Aetiology of the impairments of the musculoskeletal apparatus is based on
Disorders of the regulation of the muscle tone
Disorders of the regulation of the axes of the body
Disorders of the regulation of the joint centration
Disorders of the regulation of the muscle coordination of the motion
Aetiology of the impairments of the musculoskeletal apparatus that developed postnatally
Developmental disorder of the musculoskeletal apparatus in childhood
Subsequent developmental disorders of the musculoskeletal apparatus
Functional disorders of the musculoskeletal apparatus in adulthood
Posttraumatic and postoperative disorders of the musculoskeletal apparatus in children and adults
Early Diagnosis of the Imminent Developmental Disorders of the Musculoskeletal Apparatus in the First Year of Life
The first year of development of the musculoskeletal apparatus is extremely important, and the consequences of the impairments that could occur in this period would in actuality impact on the whole future life. Therefore, it is meaningful to carefully monitor the development in this period.
There are several evaluation scales of motor development in the first year of life. It turns out that the one created by V. Vojta is very suitable. It’s important to mutually compare spontaneous locomotion, elicited locomotion in positional reactions and the reactions within reflexes at the new-born and infant age. All three components should be related to the actual age of the child.
Like Dr. Vojta, Prof. Prechtl described that children with a high risk of developmental defects present themselves differently in terms of spontaneous locomotion than children undergoing normal development. His diagnostic methodology confirms the significance of monitoring spontaneous locomotion of infants. He called it “evaluation of general movement” (1990). During the last 25 years, it’s been demonstrated that the GM patterns represent sensitive indicators of some neurological disorders and they have been compared to a “window” into the developing brain.
Monitoring of the Spontaneous Development
Permanent regulation is necessary in the position on the back, on the side, semi-sitting position on the side, when supported on hands and when standing on two feet.
Every instance of standing upright and locomotion requires autonomic regulation of the posture of the body just as the spontaneous locomotion of the child requires spontaneous motor skills. The posture related to the spontaneous motor skills has been carefully analysed and described by Dr. Vojta, Prof. Prechtl and others.
These basic concepts allow for the correlation of the exhibited locomotion the child with the corresponding posture of the torso.
Analysis and evaluation of the spontaneous motor skills of the child serves to estimate its motor developmental age. Therefore, it is particularly important to observe the movement patterns the child can do. The evaluation of movement patterns should be oriented to the patterns implemented by approximately a half of the normally developing children in the first year of life. They serve as an approximate measure for evaluation of quality related to the physiological posture of joints and predominantly the functional patterns of muscles or alternatively their regulation. Deviations from normal development can be monitored quantitatively (number and frequency of movements) and qualitatively (vehemence, inadequate expansion, overall tension and motor discoordination)
To apply the Vojta method in children at the first year of age with motor disorders of various aetiologies requires the authorised therapist to know these developmental motion patterns.
Their knowledge is necessary for the assessment of the initial values for quantitative (what does the child do?) and qualitative (how does the child do it?) evaluation of the autonomic posture, righting and postural reflexes as well as the phasic motion of the examined child.
To assess the results of observation of the spontaneous locomotion of the infants, it is appropriate to distinguish several evaluated regions:
Observation of the spontaneous locomotion of the whole body in the supine position
Observation of the posture of the head
Observation of the posture and movements of the arms
Observation of the posture and movements of the legs
Observation of the posture of the pelvis
Observation of the supporting base of the body
Observation of the spontaneous locomotion of the whole body in prone position
Observation of the postureof the head
Observation of the posture and movements of the arms
Observation of the posture and movements of lower limbs
Observation of the posture of the pelvis
Observation of the supporting base of the body and supporting points
Assessment of the stereotypical breathing
Assessment of the stereotypical turning
Assessment of the stereotypical crawling and crawling on all fours
Assessment of the stereotypical of upright stance and quadrupedal gait
Assessment of the stereotypical gait and grip
Observation and assessment of elicited locomotion and positional reactions
Either positional reactions were a genius idea, or Dr. V. Vojta was a genius himself. Since the mid-fifties, Dr. V. Vojta had been looking for a way, how to early identify the risk of pathological development of motor skills in infants. It was known at that time that children who developed cerebral palsy showed some abnormalities, which were observed by their mothers and paediatricians during the first year of life. Nevertheless, it was impossible to assess, whether the development of the individual child would be pathological or not.
Neurological reflexes show the abnormalities, but basically, they cannot sufficiently predict the upcoming pathological development. It was the extensive work of Dr. V. Vojta that let him create a screening set, which would enable such prediction. Most of the positional tests had been known since the mid-twentieth century, but what Dr. V. Vojta essentially did was arrange the results of the test into a timeline. That’s how the table of positional reactions was made. It was first published in 1972. Many trials have demonstrated that “Vojta screening” has high sensitivity and specificity and can be clearly recommended in diagnosis of developmental disorders of motor skills.
According to this table, it could be determined, what is the “actual” status of the development of the child, i.e. whether his responses in individual positional tests correspond with the normal results in the respective age or whether they deviate. According to the number of deviated responses, it could be estimated whether the child was healthy or whether his motor development was at risk to some degree. The number of abnormal responses determines the level of risk. If the motor development were endangered, we would talk about the so-called “Central Coordination Disorder” (CCD), which is not a definitive diagnosis. It is an evaluation of the condition, which is important for the decision on the necessity of either therapy or alternatively careful monitoring. It is necessary to start the therapy in children who show signs of mild CCD.
Mildest CCD 1-3 abnormal responses
in positional tests
Mild CCD 4-5 abnormal responses
in positional tests
Moderate CCD 6-7 abnormal responses in positional tests
Severe CCD 7 abnormal responses
in positional tests with concurrent severe tone disorder
Of course, the tests serve as a very good indicator on the course of the therapy and on the success of leading the child towards normal motor development. If a child with signs of severe CCD started the therapy, the number of abnormal responses should decrease with correct therapy. Thus the degree of CCD gradually decreases to normal.
Assessing the degree of CCD is not only a result of positional tests that are very sensitive to evaluation of the condition, in which the brain of the child is. The reaction to primitive reflexes and the assessment of the spontaneous locomotion of the child should also be considered. This complex view is sufficient to decide whether it’s necessary to initiate the therapy.
Observation of these functional relations allows the therapists to assess the child’s overall condition within its spontaneous sensorimotor expressions. Concurrently, incorrect patterns could be revealed before they could significantly manifest themselves in the upcoming development. These findings constitute the goals of the therapy.
Position and reaction merge in the term positional reaction. Position means the position of the body, and reaction means the response to the change of the position of the body induced by the therapist. Reactions are presented within the patterns of posture and locomotion. Positional reactions could be considered as the key to the innate movement programs. Every positional reaction consists of a set of stimulations, by which the therapist stimulates the CNS to certain responses.
Initiation of positional reactions happens in a previously determined standardised way by changing the position of the infant’s body. This releases many impulses from tension receptors of the muscles, tendons, fasciae, joints, joint capsules and ligaments. The impulses also stimulate the receptors of the thoracic and abdominal cavity and the telereceptors. The vestibular organ of the inner ear is concurrently stimulated by continuous change in the body position. During the standardised performance of the positional reactions, the sum of these various impulses leads to their constant input into the regulatory levels of the spinal cord and the brain, also in repeated examinations. The ability of CNS to regulate certain motor patterns in a coordinated fashion constitutes the response.
Processing of the impulses in the CNS is manifested in the responses to individual changes in position. The explanation is that the brain always responds in general and can reorganise itself continuously. Vojta called this complex course as postural reactivity. It stands behind the ability of the CNS to respond to the above-mentioned impulses with corresponding reactions of posture and movement within pre-set positions.
The CNS of a healthy new-born has the possibility to control the patterns of posture and motion after certain stimulation. They are relevant for the whole body and can anticipate the existing development of the posture of the body with positional reactions described by Vojta, which couldn’t be spontaneously performed by new-borns yet.
To achieve precise diagnostic technique, recording the examination of infants on the computer with webcam was proved to be useful. Retrograde analysis of both the spontaneous locomotion and the course of the reactions helps to recognise the level of development correctly. Records obtained over several months can easily demonstrate, whether the therapeutic interventions really lead to normalisation of the motor development of the child.
Motor analysis is an inseparable part of the assessment of the development of the child. It largely consists of the assessment of the posture, which only enables the movement
(postural ontogenesis). Posture of the torso is assessed in relation to movements of the limbs and the head. Observations of these functional relations allow the therapists to evaluate the child in general within its spontaneous sensorimotor expressions and possibilities. Thus, it allows the discovery of false patterns that would be insufficient for further development. These findings can lead to determination of the backgrounds and goals of the therapy.
Long-term practice shows that the elaborated guidelines for general practitioners for early identification of the initial motor and posture disorders and the cerebral palsy especially were flawed.
According to these guidelines, the general practitioner for children and adolescents performs the screening of the psychomotor development “according to Vlach”. This type of screening doesn’t have sufficient predictive sensitivity. Children at risk of motor disorder aren’t usually identified by the first line physicians in time. Consequently, the adequate rehabilitative care comes too late and the chances of normalisation of their motor development are wasted.
The above-mentioned guidelines recommend that the screening of the postural development “according to Vojta” in all children at risk and in children suspected from retardation of the psychomotor development should be performed by paediatric neurologists, paediatricians specialised in diagnosis of early motor disorders or rehabilitation physicians and eventually physiotherapists.
Thus, the children get to specialists that can perform early diagnosis of infants at risk of pathological motor development later than desirable.
In common practice, a child in which the paediatric practitioner didn’t identify the risk of pathological motor development through routine examination is being recommended to the facility of a paediatric neurologist too late. The neurologist identifies the disorder and sends the child to the physiotherapeutic facility. Thanks to long waiting lists at these facilities, the child doesn’t receive therapy in time.
Best results are achieved in children, who, due to early diagnosis, got the early therapy and the intensive care was initiated from the 3rd month or earlier. The later the diagnosis is performed and the therapy initiated, the more the chances of future flawless development of the child decrease. Commencement of therapy in later months is significantly more demanding for all involved. The child could start to manifest the substitute pathological motor skills, if only slightly indicated. Their elimination is more difficult therapeutically. Moreover, the child tolerates the intensive and regular therapy with problems. For parents, the initiation of the therapy either in 3rd or 9th month makes a significant difference. The late initiation of the therapy is very complicated for physiotherapists, too. They know that the conditions for the normalisation of the motor functions of the child are far from optimal and that the time remaining for the intensive therapy is shorter. The summary of all these factors is stressful and may lead (and sometimes does, unfortunately) to unfavourable results and to the impairment of the child. The window of “therapeutic opportunity” opens right at the beginning of the child’s first month of life and it closes gradually with the accomplishment of the development of the basic programs of motor skills, i.e. from the twelfth to the fifteenth month of life of the child. In this period, the process of synaptogenesis is highly active and allows easy “repairs” of the cerebral “hardware” within the neuronal plasticity of the brain tissue, and the “installation” and normal function of basic programs of motor skills in particular.
This situation was well described by P. Borys (2010) “Many of the children that suffer from neuro-motor problems could have been cured in their infancy!”
The experience form the previous twenty years indicate (Kolář 2009) that omitting the early diagnosis leads to problems within the disorders of gross motor skills like cerebral palsy, but far more often missed detection and failing to notice the warning signs in the first year are manifested in several subtler neuro-psychological disorders.
Understanding the early diagnosis by Vojta is closely related to understanding the developmental kinesiology of the child. Only through the interplay of this knowledge can a qualified assessment of the obtained diagnostic data be performed. The very performance of the early diagnosis requires obtaining the manual dexterity and physical skills that would allow sufficiently quick and safe manoeuvres of the positional tests. Only the repeated practical training ensures the manual skills in the treatment of the child and the ability to “read” the reflex responses quickly. Recording of the examination on the webcam has proved to be a great aid for training and for long-term monitoring of the development of the in the field. It allows later evaluation of spontaneous locomotion and of the reactions to the positional tests of the child at rest and with the possibility of comparing the reactions and conditions of spontaneous locomotion from the previous examinations. Moreover, the recording may be important because of legal issues.
Diagnosis of the Disorders of the Musculoskeletal Apparatus in Walking Children and Adults
Static Assessment of the Standing
Axes of the standing body
Configuration of the pelvic girdle and the lower limbs
Configuration of the girdles of the upper limbs
Posture if the head and mandible
Assessment of the patient in the supine position
Axes of the lower limbs
Axes of the upper limbs
Configuration of the ribcage
Dynamic Assessment of the Basic Stereotypical Movements
Assessment of the stereotypical breathing
Assessment of the stereotypical movements in the orofacial region
Assessment of the stereotypical gait
Assessment of the stereotypical grip