EARLY PHYSIOTHERAPY IN THE TREATMENT

OF SPASTIC DIPLEGIA
T. Kanda
M. Yuge
Y. Yamori
J. Suzuki
H, Fukase

30

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The present study reports the effect of early

physiotherapy on patients with spastic
diplegia, according to the classification of
Hagberg er al. (1975). CT scans of all the
patients were examined to investigate the
severity of brain damage, and children
treated early were compared with those
treated late. Computed tomography (CT)
recently has come into general use for the
investigation of brain damage in cerebral
palsy (Koch et al. 1980). We have found
that the severity of motor disturbance
among children with spastic diplegia is
reflected by the extent of abnormality on
the CT scan (Kanda ez af. 1982).

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Material and method

Between 1976 and 1980 we examined a
total of 2203 children at St. Joseph
Hospital, Kyoto, Japan. Of these, 856 were
treated in our out-patient clinic for such
disorders as motor risk, congenital
cerebral palsy treated late, acquired
cerebral palsy secondary to encephalitis,
CO intoxication, vitamin K deficiency,
spina bifida, or severe head asymmetry. CT
scans were done for almost all of these 856
children.
We selected 194 motor-risk infants
under nine months of age who had been
treated for more than six months. The
basis for selection was at least six abnormal
postural reflexes out of the seven
standardised postural reflexes proposed by

Vojta (1974) or, exceptionally, fewer

abnormal reflexes but obvious asymmetry
of neuromotor patterns and persisting
primitive reflexes. Of these children, 56
subsequently developed cerebral palsy (21
dystonic syndrome, nine dyskinetic syndrome, nine spastic hemiplegia, eight
spastic diplegia, four atonic diplegia, three
spastic tetraplegia and two ataxic diplegia).
The eight children with spastic diplegia
who had been treated early were compared
with 21 children with spastic diplegia
whose treatment had started between nine
months and three years of age. We refer to
the two groups as early a n d late,
respectively. All children were given
treatment within one month of the first
check-up.
Examination included taking photographs (especially a t the first examination)
and recording motor patterns at each clinic
visit (every two or three months) i.e.
stability of walking, CT findings, a n d time
of starting to crawl, sit and walk.
The method of screening a n d treatment
used was that of Vojta (1974). The parents
of the two groups co-operated in the
training of their children, with similar
devotion to their tasks. Group differences
were calculated by the Mann Whitney (Jtest for random or paired samples.
Results
The characteristics of the two groups are

TABLE I
Characteristics of groups

m
d

Early group
(N=8)
Meant SD
Range
Age at time of evaluation

53.5i14.2mths

Age at start of training

Training term
No. ambulatory cases (%)

6 . 0 t 1 . 7 mths
39.3-t 1 9 . 5 mths

2yrs4mths6 yrs 0 mths

51.3f17.4mths

d
N
P

2yrslmth7 yrs 3 mths

l 5 . 7 * 5 . 5 mths
3 5 . 1 f 1 9 . 3 mths
13 (61.9)

5 (62.5)

listed in Table I. The average age at which

training was started was 10 months older in
the late group than in the early group. The
other characteristics, such as average age
at time of follow-up evaluation, average
duration of training, and percentage of
children who could walk, were similar.
The complications are listed in Table 11.
In the early group, abnormal CT scans were
found in seven cases and the one patient
with a normal CT scan had microcephaly
(head circumference 44cm at 26 months):
i.e. organic brain-damage was confirmed
in all infants in the early group (Fig. 1).
In the late group, 14 had abnormal CT
scans and none had microcephaly. Four
children in the early group and four in the
late group had epilepsy. The early group
contained two children and the late group
five with Dy<75. Visual impairment
was noted in four in the early group and in
three in the late group. There was no
evidence of hearing impairment in either
group. Thus the early group had more
severe complications.
Five children in the early-treated group
(62.5 per cent) and 13 in the late-treated
group (61.9 per cent) became ambulatory.
The mean age at which walking started
was 22.4 months ( S D 5 7 . 5 ) in the early
group and 3 0 . 8 months ( S D k 7 . 8 ) in the
late group (Table 111). Thus the children in
the early group walked on average eight
months earlier than those in the late group.
This difference is statistically significant
(p<O.O2) and seems t o depend on whether
treatment was started before or after
crawling began. In the early group,
crawling patterns were partially corrected
by treatment started six months before

Lute group
(N=21)
Mean f S D
Range

NS

NS

TABLE I1
Complications of groups

Early group
No.
%
Abnormal CTfindings
Epilepsy

DQ<75
Visual impairment

7
4
2
4

87.5
50.0
25.0
50.0

Lute group
No.
%
14
4

66.7
19.0
23.8

14.3

crawling began. In the late group,

treatment was started after the onset of
abnormal crawling. Steady walking was
achieved by all ambulatory patients in the
early group, regardless of the age at which
walking started o r the age at the time of
evaluation. Children in the early group
started to walk before three years ofage. In
the late group most children could walk
steadily if walking started before three
years of age, regardless of the age a t time of
evaluation. However, four of five children
who started to walk at three years of age
walked unsteadily. Although the two
groups had a similar percentage of children
who could walk, the degree of stability
differed. Finally, five in the early group
(62.5 per cent) could walk steadily for
more than 30 minutes, but in the late group
only seven ( 3 3 . 3 per cent) could d o so
(Tables IV t o VI).
Typical motor patterns of the early and
late groups are shown in Figure 2. Both
groups had similar degrees of lateral
ventricular dilatation on CTSCanS, although
cortical atrophy was more severe in the
early group. The walking patterns in the

439

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x

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c.

Fig. 1. CT scans of early-treated infants with spastic diplegla.

A . Roy aged 3 vears 6 months: a typical case of good effect of early treatment. He also had epilepsy. convergent
strabismus and weak eyesight. CT findings were slight dilatation of lateral ventricles ( b r ) and interhemispheric
.fissure.
B. Girl aged 4 years 9 months. treated.from 8 months of age bur still unable to tvalk. Premature (30 weeks.
I590g) u'ith severe risk factors; also had epilepsy. Crfindings .similar to those in A.
C. Boy aged 4 ,years 7 months: small for dates (40 weeks, 217Og). with dyspnoea: also had epi1eps.v. Walked
at I ,year 6 months. CT shows slight symmetrical dilatation of lateral ventricles.
D. Boy aged 6 )'ears: premature birth (34 weeks. 1 8 6 0 ~ )with asphyxia. Treated.from 8 months of age:
walked at 2 years 10 months. Alro had convergent strabismus. CT findings were slight dilatation of right
lateral ventride and minimal dilatation of interhemispheric fi.rsure.
E. Girl aged 5 years I month: intracerebellor bleeding in neonatal period; drqmoea and convulsions. Treated
from 4 months of age: now u,alking with support; D Q 67. She was near-sighted and astigmatic. CT shows
porencephaly in cerebellum.
E Girl aged 5 years; verj, premature (28 weeks, 1160g) with dj,spnoeo. Treated from age 7 months: walked at
I year 5 monrhl. Also had epilepsy. CT show,s left porencephalj, joined to left lateral ventricle in occipital
area.
G. Roy aged 3 )'ears I I months; premature (30 weeks. lS00g) with severe risk factors. Treated.from age 6
months: nalked at I year 8 months. No complications. CTfindings \('ereslight dilatation of right lateral
ventricle.
Ii. Roy aged 3 years 4 months; premature (37 weeks. 2450g) with precipitate delivery. Treated from age 8
months: crawling now abnormal; D Q 63 and rnicrocephaly (HC 44cm at 2 years 2 months). Convergent
strabismus. CT normal.

TABLE 111
Age at time of starting to sit, crawl and walk

No.

440

Sitting

Crawling
Walking

8
5

Early group
Mean T.S D
19.8t 1 3 . 1 mths
1 2 . 0 t 5 . 6 mths
22.4-t 7 . 5 mths

No.

21

21
13

Late group
Mean + SD
15.2i 8 . 6 mths
1 5 . 5 i 5 . 2 mths
3 0 . 8 1 7 . 8 mths

NS

NS
<0.02

Fig. 2. Typical dvferences between early-treated (left o f pair) and late-treated (right o f pair) groups. (a) The
typical partern of spastic diplegia--flexed upper extremities and extended lower extremities with tiptoeing-is

seen in borh cases at I year I month. The child on the left seems more severely affected as the feet are crossed.
CTs after 1 year of age showed slight ventricular dilatation. Cortical atrophy was more severe in the case on
the left. (b) As the child begins to crawl and sit ( I ,year 9 months). rhe typical pathological pattern of neck
extension and inner-rotation of the legs becomes worse. Anteversion of the pelvis and opisthotonus are less
marked in the early-treated child. (c) Prolonged sitting with hands in the air was possible at 2 years 9 months in
the early-treated child. Steadiness was achieved because he could extend his legs. The late-treated child achieved
prolonged sitting by 2 years II m o n t h of age. Legs were-fle.xedfor anteversion of the pelvis, and therefore he
could nor sit steadily for a long time. (d) Walking was achieved in the early-treated child b.v 2 years 2 months.
and he could walk steadily by 2 years 3 months. The late-treated child walked at three ,years of age but in an
unstable pattern rather similar to that of classical spastic diplegia. l h e pathological pattern of neck extension
and anteversion of the pelvis could not be changed b,v treatment, which started too late.

TABLE IV
Relation between prognosis of walking and age at time of evaluation
Age at time
of evaluation

Total No.

Early group
Walking Not walking

Total No.

Lore group
Walking Not walking

~~

Total

1
2

0
2

I
3
I

I
I
1

I*

0
0

2
0

3
3

I
6
2
2
I

I
I
2
0

21

13

1'
3.'

'2 yrs 4 mths at time of evaluation; **one infant 3 yrs 2 mths and two infants 3 yrs I I mths
at time of evaluation.

441

TABLE V
Relation between stability of walking and age of starting to walk
4

Age of
starting
to walk (yrs)

Early group
Walking Steady walking'
~

4;

I
2

3
2
0

4
4

4
2

4-7

3
2
0
0

I
0

Total

I3

Late group
Walking Steady walking

*Able to walk for more than 30 minutes.

T A B L E VI
Relationship between stability of walking and age at time of evaluation
Age a i lime
of evaluation
L

(YW

Early group
Walking Steady walking.

0
2
1

2
I

Total

Late group
U'alking
.S:rady u,alking

I
I

I
2
2

6
2
2

I
I

13

*Able to walk for more than 30 minutes

T A B L E VII
Evaluation of 138 patients who did not develop cerebral palsy
(a) Characteristics
No. children

I38

3 4 . 0 * 1 3 . 7 mths

(b) Complications
Children studied
by C T
%
'
No.

138

Age at time of evaluation

Mean r SD
Range

100

Training term
Mean Sl)

5 . 0 ~ 1 . mths
7

1 0 . 6 1 4 6rnths

I yr 6 mths4 yrs 7 mths

Abnormal C T
findings.
%5
No.

47

StarrrnK rime of training

Mean i SD

33.9

Epilepsy
No.
(2

II

8.1

UQ< 75
'X
No.
9
6.5

Vi.rual impairmenr

1 0 . 8 * 3 . 8 mths

442

l 0 . 5 i 4 . 2 mths

138(1004)

iirurrnp imporrmenr

No.

No.

16

11.3

*Examined before the age of one year

(c) Time of sitting, crawling and walking
Sitting (N = SD
Crawling
fN- 138)
(N= 138)
Mean i SD
Mean i SD

Ambularorj

Walking
( N - 138)
Mean I SD

Ronge

l5.0+6.I mths

10 mths 1 yr 10 mths

early group were stable, whereas those in

the late group were unstable and similar to
the classical pattern, with neck extension
and anteversion of the pelvis.
The characteristics, complications and
times of starting to sit, crawl and walk of
the 138 treated children who did not
develop cerebral palsy are shown in Table
VII. It is interesting that the times of
starting to sit ( 1 0 . 8 months*3.8) a n d to
crawl (10.5 m o n t h s i 4 . 2 ) were similar in
this group, and that some of them showed
minimal internal rotation of the legs,
knock-knees, flat feet with external
rotation, a n d unskillful pincer grasp when
walking started. It is not clear why internal
rotation of the left leg persisted in spite of
prolonged training for 11 months.

Discussion
In two controlled studies, Brandt et al.
(1980) reported the effect of Vojtas
method of treatment on 21 children and
compared them with 30 in a control group.
Uncomplicated cerebral palsy tended to be
rare in the Vojta group, although the
difference was not significant. dAvignon
et al. (1981) compared 10 cases treated by
Vojtas method with 12 treated by
Bobaths method and eight untreated
cases; they reported that normal development was significantly more frequent in the
Vojta group than in the Bobath group(but
the Vojta group had fewer neonatal risk
factors).
The effects of physiotherapy depend
partly o n the severity of brain damage.
Brain damage in cases of spastic diplegia
has been described by Volpe (1976). For
patients with the smallest lesions, C T scans
are normal, and normal C T findings are
frequent in cases of spastic diplegia (It0 et
al. 1979, Koch et al. 1980, Kanda et al.
1982).
In this study we investigated C T scans
taken after one year of age because of the
occurrence of changes with age, especially
cortical atrophy (Kanda at af. 1980). The
reason that more severe cases were present

in the early-treated group seems to be twofold: first, severe cases might be discovered
early and mild cases not until after nine
months of age; second, mild cases might
not progress to spastic diplegia if treated
early.
Treatment might be expected to be more
effective in the late group than in the early
group, since normal C T scans were more
frequent i n the late group and other
complications were less frequent. However, treatment was actually more effective
i n the early group, with children walking
eight months earlier than those in the late
group, and 62.5 per cent of them in a
steady manner. I n the late-treated group it
was difficult t o change the abnormal
patterns of crawling to normal ones, so the
patterns of neck extension and anteversion
of the pelvis remained, resulting in
unstable walking.
From the results of this study of the early
treatment of spastic diplegia, even with
severe complications, we think that it is
possible that motor-risk infants without
complications can avoid classical cerebral
palsy, but that without treatment they
would develop cerebral palsy. Some of the
138 motor-risk infants might be such
children.
The most noteworthy finding in this
study was the marked improvement in
walking in the early-treated spastic group,
although this group had the more severe
complications.

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Acknowledgements

This study was reported a t the 24th Annual Meeting

of the Japanese Society of Child Neurology, 1982.
T h e paper was revised by Takehiko O k u n o , M.D.,
Instructor, Department of Pediatrics, Kyoto University, Kyoto, J a p a n .
Authors Appoin [men I s

Toyoko Kanda, M.D., Paediatric Neurologist;

Yuriko Yamori, M.D., Paediatric Neurologist;
Mariko Yuge, M.D., Paediatric Neurologist.
Hiroshi Fukase, M.D., Orthopaedist;
St. Joseph Hospital for Handicapped, Kita-ku
Kitano Higashi Kobai-cho 6 , Kyoto, Japan.
J u n k o Suzuki, M.D., Paediatric Neurologist;
Department of Pdediatrics, Shiga Paediatric Orthopaedic Centre, Shiga, J a p a n .
*Correspondence

10

firs! aurhor

SUMMARY
This study reports the effect of early physiotherapy, using Vojtas method, o n children with spastic diplegia.
Eight children with spastic diplegia (in spite of earl?, treatment which was started before nine months of age)
were compared with 21 children with spastic diplegia in which treatment was started between nine months
a n d three years of age. The average age of starting lo walk was eight months earlier in the g r o u p treated
early. although they had more severe complications. They tended to walk steadily with a gait pattern which
was quite different from the classical pattern. All of the early treated patients had confirmed organic brain

443

damage with abnormal CT scan or microcephaly. In conclusion, Vojtas method of treatment

which improves the prognosis for walking if performed early.

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RkSUMk
RePducalion prhcoce dans le trairemenr de la diplkgie spasrique
Cette etude rapporte les effets dune reeducation prkcoce faisant appel B la methode de Vojta sur des enfants
atteints de diplegie spastique. Huit enfants presentant une diplegie spastique en dCpit dun traitement prkcoce
ayant dkbuti: avant neuf mois ont it6 compares B 21 enfants avec diplCgie spastique, chez qui le traitement
avait debut6 entre neuf mois et trois ans. La moyenne dige de debut de la marche a ete plus precoce de huit
mois dans le groupe traiti precocement bien quils aient present6 des complications plus graves. 11s tendaient
a marcher pesamment avec une allure de d h a r c h e tout B fait diffirente de la disposition classique. Chez
tous les enfants trait& precocement, la lesion ctrkbrale organique a kte confirmbe avec scanner anormal ou
microciphalie. En conclusion, la mithode de traitement de Vojta est un systkme qui amkliore le pronostic de
marche sil est applique prkcociment.
ZUSAMMENFASSUNG
Fruhreiriges Einserzen einer physikali.when Therapie bei der Behandlung der spasrisehen Diplegie
Diese Studie berichtet iiber das Ergebnis friiheinsetzender physikalischer Therapie nach der Methode von
Vojta bei Kindern mit spastischer Diplegie. Acht Kinder mit spastischer Diplegie trotz friiheinsetzender
Behandlung, Rehandlungsbeginn vor dem neunten Lebensmonat, wurden mit 21 Kindern mit Diplegie
verglichen, bei denen die Behandlung erst im Alter zwischen neun Monaten und drei Jahren begonnen
worden war. Die friihbehandelten Kinder lernten im Durchschnitt acht Monate eher laufen, obwohl sie
schwerere Komplikationen hatten. Sie neigten zu einem gleichmaaigen Gang, dessen Muster sich jedoch von
dem klassischen Gangmuster deutlich unterschied. Alle friihzeitig behandelte Patienten hatten einen
nachgewiesenen organischen Hirnschaden mit abnormem CT-Oefund und Mikrocephalie. Zusammenfassend
kann gesagt werden, dal3 die Behandlung nach Vojta bei friihzeitigem Beginn die Prognose im Hinblick auf
das Laufenlernen verbessert.
RESUMEN
Fisiorerapia precoz en el rraramienro de la diplegia espasrica
Este estudio aporta el efecto de la fisioterapia precoz utilizando el metodo de Vojta en niiios con diplegia
espistica. Ocho niiios con diplegia espastica a pesar de u n tratamiento precoz que se inici6 antes de 10s nueve
meses de edad, fueron comparados con 21 niiios con diplegia espistica en 10s cuales el tratamiento se inicio
entre 10s neuve meses y 10s tres aiios de edad. El promedio de edad a la que se inicio la marcha fue de ocho
meses antes en el grupo tratado precozmente. aunque tuvieron complicaciones mas graves. Tendian a andar
segun un esquema de marcha que era completamente diferente del modelo cllsico. A todos 10s pacientes
tratados precozmente se les confirm6 tener una lesion organica cerebral con TAC an6malo o microcefalia.
En conclusion. el metodo de Vojta es u n sistema que mejora el pron6stico de la deambulacibn si SK inicia
precormente.
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