Key Points of Control ( Neurodevelopmental Treatment Technique )

Neurodevelopmental Treatment Technique

Key Points of Control

Following are the points from which spasticity is reduced and simultaneously to facilitate more normal postural and movement reactions.

1. Head

 Extension of the head (with extension of the shoulder girdle)

1. Rising of the head in prone - lying, in sitting and standing, helps in most cases to facilitate extension in the rest of the body. But if there is an influence of symmetrical tonic reflex activity when the head is raised, flexion of the hips and legs may follow, and this , although neck and spine extend, may lead to lordosis and increased flexor spasticity of the hips and legs.

If rising of the head produces a total extension pattern it is useful in prone lying and standing, but will interfere with hip flexion in sitting.

2. Flexion of the head with flexion of the shoulder girdle. This will inhibit extensor spasticity or extensor spasms, (e.g. in spastic and athetoid patients with strong neck and shoulder retraction when they are in supine), and facilitate head control when pulled to sitting, and when turning to either side. It will also inhibit hyperextension of hips and knees in athetoids when standing and walking.

If, however, symmetrical tonic reflex activity is present, flexion of the head and shoulder girdle forwards, in supine, will tend to increase extensor spasticity of hips and legs and in this way interfere with sitting up, even if head control is improving. Sitting up, then using flexion of head and shoulders against this resistance may result in a Kyphosis of the spine. 

2. Arms and shoulder girdle.

 All inward rotation at the shoulder with pronation of the elbows inhibits extensor spasm and is useful in athetoids, but in spastic patients it increases flexor spasticity of neck, trunk and hips, as well as in the legs. 

 All outward rotation with supination and extended elbows inhibits flexion and increases extension in the rest of the body.

1. Horizontal abduction of the arms in outward rotation with supination and extended elbows inhibits flexor spasticity, especially of the pectorals and neck flexors, and facilitates the spontaneous opening of the hand and fingers. It also facilitates abduction of the legs with outward rotation and extension. 

2. Elevation of arms in outward rotation inhibits flexor spasticity and downward pressure of the arms and shoulder girdle and helps extension of spine, hips and legs in spastic quadriplegias and diplegia. However, if this flexor spasticity of the arm is part of the pattern of extensor spasticity of the leg as in spastic hemiplegia, elevation of the arm with extension of the hemiplegic side flexors of the trunk, facilitates flexion and abduction of the hemiplegic leg, because it breaks up the pattern of flexion of the arm and extension of the leg.

3. Extension of the arms diagonally backwards, inhibits flexor spasticity as in horizontal abduction and may be more effective in severe cases and better to start with than the former, because when the arm are moved forwards into horizontal abduction, flexor spasticity may become stronger .It facilitates, like the horizontal abduction, the opening of the hand and fingers, even when at first the arms are in inward rotation and extension (Temple Fay, unlocking of Reflexes), but it should be done if possible with outward rotation. (Adduction and inward rotation of the arms increases adduction and inward rotation of the legs and flexion of the trunk. It should therefore be avoided in treatment.)

4. Abduction of the thumb with the arm in supination. Outward rotation and extension facilitates opening of all fingers. The wrist should be extended.

3. Legs and pelvis

1. Flexion of legs favors (facilitates) abduction and outward rotation as well as dorsiflexion of ankles.

2. Outward rotation in extension facilitates abduction and dorsiflexion of ankles. 

3. Dorsiflexion of the toes, especially of the outer 3 or 4 toes inhibits extensor spasticity throughout the leg and facilitates dorsiflexion of the ankle, as well as outward rotation and abduction of the leg, but it makes extension of knees and hips more difficult, especially when standing.

4. Prone

1. Head raised, arms extended above head, spine extended facilitates extension of hips and legs.

2. The same, i.e. head raised but with horizontally abducted extended arms, facilitates extension of dorsal spine, opening of fingers, and abduction of legs.

3. Head to one side, while lifting it up, facilitates flexion - abduction of the leg of that side and movement of arm upwards as in creeping.

Head towards affected side facilitates activity of arm and leg on that side in hemiplegia.

5. Supine

In young children (not very spastic) but with neck and shoulder retraction, flexion of the legs in abduction against the abdomen, with some pressure downwards, facilitates the child's arms moving forwards and hands engaging in midline.

6. Sitting 

1. Flexion of hips, trunk well forwards, legs abducted, facilitates extension of spine and head rising. (Tailor sitting makes this easier, but is a danger to feet and gives too much flexion at hips with subsequent danger of flexor contractures at hips, difficulty in standing later on and lordosis.) It should be done with extended legs, i.e. long - sitting.

2. Adduction of the extended arms: Arms held forward stabilizes the shoulder girdle and facilitates head control when pulled up to sitting and back to supine again.

3. Pushing against the sternum, thus flexing the dorsal spine inhibits neck and shoulder retraction and brings head and arms forward, for head control, and reaching out forwards with arms. 

7.  Kneel standing, standing and walking  

 Flexion of arms with pronation and inward rotation and flexion of the dorsal spine inhibits extensor spasms and hyperextension of hips and knees in athetoids, but produces flexion at hips and knees in spastics.

1. Extension of arms in outward rotation, holding them slightly diagonally backwards, inhibits flexor spasticity of trunk, hips and legs in spastics, and facilitates extension of spine, hips and legs with outward rotation and abduction.

8. Four - foot kneeling and weight bearing with extended arms and open palm.

This is facilitated be lifting the child’s shoulder- girdle up and pulling his shoulders backwards. This prevents excessive protraction of the shoulder (with pectoral spasm). It inhibits flexor spasticity and adduction of the arms and facilitates extension, abduction and the opening of hands and fingers.

Written and edited by 

Dr Akshya Raj Chandra 

Consultant Pediatric Physiotherapist

Active Learning Child Development Centre Noida 

pH +917827068879

       

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