Physiotherapy Theory and Practice

An International Journal of Physiotherapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

Physical therapy with newborns and infants:

applying concepts of phenomenology and
synactive theory to guide interventions

Yvette Blanchard PT, ScD, PCS & Gunn Kristin berg PT, PhD, PCS

To cite this article: Yvette Blanchard PT, ScD, PCS & Gunn Kristin berg PT, PhD, PCS
(2015) Physical therapy with newborns and infants: applying concepts of phenomenology and
synactive theory to guide interventions, Physiotherapy Theory and Practice, 31:6, 377-381, DOI:
10.3109/09593985.2015.1010243

To link to this article: http://dx.doi.org/10.3109/09593985.2015.1010243

Published online: 11 Feb 2015.

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ISSN: 0959-3985 (print), 1532-5040 (electronic)

Physiother Theory Pract, 2015; 31(6): 377381

! 2015 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2015.1010243

PROFESSIONAL THEORETICAL ARTICLE

Physical therapy with newborns and infants: applying concepts of

phenomenology and synactive theory to guide interventions
Yvette Blanchard, PT, ScD, PCS1 and Gunn Kristin berg, PT, PhD, PCS2,3
1
Department of Physical Therapy and Human Movement Science, College of Health Professions, Sacred Heart University, Fairfield, CT, USA,
2
Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Troms, Norway, and 3University
Hospital North Norway HF, Troms, Norway

Abstract Keywords
Physical therapy involving newborns and young infants is a specialized area of practice Intersubjectivity, neonatal physical therapy,
reserved for therapists who have advanced training and the competence to help newborns, phenomenology
young infants and their families meet their goals. Beginning at birth, infants apply a significant
amount of effort to actively participate in and shape their world. Infants make their intentions History
and requests for support known through their behaviors during social and physical therapy
encounters. The therapeutic encounter viewed from the infants perspective has received Received 22 June 2014
limited attention in the physical therapy literature. The purpose of this article is to discuss Revised 10 October 2014
concepts related to phenomenology and synactive theory that are relevant to physical therapy Accepted 11 December 2014
with newborns and young infants during the first few months of life after birth. Published online 11 February 2015

Introduction 1962) is relevant to physical therapy. Although all experiences are

embodied, mutually meaningful embodied experiences should be
Physical therapy involving newborns and fragile infants is a
the most beneficial experiences. The research by berg (2009)
specialized area of practice reserved for therapists who have
identifies matches and mismatches between the intentions of the
advanced training and the competence necessary to help infants
infant and the therapist throughout the course of a therapy session.
and their families meet their goals (Sweeney, Heriza, and
The matches reflect synchrony in action, whereas the mismatches
Blanchard, 2009; Sweeney, Heriza, Blanchard, and Dusing,
reflect a disconnect between what the infant intends to do and the
2010). The recently published clinical practice guidelines for
therapists subsequent actions or vice versa. Both matches and
neonatal physical therapy recommend that therapists participate in
mismatches lead to embodied experiences, but their outcomes are
precepted clinical training to refine their ability to examine and
quite different in terms of meaningfulness from each participants
intervene with infants with structural, physiological and behav-
perspective.
ioral vulnerabilities that predispose them to instability during
Currently, the best-developed and best-applied model for
routine procedures (Sweeney, Heriza, and Blanchard, 2009;
guiding handling practices with infants is the one developed by
Sweeney, Heriza, Blanchard, and Dusing, 2010). These advanced
Als (1982, 1986) and Als et al. (1994). This developmental care
clinical competencies; detailed knowledge of the musculoskeletal,
model discusses the importance of incorporating the infants self-
neuromuscular, cardiovascular, pulmonary and integumentary
regulation efforts into all caregiving exchanges between infants
systems; and sensitive handling skills form the basis for effective
and caregivers in the newborn intensive care unit (NICU).
physical therapy interventions with this population. berg,
Research regarding this approach has yielded dramatic results in
Blanchard, and Obstfelder (2013) recently described therapeutic
terms of lengths of hospital stay, incidences of brain hemorrhages
encounters between preterm infants and physical therapists (PTs)
and improvements in long-term medical and developmental
from a phenomenological perspective, using the concepts of
outcomes (Als, 1986; Als et al, 1994, 2004; McAnulty et al,
embodiment and enactive intersubjectivity to describe the
2012, 2013). Als synactive theory of development describes in
encounter from the infants perspective. Phenomenology is a
detail how an infants behaviors in four systems of functioning:
theory related to the field of philosophy that studies structures of
(1) autonomic, (2) motor, (3) state and (4) attention/interaction
consciousness from a first-person point of view and highlights
provide the means through which the caregiver can determine the
that all experiences are experiences of something (i.e. all
infants intentions and efforts to self-regulate and encourage them
experiences have intentionality or meaning; Gallagher, 2012).
via supportive maneuvers and handling. The synactive theory
The phenomenological notion that the world is experienced
provides the clinical framework through which the theoretical
through the body (because it is through the body that we have
concepts of phenomenology of the body can be applied to
contact with other people, objects and life itself) (Merleau-Ponty,
physical therapy practices involving infants. Limited attention has
been given to the therapeutic encounter from the infants
Address correspondence to Yvette Blanchard, PT, ScD, PCS, Department
perspective and the application of synactive theory in physical
of Physical Therapy and Human Movement Science, College of Health therapy involving infants. We propose that when the theoretical
Professions, Sacred Heart University, 5151 Park Avenue, Fairfield, concepts of phenomenology of the body and the behaviorally
CT 06825, USA. E-mail: blanchardy@sacredheart.edu based interventional approach of synactive theory closely
378 Y. Blanchard & G. K. berg
intertwine and support each other, they provide a framework that
promotes meaningful experiences for both PTs and the high-risk
infants they work with.
Phenomenology of the body
Phenomenology of the body focuses on the ways in which the
body experiences itself, the world and itself in the world; that is,
the perceiving body (Merleau-Ponty, 1962). Within the phenom-
enological framework, the perceiving body is both the lived body,
or the body-as-subject, and the biological and biomechanical
body, or the body-as-object (Gallagher, 2005, 2012; Merleau-
Ponty, 1962). We simultaneously have a body and are a body,
meaning that we are embodied and act in the world as an
embodied agent (Gallagher, 2005, 2012). The infant sees his hand
move but also feels the movement of his hand. Phenomenology of
the body also suggests that intentionality is an intrinsic aspect of
live bodily movements that contributes to the development of a
body schema and a body image (Gallagher, 2005). Body image is
the system of perceptions, attitudes and beliefs pertaining to ones
body, whereas body schemas consist of central and peripheral
sensorymotor processes that register the position of ones body
parts in space. According to Gallagher (2005), body schemas
regulate posture and movement during intentional actions that are
visible to others in the context where they are formed as in the
context of infant behavioral communications with caregivers.
Intentional actions in the context of an interaction between at least
two individuals create intersubjectivity and mutual understanding
during moment-to-moment interactions (Fuchs and De Jeagher,
2009; Trevathen and Aitken, 2001). These intentional actions
create embodied experiences for each individual, as is the case
during a physical therapy session between an infant and a PT. The
phenomenology of the body considers the intersubjective aspects
of an interaction (Gallagher, 2012; Merleau-Ponty, 1962) and
highlights the importance of the active role the infant plays in the
interaction because it influences his or her development
(Gallagher, 2005).
Principles of synactive theory and neonatal physical
therapy
Newborn infants are predisposed to interact with the world and
actively shape their interactions with caregivers (Nagy, 2008).
The newborns world is full of new experiences, sights, sounds,
tastes, touches, smells and movements that the newborn appar-
ently learns to manage quickly. Newborns appear to experience
the world in a meaningful way; they quickly learn how to regulate
their behaviors while they express their intentions and their
requests for support (Als, 1982). They successfully achieve these
behavioral goals through the support of self-regulation and the
successful integration of the behaviors of the autonomic system,
motor system, and state and attentional/interactional systems (Als,
1982; Als, Butler, Kosta, and McAnulty, 2005; Als, Lester,
Tronick, and Brazelton, 1982). According to Als (1982), these
systems are interdependent, and the behaviors that express them
are meaningful, communicative and representative of the infants
efforts, successes, and failures to self-regulate at any given
moment. An infants behaviors therefore indicate his or her level
of self-regulation at any given time and the contributions of each
behavioral system to this regulatory process. Self-regulation is
always determined within the context of an environmental event,
such as a physical therapy intervention, that occur at the time of
the observation; environmental events place demands on the
infant and challenge his or her ability to maintain a state of good
behavioral organization.
Als (1982) has categorized behaviors within each of the four
behavioral dimensions as either approach/regulatory behaviors or
Physiother Theory Pract, 2015; 31(6): 377381
as avoidance/stress behaviors. Regulatory behaviors indicate a
state of well-being and are observed when infants self-regulatory
abilities support the social and environmental demands placed on
them; stress behaviors indicate a state of fatigue, exhaustion or
disorganization and are observed when infants thresholds for
self-regulation are exceeded by the demands placed on them.
A bimodal approach to understand neurobehavioral functioning
may, however, only partially account for the behaviors that
manifest as the infant transitions from a state of self-regulation to
one of a loss of self-regulation.
Regulatory and approach behaviors represent a good state
of self-regulation and communicate readiness, organization and
stable neurobehavioral functioning with little evidence of stress.
These behaviors indicate that it is appropriate to continue
interacting with the infant with few or no adjustments. An
infant with good regulatory behaviors demonstrates an adaptive
level of self-regulation that is appropriate to the demands
presented during the session. Avoidance or stress behaviors
require the observer to pay close attention to the moment when
the infants sensory thresholds are reached, as indicated by early
signs of disengagement, and offer support to the infant to
minimize or prevent the complete loss of self-regulation. Early
signs of disengagement indicate that a sensory threshold has been
reached and suggest that the therapist should pause, adjust his or
her approach and observe the infants behavior to determine
whether the infant will recover before continuing with the
intervention. The infant who displays early signs of disengage-
ment needs a break from the intensity of the interaction and
exhibits a desire to modulate either the intensity or the duration of
the interaction. Once a sensory threshold has been surpassed, the
infant demonstrates behaviors that indicate a state of stress,
exhaustion and loss of self-regulation because the infants earlier
attempts to self-regulate were either unsuccessful or were
unsupported by the therapist. These behaviors signal the need to
stop or change the demands placed upon the infant and to take a
prolonged break and offer the infant individualized support.
In neurobehavioral observations, the early signs of disengage-
ment may be challenging to recognize because they are subtle and
ephemeral and signal a transitional state. The two extremes of
self-regulation, the regulatory behaviors or those that indicate a
loss of self-regulation, are easier for observers of infant behavior
to identify. The early signs of disengagement tell an important
part of the infants self-regulatory story and are characterized by a
range of warning signals that the infant displays to elicit support
from a caregiver when his or her sensory thresholds have
been reached. Although all behaviors signal the infants inten-
tions, the examiners ability to notice early signs of disengage-
ment and offer well-timed facilitation will best support the
infants attempts to maintain self-regulation and avoid prolonged
periods of stress.
Blanchard (2009) and Blanchard and Mouradian (2000) have
described the importance of behavioral observation in clinical
practice with young infants by relating it to the role therapists play
in developmental assessments and their ability to determine the
infants developmental status and identify individualized inter-
vention strategies. The infants successes at self-regulation, as
indicated via regulatory behaviors, are indicative of the infants
current level of developmental maturity and robustness and what
he or she is capable of. Supporting the infants regulatory abilities
offers the best point of entry into a therapeutic alliance with the
child. Recognizing the early signs of disengagement helps PTs
identify the environmental conditions under which an infants
self-regulation becomes compromised; furthermore, it allows
therapists to individualize their interactions with the infant and
identify the infants developmental goals. The loss of self-
regulation and the manifestations of disorganization represent the
DOI: 10.3109/09593985.2015.1010243
infants developmental vulnerabilities, or what the infant has
difficulty doing under specific conditions.
The use of behavioral observation during physical therapy
requires the examiner to develop awareness of the infants
regulatory capacities and an intuitive ability to help the infant
maintain a state of self-regulation (Als, Lester, Tronick, and
Brazelton, 1982; Brazelton and Nugent, 1995). To be effective, the
examiner must precisely time the amount of facilitation or handling
and gradually align it with the infants behavioral responses and
intentions. As we will discuss later, the creation of shared
experiences is the essence of embodied therapy. The competent
integration of neurobehavioral observation into an intervention
implies an intimate connection between the infants body and the
examiners body and the clinicians awareness of his or her own
contributions to the infants self-regulatory processes. The clin-
ician must become conscious of how his or her actions influence
the infants ability to show pleasure in achieving his or her goals.
The therapeutic encounter from phenomenological and
neurobehavioral perspectives
The newborns life is composed of bodily processes, with mind
and body in a dyadic interplay (embodiment). The infants
experiences in the world shape his or her development. The
neuronal structures responsible for motor actions, self-conscious-
ness, interaction and the perception of ones surroundings develop
as the infant moves (Gallagher, 2005). The study of how the body
shapes the mind highlights the ambiguity of both having a body
and being a body (Gallagher, 2012). On one hand, the body may
be viewed as biological (the body-as-object), as when the PT
observes an infant and notes asymmetry, body alignment and
muscle tone and assesses the infants neuromuscular, musculo-
skeletal and cardiopulmonary status. Similarly, as the PT observes
asymmetry in the infants body alignment, the infant experiences
his or her body (the body-as-subject). Knowledge of the body-as-
object, the biological body, forms the basis of a PTs entry-level
education, whereas an understanding of the body-as-subject may
arise from advanced training in neurobehavioral functioning and
contribute to developing an understanding of concepts related to
phenomenology of the body.
The PTs identification and categorization of an infants
neurobehavioral manifestations as solely regulatory or stress
behaviors is an example of seeing the infants body-as-object; the
infants body is viewed as body-as-subject when the therapist
recognizes the infants intentional efforts to self-regulate in a
situation. The therapist must recognize his or her own contribu-
tions to the infants state of behavioral organization and coord-
inate his or her handling with the infants expression of him- or
herself at that moment. The infant is embodied, the therapist is
embodied, and both of them act as embodied agents creating
meaning in that situation (Rochat, 2001; Trevarthen and Aitken,
2001). This clinical process will be described further in a clinical
vignette.
Eric was born at 28 weeks gestation and weighed 800 g. He
was intubated soon after birth and received supplemental oxygen
for 2 weeks. During his first week after birth, he sustained a left
grade III intraventricular hemorrhage. His most recent cranial
ultrasound demonstrated two small cysts in the left periventricular
area. He is now 7 weeks old (35-week post-conceptional age) and
is in the step-down nursery. He is progressing on oral feeding and
is on an apnea monitor at night.
The physical therapist is seeing Eric to update his develop-
mental status prior to discharge. This vignette describes the
physical therapists observations of Erics movements during
visual tracking with Eric in the supine position. Eric is uncovered
and is lying in his bassinette:
Physical therapy with newborns and infants 379
Eric is alert and becomes more active; he lies with his head
turned to his right, his neck extended back, his trunk in left lateral
flexion, his right leg extended and his left leg flexed. Both legs
are active and move in and out of position; his arms move in large
arcs away from his body, and his fingers make grasping
movements. His breathing is irregular, and his skin color is
pink, with some mild paleness around the mouth. Eric attempts to
bring his arms and legs close to his body and maintains this
posture for close to 2 s. The therapist notes his posture, the quality
of his movements and his physiological reactions (respiratory rate,
skin color and visceral function) and positions his head at midline.
She then proceeds to elicit his rooting and sucking reflexes,
palmar and plantar grasps and asymmetrical tonic neck reflex.
She repositions his head at midline and places a red ball 10 in
away from his face to examine his visual tracking. Eric fusses
during the examination of his reflexes and becomes increasingly
active, with jerky movements of his arms and legs, and looks at
the red ball. His breathing remains irregular, and there is paleness
around his mouth. Taking her cue from his attention to the red
ball, the therapist proceeds to move the ball slightly to his right
and places her hand on his stomach. Eric responds to the touch of
the therapists hand on his stomach by briefly grasping the
therapists hand with the fingers of his right hand. His legs are
now extended in midair. He turns his head slightly to his left; the
therapist removes her hand from his stomach and places his head
back at midline while she holds the ball with her other hand.
Because Eric has become increasingly active and begins to cry,
the therapist puts the ball down and holds his arms and legs close
to his body with her hands. Eric quiets, attains a quiet alert state
and looks at the therapists face. The therapist becomes aware that
Eric is looking at her and determines that he may prefer her face
to the red ball. She coordinates the movement of her face with his
gaze and notices that Eric follows her briefly before closing his
eyes. She stops her tracking movement and waits for him to open
his eyes again. When he does so, he again averts his gaze from her
face as soon as she moves slightly.
In the clinical vignette, Eric expresses himself through his
body (i.e. paleness around the mouth, irregular breathing,
extended postures, grasping movements, gazing at the face and
ball, and gaze aversion) and experiences himself and the world
through his body. During the first part of the encounter, the
therapist examines Erics reflexes and positions his head at
midline, whereas Eric expresses his self-regulatory efforts through
the following behaviors: mild paleness, grasping movements,
attempts at flexion, eventual extension of the neck and limbs,
increased paleness and crying. Up to this point, the therapist treats
Erics body as an object without recognizing that his neurobe-
havioral functioning is an expression of his experience. It is only
when Eric cries that the therapist responds to his attempts to shape
his interaction with him or her. This section of the vignette
illustrates a lack of synchrony, or a mismatch, between the infants
intentions and the therapists.
The infants experiences structure the brain; synaptic connec-
tions are strengthened as they are used, and those that are not used
weaken. Als et al. (1994, 2004) have presented a strong argument
supporting the importance of providing preterm infants with
experiences that match their processing capacities, as evidenced
by their neurobehavioral functioning during their experiences.
The synchrony between caregiver and preterm infant exerts
effects on the infants functional brain connectivity (Als et al,
2012). Therefore, the PT can best support the development of
synaptic connections in the brain of the developing infant by
considering the experience from the infants perspective, attend-
ing to his or her self-regulation attempts and responding to them
in a supportive manner. The manifestation of stress in the infant
cannot be completely avoided; the infants development level
380 Y. Blanchard & G. K. berg
compounded by the medical consequences of an early birth may
cause the infant to reach his or her thresholds of neurobehavioral
disorganization much sooner than a healthy, robust infant
would (Als et al, 2012). It therefore becomes the therapists
responsibility to consider the infants neurobehavioral organiza-
tion level during therapeutic encounters and to adapt the
therapeutic approach and demands to the infants capabilities.
Early signs of disengagement play an important role because they
indicate the moment when an infant begins to lose his or her
ability to self-regulate. In the vignette above, Eric manifested
many signs of disengagement during his interaction with the
therapist. If the therapist had recognize these signs, he or she
might have been able to prolong his or her interaction with the
infant by providing containment support earlier and adapting
the interaction to his responses (i.e. assessing visual tracking with
his or her face instead of the red ball requiring the infant to only
look rather to than look and move his head at the same time),
thereby creating an experience that was meaningful from the
infants perspective. After the infant had resumed self-regulatory
behaviors, the therapist could then have scaffolded the encounter
with increasing demands that stayed within the infants self-
regulatory capacity. The goal of physical therapy with young
infants is to promote the development of the brain and the motor
system; in particular it is the therapists responsibility to guide
and push the infant gently toward his or her limits. It is also the
therapists responsibility to facilitate interactions that provide
opportunities for positive and meaningful experiences.
When the therapist put the red ball down and contained Erics
arms and legs with her hands, Eric immediately calmed. At that
moment, the therapists actions were in synchrony with Erics
expressions of a desire for changes in the interaction. At that point,
the infant and therapist were interacting with one another and were
accomplishing something together; they acted as an embodied unit.
The therapist noted Erics regulatory behaviors (his gaze and his
quiet alertness) and signs of disengagement (brief tracking with
pauses) used them to shape the interaction. Erics behaviors guided
the therapist to identify his preferences for listening over visually
tracking objects or faces. At that moment, the embodied infant and
PT mutually shaped each others experience. The phenomeno-
logical perspective emphasizes that humans are embodied agents
and that social interactions are dynamic and embodied actions (De
Jaegher, DiPaolo, and Gallagher, 2010; Fuchs and De Jaegher,
2009). Synchrony between the therapist and the infant during
physical therapy interventions supports the attainment of shared
goals, which fosters the emergence of developmental growth
(berg, Blanchard, and Obstfelder, 2013). The infants body is an
integral part of any physical therapy intervention; it is through the
infants body that we deliver our interventions. Self-touch,
movement and touch by the therapist are experienced extensively
during the therapeutic encounter and contribute to the infants
experience of self, development of body image and body schema.
The infant has an embodied existence; the infant and his or her
world are one.
Development unfolds in a context of shared experiences and
intersubjectivity. Social understanding between the infant and the
therapist is a vital aspect of therapy; it consists of mutual,
interactional, ongoing processes in which both the PT and the
infant participate in moment-by-moment sense-making during
the actual therapy session. Additionally, phenomenology of the
body suggests that the manner in which ones movements affect
the environment results in changes in sensory stimulation for the
other agent, and vice versa, creating a mutual agent-recursive
interaction. Both agents activities become entwined in such a
manner that their mutual interaction results in an interactive
process, which is itself characterized by an autonomous organ-
ization and is an emergent structure in its own right (Froese
Physiother Theory Pract, 2015; 31(6): 377381
and DiPaolo, 2011). Therefore, the subjective meaning of the
experience is created through the interbodily resonance that
occurs during the interaction. Facial and vocal expressions,
gestures, postural adjustments, changes in muscle tone, and
movements affect attunement and interbodily resonance, and the
meaning of the interaction emerges as the interplay between the
interacting partners and the interactive process itself unfold
(Fuchs and De Jeagher, 2009). The capacity for both the therapist
and the infant to exert a specific influence on the therapeutic
interaction process exists in what they create together.
A significant part of the process is the therapists recognition
and understanding of the infant as an interactive partner; the
infant is considered an agent involved in his or her own therapy
rather than a passive recipient (berg, Normann, and Gallagher,
2015). For this recognition to occur, the therapist uses an
understanding of the infants intentions, as manifested through
bodily behaviors, to shape the therapeutic responses and demands;
only then are there two partners who shape the therapeutic
interaction and create the emergence of new behaviors (e.g. motor
actions). In this phenomenological model of shared experiences,
the therapist must relinquish some control over the sequence of
events and transfer the leadership of the intentional actions to the
infant. Guided by the infants behavioral expressions and inten-
tional actions, the therapist gently shapes subsequent actions, as
long as the infant desires them (berg, Blanchard, and Obstfelder,
2013). However, both therapist and infant will have limited
control over the ongoing interactive process because of the
influence of the interactive process itself. Each of the actors
surrenders to the other actor and to the interactive process to some
extent. Therefore, the direction of the interaction becomes open-
ended. However, the therapists therapeutic goals and implicit
expectations and the infants current intrinsic developmental goals
for the therapeutic interaction give the encounter a global
direction and contribute to the creation of new meaning and the
development of the infants next movement. To successfully
encourage this process, the PT must be aware of the infants
bodily expressions and their meaning.
Conclusion
Closely intertwined concepts from the fields of phenomenology
and neurobehavioral functioning provide a clinical framework
that considers infants as active agents during physical therapy
sessions and highlights the need for PTs to develop an
understanding of the significance of the infants active contribu-
tions during therapy. The phenomenological framework highlights
knowledge about the body and suggests that shared intentions,
matches and mismatches with quick repairs and a dynamic
interpersonal coordination of movements are critical aspects of
therapeutic actions and achievements. During physical therapy,
the infants behavioral organization is supported when there is
synchrony between the PT and the infant. Episodes of mismatch
during therapy, however, lead to a loss of synchrony between the
PT and the infant and to disorganization in the infant. Little is
known about the frequency of mismatches in therapy sessions; we
suggest that they should be minimized for both agents to
positively affect the therapeutic encounter and guide its direction.
The existing body of research on motor interventions for young
infants has devoted only limited attention to the infants contri-
butions to the intervention itself. Als synactive intervention
model of developmental care with preterm infants in the NICU
has described the effects of intervention on the infants brain
function and structure (Als et al, 1994, 2003, 2004). PTs may
therefore benefit from the combined perspectives of phenomen-
ology and Als synactive theory when designing interventions for
very young infants.
DOI: 10.3109/09593985.2015.1010243
Declaration of interest
The authors report no declarations of interest.
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