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RHYTHMICAL INTENTION AS A METHOD OF TREATMENT FOR THE CEREBRAL PALSIED PATIENT1
RHYTHMICAL INTENTION FOR THE CEREBRAL PALSIED
57
RHYTHMICAL INTENTION AS A METHOD OF TREATMENT FOR THE CEREBRAL PALSIED PATIENT 1 MISS JANET CLARKE
Tutor Therapist, The Spastic Centre
0/
N . S.W.
MRS. ELIZABETH EVANS
OccupatioJUil Therapist, The Spastic Centre oj N.S.W.
Conductive Education as described by Cotton (1967, 1970) and Hari (1968) is the method of treatment introduced hy Professor Andreas Peto at the State Institute for the Motor Disabled in Budapest.. It is a system of treatment which does not separate the learning of intellectual, linguistic and functional skills into the usual areas of school, speech therapy, occupational therapy and physiotherapy. Instead the child approaches a total learning situation where the conductor is teacher/therapist and Rhythmical Intention is used as the method of learning all tasks. At the Institute children of similar age and handicap work together in groups of 15-20. Selection for the group depends only on the child's ability to participate in group work. The children learn in a room where they can concentrate on work without being distracted. The walls are hare and visual aids and other equipment produced only when needed. Exer cises are done on plinths which are also used as tables (at the Institute they sleep on these plinths) and they have chairs with ladder backs which are used as aids for standing and walking, with small bags attached for the child's personal items. The children are toileted and fed in this room so that there is not the disturbance of being moved in and out for these activities. The conductors (who are trained in a four-
year course at the Institute and the University of Budapest) work with the children, taking them through their daily routine - getting
out of bed, dressing, eating, toileting, general and specific exercising, working at academic subjects. Working so closely with the children, the conductor understands their special needs 1
Received March, 1972.
and can regulate the daily activities accordingly. The conductor gives extra practice to any child whose performance is falling be.. hind the level of the group, and is able to provide opportunities for repetition of any newly learned activity in different situations throughout the day. Working in a group appears to provide the child with the following advantages for learning. The child becomes motivated to maintain his levels of performance with those of the group. Although the children are conducted through a task each chifd performs the move.. ments alone and so he has the experience of finding the way alone. In addition when one member succeeds in performing a task the others understand that it is possible and know how it was achieved.. The group is taught a number of different ways of doing each task, for example, sitting up from lying, and later each child is able to choose for himself the method which is best. The child is encouraged to be more independent because he can be given the time to finish a task himself. This differs from the half-hour treatment situation where the child may not he able to complete the task or the therapist will finish it quickly
for him. There is a general programme and a d1aily
timetable. The general programme is care-
fully worked out, according to the type of
handicap, the abilities of the group, an under.. standing of normal development, and an analysis of the series of movements involved in the task. It sets out to achieve a number of functional skills within a certain period. A daily timetable is worked out to allow the practice of the movements of each task series in different situations throughout the day. There are exercises for general body control, Aust.l.Pkysiother., XVIV, 2, June, 1973
58
THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY
for example, sitting still with both feet on the floor and both hands on the table, which must be mastered before the group can move on to the more specialised exercises, for eXM ample, taking a spoon to the mouth. This intense and repetitive training will establish new motor patterns and more selective move.. ments which form the hasis of skilled movement. Each skill has a series of special exercises that are done with precision and in the form of games and action songs. The method by which the task series is taught is known as Rhythmical Intention. The children perform normal active movements while using their speech or efforts to speak. The conductor says the command "I sit very still with my two feet flat on the floor and my two hands flat on the table", the children repeat this with the conductor - this is the "intention" and puts the children in a ..,t.:tte of readiness for the task. Then they perform the movement while counting slowly and rhythmically to five. Counting continues until each child has completed the exercise to llis full capacity. The practice is repeated ,vithM out breaking the rhythm until all the children are performing well. Songs with actions are also used to repeat the movement patterns. The commands refer to the child's body image, his position in space, and direction of move ment, for example, "I look right to the WiUM dow, left to the door, up to the ceiling and down to the floor". This continuous vocalisHM tion in a quiet atmosphere helps the child to concentrate on the tasks and to become more aware of himself and his movements - he alsfl learns to vocalise in all positions. Repeti tion of the tasks in a structured daily routine helps the child to feel secure, he is able to measure his improvement day by day and the experience of sUCcess will make him Inore willing to attempt new tasks. M
M
It appears that Professor Peto has based his theory of Conductive education on the investigations of Pavlov and Luria. Luria has discussed the importance of speech as a regu.. lator of all voluntary behaviour and in the formation of all mental processes. It is Luria's contention that underlying all voluntary acts is internal speech which reanimates the traces of previous experience. Aust.r.Physiother., XVIV, 2, June, 1973
FIGURE
I
HI stretch my elbows" and "I look up at the ceiling".
FIGURE
2
"I put the quoit over the cotton reel".
Experiments by Luria (1961) have shown that at first the child's behaviour is regulated by the spoken instruction of adults; however it is not fully regulated because the child, if told to stop, is unable to inhibit the action he has started. The child hegins to use his own speech to formulate rules of motor behaviour at 3!-4 years. For example, at this age, if shown a red and green light and told to press a button for the red light, he is able to formUM late the rule, "I must press for the red light and I must not for the green". In addition his movements are no longer merely mechanical hut are becoming conscious, and he forms habits more quickly and with greater stability. At first he performs tasks while speaking out loud to himself, but by 4!..5 years his own speech is internalised and a strong regulating force. Luria found that the way to regulate the role of verbal instructions and overcome
RHYTHMICAL INTENTION FOR THE CEREBRAL PALSIED
59
the diffuseness of the nervous processes in the 3-3i year old was to bring the child himself into speech; for example, the child unable to press twice in a regular sequence in response to a signal was able to do so when asked to say "go-go".
function. Three children could stand with therapist's support, none of the children were able to walk, three of the children had speech that was easily intelligible, while two spoke with difficulty and one had no speech at all (for details see results below).
The method of Rhythmical Intention will condition patterns of movement using the child's own speech to reinforce and regulate his behaviour.
A quiet room was used; the walls were bare and furniture was kept to a minimum. Each child had a plinth/table, a chair with a ladder back and arms (if needed), a bag attached to the back of the chair for his personal effects and a pot with a wide base. A wooden bench was used to practice sitting unsupported either at the tables or away from the tables. Equipment was kept in a cupboard and introduced only when needed. It was essential to keep the furniture in the same position, to toilet and feed the children in the room and f or observers to remain through an entire part of the programme. It was also important for the children to know the routine and to start working from the time they entered the room.
REPORT
During the last three years Rhythmical Intention was used as one method of treatment at The Spastic Centre of N.S.W. The following describes a study that was made of one of the groups of children with whom this method was used. Conductive education was not used as the method of treatment because a trained conductor was not available and as a consequence the children's day had to be divided between therapy and schooL It was intended to explore the principle of Rhythmical Intention as a possible method of group treatment - incorporating physiotherapy, occupational therapy, speech therapy and play experience. The six children chosen for this group were 2.11 severely handicapped athetoids aged 6~-7i years, of average intelligence. All of them reacted well to heing in a group, it was apparent that the group situation lessened frustration for some of the children; within the group the children seemed more able to accept their inability to perform tasks or to he understood. It was hoped that this method would teach them to organise their own motor behaviour towards becoming as functionally independent as possible, while deveIoping more normal speech. The children came five mornings a week, lunched as a group and then returned to school for the afternoon. Their parents and teachers came and watched the treatment and the parents were given a list of the activities to he continued during the holidays.
All the children in the group had the following motor deficit: poor head control, poor trunk balance, lack of protective extension of arms, d-isorganised gross upper limb function (only one of the children was ahle to reach and grasp an object at will), lack of fine hand
Rhythmical Intention was used for pattern.. ing, as described, together with action songs. Once the patterning was established it was possible to introduce the following variations into the routine without any apparent disorganisation. The children enjoyed fantasy and so an entire sequence might be spent with the children being bears and moving their "paws". We encouraged them to make suggestions for play and then adapted the morning's programme to prepare them for the activity. If a child arrived with a new toy or with a task he wanted to do we planned the activity around his ideas. The sound of the words being used could be varied from a whisper to a shout when lying or sitting still. Some chifdren found difficulty in organising speech with movement - they either spoke or performed the movement. It was possible to overcome this by guiding the movement until they became used to speaking when moving. Some of the children had difficulty with arm and hand movements when the limb was out of sight, e.g. lying on their backs holding a cotton reel by their sides. In these cases the movement was learned with the limh in sight then it was moved slowly out of sight. Sometimes altering the stimurus from proprioceptive to visual gave a better response, e.g. Aust.J.Physiother., XVIV, 2"June, 1973
60
THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY
instead of saying, "1 stretch my hand above my head", saying, "I am touching the hall above my head". Sometimes the children asked to be the leader and here it is interesting to note that they kept to the sequences and seemed to understand the level of performance of each member of the group. If the children were enjoying an activity in prone it would occasionally be continued with variations for a longer period and other sections of the morn.. ing missed out to al'}ow time for the continuing experience of success. The aims of the programme were:
(1) To improve head control (2) To improve balance and organisation in all positions especially lying, sitting and standing
(3) To find some method of locomotion on the floor (4) To enable the child to stand up and hold on to a tabfe and to stand holding a chair
(5) To enable the child to get on and off a table (bed) and into a chair ( 6) To enable the child to get on and off a pot
(7) To enable the child to walk pushing a chair and to walk sideways around a
tabl'e
(8) To establish use of one hand for sup.. port while other hand is working (9) To improve patterns of reach and grasp and co-ordinated hand and arm activities (10) To enable the child to use a spoon for feeding and a two-handled mug for drinking
(11) To enable the child to hold and use a crayon or pencil (12) To enable the chifd to undress and dress. The daily timetable was as follows:
9.00-9.30 Arrive, take shoes and socks off,
practice of individual difficul.. ties
Aust./.Physiother., XVIV, 2, June, 1973
9.30-10.00 10.00-10.30 10.30..11.00
11.00..11.30 11.30.. 12.30
Get on to the tables - exercise in prone and supine and rolling Get off the tables ~ practice standing and walking Exercises in sitting at the tables or away from the tables General activity for the trans.. ference of learning of the patterns practised earlier Prefeeding exercises, lunch, wash faces and hands and the table.
The children were toileted when necessary. Sequences of exercises were designed to inhibit abnormal patterns and develop the more skilled and purposeful movements that were aimed to achieve. Games were selected to allow opportunity for group interaction and for the carry-over of newly l'earned movements. Following each section some examples of the games used in the general activity period are described.
A. General Control
0/ the
Whole Body
It was necessary to establish general control of the whole body lying in prone, supine and on each side, rolling continuously, sitting stilt with feet on the floor, kneeling and standing. It is in this way that a child obtains the concept of his whole body in different positions; it prepares him for the time when he must learn to keep one part still while moving another. Also, it is knowing where "he" is that helps the child make sense of spatial relations such as near, above, bel'ow, behind. The very handicapped child finds great pleasure in gross movement and the physical contact involved, for it is a situation of little frustration and one in which he can easily be successful. Often it was necessary to return to the large rolling movements because it was here that the chird.. ren gained confidence in their ability to move. The games used here were: (1) Maintaining a chosen position for five counts after the music stopped. (2) Simple obstacle games involving getting "under" and "over" and "through".. (3) Rolling out of the way of a halL
RHYTHMICAL INTENTION FOR THE CEREBRAL PALSIED
(4) Making their bodies different sizes ~ being "small" and "tall". (5) Moving and stopping games such as "What's the time, Mr. Wolf?". When the children had learned to be still, listening games were played.
B. Independent Head Movements The children practised moving their heads up, down, to the right and left while keeping their arms symmetrical and still, while in supine, prone and sitting. Later they learned to keep their heads still and move their eyes or watch what their hands were doing.. Action songs involving head movements, looking at hooks during stories, looking at projected pic.. tures, following moving objects and playing games like "1 Spy" were used.
C. Development of Sitting To develop control of sitting the children had to learn to sit with both hands on the
table for support, to move forward at the hips while keeping their feet on the floor, to lift one arm in the air while supporting themselves with the other and finally to Tift both arms in the air. They later learned to sit away from the tables, to go down to touch their toes and sit up, to lean to the right and left and forwards and come back to the midline. After learning to do this on a chair they sat on a bench for their exercises. Arm exercises were included, and action songs. The games used here were: (1) Pass the parcel. (2) Big floor-sized games of draughts and deck quoits - using quoits or bean bags thrown on to numbered squares. (3) Car races with cars attached by knotted cord to the children's hands. (4) Dressing up with hats, beads and throwover garments.
D. Gross Arm Function At the tables the chifdren first learned to sit with their feet on the floor and their two hands flat on the table. They then learned(a) To keep one hand still while moving the other on the table. (b) To lift one hand up in the air while using the other for support.
61
(c) To lift both hands up in the air. (d) To keep their elbows on the table and take their hands to their mouth and ears. (e) To perform movements while grasping a cotton reel' in the dominant hand, the non-dominant hand being used for support. (f ) To use two hands together. (g) To touch parts of their bodies. Several of the children found difficulty looking at the task they were doing with their hands, so special attention was given to include "I am looking at my hands" during exercises. The foltowing simple activities helped them look at their hands and at the task: (1) Drawing on and around their hands and arms. (2) Getting them to wash marks off their hands or the hands and arms of other members of the group. (3) Hiding their hands under a cloth or table and finding them.. (4) Hiding a picture or object under one or both hands so none of it could be seen. Some of the simple gross movement games used were: (1) Placing one or both hands on wellstabilised picture cards usin~ left to right sequencing and later jumping around. The child's own spontaneous speech can be used as they take turns in saying where to place the hand. (2) Animal glove puppets used for arm and hand exercises followed by songs like "Old Macdonald Had a Farm". (3) Picture hunt games with specific movements for going through the long grass, the short grass, the water, climbing a tree. (4 ) Turning the pages of a large wallpaper book to :find all the hidden objects beginning with, e.g., "p" using large wooden objects at first and rater paper cut-outs. (5) Guiding large blocks or cars around a track on the table; this was also done Aust.J.Physiother., XVIV, 2, June, 1973
62
THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY
using mechanical toys (helping the toy to turn a corner or pass between two obstacles)" (6) Keeping balls of different size and weight on the table - this was done as a two~team game with the children sitting around a table; points were lost if the ball fen off the table. (7) Hitting balls and balloons which are hung on a string..
E. Gras p and Release Most of the children had great difficulty opening their hands to grasp objects - one child used to hit her hands hard on the table when they wouldn't open, another child would say, "Open, you stupid hands!". It was found that release came more easify as part of a reach and grasp sequence than just practising to spread the fingers although this was done at the same time. Patterns such as standing and holding the edge of the table, practising extension of elbows with hands held together and establishing some supination with wrist extension and thumb abduction helped them to develop patterns of extension and hand opening. The following games were used to help the children to keep their hands open and feef different shapes and textures:
(1) Identifying by feel objects and parts of other people hidden under a cloth. (2) Washing their faces and different surfaces with towelling mittens.. (3) Making hand prints or painting the table and taking prints. (4) Hand painting three~dimensional shapes, for example, big boxes to make houses or cars.. (5) Collage, putting glue on both surfaces of the paper - the whole top of the table was covered with paper and later the shape needed was cut out because this avoided the frustration the children felt if they tore the paper.
In prone, supine and sitting the children
learned to grasp four-inch cotton reels, quoits and rods.. Cotton reels were useful because they had a flat end on which to stand and the hand fitted snugly between the ends.. The Aust.J.Physiother.; XVIV, 2, June, 1973
cotton reels also gave visual clues to different positions of grasp which made grasp and movement easier" They were fitted with dowelling at one end to fit into holes (drilled
at two~inch intervals) on large hoards which were clamped to the tables . Using the cotton reels the children learned(a) To grasp and then release the stabil~ ised cotton reels.. (b) To place one cotton reel on top of another. (c) To move them from one hole to an~ other. (d) To put quoits over and lift them off the stabilised cotton reels.. (e) Then to hold unstabilised cotton reels and maintain a grasp in different posi.. tions and through a range of movement.
Using their hands to climb up vertical poles and the bars of their chairs help de~ velop patterns of reach, grasp and release.. When the children could hal'd the cotton reels, sponges could he glued on the bottom for printing and painting or drawing with water on a blackboard table, and candles, chalk or crayons could be placed in one end.. Household paint brushes and rolling pins were used for other grasping activities. The children also practised using their spoons and their two~handled drinking mugs. RESULTS
Numbers indicate number of children who couId perform the task consistently.
Prone: Lie still with arms above head Lift and hold head up _ Reach and grasp one hand _
_
Aug. Dec. 1970 1971 3 2
6 6
2
6
Supine: Lie still with arms by side _ 2 Lie still with arms by side and feet
6
Rolling:
Roll in both directions
_- -
against wall ___ Hold hands together Extend arms with hands together Lift rod in one hand, keeping other hand by side __ Lift rod/quoit in two hands Move legs keeping arms by side . Getting on to tables alone _ __ Getting off tables alone ----
o
5
2 2 1
5
2
6
1
5
o
4
1
o
4 6
5
4
RHYTHMICAL INTENTION FOR THE CEREBRAL PALSIED
Aug. Dec. 1970 1971
Sitting: Sit still in a chair with arms and keep fu~onflooc _ Touch tDes and sit up _ Sit alone on a stool
1
o
6
o
5 4·
3
6
I
3 3
6 6 6 6
I 1 0 I 0
6 6 5 4 5
1 0 0
6 4 4
1 0 I 0 0
4 2 4 4 3
2 I 1 2
4
1 0
4 2
0
5
0 0
4 2
Arm and Hand Function: Keep feet on floor and hands flat on table Keep one hand supporting while other hand moves(i) on the table __ (ii) in the air __ _ ___ ___ Spread fingers with hands flat __ Maintain a fist with wrist extension _ Results for Dominant Hand OnlyGrasp stabilised cotton reel Maintain grasp pronation __ _ __ ~ mid supination _ while moving arm __ Release with wrist extension _--_ grasp and drawhorizontal line vertical line __ _ circle ___ __
Sitting to Standing and Walking: Standing holding table __ ~_ __ _ Standing holding table with support Stand holding on to a chair Walk sideways around table Walk pushing chair
1
Activities: FeedingTake hand to mouth __ Take spoon to mouth without food with food Eat sandwiches alone Hold cup and take to mouth without __ _ milk _~_ __ _ Hold cup and drink alone UndressShoes and socks __ _ Slip-over garments Pants __
Toilet-
Balance on pot alone - __ Get on to and use pot alone
0 0
6
3 4
4 3
CONCLUSION
There appears to have been great improve.. ment in general body control and gross move.. ment patterns, and little improvement in any fine hand movements. This is probably due to the degree of handicap - it took nearly a
63
year to obtain good voluntary release in one child and good symmetry in another child with a strong asymmetric tonic neck reflex. The number of children who achieved success at being able to eat and drink alone appears smalL As these were situations of tension, it was felt that children with poor head and hand control needed to have some help. Although the children could hold their cups and drink, it was.. felt they needed help to pick them up and put them down when they had milk in them. The chilaren were allowed to try to eat and drink alone and were often able to manage. However, in tabling the results shown above, only those children who could repeat the task consistently were included. The chifdren's speech appeared to improve particularly in regard to the increase in inner language in relation to other motor activities. There was a reduction in the delay of the initiation of motor speech, words were pro.. duced with less effort and increased intelligihility. As the children became able to say more of the words of the commands or songs, they seemed to be able to express themselves more spontaneously and freely in conversa.. tion with each other and the therapist. Working together in a group over a long period appears to have been an important factor in building up the self..confidence of each child and the concept of social co-operation within the group. It seemed that the children realised that they could compensate for lack of achievement in one area by being better than another child in some other area. It has helped them to become more independent and aware of the needs of the others in the group. One day when one of the therapists was alone and helping one chifd to stand the others went and got the equipment from the cupboard for the next section of the morning then they pulled their chairs around the table. When asked during this rather noisy pro.. cedure what they were doing, the children replied - "Yon help us so we're helping you". They often assisted another child when he was having difficulty with a task. Those children who arrived in a group with little experience of success were at first very unwilling to attempt most tasks. After they had watched the others and began to achieve sue.. Aust.J.Physiother., XVIV, 2, June, 1973
64
THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY
cess at simple activities they stopped saying "1 can't do this" or being disruptive and would often develop their own games. If left alone with some new material they began to explore it. If one of the children was being disruptive the others usually found some ,vay of making him co-operative. The possibility of long continued practice of tasks with success increases the children's feeling of security - one of the children was able to ask her parents to leave her alone in the bath, after she had learned to lie in prone.
Our experience with Rhythmical Intention in the situation described would suggest the suitability of this treatment with the severely handicapped Athetoid in similar situations. SUMMARY
Details of Rhythmical Intention as a method of group treatment for the Cerebral Palsied patient have been given. The specific pro-
Aust.J.Physiother., XVIV, 2, June, 1973
cedures used have been mentioned and an analysis of results achieved have been dis~ cussed. ACKNOWLEDGEMENTS
The authors wish to thank Dr. C. Reye, Director of The Spastic Centre of N.S.W., who gave them the opportunity to undertake this study. REFERENCES
E. and PARNWELlJ, M.. (1967), "From Hun· gary: the Peto Method", Special Education, 56.4. COTTON, E. (1970), "Integration of Treatment and Education in Cerebral Palsy", Physiotherapy, 56.4. HARI, (1968), Address given at Castle Priory College, Wallingford, Berks., England. LE GAY BRERETON, B. and SAITLER, J. (1967), Cerebral Palsy: Basic Abilities. LURIA, A. R. (1961), The Role of Speech in the Regulation of Normal and Abnormal Behaviour, ed. J. Tizard, Pergamon Press, London. LURIA, A. R. (1963), Restoration of Function after Brain Injury, ed. O. Zangwill, Pergamon Press, London. LURIA, A. R. (1963), Educational Psychology in the COTTON,
U.S.S.R.
57
RHYTHMICAL INTENTION AS A METHOD OF TREATMENT FOR THE CEREBRAL PALSIED PATIENT 1 MISS JANET CLARKE
Tutor Therapist, The Spastic Centre
0/
N . S.W.
MRS. ELIZABETH EVANS
OccupatioJUil Therapist, The Spastic Centre oj N.S.W.
Conductive Education as described by Cotton (1967, 1970) and Hari (1968) is the method of treatment introduced hy Professor Andreas Peto at the State Institute for the Motor Disabled in Budapest.. It is a system of treatment which does not separate the learning of intellectual, linguistic and functional skills into the usual areas of school, speech therapy, occupational therapy and physiotherapy. Instead the child approaches a total learning situation where the conductor is teacher/therapist and Rhythmical Intention is used as the method of learning all tasks. At the Institute children of similar age and handicap work together in groups of 15-20. Selection for the group depends only on the child's ability to participate in group work. The children learn in a room where they can concentrate on work without being distracted. The walls are hare and visual aids and other equipment produced only when needed. Exer cises are done on plinths which are also used as tables (at the Institute they sleep on these plinths) and they have chairs with ladder backs which are used as aids for standing and walking, with small bags attached for the child's personal items. The children are toileted and fed in this room so that there is not the disturbance of being moved in and out for these activities. The conductors (who are trained in a four-
year course at the Institute and the University of Budapest) work with the children, taking them through their daily routine - getting
out of bed, dressing, eating, toileting, general and specific exercising, working at academic subjects. Working so closely with the children, the conductor understands their special needs 1
Received March, 1972.
and can regulate the daily activities accordingly. The conductor gives extra practice to any child whose performance is falling be.. hind the level of the group, and is able to provide opportunities for repetition of any newly learned activity in different situations throughout the day. Working in a group appears to provide the child with the following advantages for learning. The child becomes motivated to maintain his levels of performance with those of the group. Although the children are conducted through a task each chifd performs the move.. ments alone and so he has the experience of finding the way alone. In addition when one member succeeds in performing a task the others understand that it is possible and know how it was achieved.. The group is taught a number of different ways of doing each task, for example, sitting up from lying, and later each child is able to choose for himself the method which is best. The child is encouraged to be more independent because he can be given the time to finish a task himself. This differs from the half-hour treatment situation where the child may not he able to complete the task or the therapist will finish it quickly
for him. There is a general programme and a d1aily
timetable. The general programme is care-
fully worked out, according to the type of
handicap, the abilities of the group, an under.. standing of normal development, and an analysis of the series of movements involved in the task. It sets out to achieve a number of functional skills within a certain period. A daily timetable is worked out to allow the practice of the movements of each task series in different situations throughout the day. There are exercises for general body control, Aust.l.Pkysiother., XVIV, 2, June, 1973
58
THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY
for example, sitting still with both feet on the floor and both hands on the table, which must be mastered before the group can move on to the more specialised exercises, for eXM ample, taking a spoon to the mouth. This intense and repetitive training will establish new motor patterns and more selective move.. ments which form the hasis of skilled movement. Each skill has a series of special exercises that are done with precision and in the form of games and action songs. The method by which the task series is taught is known as Rhythmical Intention. The children perform normal active movements while using their speech or efforts to speak. The conductor says the command "I sit very still with my two feet flat on the floor and my two hands flat on the table", the children repeat this with the conductor - this is the "intention" and puts the children in a ..,t.:tte of readiness for the task. Then they perform the movement while counting slowly and rhythmically to five. Counting continues until each child has completed the exercise to llis full capacity. The practice is repeated ,vithM out breaking the rhythm until all the children are performing well. Songs with actions are also used to repeat the movement patterns. The commands refer to the child's body image, his position in space, and direction of move ment, for example, "I look right to the WiUM dow, left to the door, up to the ceiling and down to the floor". This continuous vocalisHM tion in a quiet atmosphere helps the child to concentrate on the tasks and to become more aware of himself and his movements - he alsfl learns to vocalise in all positions. Repeti tion of the tasks in a structured daily routine helps the child to feel secure, he is able to measure his improvement day by day and the experience of sUCcess will make him Inore willing to attempt new tasks. M
M
It appears that Professor Peto has based his theory of Conductive education on the investigations of Pavlov and Luria. Luria has discussed the importance of speech as a regu.. lator of all voluntary behaviour and in the formation of all mental processes. It is Luria's contention that underlying all voluntary acts is internal speech which reanimates the traces of previous experience. Aust.r.Physiother., XVIV, 2, June, 1973
FIGURE
I
HI stretch my elbows" and "I look up at the ceiling".
FIGURE
2
"I put the quoit over the cotton reel".
Experiments by Luria (1961) have shown that at first the child's behaviour is regulated by the spoken instruction of adults; however it is not fully regulated because the child, if told to stop, is unable to inhibit the action he has started. The child hegins to use his own speech to formulate rules of motor behaviour at 3!-4 years. For example, at this age, if shown a red and green light and told to press a button for the red light, he is able to formUM late the rule, "I must press for the red light and I must not for the green". In addition his movements are no longer merely mechanical hut are becoming conscious, and he forms habits more quickly and with greater stability. At first he performs tasks while speaking out loud to himself, but by 4!..5 years his own speech is internalised and a strong regulating force. Luria found that the way to regulate the role of verbal instructions and overcome
RHYTHMICAL INTENTION FOR THE CEREBRAL PALSIED
59
the diffuseness of the nervous processes in the 3-3i year old was to bring the child himself into speech; for example, the child unable to press twice in a regular sequence in response to a signal was able to do so when asked to say "go-go".
function. Three children could stand with therapist's support, none of the children were able to walk, three of the children had speech that was easily intelligible, while two spoke with difficulty and one had no speech at all (for details see results below).
The method of Rhythmical Intention will condition patterns of movement using the child's own speech to reinforce and regulate his behaviour.
A quiet room was used; the walls were bare and furniture was kept to a minimum. Each child had a plinth/table, a chair with a ladder back and arms (if needed), a bag attached to the back of the chair for his personal effects and a pot with a wide base. A wooden bench was used to practice sitting unsupported either at the tables or away from the tables. Equipment was kept in a cupboard and introduced only when needed. It was essential to keep the furniture in the same position, to toilet and feed the children in the room and f or observers to remain through an entire part of the programme. It was also important for the children to know the routine and to start working from the time they entered the room.
REPORT
During the last three years Rhythmical Intention was used as one method of treatment at The Spastic Centre of N.S.W. The following describes a study that was made of one of the groups of children with whom this method was used. Conductive education was not used as the method of treatment because a trained conductor was not available and as a consequence the children's day had to be divided between therapy and schooL It was intended to explore the principle of Rhythmical Intention as a possible method of group treatment - incorporating physiotherapy, occupational therapy, speech therapy and play experience. The six children chosen for this group were 2.11 severely handicapped athetoids aged 6~-7i years, of average intelligence. All of them reacted well to heing in a group, it was apparent that the group situation lessened frustration for some of the children; within the group the children seemed more able to accept their inability to perform tasks or to he understood. It was hoped that this method would teach them to organise their own motor behaviour towards becoming as functionally independent as possible, while deveIoping more normal speech. The children came five mornings a week, lunched as a group and then returned to school for the afternoon. Their parents and teachers came and watched the treatment and the parents were given a list of the activities to he continued during the holidays.
All the children in the group had the following motor deficit: poor head control, poor trunk balance, lack of protective extension of arms, d-isorganised gross upper limb function (only one of the children was ahle to reach and grasp an object at will), lack of fine hand
Rhythmical Intention was used for pattern.. ing, as described, together with action songs. Once the patterning was established it was possible to introduce the following variations into the routine without any apparent disorganisation. The children enjoyed fantasy and so an entire sequence might be spent with the children being bears and moving their "paws". We encouraged them to make suggestions for play and then adapted the morning's programme to prepare them for the activity. If a child arrived with a new toy or with a task he wanted to do we planned the activity around his ideas. The sound of the words being used could be varied from a whisper to a shout when lying or sitting still. Some chifdren found difficulty in organising speech with movement - they either spoke or performed the movement. It was possible to overcome this by guiding the movement until they became used to speaking when moving. Some of the children had difficulty with arm and hand movements when the limb was out of sight, e.g. lying on their backs holding a cotton reel by their sides. In these cases the movement was learned with the limh in sight then it was moved slowly out of sight. Sometimes altering the stimurus from proprioceptive to visual gave a better response, e.g. Aust.J.Physiother., XVIV, 2"June, 1973
60
THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY
instead of saying, "1 stretch my hand above my head", saying, "I am touching the hall above my head". Sometimes the children asked to be the leader and here it is interesting to note that they kept to the sequences and seemed to understand the level of performance of each member of the group. If the children were enjoying an activity in prone it would occasionally be continued with variations for a longer period and other sections of the morn.. ing missed out to al'}ow time for the continuing experience of success. The aims of the programme were:
(1) To improve head control (2) To improve balance and organisation in all positions especially lying, sitting and standing
(3) To find some method of locomotion on the floor (4) To enable the child to stand up and hold on to a tabfe and to stand holding a chair
(5) To enable the child to get on and off a table (bed) and into a chair ( 6) To enable the child to get on and off a pot
(7) To enable the child to walk pushing a chair and to walk sideways around a
tabl'e
(8) To establish use of one hand for sup.. port while other hand is working (9) To improve patterns of reach and grasp and co-ordinated hand and arm activities (10) To enable the child to use a spoon for feeding and a two-handled mug for drinking
(11) To enable the child to hold and use a crayon or pencil (12) To enable the chifd to undress and dress. The daily timetable was as follows:
9.00-9.30 Arrive, take shoes and socks off,
practice of individual difficul.. ties
Aust./.Physiother., XVIV, 2, June, 1973
9.30-10.00 10.00-10.30 10.30..11.00
11.00..11.30 11.30.. 12.30
Get on to the tables - exercise in prone and supine and rolling Get off the tables ~ practice standing and walking Exercises in sitting at the tables or away from the tables General activity for the trans.. ference of learning of the patterns practised earlier Prefeeding exercises, lunch, wash faces and hands and the table.
The children were toileted when necessary. Sequences of exercises were designed to inhibit abnormal patterns and develop the more skilled and purposeful movements that were aimed to achieve. Games were selected to allow opportunity for group interaction and for the carry-over of newly l'earned movements. Following each section some examples of the games used in the general activity period are described.
A. General Control
0/ the
Whole Body
It was necessary to establish general control of the whole body lying in prone, supine and on each side, rolling continuously, sitting stilt with feet on the floor, kneeling and standing. It is in this way that a child obtains the concept of his whole body in different positions; it prepares him for the time when he must learn to keep one part still while moving another. Also, it is knowing where "he" is that helps the child make sense of spatial relations such as near, above, bel'ow, behind. The very handicapped child finds great pleasure in gross movement and the physical contact involved, for it is a situation of little frustration and one in which he can easily be successful. Often it was necessary to return to the large rolling movements because it was here that the chird.. ren gained confidence in their ability to move. The games used here were: (1) Maintaining a chosen position for five counts after the music stopped. (2) Simple obstacle games involving getting "under" and "over" and "through".. (3) Rolling out of the way of a halL
RHYTHMICAL INTENTION FOR THE CEREBRAL PALSIED
(4) Making their bodies different sizes ~ being "small" and "tall". (5) Moving and stopping games such as "What's the time, Mr. Wolf?". When the children had learned to be still, listening games were played.
B. Independent Head Movements The children practised moving their heads up, down, to the right and left while keeping their arms symmetrical and still, while in supine, prone and sitting. Later they learned to keep their heads still and move their eyes or watch what their hands were doing.. Action songs involving head movements, looking at hooks during stories, looking at projected pic.. tures, following moving objects and playing games like "1 Spy" were used.
C. Development of Sitting To develop control of sitting the children had to learn to sit with both hands on the
table for support, to move forward at the hips while keeping their feet on the floor, to lift one arm in the air while supporting themselves with the other and finally to Tift both arms in the air. They later learned to sit away from the tables, to go down to touch their toes and sit up, to lean to the right and left and forwards and come back to the midline. After learning to do this on a chair they sat on a bench for their exercises. Arm exercises were included, and action songs. The games used here were: (1) Pass the parcel. (2) Big floor-sized games of draughts and deck quoits - using quoits or bean bags thrown on to numbered squares. (3) Car races with cars attached by knotted cord to the children's hands. (4) Dressing up with hats, beads and throwover garments.
D. Gross Arm Function At the tables the chifdren first learned to sit with their feet on the floor and their two hands flat on the table. They then learned(a) To keep one hand still while moving the other on the table. (b) To lift one hand up in the air while using the other for support.
61
(c) To lift both hands up in the air. (d) To keep their elbows on the table and take their hands to their mouth and ears. (e) To perform movements while grasping a cotton reel' in the dominant hand, the non-dominant hand being used for support. (f ) To use two hands together. (g) To touch parts of their bodies. Several of the children found difficulty looking at the task they were doing with their hands, so special attention was given to include "I am looking at my hands" during exercises. The foltowing simple activities helped them look at their hands and at the task: (1) Drawing on and around their hands and arms. (2) Getting them to wash marks off their hands or the hands and arms of other members of the group. (3) Hiding their hands under a cloth or table and finding them.. (4) Hiding a picture or object under one or both hands so none of it could be seen. Some of the simple gross movement games used were: (1) Placing one or both hands on wellstabilised picture cards usin~ left to right sequencing and later jumping around. The child's own spontaneous speech can be used as they take turns in saying where to place the hand. (2) Animal glove puppets used for arm and hand exercises followed by songs like "Old Macdonald Had a Farm". (3) Picture hunt games with specific movements for going through the long grass, the short grass, the water, climbing a tree. (4 ) Turning the pages of a large wallpaper book to :find all the hidden objects beginning with, e.g., "p" using large wooden objects at first and rater paper cut-outs. (5) Guiding large blocks or cars around a track on the table; this was also done Aust.J.Physiother., XVIV, 2, June, 1973
62
THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY
using mechanical toys (helping the toy to turn a corner or pass between two obstacles)" (6) Keeping balls of different size and weight on the table - this was done as a two~team game with the children sitting around a table; points were lost if the ball fen off the table. (7) Hitting balls and balloons which are hung on a string..
E. Gras p and Release Most of the children had great difficulty opening their hands to grasp objects - one child used to hit her hands hard on the table when they wouldn't open, another child would say, "Open, you stupid hands!". It was found that release came more easify as part of a reach and grasp sequence than just practising to spread the fingers although this was done at the same time. Patterns such as standing and holding the edge of the table, practising extension of elbows with hands held together and establishing some supination with wrist extension and thumb abduction helped them to develop patterns of extension and hand opening. The following games were used to help the children to keep their hands open and feef different shapes and textures:
(1) Identifying by feel objects and parts of other people hidden under a cloth. (2) Washing their faces and different surfaces with towelling mittens.. (3) Making hand prints or painting the table and taking prints. (4) Hand painting three~dimensional shapes, for example, big boxes to make houses or cars.. (5) Collage, putting glue on both surfaces of the paper - the whole top of the table was covered with paper and later the shape needed was cut out because this avoided the frustration the children felt if they tore the paper.
In prone, supine and sitting the children
learned to grasp four-inch cotton reels, quoits and rods.. Cotton reels were useful because they had a flat end on which to stand and the hand fitted snugly between the ends.. The Aust.J.Physiother.; XVIV, 2, June, 1973
cotton reels also gave visual clues to different positions of grasp which made grasp and movement easier" They were fitted with dowelling at one end to fit into holes (drilled
at two~inch intervals) on large hoards which were clamped to the tables . Using the cotton reels the children learned(a) To grasp and then release the stabil~ ised cotton reels.. (b) To place one cotton reel on top of another. (c) To move them from one hole to an~ other. (d) To put quoits over and lift them off the stabilised cotton reels.. (e) Then to hold unstabilised cotton reels and maintain a grasp in different posi.. tions and through a range of movement.
Using their hands to climb up vertical poles and the bars of their chairs help de~ velop patterns of reach, grasp and release.. When the children could hal'd the cotton reels, sponges could he glued on the bottom for printing and painting or drawing with water on a blackboard table, and candles, chalk or crayons could be placed in one end.. Household paint brushes and rolling pins were used for other grasping activities. The children also practised using their spoons and their two~handled drinking mugs. RESULTS
Numbers indicate number of children who couId perform the task consistently.
Prone: Lie still with arms above head Lift and hold head up _ Reach and grasp one hand _
_
Aug. Dec. 1970 1971 3 2
6 6
2
6
Supine: Lie still with arms by side _ 2 Lie still with arms by side and feet
6
Rolling:
Roll in both directions
_- -
against wall ___ Hold hands together Extend arms with hands together Lift rod in one hand, keeping other hand by side __ Lift rod/quoit in two hands Move legs keeping arms by side . Getting on to tables alone _ __ Getting off tables alone ----
o
5
2 2 1
5
2
6
1
5
o
4
1
o
4 6
5
4
RHYTHMICAL INTENTION FOR THE CEREBRAL PALSIED
Aug. Dec. 1970 1971
Sitting: Sit still in a chair with arms and keep fu~onflooc _ Touch tDes and sit up _ Sit alone on a stool
1
o
6
o
5 4·
3
6
I
3 3
6 6 6 6
I 1 0 I 0
6 6 5 4 5
1 0 0
6 4 4
1 0 I 0 0
4 2 4 4 3
2 I 1 2
4
1 0
4 2
0
5
0 0
4 2
Arm and Hand Function: Keep feet on floor and hands flat on table Keep one hand supporting while other hand moves(i) on the table __ (ii) in the air __ _ ___ ___ Spread fingers with hands flat __ Maintain a fist with wrist extension _ Results for Dominant Hand OnlyGrasp stabilised cotton reel Maintain grasp pronation __ _ __ ~ mid supination _ while moving arm __ Release with wrist extension _--_ grasp and drawhorizontal line vertical line __ _ circle ___ __
Sitting to Standing and Walking: Standing holding table __ ~_ __ _ Standing holding table with support Stand holding on to a chair Walk sideways around table Walk pushing chair
1
Activities: FeedingTake hand to mouth __ Take spoon to mouth without food with food Eat sandwiches alone Hold cup and take to mouth without __ _ milk _~_ __ _ Hold cup and drink alone UndressShoes and socks __ _ Slip-over garments Pants __
Toilet-
Balance on pot alone - __ Get on to and use pot alone
0 0
6
3 4
4 3
CONCLUSION
There appears to have been great improve.. ment in general body control and gross move.. ment patterns, and little improvement in any fine hand movements. This is probably due to the degree of handicap - it took nearly a
63
year to obtain good voluntary release in one child and good symmetry in another child with a strong asymmetric tonic neck reflex. The number of children who achieved success at being able to eat and drink alone appears smalL As these were situations of tension, it was felt that children with poor head and hand control needed to have some help. Although the children could hold their cups and drink, it was.. felt they needed help to pick them up and put them down when they had milk in them. The chilaren were allowed to try to eat and drink alone and were often able to manage. However, in tabling the results shown above, only those children who could repeat the task consistently were included. The chifdren's speech appeared to improve particularly in regard to the increase in inner language in relation to other motor activities. There was a reduction in the delay of the initiation of motor speech, words were pro.. duced with less effort and increased intelligihility. As the children became able to say more of the words of the commands or songs, they seemed to be able to express themselves more spontaneously and freely in conversa.. tion with each other and the therapist. Working together in a group over a long period appears to have been an important factor in building up the self..confidence of each child and the concept of social co-operation within the group. It seemed that the children realised that they could compensate for lack of achievement in one area by being better than another child in some other area. It has helped them to become more independent and aware of the needs of the others in the group. One day when one of the therapists was alone and helping one chifd to stand the others went and got the equipment from the cupboard for the next section of the morning then they pulled their chairs around the table. When asked during this rather noisy pro.. cedure what they were doing, the children replied - "Yon help us so we're helping you". They often assisted another child when he was having difficulty with a task. Those children who arrived in a group with little experience of success were at first very unwilling to attempt most tasks. After they had watched the others and began to achieve sue.. Aust.J.Physiother., XVIV, 2, June, 1973
64
THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY
cess at simple activities they stopped saying "1 can't do this" or being disruptive and would often develop their own games. If left alone with some new material they began to explore it. If one of the children was being disruptive the others usually found some ,vay of making him co-operative. The possibility of long continued practice of tasks with success increases the children's feeling of security - one of the children was able to ask her parents to leave her alone in the bath, after she had learned to lie in prone.
Our experience with Rhythmical Intention in the situation described would suggest the suitability of this treatment with the severely handicapped Athetoid in similar situations. SUMMARY
Details of Rhythmical Intention as a method of group treatment for the Cerebral Palsied patient have been given. The specific pro-
Aust.J.Physiother., XVIV, 2, June, 1973
cedures used have been mentioned and an analysis of results achieved have been dis~ cussed. ACKNOWLEDGEMENTS
The authors wish to thank Dr. C. Reye, Director of The Spastic Centre of N.S.W., who gave them the opportunity to undertake this study. REFERENCES
E. and PARNWELlJ, M.. (1967), "From Hun· gary: the Peto Method", Special Education, 56.4. COTTON, E. (1970), "Integration of Treatment and Education in Cerebral Palsy", Physiotherapy, 56.4. HARI, (1968), Address given at Castle Priory College, Wallingford, Berks., England. LE GAY BRERETON, B. and SAITLER, J. (1967), Cerebral Palsy: Basic Abilities. LURIA, A. R. (1961), The Role of Speech in the Regulation of Normal and Abnormal Behaviour, ed. J. Tizard, Pergamon Press, London. LURIA, A. R. (1963), Restoration of Function after Brain Injury, ed. O. Zangwill, Pergamon Press, London. LURIA, A. R. (1963), Educational Psychology in the COTTON,
U.S.S.R.