THE VOJTA CONCEPT

HISTORY

In the years fifty, in Czechoslovakia, Vaclàv VOJTA, neurologist concerned by the

motor rehabilitation, began the long way from the first empirical attempts to the
current therapeutic concept. This evolution has continued in Germany where V. Vojta
had emigrated in1968. From Munich, an international system of collaboration and
formation has gradually developed in Europe and in the whole world..

The research committed by the Professor V. Vojta has always comprised two
simultaneous ways :

* The neurological investigation, led to the elaboration of an evaluation methodology

of the child development, of its dynamics, and its main disorders.
* V. Vojta has always considered the nervous system as an open system, endowed
with a basic, phylogenetic organization, but also with a receptivity to various
stimulations able to affect its functioning and even to have an effect on its anatomical
maturation.

The " reflex locomotion" gives physically shape to the conjugation of these two
complementary aspects; it constitutes the axis major of an original therapeutic
protocol that has first intended to the children with Cerebral palsy ( CP).

In the course of years, the constant refinement of the observation and the theoretical
reasoning, based on the practical experience of an increasing and dynamic team,
operating in multiple sectors of activity, has contributed to a considerable widening of
the indication field : peripheral or central neurological disorders of the child from the
neonatal stage up to the adult, and a majority of disorders concerning the locomotor
anatomical system.

OBJECTIVES
The Vojta "method"is for the physician a precious clinic tool for the evaluation of
the child development from birth, and a reliable element of diagnosis; it is for the
physiotherapist an efficient global therapy which can be used from the first days of
life, in a preventive or curative intention.

The treatment based on the reflex locomotion contributes to:

* Modify the reflex activity of the young child and to orient the neuromotor
development in a more physiological direction, by the induction of a different
central neurological activity that supplies to the patient a new corporal perception.
The muscular "proprioception" plays here a very important part.

* Modify the spinal automatisms in lesions of the spinal cord .

* Control the breathing in order to increase the vital capacity.

* Control the neurovegetative reactions , and promote an harmonious growth of the

locomotor anatomical system .

* Prevent the orthopaedic degradation, frequent in severe pathological situations.

THEORETICAL FOUNDATION, METHOD

A- MEDICAL POINT OF VIEW

V. Vojta proposes a methodology in three parts for clinic evaluation of the

development :

1 - Study of the postural automatic reactivity:

The test of global reactions to sudden corporal position changes in the space (7 to 11
tested reactions), enables to highlight every perturbation in the automatic management
of the postural mechanisms by the Central Nervous System (CNS). The progressive
transformation of these reactions in the course of the first year of life, in the context of
a normal development, is perfectly codified; their examination enables, not only to
signal functional anomalies from central or peripheral origin, but also, to specify the
level of development reached at the moment of the examination.

Picture 1 - Evaluation of the postural reactivity:

example of 3 main
stages of the Vojta
reaction . Tests
consist of a sudden
change of the
corporal posture in the space (here a rapid lateral incline), that induces a reaction of
the vertebral axis and of the limbs (here these of the upper side ). The normal reaction
transforms in the course the first year according to precisely codified modes. It is
therefore possible to discern a normal reaction for the age, a reaction indicating a
delay, or an erroneous reaction indicating a central coordination deficiency.

2- Cinesiologic analysis of the spontaneous motor function:

Each stage of a normal development is characterized by behaviours answering to
precise finalities (orientation, appropriation, locomotion, etc...); these fundamental
needs induce the implementation of locomotor strategies, automatically adapted to the
postural context of the moment.
The originality of the Vojta methodology is to define clearly the cinesiologic content
of these locomotor strategies; in other words, postures, support polygons, movements
characterizing the main stages of an optimal development are precisely defined; the
distinction between a multitude of individual variants and fundamental postural
components is clearly made, in order to enable their systematic research at the patient
and the comparison with possible pathological succedaneas..

Picture 2: Healthy child, 3 months old:

In the prone position, the baby releases automatically
the upper limbs and builds a triangular support
polygon, with symmetrical support on both elbows that
enables the elevation of the shoulder belt and of the
superior thorax to heave the head freely in the space,
out of this polygon.
This postural automatic mechanism, entirely enslaved
to the visual need, contributes to the orientation in the space, it consists of a
combination of very precise muscular synergisms in the vertebral axis and the
shoulder belt insuring the alignment, the symmetry and the stabilization of these
corporal regions, that will guarantee the coordinate rotation of the head. The artificial
activation of these synergisms is possible from the birth during the reflex locomotion.

Picture 3: Healthy child, 4,5 months old:

In the prone position, the child has to liberate one upper
limb for the prehension. That will be possible by releasing
sideways the homolateral lower limb to constitute a new
support point on the knee, this new support point will
automatically substitute for the disappearing support point
at the homolateral elbow . The support polygon is
modified. This operation concretizes the appearance of a
support diagonal line (from one elbow to the opposite
knee); it announces ulterior forms of locomotion such as
the dissociated quadrupedic locomotion, the dissociated
walking.
The automatic emergence of this global postural pattern is a preliminary condition to
the good progress of the prehension in the prone position ; it's again an "enslaved
pattern". This postural pattern includes very precisely coordinated muscular
synergisms, of the vertebral musculature, of the trunk and of the limbs; these
muscular games are also present in the reflex creeping, which can be activated from
the birth under adequate stimulations.
Picture 4: Child with a cerebral palsy:
The global support pattern on one single
elbow has never been accessible, the
lower limb is not released to constitute a
new support point on the knee because
the necessary coordinated vertebral
rotation for this movement is not realized.
The prehension unfolds according to a
postural substitution pattern,
fundamentally different of the pattern illustrated by the picture 3. A functional
rehabilitation soliciting frequently a such activity contributes to perpetuate the
pathological postural procedure, by delivering to the central nervous system an
erroneous afferent proprioceptive flow...

3 - Reflexology:
A series of reflexes selected in the medical literature, whose modes of provocation,
answers and interpretation are precisely described, come to complete the diagram of
examination to refine the immediate evaluation but also to specify the prognosis.
The long term follow up of many children has shown that the presence or the absence
of these reflexes, their quality, their validity period, could be corroborated with
different paths of development (spastic, dyskinetic, etc...).

The severity of the " central coordination disorder " (CCD) is appreciated
according to the number of abnormal postural reactions, and of the possible
conjugation with aberrations of the reflexology (exceeding normal validity periods of
reflexes, qualitatively abnormal answers etc...).

The confrontation of these three types of data enables to classify the CCD in several
categories, whose the most benign do not justify a physiotherapy, as it was proved by
several a posteriori statistical studies, realized with important series of patients.
Severe or medium CCD, correspond to a major risk of invalidating complaint
( cerebral palsy, or other illness), and justify therefore the early therapy.
light C.C.D can be the expression of sensory or psychomotor various disorder,
belonging or not to a definite syndrome , and justifying an attentive supervision of
the ulterior evolution or further medical investigations .

That shows the importance of this classification that helps the physician to prescribe
the early physiotherapy in every necessary case, to avoid useless prescriptions, to
anticipate complementary investigations. The CCD is a transitory situation,
already pointing out the functional disorder of the CNS. The severity of this disorder
has to be quantified to specify the therapeutic indication. More about C.C.D.

B - PHYSIOTHERAPY

The physiotherapy according to V. Vojta is based on the notions of reflex locomotion

and "pathing" (forcing a neuronal way).

V.Vojta has described (1954) motor global behaviours, or patterns, activated with the
spastisc patients: by realizing movements against resistance in the axial region of the
body ( trunk, head, hip or shoulder key-articulations) appeared particular muscular
synergisms, propagating to the rest of the body. The cinesiologic content of the
pattern varied according to the initial posture (start position), but the phenomenon
appeared organized and repetitive. It presented especially a reciprocal character,
such as can be found in the different forms of locomotion.
The analysis of these muscular activities (synergisms) has shown that they were
elements of a combination clearly devoted to the locomotion.

The observation of these movements against resistance by the fixed spastic patient,
announced the discovery of innate and global locomotor systems : the reflex
creeping and the reflex rolling. The reflex locomotion is used since 1959 for the
treatment of the child's motor disorders, it was later used with babies to prevent
the installation of these disorders.

Reflex locomotion patterns (ref.creeping and ref. rolling) are global; during these
activities, the totality of the musculature is activated according to a coordinate
mode. The different levels of the CNS are concerned by this activation . The reflex
locomotion is provoked by specific stimulations (pressures) applied on defined zones.

Picture 5: Start position for the reflex creeping and general situation of the zones:
The head position
determines the position
of the limbs, different
on the face-side and the
nape-side

The reflex creeping

appears from two
opposite start positions
called "reciprocal
positions"; each zone is
therefore bilateral and
the therapist has at one's disposal 18 access points to the afferent nervous system
(proprioceptors, exteroceptors, connective tissue...) that can be used in an infinity of
combinations. Defined pressure directions, are applied on one or several zones; during
this stimulation, the therapist must be able to control the position of the patient, and to
apply, if he wishes it, a continuous resistance to the provoked motor answering. In
order to achieve this, the therapist may use different parts of his own body (abdomen,
forearm, knees, etc...)

Picture 6: Direction of the motor answering composing the reflex creeping pattern:

The phasic movements

of the limbs ( visible
displacement of
corporal segments) and
the head rotation are
conditioned by the
active creation of fix points at the extremities of the "support diagonal " (face-elbow
and nape-heel); the therapist has to be very attentive to this point. The isometric
motor activity of this diagonal includes a finely differentiated work of vertebral
muscles and of the limbs roots .

The coordination of the antigravitic muscular activity, of the vertebral alignment, of

the opposite rotation between the pelvis and shoulder belts, of the muscular
contractions that radiate to extremities of the limbs, belongs to the patterns of the
superior human locomotion (creeping, walking).

Picture 7: Pull direction of the muscular chains during the reflex creeping.

The active creation of peripheral fix points, enables

the muscular organization in oblique chains that
exert tractions on the bone levers according to
differentiated directions. Isotonic chains (pic.7, ch.
2 and 3) have a phasic mission and determine
segmental movements; isometric chains (pic.7, ch.
1) are devoted to the stabilization and govern the
emergence of the antigravitic and locomotor
function (pic. 7 and 8). The convergence place of
these muscular chains is the spine and especially
the dorso-lumbar transition.

The experienced therapist will certainly note

- that the dorso-lumbar region is frequently the
place of the infantile cyphosis in neuropediatric
disturbances compromising the stabilization of the
vertebral axis,
- that this region is also the opposition place of the
physiological double rotation in all the
differentiated locomotor patterns (quadrupedic locomotion, walking)
- that the coordinate vertebral
rotation is the privilege of all the
fine posturo-motor functions and
is cruelly missing in the totality
of neurological pathologies from
central origin,
- finally, that the dorso-lumbar
transition is subjected, in the
active human life, to many
mechanical constraints which
require a rigourous automatic
control based on the
proprioceptive information.
This enumeration underlines the
interest to obtain for our patients
of all ages, through the
activation of precise automatic
muscular games, a good corporal experience , that makes largely call in the deep
sensitivity, and contributes to the elaboration, or to the restoration, of the unconscious
corporal scheme.

Picture 8: Main muscular elements of the support diagonal during the reflex creeping

Picture 9: Other examples of start position: a- half-quadrupedic position called "first

position", b - lateral decubitus, phase 4 of the reflex rolling, c - lateral decubitus,
phase 3 of the reflex rolling...

There are different start positions (prone position for the reflex creeping, supine or
lateral for the reflex rolling etc...); therefore the therapist can choose between
innumerable combinations of start positions, zones and stimulations corresponding to
the same number of activation procedures for a coordinated central function.

The application of resistances against the provoked activity, transforms the phasic
movement into an isometric muscular activity (without segmental displacement),
whose duration can be modulated by the therapist without addiction (proprioceptive
receivers). This practise leads to a temporo-spacial accumulation , then to a neuronal
"overflowing" phenomenon to "force" a new neuronal itinerary. This enables, by the
recruitment of new afferent ways to the CNS, the activation of possibly
underexploited central territories. This technique is called pathing, it consists in
provoking, then artificially maintaining , from outside, the muscular isometric
contraction with the aim of soliciting a widened and coordinated activity of the CNS.

Each reflex locomotion pattern (creeping or rolling) has specific zones and can be
activated from several start positions. Accessing to the same pattern from different
stimulating combinations, forces the central nervous system to resort to diversified
processing procedures of the afferenting flows; that means varied neuronal itineraries.
These neurological procedures are to the basis of the physiological postural
adaptability.

The pattern sequences ( muscular synergisms) observable during the reflex

locomotion present a strict analogy with motor sequences of the normal motor
development. They can be found in the ontogenese from the first antigravitic
activities (pic.2 and 3), until it forms the finest bipedic locomotion with its stock of
postural, antigravitic and equilibration automatisms.... These neuromotor elements ,
exist in the reflex locomotion, they can be activated from the birth under an adequate
activation procedure (table 1).

Table 1:
Comparison of reflex creeping sequences
with spontaneous motor sequences of the ontogenese
 Ontogenese
Reflex creeping (finalized,
(artficially provoked activity) spontaneous
Appearance age
activity)
Activity
Appearance age
lateral step of the upper limb in
from the birth
prone position
(nape arm) 3 months
(face arm)
elbow support
Free coordinated head rotation
from the birth 3 months
with symmetric vertebral axis
Lateral movements of the eyes, end of the 1
from the birth
independent of the head posture quarter
One elbow support from the birth middle of the 2
(support stabilizing synergisms) (face arm) quarter
Total opening of the hand, with
from the birth end of the 2
radial bending of the wrist ,
(nape hand) quarter
abduction of the metacarpus
6 months, rolling
Coordinate differentiation of the
from the birth from dorsal to
shoulder and pelvic belts
ventral
from the birth nape
Activ creation of the knee support
lower limb, variant of quarter 3
with loading
the ref. creeping)
Coordinate push with the lower
limb and heel support, foot in the from the birth (nape
14 -15 months
90° position, support on the lower limb)
external foot edge.

The V . Vojta technique presents decisive advantages in physiotherapy:

1) The patterns activated during the therapy are automatic and innate, they are
usable, even in the absence of aware participation of the patient, without lower or
upper age limit (baby, polyhandicapped person etc...).

2) The possibility to provoke precise muscular games, acting in synergism on

choosed corporal segments , and to modulate in space and time these synergisms by
the combination of start positions, zones, and stimulations, offers to the therapist a
therapeutic tool particularly adapted to peripheral or central neurological disorders.
This technique is also precious for the treatment of corporal territories whose aware
control is difficult or altered (absence of visual feedback, disorder of the corporal
schema etc...); the spine scoliosis , various congenital malformations are good
examples.

3) The first answering elements are neurovegetative and the long time practice has
shown the influence of this technique on the sanguine circulation, on breathing, but
also on the sensory system, and in the long term on the development of bones and
joints .
The activated muscular chains commonly include the abdominal muscles and the
diaphragm, the vertebral muscles and the trunk muscles; they contribute to a notable
improvement of respiratory conditions, of the urologic physiology and of the
defecation.

4) With young children, it was frequently observed that the motor progress are not
isolated, but coincide with a clear improvement (according to the severity of the
pathology) of the relational aptitude.

6) In very severe pathologies, where functional ambitions are limited and where the
orthopaedic degradation threat is major (severe spasticity, asymmetry etc...), the
regular activation of a better coordinated muscular function, that the patient cannot
produce by himself, is an important therapeutic argument to prevent deformities.

C - INDICATIONS OF THE V. VOJTA TECHNIQUE

Severe and medium central coordination disorders

Light but asymmetrical central coordination disorders
Cerebral palsy
Muscular and neurogen torticolis
Peripheral Paralyses (child and adult)
Spina bifida
Congenital myopathies - congenital deformities (athrogryposis, club foot etc...)
Morbus-Down syndrome and other syndromes - motor delays
Various postural disorders (scoliosis, cyphosis)
Hip dysplasies
Adult hemiplegy (unexhaustive list)...

D - EXAMPLES OF THERAPEUTIC SITUATIONS

The physiotherapy according to V. Vojta, consists in activating complex

neurovegetative, sensory and motor reactions, that can begin locally, then radiate to
vaster corporal territories or to the totality of the body. The starting point of reactions
can vary in the course of time with the same patient, and from a patient to the other.
 Picture 10: 3 years old child, spastic
tetraparesis, hyperlordose and severe hypertony of the adductors, pelvic asymmetry.

Picture 11: Same child as

picture 10 in the 1 phase of
the reflex rolling (variant
with maintenance of the
jawbone, and the nape-arm in
abduction). The motor
answer consists of an active
alignment of the vertebral axis, the activation of the abdominal musculature and clear
diminution of the lordose; lower limbs are maintained in medium flexion with a
beginning of abduction and external hip rotation. The active correction is insufficient
in the cervical region (lordose) and at the feet. This could be researched by modifying
the combination of stimulations.

Picture 12: 2,5 years child, left

spastic hemiparesis (down side),
provoked correction of the
valgus foot during the reflex
rolling (variant of the 4 phase). The head is stabilized (maintained) in the alignment of
the vertebral axis. The answering of the left upper limb is not correct.

Picture 13: 20 months child,

aftereffects of embryopathy with
severe psychomotor delay, great
hypotony, dorso-lumbar cyphosis
and major postural asymmetry
(level of locomotor performances
lower than 6 months). During the reflex creeping, active rotation of the head to the
median axis, contained by the resistance (abdomen of the therapist), global coordinate
activation of the trunk musculature, vertebral alignment, creation of the elbow-heel
support diagonal (beginning of the antigravitic function). The lateral phasic step of the
face-side lower limb and of the nape-side upper limb indicates the isometric
dissociated rotation of the shoulder and pelvic belts.
 Picture 14: 6 years child, spastic
diparesy (walking possible with
sticks in a limited perimeter),
variant of the reflex creeping where the nape-side lower limb is in complete flexion in
the start position . Creation of the elbow-knee support diagonal, strong activation of
the abdominal musculature, vertebral alignment, but the cyphosis is inadequately
controlled, lateral step of the phasic limbs (nape UL and face LL). Observe the
irradiation of the muscular activity to the face-hand in extension and radial bending of
the wrist, abduction of the metacarpus, harmonious finger flexion and opposition of
the thumb on the cylinder. This cylinder has been first placed in the hand to induce a
proprioceptive and exteroceptive afferent flow corresponding to a functional attitude
of radial prehension.

Picture 15: 5 years child, left

spastic hemiparesy ( nape-side). In
"first position ", imperfect
construction of the support
diagonal (from the face-elbow to
the nape-knee) because the left foot is well perpendicular to the leg during the action,
but toes would have to be bent and the supination stronger. Nevertheless the answer
of the upper limb of the concerned side (left) is good , with active opening of the
hand, a bit more abduction of the thumb would be desirable...
 Picture 16: Same child that pict.
15, left spastic hemiparesy ( nape-side). During the reflex creeping, with the nape-side
lower limb in flexion, the answer of the injured upper limb is again clearer with total
opening of the hand, in radial direction, the answer of the homolateral lower limb
comes better in the foot, although the dorso-lumbar spine is not ideally controlled.

The provoked motor activity can be right away isometric, or initially phasic and then
become isometric by application of resistances; it may be massive but also discreet
(localized muscular fibrillations for example).
The patient is only aware of a part of the provoked activity, he can also feel effects
that the therapist does not perceive; conversely, the therapist can observe clinic
activities that the patient does not feel, and whose he is not aware.
It is not easy to illustrate photographically director principles of this therapy, and the
complex internal mechanisms that participate there. Only the most flagrant
manifestations can be photographied.
It's only by the further study of the technique, and by the regular practice that the
therapist will progressively be able to discover the subtler and diversified aspects of
this therapeutic approach.

PRACTICAL FORM - FAMILY PART

It has been possible to verify (electromyographic control) that the neurophysiological

modifications induced by the pathing technique subsisted a certain time after the
working session . It is therefore beneficial to repeat the treatment several times per
day to increase the frequency and the duration of these effects.
The treatment is recommended 3 to 4 times per day; each session lasting 15 to 20
minutes, the optimal therapeutic conditions represent therefore one hour to 90 minutes
of daily rehabilitation, divided in parts of about twenty minutes.
The therapist initiates the family to a standardized treatment; he assures naturally the
technical control, and brings this treatment regular up to date. It is an advantage, with
an infant, to work at the most propitious moments of the day, and to respect the
biological rhythms.
The concrete and active collaboration of the parents, guided by the therapist,
contributes to a climate of confidence and reciprocal encouragement between the
professional and the family. It is a constant relationship support between the therapist
and the parents about the child and his evolution. This collaboration contributes to the
information of the parents, to the enlightenment of situations by a lucid perception of
the progress as well as the difficulties. It reduces the risk of inadequate behaviour
about a child with an uncertain development.
Interventions of the therapist can be spaced out, more than during a "classic" follow
up; it has also economic consequences.
The practice of this therapy is perfectly compatible with an ordinary social life, it
demands only a few organization. Sessions of work are not very long. In a lot of
specialized centers, the technique has integrated to the usual multidisciplinary follow
up.
The Vojta technicity has a lot developed in Germany in the course of the 25 last years.
The epicenter is the "Kinderzentrum -München", main pole of training for Europe,
whose medical team manages all training actions undertaken through the world.
Training courses for the physicians and physiotherapists, are regularly organized. The
training is nowadays also possible in local language, with all guarantees of
authenticity, in different countries: Austria, Spain, Italy, Norway, Holland, Sweden,
Japan, Korea ...

BIBLIOGRAPHY

- Die Zerebralen Bewegungsstِrungen im S‫ن‬uglingsalter: Vaclav Vojta - Ferdinand

Enke Verlag Stuttgart
- Das Vojta Prinzip:Vaclav Vojta, Annegret Peters - Spinger Verlag Berlin,
Heidelberg, New York, London, Paris, Tokyo, Hong Kong.
- Le concept Vojta: H Lagache - Kinésithérapie scientifique n° 366 - S.P.E.K. Paris,
1997

CONTACT - FORMATION

- Internationale Vojta Gesellschaft: Kandinskystrasse 24- 81477 München - Germany

- Deutsche Akademie für Entwicklungs-Rehabilitation - Kinderzentrum München -
Heiglhofstrasse 63, 81377 München - Germany
- In France: Mr H. Lagache, Email: Posmodev

Central
Main markers
Who are Questions, Coordination
POSMODEV of the postural
we definitions Disorder
development
(C.C.D.).
motor
More about Fitting for
Cerebral education : Documentation
reflex C.P.
Palsy (C.P.) myth or and training
locomotion children
reality..?