2.3. Procedures

The chronological infant age was confounded against the neuro-motor developmental age. The two methods were applied to all study participants, by a specialised kinesio-therapist certified in Vojta therapy, over a period of seven months in total, and motor recovery was noted. The therapy sessions were carried out in the presence of the carers; on occasion, they were informed about certain simple procedures that they could perform at home.

In order to establish the stage of motor deficiency, the infants were positioned in dorsal and ventral decubitus, and the spontaneous motility of the whole body as well as movement sequences was evaluated, thus being placed at a certain level of development (corresponding to the age of 0–2 years), a level that was then compared with the ideal motor development ontogeny (V. Vojta 2001).

The Vojta therapy programme was based on the following criteria:

The duration of the 30 min session was started by positioning the infant on the therapy table in 3 positions: dorsal decubitus (DD), ventral decubitus (DV), and lateral decubitus (DL). The activation time was 5 min for each position, with a 5 min break between positions.

The Bobath therapy was applied based on the following criteria:

For the 30 min session, the exercise program consisted of the following DD, DL, and DV positions; sitting; on all fours; kneeling; standing. Assistive devices used include the therapy table, mattress, Bobath ball, inflatable cylinder, balance disc, Sveltus, inflatable balance disc, trellis, and walking belt for recovery.

Vojta and Bobath group—the session lasted 40 min; it was carried out as follows: in the first 20 min, Bobath exercises were performed, followed by 15 min of Vojta stimulation with a 5 min break between the two therapies.

The therapy sessions were carried out in an outpatient office according to established appointment times, with a frequency of three times a week; during the rest of the days, the members were taught to perform light exercises and stimulating positions at home in order to complete the therapy carried out by the physical therapist. The therapy was administered over the course of seven months. Evaluations were performed once a month and compared against the motor development grid, with the patient being considered recovered when the chronological age corresponded to the motor development age.

Vojta therapy stimulates the brain to reflexively activate the two-movement complex-es in which all the components of locomotion are contained: “reflex crawling, reflex rolling”. At the body level, stimulation is carried out in 4 main areas on the extremities—the medial humeral epicondyle (EMH), lateral calcaneal tuberosity (TLC), radial styloid process (ASR), and medial femoral epicondyle (EMF)—and 5 secondary areas on the trunk—the medial edge of the scapula in the lower 1/3 (MMS), Acromion (A), VII-VIII intercostal space (SI), gluteal area (ZF), and anterosuperior iliac spine (SIA) [28].

The Vojta therapy improved gross motor function and dynamic locomotion and im-proved spatial-temporal parameters in children with spastic diplegia [2]. Early intervention by Vojta stimulation impacts the quality of neurological reflexes by modulating spontaneous motor abilities and postural responses [10,30,31,32]. Lim H. et al. demonstrated in a study carried out over a period of 2.8 years that Vojta therapy is more beneficial in hypertonic infants and can significantly improve posture and movement [33]. Vojta therapy can also be used as a treatment method for improving sitting position and diaphragmatic ascension during the breath in children with spastic cerebral palsy. This was demonstrated by Ha S.Y. et al. in 2018 [34].

Stage I: The patient is positioned in the DD position, the upper and lower limbs are extended, and the head is directed towards the therapist, with its turning being inhibited by the resistance given on the zygomatic bone, the nuchal line, and the mastoid tuberosity. Stimulation of the chest area for 10–15 s triggers kinesiological reactions (Figure 1).

Stage 1 reflex rolling performed in Vojta therapy.

It stimulates both the left and the right side of the child. These activations are repeat-ed 3 times for each part.

Stage II: The patient is positioned in the DL, with the upper limb below and the greater trochanter supporting the body. The stimulation areas are also the CIA, and the stimulation duration is 10–15 s. Kinesiological response is obtained as follows: in the lower upper limb: shoulder blade—adhesion to the ribcage, scapulohumeral—90° flexion with external rotation, elbow—slight flexion and pronation, fist—dorsal extension and radial inclination, metacarpals—abducted with finger extension; upper limb: scapula—attachment to the ribcage, scapulohumeral—flexion, abduction, and external rotation, elbow—slight flexion with supination, fist—dorsal extension with radial inclination, metacarpals—abduction and extension of the fingers; lower hip—external rotation, slight flexion with a tendency towards extension, knees—flexion with a tendency towards extension, talocrural joint—inversion with supination, metatarsals—abduction and flexion of the fingers; upper hip: 90° flexion with abduction and external rotation, kneeling—90° flexion, talocrural joint—in medial position, metatarsals—abducted with fingers in medial position. Stimulation is provided for both the left and the right side of the child, these activations are repeated 3 times for each side.

Stage III: The patient is positioned in the DD, and the area of stimulation is MMS and EMF of the upper part. Stimulations lasts for 10–15 s, and the kinesiological response as specified for Stage II. Stimulation is provided for both the left and the right side of the child; these activations are repeated 3 times for each side.

Stage IV: The patient is positioned in the DD, and the area of stimulation is the MMS and the lower lateral femoral epicondyle. Stimulations lasts for 10–15 s, and the kinesiological response is as specified for Stage II. Stimulation is provided for both the left and the right side of the child; these activations are repeated 3 times for each side.

This represents a complex of movements that contain all the essential components of displacement, representing the basic models of locomotion, thus ensuring postural coordination, a righting against gravity, as well as stepping movements of the upper and lower limbs.

The patient is positioned in the DV, the head rotated with the occipital part towards the therapist and the facial part towards the elbow pocket of the facial upper limb. The movement is carried out in a crossed pattern, where the right lower limb and the left upper limb move concomitantly and in the opposite direction; thus, the lower limb and the opposite upper limb support the body and move the trunk forward. By stimulating the areas, the activation of the entire body musculature is amplified, initializing the verticalization process. The upper limb on the occipital part is stretched loosely next to the trunk, and the lower facial limb is stretched loosely: the upper limb on the facial side—flexion 125°–130°, adduction, and external rotation; the elbow—flexion of 45° and pronation; the styloid apophysis—in the same line as the hip and facial shoulder, parallel to the vertebral column.

The first position applies to infants starting from the 8th month; it has no locomotion elements but is used for uprighting. We can use all the activation zones from the reflex crawl as well as the resistance points at the level of the head. The working position is at the edge of the therapy table; the patient is seated in a squatting position, the pelvis with the ischial tuberosity is resting on the heels, the feet are at the edge of the bed, out, knees are flexed at the level of the axilla with the calves parallel, the head is down and rotated to one side at 30°, the facial side is facing the facial arm, the facial arm is in trunk extension in the scapulo-humeral joint, extension 120°–135°, with support of the elbow (45°).

Reflex crawling performed in Vojta therapy: (a) stimulation in “two points”; (b,c) stimulation in “three points”.

The fundamental principles of Bobath therapy are the suppression or elimination of the activity of pathological reflexes that help to reduce and normalize muscle tone and achieve postural control through rehabilitation procedures that are subjected to a gradual increase in number, intensity, and duration, thus preventing further complications such as contractures and deformations [35,36].

The Bobath therapy was aimed at improving automatic postural reactions, lifting re-actions, balance, and adaptive changes in muscle tone. The exercises proposed and ap-plied followed the level and the functional deficit at the start of the kinetic treatment.

“Servant Knight” position.