1.Spinal cord horizontal reflexes.
Including flexor contraction reflex, extensor jerk reflex, cross extension reflex, trunk lateral bending reflex, hand grip reflex, plantar grip reflex, pedal reflex, automatic walk, and magnet reflex.
2. Brainstem horizontal reflexes.
Including asymmetrical tense neck reflex, symmetrical tense neck reflex, tense vagus reflex, and joint response.
3.Midbrain horizontal reflex.
Including neck adjustment reflex, body-to-body correction reaction, body-to-body correction reaction acting on the head, and body-to-body correction reaction.
4, brain mass horizontal reflex.
Including supine tilt response, prone for tilt response, knee-hand position balance response, standing balance response, protective stretch (parachute response), sitting protective stretch, straddle response, and foot dorsiflexion response.
5. Abnormal postural reflexes of cerebral palsy.
Including positive support reflex, crossed extension reflex, asymmetrical tense neck reflex, asymmetrical tense neck reflex, symmetrical tense neck reflex, tense vagal reflex, and joint response.
Neurodevelopmental treatment manual techniques
Treatment goals
1. To make every effort to make the child with CNS injury experience normal posture and normal movement patterns through manipulation of manual techniques.
2. To pay special attention to: the quality of motor patterns, especially the sequential adjustment and control of head and scapular girdle postures: the optimal integration and coordination of motor patterns.
3.Inhibit abnormal movement and postural reflexes (primitive reflexes) and promote or induce normal postural responses (vertical responses and balance responses).
4.The training nurse should guide the family to manage and train at home, so that the training treatment is uninterrupted and has continuity.
I. Treatment principles
1. Coordination of movement patterns.
The main content of the treatment is not for muscle paralysis, but for movement disorders and loss. Attempting to strengthen and stretch each muscle is not the true meaning of treatment. New fine movements can be learned only through the learning of motor patterns, not by activating each muscle. The key is the coordination of motor patterns and their concomitant coordination of posture. This is the higher level of unification.
2. Correlation of movement, posture and postural muscle tone
Movement is a dynamic process that accompanies posture; posture precedes movement and facilitates movement; movement is merely a changing posture. Only when the strength and distribution of postural muscle tone is normal can there be normal posture and normal movement. Normal posture and normal postural tone are the basis of normal movement. Treatment is the use of movement, posture and postural muscle tone of this interrelationship and interaction, through the correction of a certain function to change other functions, so that the direction of good, the direction of normalization.
3.Self-regulated movement and random movement
The maintenance of appropriate posture and muscle tone and balance, when normal, is unified by the subcortical center and is autonomic. Through this mechanism, the cortical centers plan for intentional (conscious) motor actions and carry out various mental activities and functional activities such as learning.
The random motor pattern is based on such autonomic postural responses as the vertical response, the balance response and the protective response. The early motor patterns that appear in utero are also autonomic postural responses.
The goal of treatment is to induce exactly these autonomic responses. The advantage of functional activity at the autonomic level is that it reduces much of the tension that occurs when excessive effort is made during treatment. It is effective even when the child is not cooperating or when mental functioning is low, and is suitable for young children.
4. Active and passive movement
Learning a new motor function must be active. It is not desirable to do only passive movement, and it is difficult to learn new motor patterns. Only active movement indicates that the motor function has formed a circuit in the central nervous system. The intervention must be at an optimal level or at a minimal level. Avoid abnormal responses due to stress and excessive effort in children. Autonomic motor responses such as the vertical response and balance response should be evoked at the subconscious level.
5. Interaction and competition between motor patterns
The principle of competition between motor modes is a characteristic of the brain. In normal development, the primitive reflex gradually disappears when the vertical response appears, and after the balance response appears, the vertical response is unified by the balance response, forming a more mature autonomic response.
In children with cerebral palsy, the primitive reflexes such as the nervous reflexes are dominant, so that the vertical and balance responses are not developed. When treating children with cerebral palsy, it is also important to avoid the long-term dominance of one motor and postural pattern that affects the development of related postures and movements.
6.Promote or inhibit the postural response through sensory afferent control
Appropriate control of sensory afferents indirectly controls motor efferents, so that a more normal sensory feedback can occur and a normal autonomic response can be established, thus effectively learning casual movements.
Sensory afferents are integrated by the central nervous system to motor efferents, forming a circuit. One of the properties of the central nervous system is that repeated sensory afferents to motor efferents can easily form circuits in the center. Sensory afferents are regulated and controlled according to the response of motor efferents. This requires a repetitive signal input process. By controlling sensory afferents to promote the normal postural response and inhibit the abnormal postural response.
Second, the general principles of training treatment
1. Perception and correction of self body image
The quality of movement and the learning of new motor refinement depend on the previous sensorimotor experience and the perception of self-image. The perception of self-image is a prerequisite for normal development. It is difficult to perceive the spatial position of the self (up and down, left and right, front and back, etc.) without first perceiving the parts of the body and their interrelationships. For example, the ability to control the head and upper trunk can only be developed if the majority of the weight in the prone and supine positions is loaded on the head and upper trunk.
2. Staging of therapeutic stimulation
Although the development is continuous, there are obvious stages. For example, erect head, turn over, sit, crawl, grasp stand, stand alone, walk, etc.
Instead of giving multiple qualitative and quantitative crude stimuli at the same time, the most critical treatment (key point) should be given in the training according to the developmental status. However, it is important to avoid the predominance of one mode and to diversify the movement patterns by adjusting them while maintaining the staging so that they experience a variety of postures and movement patterns. However, the phasing of stimuli must be continuous. It is hard to imagine that it is unscientific to train standing balance in a child who cannot even hold his head upright. It is possible to train standing balance in a child who has the ability to support his lower limbs appropriately.
3.The components of movement
The complex fine motor is based on the simple motor components acquired early in development, which is the pre-fine motor stage. The most basic and important pre-fine motor stages are the uprightness of the head and trunk; the stability of the trunk, scapular girdle and pelvis and other proximal parts.
The focus of training is not on functional movements and completion of developmental targets, but on the postural foundation and balanced motor response necessary for autonomic and casual movement. For example, for the development of sitting position, it is necessary to train many motor components such as the proper integration of flexion and extension (sagittal plane), amphibian response (coronal plane), trunk gyration (horizontal plane), parachute response (protective extension response) and sitting balance in order to make the development of sitting position perfect and stable.
4.Motion therapy and static therapy
Facilitating vertical response and balance response are the main goals of treatment, which are induced by moving weight or changing posture; therefore, treatment should not be static, but must be dynamic. Weight shifting should be used as a means to induce postural responses.
If the child is asked to lift the lower extremities and pelvis from the floor in the supine position (contraction of the abdominal flexors) and rock the body from side to side, the extension muscle groups will be stretched (unification). It is important to start with a small range of motion and gradually increase the range of motion. Stationary, fixed in one posture often causes contracture of the joint (secondary change).
5.Individual treatment and training
Developmental deviation from the normal track even a little can sometimes become a hindrance to advanced and complex fine movements in later developmental stages, making it difficult to pull back to the normal developmental track, so early treatment is necessary.
Individual differences must be taken into account when implementing treatment plans for manipulative therapy, and should be targeted. Children’s responses to stimuli and responses to various manipulations can vary considerably depending on the basic postural muscle tone. Games and activities cause hyperexcitability and increased muscle tone in some children, which should be noted.
The speed and rhythm of movement affects muscle tone. Doing very slow movements can be a fixation of abnormal patterns; in children with excessive tone, rapid movements do not provide sufficient time for postural adjustment.
The direction of gravity also has an effect on postural muscle tone. In a low tension pediatric patient, gravity sinks to the floor and paralysis does not provide an opportunity for postural muscle tone to improve, preferably in an upright position with a little support to move; in a high tension pediatric patient, the upright position will be more unstable and make the body more rigid. Special hand skills such as joint approach, tapping and vibration greatly improve muscle tone, so it is suitable for those with low muscle tone.
6.Triggering motor movements by manipulating manual skills
Touch stimulation should be appropriate, do not put excessive pressure. Do not hold the child too tightly. Pressure on the palm of the hand and all fingers can make the pain caused by local pulling and pressure from the fingertips disappear. Manipulation should be flexible and micro-mediation should be performed to induce the optimal response. Exact pressure on a single key point is desired. Key points in the central part of the trunk, scapular girdle and pelvic girdle have the greatest influence on motor patterns (Vojta method) Frequent changes in hand placement, jumping from one point to another, can become a crude stimulus confusing the senses of the child and not tolerated. Facilitate the vertical response and balance response by weight shifting.
III. Treatment means
Head control; trunk control; turning base prone crawl; supporting weight with upper limbs; protective stretching of upper limbs; four crawl movement; standing position and walking.