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Phelps Approach For Treatment of Cerebral Palsy

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W.M. Phelps, an orthopaedic surgeon in Baltimore, was one of the pioneers in the treatment of cerebral palsy who encouraged physiotherapists, occupational therapists and speech therapists to form themselves into cerebral palsy habilitation teams (Phelps 1949, 1952; Slominski 1984).
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    The main points in his treatment approach were as follows:

    Specific diagnostic classification of each child as a basis for specific treatment methods. He diagnosed five types of cerebral palsies and many subclassifi-cations.

    Fifteen modalities were described and specific combinations of these modalities were used for the specific type of cerebral palsy.

    The modalities (methods) were:

    (1) Massage for hypotonic muscles, but con-traindicated in children with spasticity and athetoids.

    (2) Passive motion through joint range for mobilising joints and demonstrating to the child the movement required. Speed of movement is slower for children with spasticity, increased for rigidity.

    (3) Active assisted motion.

    (4) Active motion.

    (5) Resisted motion followed according to the child’s capability.
    The above modalities were used for obtaining modalities 6, 8, 10 and 12.

    (6) Conditioned motion is recommended for babies, young children and mentally retarded children. This included a routine and the use of the same song or jingle for the same movement modality (2–5).

    (7) Confused motion or synergistic motion which involves resistance to a muscle group in order to contract an inactive muscle group in the same synergy. Mass movements such as the extensor thrust or the flexion withdrawal reflex were usually used. For example, using the hip–knee flexion dorsiflexion synergy, to stimulate inactive dorsiflexors by giving resistance to hip flexors. Confused motion is used by children when selective isolated movement is not possible.

    (8) Combined motion is training motion of more than one joint, such as a shoulder and elbow flexion using modalities 2, 3, 4 and 5.

    (9) Relaxation techniques used are those of conscious ‘letting go’ of the body and its parts (Levitt 1962), tensing and relaxing parts of the body. These methods are mainly used with athetoids. They attempt to lie still or relaxed or use contract–relax or active ‘tense-up and let go’ relaxation for grimacing and other involuntary motion.

    (10) Movement from relaxation is conscious control of movements once relaxation has been achieved. It was mainly used for children to consciously control involuntary movements.

    (11) Rest: Periods of rest are suggested for athetoids and children with spasticity.

    (12) Reciprocation is training movement of one leg after the other in a bicycling pattern in lying, crawling, knee walking and stepping.

    (13) Balance: Training of sitting balance and standing in braces.

    (14) Reach and grasp and release used for training of hand function.

    (15) Skills of daily living such as feeding, dressing, washing and toileting.
    Many aids were devised by the occupational therapists.

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    Braces or calipers

    The appliances were designed and developed by Phelps. He prescribed special braces to correct deformity, to obtain the upright position and to control athetosis. The bracing is extensive and worn for many years. The children are taught to stand and step in long leg braces with pelvic bands and back supports or sometimes spinal brace. As they progress, the back supports are removed, then the pelvic band and finally they wear below-knee braces. The full-length brace has locking joints at hip and knee, so control can be taught with them, locked or unlocked.

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    Muscle education

    Children with spasticity are given muscle education based on an analysis of whether muscles are spastic, weak, normal or zero cerebral – being unable to act. Muscles antagonistic to spastic muscles are activated. This is to obtain muscle balance between spastic muscles and their weak antagonists. Athetoids were trained to control simple joint motion and do not have muscle education. Ataxics may be given strengthening exercises for weak muscle groups.

    Others, including Rood (1962) and Tardieu et al. (1982), have also developed ideas on muscle education. Plum and Molhave (1956) advocated strengthening spastic muscles as well as their antagonists. However, Plum exercised the spastic muscles in their outer ranges as the muscles are usually shortened, whereas the antagonists are exercised in their middle and inner ranges. Tabary et al. (1981), in a ‘factorial analysis’, identified the specific problem in the muscles which gives rise to abnormalities and deformities. According to this careful analysis, treatment is given where indicated. Alcohol injections were used to diminish spasticity. Today, neurologists no longer recommend this due to side effects. Other drugs are used by them.

    Tabary et al. (1972), Tardieu et al. (1982) and Dietz (1992) have shown specific changes in muscle length (hypoextensibility) of spastic muscles and also changes in the muscle structures which are quoted in current therapy literature. Studies by Tardieu et al. (1988) suggest prolonged passive stretch for 5–7 hours to obtain a change in length. This was carried out in braces by Phelps, but currently, better designed, lighter orthoses have been developed. The equipment suggested by the therapists in Phelps’ centre continues to be used in occupational therapy and physiotherapy, with improvement of their designs as well as design of additional aids. For example, an upright standing frame was used but has also been improved in various currently used designs which are also adjustable in more ways. Weight bearing to prevent hip dislocation was advised by Phelps (1959). Current treatment to prevent hip subluxation stresses the use of modern standing frames for early weight-bearing and hip joint development.

    Damiano (2007) refers to recommendations by Phelps to use resisted motion in cerebral palsy to develop strength. Researches by Damiano and others confirm the value of resisted exercises (Dami-ano et al. 1995a,b, 2002a). However, she recognises difficulties such as problems of poor isolation of muscle control (selective motor control) in some children with spasticity. Phelps called this ‘confused motion’, which therapists later generally discouraged by training selective motion of a particular muscle group as part of motor development.

    Progressive pattern movements

    Temple Fay, a neurosurgeon in Philadelphia, recommended that the cerebral palsied be taught motion according to its development in evolution. He regarded ontogenetic development (in humans) as a recapitulation of phylogenetic development (in the evolution of the species). In general, he suggested building up motion from reptilian squirming to amphibian creeping, through mammalian reciprocal motion ‘on all fours’ to the primate erect walking. As lower animals carried out these early movements of progression with a simple nervous system, they can similarly be carried out in the human in the absence of a normal cerebral cortex. The midbrain, pons and medulla could be involved in the stimulation of primitive patterns of movement and primitive reflexes which activate the handicapped parts of the body. Fay also described ‘unlocking reflexes’ which reduce hypertonus. Based on these ideas, he developed progressive pattern movements which consist of five stages.

    Stage 1. Prone lying
    Head and trunk rotation from side to side.

    Stage 2.
    Homolateral stage
    Prone lying, head turned to side. Arm on the face side in abduction–external–rotation, elbow semi-flexed, hand open, thumb out towards the mouth. Leg on face side in abduction, knee flexion opposite stomach, foot dorsiflexion. Arm on the occiput side is extended, internally rotated, hand open at the side of the child or on the lumbar area of his back. Leg on the occiput side is extended. Movement involves head turning from side to side with the face, arm and leg sweeping down to the extended position and the opposite occiput arm and leg flexing up to the position near the face as the head turns round.

    Stage 3. Contralateral stage
    Prone lying. Head turned to side, arm on the face side as in stage 2.

    The leg on the face side is, however, extended. The other leg on the side of the occiput is flexed. As the head turns, this contralateral pattern changes from side to side.

    Stage 4. On hands and knees
    Reciprocal crawling and reciprocal stepping on hands and feet in the bear walk or elephant walk.

    Stage 5. Walking pattern
    This is a sailor’s walk called by Fay ‘reciprocal progression on lower extremities synchronized with the contralateral swing of the arms and trunk’. A wide base is used and the child flexes one hip and knee into external rotation and then places his foot on the ground, still in external rotation. As the foot is being placed on the ground, the opposite arm and shoulder are rotating towards it. As weight is taken on the straight leg, the other leg flexes up.

    Synergistic movement patterns

    Signe Brunnstrom, a physical therapist who worked with adult hemiplegia, assessed the stages of recovery and compared them with normal sequential neu-romotor development in early childhood. Her studies consider flexion and extension limb synergies leading to isolated motion. She produced motion by stimulating primitive movement patterns or syn-ergistic movement patterns which are observed in fetal life or immediately after pyramidal tract damage. The main features of her work are as follows (Brunnstrom 1970):

    Reflex responses are used initially which a patient could ‘capture’ and use later in voluntary control of these synergies to move. Later, the flexor and extensor synergies were modified (broken up), and voluntary function with more variety that was possible was elicited and practised.

    Control of head and trunk is attempted with stimulation of attitudinal reflexes such as tonic neck reflexes, tonic lumbar reflexes and tonic labyrinthine reflexes. This is followed by stimulation of righting reflexes and later balance training.

    Associated reactions are used as well as hand reactions; for example, hyperextension of the thumb produces relaxation of the finger flexors. Resisted action was used on the unaffected side to activate the affected side. The training of a patient’s voluntary control is developed later in the therapy programme.

    Sensory stimulation. Brunnstrom uses proprio-ceptive and other stimuli in her training, such as tapping or stroking for adult hemiplegia. We see some of these methods in the early Bobath approach and in other neurophysiological approaches which used hierarchical theories and sensory input.

    Proprioceptive neuromuscular facilitations (PNF)

    Herman Kabat, a neurophysiologist and psychiatrist in the United States, has discussed various neu-rophysiological mechanisms which could be used in therapeutic exercises. With Margaret Knott and Dorothy Voss, he developed a system of movement facilitation techniques and methods for the decrease of hypertonus, for strengthening, coordination and improving joint range (Kabat et al. 1959; Knott & Voss 1968; Voss 1972; Voss et al. 1985). The main features of these methods are the use of the following:

    Movement patterns (called mass movement synergies) based on patterns observed within functional activities such as dressing, walking, playing tennis, golf or football. These patterns are spiral (rotational) and diagonal with a synergy or chain of muscle groups. Isolated muscle education was not used as a movement pattern could activate a muscle group within a chain of muscles. The movement patterns are therefore not the ‘mass movements’ seen after brain damage, but are functionally derived patterns. They consist of the following simultaneously activated components in hips, knees and feet or in shoulders, elbows, wrists and hands:

    (1) Flexion or extension
    (2) Abduction or adduction
    (3) Internal or external rotation

    Sensory (afferent) stimuli are skilfully applied to facilitate movement. Stimuli used are touch and pressure, traction and compression, stretch or limb elongation and the proprioceptive effect of muscles contracting against resistance. Visual and verbal stimuli are included. All these stimuli provide clues for the direction of movement and are gradually reduced as the individual achieves the movement independently.

    Resistance to motion is used to facilitate the action of the muscles which form the components of the movement patterns.

    Special techniques

    (1) Irradiation is the predictable overflow of action from one muscle group to another within a synergy or movement pattern or by reinforcement of action of one part of the body stimulating action in another part of the body.
    (2) Rhythmic stabilizations which use stimuli alternating from the agonist to its antagonist in isometric muscle work.
    (3) Stimulation of reflexes such as the mass flexion or extension which are now no longer used.
    (4) Repeated contractions of one pattern using any joint as a pivot.
    (5) Reversals from one pattern to its antagonist and other reversals based on the physiological principle of successive induction.
    (6) Relaxation techniques such as contract–relax and hold–relax. Ice treatments are used for relaxation of hypertonus.
    (7) Timing in using various techniques to train coordination or timing-for-emphasis to improve an element of movement synergy.

    There are various combinations of techniques depending on the individual’s physical condition and the therapist’s goals. The use of stretch or traction and the optimal resistance needs careful use on unstable joints and level of muscle contraction.

    Neuromotor development

    Eirene Collis, a therapist and pioneer in cerebral palsy in Britain, stressed neuromotor development as a basis for assessment and treatment (Collis 1947; Collis et al. 1956). Her main points were as follows:

    The mental capacity of the child would determine the results.

    Early treatment was advocated before abnormal patterns could be established.


    The word ‘treatment’ was considered misleading in that besides the physiotherapy session there should be ‘management’ of the child throughout the day. The feeding, dressing, toileting and other activities of the day should be planned.

    Strict developmental sequence

    The child was not permitted to use motor skills beyond his level of development. If the child was, say, learning to roll, he was not allowed to crawl, or if crawling he was not allowed to walk. At all times the child was given a ‘picture of normal movement’ and, as posture and tone are interwoven, Collis placed the child in ‘normal postures’ in order to stimulate ‘normal tone’. Once postural security was obtained, achievements were facilitated and developmental sequences were followed throughout this training.

    The CP therapist. Collis disliked the separation of treatment into physiotherapy, occupational therapy and speech therapy. She established the idea of the cerebral palsy therapist.

    The developmental sequences became much more sophisticated and less strict. The idea of a cerebral palsy therapist has some appeal in the concept of a developmental therapist or primary interventionist. The worries of mothers were assumed to be helped by the treatment and by her willingness to be able to help her child. One hopes there is deeper understanding of parents’ predicaments and feelings today.

    Neurodevelopmental treatment (Bobath approach)

    Karl Bobath, a neuropsychiatrist, and Berta Bobath, a physiotherapist, based assessment and treatment on the premise that the fundamental difficulty in cerebral palsy is lack of inhibition of reflex patterns of posture and movement (Bobath 1965, 1971a,b, 1980; Bobath & Bobath
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