of lumbar spine is present,
3-dimensional pelvic movements will also be difficult.
All these movements of the spine are the bases for
arm and foot movement but if the spine is not
connected from the cervical spine level, all parts of the
spine will be fixed and immobile.
Capital flexion is the starting point of all
movements of the spine and all dynamic activation of
body musculature. That is the reason why poor neck
muscle activation leads to poor movement of the spine
which then contributes to weak muscles, low tone of
the body, especially, proximal part of the body.
When all kinds of spinal movement are limited, all
parts of the trunk muscles do not work; thus, driving
the body to low tone, especially with the weakness of
flexor muscle groups in premature cases.
Consequently, these children show typical low tone on
the trunk.
4.1.3 Muscle tone of the neck
To further illustrate how flexible and adaptable the
postural control of a child should be, let us consider
this example. Sport players such as wrestlers or
weightlifters, show remarkable thickness of neck
muscles compared with other individuals. They
execute power and speed from arm and leg use but a
strong neck provides stability for movement of
extremities. Chin tuck results from increased exertion
of the neck.
The muscle tone of the neck is affected both by low
tone or hypertonus of the body. If the child shows low
muscle tone of the neck or weakness, the therapist
must build up muscles with capital flexion to increase
muscle tone of the neck. In contrast, if the child shows
hypertonus on the body along with the neck, the
therapist must decrease or release the muscle tone of
the neck. A strong neural signal contracts the muscles
of neck and body continuously.
Severe hypertonus is always accompanied by
altered vestibular information from the eye and face
muscles due to muscular changes. Thus, the most
important aspect to consider before increasing tone of
the specific parts of the neck is the modulation of the
hypertonus of the body requiring restoration of the
midline (axis) and reduction of strong muscle tone of
the eye and face.
4.1.4 Problems of children with spastic diplegia
In children with spastic diplegia, neck flexion with
the absence of capital flexion limits the activity of the
flexor muscles of the neck as well as the trunk.
Because of the alteration of the structure of the
cervical spine in children with hyperextended neck,
the cervical muscles cannot function optimally, most
especially the sternocleidomastoid (SCM) muscles,
upper trapezius and deep neck muscles, which work
for straightening of the neck. Over time, further
shortness of other muscles, such as the trapezius and
deep capital extensor muscles should be expected.
This means that the neck is incapable of becoming a
strong axis and information center for providing
signals regarding the position and direction of the
head.
Disappearance of or noticeable weakness of one or
both sides/heads of the sternocleidomastoid muscles
may probably be seen. Poor extension and capital
flexion of the neck also lead to poor activation of both
upper Trapezius muscles seen at the back of the neck,
below the base of the skull. Weakness of one side of
the neck (i.e. one side of the upper Trapezius muscles),
which can be seen as the neck collapsing towards one
side, leads to low tone on one side of the proximal.
This presentation is commonly seen not just in
hemiplegia but also in diplegia cases with unequal
 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
activity of both sides. Generally, in hemiplegia cases,
they show low proximal tone and less movements on
more affected side because of hypertonus, poor body
scheme or noted infrequent or limited weight bearing
on the more affected side.
When a child with CP shows hyperextended neck, a
corollary to this is the presence of an altered vestibular
system which leads to activation of purely extensor
muscle groups. This should be a primary
consideration of the therapist. There is a need to
change the axis in order to neutralize the vestibular
system of the neck and head which is necessary to
activate the appropriate muscles on the body.
In human movement, rotation or displacement of
the head to one side activates the muscles of the same
side. This is mainly based on the vestibular
information from the head and neck. Thus, the
location of the head must be taken into special
consideration. In order to activate the more affected
side, the therapist should consider changing the
location of the head and then, encourage watching on
the more affected side.
The presence of weak capital flexion could be a
logical sign of weakness or disappearance of muscle
activity of one side. Capital flexion is the basis of
muscle tone of the neck which in turn is the basis of
postural tone of the body; thus, capital flexion
modulates the muscle tone not just of the neck but
also the whole body. To facilitate clear description of
the location of the neck, 3 terminologies can be used:
out of axis, on axis, and in capital flexion (which is
also termed as chin tuck).
4.1.5 Cerebral Palsy
In case of CP children with severe brain damage
such as spastic quadriplegia or dystonic athetosis, they
typically show a hypertonic pattern from head to feet.
Although some are not born prematurely, management
through capital flexion construction for postural tone
and spinal movement should be applied. They present
with asymmetric posturing such as head rotation with
the trunk, arm/s, pelvis, and legs rotated to one side as
67
well. The location of the head is totally changed so the
resultant altered vestibular system and the difficulty in
executing capital flexion are expected. The spine is
immobile as well. The therapist should change all the
wrong information being received and mobilize the
spine in order to make the right movement and
modulate postural tone appropriately; otherwise, it
will be difficult to change their movements and make
these as close to normal as possible.
Another important reason for the problems seen in
children with cerebral palsy is instability of the base
of support. Whether the child maintain a posture or do
a movement, base of support helps in initiating the
increase and modulating the postural tone. The base of
support refers to the point where the body and the
neck align with each other so as to maintain the axis
(midline). Without a stable base of support, activation
of the neck muscles especially the posterior column
will not be observed.
In hemiplegia cases, for example, because of the
tendency to lean on one side and not use equal bases
of support in sitting or standing, the activity of both
sides of the back and neck muscles are not be equal.
The presence of contractures on the ankles or pelvis,
in the case of hemiplegia or diplegia, may also
contribute to the inability of the child to maximally
use the stated structures for support. Activation of
postural tone is, therefore, not maximized and
sustained.
4.2 The Eyes
4.2.1 Vestibular system of the eyes
One of the basic roles of the eyes is to be the point of
reference for neutral vestibular system of the head in
relation to body. This refers to the position where both
eyes are exactly in midline (axis) in relation to the head.
The most functional and voluntary type of movement
of eyes is watching.
When human beings wake up (without any
movement), the two eyes align at the middle, in the
same line as the head and even up to the bottom. In the
68 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
presence of any displacement of the head or any other
part, the eyes do automatic and appropriate movements
to maintain the eyes at the middle. When the head is
moved from side to side, the eyes follow the same
midline as the head. But when watching starts, both
eyes are kept in midline even though the head is moved
in various directions or when the body is swaying. This
is called the Vestibulo-ocular Reflex (VOR).
The VOR is a reflexive eye movement that stabilizes
images on the retina during abrupt and brief head
movement. The eyes move in the opposite direction of
the head movement. For example, when the head
moves to the right, the eyes reflexively do a left side
movement. This is in response to the neural input from
the vestibular system of the inner ear. This response is
seen for head movements going up and down, left and
right, and tilting to the right and left; all of which give
input to the ocular muscles in response to sustain visual
stability.
Other types of eye movements are saccades, smooth
pursuit, and optokinetic, all of which function to direct
the eyes on target and keep it there: watching. Saccades
happen when scanning the environment and when
discerning what to watch by moving the eyes from one
point to another. Smooth pursuit, on the other hand,
keeps the eyes on a moving target by calculating the
speed of the target and moving the eyes at the same
time. It is easy to follow a moving object in a constant
speed but with disturbance or increase in speed,
saccadic jerks happen to keep up. The combination of
smooth pursuit and saccadic eye movements is called
optokinetic reflex. It is responsible for keeping the
target stationary with continuous head movements like
rotation and translation [12].
All of the eye movements are important to consider
and check when analyzing the vestibular system
function in relation to movement.
4.2.2 The muscles of eye
There are six muscles of the eye which control its
movements: the lateral rectus, the medial rectus, the
inferior rectus, the superior rectus, the inferior oblique,
and the superior oblique. When the muscles exert
different tensions, a torque is exerted on the globe-like
structure that causes it to turn, in almost pure rotation,
with only about one millimeter of translation. Thus, in
essence, the eye rotates around a single point at the
center of the eye.
All ocular muscles react very fast to any
displacement, similar to the activation of the muscles
of the body when balance reactions are triggered.
Grading of the movement of the eyes is also noted as
necessitated by watching. The eyes are composed of
small and short muscles that are basically higher in
density of muscle spindles compared to other muscles
of the body. As such, it is possible for the eyes to
contribute to the vestibular network by stabilizing the
eye in relation to head movement.
The muscles of the eyes may not develop because
of limited watching or because of blindness and
problems related to the visual system such as
sensitivity to light. Imbalance of movements of the
eyes, as seen with strabismus, may also cause delay in
ocular muscle development. These may lead to “fixed”
eyes which in turn, causes fixed neck and can be an
evidence of typical hypertonic pattern of movement.
4.2.3 Capital flexion with eye movement
When analyzing eye movement in relation to neck
movement, particularly capital flexion, the flexor
muscles of the proximal and the neck are the ones
primarily firing. To initiate and follow through capital
flexion, downward movement of the eyes should be
noted with simultaneous closing of the mouth which
then straightens the neck. These are “packaged” or set
of movements that are mostly automatic except when
there is a specific context or purpose for a part of the
movement. Limitation in downward gaze produces a
consequent weakness or difficulty in performing
capital flexion and therefore, the precise activation of
flexor movements will not be present.
Capital flexion does not only occur automatically
when the neck starts to move flexion but also when it
moves towards extension. This may then be
 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
instrumental in the construction of the neck in relation
to the spine. When capital flexion is weak or absent as
the person moves the neck towards flexion or
extension, proximal muscles do not get activated
completely thus, contributing to confusion about
which muscles need to fire.
When the child is unable to move the eyes down or
close the mouth completely, weakness of the neck (i.e.
inability to do capital flexion) logically presents with
general low tone of the body.
4.3 The Face Muscles
When the eyes move in various directions, the
Frontalis muscles automatically and simultaneously
move with these. This direct relationship is notable
when you try to move the eyes with or without
movement of the Frontalis. For example, in the case of
a child with choreoathetosis who has low tone of the
face and the body as well, there is weak movement of
the eyebrows, generally.
Weakness of the Masseter muscles also contributes
to weak capital flexion. This set of muscles is used
while moving towards the end range of capital flexion
in order to produce speed and power when the tone of
the face muscles is normal. For example, when a
person pulls or lifts excessively heavy things or when
initiating transition movements from supine posture,
we observe how these face muscles contract strongly
with closed mouth.
5. Deep Considerations for Treatment
As soon as possible, activate capital flexion. The
right axis of the neck will be achieved with enough
movement of the C1-C2 component, along with
greater mobility of the eyes and face muscles.
Ocular muscles should then be dissociated from the
neck to produce accurate responses as related to the
vestibulo-ocular reflex. Facial muscles should be
active as well by facilitating eyes down and closed
mouth.
Adjustment of the cervical spine curvature. Aside
69
from recovering the C1-C2 component to elongate the
structures surrounding this, the lower part of the
cervical (C7) should have more prominent spinous
process. Its appearance means good alignment of the
cervical spine curvature.
Connecting the spinal movement from cervical to
thoracic and to lumbar parts. Through mobilization of
the spine with promotion of one side elongation,
flexion, extension, and rotation, there will be a more
mobile spine which allows for connective movement.
Capital flexion should act as the key point or reference
about the movements of the lower parts of the spine
move and how these should follow through. The
inability to connect the spine with correct Capital
flexion will limit the activity of the trunk; thus,
causing it to go into low tone.
Facilitating a deeper Capital flexion. This should be
done by building up muscles of the eyes, face and
neck while facilitating a deeper and more elongated
neck. A stronger capital flexion done with neck
flexion is evident with the activity of the
Sternocleidomastoid muscles on each side of the neck.
This should, then, aid in extension of the neck where
the Upper Trapezius muscle is activated and clearly
visible.
Activation of the flexor component of the body. In
supine, full flexion of the body includes capital
flexion, neck flexion, and trunk flexion with pelvic
posterior tilting.
Mobilization of the thoracic and lumbar spines.
Facilitating thoracic spine rotation and activating the
muscles surrounding it, will generate a descent of the
ribcage and produce a wider range of scapular
movement. Lumbar spine extension and rotation, on
the other hand, will aid in three dimensional (3-D)
movement of the pelvis as well as activation of the
lower parts of the proximal.
Facilitate hand use. This should be done by
recovering the right axis of the arms while moving the
glenoid head on the fossa. Shoulder joint construction
should be done to facilitate more forward hand
70 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
movements. However, there will be smoother and
more consistent glenohumeral/scapulohumeral rhythm
after connectively mobilizing the shoulder joint with
the scapula while making sure that there is enough
spinal mobility.
Increase voluntary activation of the feet. Promoting
use of the feet as a base of support will improve
activation of postural tone in standing and walking.
Mobility of the ankles and toes also increases
connection of the flexor components; thus, gaining
axis should be done through adjustment of the
location of the muscles of the legs and mobilization of
the calcaneal bone.
Promote Base of Support. A good base of support
serves as the foundation of postural tone modulation
in a stable posture or during movement execution.
Because of poor development of the size of the pelvic
bone and gluteal muscles as a consequence of frequent
sacral sitting in children with cerebral palsy, moving
the pelvis upright while weight bearing on ischial
tuberosities should be promoted. Therapists may also
fill in the gap by using towel or cushion to promote a
more upright pelvis.
Promoting foot as base of support, on the other
hand, should include realignment of the axis of the
legs and ankles. If the foot is altered or collapsed on
the medial side, muscles of the legs, intrinsic muscles
of the feet, gastrocnemius, ankle dorsiflexors and toe
muscles should be made active to prevent further
lowering of postural tone. The priority of treatment is
to activate voluntary movement of the foot in order to
contribute not only to reducing hypertonus but also in
increasing body scheme of the foot.
5.1 The use of neck brace or pad on calcaneal bone
Since the recovery of capital flexion of the neck and
building up of the muscle tone of the neck take time, it
is quite necessary to provide a support that will serve
as a transient external stable source of vestibular
information and axis (midline) of the neck as they
move. Thus, the idea of a temporary neck brace (see
Fig. 3 Child wearing Neck Brace.
picture 3) is quite useful for them until they develop
good neck dynamic stability. This brace is tiny and
thin relative to the size of the neck and is made out of
hard sponge and reinforced by steel wires. This may
be in the form of sponge taken from electronic boxes,
which are easy to cut and pliable enough. This will
then be wrapped by a handkerchief or any cloth with
ends that can be easily tied together.
In instance when the calcaneal bone is already small
or the axis of the foot is collapsed; it is difficult to
increase postural tone dynamically even with the use
of an ankle foot orthosis (AFO). Use of pad will aid
the calcaneus to maximally function as base of support.
There will be an increase in postural tone when the
affected foot becomes more stable in standing or
walking. Therefore, the therapist should check the size
and height of the calcaneal bone and put a special
material (similar to a hard foam) to fill in the
difference in size and height of the calcaneal bone.
5.2 Early treatment for prematurity in a Neonatal
intensive care unit
Providing treatment as soon as possible is important
in reducing huge gaps in the development of
premature children in comparison with full term
infants.
5.2.1 Reinforcing the flexed posture
In NICU treatment, the therapist should hold the
infant in flexed posture to produce capital flexion with
 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
deep elongation of the neck muscles. Also, the eyes
are facilitated to go to neutral or downward gaze while
elongating the whole back with pelvis posteriorly
tilted.
This is actually describing the flexor “package” of
the head and neck: deep capital flexion, eyes down,
closed mouth, and finally, neck flexion with flexed
trunk and posteriorly tilted pelvis. The following may
be done to facilitate this flexed posture:
(1) Activate facial muscles with closed mouth,
particularly, the frontalis and masseter. This can affect
not just the movements of eye ball and mouth but also
increase the level of alertness.
(2) While lowering the eyes (from the forehead) and
closing the mouth with capital flexion, mobilize the
pelvis to initiate co-activation of the proximal muscles
with the neck muscles. This will, in effect, facilitate
nasal and deeper breathing which will increase the
tone of the proximal muscles as well.
(3) If full capital flexion cannot be done either
passively or actively, mobilize the C1-2 segments to
adjust the alignment of the neck and activate the
vestibular network through the neck. There may also
be a need to put the jaw going to the direction of the
spine (i.e. chin tuck) in order to further activate neck
flexion. Adjust the curve of cervical spine (e.g.
decrease hyperlordosis) to make capital flexion
possible.
(4) To activate the vestibular system, the therapist
puts the infant in a supine posture where the legs are
flexed towards his chest, putting the center of gravity
nearer the neck. This will simulate the vestibular
sensation that the fetus may experience during the last
trimester, when full flexion of the fetus is maximized
and the head turns towards the cervix of the mother.
(5) Facilitate hand to mouth play in the infant like
sucking of fingers while holding the cheeks together
to increase body scheme of the hand.
(6) Put both legs at the middle and then, mobilize
the foot to enhance the activation of ankle dorsiflexion.
Then, co-activation of the proximal with the foot
71
needs to be facilitated. This set of activities
contributes to increasing body scheme of the foot.
5.2.2 Sensory adaptation
(1) Tactile system. The therapist may provide tactile
sensation (e.g. gentle massage) on the whole body of
the infant to help him calm down and to increase
adaptation of the tactile receptors in the skin given the
system’s immature development.
(2) Vestibular system. The therapist holds the infant
firmly near the adult’s body, then moves from side to
side or up and down in a rhythmical manner (i.e.
similar to the movement sensation being received by
the infant while inside the uterus ) in order to facilitate
adaptation to being moved. A full term fetus will have
40 weeks to adapt to being moved while inside the
womb so a premature infant may cry easily and
frequently because of poor development of the
vestibular system and the limited experience of this
sensation.
(3) Mobilization of the joint. Although mobilization
is passive movement, it is a necessary preparation
especially when the child’s arms, hand, legs, or feet
are already very stiff and fixed. The therapist should
mobilize these affected parts to prevent the
development of contractures.
(4) Establishment of emotional attachment and
relationship between the mother and the infant. Utilize
Kangaroo care. This promotes emotional security and
a sense of connection to the mother.
6. Conclusions
With the right interpretation of the clinical picture
of prematurity and the identification of elements based
on comparison between normal and atypical patterns
of movement, the therapist may be able to set the
correct treatment priorities.
Early activation of capital flexion and building up
of neck should be the priority of treatment, as guided
by principles of basic human movement, rather than
just focusing on guidance of functional movements
such as rolling over, sitting, and walking.
72 New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck:
the Key Link in Prematurity Treatment
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