FACILITATION IN PRONE → → → → → tone normalization sensory accod.

to weight bearing surface elongation in spinal extension weight shift across central axis head righting reaction

Decreased tone; increased integration between upper and lower trunk. REACTION: elongation weight bearing side internal and external rotation – UE & LE pelvic and spinal alignment weight shift – weight bearing surfaces – hands/feet forming midline If increased tone, grade stimulus slow; small excursions; deep pressure to elongate weight bearing surface. PREPARATION SCAPULA: Prone → preparation for sidelying → to sitting H.R. weight shift, elongation, H.R. labyrinthine R – prepare before taking to sidelying Sidelying: Reinforce elongation through pressure Align pelvis and shoulder around axis Facilitate weight shift GRADE Toward prone → increased ext. BEWARE Toward supine → increased flexion (chin tuck → supine E.R.)

May need to work specific pelvis:
Hips

Mod

Shoulder: SUPINE DANGERS:

Shoulder head/abd

Neck hyperextension → inactive trunk – abdominals 1

→ overstretched neck, lumbar spine → fixed posterior tilt SOME PURPOSES: A. B. C. D. DON’Ts: elongation neck extension – preparation UE and reaching. alignment of spine – activation of flexion and extension THOUGHOUT spine activation of abdominal preparation pelvic movement for sitting.

Legs Resting (Inactive) Too Much Hip Ext (No Activation)

Anterior Tilt

Approx. into Flexed hips

Duplicates sitting position in chair. Collapsed lumbar spine or P.P.T. overstretched Neck Extensors

Always maintain good alignment Recognize difference between BABIES ↔ OLDER CHILDREN

2

A.

ELONGATION NECK: Key Points: scapula/shoulders trunk upper extremities Weight Bearing on Scapula Action: traction Lateral weight shift Alignment – balance flex/ext

B.

ALIGNMENT SPINE: Key Points: sternum abdominals/pelvis --OR-lateral trunk weight bearing/pelvis shift Action: subtle weight

deep pressure Key Points: ant/post surface trunk sides of trunk pelvic area thoracic area weight bearing/scapula Action: traction lateral weight shift approx - ONLY once aligned

C.

ACTIVATION ABDOMINALS: Key Points: Pelvis

Weight bearing

Action:

traction lateral weight shift (prepare for rolling, etc)

D.

PELVIC MOBILITY MUST HAVE ADEQUATE NECK MOBILITY Key Points: thighs inside Action: lower pelvis – cue lift 3

ankle. 2. naturally occurs on the weight bearing side. 2. slow. INHIBITION: Purpose: To increase the potential for a wide variety of differentiated (highly selective) patterns of movement. Normalization of increased postural tone is often achieved by: A. Proximally: Distally: Head. D. shoulders. your handling is not necessarily limited to these points. KEY POINTS OF CONTROL: Both inhibition and facilitation are usually performed at key points of control. Reflex inhibitory patterns (RIPs) are not static and are rarely used in isolation. and jaw Any one or combination of the key points of control can be used. shaking – counteracts fixation Weight bearing in moving patterns: 1. B. Movement: 1. II. The goal is central inhibition by the patient. & glutes (B) Weight bearing neck (A) SUMMARY OF NEURODEVELOPMENTAL TREATMENT TECNIQUES – BOBATH I. slow sustained lengthening to break up stereotyped movement patterns. Method: Inhibition techniques are used only as needed and are interplayed with facilitation techniques. Rotation: 4 . rhythmic rocking – reduces spasticity 2. however. Tonic postural dominance is inhibited peripherally (initially by the therapists) while higher level righting and equilibrium reactions are facilitated. wrist.Up/down usinf abd. and pelvis Thenar eminence. C. Elongation: 1. increases tone (depends on how it is used).it is a type of elongation when used on the involved area and is used with slow movement to prevent build-up of tone. inhibits hypertonus . toes.

Inhibition of mass movement patterns immediately allows for normal. The spontaneous achievement of these postural reactions means the abnormal reactions (including primitive reflexes) have been successfully integrated. Let the child lead the movement if possible b. moving in and out of sitting. ***It is essential to note that inhibition will only carryover during and after treatment if automatic postural reactions (righting.repeat – repeat. 2. Don’t always repeat in one way c. differentiated movement and is. and protective reactions. Give child the feeling that he can do something d. 3. Methods: A. protective) are facilitated. Repeat. not sitting per se). equilibrium. a facilitation technique. not the position itself (i. Give normal feeling of normal movement: a.1. III. therefore.e. The following points are important to remember: 1. FACTILITATION: Purpose: The righting and equilibrium reactions are stimulated to provide the patient with experience in a wide range of controlled. Repeat until child takes over – and it is automatic but not stereotyped 3. Use child’s own tempo – not yours c. Use millimeters and micromillimeters of movement b. Facilitation of Automatic Movement Sequences: Carefully selected portions of the development sequence are facilitated through use of righting. The significance parts of sensory motor development are the transitions between positions. graded movement patterns. B. elongation and rotation = dissociation VERY effective in breaking up total synergies. equilibrium. but don’t go too far: a. Respect the child – don’t impose yourself: a. A directional cue is used. extremely important component of righting and equilibrium reactions. You don’t want static positions but movement in and out of positions 5 . Your hand guide – not dominate 2.

Joint approximation used frequently but almost always during a sequence of movement. It is the automatic adaptation of muscles to a change in movement or posture. 8. 6 2. Positions need to be prepared for. e. Must not be passive or child will only depend on you. 7. c. c. Antigravity weight bearing is most common. often through trunk in a downward diagonal direction. We must give the child the possibility to take over. 5. d. Weight Bearing. . 6. 4. Or minimal movements with control in positions You want ACTIVE REACTIONS from babies They give more normal sensorimotor experiences Stop when quality goes wrong. b. Placing and Holding. Our aim is FUNCTIONAL REACTION: a. . We must gradually move away. d. Not always through joints. ENHANCEMENT TECHNIQUES OF PRIMARY FACILITATION: The following are used to enhance “B”: 1. Don’t paint in the wrong quality or wrong body image. Both Automatic and Voluntary: a. distal when combined with tapping. Compression and Resistance: a. Pressure. Example: hands to midline. 9. Key to treatment = preparation. hands to feet. First under our hands. Watch for fixes. Placing: the ability to arrest a movement at any given stage. b. Inhibition techniques continue to be used as needed but must be with drawn as central control is increasing. The child must WORK under your hands and learn to take over: a.Never do anything that doesn’t work. Find most difficult points and play with it. Find out why it doesn’t work and prepare more or try a different way. c.b. Proximal most common. Alignment should be as near normal as possible.

e. Direction due into the movement pattern. Never use when spasticity is present because it will increase spasticity – normalize tone first. place arm back in a normal position or inhibitory pattern if it is pulling into an abnormal pattern. d. antagonists together 3. Pressure Tapping a. i. Performed quickly and arrhytmically to avoid accommodation to stimulation. b. Use within framework of a movement pattern and never for a specific muscle. wrist extension desired: tap palmar surface of fingers toward wrist extension. i. Increases postural tone against gravity b.b. Four types of tapping: 1. c.e. Almost always combined with holding against gravity in some way. Increases postural time of trunk or limbs by proprioceptive and tactile stimulation. d. Often used with ataxics and athetoids to get stability in midranges Done arrhythmically – this is the difference between pressure tapping and joint compression 2. g. Often used to help break up a pattern of fixation. Inhibitory Tapping a. . Increases function of muscles which are weak secondary to opposition by spasticity. f. Alternate Tapping a. Tapping: a. The resulting movement is inhibitory to spasticity. Stimulate contraction of agonists and c. b. Follows pressure tapping – a light tapping using fingertips in an effort to facilitate balance reactions usually in a midposition. Sweep Tapping 7 4.e. 3. Patient is now allowed to relax in between tapping – want to heighten or active tone. b. Obtains proper grading of reciprocal innervation and stimulates balance reactions through recruitment.

Push – Pull: a. c. either primary hypotonia or with fluctuating tone as in athetosis or ataxia. The only type of tapping that is applied to a muscle group. c. Usually used with low tone. b. The prime mover is activated with broad sweeps and some pressure. BUT only after increased tone and clocks are NORMALIZED Enhances tone and provides strong propriception and kinesthetic Insert tables here 8 . Use when tone is normalized – a more sophisticated facilitation technique. Usually for distal movement. Really a variation of #1 (compression) combined with directional cueing or joint traction. b. 4.a.

grading. Teach control of intermediate range of movement. Use it for maintaining positions while placing limbs. Incorporate lots of graded trunk rotation. hips). Don’t treat functionally too early – prepare for function. Emphasize symmetrical alignment of head & trunk and have patient’s ACTIVE COOPERATION in so doing. Reduce tonus as when treating spastics when tonus is too high. 9 . This will indirectly give reduced tonus distally. Aim at wide –ranged movements. Movement reduces hypertonus. equilibrium. Aim at getting SUSTAINED tonus for postural control. & protective reactions & use them for sequential movements against gravity. Be aware of abnormal FIXATION. Treat functionally earlier than spastics and emphasize volitional involvement more than with spastics. move the patient and make him move. Treat primary proximally (trunk. • • • Children with Fluctuating Tone (Athetosis) • • • • • Normalize tonus. Facilitate (rather: organize) righting. Work for sustained contractions ( without effort) and grading of movement. Use weight bearing & tapping techniques when tonus is too low. shoulders.Treatment Principles for the Cerebral Palsied Child Children with Spasticity • Reduce hypertonus. equilibrium & protective reactions. Children with Ataxia • • • Normalize tonus. therefore. Introduce such movements in the normal neurodevelopmental sequence. Counteract deformities with correct therapeutic handling & positioning. holding and timing. Facilitate AUTOMATIC motor responses such as righting.

hip extension and knee flexion. use weights proximally but aim at decreasing weights and removing them. Eye contact and general response to environment is important to obtain. Emphasize breathing. Children with Low Tone (flaccidity) • • • • Build up tonus with various tapping techniques. Refine righting and equilibrium functions. place the child in “knee standing” position with weight bearing on knees. but be aware of the potential danger of eliciting spasticity or athetosis. Teach head control. especially in prone and sidelying. To stimulate head and trunk extension. engagement of hands (and feet) in midline. B. Development of head and trunk extension To stimulate head extension. A. place the child in prone on appropriate size roll. Applied Uses 1. arm extension. 10 .• • • Use techniques of intermittent holding (move – hold) If needed. hips and extended arms.

Place a child in sitting position straddled over the roll and position yourself behind him. A. 3. B. To help prevent this. Encourage reaching. Caution should be taken to prevent hyperextension of head and trunk which could elicit abnormal movement patterns. 11 . grasping and releasing. 2. Position child on all fours (creep position) with roll Giving moderate support.C. Development of forearm and hand control “Prone Prop” the child on an appropriate size roll. Place child’s head and trunk face down on roll and then ask child to slowly extend segmentally beginning with the head and neck. Development of upper extremity weight bearing Place child prone on an appropriate size roll shifting weight bearing from knees to upper arms. holding child’s arms above the wrist. therapist should hug child from behind. A.

4. A. As the motion continues. Trunk is leaning slightly forward from the hips. The hands are placed flat against the top surface of the roll between the knees. the child should be able to compensate for the shifting position of the roll and maintain his original postural attitude. 12 . Balance activities Place the child in a sitting position on the roll straddling it. See illustrations below: The child pushes up with first one foot then the other to stimulate a rocking motion. The thigh and lower leg should be at right angles to each other. The roll should be of a diameter that permits child’s feet to rest flat on the floor.

D. thus maintaining his balance with trunk and legs only.B. place hips. From a sitting position on an appropriate size roll with hands staying on the roll. 13 E. The arms will “hug” the roll as illustrated below: C. position legs out front to stretch hamstrings and abductors. but place the child in a supine position on the roll. His legs should be extended straight out from the hips with knees slightly bent to allow him to “hug” the roll with his legs. bring the child to standing position to facilitate stretching hamstrings while controlling knee extension and hyperextension. sit the child over the edge and rock the roll back and forth to stimulate full equilibrium reaction in upper and lower extremities. Gently rock the roll from side to side asking the child to maintain his original position on the roll and compensating for the shifting center of gravity. with arm hugging sides and legs extended. A variant of this activity is to have child extend his arms to the sides of his body and try to maintain his balance using only legs and shifting body weight as the roll is rocked side to side. Have child lie down on the roll in a prone position (he lies lengthwise – not across it). One a large roll. Or repeat exercises in 4C. A variation of the above activity is to have the child hold his arms straight out in front of his body while “rocking”. B. 5. To stretch heel cords. A. knees and ankles at 90 degrees or greater. . Develop lower extremities Straddle roll in sitting position and gently rock left to right to reduce muscle tone in legs and feet. Staying balanced on the roll.

Wedges B. Two children can sit together on a roll for games such as “train ride” or “Simon Says” Use rolls in an obstacle course to develop “over and under” concept. 7. A. lacks sitting balance and lacks the ability to adjust the trunk from poor posture. Application: A wedge is primarily used as an alternative to sitting when a child lacks head control. 6. Straddle appropriate size roll in kneeling position to provide moderate knee pressure with left – to – right balancing.C. Construction: Tumble Forms incline wedges are made of firm but flexible foam with durable Tumble Form covering bonded to the foam. PC 2795A Wedge 4x20x22 in (10x51x56 cm) PC 2795B Wedge 6x20x22 in (15x51x56 cm) PC 2795D Wedge 6x20x26 in (15x51x66 cm) PC 2795C Wedge 8x20x22 in (20x51x56 cm) 14 . Build on rotation by gradually leaning sideways to the point of touching the floor on either side. C. Sizes: Wedges are available in the following eight sizes (including five heights). Working with flash cards or other instructional aids while teacher and child face each other on the roll permits a more “private” atmosphere while encouraging balance control for the child. and crawled under when bridged between two chairs. Develop trunk rotation Sit the child astride an appropriate size roll and rotate trunk left and right. A. Develop perceptual skills The longer rolls make excellent seats for the teacher and child for one-to-one instructional or sensory stimulation exercises. B. Roll can be crawled over or walked over.

Favored weight bearing on extended forearms 2. Applied Uses: 1. In general the ideal size wedge for a child will be one whose surface is long enough to accommodate the child’s body (in the prone position) form sternum (breastbone) to the feet or at least to the knees. Favored weight bearing on shoulders b. 3. strip. Promote extension of hips and knees Place child in prone position symmetrically so that weight 15 . 4 in (10 cm) high. Favored weight bearing on elbows c. cm) cm) cm) Attaches Selection of a particular wedge will depend to a great extent on the size of the child who is going to use it. Provide weight bearing on upper extremities Position child in prone position on appropriate size wedge to accomplish: a. Facilitate head raising and controlled movement Position child in prone symmetrically with upper extremities extended over the upper edge allowing head to be unsupported.PC 2795E PC 2795J PC 2795F PC 2795L PC 4768B with Velcro Wedge 8x24x26 in (20x61x66 cm) Wedge 10x20x22 in (25x51x56 Wedge 10x24x26 in (25x61x66 Wedge 12x24x26 in (30x61x66 Add-on leg abductor wedge.

Proceed with gentle flexing to provide movement.bearing is felt on trunk. Facilitate normal pre-crawl development a. 4. 16 . positioning upper extremities higher. In turn the knees will be freed to extend and bear weight. This position is also useful for postural drainage. Maintain this for whort attended periods. b. Incline positioning while supine a. b. if the weight bearing is favored on lower extremities. turn child around. Facilitate rolling skills The child is placed crosswise on a moderately sloping wedge. Place child in prone position on a moderately inclined wedge so weight bearing is favored first on upper extremities as the lower extremities are positioned higher. helping the hips to extend and bear weight. Lay the child symmetrically on the wedge so that the head is in a down position (at the low end) to reduce tone. 6. Conversely. 5. The incline is used to assist the child in trunk rotation.

need a wedge that is too high for reaching and grasping. simply raise the play area on a board. Side lying positioning The wedge provides an ideal shape for relaxed side lying positioning on a slight incline. towels. the child will be weight bearing excessively on the forearms. Of course. stool or block. leaving the play area too low. The child may. If the wedge is too low. prop against and brace yourself. b. 9. for other reasons. if the wedge is too low.7. Position the child symmetrically prone. Since this condition will increase flexor spasticity. and to compensate for front to back changes while ascending and descending. place another wedge on top or prop the front of the wedge with blocks. Reaching and grasping activities also will help increase range of motion. Therapist bracing As you work with the child you will find wedges comfortable for you to lean against. 17 . Reaching and grasping activities a. or sandbags. c. preventing reaching or grasping. 8. 10. The wedge should be of a height that permits the elbows and forearms to rest lightly on the floor. The child has to adjust to balancing on the soft foam for left to right response. Develop balance reactions Place two wedges butted together at the highest end providing an up and down ramp.

pushing.Balls Application: The 16 inch and 22 inch balls are used for developing vestibular responses. body awareness and muscle strength. Sizes: PC 2769C PC 2769L Neuro Developmental Training Balls Set Contains all three sizes Neuro Developmental Training Ball 22 in (56 cm) has rigid core for adapted support PC 2769M Neuro Developmental Training Ball 16 in (41 cm) PC 2769S Neuro Developmental Training Ball 11in (28 cm) 18 . spatial orientation. yet firm foam. with colorful. cleanable. balance. Tumble Forms’ unique coating helps to prevent the balls from sliding. The 22 inch (56 cm) ball is built with solid structural core with an outer layer of firm foam to prevent “bottoming out”. The smallest (11 inch) ball is primarily designed for rolling. Construction: Soft. throwing. sealed upholstery. catching and may also be used for adapted kickball.

(16 in ball may be used with infants and small children for the gross motor activities described). have him sit on the ball while you roll it back until child is centered on top of the ball. 1. The 22 inch or 16 inch Balls. have child stand with the back of his legs against one side of the ball. hold the child at the hips with both hands and gently begin rolling from side to side. Sitting on the 22” ball. Develop head righting and trunk extension 19 . move ball in different directions to stimulate balance reactions. child’s arms should “hug” the sides of the ball while his legs are extended straight from the hips. gradually increasing the distance of the rolling motion. a. b. 2.Applied Uses: 1. Balance activities Lay child prone on surface of appropriate size ball.

20 . encourage child to raise his entire upper body from the ball’s surface to “fly like a bird” while giving him support with both hands on his hips or legs. 1. Give prone activities at a suitable working height while the child is prone on the ball as illustrated. roll the ball forward and elicit the protective extension reflex. 2. Develop trunk and upper extremities Have child lie prone on the top ball with head. d. Use as a “push” ball Elicit protective extension reflex: Lay child prone on appropriate size ball with arms in front of ball giving child support at hips. trunk and arms totally relaxed and hanging down against the sides of the balls.c.

f. Child sitting on ball with support at the hips. 2. Facilitate relaxation Especially appropriate for spastic children.e. Elicit trunk equilibrium response Lay child prone on an appropriate size ball. 1. decrease muscle tone by quietly rocking while child is in prone position on ball. Arms should be flexed as shown. Encourage child to flex head to elicit total flexion pattern. i. again giving child support at the hips. Do the same as above. It is especially important that this particular activity be supervised by a therapist. The child’s reaction to this activity should be carefully monitored so that over – inhibition does not occur. Provide vestibular stimulation in different planes 21 . Develop supine flexion Lay child supine on the ball with legs and knees flexed. h. Stimulate trunk rotation On the ball place child on his side using firm steady pressure push shoulders away from you and hip toward you. gently rock ball forward/ backward and sideways. g. alternately pulling and pushing.

with its Shepard casters. helps develop a child’s neuro-motor control as he propels himself in any direction. in pre-K or younger children by having the child sit on the ball feet flat on the floor. Both are coated with Tumble Forms’ unique material for protection and easy cleaning. The more advanced child can be asked to rotate on the ball with his arms outstretched to the side while maintaining good balance. Two scooter boards are available. 1. k. and prone extension can also be created by holding hands with the child while he is prone on the appropriate ball. It can be used to facilitate equilibrium reactions. vestibular input. Move the top child back and forth so that the ball rolls on the bottom child’s chest. while engaging in various activities. catching and may also be used for adapted kickball. abdomen and legs. 24” in diameter square. Promote weight bearing on knees and ankle For example: knee walking hugging the appropriate size ball. eliciting prone extension and automatic equilibrium reaction from the top child. Have the second child lie prone over the ball. pushing. This provides a “heavy touch” pressure to the child on the floor. The 11” ball is primarily designed for rolling. Sensory Integration “Sandwich” – begin with two children of approximately the same size. Balance reactions.j. One is a circular board. The PC 4814B Round Scooter Board. thereby creating the required movement. or 22 . throwing. Have one lie supine on the floor with the 11” or 16” ball on is abdomen. Tumble Forms Scooter Boards 2.

It should be emphasized that for reasons of safety. The convenient handles on the sides prevent injury to his hands and help to support the child. be pulled by a second child or teacher if the child on the scooter holds on to a rope. As the Scooter Board moves. the child should never stand on the Scooter Boards. he learns to orient his body to shifting space and to reorient his balance. As for the PC 2780A Gym Scooter. teacher or playmate. first in a clockwise.swivels and rotates. the smaller size of the board and the lack of handholds limit its use to the child able to propel himself and to control his balance. However. The Round Scooter may also be used like the Jettmobile to rotate the child. but this type of activity also requires a measure of control. It may. of course. Russell Sage College Department of Physical Therapy PTH 417 23 . this smaller square unit may be used for the same types of mobile activities and spatial orientation. then a counter-clockwise direction. and all activities should be supervised. The child may also be pulled or pushed or rotated by a therapist.

Magnus (10) in his 1924 publication. postural influences are needed to maintain stability. the primitive reflexes no longer dominate. In the rehabilitation of the individual with disturbances of muscular control. rationale for one component of coordinate movement – development of a normal postural reflex mechanism is proposed as follows. Posture is almost continuously mobile (3) and. the nervous system reacts to the stressful situation and the release of more primitive mechanisms can be seen in movement and posture (4. and to attaining and maintaining an upright posture. etc. In the normal development of the child. and the individual can once again control his movements and posture. When the stressful situation is removed. Rights and equilibrium reactions are vital to normal sensorimotor development (2). the righting reflex. According to R. “korperstellung”. primitive reflexes or postures are often demonstrated (as in the high guard position of the arms due to the influence of the parachute reaction) (6).Let’s get on the ball (The Swiss Ballgymnastik Technik) A handout presented to participants at a workshop on Swiss Ball Gymnastics Rationale: Mature coordinate movement (1) is achieved through the interaction and integration of several developmental components.). brain tumor.” Most postural adjustments affect the entire body through a chain of reactions (4). In attempting these higher level functions. He demonstrated that the postural reflexes were manifested in the human in certain clinical cases of cerebral dysfunction (as in Cerebral Palsy. these adjustments are provided automatically. but failed to observe these reflexes in adults as basic patterns of movement due. Martin (3) states that “associated with every voluntary movement which significantly changes the shape of the body there is a postural adjustment which has the effect of protecting the equilibrium. when in motion.8. refers to the reflex movements which occur to recover the normal position of the head 24 . in part. When an individual with an level of development. In mature coordinate movement. to the action from higher nervous system centers.7. Once such postural reflex. postural adjustments and righting and equilibrium reactions should be understood in order that adequate assessment and treatment can be accomplished.9). To aid in this understanding. He also suspected the presence of similar reflex activity in normal healthy adults. postural reflexes play a fundamental role in the formation of normal animal postures. equilibrium reactions in sitting and quadriped positions are integrated before the child will be able to independently come to standing or take his first steps alone (5).

Fukuda (11) stated that with elicitation of the reflex. One such therapeutic technique. The fine adaptations necessary for maintaining an upright posture or making the fine adaptations necessary for postural stability upon which coordinate mobility can be superimposed is difficult (12. normal coordinate movement is no longer possible. When the postural reflex mechanism is impaired. Fukuda also studied two other postural reflexes in normal. with maximal neuromuscular effort. almost all of which are based on certain common denominators. the person who has incurred a hemiplegia secondary to a CVA may not be able to walk without the use of a brace and crutch or cane. 9). higher levels of function are difficult to coordinate.and / or body when they are changed in relation to the earth or to the horizon. In the case of individuals who demonstrate some type of cerebral dysfunction. It is suggested from the research of Magnus and Fukuda that when the human nervous system is under stress. healthy adults engaged in athletic or recreational activities. the nervous system and normal coordinate movement. Following an insult to the human nervous system. In explanation of this reflex. 25 . the reappearance of primitive reflexes may interfere with coordinated functioning in the upright posture. For example. postural reflexes are either excited or not inhibited to the usual degree. or tool. healthy adults: the tonic neck and tonic labyrinthine reflexes. However. such as in strenuous neuromuscular activity or cerebral dysfunction. He concluded from his research that the postural reflexes exist in the human “extrapyramidal system” as reflex patterns and their manifestations in normal healthy adults usually are inhibited by impulses arising from the cortex or higher centers in the brain stem. supine. Rehabilitation therapists attempt to improve postural adjustments in patients with disturbances of neuromuscular control through the use of many varied techniques. sitting and quadriped positions will facilitate the development of normal coordinate movement. for attempting to activate more normal postural adjustments is the use of the Swiss Gymnastic Ball as an adjunct to the treatment program. He concluded that many such activities will include movements which can be more efficient or forceful if a postural reflex is incorporated with the volitional dynamic movement. Removing the stress on the nervous system by allowing the individual to first develop postural control in prone. He is unable to make normal postural adjustments due to the varying degrees of loss of proprioceptive and sensory motor function (13). Fukuda’s studies were done with normal. the vestibular organ mainly participates along with visual and proprioceptive senses. these higher centers “actively connect with the extrapyramidal system” and manifestations of those reflex patterns may occur in daily movements.

An imaginative and skilled therapist can adapt Swiss Ball Gymnastics for use in many varied treatment programs. Consequently. for example. depending upon your experience and training. the therapist who uses Swiss Ball Gymnastics as a part of a treatment program must be alert to the responses of the patient. your approach to treatment will be influenced by your experience and training. Assessments are available with which you can establish a baseline measurement for your patients. ranging from those designed for persons with severe neuromuscular disorders to conditioning exercises for normal healthy adults. As long as righting reflexes are present so that the individual can maintain an upright sitting posture with minimal assistance. After determining the goals of treatment in this manner. therefore. of necessity. The important thing is to ascertain a baseline measurement of the patient’s abilities and needs. whether the problem deals with neurologic 26 . The technique must be continually adapted to the individual needs of the patient in order to be effective. the assessment determines and continually influences the treatment (14). it may be the comprehensive treatment program. make fine postural adjustments in order to stay on the ball. be determined by the results of an initial and continuous patient assessment.The Swiss Gymnastic Ball seems to be more effective than a chair or stool due to it’s narrow base of support and dynamic qualities. Assessment: The primary use of Swiss Ball Gymnastics is an adjunct to the treatment programs for persons with problems of neuromuscular control. Skilled use of the Swiss Ball Gymnastic Technique will give you an additional tool in attaining the treatment goals you have established. although in selected cases. If you are skilled in the use of Brunnstrom’s (13) “Movement Therapy in Hemiplegia”. the Swiss Gymnastic Ball can be an adjunct to the treatment program. In a goal-oriented treatment program. Your own assessment or those for other therapeutic approaches to hemiplegia with which you feel comfortable could also be used effectively. Many approaches to hemiplegia emphasize the importance of initial and continuous assessment based on the identifiable stages of recovery. if. skilled in evaluating the patient’s needs and creative in developing and adjusting the techniques. The criteria for including Ball Gymnastics in a treatment program will. The patient or participant must. the patient’s diagnosis is hemiplegia secondary to CVA. you have an existing assessment form and procedure at your disposal.

Stay seated on the ball. or in strength and coordination. supine. maintaining approximately a 90 degree angle at the hip. The above will require fair abdominal function and co-contraction of trunk musculature. Head righting reflexes are present (righting reactions should be assessed in prone. This suggests that: 1. can he/she: 1. as well as poor to fair lower extremity muscle function. Blood pressure B. Protective extension responses of upper and lower extremities may be absent or delayed. Maintain a midline position (lateral stability). On the Ball A. Tendencies toward dizziness and/or nausea 4. if the patient demonstrates a problem with balance and equilibrium reactions. Review and/or check the patient’s status. Hemorrhagic tendencies 5. including: 1. 2. and sitting). Cardiopulmonary function 2. 2. 3. 2. knee. or any of a myriad of difficulties. and anteriorposterior stability. and ankle. The patient should be able to sit on a chair or mat table independently. Whatever type of assessment is used. Readiness Criteria: 1. Trunk stability and lower extremity function are sufficient to maintain a midline sitting posture provided the base of support is stable. but the potential should be considered good for an increase in functional neuromuscular control. Be sure the patient is medically stable (consult a physician before using Ball Gymnastics). functional muscle function. the Gymnastic Ball can be useful in the treatment program provided that the following minimal readiness criteria are met. In a guarded situation (giving the patient assistance if necessary by providing external support at the hips or knees and feet). 27 . Off the Ball A. Seizure activity which may be stimulated by ball gymnastics 3. decreased range of motion.disorders.

The Basal Ganglia and Posture. Milani-Comparetti. J. Philadelphia. 28 . Neurol. Develop. Georgia State University. References 1. E. Martin. E. calcification. Oogler. 1975. 3. C: Self-Instructional Package on Differentiation of Human Skeletal Muscle.B. A. 4. The Neuromuscular Maturation of the Human Infant. 9... P. MA. 631-638. Gilfoyle. The motor Deficit in Patients with Cerebral Palsy. Remember that the above are minimal readiness criteria. Welsh. Physical Therapy Dept. A. K. adapt your treatment program. Bobath. 3. Neurol. as their presence will influence the treatment program. C. From Proceedings of the Occupational Therapy Symposium on Somatosensory Aspects of Perceptual Deficit. Co. Be sure to safeguard the patient at all times. 1974. Child. Any regression in function is indication for critical re-evaluation of the patient’s abilities and your treatment program.. School of Allied Health. Boston. reassess. McGraw. Lippincott. and surgery must be noted. 7.P. posture disorders. Contractures. Clinics in Developmental Medicine. 2. No.B. 1967. Med. A Developmental Theory of Somatosensory Perception. Med. Boston University. 1972. C: Equilibrium Reactions in the Feet of Children with Spastic Cerebral Palsy and of Normal Children. and Gidoni. 580-591. Child.. Houser.. Routine Developmetal Examination in Normal and Retarded Children. 17. Additional Precautions A.P. or discontinue Swiss Ball Gymnastics. Gunsolus. 1966. particularly during the initial treatment sessions. edited by Anne Henderson & Jane Coryell. 1967. B. 6. J. & Grady.. 23. New York: Hafner. 1966. If pain or spasticity increase.. M. Published in The Body Senses and Perceptual Dificit. Develop. 5.

Springer. S. Stockmeyer. Walters. 10.R. IL...: Tonic Neck Reflexes in Exercises of Stress in Man. S. of HEW. 1975. Normal and Abnormal Development. S. Brunnstrom. 1924. Prinzipalmarkt 22/23 Postfach 1528 Germany The “Hippity Hop” can be used for simple exercises. R. Medical Dept. Stockholm.. 11. New York... A Sensorimotor Approach to Treatment. 1956. Ed. A report of two symposium. Charles C.. 1972. Physical Therapy Services in the Developmental Disabilities. Acta Oto-Laryngologica Karlavagen 41.8. Partridge. Hellebrandt. M.J.J.A. T. Berlin. Korperstellung.A. Thomas Publisher. M. Med. Houtz. 9. Phys.. 13. Movement Therapy in Hemiplegia. In The Child with Central Nervous System Deficit. S. Fiorentino. F. Amer. Leila Green.E. 1961. Stockmeyer. 29 . 35:144-159. 14. Magnus. 1970. J. A Pattern for Evaluation in the Assessment of Motor Performance. Sporthaus-Brinckmann 44 Munster/westf.S. 12. Springfield. C. U. Studies in Human Dynamic Postures From the Viewpoint of Postural Reflexes. Dept. Harper & Row Publishers. Fukuda.

C. and it seems to also facilitate dorsiflexors in some exercises. discontinue the ball. and still be close enough for safety. Part II: The Basic Routine Adapt According to Individual Needs 30 . Techniques: A good spotting technique is for the therapist to sit on another ball or rolling stool behind the patient while facing a mirror. increases motivation. and tends to decrease inhibition in some patients. Precautions: Ball gymnastics require much cortical effort in the beginning. The patient feels safe with this arrangement. recheck posture. may cause an increase in spasticity. and it is exhausting.B. The quick stretch given the biceps when bouncing. especially in the upper extremities. test abdominal strength. Work totally within your patient’s tolerance. and if necessary. The therapist can shift to facing the patient when both feel more secure. give minutes may be too much! Be extremely cautious with CVA patients due to hemorrhage or whenever there is a possibility of hemorrhage. Dental dam can be placed around the thighs just above the knees to facilitate hip abductors even more. If low back pain is experienced. From this position. it’s possible to correct postures. Music helps rhythm. At first. give resistance when indicated.

Straighten the leg to which the arms are directed. Adduct scapula. Depress shoulder. Stretch & Bounce a. Alternate sides b. Alternate sides without bounce b. Stretch to extreme & then relax into a slow bounce b. Knees should be directly over feet. Try without bounce and then with a bounce 31 . weight equally distributed over both feet in a comfortable base of support. Swing both arms in an alternating pattern Rotation Patterns: a. Trunk Rotation a. DO NOT allow anterior pelvic tilt. PNF patterns may be added to this exercise. Keep eyes on the hand which is “behind”. Stretch as far as possible. Attempt to touch the floor on each side. Alternate sides b. Stress rhythm. With bounce Stretch to the extremes of this exercise. 2. 4. Lateral Bending a. Keep knees apart and feet flat on floor. patterning 3. Use the basic technique of PNF diag. Sitting Posture Chest high! Maintain “plumb-line” posture: shoulders relaxed & level. do this slowly. Do first without bounce c. Allow basic righting and equilibrium reactions to “happen”.The Warm-Up 1.

The Gymnastic Routine (Beginning Balance) 1. Add reciprocal arm swing Constantly check on maintenance of good posture. Pelvis stability is essential for successful performance of the exercises which follow. Alternate feet only b. Lateral pelvic tilt (both sides) c. Resistance may be given at the hips. 2. Walking Rhythm a. Add reciprocal arm swing Check that lumbar curve is not lost. Basic Sitting Posture a. Anterior-Posterior pelvic tilt b. 4. Alternate legs only b. 5. Marching Rhythm a. Pelvic Mobility (for stability) a. 32 . b. Do not sacrifice correct posture for a straight leg. Try each component of the more complex techniques individually before combining them. Watch that knees remain “over the feet”. Hamstring or low back tightness will prevent maintenance of correct posture. without bounce with bounce These techniques should be attempted first without a bounce & then with a bounce. Reciprocal Arm Swing 3. Combined Circles The pelvis is to be motion & not the legs or upper trunk. Feet may be brought closer together to maintain balance. This is more difficult than it appears & most patients need careful instruction & practice to develop this skill.

Leg Abduction a. Bounce around as in “a” but keep always in contact with the floor. “Hippity-Hop” a. the ball should be under the thigh of the “forward” leg. Weak abductors will be obvious in this exercise. At extreme extension. bounce out & in change legs in rhythm to bouncing on the ball. Alternate legs b. 33 . 7. Increase timing Bounce leg out to side in short hops at first. 8. bounce from one side to the other without a center stop position. Stretch hip flexors & return by bouncing the leg. allowing feet to rise. Pelvic hike b. The footwork on this exercise is beneficial. For coordination. Progress to bouncing it out in 1 hop.These Exercises Require Fair-to-Good Balance/ Equilibrium Reactions 6. Rotate trunk to face straight leg Bounce each leg out to the side and around to the back. Slow Side Roll a. Bounce around in one direction & then the other. Alternate legs 9. Finally. Leg Extension a. b.

Roll backward In supine.c are done easily in position. Keep hips high and level (see arrow) Rotation should be accomplished in the upper trunk while pelvis stabilizes. 34 . Weak abdominals. Keep the ball at midscapular level. check to see that scapula is well stabilized. Bend and straighten elbows in prone. c.This exercise is good also for teaching one leg kneel for coming to standing. do not let it go too high. “Flutter-kick” One arm stand. roll ball slowly to the side alternating sides. kick both straight legs high. Sit to Supine a. Sit to Prone a. Toe touch b. ball should be between scapulaehips high When a. d. c.b. hamstrings or gluteus maximus may prevent this exercise from being performed correctly. More Difficult Exercises 10. Sit forward on the ball. Maintain abduction of the “bent” leg at all times. b. 11.

Alternate sides.Rotate pelvis. 12. abduct “upper” leg. and return b. Look over the shoulder at abducted leg. rotate 35 . This exercise should be performed slowly and with control. Prone to Knees a.

This posture. if continued will delay the baby in acquiring a midline head position with a chin tuck in supine. etc. engaging hands in midline and engaging in hands to knees and hands to feet play. 36 . (all important movement components and building blocks for later gross motor skills). shoulder extension and elbow flexion and the lower extremities in a frogged-like position (flexed. Through handling we can prevent. The baby learns and perceived these postures/ movements as “normal”. Some babies will arch their hips. trunk and head into extension while in their cribs or when being handled. This frequently will be to the exclusion of more normal ones. also of the degree of cortical input necessary in the beginning. or at least minimize their strength and frequency. This. at home.Become proficient at ball gymnastics before attempting to teach them to your patient. positioning and moving the baby in such a manner as to inhibit/ discourage primitive. This will give you an appreciation of how fatiguing it is and. This handling can be incorporated into the daily care of the babies while in the nursery and later. For example. Children’s Rehabilitation Hospital Department of Physical Therapy Incorporating Therapeutic Handling into Daily Care Activities Therapeutic handling can be defined as holding. hands engaging. a premature baby becomes very comfortable lying in supping with the neck hyper-extended and rotated to the side. The more the baby is allowed to lie and move in primitive/ abnormal postures. scapular adduction. the stronger and more habitual they will become. Babies become comfortable in postures in which they are placed and with movements which they have already used. widely abducted and externally rotated).) needed for normal movement. and/or abnormal postures and movements and facilitate or encourage more desirable postures and movements. too will prevent the normal acquisition of anti-gravity flexor control (head midline.

diapering and positioning while monitoring his physiologic responses to this handling.The baby who is relaxed with limbs “collected” in flexion is less irritable and better able to accept visual and auditory stimuli. She is in an ideal position to handle the baby therapeutically during feeding. feeding and general movement. In the intensive care and transitional nurseries. The handling need not add more time to the daily care program. the nurse is with the baby frequently. Some suggestions for therapeutic handling are as follows: 37 .