Motor Development PDF

MOTOR DEVELOPMENT NEUROTHERAPY Edited by Rita Xantus (Lois Bly: Components of Typical and Atypical motor development during the first year; Martin Kessler: neurologic intervention for physical therapy Chapter 4; Prof. Dr. Ferenc Katona and Dr Marianne Berényi Neurode...

MOTOR DEVELOPMENT NEUROTHERAPY Edited by Rita Xantus (Lois Bly: Components of Typical and Atypical motor development during the first year; Martin Kessler: neurologic intervention for physical therapy Chapter 4; Prof. Dr. Ferenc Katona and Dr Marianne Berényi Neurodevelopment (Book and Course Materials)  Life Span Concept Characteristics (Baltes 1987): 1. Development is life-long 2. Development is multidimensional 3. Development is plastic and flexible 4. Development is contextual 5. Development is embedded in history  Motor development is described as sensory- motor development. Sensory input contributes to development. All of the sensory systems are involved→ visual, vestibular, and somatosensory (proprioception and tactile). Typical babies are very active. They repeat all movements over and over and therefore develop an awareness of the sensation of the movements.  Basic characteristic of motor development is the ability to move and make transitions. Movement needs weight shift. → weight shifting provides the sensory stimulus for postural reactions and balance reactions. → postural responses and balance reactions can be learned (experience and practice) and anticipated (feed forward). These responses are the righting and equilibrium reactions.  During motor development, the trunk muscles begin to work in numerous and various ways. As synergistic muscle control develops, muscle groups balance each other. → Axial (trunk) flexor muscles balance antigravity (trunk) extensor muscles. Synergistic balance of the trunk muscles influences the development of head control, UE and LE control. (Stability and mobility on stability).  Trunk movements on each plane influence extremity movements on each plane. Trunk extension and flexion (sagittal plane) help to facilitate upper extremity and LE extension and flexion. Trunk lateral flexion (frontal plane) helps to facilitate shoulder and hip abduction and adduction. Trunk rotation (transverse pane) helps to facilitate shoulder and hip rotation.  When the baby can maintain sitting and standing postures, muscle coordination enables the baby to continue to practice movement on all 3 planes. → this enables the baby to make transitions → transitions enable the baby to move from one position to another.  Development time periods PERIOD TIME SPAN INFANCY BIRTH TO 2 YEARS CHILDHOOD 2 YEARS TO 10 YEARS (FEMALES) 2 YEARS TO 12 YEARS (MALE) ADOLESCENCE 10 YEARS TO 18 YEARS (FEMALES) 12 YEARS TO 20 YEARS (MALES) EARLY ADULTHOOD 18 TO 20 YEARS TO 40 YEARS MIDDLE ADULTHOOD 40 TO 65 YEARS OLDER ADULTHOOD 65 YEARS TO DEATH YOUNG-OLD 65-74 YEARS OLD MIDDLE-OLD 75-84 YEARS OLD OLD-OLD 85 YEARS AND OLDER Typical motor development during the first year Neonate: 1-10 days Physiological flexor activity in the ankles, knees, hips and elbows. Flexion is seen in both prone and supine. In prone hip flexion causes weight to be shifted forward onto the baby’s face, which is turned to the side. Head lifting is an early step in the development of antigravity extension and weight shifting. (very difficult to a newborn in prone and flexed position)  Supine: neonate in physiological flexion in the extremities, but the antigravity control of the neck flexors is not present → the baby can briefly bring the head to midline. Pulled to sit → lack of antigravity flexor →initiate head flexion, but lack of the muscle control to lift the head against gravity. Initiating head lifting means → the baby has received visual, vestibular and proprioceptive sensory feed back to indicate that the head position is incorrect.  Sitting → shows lack of trunk muscle control. If supported → baby leans forward. Round back + head drops forward. The baby is able to maintain his head in vertical position for few seconds. Standing → primary standing and automatic walking (will fade out in the 4th or 6th weeks)  Two months Characterized by semi-hypotonia, decreased flexion and increased extension and asymmetry. Physiological flexion has been reduced by gravity and the increased extensor activity. Antigravity extension has not yet been balanced by active antigravity flexion → in gross motor activities the baby may seem to have less control than he had in the previous months.  Supine: due to gravity range of head rotation is, shoulder external rotation , and hip external rotation increased. The head rotates further to the side because of gravity and increased unilateral activity of neck extensors without equal counter-balance of neck flexors. As the head rotates further to the side → asymmetrical tonic neck reflex (ATNR- “bow and arrow”). When the head is to the side, the eyes move to the same side. Lateral vision becomes more dominant, and eye-hand coordination is uncontrolled yet (swiping at toys) Typical and atypical development at months  Three months Beginning of active symmetry Beginning of bilateral control of the neck and trunk muscles The head is less frequently rotated far to the side → ATNR less frequent Starting of midline orientation of head eyes and hands  Prone: - head/neck extension with upper trunk extension → enables the baby to lift and turn the head. - Beginning to bear weight on the forearms → Upper chest is lifting from the supporting surface. - Forearm weight bearing provides increased proprioception into the shoulder joints.  Supine: - Increased symmetry is evident - Head is more frequently in midline with chin tucking - Less occurrence of ATNR - The baby’s UE come to rest on his chest and his hands come together - Hands on body and hand on hand contact and explorations are important steps in increasing body awareness - When head is maintained in midline, midline ocular control increases - Symmetry is obvious in the LE → “frog legged” position (hip flexion, abduction, and external rotation, and knee flexion)  Supported in sitting: - Able to sustain head lifting with neck hyperextension. - Head lifting is stabilized with scapular elevation - An open mouth is usually accompanies scapular elevation and neck hyperextension Supported in standing: - Takes weight on his feet. - The LE are abducted and knees are stiffy extended. Automatic walking cannot be elicited.  Four months Strong symmetry Baby uses bilateral symmetrical control of the flexor and extensor muscles. The neck flexors balance the neck extensor muscles → the baby is able to maintain midline control of the head in prone, supine and sitting. The baby can easily move the head in and out of midline.  Prone - Often moves into a total extension pattern, which demonstrates the baby’s increased extensor muscle control. - This extension is reinforced by bilateral scapular adduction. → this is also seen in initial sitting, standing and walking. - The strong symmetrical extension is balanced in prone by symmetrical forearm weight bearing  Prone cont. - The pectoral muscles adduct the arms in line with the trunk - Active shoulder adduction helps to facilitate abdominal muscle contraction and head flexion → this enables the baby to “tuck” the chin and elongate the neck. - The baby plays with pelvic tilts by actively alternating btw anterior pelvic tilts and posterior pelvic tilts. - Anterior pelvic tilts → accompanied by lumbar extension, hip flexion, knee flexion, and ankle dorsiflexion. - Posterior pelvic tilts → accompanied by hip extension, knee extension, and ankle plantar flexion  Prone cont. - The “frog legged” position of the hip is less marked - The hip adductors bring the bring the legs closer together and elongate the hip abductors and the hip flexors. - in forearm weight bearing → the baby may accidentally roll to his side. → rolling is usually initiated by strong head extension and/or collapse of control of the shoulder muscles when the weight is shifted to that side (this is still not controlled forearm weight shifting)  Supine - Increased antigravity flexor muscle control. - The baby lifts his head, arms, and legs to reach the hands to the knees. - The hands-to-knees position enables the baby to explore the body and increase body awareness. - Vision usually leads the reaching. - When the baby brings his hands to his knees → frequently rolls over to his side. → rolling is usually initiated with head rotation (head turns body follows as a unit) - In side lying, visual and vestibular feedback provide the stimulus for lateral head righting. Exploring hands  Pulled to sit: initiates the lift → lifts head symmetrically, lifts the pelvis with the abdominals, flexes the elbows, and flexes hips and knees. The shoulders elevate to stabilize the head once the movement is initiated. Supported sitting: the baby leans forward at his hips, followed by trunk extension → still lacks trunk and hip control Supported standing: takes weight on his feet. He can be supported at the hands instead of the trunk → indicates increased hip and trunk control Typical and atypical development 4 months  Five months Capabilities of lateral weight shifting and lateral righting reactions of the head and spine. Important phase of UE and LE dissociation Prone: - Can maintain forearm weight bearing and extended arm weight bearing. → beginning to shift his weight laterally and respond with a posture of lateral flexion → enables the baby to reach with one hand while stabilizing on one shoulder. - Can maintain extended arm weight bearing.  Prone cont. - Extended arm weight bearing is balanced by flexor muscle control, with the abdominal and pectoral muscles. → requires shoulder girdle stability, active elbow extension, wrist and finger extension, and hip extension with adduction and neutral rotation. → provides proprioceptive feedback into all of the weight bearing joints → leads to further development of stability - while reaching out with one arm, the shoulder does not collapse → does not fall over as he did before.  Prone cont. - Asymmetrical somatosensory feedback on the side during one side weight shift → provides stimulus for lateral righting of the head and trunk away from the weight bearing side. → sensory information stimulates lateral righting of the head and trunk to the left, and results in elongation of the right side of the neck and trunk. (The weight bearing side is the elongated side)  Prone cont. - Lateral flexion of the spine facilitates lateral hiking of the pelvis → facilitates a balance reaction of hip abduction, flexion and external rotation on the unweighted leg. → the weight bearing leg adducts, extends and internally rotates to neutral → LE demonstrate dissociative movements. - If the baby shifts weight too far → will roll onto his back → achieve the milestone of rolling from prone to supine → but it is usually accidental and uncontrolled.  Supine - Increased control in the abdominal and hip flexor muscles → enables the baby to lift his legs and bring his feet to his hands and to his mouth → the pelvis is lifted and posteriorly tilted. - The hand-mouth-foot play led to body awareness and sensory stimulation to each of this parts. → from this position the baby rolls to side lying. → not symmetrical anymore in this position → transitions to lateral flexion posture (LF of head, elongation of the floor side of the trunk, the lower leg is extended and adducted, the top leg is flexed and adducted) → increased control into LF and increased LE dissociation.  Pull to sit - No head delay. Increased abdominal control stabilizes the rib cage for head and neck flexion and prevents shoulder girdle elevation. → pulls himself up with his arms (usually needs assistance). - Abdominal activity assists with total LE flexion  Supported sitting - Still lean forward from the hips. Hip extensor control is not sufficient to stabilize the pelvis in the upright position in sitting, yet. → he props (hold) on his forward extended arms → provides trunk stability. - Postural stability is achieved with bilateral symmetrical scapular adduction (called high guard position) → which reinforces spinal extension, but it may cause the baby to fall backwards. → high guard inhibits the baby to reach forward  Six months Has good head control Can extend, lateral flex and flex the head against gravity. Increased control of the shoulder girdle → while reaching forward and protective extension forward Trunk control and mobility are increasing → lateral spinal movements are more evident.  Prone - Extensor activity is strong → however in the extended arm weight bearing position it is balanced by flexor activity - Head-neck extension is balanced by head-neck flexion → but the baby can tuck the chin and elongate the neck. - Upper trunk extensors are balanced by upper trunk flexors and good shoulder girdle stability. - Trunk extensors are balanced by active abdominal contraction - Good hip extension is possible because the abdominals stabilize the pelvis. - Pivots on tummy  Supine - Can lift his pelvis and legs and maintain his legs extended above his body → sufficient abdominal and LE muscle control - Can reach and play with his feet in mid-range suspended position - Can roll from supine to prone. → flexor components dominate the action until side lying → in side lying transition to LF with elongation on the weight bearing side → lateral righting facilitates LE dissociation → transition to prone extension becomes the dominant component  Sitting: - Independently while maintaining a straight back and tucked chin. - Increased hip extensor control helps to stabilize the pelvis in a perpendicular position. Supported standing: - Sufficient trunk and hip control to independently hold on to the support of a person. He can bounce up and down with his feet on the floor. → when he bounces he exercises the interplay of muscle groups in his LE → also provides proprioceptive and vestibular stimulations Bouncing Typical and atypical development 6 months  Seven months Can sit independently Begins to shift weight in sitting Protective extension reactions sideways are often present. Trunk control is sufficient → dissociate the LE from the trunk → begins to try various LE positions while sitting  Prone - Is usually preferred position because this is where he is most functional → has the most diversity of movements available from prone. - Can transition to quadrupled position. → first trough lateral weight shifting, LE dissociation followed by lifting of the pelvis over the flexed leg and UE elbow extension to lift the body to quadrupled position. → dissociation of the LE  All four Quadrupled → lumbar lordosis may be obvious → occurs when the abdominal muscles are not sufficiently active to support the rib cage → the shoulder girdle muscles are also not active in this case - Initial stability for the quadrupled posture is often maintained by strong contraction of the hip flexors (fixation) - With practice begin to use abdominal muscles and stabilize the trunk (rib cage and pelvis) - When the abdominals are active, the baby does not need to fix with the hip flexors and he can rock forward and backward with alternating hip flexion and hip extension. Roll back and forth  From quadrupled position the baby can move to backward to sitting → initiated with a lateral weight shift, trunk LF balance reaction, and LE dissociation. Sitting: - Starting to use trunk rotation initiated with vision - Weight is shifted to the face side - May try to bring himself to stand → initiated from quadrupled position → mobility in the lumbar spine occurs → hip-pelvic stability maintained with strong contraction of the hip flexors → the baby pushes down with both arms while simultaneously extending both knees. - Still not competent at lateral weight shifting in standing → does not lift either leg  Eight months Improved trunk control in sitting → uses LE less frequently for positional stability Frequently uses long sitting with his hips adducted in line with his body, or half-long- sitting with one leg extended and the other leg in half-ring position When the legs are more in line with pelvis, the baby can shift weight through rotation and lateral movements without falling. Can use UE protective reactions when needed.  Can transition from sitting to quadrupled → frequently made over the leg that is in the half- ring position Uses creeping as the primary means of locomotion Reciprocal creeping occurs when the trunk has sufficient control to support the counter-rotation of the shoulder girdle and the pelvis Can transition from quadrupled to kneeling to half-kneeling at the furniture to bring himself to stand → relies on his UE to the majority of the lifting  In standing the baby can independently cruise sideways around furniture by maintaining his body facing forward, and alternately abducting and adducting his legs and arms. When hands are held, the baby walks forward using a steppage-gait → each leg in wide abduction, external rotation, and flexion → does not provide the forward advancing component of hip extension needed to independently move forward (the person who he walking with does that)  Nine months Very functional in sitting → frequently changes sitting positions → side sitting, ring sitting, long sitting, W sitting Improved trunk control enables the baby to practice fine motor and manipulative skills Dynamic mobility (controlled mobility) of the lower limb improves trunk and LE muscle strength Easily moves from sitting to quadrupled position and visa versa Crawling Sitting from all four  Creeping, kneeling, half-kneeling, standing is easy → legs are stronger Climbing is a new activity → improve UE and LE dissociation Cruises around furniture → pelvic rotation begin → increased pelvic rotation changes the steppage-gait pattern → forward stepping is more obvious → Hip external rotation decreased, but the baby still uses marked hip flexion and abduction  Ten months UE and fine motor skills are becoming more refined When the baby try new fine motor skills, he goes back to a more stable gross motor position → e.g. from kneeling to ring sitting Kneeling, half-kneeling, and climbing improve In standing and cruising → increase trunk rotation over the weight bearing leg → uses only one hand for stability → turns and faces the direction in which he is moving  Able to lower himself at standing (picking up objects)→ uses posterior weight shift and maintain his balance by keeping one hand on the furniture Able to walk forward with support, with less hip abduction (narrowing BOS), more hip extension, more pelvic rotation and a greater LE step. Without support → safety reduces→ more immature gait pattern  Eleven months Time of exploration. ☺ Will not stay still! Able to rotate in long sitting (large BOS) Well-developed balance reactions in sitting. Able to stand up by actively extending his legs, rather than by pulling himself up with his arms. Frequent movement sequences : kneeling, half- kneeling, standing, squatting Minimal UE stability in standing. Improved control of the hips and legs. Wide BOS (wide abduction)  Walking with two or one hand held → has sufficient trunk control to actively assist with the lower trunk/LE weight shifting → uses more pelvic rotation If the baby try to walk alone → high guard posture is dominant (scapula adduction)→ increase his trunk stability  Twelve months Sufficient trunk control to use lateral flexion and rotation as well as flexion and extension Can easily move in and out of sitting Can transition to quadrupled and half-kneeling position Kneeling is frequently used Able to stand up without hand support. Can shift his weight laterally while standing and lift either leg alternately → with scapular adduction(high guard) and trunk extension (more stability) High guard walking  When walking (without support) the baby moves quicky → the balance and control to move slowly has not developed yet Trunk control increases, scapular adduction is no longer needed. Swings the arms reciprocally with his legs → the trunk is dynamically stable (counter- rotation of the shoulder and the pelvis girdles) Development of walking 18 months  Important stages of development AGE STAGE 1-2 months Internal body processes stabilize Basic biologic rhythms are established Spontaneous grasp and release are established 3-4 months Forearm support develops Head control established Midline orientation is present 4-5 months Antigravity control of extensors and flexors begins Bottom lifting is present 6 months Strong extension-abduction of limbs is present Complete trunk extension is present Pivots on tummy 7-8 months Spontaneous trunk rotation begins Trunk control develops along with sitting and balance  Important stages of development AGE STAGE 9-10 months Movement progression is seen in crawling, creeping, pulling to stand and cruising 11-12 months Independent ambulation occurs 16-17 months Carries or pulls an object while walking Walks sideways and backward 20-22 months Easily squats and recovers toy 24 months Arm swing is present during ambulation 3 years Mastered reciprocal actions: pedaling tricycle, climbing on ladder. Tandem standing. Jumping. 4 years Better static and dynamic balance. Standing on 1 leg. Hop on 1 foot for few times. Catch smaller ball with extended arms. 5 years Stand on 1 foot for 10 seconds, walk forward on balance beam, hop 10 times on 1 foot. Catch a ball. Run and kick a ball. Hand preference (coloring). 6 years Specialization process of the cerebral hemispheres complete. Well coordinated movements. Riding bicycle, roller skating. 6-10 years Master the adult forms of running, throwing , catching. Develop fundamental patterns of movement that form the basis for later sport skills.  Cognition and motivation Motor development, motor control and motor learning depend on the person’s intellectual ability. Impairments in cognitive ability can affect an individual’s ability to learn to move. A child with mental retardation may not have the ability to learn movement skills at the same rate as a child of normal intelligence. The learning of motor skills is often as delayed as the learning of other knowledge.  Directional concepts of development Development progress from cephalic to caudal, proximal to distal, mass to specific and gross to fine. Cephalocaudal: head control development before trunk control. Upper extremity usage before mastering lower extremity skills. Overlaps exist. Proximal to distal: trunk stability must be a stable base for head movement and for limb movement. (external or internal support) Mass to specific: development progress from the whole body to specific body parts. In early stages no isolated movements (dissociation). Head dissociated from trunk, limb dissociated from trunk, upper trunk dissociated from lower trunk etc.) Gross to fine: large muscle movement to fine. Not all gross-motor skills come before fine.  Reciprocal interweaving: At each stage of development, abilities emerge, merge, regress, or are replaced. Control of the head in prone may need to be relearned in postural changes, such as sitting. Reappearance of certain movement patterns in different times→ scapular adduction in prone→ reinforce upper trunk extension → later at beginning of walking→ high guard position of the arms  Developmental process Motor development is a result of three process: growth, maturation, adaptation Growth: important parameter → growth charts includes size, height, weight, head circumference Maturation: genetically guided changes: myelination of nerve fibers, appearance of bone growth centers, secondary sexual characteristics. Adaptation: physical changes to external stimulation. Immune system, skeletal and muscular changes Growth chart 0-36 months boys Growth chart 2-20 years (boys)  Gross motor milestones Head control → 4 months Log roll → 4-6 months (1st prone to supine → extensor control before flexor control) Segmental Rolling → 6-8 months Independent Sitting → 8 months Cruising → 9 months Reciprocal Creeping → 10 months Walking → 12 months Nothing is written in stone!  Fine motor milestones 0-6 months: reflexive grasp (mostly ulnar)→ by touching the palm of the hand 2 months: Hand recognition → ATNR triggered by head turning allows the hand to enter the visual field 6 months: voluntary grasp 7 months: thumb adduction begins → allows radial palmar grasp → radial side of the hand and thumb adduction → pick up small objects 9 months: radial digital grasp → beginning of opposition 9-12 months: inferior pincer grasp(isolated index pointing) 12 months: superior pincer grasp (tip to tip) reflexive grasp radial palmar grasp radial digital grasp inferior pincer grasp and superior p.g.  Primitive reflexes 1 stimulus – 1 answer Grasp reflex- hand, foot Moro reflex- supine Landau reflex – prone McGraw – prone, head lifting → crawling movement Gallant- prone, lumbar part paravertebral touch → increased muscle tone, extended lower limbs Schaltenbrandt (parachute) from 3-4 months  Reflex integrity- primitive spinal reflexes Primitive STIMULUS RESPONSE reflex Flexor Noxious stimuli (pinprick) to sole Toes extend, foot dorsiflexion, entire LE flexion withdrawal of foot in supine or sitting uncontrollably. Onset: 28 weeks gestation. position. Integrated:1-2 months Crossed Noxious stimulus to ball of foot. Opposite LE flexes, then adducts and extends. extension LE fixed in extension in supine Onset: 28 weeks gestation. Integrated: 2-5 position. months. Traction Grasp forearm and pull up from Grasp and total flexion of the UE. Onset: 28 supine into sitting position. weeks gestation. Integrated: 2-5 months Moro Sudden change in position of Extension, abduction of UEs, hand opening, and head in relation to trunk. Drop crying followed by flexion, abduction of arms patient backward from sitting across chest. Onset: 28 weeks gestation. position. Integrated: 5-6 months Startle Sudden loud or harsh noise Sudden extension and abduction of UEs, crying. Onset: birth. Integrated: persists Grasp Maintained pressure to palm of Maintained flexion of fingers or toes. Onset: hand (palmar grasp) or to ball of palmar: birth, plantar: 28 weeks gestation. foot (plantar grasp) Integrated: palmar: 4-6 months; plantar: 9 months  Reflex integrity – tonic /brainstem reflexes TONIC REFLEXES STIMULUS RESPONSE Asymmetrical tonic Rotation of the head one Flexion of skull limbs, extension of jaw limbs, neck (ATNR) side “bow and arrow” posture. Onset: birth. Integrated: 4-6 months Symmetrical tonic Flexion or extension of With head flexion: flexion of UEs and extension neck (STNR) the head of LEs. With head extension: extension of UEs and flexion of LEs. Onset: 4-6 months. Integrated: 8-12 months Symmetrical tonic Prone or supine position With prone position: increased flexor labyrinthine (TLR or tone/flexion of all limbs. With supine: STLR) increased extensor tone/extension of all limbs. Onset: birth. Integrated:6 months Positive supporting Contact to the ball of the Rigid extension (co-contraction) of LEs. Onset: foot in upright standing birth. Integrated: 6 months position Moro reflex Root Asymmetrical tonic neck reflex (ATNR) Primitive reflexes Signs of possible developmental delay by 1 month - Sucks poorly and feeds slowly - Lower jaw shakes constantly even when infant is not crying or exited - Does not respond to loud sounds or bright light - Des not focus on and follow a nearby object moving side to side - Rarely moves - Extremities seem loose and floppy or very stiff Signs of possible developmental delay by the end of 3rd month No Moro reflex Does not notice own hands by 2 months Does not grasp and hold objects Eyes cross most of time or eyes do not track well together Does not coo or babble Signs of possible developmental delay by the end of 4th month Head flops back when pulled up to sitting by his or her hands Does not turn head to locate sounds Does not bring object to mouth Does not smile spontaneously Inconsolable (sad) at night Signs of possible developmental delay by the end of 5th month Persistent tonic neck reflexes Cannot maintain head up when placed on stomach or in supported position Does not reach for objects Does not roll in both direction Signs of possible developmental delay by the end of 7th month Reaches with 1 hand only Cannot sit with help by 6 months Does not follow objects at a distance Does not bear some weight on legs Does not laugh; does not try to attract attention through actions Refuses to cuddle; shows no affection for caregiver Signs of possible developmental delay by the end of 12th month Does not crawl on all fours Cannot stand when supported Does not search for toy hidden while he or she watches Say no single words (e.g. mama, dada) Does not use gestures such as waving hand or shaking head Does not point to objects or pictures Signs of possible developmental delay by the end of 2nd year Cannot walk by 18 months Failure to develop heel-toe walking pattern after several months of walking Does not speak at least 15 words by 18 months Does not use 2 word sentences by 2 years Does not know the function of common objects by 15 months (spoon, brush, phone) Does not follow simple instructions Signs of possible developmental delay by end of 3rd year Frequent falling and difficulty with stairs Persistent salivation (drooling) or unclear speech Inability to build tower or more than 4 blocks Difficulty manipulating small objects Cannot copy a circle Cannot communicate in short phrases No pretend play Little interest in other children Extreme difficulty separating from caregiver Signs of possible developmental delay by the end of 4th year Cannot throw a ball from above shoulder (overhand) Cannot jump in place with both feet Cannot ride a tricycle Cannot grasp a crayon between thumb and fingers; cannot scribble (doodle) Resists dressing, sleeping, using toilet Does not use sentences of more than 3 words; does not use “me” and “you” appropriately Ignores other children or people outside the family Does not pretend in play; no interest in interactive game Persistent poor self-control when angry or upset  Signs of possible developmental delay by end of 5th year Does not engage in variety of physical activities Has trouble eating, sleeping, using toilet Cannot differentiate between fantasy or reality Seems unusually passive or distant with others Cannot correctly give her or his first and last names Do not use plurals or past tense when speaking Does not talk about daily experiences Does not understand 2 part commands Cannot brush teeth efficiently Cannot take off clothing Cannot build a tower of six to eight blocks Does not express a wide range of emotions Seems uncomfortable holding a crayon  Development of brain 350 grams at birth 700-800 grams by 1 year of age Development of new synapses enlarging the size of the brain  The development of the brain never stops in infancy. It develops typically or atypically no matter what. The impairment of the brain during pregnancy or perinatally not necessarily leads to further impairment in the development of the brain. Based on the examination there are several possible outcomes in regard to diagnostic and prognostic point of view. 1. Functional impairment of the nervous system during pre- and perinatal period can be resolved later followed by normal development of the brain. The developing neuronal pathways improves without difficulty. The neuroplasticity of the brain is huge. 2. Brain damage (proven by MRI, CT, Ultrasound) with functional impairments and atypical symptoms are more common. If parts of the brain which regulates alertness, attention, movement and posture are compromised the normal development is at risk. 3. There can be atypical neurological signs and symptoms without any proof by MRI, CT or Ultrasound.  The pathology of the atypical development of the brain is partly continuous. We born with huge amount of neurons and synapses, and there is a normal selection in the brain to eliminate the unnecessary neurons. In this case there are 2 types of destroying process occur in the brain cells at the same time. 1.necrosis is cell death that is triggered by external factors or disease, 2. apoptosis a form of cell death that is generally triggered by normal, healthy processes in the body. If there is no development of neuronal pathways in a part of the brain than those cells will be unnecessary (because there are no connections), so the apoptosis will be triggered this way.  The symptoms of the atypical development are NOT predisposed!!! The atypical development of the brain is individually different in forms and in cascade/degree/class. The progression of the pathological epigenesis could be prevented with early therapy!!! Neuroplasticity!!!  Clinical neurodevelopment Disorders what clinical neurodevelopment deals with: - congenital brain damages - hypoxia - developmental birth defect due to genetic disorders - Plexus brachialis damage - cranial nerve damage - spina bifida (myelomeningocele)  Common developmental disorders of the nervous system: Neural tube defects (NTDs) Spina bifida occulta: vertebral defect in which posterior elements of the vertebral arch fail to close. No sac. Vertebral defect usually not associated with an abnormality of spinal cord. Low pack pain is common. Spina bifida cystica: vertebral defect with a protruding cyst of meninges, or spinal cord + meninges Meningocele: cyst containing cerebrospinal fluid and meninges and usually covered with epithelium. Clinical symptoms variable Myelomeningocele: cyst containing cerebrospinal fluid, meninges, spinal cord, and possibly nerve roots. Cord incompletely formed or malformed. Most common in the lumbar area. The higher the lesion, the more deficits present. 3. Congenital hydrocephalus (dilatation of ventricle) Rachischisis (in utero the vertebrae overlying the open portion of the spinal cord do not fully form and remain unfused and open, leaving the spinal cord exposed)  Encephalocele: in middle of the skull, or between the forehead and nose, or on the back side of the skull. sac-like protrusions of the brain and the membranes. Congenital blood flow disorders of the brain: Porencephaly- cysts or cavities within the cerebral hemisphere  Birth defect of the lobes: Holoprosencephalia (prosencephalon fails to develop into two hemispheres), hydranencephalia (the brain's cerebral hemispheres are absent to varying degrees and the remaining cranial cavity is filled with cerebrospinal fluid - (life-thretening condition)  Multiple reasons Schizencephaly Lissencephaly Hemimegalencephaly Ventriculomegaly Poly cystic leukomalacia Cortical atrophy Agenesis and digenesis of the corpus callosum Microcephaly Lyssencephaly: the whole or parts of the surface of the brain appear smooth Hemimegalencephaly: excessive neuronal proliferation and hamartomatous overgrowth affecting the cortical formation. Ventriculomegaly: lateral ventricle become dilated Poly cystic leukomalacia Cortical atrophy  Traumatic hemorrhage: periventricular leukomalacia: necrosis (more often coagulation) of white matter near the lateral ventricles.  Primitive reflexes vs. elementary movement patterns Primitive reflexes has brainstem and SC regulation (grasp, Moro, Landau, Galant etc.) Elementary movement patterns regulated via the basal ganglia (subcortical). The stimulus is the gravity and the position of the head Has specific feedforward chain reactions → movement Synaptic changes during practice Practicing 30 minutes 5-6 times a day until the movement patterns disappear ( overwrite)  Katona method Elementary movement patterns: Complex antigravity functions of the muscles of the neck and head (verticalization): - sitting - sitting in the „space” - “pushing” to sitting - “pulling” to sitting The coordinated movement of the extremities (locomotion): - elementary crawling uphill or downhill - elementary rolling from supine to side-lying and to prone - elementary or “assisted” crawling - elementary walking  Every typical and atypical movement occur in gravity. In rest or during movement the sensory system “feel” and the nervous system adapts the external and internal stimulus. In this case the labyrinth and the eyes have the main role. During passive and active movement the PT brings the sensory and motor system into action in different ways. During passive moments we activate the proprioception of the muscles and the joints → the stimulus via the spinocerebellar and spinocerebral tracts reaches the thalamus then goes to the sensory cortex in the parietal lobe. CONFLICT WITH CPG AND SENSORY STIMULI  During active movement The elementary movement patterns initiates and maintain active movements in the space In this case, the sensory input/stimulus does not originates from the proprioceptors, but from the labyrinth due to the position/ movement of the head in the space. Stimulus which is originates from the labyrinth reaches the active muscles via the vestibular and cerebrospinal motor tracts. SUBCORTICAL!!!  During active movement During the elementary movements several (few dozen) muscles are active in different combination. During these movements several different stimuli generated in the proprioceptors and goes to the cerebrum, cerebellum and labyrinth (spinovestibular tract) During the elementary movements this pack of stimuli continuously change the muscle tone and the locomotor movement patterns. This process 1. maintain the activated elementary movement pattern 2. fixates the movement procedure in the CNS (learning)  What would practice of elementary movements do? Teach active movements (these are existing movement patterns in every newborn) including verticalization, head control, upper and lower limb movements These elementary forms of the specific human movement and posture can be activated until the final active movement patterns overwrite them.  Main criteria of learning and teaching is regularity The CNS without regularity in any stages of the development will not be able to learn new skills Rule nr.3 in neurology: Repetition matters! Learning and practicing the elementary movement patterns has time limit (7-8 months of age) The limit is the beginning of active spontaneous movements in different period of time (from head lifting to standing). Main criteria of learning and teaching is regularity cont. The main problem is the evolvement of atypical movement patterns and atypical development as a result The aim is to prevent the development of the atypical movement patterns with using elementary movement patterns 6 times a day for 30 minutes Education of the parents is the most important Need checkup monthly One-on-one training can be 1-3 times a week if necessary Pathological development of the brain Has impact on elementary movement patterns as well Some of the elementary movements can be evoked atypically The impact of diseases of the CNS is NOT ON THE MUSCLES (except few disorders) or the sensimotor area in the spinal cord!!! The impact is on the higher cerebral centers! Areas of planning elementary movements are intact. Neuronal pathways of execution of elementary movement patterns are damaged. Localization of planning human movement patterns are in the basal ganglia and reticular formation Perinatal hypoxia causes damage usually in the primary motor and sensory cortex  Functional effects of atypical development of the brain Beside movement impairment alertness attention can be impaired. Primary movement patterns activates the reticularis formations and improve alertness and attention→ playing important role in “wakening reactions”  Tools for practicing elementary movements Parents education and involvement are requested Room temperature: 27-28 C (the child is naked) Clean sheet (accidents can happen) Mattress or therapy bed Slide (20-25°)  Assessment History: during awake state, 27-28°C room temperature, naked 1. Age correction for preterm babies: - 40th week of gestation is normal - correction before 38th week of gestation - at 36th week the correction is 4 weeks - Until age 1-2 years 2. Comorbidities (cardiopulmonary, orthopedic) 3. without pacifier 4. Growth chart, size of head and chest  Inspection Body parts, symmetry Pathological signs Spontaneous movements Normal posture for newborn: - typical tone is flexion skin color (marble like→ O2 deprivation) spontaneous movements Fists head lifting (STNR, ATNR)  Elementary movements Trigger: the changes in position of the head and gravity Complex antigravity functions of the muscles of the neck and head (VERTICALIZATION): - sitting - sitting in the „space” - “pushing” to sitting - “pulling” to sitting The coordinated movement of the extremities (LOCOMOTION): - elementary crawling uphill or downhill - elementary rolling from supine to side-lying and to prone - elementary (assisted)crawling - elementary walking  Assessment of the elementary movement patterns Can it be evoked? Dynamics Latency time Muscle tone Atypical movements (opisthotonus, limbs movement differences, strength differences, head not in the middle, trunk lateral flexion, head control etc) Opisthotonus: spasm of the muscles causing backward arching of the head, neck, and spine, limbs are extended  Sitting in “space” Holding the child’s thighs, supporting the head and back with the therapist’s chest. Lift up the child in front of you without any support, holding only the thighs Initial reaction of the child is head down, kind of floppy posture After 10-30 seconds (latency) the child trunk is getting straight, the head and the upper limbs are in upright position also. The fingers are in adduction. The lower limbs stay in flexion. The child can keep the upright position for several seconds. (newborn: few seconds, 1-2 months old: 10-15 seconds, 3-4 months: 10-30 seconds, 5-6 months: 1 minutes) The child is balancing in the “space”. Repeat few times. Reason: the initial “hanging” head position changes the angle of the labyrinth, and the effect of gravity via the vestibular system reaches the CNS and it responds with this specific movement patterns  Sitting in space Pathological signs: Application: - Opistotonus Torticollis - Axial hypotonia Cerebral Palsy - Atypical UE movement Hypotonia - Position of the head Spastic tetraparesis - Visual attention diplegia impairment (does not follow picture or object)  “Pull” to sit Child in supine position. Eye contact if it is possible Hold the hands evoke the Grasp reflex, than hold the hands and the wrists. Lower limbs are in flexion or slight extension. Starting position: pull the child slowly up to 25-30° Wait 5-15 seconds until the child suddenly initiates the pulling with the upper limbs and lifting the head up. The child pulls up himself up to 90 degrees and can hold for several seconds Let the infant back to the starting position and start over again 2-3 times  “pull to sit” Pathological signs: Application: - UEs strength differences - Cerebral palsy - Hemiparesis - Tetraparesis, - Opistotonus hemiparesis - Increased STNR - Axial Hypotonia - Late phase of brachial plexus lesion  Push to sit Starting position: supine. The therapist puts one of her hands under only the lumbar region, not to support the thoracic part. The other hand fixing the extended and adducted lower limbs. Push the child up to 25-30 degrees. Wait few seconds until the child initiates the head and trunk lifting into sitting position while the arms are flexed and abducted. It is a push. The therapist supports the lumbar part and maintain the position which was reached by the infant.  “push” to sit Pathological sign: Application: - Torticollis - axial hypotonia - Axial hypotonia - Brachial plexus lesion - UEs asymmetry - Opistotonus - Increased STNR  Crawling downhill Angle: 25-30° Prone position on the top of the slide After 5-10 seconds spontaneous rhythmical crawling movement should occur  Crawling downhill with face uphill Angle: 25-30° Prone position on the top of the slide After 5-10 seconds spontaneous rhythmical crawling movement should occur The difference btw face up and face down is: higher intensity, more head lifting(2-5 in 5 minutes) The child is moving uphill, but cannot proceed due to the relatively big head, he crawls actually downhill Pathological: opisthotonus, less head lifting  Assisted crawling uphill The same as crawling downhill with face uphill Start at the bottom of the slide Gently lift and hold the head up No pulling! Just follow the movement of the child This movement patterns are more effective with children with generalized hypotonia, spinal cord injury, cauda injury, myelomeningocele  Assisted crawling uphill Pathological signs: application: - Axial hypotonia - Axial hypotonia - Atypical limb - Paraparesis movements - Hemiparesis - Brachial plexus lesion  Rolling from supine to prone Supine position on a clean sheet Lift gentle the two edges of the sheet Lift the edge of sheet higher under the head and the shoulder to help initiate the movement of the head (30 degrees). This is the starting position. The child turns the head first than the shoulder than the whole body The trigger of the vestibular system is the turning of the head  Rolling from supine to prone Pathological signs: Application: - Increased tonic neck - Impaired head control reflexes - Brachial plexus lesion - Atypical UE movement - Tetraparesis - Diplegia  Assisted crawling Prone position on a plinth One hand under the chest and tummy, other hand is under the jaw Starting position: Lift up the child a little (knees and elbows reach the mattress), face forward Slowly pull the child forward In 5-10 seconds, the child will start rhythmic crawling movement and can stop anytime. PT needs to pull slowly, so the crawling movement will start again The head lifting itself can start the crawling movement → position of labyrinth changes (McGraw reflex)  Assisted crawling Pathological signs: Application: - UE asymmetry - Paraparesis - Paraparesis - Brachial plexus lesion - Hypotonia - Increased tonic neck reflex  Elementary walking hold the chest, lift up the child in standing position Feet on the plinth 5-30 seconds later the extension in the lower limbs will be increased, than in the trunk and in the head Bend the child’s trunk a bit forward, it will facilitate the walking movement pattern  Elementary walking Pathological signs: Application: - Scissoring - Paraparesis - Tiptoe, heel - Generalized hypotonia - LE hypotonia - Atypical UE  Neurotherapy for infants with hemiparesis 6x/day Elementary rolling (hemi side up) 4 minutes Pull to sit 4 minutes Push to sit 3 minutes Elementary crawling uphill 4 minutes Assisted crawling 4 minutes Elementary crawling downhill 4 minutes Sitting in space 3 minutes  Spastic Diplegia 6x/day Elementary rolling (both sides) 4-4 minutes Elementary crawling uphill 4 minutes Assisted crawling 4 minutes Elementary crawling downhill 4 minutes Sitting in space 3 minutes  Plexus brachialis lesion 6x/day Passive mobilization of the arm Elementary rolling (affected side up) 4 minutes Push to sit 3 minutes (pull to sit contraindicated → risk of luxation) Elementary crawling uphill 4 minutes Assisted crawling 4 minutes Elementary crawling downhill 4 minutes Sitting in space 3 minutes Perinatal injury of brachial plexus Rita Xantus PTMsc  Etiology Occurs during a difficult natural birth - Breech delivery→ traction of the shoulder during delivery of the head → injury of C5-6 (rarely C4) and/or fracture of the humerus or clavicule - Weight is greater than 3500 g - Prolonged maternal labor  Pathophysiology Damage can be at level of nerve rootlet attached to SC, roots, trunks, divisions and peripheral nerves Neurotmesis (complete rupture) Axonotmesis (disruption of axon, sheath intact) Neurapraxia (temporary nerve conduction block, axons intact) Partial or complete rupture may evolve to neuroma Hemorrhage into the subarachnoid space →blood in the cerebrospinal fluid → serious injury Recovery is very limited after ruptures  Prognosis Axonotmesis → best prognosis Axon regrowth 1mm/day Recovery takes 4-6 months UA, 7-9 months LA Recovery continues up to 2 yrs UA, 4 yrs LA Combination of different types of lesions is common → motor recovery is vary  Types of injury Erb’s palsy C5-6 (most common) Result of injury: - shoulder: extension, IR, ADD - elbow: extension - forearm: pronation - wrist and fingers: flexion Paralysis of: rhomboids, levator scapulae, serratus anterior, subscapularis, deltoid, supraspinatus, teres minor, biceps, brachialis, brachioradialis, supinator, long extensor of wrist and thumb Grasp intact Sensory loss can be present  Erb-Klumpke palsy (C5-T1) Upper and lower roots are injured Total arm paralysis and loss of sensation Klumpke palsy (C7-T1) Shoulder and elbow movements are not impaired Paralysis of: wrist flexors and extensors, extensors and intrinsic muscles of hand  Problems During the neural regeneration children use abnormal solutions They may also neglect the extremity because of sensory loss Soft tissue contracture → vary depending on the paralysis and the pattern Abnormal bone growth (slower) Common orthopedic abnormalities: - flat humeral head, apoplasia - short clavicle - positional torticollis  Activity limitations Developmental activities may be compromised Rolling, sitting up one side only Asymmetrical strength of the trunk Delaying balance reactions Creeping, crawling may not occur Self abusing behavior → biting Injury → burns, abrasions Shoulder pain and neuritis in adults  PT examinations Days, weeks, months or years after birth Active, passive ROM. HANDLE WITH CARE! Muscle strength, motor function, active movement scale (reflexes: MORO, parachute. Asymmetrical abdominal or thoracic movement→ phrenic nerve. Visual tracking. Neck righting. Etc) Spasticity shouldn’t be present!!! Sensory status (grading system for children with BPI) sensory loss may change to hyperesthesia before achieve normal sensation Developmental status → in all positions (spontaneous or facilitated? Against gravity? In neonates frequent re-examination (2 weeks, 1-2- 3 months of age) MRI, EMG  Mallet’s classification of function in obstetric brachial plexus palsy I-V grade  Physical therapy goal 5-10% neurosurgery 60-80% spontaneous complete recovery Parent education, home program ROM (precaution regarding of subluxation, contracture, sensory loss) Positioning, splinting, therapeutic play Direct, indirect electrical stimulation Neonates-Katona method: sitting in the “air”, elementary rolling, elementary crawling. Strengthening, facilitation, assisted reaching, guiding etc. Sensory perception: different textures, temperatures, finding toys in water or rice Electrical stimulation maybe… after neurosurgery yes, but without neurosurgery no evidence.  Reference Suzan K. Campbell, Physical therapy for children David J. Magee,James E. Zachazewski,William S. Quillen,Robert C. Manske, Pathology and Intervention in Musculoskeletal Rehabilitation N Smania et al, rehabilitation of brachial plexusinjuries in adults and children  Permanent disorder of movement and posture Caused by a non-progressive pathological condition of the immature brain Combination of motor dysfunctions Can occur pre-natally, peri-natally, post-natally May be associated with: intellectual, personality disorders, epilepsy Pathogenesis of CP in a large number of cases of hypoxic-ischaemic encephalopathy  Risk factors: chronic neural impairing factors Prenatal 70-80% (prematurity, low birth weight, genetics, infection, twin pregnancy, maternal cause) Perinatal 10% (birth asphyxia, complicated delivery) Postnatal 10%( cranial trauma, KIR infection, cardiac arrest, trauma)  In the case of newborns, intrauterine causes are thought to have occurred natal to term, in many cases premature infants, it is most often considered to be the result of hypoxic-ischaemic or haemorrhagic damage due to immaturity.  Permanent, not progressive, but may change in appearance as the brain matures Symptoms may be characteristic from infancy, with clinical presentation becoming complete at 3-4 years of age Differential diagnosis: tumour, degenerative metabolic disorder, muscular dystrophy  Classification of CP: Based on clinical signs: when and what damage has been done to the developing brain Motor symptoms: determines the state of muscle tone Anatomical localization  Motor symptoms: Hypertonic, hypotonic Persistent muscle tone disturbance: spastic bilateral (60%), spastic unilateral, spastic tetraparesis (10%), hemiparesis (30%)Variable muscle tone - dyskinetic form: dystonic form (6%), choreoathetotic form Generalized hypotony(less common)  CP may be associated with intellectual disability Epilepsy Hearing impairment Conduct disorder Complications: Severe contractures, luxation, limb shortening, deformity, severe contracture of adductors often causes hip dislocation  Spastic type/Hypoton type: mild, moderate, severe The importance of early treatment is even greater for spastic signs Late treatment results in less improvement in function  Therapy is based on early diagnosis Prevention of secondary complicationsIf necessary, surgical procedures: tenotomy, joint reconstructive surgery, bone correction surgery Early physiotherapy: DSGM, Katona, HRG, Bobath, Vojta, Pfaffenrot, NHT1,2, TSMT, HRG, Halliwick At older ages, use of virtual devices, robotics for self-care and movement development. Use of orthotics: peroneal lift, walking machine corset, individual lower limb orthosis to correct leg position SDR surgery - an irreversible procedure Used for large spasticities involving many muscles Patient selection: patients between 5 and 9 years old, able to walk with an aid, able to cooperate properly, who accept the 2 years of treatment and have no fixed deformities or over-mobility – Pre-operative rehabilitation: ensuring adequate fitness Preoperative localisation MRI Thank you for your attention!  History of Pediatrics Foundling-Foundlings’ Home, Midle Ages, City civilization Turning box/Nunnery–Foster–bastard (illegitimate) 25%. Mortality rate untill XIX. C.30-90% Inflamation of the Lung inflamation bowel (dysenteria), (pneumonia), Croup (diphteria), Whooping cough (pertussis)  Rosén von Rosenstein the Swedish paediatrician, author of the first textbook on paediatrics. The German version of this work of 1764 was interestedly read by Bókay.  The organized medical care of infants and children can be traced back only to the late Middle Ages. All paediatric knowledge of the age was described in a small booklet in Hungarian.  Children’s Hospitals – 1802 Paris 1839 St Petersburg, Wienna, Budapest, then London, Stockholm Infant mortality rate 70% August Schoepf Merei 26 Sept 1804 Győr  There was not organized pediatric care and education of pediatrics in Hungary untill 19 Century August Schoepf- Merei was established – at private expense – the first private institution at Pest. And later Poor Children’s Hospital, Pest, 1839. Infants taking the air in the yard of the hospital in the Szentkirályi street building. The nurses –actually nuns – used linen ‘umbrellas’ to protect the children from the sun. Stetoscope After losting freedom fight 1848-as. He emigrated to Manchester. 1856 Clinical Hospital for Disease of Children  XVI. International Medical Conference, Budapest 1909. Scientific discussion of Paediatricians in 10th section Presidential opening by János Bókay  Victor H Hutinel Parisian Professor of Paediatrics Accepted to organize an International Paediatric Association V H Hutinel  The Hungarian Paediatricians established the Hungarian National Association of Paediatrics in April 30, 1910 President: János Bókay Secretary: Pál Heim Pál Heim PREVENTIV/VISITING NURSE SYSTEM IN HUNGARY  Orphan and abandonend children were admited to a palace in Edelény by Countes Ludmille Ghimesi Forgách. Children were treated here. The beginning of Child welfare in Hungary concerne of the illegitime child and poor chidren hospital care.  Mór Szalárdy organized the White Cross Union for tending left children in maternity hospitals in 1885 in Hungary. 29 towns joined to the White Cross Union during the next 10 years.  Later White Cross Hospital was built on Tüzoltó street in Budapest. The first chairman of White Cross Foundlings Home Union was Pál Heim. Pierre Constant Budin (1846-1907) obstetrician organized infant care at University in Paris  Infant care was organized in Leipzig, Germany, by Professor Taube in 1890. Many „Fürsorgestelle” functioned before the World War I. in Germany. Charlottenburg Infant mortality rate /100 newborn in Europe Country 1913 1914 1915 1916 1917 1918 Hungary 20,1 19,7 26,4 21,8 21,6 21,7 Germany 15,1 16,4 16,8 14,9 15,5 15,4 Austria 19,0 17,2 21,8 19,2 18,6 19,3 Finnland 11,3 10,4 11,0 11,0 11,8 11,5 France 10,9 10,9 14,1 12,2 12,3 13,8 England 10,3 10,5 11,0 9,1 9,6 9,7 Swith 9,6 9,3 9,0 7,8 7,9 8,8 Norway 6,5 6,8 6,8 6,4 6,4 6,3  National Stephanie Association (1915-1940) Ceremonial founding session was organized at city hall on 13th of June in 1915 with the patronage of Princess Stephanie. Stephanie was a Belgian princess who was the wife of Rudolf hereditary Prince. Rudolf died very early and Stephanie got married count Elemér Lónyai. The most important task of protection work was the PREVENTION National Stephanie Association  Vilmos Taufer „Intelligence of our people is not sufficient yet. We have to penetrate into the people, visit them at home.”  Preventive Nurse District nurse PCP or Visiting Nurse  Infant mortality rate /1000 newborn 200 200 %0 in Hungary 180 160 140 120 100 90 80 60 48 36 40 23 15 9 20 5 5 4,6 0 1915 1949 1960 1970 1980 1990 2000 2010 2013 2014  How long the babies 100% 96% have breast-feeding? 89% 90% 83% 80% 75% 68% 70% 61% 60% 60% 54% 50% 50% 42% 40% 40% 34% 34% 30% 20% 10% 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 month 60% was exclusively breast-fed N=400 until the age of 6 months The vaccination rate is 99% on average in Hungary. WHAT WILL BE THE FUTURE? MAYBE, Virág Szabó great price 2002, Seixal, Portugal  BSc in Preventive Nursing Semmelweis University, Budapest, Hungary How to apply http://www.studyhungary.hu/ or the official website of Semmelweis University. www.semmelweis-english- program.org Data of Live birth and Mortality rate in Hungary, 1960-2011 Per 1000 inhabitants Mortality Natural increase Natural decrease Live birth  151819 LIVE BIRTH AND ABORTION 160000 IN HUNGARY 140000 125679 120000 97597 100000 92283 90394 90335 88050 80000 59249 60000 40449 38400 40000 20000 0 1970 1990 2000 2010 2011 Live birth Abortion  Infant mortality/1000 live birth in 2008 25 21,4 19,8 20 National average Borsod County 15 9,5 More deprived 10 5,6 part of BC Gipsy population 5 0 Changes of Infant mortality/1000 live birth 18 17,5 15,2 16 14 11,1 12 10,1 10 8,1 7,4 8 6 4 2 0 1997 2002 2007 Gipsy Hungarians Non-Gipsy Hungarians Changes of Intaruterin mortality/1000 live birth 16 14,2 14 10,9 12 10 8 5,6 6,2 6 4 2 0 1997 2007 Gipsy Hungarians Non-Gipsy Hungarians In 2007 Non Gipsy Gipsy Distribution 60% 40% (35%) Premature 8.2% 12.8% Short forearm cast for 4 weeks PRONATION– SUPINATION decrease usually PT: start with flexion-extension, than pronation-supination In relieved position, the with gravity and later with resistence Use tools: e.g. balls(smaller, bigger),  PT after wrist fracture (radius,ulna)  Take care of circulation and perception  Positioning the extremity is important  Ratschow–technique: Exercise the injured limb every hour with pumping and lifting exercises pain around fracture during PT→can be the sign of redislocation Cast would need correction if the patient feels: the fixation is too tight, the limb is swollen, feels numb  PT after wrist fracture(radius,ulna)  You have to practice the movements of the forearm and wrist fingers and during this you have to try to keep the hand functional  Perform pro-supination with elbow and forearm support  Flexion-extension of the wrist with forearm support, so that the wrist rests on the edge of the table  Great attention must be paid to the function of the hand and fingers, because flexion is often limited  Care must be taken not to perform wrist and finger flexion at the same time in the begining, because shearing forces are generated in the fracture! Elbow Fracture At birth, the bones of the elbow joint are still completely cartilaginous Typical injury of children under 10 years of age Stabilizing bands are loose Metaphysis is weak The olecranon is stretched into the fossa olecrani -> a stretching force acts on the supracondylar area Elbow Fracture A REPOSITION: -> FIZIOLOGICAL VALGUS: 5- 10 degree -> TROCHLEA-HUMERUS ANGLE IS: 25-40 degree -> BAUMAN-ANGLE IS: 75-80 degree / HUMERUS – CAPITULUM RADII/ TAKE CARE CARTILAGEA HUMERUS SUPRACONDYLER FRACTURE Hyperextension fracture -> supracondyler fracture Neuro-vascular co-injury is high level Usually dislocated – Surgical repositio -> percutan fixation – fixateur externe Post-med dislocatio ->n. Radialis injury is high level Post-lat dislocatio -> n. Medianus, a. brachialis Compartment syndrom are high level! Very careful PT -> myositis ossificans If it is allowed, selective electrotherapy is possible Fixateure externe Useful, because PT can start inmediatelly  PT AFTER HUMERUS SUPRACONDYLER,ELBOW FRACTURE PT have to start with flexion-extension and in supported position, than followed pro-, supination During PT :  The elbow joint and the connective tissue around the joint are very sensitive →→ →→ Try to avoid pain!  No use too much force against the muscles!  No use too hot hydrotherapy !  These points could cause myositis, SSRD(Somatic Symptom Related Disorders )  Other complication: deformities, contractures, length asymmetry Humerus luxation Bancart laesio : antero-inferior dislocation of Atraumatic luxation: in case of the humerus with labrum injury instabil shoulder joint Common by teenagers  Teenagers  6 weeks Gilchrit  After 12 month conservative  rehabilitation if the patient’s condition requires an operation is performed.  At anterior luxation Neer surgical method is used (Reinforcement of the front part of the capsule)  Posterior luxation needs Rotator Cuff reconstruction (maybe bone block too) PT after humerus luxation After 6 week fixation start PT with pendulum excercises, frontal plane abduction first till 90˚ Isometric excercises External rotation allowed after 3 month  Pelvic fracture Because the flexibility of the bones, internal damage is more common, but fracture of the pelvis also possible. Remodelation is good, but lower limb asymmetry is a high risk Type of classification: Tile  Pelvic fracture classification A-os pubis, os ilium fracture without A deformity B-symphysis ring fr., transacetabul fr-with dislocation or without B C-vertical dislocation C with deformity  Surgical treatment of pelvic fracture Surgical treatment: Surgical reposition Osteosynthesis Minimal invasive methods: Closed reposition Fixateur externe Combination of surgical methods  PT Start with innervation, without resistence excercises, passive mobilisation of lower limb flexation only till 90˚ Instabil cases: flection and adduction would be delayed movements In case of stabil fractures- positioning is important Prone position important in contracture profilaxis – only in stabil fracture possible Isometric closed chain innervation excercises Open chain excercises without resistence Strengthening excercise start with short load Strengthen the core muscles, gluteal muscles, m.quadriceps Start in lying position and later followed vertical positions  Fracture of lower limb in childhood Femoral collum racture Femur diaphysis fracture Fracture of femur distal part tibia proximal part fr. eminentia intercondylaris fr. Patella fr. Luxation of patellae talocruralis fr. Ligament injuries  Femoral collum fracture Differ from adult cases: - have a physis - The trabecular part not formed-> solid part - Physiotherapy Early mobilisation – contracture profilaxis Physio without any load can be 4 weeks adduction, rotation till mid position, flexion with short load complication – Caput femoris necrosis – Early epyphysis close – limb asymmetry – Collodiaphyaseal angle discrepancy-coxa vara/valga Fracture of lower limb Surgical treatment ESIN fixation- Elastic stable intramedullary nailing (till 13 years) Is most common surgical technique Loading is allowed in early period  Physiotherapy Pain relief – Iontoforesis, ultrasound (Fastum, Activon, Voltaren) – Laser Muscle stimmulation – Electrotherpay-under muscle strength 3  PT after ACL, PCL injury ROM correction 0-2 weeks without loading – CPM 2-4 weeks 0-60˚flexion, partial – Active excercises with loading innervation 4-6 weeks 0-90˚ flexion, with – Active streching more loading – Isometric excercises 6-12 weeks full ROM, full loading Over 12 week sport  PT Developement of muscle strength: Isometric, close cinetic chain, later open cinetic chain With and without resistence, muscle specific excercise  PT Propriocepcion Balance control  PT Develope cardiovascular Capacity Sport specific method Sport specific excercises  Burn injury Burn: Pathological changes resulting from the local or general effect of high heat Local burn: When the thermal trauma has a short and circumscribed effect Burning desease: extensive tissue damage impairs the functioning of the entire body Reasons: heat, electric shock, chemicals,  Classification of burn injury According surface and age: Lund-Browder system Under 2 years: 5% 3-10 years: 10% serious 10-15 years: 15% Over 15 years: 20% Burn injury  Burn injury Hypermetabolic process: increased protein breakdown Inadequate protein synthesis Muscle atrophy Needs: Increased calorie intake, mineral, amino acid, vitamin supplementation In the acute department, insulin supports the protein synthesis  PT in burn injury Maximum protection-acute period, first 12 days Goal: prevention of pulmonary complications, improvement of circulation of burned body parts Therapy: ventilation of lung lobes, improvement of blood circulation, prevention of restricted joint movement, promotion of wound healing, prevention of infections, Method: oxygen therapy, chest vibration, positioning, fluid bed, passive and guided active movement  PT in burn injury Subacute phase: scarring phase day: 12 – 90 Goal:protection of burn scars, promotion of flexibility, mobility Therapy : protection of a healing scar, prevention of contractures, maintenance of muscle strength, preparation for walking Method: mobilization, use of isometric exercises, active movement compression dressing, plaster cast,  PT in burn injury Chronic and rahabilitation phase: stage of scar maturation from 3. month till 1,5years Goal : achieving the full joint range of motion, improving the reduced flexibility of burn- damaged areas Method: manual therapy: joint and soft tissue mobilization, stretching, posture correction, development of correct gait, psychological support, walking exercises Rehabilitation phase, reintegration, socialization, ADL  Skull injury Rate of falls in the first year of life 8. ábra Leesések száma az első életéven belül 12 10 10 8 8 6 6 5 4 4 4 3 3 3 2 2 1 1 0 1 hó 2 hó 3 hó 4 hó 5 hó 6 hó 7 hó 8 hó 9 hó 10 11 12 hó hó hó ->In neonatology and pediatry skull injury common as result of trauma and abuse  Skull injury Important points in case of skull injury Know the mechanisum of the injury Is it a low energy injury? Is it a high energy injury? How old is the child? Did an adult or an older child see the accident? What is the child's state of mind? What symptoms can be detected?  Skull injury Low energy injury: the child hit her/his head on the door jamb, chair, bed headboard, fell off the bed, etc. Or falls while running Important: what the child fell on (e.g.: concrete, carpet, floor tiles, etc.) High energy injury: traffic accidents (bicycle, car) falling from twice your body height or more (not only if you fall directly on your head!) In this case, immediate call the emergency service!  Skull injury She/he remembers what happened How was the crying and reassurance after the accident Vegetative symptoms: Nausea, vomit,dizziness, visual impairment,headache Neurological symptoms: strange gait, confusion, unusual behavior, Pupillary abnormalities, clones  Skull injury Commotio cerebri (brief loss of Surgical treatment: consciousness, headache, Craniotomy, haematom punctio, nausea, vomiting, amnesia, drainage dizziness) Medical treatment: barbiturates, Shaken baby diuretics syndrome=SBS(intracranial haemorrhage,somnolence, nutrition problem, CP- consequence) Polytrauma Contusio cerebri Skull fracture Subdural haematom Epidural haemateom Posttraumatic hydrocephalus Posttraumatic epilepsy Shaken Baby Syndrome /SBS/  Physiotherapy The nature and rate of Respiratory complications recovery of the most serious injury dictates the Complications of the physiotherapist's treatment cardiovascular system Neurological complications Gastrointestinal complications Disorders of immune function Changes in metabolism Musculoskeletal complications  PT prevention of early and late complications resulting from immobility and polytraumatization: 1. Pneumony profilaxis 2. Thrombosis and embolism profilaxis 3. Decubitus profilaxis 4. contracture profilaxis, positioning 5. Passive mobilisation starting injury-specific physiotherapy Early mobilisation psychosocial support  Subacute phase PT Maintaining the muscle strength of non-injured limbs, improving the general physical condition ADL excercises Preparation of a physiological gait pattern Core training, vertical positioning, Amputation  Surgical removal of a limb is amputation. It is possible with intraarticular or exarticular amputation.  Physiotherapy Reduction and prevention of edema Contracture prevention and resolution Muscle strengthening Reduction of phantom sensation/desease Balance and coordination training Development of body schema formation Complications Prevention of abnormal postures and deformities Wheelchair or prothesis use  Physiotherapy Use a prothesis as fast as possible Its early use helps in the development of a body schema Teach the indepent and harmonic use of the limbs In case of junger children:easy and functional prothesis is important In casse of teenagers esthetic part is important too. Prothesis  Upper limb prothesis In most cases upper limb prothesis is aesthetics  Peak of the physiotherapy Sport after amputation or any other physical disabilty  Questions Acceptance of the prosthesis-mostly by teenagers or parents Growing – Over groving the prothesis – needs reoperation and new prothesis – frequent prosthesis correction and replacement https://www.youtube.com/watch?v=3hA07m5i-7M&t=5s Thank you for your attention!