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Rehabil i tation in gatr and th Nandic.pped PatLentrs louth.H . Hab r fe l l ne r .

In a recent editorial on sports for th padiatric age groupw,B. stlong (17) cites a handicapped athlt on vhat you canIearn in sports:t 'D isc ip l ine . . . how to nake most o f your t i rne . . . f tex ib i l - i t y . . r land he continus su[nj-ng up |tth essence of sports - to ]ravefun, to learn onrs abilities and to learn hov to take approp-riate but safe risks. sports should prepare a youngstr forth game of life, \. 'hich afCr all, should be an enj oyablejourney . I 'I an sur that alt who kno . the Hallirrick nethod as it hasbeen crated and devlopped by J. McMillan ("Mac" for hisfriends) over th yars vilt agree hat this citation althoughaind at th abl bodid is applicabl-e to the handicapped andt their able bodid trhlprsn and I'insructors" as ,t1fEspec ia l ly the not ions of gamerrnr r joy r r f i t we l l to l l lac tshabilitatj.on and rbabilitacion concept in water,with rspect to cerebral palsy, the condition from v,rhich thenajority of our patints suffers, it is appropriate to pointto ' f lex ib i l i t y r and "1 ,arn ing onrs ab i l iL ies" (by push ingon 's l in i taU ions) and I ' to hav funr r .The clinical pictures of practically a1I handicaps ar charac-terized by too fevr performanc variations of postures andmovenents. It i s this restriction of functional choics whichconstitutes th nain rason for individual clj.nical picturs.n so called ricerebral pafsy" as wIl as in othr cntralnovhent dj.sorders thes restrictions usually ar not a directconsquence of an alteled qualiy of central nervous syLhfunctions. Not are such restrictions th consequenc of struc-tural (e.g. skletal) changes in t[any othr case. nixtureof sevral factors anongst vhich the psycho-social ones arenot the least ihportant in restricting the perfornance level.Tbis can be seen even in sound and valid persons. w all arewell aware that at least the najority of us having to actunder diffelent sorts of strss usually r.r i l l fal l back to apoorr functional lvl end rarely prforn in an optlnal nan-n e r .stress in itts different forns does not only seduce a prsono perforr on a lowr functional Levl but also to reduc thdegrees of functional freedoh for an j.ntended novenent (10).Motor behaviour thus becones a prdictable sereo-yp. whj.chin i tse l f i s cons idred as a na jo r express ion o f pa tho logy .lthough th rpatternsr used by a handicapped person do belongto the reper to i re a lso found in the non-hand icappd popu la t ionthe exclusive use of too few of then has il l functional - andultirnately structural - consequncs. That is nhy in a highrsense the us of such a res t r ic ted se t o f pr s Inorna l lpostural and novenent patterns has ben terned rpathological .The feveL at r.rhich ngative and positiv strss such as joy,exc i tenen l of rovrwhe ln ing good wi l l ' s ta res to reduce var ia -

tional fredoh is an inportant derrninant of the dgre ofhand icap in a g iven person .

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To raise this critical threshold of stress that triqqersdetrioration, to break up thse functionat restrictins infact is the_prinary target of a1l forns of physical trat-rnents. Particularty of Bobath's neurodewelolnntal therapy asve l l . as i t - ,s d i f fe rn t aspec ts of 'hand l ing- ' (3 ) . Therap i t i cspor ts .such as r id ing on horsback and spec ia l ly McMi l lan 'sHallj.wick approach to therapeutic swirnrninghave ffered excep-tionally frtile countractions to the evr-threatening ten-'dncy o f rs t r ic t ion .This also holds tru for the "borderlandst' of sensor] -nocorpathology, aggravated by hental, emotional and bhavioralprobl.ens, such as ' psudospasicityr (tiaberftlner, in prepa-ract otr .Hallirrick is not intended to teach swirnming exclusively, asMac is used to state. It is intnded to brak up restr-ictionsand to gve nor fredon to a population that i on th easybut dangerous way of avoiding runncessary' risks and hardslbips. The psycho-social constellation of oth the patient andhis _ elpr/ instructor sinuftaneously bing in the ool andhaving to adapt to th conditions in watei offers i.rnrquepossibil" ities. They are further augnentd by the HaIlii,rick_specific features that can downgrae negative stress of inse-cur j . ty of fear : e .g . th l - :1 raa io o f hnd icapped and 'he t -persr, the special garns, and the us of sonq which areproviding the supporting tin-frame of rhythi and abov allthe enotional sptint of conmonly expressed feelinqs of mutualrespect, trust and joy. Lewin has defi.ned swinrnin asr rb rea th ing in waer ' r (11) . The in te r re la t ions bet ieenlespiration, nuscular tone, posture, novennt and on,sfeelings are colnnon knoeledge and nd no furthr delination.fo si.ng together in watr i a royal short-cut towards thenornalization of ths factores which are so badlv out ofba lanc dur ing every day l i f in fa r too nany o f ur pa t ien ts .singing, or hunrning when used optihally, is itarted by anat tempt to - tune in to . the pa t ien t 's pecu l ia r typ o f b ;ea th ing .'rn1s power u-L cornnunj.cative tool can giv the patint trustand confidence and provide an enotional anchor. skilledinstructor \^' i l l change this individual pac in du tlne tobr ing i t c loser to the pace of the g roup in watr .The 'v lc ious cyc le , o f con t inuous res t r ic t ion is b rokn up andby and by rplaced by elnnts of a rbeneficious cycle ora1-le l ing th pat ien t 's s ta r t to en joy tha t tas te o f e ing ccep-ted into this cordial comrnunity ln waler, and gain of notiolnal stability. Enhanced effctivhess wth respect to posturaland rnovernentcontrol reinforces this tendency. On top f allthese positive cirsunstanqes .we have to rnention that thephnornenonof rtransfer' into every day Iif dos exist.lthough even tenporary experiences of this sort - during 15-30 hinutes - of inhrsion in watr - woutd ju6tify all ourActual woak in watr as e1svrhre usualLy rneets vith rnanydifficulties which inpede our attnpts Lo enhance thepat iqn t rs ab i l i t ies as qu ick ly as we wan to . F i f ten year 'swork larith spcj-al ernphasis on inpaired fac-, nouth- andthroat- functions have taught us some insight into the reasonsof the r rs tubborn c l ing ing" to son ' iner t ia pa t te rns r - as Mac

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has happily dubbed the individually nodified tonic patternsdsplayed by so nany patients. We larned sone of the reasonswhy nany good-will j.ng popl unadvrtedly fel offnded ofrernotionally left aloner by the specific behaviour of handi-capped pople. and why so\ potntial and actual hIprs felso uneasy that they hav troubles to share their tine lrithpatients suffering .9. from crtain cerebral novernnt disor-ders .In short: fhre is a hieralchy of hurnan ihterests. First ofall comes the ned to feel secur. That is. whenvr ttrpatint gains the ihpression that vitat functions, his verysurvival are on stak, he turns to a stabilizing, securingrnanoeuvre - one of these fev restricting tpattrnst usually ofnixed but nostly extensor type - at teast r,Jj.th respect to thneck (see bLow) . nd h viIl stick t it as long as h feelsinsecur. Nxt on the hierarchy scal comes th hunan interstin cornmunication. Not that vital intrests al\^rays will prece-de conununi.cative wishes while thes prcede locorotiv onessrhich in turn are given way by the dsir to chang onerssur round ings d i rec t ly by ' manpu la t ion ' .n untrained person nay ned tine to realiz that painfullyexperinced robvi.ous offensesr against eslablished but narrow-Iy frahd cornrnunicativ rutes (as thy are st by a soundcoununity) are causeil by the patientrs handiqap. fhes rulesexist only in the unconscious part of our nind. Neverthlssthey are very potent.Non-vrbal xprssj.ons such as postures, gstures, fcialnovennts, vocal utterancs and their refinements by articul-a-tion and prosody all ar influenced dirctly and indirctly bythe sensorinotor control of one very delicate ara, the necknppropriate hyper- or hypomobility of this region vithvisible consequencs in practically all parts of he body arefound in tnany nuscular, spinal, or cerbral movenent disordrsas soon as the patint facs a potential vital thrat - suchas f ind ing h i rns I f in va t r .Letrs have a look on hov specifical"ty dysfunctions of thisregion can prolongue the tiln neded for rmental adjustrnent'to the being in vater: Had and trunk ar linked dynarnicallyby the nobil-e structu s of the nck. By adapting th positionof the head in space and relatively to shoulder girdle andtrunk these neck-structurs provid th basis for passiveco lu lun ica t ion : i . . v is ion , hear ing , smet l ing , as v l1 asactive conrnunication: posture and expressive novenents of thebody, the lihbs and especially the face and - not least - ofvoca l u t te rances .On the other hand the neck contains the vitallv criticalc ross ing o f rsp i ra to ry and d igs t iv t rac t . fe pos tu ra lp ro tec t ion o f th is a rea , th por ta l , a rea o f J .F . Bosha (2) , isgiven perhannt prefernce. ndeed as long as th individuatis breathing, by day and by night th wi-dth of this ara hasto be guarded, and collapse as re1l as undue widening andd isqor t ion o f i t ' s hob i l \ i ra l l s hav to b prevntd . In fac tthe s ing ]e par ts o f th is a ra , espec ia l ly the tongue and i t ' sneighbouling structures are kept at an indivj-dual distancfrorl ach other. This fact provides a sense of security and

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rInains unchanged throughout liftine within very narrowr t l t ] ' E s .Eruption of teth as well as toss of teth thus tads to achange of facial rsting xpression and facial dynanics. _More seriously for the handicapped's sensory-motr function ofhis tongue is this influence of positional hange on transportof saliva, of food and speech articulation. Tha is \,hy I- try9 protect every single tooth by proper dental hygi.en andffuoride prophylaxis - speciafly in the group oi-severelynanorcappct patrents. positional adaptations in most casesnean forward dj.splacnent of the tongu, part of an ,extensors te reo typ ' (see b1o ' ) .Itrs worth to remenber that. physical and enotional stressnakes alf human beings pron to exaggeration of certain func-tional traits by turning their casuaL us into streotvDed us- at the expense of a whol range of other possibiliti.One of the nost frequntty eneountered and nrost inrpressivepostural stereotypes is th pattrn of neck extension. It,ssudden onset specially in patients r.ri th athetosis or anadditional athetotic cohponent to anothr movment disordrusually does not only offend connunicative rules but actuallylerrify the- lsser exprinced helper/instructor. neferring Lothe hierarchy of doraines w are to conclude that this paternis caused by the patintrs irnprssion of inadequate vit1security.But then * narked and usually asyrnrnetric neck extension willcause asynnetric extension in other parts of the body too( 4 , 1 0 , 1 2 , 1 . 3 , 1 6 ) : I n l r a t e r i t f i r s t c a u s e s l h e p a t i n t t ochang h is pos i t ion . I f h vas , I t rs say in an a ided upr igh tposition, patient and helper wil l have troubles to keep it.Thy rathr tend to turn asynhtrically into the horizntalp lane.Ther will also be changes in th facio-oral reqion. Bvmechanical and reflexive hchanisrns of rtonic' haractr thefac ia l express ion wi } l be one of a te r ro r ized person : w ide lvopend eyes and nouth, further accentuated by ietracted Iipsand protruded tongue. t first glance this is not a very godadaptatin to the submersion under nater that is likel.v tfo l lov . s t i l l the unexpr ienced he lper 's ins t inc t ive rac t ion ,narnly to lift the patient so "that th water dos not qo intohis widely opned mouthrt is a step into the wrong dj.recion.constant rnouth closure in and under riratr is not practisd byable bodied persons eithr. Expiration, sealing of ttre airwaby velo-pharyngal contact and opposition of th back of the-tongue to the soft palate as lrell as closure of the dl ft.i qare vry effective ineans of airway proieciio" ...tr3-i. uuthe nost severly handicappd persons.So, lrbat causs a frightned patient as wll as a soundathlete $rho approaches the poin of xhaustions or the pop1ewho ar about to raise thi.r voic to retatively xtend theirneck? First of atl the structural pecul iarities- of the neckregions r,rhich effectively widn and stabilize th DharvnqealIc ross- road-ra | .J.F. Bosna has shown that the neck lordosis provides as muchwider sagittal- diaheer of this pharyngeat prt (2). Forwardnovenent of th tongu lrhich constitutes it,s nobile anEerror

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haviour rnay partly have it's roots in lhe early \reks ofextrauterine Iife vhen blocked nasal airways are in fact adahgerous s i tua t ion fo r the major t iy of in - fan ts .Fron the reflexs irhich are to protect and to clar the vital-ly inportant pharyngal ara onl.y is facifitated by realtiveneck fIxion (note that this is a flexion lrith a rrlong" nck) :svallo\^ring. The othr thr are favourd by rIative neckex tens io r l : sneez ing , cough ing and gagg ing / i romi t ing .On considering the conplx task of protecting the permanntlyndangered cross-road of the pharyngeal aj.r'ay. it beconesclear why the needs of this area doninate posture. and vhv onhas to respc t i t i f one is to chang a pe ison 's hab i tua l 'postures and rnovennts, and finally Lrhy illustratiobs ofsornatotopic rspresentations at all- leve1s of the centrafnrvous systern give a disproportionally large share to thefac ia l -o r f -and pharyngea l rg ion .No r, this ras only the situalion on l"and. fhere are additionatfactors in water: titac taught us theoreically and practicalfyabout th big changs that lnan experiences ii beinq upright inthe water rrhile th waterlih reaches hiqhr than ih tl-.I nril l not repeat her alt the details oi posturaL and nove-rnent chang brought about by the interactins of water withit's specific quatitis and the hurnan body. OnIy sorn hainconsequences: Control of position of lgs and feet bcohesdifficult and th genral human tendency towards vrticalposture rs replacd by a horizontal one. Th snsory organsproviding references for position in space thus \rork underd i f fe ren t cond i t ions .Expecially the telereceptors (eyes, ears) but also vstibularolgans and -obviously tactile and tenperature receptors of thebody surface. Partial veight-loss and different (rotatory)novlnent pattrns chang propriocptive afferences. Ithoughrduction of posturaf huscl ton clinically becones irnpre-srve 10-1.5 ninutes after ihnersion, to hold on for 3-5 hoursafter feaving the pool the change of affrncs j.s an im-lnedlaEe one.Inscurrty by alteration of sensori-rnotor and othr conpeten-cles force th patients to Iook for compensation. propriocep-tion clos to th spj-na1 cotunn, expecilly of neck, houth andthroa s t i l l o f fe rs ( re la t ive ly ) una l te red a f f rencs . Sna l ts/ondr that postures activating these structures are preferredand often in an xtrene way.Bfore going on the othr aspects of oral and nqk interrIa-tions let us stat again that nck xtnsion is a relativelvsafe but functionalfy vry restrictive postur. Expeciallywith respct to muscular intrp1ay as ncessary foi adequteconrnunication by facial expression, speech articul-ation,swallowj-ng of saliva and intak of food for instance.stil l inost of us have witnesseal ptients in watr \rhoprofitted fron Hallir^?ick with respect to facial and oralcontrol by rductj.on of drooling and anelioration of speech.The min reason is that alt rnntioned factor have diffrent

consquncs indiffernt patients (ven in on individuun atdiffernt. developnental stages) . The posture(s) as facilitatedin vatr seen(s) to be optirnal uith respect to these func-

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t r o n s .By a series of lucky circunstancs we can offer nodifiedorthodontic devices (ISl,R= nnsbruck-sensory-notor-actvatorand regulator) to our orally handicappd patients. Thyconsist nainly of Ienents of Andresn-Huple Ironoblocactivators and Frnkel's function regulators which have been\.ridely usd by orthodontists since decades. such ISMR|s(6 ,7 t8 ,9 ,1 ,4 \ a r used by the pat ien t rs a t horndur ing per iodsof little or no conmunicative urge, - evn during sleep justas cfassical orthodontic devices ar, Thy are produced andconscutively adapted by orthodontists and their lespectivtearns to the individual needs of our patients acordj.ng totheir progress. Basically they consist of two Iateral'shlves', allolring the patient to stabilj-ze their javs bybiting a then. This wil-l provide stabilization for th hyoidbon cornplex and hence for the critical pharyngeal area. Thefrontal and ndial connecting part of the shlves called'tongue shield' brings the tongue into a better startingposition for s$rallo$iing. This intra-oral part is conncted byvires to - usually four - vstibular pads in the vestibulararea, that is between teeth and lips. Many nodifications ofthes pads and their connctions to the l"ingual (rtrodental)parts allow f or very selective and succssful training tocounteract dficits of the nobility of lips, cheks, tonguelv1un and soft pafate. But abov a1I they aflow training ofco-ordinatd movennts of these parts as neded of intake offood of speech for instance. (For details and illustrationsplase see ref. 6-9, 14). Ths Isl,Rs have furthrd ourunderstanding of functional intrrelations \'hieh ar notvisible readily. Inprovernents of nobility and coordihation oforaf structures, especially the tongu also act on ttre nck(e.9. via the sternocleid rnastoid rnuscles) and thence on thebody as a whole as we coul,d denonstrat even in healthy volun-teers (5). we wr hintd to thj.s phenonnon by spontaneoustongrJe novhents of handicapped patients acconpanying theirattenpts to rotate their trunks (but did not appreciae itthen) as vell as by aheLioration of gait and autonatic reac-tions of the trunk in Sl,R-treated patients ltho achievdbtter lateral tongu nobility. Either by narks on the rtongush i ld ' p rovok ing rwe i f fnbachts cur ios i ty - re fLex o f thetongue ' (18) or , to the sarnend by us of sna l l res j .n pearLsnobilly attached to th rtongu-shield' of their rsMR.Nature is cononic. such bidirectional rnechanisns seen nces-sary . I f ac t ive o r pass iv changes of head pos i t ion in re la -tion to the trunk position are able to chang size and shapof the vj.tally important pharyngal airway crossing, thremust be a loca l ' f i rs t l ine ' de fense sys tem. And th is conis tso f vo lun ta r i l y rnov ing o r ton ica f ly pos tu r ing onrs tongue 'w alvays would renenLber that our vork on trunk _ and finb-syhntry never lril l- b ltithout inpact on th functions of face-, routh and throat. But if w rspect he prrequistes ofthe o ra t and pharynqe l reg ion (e .9 . ne l fo r fee l ing secure ;'s tab i l i za t ion i o f hyo id bon conp lex , tc . ) ve can ass is t ourtherapeutic fforts h'ith respect to body and lirnbs al-so frolthe roraL co lner ' ln a very po ten t way . I t a lways pays o f f tor < n . f t h 1 i n L . n f n a t t e r n s s u c h a s :

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-E : "= :? r o f body . and neck - pro t rus ion of tongue _ rnspr ra_ron , f lex j .on of body and nck - broad and spon_shaped ongue-exp i ra t ion and a lso of Ia te ra l novennts o f - the tongue in t io_and/or extraorally to assist rotation of th trunk ii thpat ien t 's o raL reg ion is re la t ive ly fesser nan ieappeA.-L. rs worth whle at Ieast to respect oro_pharynqei difficul_ i : : l . : :pg" i . t ty dur ins. nfect ions of rh. i r ;a; ;" i ;uy=hab r l . i t a t ng o r rhab i l i t a t j ng a pa t in _ i t i n va te r o f16ewhere .1) Bernstin N. Th Co-ordinatj .on and Rgulation of Movnent.1967 , Perganon p ress , Ox fo rd , London tc .2 ) Bosna , J . f . Ora l and pharynga l Dve loprnen and Func t i on .Journa l o f Den ta l Resa rch 1963 , 42 : 3 t5_380 .3 ) F inney , N .R. Hand l ing th young Cerebra l pa ls ied Ch i l d a t

. Home . 1974 , 2nd Ed i t . , w . He innann , London .4) Fukuda, T. Studies on Huhan Dynarnic postures fron theViwpoint of postural Rf1ex-s, lcta oto_i i iyng'i"g i"u,1 96 1 , S u p p l . 1 6 L : 1 - 5 2 .5 ) Habe r fe f l ne r , H . , Nobsa , K . , R i l gg , V . , Wechse lw i r kungzwischen Gesamtkrperhaltung, Mund- und Gesichtsbereich(Ta I I I ) , Pd ia t r ie und pdo log i 1981 , I6 : 215_225 , co r r .3 4 4 .6 ) Habe r fe l . l ne r , H . , R i ch t r , M. Zu r appara t i ven Therap leoro faz ia l r Dysk ines ien be i ze rebra i - bewequnqsqs to r tenPa t j en tn . Fo r t sch r i t t e de r K ie fe ro r thop ie ; 9g5 , 46 :7) HaberflInr, H. pparativ Bhandtung snsonotorischerslorungen in Mund- und Rachenberich: Indikationen,Bhandlungsweisen und beglitende Therapin. Beri.cht voh 4.synrposion Frtihfrderung, .Mnchen 1987, dit. Vertnagungfi ir interdis z pl inre ruhf rd.r,.,rrq ". V.8 ) Habe r fe l l n r , H . Ubr legungen zu r he rap ie oro faz ia le rDyskinesin und Erfahru;gen rnit kietero'rthopdiscnen- . G r ten , Krankeng) rmnast k . in p rss (Jun Lb89) .9) Haberfel lnr, H. Thrapy of Facio-oro_phar:yngeal Dysfunc_t rons . In p ress? J .J . cebhard t Ed i t . , 1989 ; ub r , Be rn_To ron to .10) H l leb rand t , F . . r Hou tz a l t r s . C . E . Ton i c Neck

Man. Arnrican ,fournal of1 5 9 .11) Lewin, c. Schla' i tnrnen niLBe r l i n .

, S . , t . , P a r t r i d g e . M . J . ,Rf1exs in Exrcises of stress inPhys ica l Md ic in 1956. 35 : 144-k le inen Leutn 1967, Spor tver l ag ,12 ) l , agnus , R . K rpe rs t I l ung , 1924 , J . Sp r i nge r , Be r l i n .1 3 ) M c c o u c h , c . p . , D e e r i n g , I . D . ? L i n g , T . t t . i o c a t i o n o tReceptors for Tonic Neck Reflxes, Journal of Neurophysio_l o g y , 1 9 5 1 , 1 4 : 1 9 1 - 1 9 5 .14) R i ch te r , M , , Habe r fe l l ne , H . Mod i f i z i e r te Ak t i va to ren b lzrebral ber^regungsgestrten patinten - ein neuerAnwendungsbereich. Fortschritte dr Kiefrorthopdie 1985,4 6 1 2 3 3 - 2 4 0 .1 . 5 ) S a u e r l " a n d , 8 . K . , M i r c h e l I , S . p . E e c t r o n y o q r a p h c . r i w i i wof the Hurnan enioglossus Muscte in R;;;;;;-i; -;..; i;; i i"

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and to Postura] changes of the Had. Butletin of the Losnge les Neuro log ica l Soc ie ty , 1970, 35r 69-73 .16) Stejskal, L. Postural Reflexes in Theory and MotorRe-ducat ion . L972, cadern ia , p rague.17) S t rong , W.B. So What ts cood about Spor ts (Ed i to r ia l ) .merican Journal of Diseases of Children, 1999, l-42: 14318) Weiffnbach, J.I.t, Discrete Elicited ttotions of the Ne ,,-bornts Tongue. In: 3rd Synposion on OraI Sensation andPercep t j .on , J .F . BosmaEdi t . , t -972 : 347-36L, C.C. Thornas ,Spr ing f ieLd , I11 .