129

Rehabilitation H. Habrfellner.

in

gatr

and th

Nandic.pped

PatLentrs

louth.

age group on sports for th padiatric In a recent editorial you can (17) athlt on vhat cites a handicapped w,B. stlong Iearn in sports: t'Discipline... how to nake most of your tirne...ftexibil-ity..rl and he continus su[nj-ng up |tth essence of sports - to ]rave and to learn hov to take appropfun, to learn onrs abilities sports should prepare a youngstr for riate but safe risks. game of life, \.'hich afCr all, should be an enj oyable th journey.I' nethod as it has I an sur that alt who kno!. the Hallirrick been crated and devlopped by J. McMillan ("Mac" for his although over th yars vilt agree hat this citation friends) aind at th abl bodid is applicabl-e to the handicapped and as !,t1f . t their able bodid trhlprsn and I'insructors" E s p e c i a l l y t h e n o t i o n s o f g a m e r r n r r j o y r r f i t w e l l t o l l l a c t s concept in water, and rbabilitacion habilitatj.on from v,rhich the with rspect to cerebral palsy, the condition to point of our patints suffers, it is appropriate najority " 1 , a r n i n g ' f l e x i b i l i t y r ( b y pushing and onrs abiliLies" to I ' t o hav funrr. and on's linitaUions) pictures of practically a1I handicaps ar characThe clinical of postures and terized by too fevr performanc variations choics which of functional movenents. It is this restriction picturs. th nain rason for individual clj.nical constitutes ricerebral pafsy" as wIl as in othr cntral n so called usually ar not a direct novhent dj.sorders thes restrictions consquence of an alteled qualiy of central nervous syLh th consequenc of strucNot are such restrictions functions. (e.g. skletal) changes in t[any othr case. nixture tural ones are of sevral factors anongst vhich the psycho-social in restricting the perfornance level. not the least ihportant Tbis can be seen even in sound and valid persons. w all are of us having to act well aware that at least the najority sorts of strss usually r.rill fall back to a under diffelent poorr functional lvl end rarely prforn in an optlnal nanner. in itts different forns does not only seduce a prson stress Levl but also to reduc th !o perforr on a lowr functional freedoh for an j.ntended novenent (10). degrees of functional sereo-yp. whj.ch Motor behaviour thus becones a prdictable a s a n a j o r e x p r e s s i o n of pathology. i t s e l f i s c o n s i d r e d in rpatternsr person do belong th used by a handicapped lthough t h e r e p e r t o i r e a l s o f o u n d i n n o n h a n d i c appd population to the - and of few of then has ill functional too the exclusive use nhy a highr consequncs. That is in structural ultirnately sense the us of such a restricted set of pr s Inornall postural and novenent patterns has ben terned rpathological!. strss such as joy, The feveL at r.rhich ngative and positiv r o v r w h e l n i n g g o o d s t a res to reduce variawill' excitenenl of fredoh is an inportant derrninant of the dgre of tional handicap in a given person.

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To raise this critical threshold of stress that triqqers detrioration, to break up thse functionat restrictins in fact is the_prinary target of a1l forns of physical tratrnents. Particularty of Bobath's neurodewelolnntal therapy as vell. as it-,s differnt aspects of 'handling-' (3). Therapitic sports.such as riding on horsback and specially McMillan's Hallj.wick approach to therapeutic swirnrning have ffered exceptionally frtile countractions to the evr-threatening ten-' dncy of rstriction. This also holds tru for the "borderlandst' of sensor] -nocor pathology, aggravated by hental, emotional and bhavioral probl.ens, such as ' psudospasicityr (tiaberftlner, in preparact otr | . Hallirrick is not intended to teach swirnming exclusively, as Mac is used to state. It is intnded to brak up restr-ictions and to gve nor fredon to a population that i on th easy but dangerous way of avoiding runncessary' risks and hardsl bips. The psycho-social constellation of oth the patient and his _helpr/ instructor sinuftaneously bing in the ool and having to adapt to th conditions in watei offers i.rnrque possibil"ities. They are further augnentd by the HaIlii,rick_ specific features that can downgrae negative stress of insecurj.ty of fear: e.g. th l-:1 raaio of hndicapped and 'hetpersr, the special garns, and the us of sonq! which are providing the supporting tin-frame of rhythi and abov all the enotional sptint of conmonly expressed feelinqs of mutual respect, trust and joy. Lewin has defi.ned swinrnin as rrbreathing in waer'r (11). The interrelations betieen lespiration, nuscular tone, posture, novennt and on,s feelings are colnnon knoeledge and nd no furthr delination. fo si.ng together in watr i a royal short-cut towards the nornalization of ths factores which are so badlv out of balanc during every day lif in far too nany of ur patients. singing, or hunrning when used optihally, is itarted by an attempt to-tune into.the patient's peculiar typ of b;eathing. 'rn1s power!u-L cornnunj.cative tool can giv the patint trust and confidence and provide an enotional anchor. skilled instructor \^'ill change this individual pac in du tlne to bring it closer to the pace of the group in watr. The 'vlcious cycle, of continuous restriction is brokn up and by and by rplaced by elnnts of a rbeneficious cycle! ora1leling th patient's start to enjoy that taste of eing ccepted into this cordial comrnunity ln waler, and gain of notiol nal stability. Enhanced effctivhess wth respect to postural and rnovernent control reinforces this tendency. On top f all these positive cirsunstanqes .we have to rnention that the rtransfer' phnornenon of into every day Iif dos exist. lthough even tenporary experiences of this sort - during 1530 hinutes - of inhrsion in watr - woutd ju6tify all our Actual woak in watr as e1svrhre usualLy rneets vith rnany difficulties which inpede our attnpts Lo enhance the patiqntrs abilities as quickly as we wan to. Fiften year's work larith spcj-al ernphasis on inpaired fac-, nouth- and throat- functions have taught us some insight into the reasons of the rrstubborn clinging" to son 'inertia patternsr - as Mac

t 3l-

has happily dubbed the individually nodified tonic patterns dsplayed by so nany patients. We larned sone of the reasons why nany good-willj.ng popl unadvrtedly fel offnded of rernotionally left aloner by the specific behaviour of handicapped pople. and why so\ potntial and actual hIprs fel so uneasy that they hav troubles to share their tine lrith patients suffering .9. from crtain cerebral novernnt disorders. In short: fhre is a hieralchy of hurnan ihterests. First of all comes the ned to feel secur. That is. whenvr ttr patint gains the ihpression that vitat functions, his very survival are on stak, he turns to a stabilizing, securing tpattrnst rnanoeuvre - one of these fev restricting usually of nixed but nostly extensor type - at teast r,Jj.th respect to th neck (see bLow) . nd h viIl stick t it as long as h feels insecur. Nxt on the hierarchy scal comes th hunan interst in cornmunication. Not that vital intrests al\^rays will precede conununi.cative wishes while thes prcede locorotiv ones srhich in turn are given way by the dsir to chang oners surroundings directly by ' man ipulation ' . n untrained person nay ned tine to realiz that painfully experinced robvi.ous offensesr against eslablished but narrowIy frahd cornrnunicativ rutes (as thy are st by a sound coununity) are causeil by the patientrs handiqap. fhes rules exist only in the unconscious part of our nind. Neverthlss they are very potent. Non-vrbal xprssj.ons such as postures, gstures, fcial novennts, vocal utterancs and their refinements by articul-ation and prosody all ar influenced dirctly and indirctly by the sensorinotor control of one very delicate ara, the neck nppropriate hyper- or hypomobility of this region vith visible consequencs in practically all parts of he body are found in tnany nuscular, spinal, or cerbral movenent disordrs as soon as the patint facs a potential vital thrat - such as finding hirnsIf in vatr. Letrs have a look on hov specifical"ty dysfunctions of this region can prolongue the tiln neded for rmental adjustrnent' to the being in vater: Had and trunk ar linked dynarnically by the nobil-e structu!s of the nck. By adapting th position of the head in space and relatively to shoulder girdle and trunk these neck-structurs provid th basis for passive colulunication: i.. vision, hearing, smetling, as vl1 as active conrnunication: posture and expressive novenents of the body, the lihbs and especially the face and - not least - of vocal utterances. On the other hand the neck contains the vitallv critical crossing of rspiratory and digstiv tract. fe postural protection of this area, th portal, area of J.F. Bosha (2), is given perhannt prefernce. ndeed as long as th individuat is breathing, by day and by night th wi-dth of this ara has to be guarded, and collapse as !re1l as undue widening and disqortion of it's hobil \iralls hav to b prevntd. In fact the sing]e parts of this ara, especially the tongue and it's neighbouling structures are kept at an indivj-dual distanc frorl ach other. This fact provides a sense of security and

t32

rInains unchanged throughout

rtlt]'Es.

liftine

within

very narrow

Eruption of teth as well as toss of teth thus tads to a change of facial rsting xpression and facial dynanics. _ More seriously for the handicapped's sensory-motr function of his tongue is this influence of positional hange on transport of saliva, of food and speech articulation. Tha is !\,hy !I- try tooth by proper dental hygi.en and !9 protect every single - speciafly prophylaxis ffuoride in the group oi-severely positional nanorcappct patrents. adaptations in most cases nean forward dj.splacnent of the tongu, part of an ,extensor stereotyp' (see b1o'). Itrs worth to remenber that. physical and enotional stress nakes alf human beings pron to exaggeration of certain functional traits by turning their casuaL us into streotvDed us - at the expense of a whol range of other possibiliti. One of the nost frequntty eneountered and nrost inrpressive postural stereotypes is th pattrn of neck extension. It,s sudden onset specially in patients r.rith athetosis or an additional athetotic cohponent to anothr movment disordr usually does not only offend connunicative rules but actually lerrify the- lsser exprinced helper/instructor. neferring Lo the hierarchy of doraines w are to conclude that this patern is caused by the patintrs irnprssion of inadequate vit1 security. But then * narked and usually asyrnrnetric neck extension will cause asynnetric extension in other parts of the body too (4,10,12,1.3,16): In lrater it first causes lhe patint to chang his position. If h vas, Itrs say in an aided upright position, patient and helper will have troubles to keep it. Thy rathr tend to turn asynhtrically into the horizntal plane. Ther will also be changes in th facio-oral reqion. Bv mechanical and reflexive hchanisrns of rtonic' haractr the facial expression wi}l be one of a terrorized person: widelv opend eyes and nouth, further accentuated by ietracted Iips and protruded tongue. t first glance this is not a very god adaptatin to the submersion under nater that is likel.v t follov. still the unexprienced helper's instinctive raction, narnly to lift the patient so "that th water dos not qo into his widely opned mouthrt is a step into the wrong dj.recion. constant rnouth closure in and under riratr is not practisd by able bodied persons eithr. Expiration, sealing of ttre airwa! by velo-pharyngal contact and opposition of th back of thetongue to the soft palate as lrell as closure of the dl ft.i q are vry effective ineans of airway proieciio" ...tr3-i. uu the nost severly handicappd persons. So, lrbat causs a frightned patient as wll as a sound athlete $rho approaches the poin! of xhaustions or the pop1e who ar about to raise thi.r voic to retatively xtend their neck? First of atl the structural pecul iaritiesof the neck regions r,rhich effectively widn and stabilize th Dharvnqeal Icross-road-ra | . J.F. Bosna has shown that the neck lordosis provides as much wider sagittal- diaheer of this pharyngeat prt (2). Forward novenent of th tongu lrhich constitutes it,s nobile anEerror

t-33

factor. The Y-shaped walL is th single rnos! effective suspension systen of the hyoid bone which in turn provids support for the base of the tongue causes by purely nechanical reasons a forward novenent of th tongu by virtue of an posture of tbe nck. her ar additional xtended/ lordotic reftex hchani.sms such as the tonic genioglossus rflx - all acting in lhe (sauerl.and and MitchIt) but atso votition Bfore considering other factors that favour neck extension and j.trs dscribed effcts on nouth and throat letrs pause for a nonent and face a structural and fj.nally facial-cohconsequenc of th described motor conplx: Th nunicative position of front teeth is securd by the balance betwen with tongue and lips in thir respctj.v rsting positions, of lips andn forward swal.loving etc. Frequent retraction of the tongue alters front teth position so ehat thrusting or also the facial lip closur hay becone very difficult. the cornmunicaexpression acconpanying lip closure nay distort tive situation in such a !'ay that the patient prefers to have of lynphoid his rnouth pernanently opn. constant irritation tissues vill aggravate the problen of rnouth closur further. Drooling of saliva is but one of the consquences of th vj.cious circle rferred to here. If we want to h1p th patint with this probleh using the possibilitis that ar stress by reduce the patient's offred in r./ater we rnust first the specific Halli\^'ick techniqus partly aIrady alluded to of the neck and second help hin with indirect stabilization into area. The Halliwick-spcific way of hel-ping th patint the pool slabilizinq his arrns and shouLder girdl and hence his neck is aptly illustratinq this point. Hetp with postural control of the neck by influnc on th posture of arm and shoulder girdle is a {'ide1y and spontaneously used technique. witness ttte slping infants with 'floppy! muscular tone in the supine posj.tion (expcially froh rnuscular or spinal diseases) or th nckthos suffering of the infant or young child who stabiLizing aurposition starts to al-k, or the beautiful but - with rspct to th u n c o n n e n t e d i l l u s t r a t i o n i n N.R. Finney's book (3). It face of dnonstrates the well-known fact of nutual intnsification nck xtnand abduction of the shoulder and outward rotation sion, and on ttie other hand, of shoulder pronation and -in$rard and rotation and neck flexion. P1ease note that rflexion' rextension' ar relative and show grat inter-individual variations, such hutual interaetions lad to larger rfunctional blocks'. Bernstein (1) xplains that notor cntrol becones nuch asier for the central nervous systn if large parts of the body ale instead of being loosely novabl at the joints, kept rigidly This is on of th prihary functions of 'patterns'. Tirne, space, and knowledge does not allow us to analys other comnonly observd patterns too - that is vhy !r here in an xmplary tnannr only shal1 continu to considr nck xtension and itrs causes as this pattern is by far the lnost conlhon one if nre consi,dr all forhs of handicap and all age groups. Blockage of nasal airlrays will chang neck posture tonrards extnsion though sornetines in a vry subtle way. This b-

134

haviour rnay partly have it's roots in lhe early \reks of extrauterine Iife vhen blocked nasal airways are in fact a dahgerous situation for the majortiy of in-fants. Fron the reflexs irhich are to protect and to clar the vitalpharyngal ara onl.y is facifitated ly inportant by realtive neck fIxion (note that this is a flexion lrith a rrlong" nck) : svallo\^ring. The othr thr are favourd by rIative neck extensiorl: sneezing, coughing and gagging/iromiting. On considering the conplx task of protecting the permanntly ndangered cross-road of the pharyngeal aj.r'ay. it becones clear why the needs of this area doninate posture. and vhv on has to respct it if one is to chang a peison's habitual' postures and rnovennts, and finally Lrhy illustratiobs of sornatotopic rspresentations at all- leve1s of the centraf nrvous systern give a disproportionally large share to the facial-orf -and pharyngeal rgion. No!r, this ras only the situalion on l"and. fhere are additionat factors in water: titac taught us theoreically and practicalfy about th big changs that lnan experiences ii beinq upright in the water rrhile th waterlih reaches hiqhr than ih tl-. I nrill not repeat her alt the details oi posturaL and novernent chang brought about by the interactins of water with it's specific quatitis and the hurnan body. OnIy sorn hain consequences: Control of position of lgs and feet bcohes difficult and th genral human tendency towards vrtical posture rs replacd by a horizontal one. Th snsory organs providing references for position in space thus \rork under different conditions. Expecially the telereceptors (eyes, ears) but also vstibular olgans and -obviously tactile and tenperature receptors of the body surface. Partial veight-loss and different (rotatory) novlnent pattrns chang propriocptive afferences. Ithough rduction of posturaf huscl ton clinically becones irnpresrve 10-1.5 ninutes after ihnersion, to hold on for 3-5 hours after feaving the pool the change of affrncs j.s an imlnedlaEe one.

Inscurrty by alteration of sensori-rnotor and othr conpetencles force th patients to Iook for compensation. proprioception clos to th spj-na1 cotunn, expecilly of neck, houth and throa still offers (relatively) unaltered affrencs. Snalt s/ondr that postures activating these structures are preferred and often in an xtrene way. Bfore going on the othr aspects of oral and nqk interrIations let us stat again that nck xtnsion is a relativelv safe but functionalfy vry restrictive postur. Expecially with respct to muscular intrp1ay as ncessary foi adequte conrnunication by facial expression, speech articul-ation, swallowj-ng of saliva and intak of food for instance. still inost of us have witnesseal ptients in watr \rho profitted fron Hallir^?ick with respect to facial and oral control by rductj.on of drooling and anelioration of speech. The min reason is that alt rnntioned factor have diffrent consquncs indiffernt patients (ven in on individuun at differnt. developnental stages) . The posture(s) as facilitated in vatr seen(s) to be optirnal uith respect to these func-

trons. By a series of lucky circunstancs we can offer nodified devices (ISl,R=Innsbruck-sensory-notor-actvator orthodontic Thy to our orally handicappd patients. and regulator) consist nainly of Ienents of Andresn-Huple Ironobloc and Frnkel's function regulators which have been activators since decades. such ISMR|s \.ridely usd by orthodontists ( 6 , 7 t 8 , 9 , 1 , 4 \ a r u s e d b y t h e p a t i e n t r s a t h o r n d u r i n g p e r i o d s or no conmunicative urge, - evn during sleep just of little orthodontic devices ar, Thy are produced and as cfassical and their lespectiv adapted by orthodontists conscutively needs of our patients acordj.ng to tearns to the individual their progress. Basically they consist of two Iateral 'shlves', allolring the patient to stabilj-ze their javs by for th hyoid a then. This wil-l provide stabilization biting pharyngeal area. The bon cornplex and hence for the critical and ndial connecting part of the shlves called frontal 'tongue shield' brings the tongue into a better starting part is conncted by position for s$rallo$iing. This intra-oral pads in the vestibular vires to - usually four - vstibular of area, that is between teeth and lips. Many nodifications thes pads and their connctions to the l"ingual (rtrodental) to parts allow for very selective and succssful training cheks, tonguel of the nobility of lips, counteract dficits of v1un and soft pafate. But abov a1I they aflow training co-ordinatd movennts of these parts as neded of intake of (For details and illustrations food of speech for instance. plase see ref. 6-9, 14). Ths Isl,Rs have furthrd our \'hieh ar not intrrelations understanding of functional of and coordihation readily. Inprovernents of nobility visible especially the tongu also act on ttre nck oraf structures, (e.9. via the sternocleid rnastoid rnuscles) and thence on the body as a whole as we coul,d denonstrat even in healthy volunteers (5). we wr hintd to thj.s phenonnon by spontaneous tongrJe novhents of handicapped patients acconpanying their attenpts to rotate their trunks (but did not appreciae it of gait and autonatic reacthen) as vell as by aheLioration tions of the trunk in Sl,R-treated patients ltho achievd tongu nobility. Either by narks on the rtongu btter lateral r w e i f f n b a c h t s p r o v o k i n g of the curiosity-refLex shild' t o n g u e ' ( 1 8 ) o r , t o t h e s a r n e n d b y u s o f s n a l l r e s j . n p e a r L s of their rsMR. nobilly attached to th rtongu-shield' rnechanisns seen ncesNature is cononic. such bidirectional sary. If active or passiv changes of head position in relaare able to chang size and shap tion to the trunk position thre important pharyngal airway crossing, of the vj.tally line' defense system. And this conists must be a local 'first rnoving or tonicafly posturing onrs tongue' of voluntarily w alvays would renenLber that our vork on trunk _ and finbsyhntry never lrill- b ltithout inpact on th functions of face -, routh and throat. of But if w rspect he prrequistes the orat and pharynqel region (e.9. nel for feeling secure; 'stabilizationi of hyoid bon conplex, tc.) ve can assist our fforts h'ith respect to body and lirnbs al-so frol therapeutic r o r a L a very potent way. It always pays off to c o l n e r ' l n the
r<n.f th 1inL. nf natterns such as:

of body. and neck - protrusion of tongue _ rnsprra_ E : ", = :f? r xj.on of r o!n le b o d y a n d n c k - b r o a d a n d s p o n _ s h a p e dt o n g u e -expiration and also of Iateral novennts of-the tongue intio_ and/or extraorally to assist rotation of th trunk ii th patient's oraL region is relatively fesser nanieappeA. -L t. rs worth whle at Ieast to respect oro_pharynqei difficul_

! :: g y hia blr l . i. t: a:tp n g" i . t t or

16ewhere.

rhabilitatjng

durins. infect ions of rh. ir;a;;"i;uy=

a patin _ it

in vater

of

1) 2) 3) . 4) 5)

6)

Bernstin N. Th Co-ordinatj.on and Rgulation of Movnent. 1967, Perganon press, Oxford, London tc. Bosna, J.f. Oral and pharyngal Dveloprnen and Function. Journal of Dental Resarch 1963, 42: 3t5_380. Finney, N.R. Handling th young Cerebral palsied Child at Home. 1974, 2nd Edit., w. Heinnann, London. Fukuda, T. Studies on Huhan Dynarnic postures fron the Viwpoint of postural Rf1ex-s, lcta oto_iiiyng'i"g i"u, 1 96 1 , S u p p l . 1 6 L : 1 - 5 2 . Haberfeflner, H., Nobsa, K., Rilgg, V., Wechselwirkung zwischen Gesamtkrperhaltung, Mund- und Gesichtsbereich (TaI II), Pdiatrie und pdologi 1981, I6: 215_225, corr. 344. Haberfel.lner, H., Richtr, M. Zur apparativen Theraple orofazialr Dyskinesien bei zerebrai- bewequnqsqstorten Patjentn. Fortschritte der Kieferorthopie; 9g5, 46:

HaberflInr, H. pparativ Bhandtung snsonotorischer slorungen in Mund- und Rachenberich: Indikationen, Bhandlungsweisen und beglitende Therapin. Beri.cht voh 4. synrposion Frtihfrderung, 1987, dit. Vertnagung .Mnchen fiir interdis z ipl inre ruhf rd.r,.,rrq ". V. 8) Haberfellnr, H. Ubrlegungen zur herapie orofazialer Dyskinesin und Erfahru;gen rnit kietero'rthopdiscnen G r t e n , K r a n k e n g ) r m n a s ti k . i n p r s s ( J u n L b 8 9 ) . -. 9) Haberfellnr, H. Thrapy of Facio-oro_phar:yngeal Dysfunc_ trons. In press? J.J. cebhardt Edit., 1989; ubr, Bern_ Toronto. 10) Hllebrandt, F..r Houtz , S . , t . , P a r t r i d g e . M . J . , !altrs. C . E . T o n i c N e c k Rf1exs in Exrcises of stress in Man. Arnrican ,f ournal of P h y s i c a l M d i c i n 1 9 5 6 . 3 5 : 1 4 4 159. 11) Lewin, c. Schla'itnrnen rniL k l e i n e n L e u t n 1 9 6 7 , S p o r t v e r l a g , Berlin. 12) l,agnus, R. KrperstIlung, 1924, J. Springer, Berlin. 13) Mccouch, c.p., Deering, I.D.? Ling, T.tt. iocation ot Receptors for Tonic Neck Reflxes, Journal of Neurophysio_ logy, 1951, 14: 191-195. 14) Richter, M,, Haberfellne!, H. Modifizierte Aktivatoren bl zrebral ber^regungsgestrten patinten - ein neuer Anwendungsbereich. Fortschritte dr Kiefrorthopdie 1985, 461 233-240. 1.5) Sauerl"and, 8.K., MirchelI, S . p . E I e c t r o n y o q r a p h -;..;i;;ii" ic .riwiiw

7)

of the Hurnan cenioglossus Muscte in R;;;;;;-i;

I37

and to Postura] changes of the Had. Butletin of the Los ngeles Neurological Society, 1970, 35r 69-73. 16) Stejskal, L. Postural Reflexes in Theory and Motor Re-ducation. L972, cadernia, prague. 17) Strong, W.B. So Whatts cood about Sports (Editorial). merican Journal of Diseases of Children, 1999, l-42: 143 18) Weiffnbach, J.I.t, Discrete Elicited ttotions of the Ne!,,bornts Tongue. In: 3rd Synposion on OraI Sensation and P e r c e p t j . o n , J . F . B o s m aE d i t . , t - 9 7 2 : 3 4 7 - 3 6 L , C . C . T h o r n a s , SpringfieLd, I11.