POSMODEV Who are we Main markers of the postural development Questions, definitions Central Coordination Disorder (C.C.D.).
Cerebral Palsy (C.P.) motor education : myth or reality..? More about reflex locomotion Fitting for C.P. children Documentation and training


THE VOJTA CONCEPT



HISTORY


In the years fifty, in Czechoslovakia, Vaclàv VOJTA, neurologist concerned by the motor rehabilitation, began the long way from the first empirical attempts to the current therapeutic concept. This evolution has continued in Germany where V. Vojta had emigrated in1968. From Munich, an international system of collaboration and formation has gradually developed in Europe and in the whole world..

The research committed by the Professor V. Vojta has always comprised two simultaneous ways :

* The neurological investigation, led to the elaboration of an evaluation methodology of the child development, of its dynamics, and its main disorders.
* V. Vojta has always considered the nervous system as an open system, endowed with a basic, phylogenetic organization, but also with a receptivity to various stimulations able to affect its functioning and even to have an effect on its anatomical maturation.

The " reflex locomotion" gives physically shape to the conjugation of these two complementary aspects; it constitutes the axis major of an original therapeutic protocol that has first intended to the children with Cerebral palsy ( CP).

In the course of years, the constant refinement of the observation and the theoretical reasoning, based on the practical experience of an increasing and dynamic team, operating in multiple sectors of activity, has contributed to a considerable widening of the indication field : peripheral or central neurological disorders of the child from the neonatal stage up to the adult, and a majority of disorders concerning the locomotor anatomical system.


OBJECTIVES


The Vojta "method"is for the physician a precious clinic tool for the evaluation of the child development from birth, and a reliable element of diagnosis; it is for the physiotherapist an efficient global therapy which can be used from the first days of life, in a preventive or curative intention.

The treatment based on the reflex locomotion contributes to:
* Modify the reflex activity of the young child and to orient the neuromotor development in a more physiological direction, by the induction of a different central neurological activity that supplies to the patient a new corporal perception. The muscular "proprioception" plays here a very important part.

* Modify the spinal automatisms in lesions of the spinal cord .

* Control the breathing in order to increase the vital capacity.

* Control the neurovegetative reactions , and promote an harmonious growth of the locomotor anatomical system .

* Prevent the orthopaedic degradation, frequent in severe pathological situations.


THEORETICAL FOUNDATION, METHOD


A- MEDICAL POINT OF VIEW


V. Vojta proposes a methodology in three parts for clinic evaluation of the development :

1 - Study of the postural automatic reactivity:
The test of global reactions to sudden corporal position changes in the space (7 to 11 tested reactions), enables to highlight every perturbation in the automatic management of the postural mechanisms by the Central Nervous System (CNS). The progressive transformation of these reactions in the course of the first year of life, in the context of a normal development, is perfectly codified; their examination enables, not only to signal functional anomalies from central or peripheral origin, but also, to specify the level of development reached at the moment of the examination.

Picture 1 - Evaluation of the postural reactivity:
example of 3 main stages of the Vojta reaction . Tests consist of a sudden change of the corporal posture in the space (here a rapid lateral incline), that induces a reaction of the vertebral axis and of the limbs (here these of the upper side ). The normal reaction transforms in the course the first year according to precisely codified modes. It is therefore possible to discern a normal reaction for the age, a reaction indicating a delay, or an erroneous reaction indicating a central coordination deficiency.

2- Cinesiologic analysis of the spontaneous motor function:
Each stage of a normal development is characterized by behaviours answering to precise finalities (orientation, appropriation, locomotion, etc...); these fundamental needs induce the implementation of locomotor strategies, automatically adapted to the postural context of the moment.
The originality of the Vojta methodology is to define clearly the cinesiologic content of these locomotor strategies; in other words, postures, support polygons, movements characterizing the main stages of an optimal development are precisely defined; the distinction between a multitude of individual variants and fundamental postural components is clearly made, in order to enable their systematic research at the patient and the comparison with possible pathological succedaneas..

Picture 2: Healthy child, 3 months old:
In the prone position, the baby releases automatically the upper limbs and builds a triangular support polygon, with symmetrical support on both elbows that enables the elevation of the shoulder belt and of the superior thorax to heave the head freely in the space, out of this polygon.
This postural automatic mechanism, entirely enslaved to the visual need, contributes to the orientation in the space, it consists of a combination of very precise muscular synergisms in the vertebral axis and the shoulder belt insuring the alignment, the symmetry and the stabilization of these corporal regions, that will guarantee the coordinate rotation of the head. The artificial activation of these synergisms is possible from the birth during the reflex locomotion.

Picture 3: Healthy child, 4,5 months old:
In the prone position, the child has to liberate one upper limb for the prehension. That will be possible by releasing sideways the homolateral lower limb to constitute a new support point on the knee, this new support point will automatically substitute for the disappearing support point at the homolateral elbow . The support polygon is modified. This operation concretizes the appearance of a support diagonal line (from one elbow to the opposite knee); it announces ulterior forms of locomotion such as the dissociated quadrupedic locomotion, the dissociated walking.
The automatic emergence of this global postural pattern is a preliminary condition to the good progress of the prehension in the prone position ; it's again an "enslaved pattern". This postural pattern includes very precisely coordinated muscular synergisms, of the vertebral musculature, of the trunk and of the limbs; these muscular games are also present in the reflex creeping, which can be activated from the birth under adequate stimulations.

Picture 4: Child with a cerebral palsy:
The global support pattern on one single elbow has never been accessible, the lower limb is not released to constitute a new support point on the knee because the necessary coordinated vertebral rotation for this movement is not realized. The prehension unfolds according to a postural substitution pattern, fundamentally different of the pattern illustrated by the picture 3. A functional rehabilitation soliciting frequently a such activity contributes to perpetuate the pathological postural procedure, by delivering to the central nervous system an erroneous afferent proprioceptive flow...

3 - Reflexology:
A series of reflexes selected in the medical literature, whose modes of provocation, answers and interpretation are precisely described, come to complete the diagram of examination to refine the immediate evaluation but also to specify the prognosis.
The long term follow up of many children has shown that the presence or the absence of these reflexes, their quality, their validity period, could be corroborated with different paths of development (spastic, dyskinetic, etc...).

The severity of the " central coordination disorder " (CCD) is appreciated according to the number of abnormal postural reactions, and of the possible conjugation with aberrations of the reflexology (exceeding normal validity periods of reflexes, qualitatively abnormal answers etc...).

The confrontation of these three types of data enables to classify the CCD in several categories, whose the most benign do not justify a physiotherapy, as it was proved by several a posteriori statistical studies, realized with important series of patients.
Severe or medium CCD, correspond to a major risk of invalidating complaint ( cerebral palsy, or other illness), and justify therefore the early therapy.
light C.C.D can be the expression of sensory or psychomotor various disorder, belonging or not to a definite syndrome , and justifying an attentive supervision of the ulterior evolution or further medical investigations .

That shows the importance of this classification that helps the physician to prescribe the early physiotherapy in every necessary case, to avoid useless prescriptions, to anticipate complementary investigations. The CCD is a transitory situation, already pointing out the functional disorder of the CNS. The severity of this disorder has to be quantified to specify the therapeutic indication. More about C.C.D.

B - PHYSIOTHERAPY


The physiotherapy according to V. Vojta is based on the notions of reflex locomotion and "pathing" (forcing a neuronal way).

V.Vojta has described (1954) motor global behaviours, or patterns, activated with the spastisc patients: by realizing movements against resistance in the axial region of the body ( trunk, head, hip or shoulder key-articulations) appeared particular muscular synergisms, propagating to the rest of the body. The cinesiologic content of the pattern varied according to the initial posture (start position), but the phenomenon appeared organized and repetitive. It presented especially a reciprocal character, such as can be found in the different forms of locomotion.
The analysis of these muscular activities (synergisms) has shown that they were elements of a combination clearly devoted to the locomotion.

The observation of these movements against resistance by the fixed spastic patient, announced the discovery of innate and global locomotor systems : the reflex creeping and the reflex rolling. The reflex locomotion is used since 1959 for the treatment of the child's motor disorders, it was later used with babies to prevent the installation of these disorders.

Reflex locomotion patterns (ref.creeping and ref. rolling) are global; during these activities, the totality of the musculature is activated according to a coordinate mode. The different levels of the CNS are concerned by this activation . The reflex locomotion is provoked by specific stimulations (pressures) applied on defined zones.

Picture 5: Start position for the reflex creeping and general situation of the zones:
The head position determines the position of the limbs, different on the face-side and the nape-side

The reflex creeping appears from two opposite start positions called "reciprocal positions"; each zone is therefore bilateral and the therapist has at one's disposal 18 access points to the afferent nervous system (proprioceptors, exteroceptors, connective tissue...) that can be used in an infinity of combinations. Defined pressure directions, are applied on one or several zones; during this stimulation, the therapist must be able to control the position of the patient, and to apply, if he wishes it, a continuous resistance to the provoked motor answering. In order to achieve this, the therapist may use different parts of his own body (abdomen, forearm, knees, etc...)

Picture 6: Direction of the motor answering composing the reflex creeping pattern:


The phasic movements of the limbs ( visible displacement of corporal segments) and the head rotation are conditioned by the active creation of fix points at the extremities of the "support diagonal " (face-elbow and nape-heel); the therapist has to be very attentive to this point. The isometric motor activity of this diagonal includes a finely differentiated work of vertebral muscles and of the limbs roots .

The coordination of the antigravitic muscular activity, of the vertebral alignment, of the opposite rotation between the pelvis and shoulder belts, of the muscular contractions that radiate to extremities of the limbs, belongs to the patterns of the superior human locomotion (creeping, walking).

Picture 7: Pull direction of the muscular chains during the reflex creeping.


The active creation of peripheral fix points, enables the muscular organization in oblique chains that exert tractions on the bone levers according to differentiated directions. Isotonic chains (pic.7, ch. 2 and 3) have a phasic mission and determine segmental movements; isometric chains (pic.7, ch. 1) are devoted to the stabilization and govern the emergence of the antigravitic and locomotor function (pic. 7 and 8). The convergence place of these muscular chains is the spine and especially the dorso-lumbar transition.

The experienced therapist will certainly note
- that the dorso-lumbar region is frequently the place of the infantile cyphosis in neuropediatric disturbances compromising the stabilization of the vertebral axis,
- that this region is also the opposition place of the physiological double rotation in all the differentiated locomotor patterns (quadrupedic locomotion, walking)
- that the coordinate vertebral rotation is the privilege of all the fine posturo-motor functions and is cruelly missing in the totality of neurological pathologies from central origin,
- finally, that the dorso-lumbar transition is subjected, in the active human life, to many mechanical constraints which require a rigourous automatic control based on the proprioceptive information.
This enumeration underlines the interest to obtain for our patients of all ages, through the activation of precise automatic muscular games, a good corporal experience , that makes largely call in the deep sensitivity, and contributes to the elaboration, or to the restoration, of the unconscious corporal scheme.

Picture 8: Main muscular elements of the support diagonal during the reflex creeping


Picture 9: Other examples of start position: a- half-quadrupedic position called "first position", b - lateral decubitus, phase 4 of the reflex rolling, c - lateral decubitus, phase 3 of the reflex rolling...


There are different start positions (prone position for the reflex creeping, supine or lateral for the reflex rolling etc...); therefore the therapist can choose between innumerable combinations of start positions, zones and stimulations corresponding to the same number of activation procedures for a coordinated central function.

The application of resistances against the provoked activity, transforms the phasic movement into an isometric muscular activity (without segmental displacement), whose duration can be modulated by the therapist without addiction (proprioceptive receivers). This practise leads to a temporo-spacial accumulation , then to a neuronal "overflowing" phenomenon to "force" a new neuronal itinerary. This enables, by the recruitment of new afferent ways to the CNS, the activation of possibly underexploited central territories. This technique is called pathing, it consists in provoking, then artificially maintaining , from outside, the muscular isometric contraction with the aim of soliciting a widened and coordinated activity of the CNS.

Each reflex locomotion pattern (creeping or rolling) has specific zones and can be activated from several start positions. Accessing to the same pattern from different stimulating combinations, forces the central nervous system to resort to diversified processing procedures of the afferenting flows; that means varied neuronal itineraries. These neurological procedures are to the basis of the physiological postural adaptability.

The pattern sequences ( muscular synergisms) observable during the reflex locomotion present a strict analogy with motor sequences of the normal motor development. They can be found in the ontogenese from the first antigravitic activities (pic.2 and 3), until it forms the finest bipedic locomotion with its stock of postural, antigravitic and equilibration automatisms.... These neuromotor elements , exist in the reflex locomotion, they can be activated from the birth under an adequate activation procedure (table 1).

Table 1:
Comparison of reflex creeping sequences
with spontaneous motor sequences of the ontogenese
Reflex creeping
(artficially provoked activity)

Activity
Appearance age
Ontogenese
(finalized, spontaneous activity)

Appearance age
lateral step of the upper limb in prone position

elbow support
from the birth
(nape arm)
(face arm)
3 months
Free coordinated head rotation with symmetric vertebral axis
from the birth
3 months
Lateral movements of the eyes, independent of the head posture
from the birth
end of the 1 quarter
One elbow support
(support stabilizing synergisms)
from the birth
(face arm)
middle of the 2 quarter
Total opening of the hand, with radial bending of the wrist , abduction of the metacarpus
from the birth
(nape hand)
end of the 2 quarter
Coordinate differentiation of the shoulder and pelvic belts
from the birth
6 months, rolling from dorsal to ventral
Activ creation of the knee support with loading
from the birth nape lower limb, variant of the ref. creeping)
quarter 3
Coordinate push with the lower limb and heel support, foot in the 90° position, support on the external foot edge.
from the birth (nape lower limb)
14 -15 months


The V . Vojta technique presents decisive advantages in physiotherapy:

1) The patterns activated during the therapy are automatic and innate, they are usable, even in the absence of aware participation of the patient, without lower or upper age limit (baby, polyhandicapped person etc...).

2) The possibility to provoke precise muscular games, acting in synergism on choosed corporal segments , and to modulate in space and time these synergisms by the combination of start positions, zones, and stimulations, offers to the therapist a therapeutic tool particularly adapted to peripheral or central neurological disorders.
This technique is also precious for the treatment of corporal territories whose aware control is difficult or altered (absence of visual feedback, disorder of the corporal schema etc...); the spine scoliosis , various congenital malformations are good examples.

3) The first answering elements are neurovegetative and the long time practice has shown the influence of this technique on the sanguine circulation, on breathing, but also on the sensory system, and in the long term on the development of bones and joints .
The activated muscular chains commonly include the abdominal muscles and the diaphragm, the vertebral muscles and the trunk muscles; they contribute to a notable improvement of respiratory conditions, of the urologic physiology and of the defecation.

4) With young children, it was frequently observed that the motor progress are not isolated, but coincide with a clear improvement (according to the severity of the pathology) of the relational aptitude.

6) In very severe pathologies, where functional ambitions are limited and where the orthopaedic degradation threat is major (severe spasticity, asymmetry etc...), the regular activation of a better coordinated muscular function, that the patient cannot produce by himself, is an important therapeutic argument to prevent deformities.

C - INDICATIONS OF THE V. VOJTA TECHNIQUE


Severe and medium central coordination disorders
Light but asymmetrical central coordination disorders
Cerebral palsy
Muscular and neurogen torticolis
Peripheral Paralyses (child and adult)
Spina bifida
Congenital myopathies - congenital deformities (athrogryposis, club foot etc...)
Morbus-Down syndrome and other syndromes - motor delays
Various postural disorders (scoliosis, cyphosis)
Hip dysplasies
Adult hemiplegy (unexhaustive list)...

D - EXAMPLES OF THERAPEUTIC SITUATIONS


The physiotherapy according to V. Vojta, consists in activating complex neurovegetative, sensory and motor reactions, that can begin locally, then radiate to vaster corporal territories or to the totality of the body. The starting point of reactions can vary in the course of time with the same patient, and from a patient to the other.

Picture 10: 3 years old child, spastic tetraparesis, hyperlordose and severe hypertony of the adductors, pelvic asymmetry.


Picture 11: Same child as picture 10 in the 1 phase of the reflex rolling (variant with maintenance of the jawbone, and the nape-arm in abduction). The motor answer consists of an active alignment of the vertebral axis, the activation of the abdominal musculature and clear diminution of the lordose; lower limbs are maintained in medium flexion with a beginning of abduction and external hip rotation. The active correction is insufficient in the cervical region (lordose) and at the feet. This could be researched by modifying the combination of stimulations.


Picture 12: 2,5 years child, left spastic hemiparesis (down side), provoked correction of the valgus foot during the reflex rolling (variant of the 4 phase). The head is stabilized (maintained) in the alignment of the vertebral axis. The answering of the left upper limb is not correct.


Picture 13: 20 months child, aftereffects of embryopathy with severe psychomotor delay, great hypotony, dorso-lumbar cyphosis and major postural asymmetry (level of locomotor performances lower than 6 months). During the reflex creeping, active rotation of the head to the median axis, contained by the resistance (abdomen of the therapist), global coordinate activation of the trunk musculature, vertebral alignment, creation of the elbow-heel support diagonal (beginning of the antigravitic function). The lateral phasic step of the face-side lower limb and of the nape-side upper limb indicates the isometric dissociated rotation of the shoulder and pelvic belts.


Picture 14: 6 years child, spastic diparesy (walking possible with sticks in a limited perimeter), variant of the reflex creeping where the nape-side lower limb is in complete flexion in the start position . Creation of the elbow-knee support diagonal, strong activation of the abdominal musculature, vertebral alignment, but the cyphosis is inadequately controlled, lateral step of the phasic limbs (nape UL and face LL). Observe the irradiation of the muscular activity to the face-hand in extension and radial bending of the wrist, abduction of the metacarpus, harmonious finger flexion and opposition of the thumb on the cylinder. This cylinder has been first placed in the hand to induce a proprioceptive and exteroceptive afferent flow corresponding to a functional attitude of radial prehension.


Picture 15: 5 years child, left spastic hemiparesy ( nape-side). In "first position ", imperfect construction of the support diagonal (from the face-elbow to the nape-knee) because the left foot is well perpendicular to the leg during the action, but toes would have to be bent and the supination stronger. Nevertheless the answer of the upper limb of the concerned side (left) is good , with active opening of the hand, a bit more abduction of the thumb would be desirable...


Picture 16: Same child that pict. 15, left spastic hemiparesy ( nape-side). During the reflex creeping, with the nape-side lower limb in flexion, the answer of the injured upper limb is again clearer with total opening of the hand, in radial direction, the answer of the homolateral lower limb comes better in the foot, although the dorso-lumbar spine is not ideally controlled.

The provoked motor activity can be right away isometric, or initially phasic and then become isometric by application of resistances; it may be massive but also discreet (localized muscular fibrillations for example).
The patient is only aware of a part of the provoked activity, he can also feel effects that the therapist does not perceive; conversely, the therapist can observe clinic activities that the patient does not feel, and whose he is not aware.
It is not easy to illustrate photographically director principles of this therapy, and the complex internal mechanisms that participate there. Only the most flagrant manifestations can be photographied.
It's only by the further study of the technique, and by the regular practice that the therapist will progressively be able to discover the subtler and diversified aspects of this therapeutic approach.

PRACTICAL FORM - FAMILY PART


It has been possible to verify (electromyographic control) that the neurophysiological modifications induced by the pathing technique subsisted a certain time after the working session . It is therefore beneficial to repeat the treatment several times per day to increase the frequency and the duration of these effects.
The treatment is recommended 3 to 4 times per day; each session lasting 15 to 20 minutes, the optimal therapeutic conditions represent therefore one hour to 90 minutes of daily rehabilitation, divided in parts of about twenty minutes.
The therapist initiates the family to a standardized treatment; he assures naturally the technical control, and brings this treatment regular up to date. It is an advantage, with an infant, to work at the most propitious moments of the day, and to respect the biological rhythms.
The concrete and active collaboration of the parents, guided by the therapist, contributes to a climate of confidence and reciprocal encouragement between the professional and the family. It is a constant relationship support between the therapist and the parents about the child and his evolution. This collaboration contributes to the information of the parents, to the enlightenment of situations by a lucid perception of the progress as well as the difficulties. It reduces the risk of inadequate behaviour about a child with an uncertain development.
Interventions of the therapist can be spaced out, more than during a "classic" follow up; it has also economic consequences.
The practice of this therapy is perfectly compatible with an ordinary social life, it demands only a few organization. Sessions of work are not very long. In a lot of specialized centers, the technique has integrated to the usual multidisciplinary follow up.
The Vojta technicity has a lot developed in Germany in the course of the 25 last years. The epicenter is the "Kinderzentrum -München", main pole of training for Europe, whose medical team manages all training actions undertaken through the world. Training courses for the physicians and physiotherapists, are regularly organized. The training is nowadays also possible in local language, with all guarantees of authenticity, in different countries: Austria, Spain, Italy, Norway, Holland, Sweden, Japan, Korea ...


BIBLIOGRAPHY


- Die Zerebralen Bewegungsstörungen im Säuglingsalter: Vaclav Vojta - Ferdinand Enke Verlag Stuttgart
- Das Vojta Prinzip:Vaclav Vojta, Annegret Peters - Spinger Verlag Berlin, Heidelberg, New York, London, Paris, Tokyo, Hong Kong.
- Le concept Vojta: H Lagache - Kinésithérapie scientifique n° 366 - S.P.E.K. Paris, 1997


CONTACT - FORMATION


- Internationale Vojta Gesellschaft: Wellersbergstraße 60, 57072 Siegen - Germany
- Deutsche Akademie für Entwicklungs-Rehabilitation - Kinderzentrum München - Heiglhofstrasse 63, 81377 München - Germany
- In France: Mr H. Lagache, Email: Posmodev

POSMODEV Who are we Main markers of the postural development Questions, definitions Central Coordination Disorder (C.C.D.).
Cerebral Palsy (C.P.) motor education : myth or reality..? More about reflex locomotion Fitting for C.P. children Documentation and training