Reflex Ambulation Therapy

Reflex Ambulation Therapy is an approach introduced by Sharon Weiselfish-Giammatteo in the final chapter of her 1998 book, *Integrative Manual Therapy for the Upper and Lower Extremities*. It provides a framework for restoring gait by stimulating the reflexes and control abilities needed for walking one at a time.

The book explains that although these 11 steps take considerable time, they are worth the effort for people whose treatment is challenging and complex. It presents them as a procedure to help people with cerebral palsy or spinal cord–related problems walk normally for the first time. This description comes from the author's clinical experience. The extent of change varies from person to person, so please read it as the perspective of this approach.

Walking involves more than moving the legs. The stance phase, when the foot contacts the ground and supports body weight, alternates with the swing phase, when the leg moves forward. Multiple layers of reflex responses in the lower back, pelvis, and feet work together during this process. This approach views an inability to walk as a sign that a link in this chain of reflexes has been disrupted or weakened. For an overview of the walking sequence, see Gait cycle.

The approach therefore involves identifying which links to awaken, then repeatedly delivering stimuli that elicit those reflexes in a set sequence.

Integrative Manual Therapy synchronizers are reflex points used in this approach. They are described as having been identified by Sharon Weiselfish-Giammatteo together with Frank Lowen (Frank Lowen). According to the book, responses are more readily elicited when the practitioner applies a technique with one hand while keeping the other hand in contact with one of these points.

The points used in Reflex Ambulation Therapy are spread across various parts of the body. Locations include the parietal bones on either side of the crown of the head, both transverse processes of the first lumbar vertebra, the area of the Sigmoid colon in the lower abdomen, the medial end of the scapular spine, and a bony prominence at the front of the pelvis. Each point elicits a different response. For example, some are described as helping control the upright position of the lower back, while others help with head control during walking.

There are 11 steps in total. Here is a broad outline of the sequence in the book.

1. Positive supporting reflex — Upward pressure is applied to the metatarsal heads at the front of the sole to awaken a reflex that puts the leg into a state in which it can “stand.” This is the response in which the front of the foot makes contact first when going down stairs and the leg supports body weight. For details, see Positive supporting reflex. 2. Lumbar control — Standing and walking require an upright spine. This step restores the coordination of the lower back muscles needed for that. 3. Reciprocal mobility — This step coordinates the interplay of movement among the pelvis, hip joints, sacrum, and last lumbar vertebra. For details, see Reciprocal mobility. 4. Lumbar propulsion — This is the momentum that moves the spine forward during walking. The lower back and abdominal muscles contribute together. 5. Occiput–atlas traction — This is a “head control” response that keeps the head aligned upright on the neck. 6. Occiput–sacrum traction — This response maintains the distance between the occiput and sacrum during standing or walking. 7. Protective responses of the legs — These responses help the hips, knees, and ankles withstand weight without collapsing, allowing a person to stand on one or both legs. 8. Talocrural joint glide — This is the forward gliding movement of the tibia at the ankle. 9. Subtalar joint pressure — Cushioning between the calcaneus and talus creates movement between the ground and foot, and between the heel and leg. 10. Flexors — This is the force extending from the toes to the muscles on the abdominal side of the lower back. 11. Extensors — This is the pressure extending from the toes to the gluteal muscles and spinal extensors.

The key is to progress gradually into more upright positions. The same stimulus begins in lying, then moves through sitting, kneeling, half-kneeling, and standing, and is finally also tried during walking. This approach describes the progression as following milestones of neurological development. Initially, the practitioner produces the movement; the person receiving treatment then begins to assist, before progressing to movement against resistance.

The number of repetitions or sessions varies with the person's condition. A single stimulus may be continued for about 10 minutes. The book states that one or two treatment sessions to awaken the positive supporting reflex are sufficient for people without major neurological problems. For those with marked neurological deficits, it describes adding three to five more sessions.

• People seeking to begin walking despite cerebral palsy or spinal cord–related problems, and their caregivers
• People who want to rebuild balance and coordination in their gait after nervous system injury
• People whose foot placement on one side is unstable when walking

• This is generally not a one-session method; it usually proceeds in stages over multiple sessions.
• This approach does not replace rehabilitation or hospital treatment. Let the practitioner know about your circumstances and discuss it alongside the treatment you are currently receiving.
• For the lumbar propulsion stage, the book also introduces an exercise involving exerting force for 10 seconds at a time, ten times a day, while keeping a hand on a synchronizer. Before beginning exercises to continue at home, it is a good idea to ask the practitioner which movements suit your body.
• Positions change at each stage, including lying, sitting, and standing, so it is helpful to bring comfortable clothing and shoes or socks that will not slip on the floor.