Development of Locomotor Function and Its Importance in ...Chapter Twenty-Three: Development of...

IntroductionCentral and Reflex Changes of Muscle FunctionMuscular ImbalanceMuscular imbalance and Its NatureThe Development of Muscle Function in Light of Postural OntogenesisPostural Ontogenesis—Motor ProgramsThe Development of Functional Joint CentrationThe Neonatal StageThe Suprapubic ReflexSupport ReactionAutomatic GaitThe Crossed Extension ReflexCalcaneal (Heel) Reflex

The Fourth Through Sixth Week of MotorDevelopmentThe End of the First and the Beginning of the Second TrimenonMotor Development From the SecondHalf of the Second TrimenonSummaryReflex Locomotion

Postural Function of Phasic MusclesTonic and Phasic Muscles—The Developmental AspectThe Influence of Gravity on Function and StructurePhasic Muscles—Functional InsufficiencyDevelopmental Kinesiology of SpinalStabilization in the Sagittal PlaneThe Cervical and Upper Thoracic RegionThe Lower Thoracic and the Lumbar SpinePostural Ontogenesis and the Functionof the DiaphragmMuscular Imbalance in Disturbed Co-activation and Impaired SpinalStabilization in the Sagittal PlaneNormal and Abnormal Kinesiology ofRespiration: Its Relationship to SpinalStabilizationExamination of the Deep StabilizationSystem of the Spine in the SagittalPlaneTreatment of Insufficient Stabilization of the Spine

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Pavel Kolár

23Development of Locomotor Function andIts Importance in Clinical Medicine

PLEASE CHECK THIS OPENING PAGECOUTH1 WERE TOO LONG.

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Making Use of Reflex StimulationTreating Pathological RespirationPatient’s Voluntary Activity

Motor Patterns and Trigger PointsPrinciples of Examination and Correctionof Pathological Articular Patterns

Learning ObjectivesAfter reading this chapter, you should be able to understand:

• The role of agonist–antagonist muscle co-activation and functional joint centration

• The relationship between developmental kinesi-ology and muscle balance/imbalance

• The stages of neurodevelopment of uprightposture

• The use of reflex locomotion methods techniquesinvolving creeping, crawling, and rolling move-ments to facilitate muscle balance and jointcentration

• The relationship of coordination between theabdominal wall and diaphragm for promotingspinal stability

532 —— Part Five: Acute Care Management (first 4 weeks)

Introduction

Two types of motor behavior result from the struc-ture and function of the nervous system. One mani-fests itself by motor function as a result of motorlearning. This consists of conditioned reflexes, whichare formed by constantly repeated stimuli. The sec-ond is automatic learned motor functions, which aretermed motor stereotypes.

The nervous system produces motor functions thatappear in the same way from one generation to thenext. These genetically determined factors of motorbehavior are called motor patterns. Muscle functionis encoded in motor patterns, which develop as thecentral nervous system (CNS) matures. Motor pat-terns, i.e., the reactions of the motor system to affer-ent stimulation, represent the programs of the CNS.The response to a given stimulus depends on the levelof integration in the CNS. The reactions of specificstimuli described so far are at the spinal and brainstem level. This level of organization corresponds tophenomena such as the supporting reaction, thecrossed extension reflex, gait automatism, segmentalcutaneous motor reflexes, deep tonic neck reflexes,vestibular reflexes, etc. In addition to these reactions(programs), it is now possible to demonstrate motorpatterns integrated above the brain stem level. Theseprograms mature only in the course of postural onto-genesis.

If a 1-year-old is lifted by one arm and the leg ofthe same side from the supine position and heldhorizontal (Collis horizontal reaction), a character-istic motor response is obtained (Figure 23.1). Thisresponse, if repeated, is constant, with the childreacting in the same way each time. This responsedoes not result from motor learning but will be thesame in all children with a normal CNS. The type of

response depends on postural function resulting frommuscular co-activation, corresponding to the stageof maturity reached by the CNS.

Motor patterns at this level of integration areneglected by clinicians and by neurophysiologists,despite their fundamental clinical significance. Inthis chapter we demonstrate that these motor func-tions, which though genetically determined, are con-trolled and integrated on a higher than brain stemlevel and can be explained by mechanisms of theontogenesis of posture.

Central and Reflex Changes of Muscle Function

To fully appreciate muscular function it is necessaryto describe, study, and understand not only its ana-tomy but also its function under the control of theCNS. It has been pointed out that muscle activity isthe result of very complex reflex processes, which arebetter termed programs, because their nature is pro-cessing information by very complex and in manyways unknown physiological mechanisms. The rela-tionship between receptors and effectors cannot beexplained by a simple reflex pathway, but only by aprogram worked out by the CNS.

If there is disturbed activity of the CNS or of anyother part of the human organism, including visceralorgans, there will be repercussions in the somatic,i.e., muscular system. There are, however, only twotypes of response.

1. Inhibition, with signs of hypotonus, decreasedactivity and weakness.

2. Hypertonus, spasm, rigidity, and even spasticity.

In most cases, these changes affect only the contrac-tile elements. However, they may affect connectivetissue, resulting in shortening, or even contracture.In this case, the muscle cannot reach its full length.At a certain point contracture can change the align-ment of joints the muscle is related to, even in theneutral position. Even when slowly stretched, the fullrange of movement cannot be reached (8).

Changes in muscular function, whether caused byhyperactivity or hypoactivity, can affect the wholemuscle or group of muscles, or only a small part ofit. If it is only a small localized lesion, it is called atrigger point (TrP). It consists of only a few musclefibers with a decreased threshold to stimulation. Involuntary movement they contract first, but uneco-nomically. In the center of the TrP, the fibers are in astate of contraction, whereas at the periphery thefibers are distended and inhibited. This can be calledintramuscular incoordination.Figure 23.1 The Collis horizontal reaction.

Chapter Twenty-Three: Development of Locomotor Function —— 533

The muscle may not be weak in itself, but it maynot function well because its attachment point isinsufficiently fixed. A muscle must have a punctumfixum. Thus in resisted flexion of the wrist, theattachment point of the wrist flexors must be stabi-lized by the muscles that stabilize the elbow, and theelbow in turn by the shoulder girdle. In this way, sta-bilization of attachment points depends on a chainof muscles. Disturbed function of a muscle cantherefore be caused by dysfunction of a far-distantmuscle. As the shoulder girdle is stabilized by theabdominal muscles in the upright position, wristflexion can be impaired by dysfunctional abdominalmuscles. In this way, the condition of the abdominalmuscles may change the quality of wrist flexion. Thisprinciple holds for specific muscular activity. It fol-lows therefore that the functioning of any muscle isdetermined not only by its specific function but alsoby its stabilization. Insufficient stabilization is a veryfrequent cause of muscular dysfunction. Unfortu-nately, muscle function is usually examined withoutadequate regard to stabilization. This takes placeautomatically and unconsciously, programmed bythe CNS. It is very important in treatment of distur-bance of motor function to analyze the chain ofmuscles determining the stabilizing function.

The following characteristic features of thesechanges in function are:

1. They are interrelated, i.e., they are never isolated,but form chain reactions.

2. The dysfunctional chains are not at random, butfollow definite rules.

3. Muscular dysfunction goes hand in hand withfunctional changes of joints, skin, fascia, perios-teum, and even visceral organs.

Muscular Imbalance

There is clinical and experimental evidence that somemuscles are inclined to inhibition (hypotonus, weak-ness, inactivity), and other muscle groups are likely tobe hyperactive with a tendency to become short(2–4,6,7,9). This fact was already known. Janda, how-ever, was the first who showed that the ensuingimbalance followed certain rules, which are suffi-ciently constant and characteristic to be called syn-dromes (the upper and lower crossed syndrome, thestratification syndrome) (see chapter 10).

A number of pathological conditions producehypertonus and even contracture in some musclegroups and in other groups inhibition, ending up inatrophy. This is true, e.g., in organic lesions of theCNS. Those muscles that tend to develop spasm inacute poliomyelitis are the same as those that in the

chronic stage of the disease produce contracture,and in patients with cerebral palsy (with signs ofspasticity) cause spastic contracture. Their antago-nists, however, are inhibited.

The same muscles that are likely to produce con-tracture and those that incline to inhibition in lesionsof the CNS can be found to be hypertonic or weakrespectively in disturbed posture.

Muscular Imbalance and Its Nature

The muscular system reacts according to certainrules. What, then, are the common features of mus-cles with a tendency to hypertonus, hyperactivity,and tightness, to spasticity, and even to spastic con-tracture in cerebral lesions? The same question canbe asked about muscles tending to inhibition. In whatfunction do these muscles differ?

The contemporary theory suggests that the twomuscular systems have opposite characters. One basicfeature stems from their function against gravity.Janda distinguishes tonic muscles with a tendency toshortness, and even contracture with a mainly pos-tural function (3,4), hence the term postural muscles.It is, however, questionable which position (posture)is formative in the first place. Which position is deci-sive in opposing gravity? Janda considers gait to bethe basic typical human motor activity (see chapter10). He further explains that we stand on one leg dur-ing 85% of the time spent walking. He considers themuscles responsible for erect posture during a givenstage of walking to be postural muscles in the truesense of the word (5,7).

Physiologists have shown that the two types ofmuscles differ in both function and structure. Thesame difference is also found in the nervous struc-tures in control of these muscles, for it is the type ofmotor neurons that determine the type of musclefiber. It is therefore better to speak of tonic and pha-sic motor units. Tonic motoneurons, i.e., small alphamotor cells, innervate red muscle fibers, whereas pha-sic motoneurons (large alpha cells) innervate whitemuscle fibers. In humans, both types of motor unitsare present in every muscle, in different proportions.Such muscles are “mixed.” According to the prepon-derance of one or the other type of motor units, tonic(postural) and phasic (kinetic) muscles can be distin-guished. Contraction and decontraction is slower intonic than in phasic motor units.

Having understood the functional and morpho-logical difference between the two antagonistic mus-cular systems, this difference is particularly strikingfrom the point of view of phylogenesis and ontogene-sis. This also provides a more specific and effective

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approach for treatment of disturbances resulting fromthe functional antagonism of the two systems.

The Development of Muscle Function in Light of Postural Ontogenesis

It is common knowledge that unlike most animals,humans are immature at birth, both in function andeven morphologically. The CNS maturates in thecourse of postnatal development, as does useful mus-cular function. The position of the joints, and pos-ture, are the essential items of ontogenesis. This is toa great extent because of the stabilizing function ofmuscles acting interdependently. The specific bipedalerect posture matures during ontogenesis with trunkrotation and abduction and outward rotation of thearms. Thus, also, the development of joint position isdetermined by muscles responsible for coordinatedstabilization of their attachment points.

The morphological development of the skeletontakes place at the same time (the shape of the hipjoint, the plantar arch, spinal curvature, etc.)depending on the postural and stabilizing function ofthe “phasic” muscles, which are phylogeneticallyyounger. Thus, intrauterine evolution continues infunction and in morphology and is accomplished atthe age of 4 years, when gross motor function hasreached full maturity. This development can be illus-trated at the shoulder blade. It does not stop at birth;during pregnancy, the shoulder blade begins todescend in a caudal direction, and if this does nottake place, Sprengel deformity results.

Under normal conditions, CNS maturation contin-ues at the shoulder blade after birth as the maturationof muscle function causes it to descend further. Afterthe fourth week, the caudal part of the trapezius andthe serratus anterior come into play. The stabilizingfunction of other muscles, in particular, of the abdom-inal muscles and even the diaphragm, is essential tofacilitate outward rotation of the caudal angle of theshoulder blade, resulting in abduction of the arm tomore than 90 degrees. This represents the most recentstage in the evolution of the scapulae’s position.

In infantile lesions of the CNS, the musclesresponsible for posture and stabilization do not func-tion, and neither the descent nor outward rotation ofthe shoulder blade takes place. The shoulder bladeremains in the neonatal position, i.e., elevated as aresult of pull by the upper trapezius and the levatorscapulae (Figure 23.2). This is also the case in badposture because of incomplete maturation. Onlyhumans can fix the shoulder blade to the thorax in acaudal and outward rotated position. This functionmatures only during postural ontogenesis after birth.

The muscles responsible for this position are veryprone to inhibition, and similar disturbances can beobserved in other parts of the human skeleton.

Not unlike posture, the position and stabilizationof joints results from coordinated muscular activityunder the control of the CNS. This follows logicallyfrom the development of some characteristic posi-tions of the body (prone, supported on elbows,“oblique” sitting, standing erect), and also from thepositions the joints take up in the course of primitivelocomotion. Studying the separate phases of loco-motion “frozen phases” Janda helps us to understandposture better and to infer joint position at eachstage of motion (5,7). In the case of locomotion, onall fours we obtain the sum of momentary positionsbeginning with the starting position and reaching theopposite end position of side-bending, rotation, andanteflexion and retroflexion.

Postural Ontogenesis—Motor Programs

Muscular synergy develops during evolution, fol-lowing patterns stored in the brain. The infant doesnot need to be taught how to lift his head, to grasp

Figure 23.2 Child with spastic diparesis. Theposture corresponds to the neonatal stage ofdevelopment and morphological immaturity.


a toy, to turn around, or to move on all fours. Allthis occurs automatically in the course of matura-tion of the CNS by muscular coordination. Thesefunctions are genetically determined. Postural activ-ity of the muscles comes into play automaticallydepending on optic orientation and the emotionalneeds of the child. This activity ensures active pos-ture, i.e., all possible positions in the joints deter-mined by their anatomical shape. Morphologicaldevelopment of the skeleton depends on posturalfunction of the muscles. Understanding the kinesi-ology of postural development is essential for boththe diagnosis and treatment of the locomotor sys-tem (10).

The Development of Functional Joint Centration

The position of joints is controlled from infancy (evenduring movement) by coordinated co-contraction ofantagonists. It is also linked up with muscles provid-ing joint stabilization. The co-activation pattern ofantagonists develops between the fourth and sixthweek of infancy. Well-balanced activity of antagonistsguarantees well-centered joints. This depends only ona normally developed CNS. Any abnormality of theCNS causes abnormal joint position. This is veryimportant for diagnosis, particularly in the early stageof development.

The concept of functional centration is essentialto understand the relationship between joints andmuscles. The terms “centration,” “decentration,”“subluxation,” and “luxation” used mainly in ortho-pedics describe the morphological and/or patho-logical condition of joints. Functional centration,however, implies maximum load bearing, i.e., thebest possible distribution of the load at the articu-lar surfaces. In other words, it implies maximumcontact of articular surfaces during each position inthe course of movement.

A good example is the hip joint. If functional cen-tration is to be maintained during flexion, there mustbe abduction and outward rotation at the same time.Thus, only maximal contact of the articular surfacescan be achieved. Under the same conditions the axisof rotation, too, is at the center of the joint cavity andof the femoral head. As flexion decreases, outwardrotation and abduction decreases as well, and thereis none in extension.

If hip movement is separated into individual stages,with each stage being correctly centered from oneextreme to the opposite end position, a sum of “frozen”articular positions is obtained, i.e., of coupled flexion,rotation, and abduction. Maximum contact of thearticular surfaces also produces maximum facilita-

tion of muscle activity. Kabat’s diagonal movementsmake excellent use of this principle.

The weight lifter can serve for illustration. He putshimself into a position in which the spinal column,the hip joints, the knees, etc. are loaded most favor-ably. His joints are centered during all the stages ofweight lifting to bear the maximum load. In anyother position the articular surfaces would be incon-gruent, risking tissue damage. This is an example ofthe balanced function of antagonists and goes hand-in-hand with well-balanced loading of the spinal col-umn, its discs, and articulations.

The same principle of joint centration is adheredto during all the stages of postural ontogenesis be-cause of balanced muscular activity. This principleholds for the spinal column because of the activityof the deep intrinsic back muscles, the deep neckflexors, and the abdominal muscles. Under theircontrol, the optimum position of the individual seg-ments is achieved in the sagittal plane. In this way,the most favorable loading of the intervertebral discsand the centration of intervertebral joints is achieved.It constitutes a motor program forming spinal cur-vatures in the sagittal plane. This postural programis completed during the fourth month. It is the pos-ture we have seen in the weight lifter.

Further differentiation of muscle function fromthe fifth to the seventh month enables the child toachieve a well-centered posture, even during trunkrotation, having learned how to turn from prone tosupine and back. A well-centered posture both in thesagittal plane and during rotation can be maintainedonly if the CNS develops normally. According toVojta, this degree of maturity is never attained in30% of children (1,11,13). In such children, faultyposture and muscular imbalance begin at an earlystage of their development.

It must be particularly stressed that muscular syn-ergy related to this model of evolution always dependson body posture as a whole and not that of a partic-ular segment. Decentration of a single joint has itseffect on the centration of all the other joints. Theinterrelation of all body segments is best demon-strated by Vojta’s method of reflex locomotion. Ifstimulation is performed in a position of decentra-tion, e.g., of the head, not a single joint will be cor-rectly centered. In conclusion, correct centration ofjoints can be considered an important sign of normalfunction of the CNS.

Motor Programs During IndividualDevelopmental Stages

During each stage, partial motor patterns mature rep-resenting the basic elements of adult motor behavior

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The Neonatal Stage

During this stage of development, the posture of theinfant is unbalanced (Figure 23.3). The point of grav-ity is in the sternal and umbilical region. In this unbal-anced posture there is neither a differentiated functionnor any point of support. The whole body rests on thesurface. If prone, the child lays on one half of the bodyfrom the cheek to the chest as far as the umbilicus. Theupper and the lower extremities are in flexion, unableto give any support. The same unbalanced posture canbe seen with the baby supine (Figure 23.4).

This neonatal posture is given her in detail:

• The hand—the fingers are flexed and in ulnarflexion, there is also flexion at the wrist

• The elbow is in flexion and pronation

• The shoulder is protracted and in internalrotation

• The shoulder blade is elevated

• The spine is in flexion

• The pelvis is in anteversion

• The hip joint is in flexion and internal rotation

• The knees are flexed, the legs rotated outward

• The foot in plantar flexion

In the neonatal period, the tonic muscular system isin complete control. As we have pointed out, all theanatomical structures of the skeleton at this stageare immature, too. This holds for the angle of ante-version and the colodiaphyseal angle of the femur,the plantar arch, the plateau of the tibia, leg rota-tion, and the horizontal position of the collar bones,etc. These are related to the formative influence ofthe postural function of the phasic muscular system:the abductors and outward rotators at the hip, the

spinal extensors, the short extensors at the knee, thetibialis anterior, the peroneal muscles etc. Becauseno higher centers of nervous control are as yet func-tioning and the tonic system is in complete control,there is no postural balance and it is yet possible toelicit certain motor responses (programs), which areintegrated at the spinal level of control.

The Suprapubic Reflex

On slight (not nociceptive) pressure at the upperedge of the symphysis extension and inward rota-tion at the hip, extension at the knee, plantar flexionof the feet, and fanning out of the toes takes place(Figure 23.5). This response is symmetrical on bothlower extremities.

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Figure 23.3 Posture at birth: prone.

Figure 23.4 Posture at birth: supine.

Figure 23.5 Suprapubic reflex.


Support Reaction

The baby is held under the armpits and the soles ofhis feet are stimulated (Figure 23.6). The response isextension (support) of both lower extremities. If thisreflex continues for some time, it can be mistaken forthe infant attempting to stand

Automatic Gait

This reflex is elicited similarly to the previous one;however, in this case, only one sole is stimulated(Figure 23.7). Triple flexion of the opposite extrem-ity takes place. In this reflex, the infant demonstratea walking pattern on an involuntary basis.

The Crossed Extension Reflex

With the baby supine and the lower extremity flexedat the hip and knee, slight pressure is exerted againstthe knee in the direction of the hip joint (Figure23.8). Extension and inward rotation at the hip,extension of the knee, plantar flexion of the foot,extension at the metatarsophalangeal, and flexionat the interphalangeal joints take place in the otherlower extremity.

Calcaneal (Heel) Reflex

The heel is tapped and the hip and knee are in a semi-flexed position (Figure 23.9). Extension of the kneeand hip takes place.

In all the motor programs given, we find a recip-rocal response of antagonists on stimulation, i.e., for

Figure 23.6 Support reaction.

Figure 23.7 Gait automatism.

Figure 23.8 Crossed extension reflex.


every reflex response of one muscle, its antagonist isinhibited.

The Fourth Through Sixth Week ofMotor Development

Optic fixation appears between the fourth and sixthweek and with it the infant’s orientation in space. Itbegins to lift the head against gravity (Figure 23.10).In this way, the head is lifted beyond its base of sup-port and supports itself on the forearms. The upperarms are no longer in a frontal plane, they movetoward the sagittal plane by adduction and flexion atthe shoulder. At the same time, the point of gravitymoves in a caudal direction toward the symphysis,and anteflexion of the pelvis decreases. It must bestressed that lifting the head first is in no way an iso-lated movement but that this goes hand in hand withthe upper extremity providing support to lift the tho-rax, changing in this way the entire body posture. Thisdepends on precisely coordinated muscular functionproviding stabilization. This all-around change of pos-ture is automatic; however, it depends on the child’smental development and is encoded in locomotorontogenesis.

Higher levels of CNS control come into play whenoptic fixation is established. The characteristic fea-tures of this stage are:

1. The spinal motor patterns disappear or arehidden, i.e., the supporting reaction, the gaitautomatism, etc.

2. Muscular co-activation appears, resulting in abalanced activity by simultaneous action of

Figure 23.9 Heel reflex.

Figure 23.10 First stage of erect posture after optic ori-entation between 4 and 6 weeks (A–C).

A

B

C


antagonists and their mutual reciprocal facilita-tion and inhibition.

3. “Phasic muscles” begin to take part in the stabi-lization of posture. As a consequence, muscleswith a tendency to weakness take part in themaintenance of posture as links of a chain. Thesemuscles, as pointed out, are not true phasic mus-cles and, in view of their postural function,should be better-considered as phylogeneticallyand ontogenetically younger postural muscles.The most important phasic and tonic musclesare listed in Table 23.1.

The End of the First and theBeginning of the Second Trimenon

At 3.5 months, the first support base is defined andthe points of support can be shown to be the elbowsand the symphysis with the infant prone (Figure23.11). If supine, the area of support is formed by theupper part of the gluteal muscles, the scapularregion, and the linea nuchae (Figure 23.12). Postureis fully determined at this stage, controlled by theCNS. Spinal straightening, ensured by well-balancedactivity of the deep extensors and flexors, can beobserved starting at the occipital level and ending at

Table 23.1 Muscles With Predominately Phasic and Tonic Function

Tonic Muscles Phasic Muscles

m. adductor policis m. abductor pollicis brevism. flexor digiti minimi m. opponens pollicism. interossei palmares m. interossei dorsalesm. palmaris longus m. extensor digiti minimim. flexor digitorum superficialism. flexor digitorum profundus m. extensor carpi radialis longus et brevism. flexor carpi ulnaris m. extensor carpi ulnarism. flexor carpi radialis m. extensor digitorum

m. abductor pollicis longusm. pronator teres m. abductor pollis brevism. pronator quadratusm. biceps brachii caput breve m. anconeusm. brachioradialis m. triceps brachii caput laterale et medialem. triceps brachii caput longum m. teres minor

m. infraspinatusm. subscapularis m. supraspinatusm. pectoralis major m. serratus anteriorm. pectoralis minor m. deltoideusm. teres major m. biceps brachii caput longumm. latissimus dorsi m. trapezius—lower partm. coracobrachialis m. rhomboideim. trapezius hor.cást abdominal musclesm. levator scapulae extensors and outward rotators of the hip joint

m. vastus med. et lat.neck extensors hipjoint abductoresm. sternocleidomastoideus m. gastrocnemiusm. scaleni peroneal musclesm. quadratus lumborum m. longus colli

m. longus capitism. iliopsoas m. rectus capitis ant.m. rectus femoriship joint adductorsm. tensor fascie lataeischiocrural musclesm. soleusfoot adductorsAQ4


sacrum. Equilibrium between the lower and upperfixators of the shoulder blade is established: in thecourse of the fourth month, stabilization of thespinal column in the sagittal plane matures. Thisforms the basis of the stepping forward (grasping)and support function of the extremities, whichinvolves rotation of the spinal column. Maturity ofthe spine in the sagittal plane is also necessary for thegrasping function of the upper extremity. Furtherdevelopment depends on this basic synergy. Turningover, sitting, standing, getting on all fours, and so oncan be achieved only if there is stability in the sagit-tal plane. The spinal column thus provides the basisfor stabilizing the muscles of the extremities, playingthe role of a punctum fixum. If there is any abnormal-ity, there will also be dysfunction at the extremities.This relationship is, however, reciprocal. Develop-ment in the sagittal plane that is not ideal can alwaysbe observed even later (during adulthood).

The muscular interplay described, very well-definedfrom the kinesiological point of view, is essential forerect posture. It represents a genetically fixed model,specific exclusively for the human species, and deter-

mines the formation of the characteristic spinal cur-vatures (kyphosis and lordosis) in the sagittal plane.It is very important that this model can be evoked byVojta’s method of reflex locomotion in the neonatalstage of development, at a time when the anatomicalstructures are not yet fully developed. This proves thegenetically determined formative role of posturalfunction.

Motor Development From theSecond Half of Trimenon 2

At age 4.5 months, the child is able to grasp an objectwhen lying prone. The head, the upper extremity, andthe shoulder are lifted against gravity. If the CNSfunctions normally, the spine and the extremity jointsare in a centered position, and the support is of a tri-angular shape, formed by the elbow, the anteriorsuperior iliac spine of one side, and the medial epi-condyle of the femur of the opposite side (Figure23.13). Thus, the support pattern of the lower extrem-ity is partially formed. In this model of development,the fist is formed with radial flexion. At the same time,there is thumb flexion with abduction of the fingers.Lifting of the upper extremity prone is possible onlyif muscle pull of the opposite weight-bearing extrem-ity is directed distally to the point of support.

At age 4.5 months, the child lying supine is able to lift his pelvis, supporting himself on the thora-columbar junction, which is stabilized by muscularcoactivation. This point of support enables the childto grasp an object situated above mid-line whilesupine. At this stage, the chest can also be asymmet-rically stretched with the child supine. In this way,the lower shoulder becomes the point of support,which, too, is possible only if there is distal musclepull. From this position, trunk rotation can followwith the spine straight, a function completed by theend of the sixth month. Two oblique muscle chainsappear at this time. The first produces pelvic rotationin the direction of the supporting upper extremity.Muscle contraction starts at the obliquus abdominisinternus on the side to which the chin is turned, pass-

Figure 23.11 Posture when prone at3.5 months.

Figure 23.12 Posture when supine at 3.5 months.AQ5


ing by the transversus abdominis to the obliquusexternus of the opposite side (Figure 23.14). The dor-sal muscles take part in the co-activation synergy.The second oblique chain taking part synergisticallyin rotation is formed by the abdominal muscles withthe pectoralis major and minor of both sides, pro-ducing rotation of the upper part of the trunk andstraightening at the shoulder (Figure 23.15).

When turning over from supine to prone, one legis supporting and the other is “swinging” (steppingforward). The arms behave in an analogous way. Thereciprocal movement pattern has been finished, i.e.:

1. The supporting leg (which takes off) moves intoinward rotation, adduction, and extension, andthe other leg moves in external rotation, abduc-tion, and flexion at the hip. The other articula-tions function analogically, i.e., their movementhas a reciprocal pattern.

2. The muscles of the supporting leg exert a pull ina distal direction, i.e., “the punctum fixum” isdistal and “the punctum mobile” is proximal.The muscles of the swinging (stepping forward)leg, however, have their punctum fixum proximalwhile the punctum mobile is distal.

3. Thus, muscle pull is differentiated at this stage ofdevelopment, i.e., in the supporting leg (arm) thejoint cavity moves against the head of the joint,whereas in the swinging leg (arm) the headmoves against the joint cavity.

It is characteristic for locomotion during the fifthand sixth month that the supporting and swingingextremities are ipsilateral. Differentiated musclefunction is established, by which is meant an oppo-site direction of muscle pull in swinging and sup-porting extremities. In stepping forward or grasping,the extremity muscles pull against a fixed point(punctum fixum) located proximally. The femoraland humeral heads move against the joint cavities.However, in the supporting extremities the situationis the opposite. In support function, the extremitymuscles pull against a fixed point located distally.Now, the joint cavities move against the femoral orhumeral heads.

We mean the direction of muscle pull, i.e., the loca-tion (proximal or distal) of the fixed point (“punctum

Figure 23.13 Posture at 4.5 months: support based onthe elbow, the anterior superior iliac spine of one side,and the medial epicondyle of the opposite knee.

Figure 23.14 The first oblique muscle chain accord-ing to Vojta.

Figure 23.15 The second oblique muscle chain accord-ing to Vojta.

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fixum”) against which the muscles pull and the move-ment of the joint head and cavity. The swinging(grasping) and the support extremity behave in thesame way. The only difference is that the movementis reciprocal.

The oblique sitting position develops from boththe prone and the supine position. The points of sup-port are the gluteus medius and the hand. The grasp-ing upper extremity is flexed at the shoulder at anangle above 120 degrees. Crawling on all fours devel-ops from this position. The next step is for the childto stand up and walk toward the side. This is fol-lowed by true bipedal locomotion. After the age of 6 months, the supporting and swinging function ofthe arms and legs takes on a contralateral pattern.Thus, the “swinging” or grasping arm is on the sideof the supporting leg and vice versa. The course ofthe movement of the stepping forward and the sup-porting extremity is the same. The difference is in thepunctum fixum, which in the former is the joint cav-ity and in the latter the head of the femur. There aretwo basic models of the phasic movements. The step-ping forward (grasping) and support function maybe either contralateral or ipsilateral. This coordi-nated muscular activity is genetically programmed.It stabilizes the spinal column in the sagittal plane(fourth month) and later develops the function ofswinging (stepping forward, grasping) and support.It forms the basis of our “motor subconsciousness.”All joint positions result from muscular synergiesmaturing during early development. The range ofmovement depends not only on the anatomicalstructures but also on the muscles and muscular syn-ergies performing the movement. Muscular syner-gies resulting in this model always depend on bodyposture, never that of a single segment. This func-tional goal explains the relationship between theanatomical structure of muscles and joints and theirfunction.

Summary

Motor development in infancy is automatic, depend-ing on optical orientation and the emotional needs ofthe child. It is genetically determined, developing themotor functions that form the basis of our automaticsubconscious motor behavior. Two basic functionsplay a decisive role in this context:

1. The development of stabilization in the sagittalplane at the end of the fourth month. At thisperiod, the muscular stabilizing functionmatures, enabling the spinal column to adoptideal weight-bearing posture. If the CNS func-tions normally, the principles of neurophysiology

and biomechanics must be in harmony. Stabi-lization in the sagittal plane forms the basis forevery phasic movement.

2. The development of specific phasic movements.These are the swinging (stepping forward orgrasping) function and the take off. They areclosely related to the stabilizing function anddevelop at a precise date. Grasping takes placefirst from the side (third month), later from themid-line (4.5 months), and finally across the mid-line (fifth to sixth months). The other extremityprovides the function of support or take off.

Later in the development, the stepping forward(grasping) and support (take off) functions occur oncontralateral sides. In other words, there are twomodels of stepping forward and support (taking off)functions:

1. Stepping forward and support (taking off) takeplace on the same side. (e.g., the left arm is mov-ing forward and the leg is also stepping forward)

2. Stepping forward and support (taking off) takeplace on the contralateral side

Under normal conditions, both the stepping forwardand support function take place according to a bio-mechanically ideal pattern when all the joints arefunctionally centered. This can be true only if thereis normal maturation of the CNS.

Reflex Locomotion

Partial motor functions maturing in the course ofpostural development, such as postural stabilizationin the sagittal plane, the swinging, and the supportfunction (ipsilateral and later on opposite sides) canbe evoked by reflex stimulation. This constitutes anew and fundamental principle that has changed ourunderstanding of the motor system, i.e., its func-tional pathology controlled by the CNS.

It is possible to evoke partial movement patternsby innocuous pressure (pressure must be in the cor-rect direction and vary in intensity) at stimulationpoints (Figure 23.16), which are points of support.Two types of complex responses result: reflex turningover (Figure 23.17) and reflex creeping (Figures23.18 to 23.20) are both described by Vojta (12). Theyare general patterns in which the entire muscularsystem is involved in a well-defined coordinated way,and all levels of the CNS are involved. The movementevoked by stimulation involves the partial patternsdescribed. Thus, in reflex turning over, we mayobserve partial movements according to the stage ofdevelopment: lifting the legs over the table and keep-


ing them in triple flexion and abduction (fourthmonth), grasping over the midline (4.5 months), com-bined with turning to the side (fifth month), turning toprone position (sixth month), lying on the side usingthe elbow as a support (seventh month), oblique sit-ting position (eighth month), crawling on all fours(tenth month), walking sideways (twelfth month).These general patterns controlled by the CNS areconstant and can be reproduced.

By stimulation of reflex zones in a given position,involuntary muscle activity is evoked, including theorofacial system. This response is constant and pur-poseful. The genetically programmed locomotor pat-tern is as follows:

1. By evoked muscle activity, the point of gravity istransferred and the body is supported automati-cally at given points. These points are geneticallydetermined and represent structures that play animportant role in upright posture. At these siteswe find a great number of muscular and/or liga-mentous attachment points rich in receptors. Ifstimulated, muscle activity is directed towardthese points of support. The initial position inwhich stimulation takes place determines thezone of support. The automatic choice of thesupport point is made by stereognosis, i.e. byawareness of the point of contact and its positionin space (making no use of vision), related to thebody scheme. Therefore, no matter whether thebody is lying on the side, supine, or prone, therewill be the same response to the same stimula-tion, but the point of support will change.

2. The stabilizing system in the sagittal plane willbe activated (fourth month). The spinal column,the thorax, and the shoulder blade automaticallyadopt the ideal position of maximum load bear-ing as the principles of neurophysiology and bio-mechanics are in harmony. The pattern ofstabilization in the sagittal plane is the constantresponse to stimulation whether stimulation

takes place when lying on the side, prone, orsupine. Only the points of support are changed.

3. Stabilization of the spinal column is followed bythe swinging (grasping) and support function ofthe extremities which is coupled with spinalrotation. The oblique abdominal muscles comeinto play. The choice of the ipsilateral or con-tralateral pattern of swinging (grasping) and thesupporting extremity depends on the initial posi-tion. This, too, is automatic depending on headposition and visual orientation. The mechanismof swinging (grasping) and mechanism of takingoff is always identical, but in the opposite sense.On the swinging leg, we find:

• The hip in flexion, external rotation, andabduction

• The knee in flexion and external rotation

• The foot in dorsal flexion and supination

• On the grasping, upper extremity:

• The shoulder in flexion, external rotation,abduction

• The elbow in supination and slight flexion

• The hand in extension, supination, and radialflexion

The supporting extremity moves in the oppositeway. During the movement, all the joints are per-fectly centered. The direction of muscular pull dif-fers in the two patterns: in the swinging (grasping)extremity the punctum fixum is proximal and thepunctum mobile distal; in the supporting limb, it isthe reverse. In the former the head of the jointmoves against the joint cavity, in the latter the jointcavity moves against the head. This model can beevoked throughout life, at every age. It differs, how-ever, in the adult, because the response to stimula-tion is under the control of the cortex. In everybody,however, there will be changes in respiratory func-tion that enhance the stabilization of the spinal col-umn and the thorax, and also changes in muscletonus, including those muscles that are not com-pletely under the control of our will. To increasefacilitation in addition to zone stimulation, we canalso resist the locomotion movement (stepping for-ward) isometrically.

Postural Function of Phasic Muscles

The phasic muscles start their postural activity afterthe age of 6 weeks, as pointed out. As the CNSmatures, these muscles play an increasingly impor-tant part in posture and its stabilization, and greatlyinfluence the formation and shape of anatomical

Figure 23.16 Stimulation zones.


A B

C D

E F

Figure 23.17 Reflex turning stimulation: supine (A–I).

structures. The development of postural function ofthe phasic muscles is completed by the age of 4 years,when the central motor control of gross mobility hasmatured. At this stage of development, the child canattain at each joint the opposite position to that ofthe infant at birth (Figure 23.21). This was earlier

described for the shoulder blade and is further demon-strated on the entire upper extremity.

At birth, the position of the upper extremity ischaracterized by fingers in flexion and adduction, thewrist in ulnar and palmar flexion, the elbow inpronation and flexion, and the shoulder in protrac- 1 LINE LONG


I

G

H

Figure 23.17 (Continued)

tion, adduction, and internal rotation. Posture isunder the predominant influence of the phylogenet-ically older tonic system. At full postural maturity,the child can acquire a posture in which the fingersare extended and in abduction, the wrist in extensionand radial flexion, the elbow in supination and exten-LONG

Figure 23.18 Reflex creeping—basic position forstimulation.

sion, and the shoulder in depression, abduction, andexternal rotation (Figure 23.22 A–D and Figure 23.23A and B). A similar development takes place in otherbody segments.

This posture is the youngest from the phylogeneticand ontogenetic point of view, and this also goes forits structure (no animal can attain a similar positionwith respect to the anatomical shape of the jointsand even the muscles, responsible for posture). Themuscles or their parts involved in posture are phylo-genetically young in their postural function (activeonly in humans) and tend to become weak.

Tonic and Phasic Muscles—The Developmental Aspect

It is often expressed that tonic muscles are mainlyconcerned in posture (“postural muscles”) and pha-sic muscles in movement (“kinetic muscles”). Butboth types have dual functions participating in bothposture and movement.

Ontogenesis clearly shows that the decisive differ-ence between the two systems consists in the timing oftheir development, i.e., at which period they are inte-grated into the postural function. Muscles with a ten-dency to weakness, i.e., the phasic muscles, come intoplay later; hence, they are younger with regard to theirpostural function. This postural function is also relatedto the developmentally youngest morphological struc-tures. This system is not only young but also very frag-ile. The postural activity of phasic muscles goes handin hand with central nervous control at a higher levelof integration, compared to the neonatal period. It is of great clinical importance that at this higher level of integration a different interplay between differentmuscle systems are achieved than on the spinal orbrain stem level. Motor programs at the spinal and


A B

C D

E

Figure 23.19 Reflex creeping—lower extremity locomo-tion reaction (A–E). The support function of the other legis identical but in the opposite sense.

brain stem level function mainly by reciprocal inhibi-tion of the antagonist (activation of the muscle causesinhibition of its antagonist), as can be seen fromneonatal reflex activity. Co-activation patterns developonly as higher levels of integration mature. At the sametime neonatal reflexes are inhibited.

Phasic muscles are involved in postural activityas a whole, as a system, and its activity automati-cally changes posture. The moment the deep neckflexors become activated (when between the fourthand sixth week the child lifts its head), all the otherphasic muscles take part in postural function by


means of their interacting attachments, includingthe external rotators and abductors of the hip joint,the external rotators and abductors of the shoulder,and the deep spinal extensors, the lower fixators ofthe shoulder blade, and other muscles of the samesystem. This represents a highly integrated globalreflex stabilization function.

It can be shown that this program involves boththe tonic and the phasic system as a whole and thatthe two cooperate in stabilizing posture by reflexaction. If only a single phasic muscle is weak, notonly is joint position automatically changed butalso will inhibition irradiate into the entire system.Equilibrium between the two systems will changein favor of the tonic system. The tonic system pre-dominates in stabilizing posture. By restoring thefunction of a single phasic muscle, however, inhibi-tion of the entire tonic system will occur. If, e.g., weenhance the postural activity of the lower fixators ofthe shoulder blade, we lower the tension not only oftheir antagonists, i.e., the upper fixators of theshoulder blade, but also of tonic muscles at a dis-tance, e.g., of the hamstrings (increasing the rangeof hip flexion). Resisting external rotation at theshoulders, extension at the elbow, supination, or

A

B

C

Figure 23.20 Reflex creeping—upper extremity locomo-tion reaction (A–C). The support function of the otherarm is identical but in the opposite sense.

Figure 23.21 Posture reached at the age of 4 years.


lished between muscles situated far apart. In thisconnection, the upper part of the trapezius (a tonicmuscle) is an antagonist not only of the lower partof trapezius but also of the vastus medialis in thesystem of phasic muscles. Such reflex relations areestablished on a higher than brain stem level.

A B

C

Figure 23.22 Development of hand position from birthto 9 months (A–E).

D

E

finger extension, not only will the antagonists ofeach muscle be inhibited but also will the tonicmuscles be affected at a distance, e.g., the ham-strings may cause a change in the straight leg rais-ing test. This higher level of integration results innew types of reflex relations, which can be estab-


The Influence of Gravity on Function and Structure

The development of the postural function of phasicmuscles is closely related to maturity or immaturityof the skeleton.

At birth, for example, the extremity abductors andoutward rotators have no postural function. This canfirst be traced at the age of approximately 6 weeks. Itnot only changes posture but also influences ante-version and the colodiaphyseal angle of the femur.Insufficiency of the postural function of the abduc-tors and external rotators results in anteversion andvalgosity of the hip joint. The muscles necessary toattain the highest stage of morphological develop-ment are the middle and posterior part of the abduc-tors and the outward rotators of the hip joint. Thesemuscles belong to the phasic system with a tendencyto inhibition.

Another example is the foot. The longitudinal axisof the calcaneus lies laterally because of the positionof the talus at birth, and the heel is high because thecalcaneus has not yet slipped under the talus. Thecalcaneus reaches this position underneath the talusthanks to the postural activity of the short muscles ofthe foot and the tibialis anterior, tibialis posterior,and the peroneal muscles. The shape of the longitu-

dinal arch is not complete until the age of 4 years,i.e., when the postural function of all the pertinentmuscles has been fully developed. In cerebral palsythe foot remains at the neonatal or even at an earlierstage, because the function of the muscles has failedto mature. The same is true in children with a centraldisturbance of coordination.

Thus, the phasic muscles determine the shape ofmost anatomical structures, including also the colo-diaphyseal angle and the angle of anteversion at thehip joint, the plateau of the tibia, the transverse archof the foot, the horizontal position and the torsion ofthe collar bones, the spinal curvatures, etc. Thus, amature phasic muscle system ensures morphologicalmaturity at the age of 4 years.

Phasic Muscles—Functional Insufficiency

Absent or faulty stabilizing postural function of pha-sic muscles not only causes faulty posture similar tothat of patients affected by neonatal cerebral palsybut also causes typical changes in the skeleton: coxavalga antetorta, a kyphotic spinal column, an obliquetibial plateau, an insufficiently developed foot withvalgosity, genua valga, and pelvic anteversion.

B

A

Figure 23.23 Development of posture at the shoulder gir-dle up to 4 years (A, B).


In almost 30% of the child population, there issome degree of faulty posture caused by dysfunctionof the phasic muscles, which also affects the skeleton(1,11,13). Systematic weakness of the phasic musclesis also characteristic in old age, with insufficientextension of the spine, restricted elevation of the arms,faulty posture during trunk rotation, etc. The entiresystem tends to revert to an earlier neonatal posturalmodel. Protective posture caused by joint pathologyshows a similar pattern, as described by Cyriax, butwas never explained. Here again we can see thatpathological posture reverts to an earlier stage ofdevelopment.

Developmental Kinesiology of Spinal Stabilization in the Sagittal Plane

The CNS program controlling the development of sta-bilized erect posture starts at the beginning of the sec-ond month. It is not restricted to the head and neck,but results in a change in the entire body posture.Spinal straightening, i.e., balanced co-activation ofthe muscles on the dorsal and ventral body aspect, iscomplete by the end of the fourth month. It is relatedto the first basis of support, i.e., for the prone positionthe triangle formed by the elbows and the symphysis,and for the supine by the glutei, the scapular region,and the linea nuchae (Figures 23.11 and 23.12).

At this stage of development, the foundations ofstabilization of the spine in the sagittal plane arelaid. Only on this basis can phasic movement beachieved. Any disturbance of stabilization will be evi-dent in phasic movement. Stabilization in the sagit-tal plane, the prerequisite of physiological centeredspinal posture, therefore requires:

1. The co-activation of the dorsal and ventral mus-culature. This is of crucial importance for physi-ological (“centered”) posture, i.e., optimumstatic function. This applies in particular to thedeep neck flexors and the abdominal muscles,and to the extensors of the spinal column on thedorsal aspect. Only this co-activation canachieve a centered position and provide opti-mum static function.

2. The cooperation of antagonistic muscles that areattached to the thorax and the shoulder blades.Both these anatomical structures transfer musclepull to the spinal column. This applies particu-larly to the cooperation of the inferior serratusanterior and abdominal muscles, and, also, thescapular adductors and the pectoralis major.

3. The integration of the diaphragm into stabiliza-tion by respiration.

The muscles of the stabilization system function as aunit; they are interdependent. If one muscle is weakor overactive, this never remains isolated, affectingthe static and dynamic function of the entire spine—the individual segments will be no longer in a cen-tered position.

The Cervical and Upper Thoracic Region

Erect posture (centration) of the cervical spine devel-ops after the age of 6 weeks. In an anatomic sense,the cervical spine ends at C7, but from a functionalperspective it ends at T4, because the upper thoracicspine participates in flexion, extension, as well as inside bending and rotation of the head. This is borneout by the anatomy of the most important musclesthat extend the cervical spine and originate in themid thoracic region.

The extensors of the cervical spine are the m. semi-spinalis capitis cervicis, M. semispinalis capitis, m.splenius capitis, m. splenius cervicis, and m. longis-simus cervis et capitis. These muscles originate at T4,T5, and T6. At this stage of development, extension isfurther enhanced by the rhomboids and the middleand lower trapezius in cooperation with the serratusanterior, which serves as a punctum fixum for thespinal extensors. The serratus anterior, however, canfulfill its stabilizing function only if its attachmentpoints are stabilized by the abdominal muscles.

Erect posture, i.e., correct centration of the cervi-cal spine, is possible only if there is activity of themuscles on the ventral aspect, i.e., the longus colliand primarily the longus capitis, in addition to thoseon the dorsal aspect. These muscles also originate atthe level of the upper thoracic spine and preventreclination (i.e., back-bending) of the head and cer-vical hyperlordosis. The balanced co-activation ofthese muscles ensures correct centration and pre-vents overstrain of the sternocleidomastoids and thescaleni. In pathological cases, there is reclination ofthe head and flexion/extension takes place only at thecranio-cervical junction. When this occurs, normaldevelopment of the entire spinal column is impaired.Centration of the cervical spine also depends on thestabilizing function of the deep extensors of the midthoracic spine. They provide the punctum fixum forthe deep extensors of the cervical spine. Their weak-ness is accompanied by hyperlordosis, inhibition ofthe deep neck flexors. Activity of the deep neck flex-ors and extensors depends on stabilization of theirattachment points, which in turn depend on a mus-cular chain. For instance, if the lumbar section of thediaphragm and the lateral section of the abdominalmuscles do not function, forward-bending of the

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head occurs with substitution of the sternocleido-mastoids for the deep neck flexors, with the resultbeing a chin poke.

The Lower Thoracic and the Lumbar Spine

There is a similar close relationship between thefunction of the lumbar and lower thoracic spine asthere is between the cervical and upper thoracic spinedown to the mid thoracic region (T5). This results,too, from the anatomy of the relevant muscles. Erectposture of the thoracic and lumbar spine develops inclose relation to the cervical spine. This is related tothe anatomy the muscles. Straightening of the tho-racic and lumbar spine is closely related to that of thecervical spine. Activity of the spinal extensors mustbe kept in balance by simultaneous activity of theabdominal muscles and the diaphragm, resulting inthe correct centration of individual segments. Theabdominal muscles with the diaphragm becomeinvolved in posture at the same stage of developmentas the deep extensors. Both the oblique abdominalmuscles and the rectus originate from the lower ribs,beginning at T5. This anatomical and functionalrelationship enhances erect posture under the con-trol of the CNS. If this stabilizing function is dis-turbed either by hyperfunction or hypofunction, thestatic function of the spine is compromised.

The interplay of the abdominal and back muscleswith the diaphragm and the pelvic floor must beunderstood. At birth the diaphragm is still in anoblique position while the pelvic floor has no pos-tural function, nor is there any postural synergybetween the intrinsic back and the abdominal mus-cles. As the intrinsic back musculature comes intoplay, the spinal column straightens. The thorax withthe ribs is stabilized by the caudal pull of the abdom-inal muscles. The ribs are steeper than in the new-born stage. Straightening up of the spine in concertwith stabilizing activity in the abdominal musclesalters the punctum fixum for the attachments of thediaphragm, thus bringing the diaphragm into a hor-izontal position.

This is as specific for humans as is erect posture.Increased intra-abdominal pressure and decreasedpelvic anteversion through the pull of the abdominaland gluteal muscles enable the pelvic floor to per-form its postural function. The coordinated functionof the diaphragm with the abdominal muscles is cru-cial for the anterior stabilization of the lumbar spine.Stability of these structures is decisive also for thethoracic and cervical spine because they form theirpunctum fixum. The postural function of the pelvicfloor is brought about by increased intra-abdominal

pressure and a change in pelvic anteversion by theactivity of the abdominal muscles.

Postural Ontogenesis and the Function of the Diaphragm

If the CNS develops normally, the diaphragm will bethe chief respiratory muscle. At the same time, itforms part of the co-activation pattern resulting inerect posture. These functions mean that postureexerts a great influence on respiration, and respira-tion on posture. As erect posture develops, thediaphragm finds its horizontal position at the end ofthe fourth month. If the diaphragm contracts, it flat-tens and is resisted by the abdominal wall. In co-activation with the abdominal muscles, it producesintra-abdominal pressure. This plays an importantrole in stabilizing the lumbar spine. Thus, thediaphragm not only is the main respiratory musclebut also stabilizes posture. Its activity depends alsoon the position of the spine and the thorax, which actas a punctum fixum. The inspiratory position of thechest together with thoracolumbar hyperlordosisimpairs the activity of the diaphragm in all of itsthree sections. Activity of the lumbar section of thediaphragm is particularly impaired and the stabiliz-ing co-activation of the abdominal muscles is lack-ing. Respiratory activity is transferred mainly to thethorax and via the auxiliary respiratory muscles tothe cervical region. Under normal conditions, how-ever, the diaphragm with the abdominal muscles andthe spinal extensors stabilize the punctum fixum forthe psoas at the thoracolumbar junction.

Muscular Imbalance in DisturbedCo-activation and Impaired SpinalStabilization in the Sagittal Plane

The spinal column forms a fulcrum stabilizing mus-cles, which relate to the extremities, i.e., a punctumfixum. Faulty position of the spinal column is accom-panied by functional imbalance of the muscles of thepelvic and shoulder girdle and the extremities. Thereverse is also true.

Erect posture (sagittal plane function) is completedat an earlier stage than vertical stance. As pointed out,the postural model, i.e., well-balanced muscular co-activation resulting in optimum loading of the spine,is completed during the fourth month. At this earlystage of development, the final basic posture is estab-lished. It remains unchanged even when the childstands up and during further postural development,but it adapts to the varying areas of support. A childwith even a slight lesion of the CNS (approximately


30%) never reaches this ideal level of co-activationbetween the two functional systems (1,11,13). Theposture of such children when standing is never trulyerect. Generalized muscular imbalance caused byfaulty development is the cause of future faulty pos-ture. Hence, it requires treatment at this initial stage.Similar muscular imbalance need not, however, becaused by abnormal development, but by affectionsat a later stage, which result in reflex changes of astereotypical character.

The muscles responsible for well-centered posture(the deep stabilizers) act as a functional unit. Hypo-function or hyperfunction of a single muscle neverremains isolated but involves the entire complex byaffecting the points of attachment. We therefore findthat weakness of the pelvic floor is usually accompa-nied by weakness of the deep neck flexors and viceversa. This interrelation is very important for treat-ment. This functional unit is young from the phylo-genetical standpoint.

Insufficiency of the deep flexors is characteristicfor the cervical region. This results in head reclina-tion with hyperextension of the lower cervical spine.The upper thoracic spine is in a forward-drawn posi-tion. Neck rotation is not proportional throughoutthe cervical spine and is therefore restricted. Fixationby the serratus is insufficient and therefore the rhom-boids and the lower and middle trapezius cannotachieve erect posture in the cervical spine. The uppertrapezius, the levator scapulae, sternocleidomas-toids, and the scaleni predominate and function alsoas auxiliary inspiratory muscles.

Normally, co-activation of the abdominal wall,spinal extensors, and the diaphragm controls intra-abdominal pressure and centrates the low thoracicand lumbar spine. Weakness of the abdominal walland insufficient intra-abdominal pressure result inpermanent pelvic anteversion and increased lumbarlordosis. This is frequently accompanied by diastasesof the abdominal muscles. Weakness of the abdomi-nal wall not only induces hyperlordosis and pelvicanteversion but also prevents extension of the tho-racic spine below T5. Lumbar lordosis thus ends inthe low thoracic region, most frequently at the thoraco-lumbar junction, and kyphosis starts fromthis level. In the kyphotic segments there is no exten-sion. The thorax is in an inspiratory position andthere is obliquity of the diaphragm. The intercostalspaces do not widen at inhalation and the thorax islifted as a whole. Thus, inhalation takes place by con-traction of the auxiliary respiratory muscles. Thiscondition goes hand-in-hand with weakness of thepelvic floor. At the same time there is disturbed co-activation of the serratus anterior and the lowertrapezius, which normally straightens the thoracicspine and facilitates the transversus abdominis.

The mid thoracic spine, i.e., the transitional verte-bra T5, plays a very important role both in ontogen-esis and in pathogenesis. It represents the punctumfixum, from where the cervical spine straightens andwhere the most important postural muscles origi-nate: the splenius cervicis and capitis, the longis-simus capitis and the longus colli, and where thelongigissimus thoracis is attached. The abdominalmuscles also originate from the fifth rib. This is thelevel where the lumbar lordosis ends because of mus-cular co-activation.

In normal posture, T5 forms the apex of the tho-racic kyphosis or the end of lumbar lordosis. Thus,the area from T4 to T6 is the region that functionallydivides the upper and lower half of the human body.

Clinical examination of this section of the spine isparticularly important. Only if there is well-balancedmuscular activity in the entire motor system is itpossible to straighten up below T5. It appears thatalmost every disturbance of muscle activity relatedto the spinal column as well as to the extremities willaffect this region, keeping it in flexion, with kyphosisand movement restriction into extension below T5.The extent of this fixed kyphosis varies but can reachas far as to the thoraco-lumbar junction in somecases. Abnormality of the spine in the sagittal planeresults from faulty activity of the oblique abdominalmuscles. Thus, rotation of the spine, too, depends onstabilization of the spine in the sagittal plane.

Normal and Abnormal Kinesiologyof Respiration: Its Relationship to Spinal Stabilization

Movement of the thorax plays an essential role in res-piration. It is formed to comply with the movementsof breathing. The muscles involved can be describedas inspiratory and expiratory, and as main and aux-iliary respiratory muscles. Auxiliary muscles comeinto play only when great effort is required or underpathological conditions.

During respiration the ribs are raised and low-ered, moving around an axis starting at the head ofthe rib and ending at the transverso-costal joint, in adorso-lateral direction. Torsion of the rib is mostimportant for movement. There are three types oftorsion:

1. Around the thorax

2. Along the lower edge of the rib (if placed on its edge on a table the rib touches it only at two points)

3. Twisting—at its dorsal end it is almost vertical,and in front oblique, pointing in a ventro-cranialdirection.


Curvature of the ribs is important for the enlarge-ment of the thoracic cavity. The joints between theribs and the sternum have very tight capsules, allow-ing only slight movement. The ventral ends of theribs are raised together with the sternum. In thisway, the thoracic cavity widens in the sagittal plane.It should be noted that during inhalation the ster-num should also move forward.

This is accompanied by rotation in the sternoclav-icular joints. The clavicle does not move and the ster-num rotates at the sternoclavicular joint. (The cavityat manubrium sterni moves against the articularhead of the clavicula). The axis of the neck of thelower longest ribs (6–8) runs in a dorso-lateral direc-tion, which makes the thoracic cavity widen in thefrontal plane. This movement may be disturbed inpathological cases. The upper ribs move much lessunder normal conditions. If the development of theCNS is normal, the diaphragm is the main respira-tory muscle, but it also stabilizes posture.

The diaphragm flattens and acts against theresistance of the abdominal wall. It controls intra-abdominal pressure in cooperation with the abdomi-nal muscles and the pelvic floor, which are alsoimportant for stabilization. Its activity depends on theposition of the spine and the thorax, which form apunctum fixum. If the thorax is in inhalation positionwith the sternum and the ribs raised, and the thora-columbar junction in extension, then activity of thediaphragm is impaired in all its three sections. Thisparticularly affects its lumbar section. Respiration isthen limited to the thorax, which is pulled upward by the auxiliary muscles. The diaphragm and theabdominal muscles stabilize the thoracolumbar junc-tion, providing a punctum fixum for the iliopsoas. In this way, physiological respiration stabilizes the lumbar spine. Examination of respiratory and stabi-lization function is therefore an essential part ofexamination and treatment of the locomotor system.

Examination of the DeepStabilization System of the Spine in the Sagittal Plane

Disturbance of spinal stabilization is an importantfactor in back pain and other conditions. We have tobear in mind that any purposeful movement firstrequires spinal stabilization. Stabilization also playsan important role in compensation and normaliza-tion of dysfunction. Control of spinal stabilization istherefore a prerequisite for successful therapy.

Diagnostic Tests

1. Examination sitting erect or supine. We palpatebelow the last ribs at the lateral aspect of the

abdominal wall. The patient is told to pressagainst our hands, which press gently against theside of his abdominal muscles during exhalation,when his thorax is lowered. The spinal columnmust remain straight during examination; nospinal flexion should be observed.

Muscular activity at the waist is also palpated dur-ing inhalation. This test serves to examine to whatextent the diaphragm is able to perform its stabiliz-ing function (Figure 23.24A with the patient seated;Figure 23.24B with the patient supine).

Signs of Impairment The patient exerts minimalcounterpressure or none at all. He may show some

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Figure 23.24 We ask the patient to press against our fin-gers: assessment of the patient’s ability to activate thediaphragm (especially its lumbar part) together with thelateral parts of the abdominal muscles, with the ribsremaining in the caudal position. A: Examination withthe patient sitting B: Examination with the patient lyingsupine.

A

B


activity during exhalation, but none during inhala-tion. Quite often he is not aware that he could acti-vate those muscles. This shows lack of cooperationbetween the diaphragm and the lateral part of theabdominal muscles, creating an eccentric and finallyisometric contraction. The pelvic floor also takes partin this muscular co-contraction, essential for thecontrol of intra-abdominal pressure that stabilizesthe lumbar spine from in front. The patient substi-tutes for this dysfunction by exaggerated activity ofthe rectus abdominis, particularly of its upper part,which is connected with the anterior paramedialpart of the diaphragm, and by increased activity ofthe paravertebral muscles, especially at the T/L junc-tion level. A patient unable to control the activity ofthe diaphragm in co-contraction with the lateral por-tion of his abdominal muscles is most likely to havelow back pain. If this activity is asymmetrical atexamination, disc herniation between L4/5 or L5/S1is probable. Such a herniation can be asymptomatic;the patient does not have to have symptoms of spinalroot irritation.

2. Examination supine with the legs extended or inslight flexion, followed by examination in theerect seated position. Supine, the patient exhales.With our palpating hands, we encourage thepatient to move his thorax as far as possible withthe sternum in a caudal direction (Figure 23.25).We hold the patient’s chest in this expiratory(caudal) position and ask him to relax theabdominal wall completely. He is then asked toinhale while maintaining the caudal position ofthe thorax. With our hands we follow the move-

ment of the sternum (we palpate the lower partof it) and the low false ribs (laterally from themedioclavicular line) (Figure 23.26). Inability tomaintain the caudal position of the chest duringinspiration indicates poor spinal stabilization;there is insufficient functional cooperationbetween the diaphragm and the abdominal wall.The patient cannot properly control intra-abdominal pressure. During the test we alsocheck if the lateral aspect of the patient’s abdom-inal wall protrudes below the last ribs. If thisarea bulges, it is a sign of good cooperationbetween the posterior part of the diaphragm(where eccentric contraction takes place) and thelateral group of abdominal muscles that alsowork eccentrically. This muscular cooperation iscrucial for spinal stabilization.

With the patient seated, we palpate at the costal angleof the lower ribs (Figure 23.27) and follow rib move-ment during inhalation and exhalation. Under normalconditions, these ribs move in a lateral but not in acranial direction; the caudal position is possible evenduring the inhalation. If the patient is in good controlof his stabilizing functions, he should be able to per-form this lateral rib movement even without breath-ing. He thus demonstrates his ability to control thelumbar section of his diaphragm. This is very impor-tant for the stabilization of the lumbar spine.

Signs of Impairment If the deep stabilizers areinsufficient, the patient cannot control chest positionduring breathing. The initial position is cranial, i.e.,

Figure 23.25 Assessment of the patient’s ability to stabi-lize the chest during respiration. The sternal bone shouldreach the caudal position. The arrow indicates the direc-tion of rib movement under physiological conditions.

Figure 23.26 Palpatory assessment of false rib move-ment: the therapist notes whether the movement takesplace in the cranial or lateral direction. The arrow indi-cates the direction of rib movement under physiologicalconditions.


the inspiratory position of the chest. The axis con-necting sternal and lumbar attachments of thediaphragm is oblique (normally it is horizontal). Thelumbar attachment points are lower than the sternal.During inhalation the chest reaches an even morecranial position (Figure 23.28); its lower part does notwiden and the axis becomes steeper. The patient can-not inhale while keeping his chest in a caudal posi-tion (Figure 23.29). By examination at the angeluscostae during inhalation and exhalation, we observecranio-caudal, but not lateral, movement. The inter-costal spaces do not widen. By transmitting muscu-lar activity, the thorax enhances stabilization. If,

however, the thorax moves in a cranio-caudal direc-tion during respiration, mainly by the activity of theauxiliary respiratory muscles, without stabilization inthe transverse plane, there is no control of intra-abdominal pressure by the abdominal walls. Intra-abdominal pressure normally increases when wemake any purposeful movement with our extremities.

3. Examination of the patient sitting erect with legsapart and hanging down freely. The patient flexesone hip against gravity or slight resistance and weassess to what extent he stabilizes the thoracolum-bar spine. During hip flexion, the iliopsoas is acti-vated and its point of origin must be stabilized.Under normal conditions, we assess the contrac-tion of the muscles of the abdominal wall asabdominal pressure increases. It is important toobserve the tension of the abdominal and the func-tion of the paravertebral muscles (Figure 23.30).

Signs of Impairment Insufficient stabilization isevident in increased activity of the paravertebralmuscles and of the rectus abdominis, mainly of itsupper section. There is minimum activity of the lat-eral part of the abdominal wall palpated at the waist.Under such conditions, every contraction of theiliopsoas is performed with an insufficiently stabi-lized lumbar spine. There is increased tension in theparavertebral muscles and we may even find discretelateral shift of the thoracolumbar junction towardthe flexing leg during hip flexion (Figure 23.31).

4. The patient is supine with legs bent at the hipsand knees at right angles in abduction and slightexternal rotation; the distance between the knees

Figure 23.27 Palpating the ribs at the angelus costae:assessment of lateral or cranial movement. The arrowindicates physiological, i.e., lateral movement of the ribs.

Figure 23.28 Movement of the sternum in a cranialdirection. The patient is unable to maintain the caudalposition of the chest and so cannot stabilize the lumbarspine from the front.

Figure 23.29 Movement of the ribs in a cranial directionis a sign of poor stabilization of the lumbar spine.


should be approximately the breadth of theshoulders. This is the correctly centered positionfrom the functional point of view (Figure 23.32).The patient is told to support himself at the tho-racolumbar region by the activity of the abdomi-nal wall. This tests the quality of stabilization ofthe T/L junction by muscular activity and intra-abdominal pressure.

Signs of Impairment The first signs are revealed atthe starting position. The rectus abdominis has a con-vex shape. Below the lower ribs, however, a concavityat the level of the costal angle can be noticed (Figure

23.33). At the caudal part of the lateral abdominalmuscles on the side of the quadratus lumborum, theabdominal wall bulges because of muscular hypo-activity. Trying to straighten the thoracolumbar junc-tion (for support) increases tension in the rectusabdominis and in the paravertebral muscles, with noactivation of the lateral abdominal muscles (Figure23.34). This is a sign of insufficient co-activation ofthe lumbar section of the diaphragm and the abdom-inal muscles, which is essential for stabilization of thelumbar spine. We also note whether there is diastases

Figure 23.30 During examination, we palpate the T/Ljunction and lateral abdominal muscles below the lower ribs.

Figure 23.31 If there is abnormality, we find lateral shiftof the T/L junction, increased tension of the paravertebralmuscles, and of the m. rectus abdominis, and poor stabi-lization of the lateral abdominal muscles.

Figure 23.32 The patient’s posture corresponds to thedevelopmental stage at which stabilization of the spine inthe sagittal plane has been fully accomplished.

Figure 23.33 Insufficiency of the stabilization systemresults in hyperextension of the T/L junction; m. rectusabdominis predominates, and the chest is in a cranialposition.


of the abdominal wall, which is another sign of insuf-ficient stabilization. Diastases frequently increases if the patient tries to support himself at the thora-columbar junction.

5. The patient supine with the arms along the body.The patient slowly bends his trunk. For examina-tion, we palpate the rib movements. The lowestfalse ribs are palpated in the medioclavicular lineand their movement is assessed.

Signs of Impairment When there is insufficient sta-bilization, the ribs deviate to the side and there is lat-eral bulging of the abdominal wall (Figure 23.35).

6. The patient is supine or standing erect. With thethorax in a caudal position, the patient lifts hisarms. Activity at the thorax is assessed. If stabi-lization by the abdominal muscles is normal, thethorax should not be lifted during shouldermovement at full range (Figure 23.36)

Signs of Impairment When the patient lifts his arm,the thorax moves up as stabilization by the abdomi-nal muscles is insufficient (Figure 23.37).

7. Examination with the patient supine with thelegs extended. The patient slowly bends his headand neck. We assess the muscles performing themovement and those which stabilize theirattachment points (Figure 23.38 A and B)

Signs of Impairment The patient moves with thehead in a forward-drawn position because of exag-

gerated activity of the sternocleidomastoids and thescaleni. There is hyperactivity in suboccipital musclesand in spinal extensors. The lower ribs move in a lat-eral direction during the test and sometimes even cra-nially. The activity of the deep flexors is inhibited notonly by their weakness (which may not be apparent)but also by the lack of attachment point stabilization.

8. Sitting erect. The patient is asked to straightenthe cervical spine. The point of gravity of thehead should move in a dorso-cranial direction(Brugger’s erect seated position).

Figure 23.34 Any attempt to straighten the T/L junctionresults in hypertonus of the m. rectus abdominis and par-avertebral muscles, whereas the lateral abdominal mus-cles remain hypoactive.

Figure 23.35 Evaluation of rib movement during trunkflexion. Movement in the lateral direction is pathological.Diastases of the rectus abdominis can frequently beobserved

Figure 23.36 We assess chest position during shoulderflexion. Normally, the patient should maintain the caudalposition of the chest throughout the whole movement.


Signs of Impairment In dysfunction, we frequentlysee that straightening up begins at the thoracolum-bar region (as though the axis of rotation was there)(Figure 23.39A) or at the cervicothoracic junction,but not at T4/5, where it should start (Figure 23.39B).Extension of the mid thoracic spine is impaired.There is increased tension of the paravertebral mus-cles and of the adductors of the shoulder blade.Because extension of the mid and low thoracic spineis insufficient, the patient activates the sternocleido-mastoid, the suprahyoid muscles, and the scalenewhen trying to straighten up segment T4/5. Stabi-

lization of the thorax is insufficient. This insuffi-ciency prevents the patient from being able to com-pensate adequately for stability challenges. Undersuch conditions all exercises will be useless.

9. The patient is prone and supports himself on hishands. The patient straightens his cervical andupper thoracic spine. Below T5, extension takesplace from one vertebra to the next in succes-sion. The shoulder blades remain abducted andin a caudal position. Straightening his arms, thepatient pushes himself up and exhales. Thepatient moves to make the symphysis the mainpoint of support

Signs of Impairment Insufficient extension of themid thoracic spine and exaggerated extension of thethoraco-lumbar region. Tension in the paravertebralmuscles greatly increases. The shoulder blades movetogether and upwards (Figure 23.40).

Treatment of InsufficientStabilization of the Spine

There is controversy about whether we shouldstrengthen the abdominal, back, or other musclesand whether to train proprioception by wobbleboards, gymnastic balls, or other methods. However,it is too little realized that in the majority of cases weare unable to ensure the correct initial positionessential for any type of exercise. There is then a lackof stabilization and the effectiveness of the exercise

Figure 23.37 If there is poor muscular stabilization, thechest moves in a cranial direction during shoulder flexion.

A B

Figure 23.38 Flexion of the (C) spine is examined while the chest is fixed in a caudalposition (A). Cranial movement of the chest prevents activation of the deep neckflexors (B).


program is questionable. We should be aware thatthe chain of muscles required for any specific move-ment must be secured by stabilization of muscularattachment points.

Muscular coordination will greatly differ accord-ing to differences in stabilization. It is, for example,a great difference whether external rotation of theshoulder occurs with the shoulder blade stabilizedby the trapezius or by the serratus anterior with thelateral abdominal muscles, or whether neck flexiontakes place with the thorax in inhalation or exhala-tion. Stabilization results from the activity of a mus-cular chain that is not under the control of our will,nor do we know how to activate it deliberately. Tomake these muscles work, neither instruction norexplanation is effective. Reflex mechanisms or man-ual fixation are required to start with.

To be able to compensate for dysfunction, thepatient must control spinal stabilization or else hewill overburden the system. Every type of exercise,including sensory motor training or gym balls, depends

A B

Figure 23.39 Straightening up of the spine starts at the level of the T/L junction andeither the chest moves cranially or the movement starts from the lower segments ofthe (C) spine (A). The patient cannot straighten the mid-thoracic spine (B).

Figure 23.40 During spinal extension, the thoracic spinedoes not straighten. Tonus in the paravertebral musclesincreases and is maximal around the T/L junction. Thepatient cannot fix his shoulder blades in abduction andcaudal position.


on correct stabilization as a prerequisite of effectivetherapy.

There are three basic approaches to improvingstability, depending on whether the case is acute orchronic, or whether our aim is prevention. It alsodepends on whether the patient is able to react ade-quately to our instructions or whether he cannotcontrol his movements.

1. Reflex locomotion

2. Control of respiration

3. Treatment based on instruction and manual con-trol of stabilization.

Making Use of Reflex Stimulation

Stimulating reflex zones activates muscles for a def-inite purpose. The spinal column, the shoulderblades, and the thorax are brought into an ideal posi-tion of maximum load bearing by the activated mus-cles. In this position, muscle pull is most favorable.The response to stimulation is constant: the thoraxsettles in a caudal position, respiration is withoutany cranial displacement of the sternum or ribs, theribs move in a lateral direction, and the interverte-bral spaces widen. The diaphragm contracts regu-larly in all its sections and arrives at the horizontalposition. The abdominal muscles together with theserratus anterior provide fixation of the thorax andthere is balanced activity of the rectus abdominisand the lateral abdominal muscles. The thoracicspine extends by the activity of the deep intrinsicmuscles. The thoracolumbar junction is centeredand stabilized by the activity of the diaphragm, theabdominal muscles, and the spinal extensors, so thatthe psoas can flex the hip joint. The accessory respi-ratory muscles relax by reflex action and the deepneck flexors are brought into postural activity. Theshoulder blades move in a caudal direction and arefixed by the balanced activity of the serratus anteriorand the adductors. In this way, the spinal column isstabilized in the sagittal plane as a prerequisite forthe stepping forward and support functions. Theresponse will be the same in any position in whichwe choose to stimulate. The intensity of the reflexresponse can be enhanced by resisting against thestimulated movement.

Reflex stimulation of the stabilizing function isindicated mainly in the chronic stage of locomotordisturbance in patients with little ability to form newmotor stereotypes. It is an attempt to achieve bettervoluntary control of stabilization by reflex stimula-tion. Reflex stimulation is particularly useful in anadult who is not fully conscious (e.g., after trauma orafter a stroke). We may thus influence postural tonus,

provoke muscle activity, preventing spasticity andcontracture. Reflex locomotion is helpful in patientsin intensive care units unable to cooperate. It alsohelps in patients with lesions of the spinal cord, in par-ticular in the early stages. Making use of inborn mech-anisms, we are able to activate specifically the musclechains responsible for respiration. This is importantin patients with respiratory disturbances, becausethey are unable to control the respiratory muscles.

Treating Pathological Respiration

This has the greatest impact on intra-abdominalpressure regulation and spinal stabilization. The pre-requisite for normal stabilization is that the thorax isin a position like during ontogenesis, or as a result ofstimulation, i.e., with the sternum and the ribs in acaudal position. The sternum moves only in a ventro-dorsal (dorso-ventral) direction (not cranio-caudal),with the axis of movement being in the sternocostaland not in the acromioclavicular joints. The caudalposition of the sternum and the ribs is essential forthe eccentric contraction of the abdominal wall dur-ing inhalation. The diaphragm flattens and contractsin all its parts. Thus, the patient widens his abdomennot only anteriorly but also the lateral and lumbarpart of the abdominal wall must also distend pro-portionally. The constant height of the sternum withthe ribs in the sagittal plane is essential for a bal-anced activity of the abdominal, serratus anterior,and pectoral muscles. Respiratory movements aretaught first with the patient supine (Figure 23.41),

Figure 23.41 We have to teach the patient how tobreathe and maintain the caudal position of the chest.The chest must not be lifted. During inspiration the ante-rior and also the lateral and lumbar sections of theabdominal wall must distend. AQ9


and only gradually in more demanding positions.The basic task is to teach the patient to breathe withthe sternum in a caudal position, moving it onlyantero-posteriorly. The thorax must widen in thetransversal plane. Only under such conditions canthe diaphragm and the abdominal muscles fulfilltheir stabilizing function.

Patient’s Voluntary Activity

The patient’s voluntary activity is used in carefullychosen positions, fixed by the therapist, to controlstability of transmission systems (e.g., the shoulderblade, the thorax). The aim is to teach the patienthow to change the stabilization function. Some tech-niques and their modification are demonstrated.

*The patient is supine, the legs are lifted with thehip and the knees flexed at right angles and abducted,the knees are approximately as far apart as the shoul-ders breadth and in slight external rotation. This isthe position of functional joint centration and mus-cular facilitation. The sternum and the thorax aremoved down first during exhalation under the thera-pist’s manual control. The lower section of the tho-rax must widen. In this position, the patient is askedto support himself at the thoraco-lumbar junction,which forms a punctum fixum. Then he slightly liftshis buttocks, activating the abdominal muscles. Heshould not, however, draw in the pelvis. We fix thelower ribs from above with our hands at the level ofthe attachments of the lateral abdominal muscles toenhance their caudal position. In this way, thediaphragm and the lateral abdominal muscles areautomatically brought into action. This can be felt atthe waist (Figure 23.42).

Mistakes to be Avoided When slightly lifting thebuttocks, the ribs must not be moved up by the activ-ity of the rectus abdominis and the ventral section of the diaphragm. This is seen when the abdomenbulges in front, without contraction of the lateralabdominal muscles. It is also a mistake if retrover-sion of the pelvis occurs, as is adduction of the shoul-der blades accompanied by increased activity of theparavertebral muscles.

*The patient is prone with hands clasped behindhis head. In this position, care must be taken that theupper trapezius is relaxed. Support is given to thearms and shoulders to help the patient into exten-sion. The patient is helped to fix the shoulder bladesin a caudal position and abduction. Extension ismost important in the mid-thoracic spine. In thisposition it is essential that the patient supports him-self at the symphysis while his shoulder bladesremain fixed. In this way, centration of the thora-columbar region is achieved, and the lateral abdom-

inal muscles and the lumbar part of the diaphragmare activated.

Mistakes to be Avoided The patient flexes the tho-racic spine while seeking support at the symphysis.He adducts his shoulder blades.

*The patient is prone, supporting himself on hishands. He straightens the cervical and the upper tho-racic spine. Below T5, the vertebrae move into exten-sion one after the other, only into mid position, i.e.,to achieve centration. The patient pushes himselfup by pressing on his palms. The movement is tomake the symphysis the point of support. In thisposition, maximum caudal movement of the thoraxis attempted during exhalation. At this moment, thepatient is told to exert pressure against our resistanceunderneath the costal angle of the lower ribs, i.e., atthe laterodorsal aspect of the abdominal wall. Exten-sion should not be greater than 45 degrees abovehorizontal (Figure 23.43).

Mistakes to be Avoided the patient adducts theshoulder blades. When contracting his abdominalmuscles and the diaphragm, he increases flexion ofthe thoracic spine. The patient is unable to keep histhorax in a caudal position during the pushup.

Motor Patterns and Trigger Points

In addition to muscular imbalance between ontoge-netically older and younger muscles, it is important toshow the principles of chain reaction between muscles

AQ10 Figure 23.42 Activation of the abdominal press with thediaphragm in the caudal position. We fix the patient’sribs and chest in a caudal position and ask him to sup-port himself at the area of the T/L junction and slightlylift the buttocks up from the table.


with local differences in tension, in particular musclesharboring trigger points (TrPs). We may assume thattheir origin is nociception. Their interconnection is byno means haphazard but follows rather strict rules. Ifwe release one TrP, we obtain release in TrPs muchfurther away. Localized changes in muscle tension willalso affect joint function by changing the articular pat-tern. A TrP is never an isolated change in function. Anumber of authors have pointed out that TrPs are tosome degree interconnected. The description of indi-vidual chains has so far been empirical, without neuro-physiological explanation.

Here, too, developmental kinesiology has broughtabout a change. The existence of inborn motor pat-terns points the way for a new functional under-standing. The development of posture shows that thehighest level of control of inborn motor patterns isnot at spinal or brain stem level, but above the latter.This, too, forms the basis of our motor behavior. Twopatterns play an essential role in succession:

1. Spinal posture in the sagittal plane (whichmatures at the age of 3.5 months [Figures 23.11and 23.12]).

2. The stepping forward and support function of theextremities in connection with trunk rotation.

These functions mature in succession during themotor development. Motor patterns can be seen inthe course of the individual phases of the posturaldevelopment. It is important that they are parts of theglobal locomotor pattern. This pattern is inhibited bythe cerebral cortex but can be evoked by reflex mech-anisms not only in children but also in adults.

The locomotor pattern is made up of purposefuljoint movements from one extreme position to itsopposite. If, for instance, we stimulate the reflex pat-tern of the hip joint, it starts in one leg in extension,adduction, and internal rotation, and it ends in flex-ion, abduction, and external rotation. In the otherleg, the opposite reciprocal movement takes place atthe same time, i.e., starts in flexion abduction andoutward rotation and ends in extension, adduction,and internal rotation. At the forearm, the movementstarts in maximum pronation and ends in supination(at the other arm it will be the reverse, i.e., from max-imum supination into maximum pronation).

The wrist moves on the stepping forward sidefrom flexion and ulnar deviation into extension andradial flexion (and it will be the reverse on the oppo-site side). The principle is the same for all joints. Foreach joint there is a well-determined movement aspart of a motor pattern. The anatomical structuredetermines the biomechanically ideal joint move-ment. The neurophysiological and biomechanicalprinciples make up the normal motor pattern. Eachposition the joint adopts in the course of the motorpattern may be called “frozen.” This is controlled bymuscles that stabilize it (fixation by muscular attach-ments). The angle at which a joint is placed deter-mines the activation of specific parts of the musclesthat stabilize the joint in a given position at a givenmoment (Figure 23.44).

The role of the TrP is to immobilize the joint incertain positions or locomotor stages (“frozen posi-tions”). The articular pattern is changed automati-cally as the joint is immobilized in that position orstage of movement. The TrP is found in the part ofa muscle that stabilizes that particular locomotorstage or position. The angle at which we examine ajoint activates different portions of the stabilizingmuscle. In other words, when the joint is at a dif-ferent angle it affects different sections of the stabi-lizing muscles. For example, in a given position ofthe arm only a specific section of the pectoralismuscle will respond. In addition there will be achain of TrPs in muscles that stabilize the attach-ment points of this part of the pectoralis. They willbe found in those fibers that are functionally con-nected with the fibers of the pectoralis harboring

Figure 23.43 The patient straightens the area of the midthoracic spine while keeping his chest in a caudal positionand activating the diaphragm and the deep abdominalmuscles.


the TrP. Thus, if the pectoralis muscle is active, itsattachment point must be stabilized by other func-tionally related muscles. Other parts of the abdom-inal muscles, of the adductors (retractors), of theshoulder blade, and also of the adductors and abduc-tors of the hip, etc., must be activated if the angle ofarm abduction is changed. Attachment point stabi-lization automatically occurs under the control ofthe CNS. Every joint position is stabilized duringmovement by muscle function.

Chains of TrPs can therefore be explained by thesynergy of stabilizing muscles or their parts that cor-respond to a specific position or stage of movement(“frozen position”) of the locomotor pattern. Reflexchanges like TrPs are never isolated. They requireimmobilization of a certain position by a chain ofstabilizing muscles. Thus, if we find a TrP in thepectineus, another will be found in the correspond-ing part of its antagonist, i.e., in the posterior part ofthe gluteus medius, and also in the correspondingpart of the pectoralis, with an attachment point atthe fifth rib, in the upper part of the subscapularis,and in the adductors of the shoulder blade, withattachment points at the T5/6 level, etc.

Principles of Examination and Correction of PathologicalArticular Patterns

The basis for examination and treatment of dis-turbed function is the function of muscles and jointsdetermined by a program under central control. Theprinciples are as follows:

1. First, we try to make the joint move according toits pre-programmed pattern. For this, it is impor-tant to know the pattern of locomotion which ismost favorable with regard to its mechanism.Therefore, the joint is examined under dynamic,not static, conditions. Because examination ispassive, no resistance should be felt close to theneutral point of the joint. If there is abnormality,this pattern is changed. We feel some resistanceand normal movement is substituted in a charac-teristic way, like a detour, with the movementnot being smooth, as though a certain phase hashad to be left out. This “derailment” is very characteristic.

If we examine the segment L5-S1, passiveflexion is produced at the hip joint, with thepatient lying on the side, rotating at the sametime the pelvis and trunk, which corresponds to the stepping-forward pattern (Figure 23.45).At the stage when the segment L5-S1 comes into play, i.e., at the end of the stepping-forwardstage, we sense resistance and a change (substi-tution) of the movement pattern. This is felt like resistance, producing a lateral deviation of the pelvis. This deviation is a very sensitivesign of a movement restriction in segment L5-S1.

2. Correct positioning plays a key role in therapy.For this, we have to find the phase of the motorpattern in which resistance has been found atexamination. This position has to be fixed; then,we have to overcome the resistance, the patho-

Figure 23.44 The angle at which the articulation is posi-tioned determines which parts of the muscles will beactivated and which parts of the muscles providingstabilization will be activated.

Figure 23.45 Mobilization of the lumbar spine makinguse of the stepping-forward function of the leg. Duringmobilization, our fixation must prevent incorrect substi-tution patterns.


logical substitution, by manual contact andcomplete the full range of the locomotor pat-tern. By mobilization, we prevent the joint mov-ing in an abnormal way by using our hands.Thus, we obtain the effect of mobilization, i.e.,normal joint pattern including joint play. If, forexample, we mobilize the segment L5-S1, weposition this segment to make it move in thepattern of stepping forward (Figure 23.46). Bymanual fixation, we prevent lateral movementof the pelvis (i.e., substitution) and move oninto flexion. We do not mobilize by a movementof joint facet translation, but only by correctingthe movement that is part of the normal pat-tern. This principle can be applied to joints ingeneral.

Another possible way to correct articular patternsis by specific activation of muscles. We first take upthe slack in a joint and the patient makes a “stepping-forward movement” with his leg, againstresistance. The patient is required to exert only min-imum resistance. In this way, muscular stabilizationis obtained, securing the segment to be mobilized.By resisting the stepping-forward pattern, wechange the muscle tension at the segment we intendto mobilize, including the deep stabilizers, whichare not under the control of the patient’s will (Figure23.47). This effect can also be produced by stimula-tion of specific zones. Stimulation has to be per-formed in the position in which the slack of the jointto be treated has been taken up (Figure 23.48). Mus-cle facilitation takes place automatically. In thisway, muscle tension is normalized and mobilizationtakes place.

n CONCLUSION

An attempt has been made to integrate the principlesof developmental kinesiology with those of both neu-rophysiology and biomechanics. They comprisebasic motor functions that form the basis of a diag-nostic and therapeutic system. This principle is uni-versal. Most techniques apply the principles of thedevelopmental program, in particular of precise jointcentration, of balanced muscular stabilization, andeven of restoring proprioception.

The development of human erect posture helps usto understand chain reactions of functional lesionsof the motor system. Without understanding theanatomical and functional, co-contraction of mus-cles would be meaningless.

Figure 23.46 Mobilization of the segment without mak-ing use of movement patterns.

Figure 23.47 After taking up the slack in the segment, wewant to mobilize we resist the stepping-forward functionof the leg (supination, extension, and radial duction). Theforce developed by the patient should only be minimal.

Figure 23.48 After taking up the slack in the segment tobe mobilized, we stimulate the appropriate zones.


Developmental kinesiology of course plays a keyrole in the assessment of early development in in-fancy and in the detection of even the slightest motorlesion in the earliest stages when therapy is mosteffective.

Developmental kinesiology enables us also toassess the prognosis of children with cerebral palsy.It is even possible to assess the relation betweenwhat has been achieved by treatment and what couldhave been achieved under optimum conditions. It istherefore possible to assess the effectiveness ofrehabilitation.

2. Janda V. Movement Patterns in Pelvic and ThighRegion with Special Reference to Pathogenesis ofVertebrogenic Disturbances. (Czech.) Thesis. Prague:Charles University, 1964.

3. Janda V, Stara V. The role of thigh adductors inmovement patterns of the hip and knee joint.Courier. 1965;September:563–565.

4. Janda V. Postural and phasic muscles in the patho-genesis of low back pain. XIth Congress ISRD.Dublin Proceedings. 1969:553–554.

5. Janda V. What is the typical posture of man?(Czech). Cas lek ces. 1972;111:32:748–750.

6. Janda V. Muscle and joint correlations. ProceedingsIV Congress FIMM. Praha 1974. Rehabilitacia Suppl.1976;Suppl:10–11, 154–158.

7. Janda V. On the concept of postural muscles andposture. Austr J Physiother 1983;29:S83–S84.

8. Janda V. Muscle spasm—a proposed procedure fordifferential diagnosis. J Man Med 1991;6:136–139.

9. Janda V. Muscle strength in relation to musclelength, pain and muscle imbalance. In: Harms-Rindahl K, ed. Muscle Strength. New York: ChurchillLivingstone, 1993.

10. Kolár P. The sensomotor nature of postural func-tions: Its fundamental role in rehabilitation. J OrthopMed 1999;2:40–45.

11. Lajosi F, Bauer H, Avalle C. Early diagnosis of cen-tral motor disturbances by postural reflexes afterVojta. Barcelona: XIV International Congress ofPediatrics, 1980 (abstracts).

12. Vojta V. Die cerebralen Bewegungstoerungen imKindesalter, 4te Auflage. Stuttgart: Ferdinand EnkeVerlag, 1988.

13. Vojta V. Mozkove hybne poruchy v kojeneckem veku.Vcasna diagnosa a terapie. Crerebral motor distur-bances in babies. Early diagnosis and treatment.Prague: Grada-Avicenum [book translated from German original: “Die zerebralen Bewegungsstorun-gen im Sauglinsalter]. 1993:29,30,71,89,94,103,108,112,114,115.

Audit ProcessSelf-Check of the Chapter’s Learning Objectives

• What are the chief landmarks in neurodevelopment

of the upright posture that an infant/child achieves

from ages 1 month to 4 years?

• How would you position a patient in the supine

position to perform reflex locomotion in rolling?

• How would you position a patient prone to perform

reflex locomotion in creeping?

• How can you test and train coordination of the

abdominal wall and diaphragm?

n REFERENCES1. Costi GC, Radice C, Raggi A, et al. Vojta’s seven pos-

tural reactions for screening of neuromotorial dis-eases in infant. Research of 2308 cases. Ped MedChir 1983;5:59.

Query:

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