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13 VM2G – Basic Principles – Vojtova metodika 2.generace

13 VM2G – Basic Principles

VM2G is founded on several principles that include the knowledge of the motor program, understanding of the spiral motion dynamics, awareness of the determining force and velocity momentums within the course of the movement itself and comprehension of the movement trajectories that run in the spiral dynamics. They have a unique course determined by the biomechanical relations within the musculoskeletal apparatus and are unchangeable in every individual.
The goal of VM2G therapy is to intervene in the organisation and the functions of the CNS, so the patients could use genetically inserted motor programs that haven’t been accessible because of a motor disorder.
Through VM2G therapy, innate motor programs are activated. These motor programs are variable and can be combined. Different functional relations between the musculoskeletal system and the sensorimotor features merge in the term sensorimotor patterns. We call them patterns because the targeted movements are possible only thanks to the organised interplay of muscular and joint apparatus. The CNS regulates this organisation and so enables coordinated movement. Damage to the CNS mostly influences the innate motor programs. This handicap may appear because of incorrect intrauterine development or injury to the brain during the delivery or after birth, e.g. hypoxia or cerebral haemorrhage. Impairment of the peripheral nerves (e.g. brachial plexus pals), or trauma to the muscles or skeleton may lead to further disorders of the motor regulation.
The access to the innate motor programs is restricted or denied to children with central coordination disorder of motion. Therefore, they can use their motor skills only insufficiently within the substitute emergency “DOS” program. Consequently, pathological movement patterns occur and their implementation usually causes further secondary damages to the musculoskeletal apparatus. This influence is significantly severe in the first year of life. It strongly limits the very initiation of the physical and mental development, which stagnates without the corresponding motor skills.
Together with reflex locomotion, Vojta discovered a therapy that can overcome these obstacles. The intact or partially intact connections between nerves and muscles constitute the important precondition because the peripheral nervous system can communicate this way after stimulation.
Physicians, physiotherapists, sports coaches and others approach the musculoskeletal apparatus with certain preformed visions of a 2D anatomical concept. The real physical action of the musculoskeletal apparatus and its physiological correlates are rather different.
What was new in the approach initiated by clinical observations of Dr. V. Vojta is the more promising and open possibilities than the definition of the clinical status of the patient.
Vojta’s approach doesn’t concentrate on the “processing” of the imperfect body, but on the discovering of the potentials provided by brain and his adnexa.

It seems that the trust in the correctness of Vojta’s theory is based on its long-term therapeutic fertility and the ability to predict the upcoming course of the disorders. Equally, it is prized for the ability to predict and explain new unexpected features related not only to musculoskeletal apparatus.

In 1955, Dr. Vojta discovered the possibility of launching the “repair” program through the system of reflex locomotion. This program contains reflex turning, reflex belly-crawling and the less well-known reflex crawling on all fours.
Reflex locomotion implements ideal motor patterns that are strictly individual. It sets the level of muscle, joint and neural burdens exactly in accordance with the actual physical condition, innate dispositions and biomechanical relations of the individual and it practically eliminates the possibility of overload of the musculoskeletal apparatus.

Figure of therapeutic intervention in the first year of life.

Characteristics of the system of reflex locomotion are remarkable: the program can’t be switched off by any disease or traumatic condition, even at the level of states of deep unconsciousness. In terms of neuroanatomy, the “core” of the program is probably located above the region of the brainstem, i.e. right above the region of regulation of the basic vital functions of the “BIOS program”.
The program works with permanent multifunctional feedback and thereby enables the utilisation of all available reserves of the musculoskeletal apparatus. It is genetically determined and it can be used in every person from birth to the end of his/her life. Probably, it can influence all “application” motor programs of fine and gross motor skills in a significantly positive way.

The fundamental premise of reflex locomotion is this: the organ is developed by its function.

Bio-cybernetic Model of Action
of the Vojta Method

Vojta’s principle works with movement patterns, through which the body acts like a single unit. They are called global patterns. These movement patterns comprise the whole body, but they consist of many components and partial patterns. Arms and legs have to be coordinated with the torso. Only if all parts of the body act together, can a person stand upright and move.
If one part of the body changed (anatomically or functionally), the relationship with other parts of the musculoskeletal apparatus would change, too. Changed coordinated reaction of other parts appears.
It is necessary to realise this fact because the balance within the body must be precisely regulated during every tiny movement. It resembles a set of scales. If one weight-bowl was loaded, the other weight-bowl has to be equally loaded to reach the balance between both weight-bowls.
The human body shows similar dependency, but in a much more complex manner. This is called the coordination of the musculoskeletal apparatus. In a balanced state, the individual parts of the body are arranged and situated in a balanced manner, and the centre of gravity is situated above the supporting points. That is why every small change within the body that is related to weight bearing activates the whole sensorimotor system of the body to maintain the balance.
Permanent regulation of posture when upright and moving requires permanent cooperation of all muscles. An individual muscle is guided by an established movement pattern, which is regulated according to the common goal that the body wants to reach.
The movement patterns can be analysed and described. For example, the hand grip is a part of a common pattern. It is a part of the movement of the arm and depends on the posture of the whole body because the quality of the posture is basically dependent on the posture of the torso and the spine. Diagnostic and therapeutic interventions find their overwhelming justification only when the movements relate to the posture of the torso and the autonomic regulation of the posture of the body respectively.
The course of the movement of the crawling child that tries to reach the table might be roughly described within the above-mentioned relations as follows: the child has the idea of reaching the table. To accomplish its goal, it mobilises the general motor skills. It has to separate one hand and arm from the crawling movement pattern to reach the table above. It has to hold the body in an upright posture to shift the centre of gravity of the body from four limbs to only three. The spine slightly tilts to the side; it stretches and turns to release the needed space for the arm. If the extension of the arm towards the object wasn’t sufficient, the child would pull itself towards the table and lean back on its feet. The child would also use the hand that was formerly meant to extend to pull itself upwards and lean on the feet. Only when its body is surely standing on both feet and supported by the arm, the child extends the arm again towards the object on the table. If the child was close enough to its goal, it would grasp the object. The course of movement described in this example becomes a meaningful and targeted global pattern, within which the arms, the legs and the spine cooperate together in agreement.

The Basic Experience for Further Development

The approach to the whole body helps the child to gain basic experience. Only when it acts by itself and copes with its own body this way, its experience and perception may widen. The child has to grasp to understand. It has to hear to comprehend. It has to test the objects with its mouth and tongue to find verbal expressions. When a child in the 8th to 9th month of age throws away a toy repeatedly to pick it up again, the behaviour is important because the child is exploring the depth of space. This experience is only possible due to the possibility to use different movement patterns. Initially, the child has no idea how to treat its surroundings. It must touch it and inspect it. It does not know how its little feet taste and how painful it is to hit itself.
Initially, the gait is unknown, just like hopping or crawling. The ability to do such things is partially innate. The development of the motor skills proves that the child is curious and wants to explore and change its environment. This is the only way for the motor intelligence to become varied within all its achievable diversity. This is how their intellectual potential shows up. Mentally retarded children are usually also retarded and less creative in their motor development.

The Interdependence of Autonomic Posture and Targeted Movement

The autonomic regulation of the posture of the body is a basic element for the child and for the adult as well. Thanks to it, we can move in the gravitational field of the Earth. The posture provides support during locomotion. Without the posture, no targeted movement can happen, even a tiny one. This requires permanent adjustment of the autonomic regulation so that the body could permanently maintain the balance and muscle coordination. For example, when a man extends his arm to reach the cup and to bring it to his mouth, the autonomic regulation of the posture of the body is responsible for the continuous movement of the arm away from the torso and for the targeted lead of the cup to the mouth. The moving musculature of the arm must engage both the supporting parts and the moving parts. Only then will it be able to perform the smooth continuous movement, which carries the cup. If the moving parts of the musculature were not tuned adequately, the movement would be erroneous, uncontrolled and shaky.
Famous neurologist R. Magnus put it aptly when he said: “Every movement begins and ends with a posture. Posture follows the movement like a shadow.” In case of a limb that wants to get the cup, it begins with the posture of the torso and the support of the lower limbs that have to hold the resistance targeted against the gravity and make the way of the arm away from the body possible. Further, the musculature of the arm carries the arm against the gravity and moves towards the cup concurrently. This movement of the arm is secured while sitting, e.g., by the pelvis legs and feet.

Security within the Posture

If we watched an infant during its first 6 months of life, we would see that the security within the posture outweighs the movement. The infant remains in the supine and also prone position. If the child grasped a toy e.g. in the 5th month of age and put it in its mouth, the movement of the arms and legs would seem to be suppressed depending on the regulation of the posture. But the arms and legs cannot be intentionally raised above the pad without the posture of the torso that is safely supported in the back.
Later, in the higher upright positions, the principle seems to be even more obvious to the observer. When crawling or walking, we first see the movement of the arms and legs, that carry the body forward. We might think that the posture has lost its importance. The opposite is true. The body requires the dynamically adjusted posture of the torso and the limbs to move this way. The higher the body straightens, the less it uses the surfaces of support. Consequently, the maintenance of balance becomes more difficult. The posture has to be regulated even more finely compared to lower supine or prone positions so that it would not stagger or fall and can move intentionally.
To overcome gravity is the basic and permanent task. The centre of gravity is being transferred with every move and balance has to be reset. The movement requires permanent autonomic regulation of the posture as the firm support allows the movement towards or from a target. Thus the regulation of the body is required to develop adequate posture and enable movement. It could be seen in helpless new-borns, whose posture is not adequately regulated and cannot provide the support. The gravitational force pulls them to the pad and they cannot use it as surface of support. During the next development, e. g., the back takes over the function of the surface of support.
If the infant learnt to turn, the shoulder and hip joints and also the whole side of the body, over which the child rotates, would become the surface of support in the position on the side. If the child developed unaided gait, the centre of gravity would be set against the small surfaces of support on the soles.Sports, that are admired because of the performances of jumps and pirouettes, e.g. figure skating and gymnastics, are also extremely challenging for coordination. They are possible to do because of exceptionally powerful regulation of the posture of the body. Implementation of this precondition allows the performance of excellent physical creations, but often it is not perceived nor observed.

The lack of control over the autonomic regulation of the posture results in significantly abnormal locomotion in both above-mentioned motor disorders. Thus, the quality of motion is based on the corresponding ability of autonomic regulation of posture. The analysis of posture can exactly predict the conclusions on the future quality of the locomotion itself.
The function of most muscles is not derived from the anatomical description, but from the function, that has been “centrally given” within the autonomic regulation of posture, balancing and righting reflexes and basic stereotypical movements (gait, grip, respiration, etc.), and finally within application programs.

Concurrently, the muscle functions vary depending on the changes of physical positions and performed movements. The same muscle can provide the postural balance of the body (e.g. in supporting or straightening) and in the next moment, its function changes to active movement within the gait mechanism. This functional variability is a necessary precondition for the functionality of the musculoskeletal apparatus as a whole. It’s hard to imagine the luxury of having a body that has the muscles intended for gait and balance maintenance separated from each other. The “single-purpose” muscular function is designed only in highly specialised muscles, i.e. the muscles of the vocal apparatus, swallowing muscles or facial muscles.
Those muscular groups are rather small and energetically economic. They occur to greater extent in humans only.
More detailed observations of the musculoskeletal apparatus show that both sides of the body perform the upright standing, supporting and kinetic functions in functional steps that are mutually interconnected. This is caused by both sides of the body complementing each other in targeted movement, upright standing and walking through the central coordination.
Continuous transfer of the centre of gravity is provided by the exchange of the supporting and mobile elements. Permanent regulation of balance is related to this exchange. It can be noted that it’s nothing special to perform the above-mentioned movements. The individual with the physiological posture of the body doesn’t think about the motion at all. He takes these preconditions of locomotion for granted. Nevertheless, the initiation and the course of movement may represent insurmountable obstacles for the individual with disordered utilisation of kinetic patterns (i.e. suffering from kinetic disorder). Continuous changing of the positions of the body, which is normal in healthy individuals, requires permanent adjustment of the autonomic regulation of the posture. That is implemented by the flawless function of the CNS that regulates functional programs.

Pathological response during exercise

Miřejovská Pavla 3 years 4 months

Video of pathological stereotypes and postures

Case Study – Utilisation of VM2G in Therapy of Severe Central Palsies

Illustration of Solution of Central Palsy – Cerebral Palsy, Dyskinetic Type

The mother brought the patient Kateřina to our office when she was almost three years old. Kateřina could not walk on her own or maintain balance while standing or walking. The disability had been diagnosed too late, so the therapy was also initiated too late. The neurological conclusion said it was a cerebellar form of cerebral palsy (CP) of the dyskinetic type.
Besides walking, the patient needed help with ordinary self-care. Her movements were very uncoordinated. Previous rehabilitative efforts were focused on conscious training of coordination skills.

Description of the Problem (Clinical Findings)

A thorough history revealed that shortly after birth, the patient underwent massive cerebellar bleeding. Ultrasonography showed damage to the medial region of the cerebellum. With remarkable difficulties, the patient could maintain unaided standing; she could only walk with support. Therefore, her mother supported her by one hand when walking. Gross motor movement, the autonomic regulation of the standing and the basic stereotypical movements of gait and grip were impaired. Dressing, undressing and food intake could be managed only with the relevant help of the mother. Motor skills of fine and gross movements were impaired by dyskinesia. The movements ware asymmetrical and poorly coordinated. Perception, curiosity of the surroundings and the endeavour to communicate indicated that mental functions had not been disturbed. The mother understood well that future development of her daughter without rehabilitation would lead to deepening of the disorder, increasing in the ataxia, disability and overall dependency on the help of others.

Expert Explanation of the Problem

The incidence of cerebellar form of cerebral palsy is not too common. It affects prematurely born children, but it can also be caused by infection during pregnancy. Cerebellar cerebral palsy is characterised by ataxia. These are uncoordinated movements that appear because of considerable impairment to the targeted motor skills. Because of severe impairment of the fine motor skills, a patient with a severe cerebellar form of cerebral palsy is dependent on the help of another person. The patient can’t utilise the basic self-care tasks at all (or with great difficulties.)
This patient suffered from a pure form of cerebellar CP, so she didn’t have spastic shortenings of the muscles. These changes of regulation of muscle tone significantly worsen the regulation of motor skills, particularly if it was disturbed by dyskinesia. The effort of intensive and early rehabilitation is to prevent the development of these severe impairments of motor functions. In terms of early diagnosis, impairment of cerebellar motor functions could be observed quite early after birth. Hints of dyskinetic movements appear in both spontaneous and elicited motor expression. Symptoms of this dyskinetic pathological locomotion are quite discrete within the first six months of life, but they can be seen mostly on acral parts of the arms as torsion movements. Omission of warning signs quickly leads to the onset of ataxic motor skills after the accomplishment of the first developmental year of life. The disorder is manifested in impaired regulation of coordinated locomotion and in impaired central autonomic regulation of muscle tone in terms of general hypotonia. This type of hypotonia makes the maintenance of posture of the body difficult and disturbs the stereotypical gait.
This disorder gradually deepens and os­sifies with the development of the musculoskeletal apparatus. It is projected into the autonomic regulation of the posture of the body, basic stereotypical movements, fine and gross motor skills and the active conscious locomotion in particular. It’s the active conscious motion that is practically utterly devastated by dyskinetic and ballistic movements, which are difficult to control consciously.
The possibility of reparation is getting worse significantly as time goes on. Our experience taught us that early diagnosis of the disorder, ideally within the first three months, and early initiation of intensive and targeted rehabilitation can lead to improvement and very good prognosis. In the case of this patient, who came to us with the fully developed cerebellar form, we would like to show that with VM2G, gradual improvement of the condition can be achieved.

Illustration of the Solution

Introduction of the rehabilitative care with VM2G entailed a great divide for the patient and her mother. The previous rehabilitative care took place at the outpatient office. Mother began to accept the role of the home therapist, who bears the great part of responsibility for the future of her daughter. The home exercises were performed daily and took thirty to forty minutes. Initially, the exercises had to be performed on the mat on the floor, even during the regular biweekly check-ups at our office. The patient started to tolerate the exercises on a medical lounge much later.
The initial success was that, after several months of hard work, dyskinesia and ballistic movements ceased to worsen. Gradually, the patient reached the phase of unassisted walking. The handiness and coordination at dressing and undressing improved, and the patient began to manage the unaided food intake.
The patient had to wear tailored shoes that improved the stability of her ankles. The next success was putting aside the orthopaedic shoes and the possibility to wear the shoes bought according to her own choice. Of course, this was more comfortable and significantly less expensive than tailoring of the high orthopaedic boots. The speech expression gradually improved. The reduction in dyskinesia and ballistic movements was manifested in improvements of soft motor skills of the hand as the patient started to draw and write. She was gradually being prepared to enter elementary school – she has begun to attend the fourth grade this year. Practically, she needs no assistance in common daily activities. The therapy started to become physically demanding for the mother, who was keen to accept the offer of training together with the home therapist. They have attended the check-up visits in the office and performed the home therapeutic exercises together. The involvement of another home therapist has made the training much more effective and the results obvious. In general, the patient is more stable at standing and walking, even on rough terrain. Both mother and patient evaluate this development as very optimistic and are prepared to continue with the long-term therapy.

Explanation of the Solution

The performance of the intensive physiotherapy in children with developed CP syndrome is always a difficult task. In case of the cerebellar form of CP, the therapy of the developed syndrome is extremely complicated and is among the most complex ones in terms of physiotherapy.
The very implementation of the therapy has to return to early developmental stable supine position. As the patient perceived significant positional lability and suffered from severe positional instability due to dyskinesia, it was necessary to perform the reflex stimulation in the low position on the mat on the floor. After more than a year, we could afford to go to exercises on the launcher, as the lability and perceived instability in elevated positions ceased. The initial goals of the therapy must be concentrated on re-establishing the cornerstones of the motor skills. Any effort to stand upright and activate the walking mechanism prematurely couldn’t be successful because the resulting motor expression would be permanently disturbed by muscular dystonia and ataxia. Only gradual repair of the basic program of motor skills responsible for the basics of standing upright would enable the transition to higher positions and to a more developmentally matured movement.
Achieving the progress in normalisation of the autonomic regulation of the posture of the body allows the therapy to focus on development of basic stereotypical movements. All this is possible because of the gradual building of programs of motor skills in a reflex unconscious fashion. Functional autonomic regulation of the posture of the body provides the conditions for basic stereotypical movements and, subsequently, the possibility of implementation of fine motor skills and extension application programs of locomotion. All these circumstances have to be kept in mind during the restitution of motor functions in such a severe disorder as cerebral palsy.

The View of the Possibilities of Restitution of Motor Functions in Cerebellar CP and the Solution in Terms of VM2G

VM2G is targeted on the reconstruction of basic programs of the motor skills by the performance of reflex stimulation under uneasy, arousing conditions. The elicitation implemented with tilted training surfaces and lability support significantly helps to reconstitute the programs responsible for autonomic regulation of posture, i.e. the righting, balancing and labyrinthine reflexes.
Tilted surfaces are suitable for early use in exercises on the floor, as the feeling of stability and prevention from falls is secured.
Positional instability and the subsequent anxiety constitute the factors that have to be always considered in treatment of cerebellar palsies, i.e. even if it was possible to go to higher developmental and righting positions. Disrespect of this psychosomatic fact could significantly limit the intensity and implementation of the therapy itself. Although it might seem illogical to use these labilising aids in this type of disorder specifically, experience has shown that the sensitive approach can activate the reflex stimulation by labilisation without provoking disturbing dyskinesia or ballistic movements. Consequently, there is a growth in the programs of autonomic regulation of the posture of the body and basic stereotypical movements. We can’t conceal that fact that this is extremely difficult from a therapeutic perspective.
Another factor that must be considered is the phase of accelerated somatic growth. To become aware of this phase, the measurement of body height with sonographic altimeter during each visit in the office proved to be useful. Children within the phase of accelerated growth are in a phase of mild discoordination of the regulation of motor skills. This is visible in a very mild form even in healthy children, as is often noted in folk sayings. The explanation lies in the disproportion between the quickly grown body and the ability of motor programs to provide sufficient “computing performance” to control this abrupt increase in “HW”.
In children with cerebellar palsy, this transient increase in discoordination is much more obvious compared to healthy children. The therapy and the amount of exercise have to be adapted to this transient state of deteriorated regulation. Careful measurement would reveal the onset of accelerated growth, so we can directly react with the therapy. Therapeutic corrections have to be implemented almost continuously to utilise the potential offered by VM2G to the maximum.
The essential achievement we have attained was the prevention of development of dyskinesia and the possibility of gradual development of motor skills towards a normal state. It is necessary to expect that the late commencement of therapy of the cerebellar paresis would necessitate great strength and many years of treatment.
The goal is to get as close as possible to the normal locomotion, autonomic regulation of the posture including the basic stereotypical movements, and to normal and developing trophic features. Omission of the diagnostic and therapeutic intervention in children with cerebellar paresis is a source of upcoming severe restriction of the development of the personality of the patient. This restriction is manifested in many aspects of life, i.e. education, sports and cultural activities. It also represents significant social stigma, including the restriction of future economic self-sufficiency.

1 Orth Heidi Das Kind in der Vojta-Therapie. München: Elsevier