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Down Syndrome - S/S - 6 + contraindication; test
- Hypotonia; DEC mm tone
- Congenital heart defects
- Visual & hearing losses
- Laxity of ligaments
- Cognitive deficits
- Contraindication - Hyperextension of elbows & knees during WB; Forceful neck flexion & rotation
- LATEX ALLERGY??????
- Test - Gross Motor Function Measure (GMFM-88)
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Down Syndrome - best intervention
WB in antigravity mms bc of low tone
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Down syndrome - walking when?
24 months
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Down syndrome - why do they like to W sit? - 2
- Low mm tone
- Difficulty achieving sitting
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Retts syndrome - 5
- Normal dev until 6-18 months
- Head growth slows at 2-4 months
- Gait abnormalities
- Stereotypic hand movements (wringing, washing, clapping, bumping...)
- Test - (+) blood test for mutation
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2 ways Retts presents opposite from Autism
- Retts: prefers people to objects
- Retts: enjoys affection
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Spina bifida - types - 3
- Occult - No neural involvement. Identified by tut of hair, dimple
- Meningocele - external cyst w/CFS but spinal cord intact
- Myelomeningocele - external cyst w/CFS & herniation of spinal cord
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What complication w/myelomeningocele? + 2 facts about it
- Arnold Chiari II
- Latex allergy
- Can lead to hydrocephalus
- Foot deformities - talipes equinovarus (L4-L5)
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Spina bifida - S/S - 6
- Foot deformities, especially club foot or talipes equinovarus
- Bowel & bladder problems (L4-L5 lesion)
- Low tone with poor head control
- Hip flexor & ADD tightness
- Developmental delays
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Duchenne's Muscular Dystrophy - definition; onset; early sign; progression; test
- MM cells replaced w/fat & connective tissues
- PROXIMAL to distal
- Onset - males (3-7); soon after child begins to walk
- 1st mm affected - glutes; HS, gastrocnemius
- 2nd mm affected - sh girdle mm - pecs (sternal); deltoid; abs
- Extensors affected more than flexors
- Early sign - Gower’s maneuver - uses hands to walks up legs to get off floor
- Progression - Kyphoscoliosis (after 11)
- Test - CPK blood test
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Duchenne's Muscular Dystrophy - S/S - 7
- Proximal to distal
- Pseudo hypertrophy of calves
- Gait - waddling; toe walking
- Scoliosis - INC lordosis
- Difficulty w/climbing stairs
- Clumsiness
- Frequent falls
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Duchenne's Muscular Dystrophy - Tx - 4
- Surgery - lengthening of gastrio; scoliosis
- PT - ONLY submax exercise - heavy lifting can damage more mm
- WC bound by 10-12
- KAFO
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APGAR - 5
- @ birth, 1, 5, 10, 15 & Continues every 5 min if infant is having difficulties
- Scored 0-2
- Normal - 7 or better
- Needs some care - 5-7
- Needs immediate care - <4
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APGAR - what is tested
- A - appearance (skin color)
- P - pulse (HR)
- G - grimace (reflex irritability)
- A - activity (muscle tone)
- R - Respiration
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ROM & newborns - 2
- DEC ROM into extension due to physiological flexion
- INC DF of ankles & flexion at wrists
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Dislocated hip can be identified how?
By asymmetrical gluteal folds, hip click
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Meconium Aspiration syndrome - 3
- Meconium) that mixes w/amniotic fluid
- Infants are hypersensitive to environmental stimuli: treat in quiet environment
- 20% present w/developmental delays, some up until 3 years of age
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Gestational age - normal & premature
- Normal: 38-42 weeks
- Premature: <37 weeks GA
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Positional principles for babies - 2
- Neonates – fetal or physiological flexion, hand by mouth
- At home – not in prone due to SIDS
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Premie - Postural profile - 8
- WB on toes when placed in upright position
- Arm movement - DEC in midline
- Pelvis - Elevated
- Hips - ABD & extended
- Scapular - Retracted
- Shoulders - Elevated & extended
- Neck & trunk - Hyperextended
- UE & LE - Symmetrical flexed & ADD
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Premies - Tx positions - 2
- Sidelying & prone - chin tucked, trunk flexed, shoulders protracted, posterior pelvic tilt, flexed legs
- Gentle flexion of hips & knees in supine & supported semisitting
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Premies - Parental education for play & feeding - 7
- Position head in midline
- Position prone or sidelying
- Tilt child to encourage head balance & head righting
- Suspend toys in front of infant to encourage reaching
- Play activities that bring shoulders forward
- Minimize use of infant jumpers or walkers which INC extensor tone
- Use black/white/red objects 9 inches away
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Premies - What increases extensor tone?
Infant jumpers or walkers
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CP - characterized by - 2 + test
- Involuntary movements
- Visual, auditory, oral-motor, speech & cognitive deficits
- Test - Gross Motor Function Measure (GMFM-88)
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CP - Ataxic - 6
- Damage to cerebellum
- Poor balance & coordination
- Stance & gait - wide-based
- Poor ability of fine & rapid movement
- Low postural tone
- Intention tremor in hands
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CP - Athetoid - 5
- Damage to basal ganglia
- Hypotonia - “Floppy baby” syndrome; DEC mm tone; DEC DTR
- Dystonia - slow, writhing movements
- Poor postural control of trunk mms (proximal)
- Tonic reflexes - ATNR; STNR; TLR
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CP - Spastic - 5
- Damage to UMN
- INC DTR, mm tone
- Abnormal postures w/movement in mass flex/ext
- Gait - “crouched” (hip flex/IR; knee flex); scissoring; toe-walking
- Weakness/Contractures
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CP - Tx - 7
- Selective dorsal rhizotomy - not for dystonia; intensive strengthening
- Botox injections - last 4-6 months
- Phenol nn block - lasts 3-6 months
- Intrathecal baclofen pump - 1-4 months; reversible
- MM lengthening - achilles tendon; gastrocnemius; illiopsoas; hip ADD
- MM reverse - hip ADD into hip ABD
- Osteotomies - hip; pelvis
- Devices - posterior walker;
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How much tummy time does a baby need?
81 minutes per day - doesn't have to be consecutive
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Functional sitting - proper position; how to help child get there
- Pelvis neutral; hip/knees 90 flexion
- Tilt seat posteriorly & add wedge under thighs
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What can standers help with? - 3
- Promote WB
- Reduce primitive reflexes
- Aid in bladder & bowel functions
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Posterior walker - what it encourages (5); for what population
- Trunk extension
- Shoulder depression
- Elbow extension
- Neutral wrist
- May DEC scissoring in LE
- Pathology - CP
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Side-lyers - used for what?
- DEC TLR
- Also puts hands in visual field
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What can help a child be in prone position?
Foam wedge
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What offers maximum support to UE & trunk?
Gait trainers
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Power wheelchairs can be used when?
As early as 18 months of age depending on the specific child
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HKAFO - for what population?
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KAFO - for what population - 2
- Spina bifida
- Muscular dystrophy
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Automatic reactions - use what to help; Ex how to practice forward righting rx
- Swiss ball
- Displace ball backward - abdominals activated for forward reaction
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RGO - of what population - 2
- T-spine spina bifida
- SCI
- WHEN THERE IS NO HIP FLEXION
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To promote sensory integration use what equipment? - 1
Swings
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Pavlov harness - for what population? Does what?
- Infants w/congenital hip dysplasia
- Places hips into flex/ABD
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If child has INC extensor tone, what can be used to help maintain hip flexion in 90 deg?
Tilt-in-space WC seat
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Scooter/three wheelers require what for use?
- Fair (3/5) sitting balance
- UE control
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School Functional Assessment (SFA) - what age
For children in grades K-6 (5-12years of age)
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Whole Arm Paralysis (Erb-Klumpke palsy) - nn roots involved; Appearance; Weakness; Tx
- C5-T1 nn roots stretched during birth
- Appearance - Claw hand
- Most affected - Hand function
- Tx - Partial immobilization of limb across upper abdomen for 1-2 wks
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Erb’s palsy - nn roots involved; Appearance; Weakness; Tx
- Upper arm paralysis - C5-C6
- Appearance - “waiter’s tip” - Sh ADD/IR
- Weakness - Shoulder ABD/ER; elbow flexion & supination; DEC sh girdle function
- Tx - Early - Neutral positioning of arm; Gentle ROM exercises
- Severe - child cannot hug a doll; drink from cup; zipper coat
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Klumpke’s palsy - nn roots involved; Appearance; Weakness; Tx
- Lower arm paralysis - C8-T1
- Appearance - claw hand
- Weakness - Hand & wrist flexors
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Rolling - 3
- Prone/supine to side - 4 months
- Prone to supine - 5 months
- Supine to prone - 6 months
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Stairs - 3
- Up & down w/assistance - 18-20 months
- Up reciprocally (1 at a time) - 2yr
- Down reciprocally - 3 yr
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Grasp - 5
- Ulnar palmar grasp - 4 mon (can't transfer btwn hands)
- Radial palmar grasp (using thumb & 1st 2 fingers) - 5 months (can first hold bottle)
- Pincer grasp w/thumb & forefinger - 8-9 months
- Pincer grasp w/release - 10-15 months
- Can transfer hand to hand (FINE MOTOR) - 6 months or in THERAPY ED 8-9
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Fine pincer grasp
11 months
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Stacking 2 blocks
12-15 months
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Stacking 6 blocks
16-24 months
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Holding cup while drinking
12 months
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Transferring objects from one hand to next
8-9 months
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Sitting - 4
- Propped (hands on ankles, supporting torso) - 5 months
- IND - 6 months
- IND (arms free to reach w/o LOB) - 7-9 months
- Side-sitting - 8-9 months
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Standing - 5
- Partial WB - 5 months
- Pull to stand - 10-12 (as early as 7)
- IND - 8-9 months
- Cruising sideways - 10-12 months or 8-9????
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Head control - 2
- Head bobs in supported sitting - 2 months
- Present in supported sitting - 5 months
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Frog-legged - describe; when?
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W sitting - bad why?
Femoral antetorsion & medial knee stress
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Crawling - time
9-11 months
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Walking - time
12-14 months
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Pivot prone: on their stomachs (prone) & lift up their arms (pivot) - when
4-6 months
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Forward flexion in propped sitting after how many months is a red flag for poor abdominal, erector spinae, hip control?
7
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Hands to midline happens when
3-5 months
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Supine head lifting happens when
4-6 months
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7 reflexes present at birth
- Moro
- suck
- root
- palmar
- plantar
- ATNR
- babinski
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ATNR - asymmetrical tonic neck reflex - stimulus; response; strongest in what position
- Stimulus - turn head to side,
- Response - flexion of skull limbs, extension of jaw limbs - fencing posture
- Strongest in Supine or sitting
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Prolonged ATNR can result in what?
- Scoliosis
- Hip subluxation/dislocation if there is marked hypertonia
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Grasp reflex - stimulus; response; integration
- Stimulus: maintain P to palm of hand (palmar) or to ball of foot under toes (plantar)
- Response: maintain flexion of fingers or toes
- Integration - Palmar - 4-6 months; Plantar - 9 months or when child starts walking
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Landau reflex - stimulus & response; when is it absent?
- Stimulus - lift child under thorax in prone position - superman pose
- Response - first the head and then the head and legs will extend
- Absent w/strong flexor spasticity
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What will happen if head is pushed down after landau reflex is seen?
Extensor tone will disappear
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Moro/Startle reflex - stimulus & response; integration
- Stimulus - sudden change in position of head in relation to trunk
- Response - Extension/ABD of UE with hand opening and crying
- Followed by flexion/ADD, arms across chest
- Integration - 5-6 months
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Rooting reflex - stimulus & response; integration
- Stimulus - side of face is stimulated with light touch
- Response - infant turns head toward side of stimulation & opens mouth
- Integration - 3 months
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Symmetrical tonic neck reflex (STNR) - stimulus & response
- Stimulus - flexion or extension of head
- Response - With head flexion: flexion of UE & extension of LE
- With head extension: extension of UE & flexion of LE
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What can the symmetrical tonic neck reflex (STNR) strongly influence in a bad way?
Ability to assume quadruped position as well as ability to crawl
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What can TLR interrupt?
If reflex persists and is strong, may block rolling from supine position, due to increased extensor tone
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Tonic labyrinthine reflex (TLR) - stimulus & response
- Stimulus - prone or supine position
- Response - Prone - INC flexor tone / Supine - INC extensor tone
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Babinski reflex - stimulus & response; integration
- Stimulus - Stroke lateral aspect of the plantar surface of foot
- Response - extension & fanning of toes
- Integration - normal up to 2 years, may disappear by 1 year
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Galant reflex - stimulus; response; integration
- Stimulus - hold bay face down; stroke 1 side of spine
- Response - Side-bending to stimulated side
- Integration - 12 months
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Crossed extension reflex - stimulus & response
- Stimulus - Sharp, quick pressure stimulus to sole of foot of extremity in extension. Tested in supine
- Response - opposite LE flexes, then ADD & extends
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Crossed extension reflex, when coupled with the (+) supporting reaction, can result in what?
Hyperextension of the knee
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How can crossed extension reflex be used with hemiplegic pts?
Lifting uninvolved leg off the ground during ambulation results in increased extensor tone in involved leg
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When will the equilibrium reactions be absent?
With marked spasticity
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Equilibrium/tilting reactions onset? Different positions
- Prone (6 months)
- Supine (7-8 months)
- Sitting (7-8 months)
- Kneeling (9-12 months)
- Standing (12-21 months)
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(+) Supporting Reaction - stimulus & response
- Stimulus: contact to ball of foot in an upright standing position
- Response: rigid extension (cocontraction) of LE with ankle PF/inversion, toes "clawing," & hip IR
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(+) Supporting Reaction & CP
ADD spasm may occur
-
(+) Supporting reaction & hemiplegia
- May produce hip ABD
- Ambulation will be disrupted by inability to DF foot or to properly move leg jts
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Order of protective extensions
- Downward (parachute) - 4 months
- Forward - 7 months
- Sideways - 6 months
- Backwards - 9 months
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Protective extensions onset
- Arms - 4-6 months
- Legs 6-9 months
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Peds - color of objects - 6 months; 3yr;
- 6 months - Black & white????
- 3 yr - Multicolored
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