2 Theoretical Part – VM2G

Habituation Processes and CNS Plasticity

Neurons in the CNS dispose of many habituation mechanisms when processing information. Adaptation processes lead to improvement through certain changes in the presynaptic and postsynaptic region, i.e. an increase in synaptic efficiency. They usually fall under the term “primary activation”. It’s a type of memory at an unconscious level, which influences and orientates an individual. It is the phenomena of repeated stimulation of certain neural pathways that increases the degree of stimulation effect of the same strength or that enables the stimulation of the neural pathways by an even weaker stimulus.

This term describes mechanisms, by which the synapses reach an efficient transmission relation through more frequent activation. This condition may last for minutes, hours or even several days depending on the specific adaptation processes of enhancing reactions that have produced it. All neurons in the CNS are connected to a network by synapses.

Other possibilities of adaptation involve, for example, building new synaptic bridges or reactivation of inactive synapses. Findings from in-vitro experiments on rat neurons provide evidence that support of neuronal synaptic activity is important for the generation of new connections between neurons.

We can assume that the condition of the synapses, their strength, density and activity significantly depend on the kind and number of afferent stimulation patterns. If adequate stimuli didn’t arrive, the synaptic connections would decrease and the relevant circuits would perish.

To reach necessary CNS activity and to utilise developmental space (CNS plasticity), repeated neuronal network activation is necessary, as it subsequently complies with the adaptation process in a best possible (intrinsic) way. During the repetition of stimuli, the stimulation information heading to the CNS isn’t identical in its processing, only similar. Creation of optimal movement in response to a stimulus must always be processed into the same movement patterns depending on the innate and activated program.

Integration of various sensory impressions shows another dimension of the complex CNS networking. There are specific stimuli necessary for individual sensory organs. Vision requires light stimuli, and hearing requires acoustic ones; smell needs fragrances, and touch depends on the application of pressure. Specific stimuli are received by receptors of the relevant sensory organ. They are then transmitted to the CNS. Yet, the corresponding cell bundles associated with the CNS regions don’t function alone. Cell bundles of adjacent regions also contribute to organising and processing sensory perception, e.g., light stimulation and the interconnected ocular movement control or, as the case may be, the posture of the whole body. Thus, the networking relates to motor areas and their cell bundles because the ocular fixation is possible only through a coordinated contribution of ocular muscles through the corresponding posture of the head and body.

These complex processes could also be observed during therapy: to stay with the example of the eyes, activation of motor patterns of the torso and the head not only changes the ability of proper coordination of oculomotor muscles, (incorrect coordination leads to different types of strabismus), but also changes the ability of the eyes to focus. Again, that happens due to the influence of the normalisation of the muscle coordination of ciliary muscles of the lens.

The ingenious thing Dr. V. Vojta discovered is that there is something like an innate “backup repair program” in the brain, with which we come equipped at birth. This given property can generally be grouped with the other so-called auto-restoration mechanisms of the body such as the ability of a broken bone to heal or the repair of damaged skin. Since the normal and successful course of the healing process of the bone fracture needs to meet the conditions proven by the practice, i.e. the fusing of the bone fragments, rest and not carrying any load, meeting certain conditions is also necessary for “the start” and successful course of the treatment of the musculoskeletal apparatus with this backup program. Clinical practice has shown that the body should be brought into a previously specified position to initiate the repair program and subsequently, some of the several “trigger reflex zones” of the body should be stimulated.

In this way, reflex, i.e. involuntary, locomotion is induced. We can distinguish two types of these movements: reflex crawling and reflex turning that are subsequently differentiated into several modifications. Implementation of the technique of the crawling on all fours is still at its beginning. This is an isometric movement, as if we “froze” some real movement in its certain phase. This leads to higher efficiency thanks to the temporal and spatial summation of the stimuli that return to the brain.

Stimulation of the neuronal structures of the CNS could also be reached from given initial positions by the stimulation of so-called trigger zones. There are several trigger zones and trigger points on the body as they particularly affect the tensile receptors of the muscles and tendons, pressure receptors of the skin and periosteum and the receptor of the internal organs (interoreceptors). There are some other receptors that take part in triggering the repair program, i.e. equilibrium receptors (labyrinths) and the righting and balancing reflexes.

CNS Plasticity and its Relation to Developmental Habituation to “Hardware” Changes of the Musculoskeletal Apparatus

It seems likely that gradual somatic involutional changes are the interplay of the decrease in performance of both the “hardware” of the musculoskeletal apparatus and the “software” processes in the CNS. The level of gradual degradation is directly proportional to necessary adaptation of both parts, i.e. hardware to software and software to hardware, respectively.

Changes in the autonomic regulation of the posture of the body and in the stereotypical movements aren’t just a result of changes that involve the musculoskeletal apparatus, but the changes of other tissues and organ systems participate in them as well. There are changes in the flexibility of the bone tissue, decrease in the tone of the smooth muscles of the digestive apparatus, restrictions in the ability to ventilate the apices of the pulmonary lobes, general decrease in vital lung capacity and other changes. Thus, it isn’t possible to “push” the whole aging body to changes through exercise in an analytical way (strengthening and stretching) because these voluntary interventions don’t take all the aforementioned aspects into account. For example, if the head is forced from an excessively forward position back to its natural position by the voluntary physical exercise, swallowing and vocalisation would feel unpleasant. This is because the autonomously controlled structures aren’t subject to our conscious effort. Thus, it isn’t quite possible to change their posture and the tone.

On the other hand, the CNS plasticity can provide the adaptation to newly established posture of the locomotive apparatus, both in the musculoskeletal and the internal organ systems, particularly within their tone and functionality. This would only be possible if it happened due to reflex locomotion, unconsciously and according to a genetically given program.

Figuratively speaking, the aforementioned possibilities of stimulation and positions constitute a system of keys and locks for movement programs.

The quality and intensity of the renewed programs of motion is directly proportional to reliability, availability and stability of the newly formed circuit connections and the density of the neuronal network in the CNS. Thus, it is necessary to repeat the daily dose of therapy. Thanks to repeated stimulation, the autonomic regulation of the posture of the body and the righting and balancing reflexes normalise. This subsequently enables the involvement of spontaneous motor skills and their stabilisation.

Significant influence of the therapeutic stimulation is also represented by the normalisation of perception of the body’s arrangement. In children that can’t experience normal development of the musculoskeletal apparatus because of a central motor disorder, the sensorimotor perception of the body is significantly distorted and supressed. The perception of the body’s arrangement is also disturbed to a certain level in adult patients with a different aetiology of locomotive impairment. It is shown, e.g., in disorders of the autonomic regulation of the posture of the body or in impaired stereotypical gait. Reflex locomotion also allows the normalisa­tion of the ability of differentiated perception of the body. This perception lays the foundation for learning new functions in both children and adults. It particularly enables the triggering of complex application programs of gross and fine motor skills. Remarkable benefit is also provided by the increasing confidence in the body’s ability and “reliability”, which grow during the therapy.

When assessing the extent of damage to the CNS, it is crucial to use the plasticity and the ability of the growth of the neuronal network. The extent of the anatomical damage and the actual functional loss don’t have to bear a future negative prognosis. We know that in extensive anatomical damage, only mild functional loss may appear. On the other hand, minute anatomical flaws are often connected with far-ranging functional failure. Anatomical impairment doesn’t necessarily provide reliable information about the developmental possibilities of the CNS.

A part of VM2G therapy includes the CNS, which is provided with multiple targeted long-term stimulations. The stimuli could be modified and multiplied in countless ways by variations of the initial positions, combinations of the trigger zones and changes in the trigger pressure. During every further use of reflex locomotion, even if only by a change in the position of the body, the CNS must adjust to new requirements. Therefore, its activity is significantly increased.

The above-mentioned use of the plasticity in reflex locomotion seems to be particularly meaningful and potentially useful when the locomotive apparatus is in a repair phase, e.g., after intervertebral disc herniation. CNS tries to organise and compensate the impaired tissues through its new structuring.

To maximally restrain the incorrect regulation of motor skills and to prevent its future deviation, this phase of new structuring is particularly important in children. “False” substitute movement patterns haven’t been established yet.

Thanks to the therapeutic influence of VM2G, the CNS will be offered the use of the physiological movement patterns. These are going to become a part of the basic operational program of motor skills, resembling the “patch” to repair computer software.

Particularly, there are significant possibilities of early therapeutic interventions in central coordination disorders of peripheral palsies, predominantly in the early months after birth.

For example, early initiation of the therapy is extremely important in a child suffering from birth trauma with brachial plexus palsy. Because of this brachial plexus palsy, the affected arm stays constrained for a longer period or it becomes completely incapable of spontaneous movement. If the therapy didn’t start within 10 days, limited movement possibilities would set in. The child couldn’t sense its arm at all or only partially. Thus, it doesn’t turn around in this direction. The consequences could involve not only the incorrect sensorimotor perception, but also asymmetry of the body and possible subsequent damage.

Similarly, a defect of the inactive optic nerve occurs as it re-myelinates to a limited extent. This also applies to peripheral nerve disorders.

Every cell of the embryo, child or the adult patient has the complete genetic program, i.e. the theoretical choice to become any of the approximately 200 types of cells of the human body and belong to any of the five basic types of tissues. Centralised regulation of the morphogenetical processes in the developing and growing body doesn’t exist from the beginning. It is restricted to smaller autonomous regions and it gradually centralises.

The experiment demonstrated that the presence of a microenvironment – niche is necessary for the implementation of the multipotency of the stem cells of the differentiated tissues. The use of the stem cells in the differentiated tissues would be very limited, unless this precondition was fulfilled. A niche can be represented by a miniature space that contains one cell, or it can be a much more voluminous space. A niche is created by adjacent cells, nerves running around the stem cells, capillary walls, molecules of various substances in the intercellular fluid (hormones, ions, growth factors, etc.). A niche is always slightly different from the surrounding tissue. In every tissue, there are a greater number of spaces with a suitable environment for survival of the stem cells, but after larger trauma, e.g. combustion, the niche could be damaged and the possibilities of further tissue repair would be reduced.

Function of the niche is represented by the regulation of the actions of the stem cells, creation of the environment for their survival and securing their fitness for further differentiation.

The microenvironment of the niche can also reprogram the stem cells. It means, for example, the neural cell programmed for a differential neural pathway can be switched to the pathway of a muscle cell by the change of the niche and participate in myogenesis. As the tissue microenvironment changes, the behaviour of the stem cells changes, too. Stem cells can age, but they can also exhibit various features of their actual state. So-called resting dormant stem cells do not age and, under certain conditions, they are activated and become mature tissue cells. Conversely, activated cells can transform to resting cells with minimal substance exchange.

A specific characteristic of the stem cells consists in their huge immunity against damage to genetic information. The stem cells are provided with this feature by proteins responsible for DNA “repair”, the proteins of detoxication system, antioxidant proteins, etc. According to current knowledge, stem cell of the adult tissues can be attributed several characteristics that can be partially used in the therapeutic practice:

Stem cells possess the ability to essentially change their former direction of development depending on the environment they have been placed in. For example, neural stem cells change into blood elements within the blood environment.

Rather smaller numbers of cell populations can originate from the stem cells in adult tissues, particularly in their original tissue environment. It seems that “pluripotency” of adult stem cells is reduced compared to embryonal stem cells. Embryonal cells are closer to the totipotency of the zygote.

Stem cells in the differentiated tissues haven’t been differentiated themselves, but they are far too differentiated to follow the development of a certain cellular line of pre-existing differentiated cell. They are called: progenitor cell or – blasts (fibroblasts, chondroblasts, osteoblasts, etc.). Their critical mitosis is asymmetrical, i.e. it creates two non-identical elements: another filial precursor cell and tissue cell that contributes to the cell cycle of the repaired tissue.

Regeneration – the renewal, healing of the damaged and lost tissues or even the recovery of the parts of the organs is also partially possible in humans, but the regenerative capacity of the tissues and organs quickly decrease in the postnatal period. It is not known whether different or essentially modified processes are employed during the regeneration of the adult body than the fundamental morphogenetic processes: cellular proliferation, distribution, interaction and cellular reduction. No tissue specific “regeneration morfogene” or specifically acting gene cluster have been identified yet. Irregular decrease in regeneration capacity of the tissues in the postnatal ontogenesis haven’t been sufficiently explained yet.

I think that the clinical results achieved by the implementation of the VM2G therapy in patients in different age categories and various diagnoses may point out the fact of the function of reflex stimulation as a global program of regeneration and repair of many tissues and organ systems. The explanations of this regeneration ability must be further studied because the essence of this regeneration ability could be just the ability of the body to utilise the stem cells for repair.

Based on the many years of clinical practice I think that as the genetically predetermined developmental program responsible for the development of a child from birth to adulthood.

The results of experimental morphology and growth studies of transplanted organs indicate that, except for the tissue hormones and IGF type of growth factors, there are several other occasionally detected factors and many locally released polypeptides that haven’t been successfully isolated and their specificity and effectivity haven’t been defined.

Individual, more or less definable growth patterns represent just a schematising of the growth process. If we accepted the existing classification, we would do it with the acknowledgment of the fact that the growth in its “clean form” is implemented particularly in the early phases of the ontogenetic development.

The developing limbs could serve as an example of the gradual integration of the growth patterns. Mesenchymal cell population of the limb bud grows zonally and the covering ectoderm grows interstitially. Multiplicative growth combined with zonal growth activity is typical for the formation of the organ foundations, e.g., bones and the resulting shape and the position of the whole limb.

In the end of the prenatal period, all growth patterns “weld” together – integrate. Growth integration is not typologically proportional and could differ even within a single tissue system.

There are no greater differences among the growth activities of different types of tissues in this period. For example, the majority of neurons terminate their multiplicative growth in the early postnatal period, but a neuron in hippocampi can multiply through to adulthood. Type I pneumocytes divide during the whole childhood, and the stem cells of the bone marrow keep their lifelong division potential. Multiplicative growth is regulated by two types of substances:

Extrinsic factors produced by remote tissues, e.g., hormones, and the intrinsic, local factors with paracrine effect, e.g., the substances produced by vascular endothelium act locally, insulin-like growth factors (IGF-1) too, etc.

The spatial and temporal consequences and the harmonisation of the extrinsic and intrinsic factors regulating the multiplicative growth, haven’t been sufficiently understood yet.1

Case Study – Ema and Ela

Illustration of the Therapy of the Prematurely Born Twins

Ema and Ela were born via caesarean section in the eighth month of pregnancy. It was obvious very early on that their development didn’t conform to medical norms. The paediatrician recommended neurological examination and physiotherapy. Both children began their rehabilitative exercises during the third month after birth, so therapy started in time. Ela’s condition improved quite early, and she started to stand up in the tenth month. Despite the early onset of therapy and the intensive home exercise, Ema’s condition got worse. At ten months of age, she was only able to crawl with the help of one hand. Repeated neurological examination showed increasing risk of development into unilateral cerebral palsy. Comparing the development of both girls, it was obvious that Ema’s development went in the wrong direction.

Clinical Description of Problems

Her progressive development and previous medical history showed that Ema suffered from a severe form of central coordination disorder. Ela’s initial unfavourable condition began to improve quite quickly, but the comparison of the development of both twins only confirmed the disorder. Neurological reports spoke of an unfavourable condition, particularly in Ema’s case. The ongoing examinations performed at our office clearly showed that there was a severe central coordination disorder. There was a gradual unilateral progressive increase in muscle tone. Opisthotonus didn’t retreat, and primitive reflexes persisted unilaterally. Spontaneous locomotion was impaired when both prostrate and supine. Primitive reflexes could be triggered quite vividly, particularly the reflex of Moro. Responses to positional tests were abnormal.

Expert Explanation of the Problem

Prematurely born children face a number of medical dangers, predominantly the impairment to the future psychomotor development. The persistence of primitive reflexes is especially a very severe warning sign about the impairment of motor development because these primitive reflexes constrain the healthy physiologic development of motor skills. Impaired regulation of the spontaneous motor skills makes it impossible for the child to assume a stable resting position while lying on its back or stomach. The immaturity of the postural motor autonomic regulation is a common source of psychological unrest of the child. Its brain is “under the command” of primitive reflexes. Quite early on, the brain starts to use substitute movement programs for its development that lead to substitute pathological movement combinations. This unhealthy coordination results in pathological stereotypical movements. Impairment of the basic stereotypical movements of gait, grasp, breathing and even the orofacial region occurs. Both gross and fine motor skill regulation with all subsequent impacts on musculoskeletal apparatus are disturbed. Early and repeated diagnosis of the condition of the basic motor skill programs based on the developmental kinesiology can show not only the actual status of the child, but even propose the exact outcomes. This type of primary diagnostics becomes a continuous method of examination that can precisely monitor the development of psychomotor functions and confirm the correctness of the chosen therapeutic strategy. The therapist that treats the infant patients must by necessity be an excel­lent diagnostician. The therapy within VM2G is targeted at the normalising of the development of locomotion in accordance with the rules of developmental kinesiology. In the end, the goal is to “switch off the substitute program of locomotion” that impairs the regulation of the muscle coordination and tone. This should allow the physiological program of motor skills to be “loaded”. Thus, the normal development of locomotive apparatus should be restarted.

Video – Ema and Ela Cihlářová (shorter version)

Cihlářová Ela – Poloha na břiše

Cihlářová Ela – Trakční test

Cihlářová Ela – Poloha na zádech

Cihlářová Ela – Landau

Cihlářová Ela – Axilární vis

Cihlářová Ela – Vojtova boční metoda

Cihlářová Ela – Colis horizontál

Cihlářová Ela – Colis vertikál

Illustration of the Solution

In the first months, the therapy was carried out on both twins in an identical manner. In the eighth month, it was obvious that Ela’s condition practically normalising, but conversely, Ema’s condition began to significantly worsen. The schedule of the exercises changed and Ela exercised only once a day. Ema’s exercises intensified to five times a day. The exercise had to be performed by both parents together, while the girl had grown bigger and her mother couldn’t handle the exercise on her own. Hence, the father modified his working hours so he could come home and exercise with the children during his work breaks. This extremely challenging therapeutic regimen took almost three months. Only then were there some gradual improvements in Ema’s condition and we could decrease the intensity and the number of exercises. After the patient’s 15th month of life, her motor development normalised completely. Overall, the therapy took thirteen months.

Video – Ema and Ela Cihlářová (shorter version)

Cihlářová Ema – Poloha na břiše

Cihlářová Ema – Trakční test

Cihlářová Ema – Poloha na zádech

Cihlářová Ema – Landau

Cihlářová Ema – Axilární vis

Cihlářová Ema – Vojtova boční metoda

Cihlářová Ema – Colis horizontál

Cihlářová Ema – Colis vertikál

Explanation of the Solution

The initial condition of both children, which hadn’t seemed to be severe, changed to very severe condition in Ema’s case. This pathological progression was confirmed by repeated neurological check-ups. Thanks to the extraordinary effort of both parents in their therapeutic endeavour, Ema managed to avoid risk to the motor development and gained complete, normal function of the locomotive apparatus in all its components. The therapy was extremely difficult for the parents and child, primarily during the phase requiring the involvement of both parents in the exercise. The therapy required a strong will, discipline and a great amount of self-denial. The performance of VM2G initiated the repair processes in the CNS. In this case, the stimulation activity targeted the processes in the CNS – the neurogenesis and the prevention of apoptosis of immature neurons. By utilising the genetically given motor skill programs, it is possible to provide the stimulation with maximum efficiency and with no risk of overload. This is extremely important in children with severe central coordination disorder.

The View of the Prognosis, Diagnostics and Therapy in Children at Risk of Development of Severe Motor Developmental Disorder

It is necessary to initiate very intensive VM2G therapy in infant patients, who show severe symptoms of neurological impairment. Most often, the temporal and spatial summation of the therapeutic stimulation is combined. For this therapeutic strategy, it is essential to have a cooperative home therapist, who would offer practically all his time to the treatment goal. In the above-mentioned case, it was necessary for both parents to participate in exercises for some time. Intensive and long-term brain stimulation is probably the only possible solution that restarts the neurogenesis, ceases the process of apoptosis and neural network damage. Intensive stimulation with VM2G permanently inundates the brain with activity because, after every stimulation with exercise, the reflex activity in the cerebral centres continues for two more hours (Vojta, 1974)1. Our experience has shown that children who underwent the VM2G therapy happened to follow completely normal motor development up to normal bipedal gait regardless of the degree of the risk of CCD.

VOJTA, Václav. Mozkové hybné poruchy v kojeneckém věku. Praha: Grada, 1993. ISBN 8085424983