Ryan Joseph M.

Dela Paz, PT, PTRP

 DEFINITION OF TERMS

 Gestational age
 Conceptional age
SPINAL REFLEXES
SPINAL REFLEXES
BABINSKI REFLEX
SPINAL REFLEXES
FLEXOR WITHDRAWAL REFLEX
SPINAL REFLEXES
CROSSED
EXTENSION
REFLEX
SPINAL REFLEXES
GALANT
REFLEX
SPINAL REFLEXES
POSITIVE
SUPPORT
REFLEX
SPINAL REFLEXES
PRIMARY
WALKING
REACTION
SPINAL REFLEXES
ROOTING
REFLEX
SPINAL REFLEXES
SUCKING
REFLEX
SPINAL REFLEXES
STARTLE
REFLEX
SPINAL REFLEXES
MORO
REFLEX
SPINAL REFLEXES
TRACTION
REFLEX
SPINAL REFLEXES
PLANTAR
GRASP
REFLEX
SPINAL REFLEXES
LANDAU
REFLEX
SPINAL REFLEXES
PLACING
REACTIONS
MIDBRAIN
REFLEXES
MIDBRAIN REFLEXES
ASYMMETRIC
TONIC
NECK
REFLEX
MIDBRAIN REFLEXES
SYMMETRICAL
TONIC NECK
REFLEX
 MIDBRAIN REFLEXES
TONIC
LABYRINTHINE
REFLEX
CORTICAL
REFLEXES
 CORTICAL REFLEXES
 OPTICAL /
LABYRINTHINE
RIGHTING
 CORTICAL REFLEXES
PROTECTIVE EXTENSION

4 MOS 6 MOS

9 MOS
7 MOS
 CORTICAL REFLEXES
TILTING REACTIONS

NORMAL AGE OF RESPONSE

Prone –5mos
Supine –7 months
Sitting –8 months
Quadruped –12 months
ALL PERSIST
 CORTICAL REFLEXES
BODY RIGHTING REACTION ON HEAD (BOH)
 CORTICAL REFLEXES
 BODY RIGHTING REACTION ON BODY (BOB)
 CORTICAL REFLEXES
 BODY RIGHTING REACTION ON BODY (BOB)
 1 MONTH 2 MONTHS

• Decreased flexion • Head elevation to 45

• Momentary head elevation degrees (prone)
with minimal forearm support • Prone on elbows with elbow
• Tracks a moving object behind shoulders
• Head usually to side • Does not accept weight on LE
• Reciprocal and symmetrical (astasia-abasia)
kicking • Responds to friendly handling
• Positive support and primary
walking reflexes in supported
standing
• Hands fisted with indwelling
thumb
• Neonatal reaching
• Alert, brightening expression
 3 MONTHS
• Prone on elbows, weight-
bearing on forearms
• Elbows in line with shoulders
• Head elevated to 90
degrees
• Head in midline in supine,
hands on chest
• Increased back extension
with scapular adduction in
supported sitting
• Takes some weight with toes
curled in supported
standing
• Coos, chuckles
4 MONTHS
• Rolls, prone / supine to side
• Sits with support
• No head lag in pull-to-sit
• Optical and labyrinthine
head righting present
• Bilateral reaching with
forearm pronatedwhen
trunk supported
• Ulnar palmar grasp
• Laugh out loud
 5 MONTHS 6 MONTHS

• Rolls from prone to • Prone on hands

supine (elbow extended)
• Weight-shifting • Weighting shifting
from one forearm from hand to hand
to the other in • Rolls supine to
prone prone
• Head control in • Independent sitting
supported sitting • Pulls-to-stand,
bounces
 7 MONTHS

• Can maintain quadruped

• Pivots on belly
• Pivot prone (prone
extension)
• Assumes sitting from
quadruped
• Trunk rotation in sitting
• Recognizes tone of voice
• May show fear of
strangers
 8-9 MONTHS

• Belly crawls
• Quadruped creeping
• Moves quadruped to sitting
• Side-sitting
• Pulls-to-stand through
kneeling
• Cruises sideways
• Can stand alone
• Reaches with close arm,
radial digital grasp, radial
palmar, 3 jaw chuck grasp
• Transfer objects from one
hand to the tother
 10-15 MONTHS
• Begins to walk unassisted
• Begins self-feeding
• Reaches with supination
• Neat pincer grasp, can
release
• Build a tower of 2 cues
• Searches for hidden toys
• Suspicious of strangers
• Plays patty-cake and
peek-a-boo
• imitates
20 MONTHS
• Ascends stairs step-to
pattern (two feet on each
step)
• Running more
coordinated
• Jumps off of bottom step
• Plays make believe
 2 YEARS 3 YEARS

• Runs well • Rides tricycle

• Reciprocal stair climbing • Stands on one foot briefly
• Active, restless, tantrums • Jumps with two feet
• Understands sharing

3.5 YEARS 4 YEARS

• Hops on one foot • Hops on one foot several

• Kicks ball times
• Stands on tiptoes
• Throws ball overhand
• Relates to friends
 5 YEARS

• Skips
• Kicks ball well
• Dresses self
 HISTORY
 APGAR SCORE
 HEAD CIRCUMFERENCE
 HEIGHT
 WEIGHT
 GENERAL INSPECTION
 MUSCULOSKELETAL ASSESSMENT
 NEUROLOGIC ASSESSMENT
 SCREENING TESTS
 CRITERIA 0 1 2

Appearance Blue or pale all over Pink trunk;blue Pink

extremities
Pulse rate Absent <100bpm > 100bpm

Grimace No response Grimace Cries

(Reflex
irritability)
Activity None Some flexion Flexed arms and legs
that resist extension
Respiration Absent Weak, irregular, Strong, lusty cry
gasping
 You just delivered a baby boy. His body is pink, but
his hands and feet are blue. Vital signs are P110, R
rapid and irregular. He has a weak cry when
stimulated and resists attempts to straighten his legs.
His APGAR score is
 After assisting in the delivery of a newborn the
infant is pale and limp, has a slow heartbeat but
shows some respiratory effort. What APGAR score
would you give this infant?
AGE AVERAGE AGE AVERAGE AGE AVERAGE

Birth 35cm Birth 50 cm Birth 3.4 Kg

12 mos 75 cm
4 mos 41cm 5 mos Double
4 yo 100 cm
12 mos 47cm Early
12 mos Triple
+5 cm
adolescence
Mature 57 cm Until 2 Kg
Puberty +5-8cm
adolescence annually
GENERAL INSPECTION
 Head and neck symmetry

 Extremities

 Skin abnormalities
PREMATURITY
MOVEMENT AND POSTURAL PROFILE
 Does not develop the physiological flexion of full-term
newborn
 May exhibit hyperextended neck and trunk

 Shoulders may be elevated, abducted, extended with

scapular retraction
 Hips abducted and extended

 Pelvis tipped anteriorly (increased lumbar lordosis)

 Decreased midline arm movement

 May bear weight on toes when in supported standing

COMPLICATIONS
 Respiratory Distress Syndrome

 aka Hyaline Membrane disease

 Due to atelectasis caused by insufficient surfactant in
premature lungs
 May lead to acute respiratory failure and death
 Tx: Oxygen supplementation, assisted ventilation &
surfactant administration
 Chronic RDS -> brochopulmonary dysplasia
COMPLICATIONS
 Bronchopulmonary Dysplasia

 Chronic lung disease as a result of damage to lungs

from mechanical ventilation, oxygen administration and
chronic RDS
 Predisposes child to frequent respiratory infections
and developmental disability
 Tx: respiratory support, infection control, and
bronchodilator administration
COMPLICATIONS
 Periventricular Leukomalacia

 Necrosis of white matter adjacent to ventricles due to

systemic hypotension or ischemia
 May lead to Cerebral palsy

 Periventricular-intraventricularhaemorrhage
 Bleedinginto immature vascular matrix
 May lead to Cerebral palsy
COMPLICATIONS
 Increased fragility of skin

 Thermoregulation problems

 Feeding problems

 Interaction/ attachment problems with caregivers

INTERVENTIONS
 Play activities

 Encourage reaching for toys or parent’s face if over 32

wksconceptionalage
 Positioning

 facilitate shoulder protraction and adduction

 Supported S/L while doing visual and auditory tracking and

reaching
 Prone positioning (tummy time)

 Midline head positioning

 Supine positioning –sleeping (avoid SIDS)

 Avoid activities which may increase extensor tone (use of

infant jumpers and walkers)
CEREBRAL
PALSY
CLASSIFICATION
By area of body showing impairment
 Monoplegia

 Diplegia

 Hemiplegia

 Quadriplegia

By most obvious impairment

 Spastic

 Athetosis
SPASTIC CEREBRAL PALSY
 involvement of PYRAMIDAL
TRACTS
 MC: SPASTIC DIPLEGIA

 (+) initial hypotonia, sets in at

6mos.
 increased muscle tone in
antigravity muscles
 abnormal postures and
movements with mass patterns
of flexion/extension
 Hip dislocation, scoliosis,
contractures
SPASTIC DIPLEGIA
(N) intelligence
(+) strabismus
Flexor:
 “frog-like position”
(standing)
 “bunny-hopping” (walking)

Extensor:
 “scissoring”

 “combat-crawl”
SPASTIC HEMIPLEGIA
 Limb asymmetry

 Early hand dominance

 (+) growth and leg length

discrepancy
 (+) cortical sensory
deficits
 Good prognosis for
ambulation
SPASTIC
QUADRIPLEGIA
 Opisthotonus

 Straphanger sign

 (+) MR

 Petit mal seizure

 Drooling, dysarthric
speech
 Swallowing, sucking,
chewing difficulties
ATAXIC CEREBRAL PALSY
 Low postural tone

 Poor balance

 Intention tremor of hands

 Uncoordinated movement

 Ataxia follows initial hypotonia

 Poor visual tracking; (+) nystagmus

 Speech articulation problems

 May occur with spastic or athetoid CP

DYSKINETIC CEREBRAL PALSY
Involves EXTRAPYRAMIDAL TRACTS
 Athetosis– distal part of limbs

 Ballismus- extremities

 Chorea – proximal

 Dystonia- axial
ATHETOID CEREBRAL PALSY
 Generalized decreased muscle tone (floppy
baby syndrome)
 Poor functional stability

 Ataxia and incoordination when child

assumes upright positions with decreased
BOS
 Muscle tone fluctuations

 Poor visual tracking, speech delay and oral

motor problems
 Tonic reflexes may be persistent
GROSS MOTOR FUNCTION
CLASSIFICATION
LEVEL DESCRIPTION

I Walks without restrictions; limitations in more advanced gross

motor skills
II Walks without assistive devices; limitations walking outdoors and
in the community.
III Walks with assistive mobility devices; limitations walking
outdoors and in the community
IV Self-mobility with limitations; children are transported or use
power mobility outdoors and in the community
V Self mobility is severely limited even with the use of assistive
technology
INTERVENTION
 Individualized
 Incorporate child and family in goal setting,
intervention planning and implementation
 Focus on prevention of disability
 Static (positioning) and dynamic patterns of movement
opposite habitual abnormal spastic patterns
 Facilitate postural symmetry

 Elongate spastic hamstrings and heelcords

 Serial casting
INTERVENTION
 Use toys, fun activities, balls and bolsters to facilitate
postural control and developmental activities
 Use weightbearing and postural challenge to increase
muscle tone and strength
 Incorporate orthoses (AFO)
 Utilize adaptive equipment
 Wheelchair
 Supine/prone standers, parapodium–promote weight
bearing
 Rollator walkers
SPINA BIFIDA
 Dx: elevated serum or amniotic alpha-fetoprotein,
aminioticacetylcholinesterasein prenatal period and
sonogram
 Link between maternal decreased folic acid,
infection, hot tub soaks, and exposure to teratogens
 SPINA BIFIDA OCCULTA
 SPINA BIFIDA CYSTICA / APERTA
 Meningocele

 Myelomeningocele
 Depends on level of lesion and amount of malformation of
cord
 Muscle paralysis and imbalance resulting from spinal and
lower limb deformities and joint contractures
 L4, L5 lesion results in bowel and bladder dysfunction
 Sensory loss
 Developmental delays
 Abnormal tone
 Osteoporosis
 Cognitive impairments including mental retardation, learning
and perceptual disabilities, language disorders
LEVEL Muscles Pre-amb Ambulation Assistive Functional Musculo-
innervated Orthoses Orthoses Devices Prognosis skeletal
Problems
THORACIC Abdominals Standing RGO Parallel bars Wheelchair Spinal
frame deformity
Decubiti

UPPER Above & Standing RGO Parallel bars Wheelchair Hip flexion
LUMBAR hip flexors frame Walker Possible contracture
Forearm household/
crutches therapeutic
ambulation
Sit-to-stand
MID- Above & None HKAFO Parallel bars Wheelchair Hip
LUMBAR knee KAFO Walker (community) dislocation,
extensors & AFO Forearm Orthoses subluxation
hip crutches (household)
adductors
INTERVENTION
 Teach parent proper positioning, handling, and exercise

 Keeping physiological flexion of the newborn

 Include prone positioning to avoid shortening of hip flexors,

as well as hip ROM, low tone, and osteoporosis in mind.
 Use of adaptive equipment/orthoses

 spinal orthosesfor alignment

 adaptive chairs for sitting (if needed)

 parapodiumfor early standing

 LE orthosesand ambulation assistive devices, and or

wheelchair as needed
 Facilitation of functional motor development
HYDROCEPHALUS
 Cushing’s triad
 Congenital VS Acquired Hydrocephalus
 Obstructive / Non-communicating
 Non-obstructive / Communicating
 Normal Pressure Hydrocephalus
 Hydrocephalus ex Vacuo
INFANTS
 Macrocephaly

 Dysjointed sutures

 Tense fontanelle

 Sunset gaze

 Vomiting

 Sleepiness

 Irritability

 Seizures
CHILDREN & ADULTS
 Headache

 Vomiting

 Nausea

 blurred or double vision

 sun setting of the eyes,

 problems with balance,

 poor coordination

 gait disturbance

 urinary incontinence

 irritability, or other changes in personality or cognition including

memory loss.
 slowing or loss of developmental progress

 Lethargy, drowsiness
 DOWN’S
SYNDROME
CLINICAL MANIFESTATIONS
 Simian crease

 Almond-shaped eyes, Upslanting palpebral fissures

 Very round face

 Shorter limbs and neck

 Protruding tongue

 White spots on the iris known as Brushfield spots

 Behaviour: natural spontaneity, genuine warmth,

cheerful, gentle, patient and tolerant. A few pts exhibit
anxiety and stubbornness.
CLINICAL MANIFESTATIONS
 Hypotonic

 Joint laxity (Atlanto-axial joint instability)

 Decreased muscle force generation

 Congenital heart defects

 Visual and hearing losses

 Mental Retardation
FUNCTIONAL LIMITATIONS
 Gross motor development delay

 Difficulties in eating & speech development

 Forceful neck flexion & rotation activities should

be limited, d/t AA ligament laxity
 Cognitive & perceptual deficits may result in delay
of fine motor & psychosocial development
INTERVENTIONS
Minimize gross motor delay.
 Facilitate gross and fine motor development through appropriate
positioning, posture and movement activities.
 Increase strength and stability by manipulating gravity and
resistance in a graded manner.
Encourage oral motor function.
 Facilitate lip closure and tongue retrusion.

 Short, frequent feeding sessions for energy conservation.

Avoid hyperextension of elbows and knees during weight bearing

activities.
Prognosis may be correlated with tone, the lower the tone the more
significant the motor delay.
All children with Down Syndrome will eventually become ambulatory.
CLINICAL MANIFESTATIONS
 Proximal to distal muscle weakness

 Primarily involves: hip and knee extensors

 Gower’s sign

 Calf pseudohypertrophy

 Increased lumbar lordosis

 Waddling gait

 Wheelchair bound usually by 10-15 y.o.

 MC Cause of death: respiratory failure

INTERVENTIONS
 Maintain mobility
 encouraging recreational and functional activities
 Maintain joint range of motion
 AROM, PROM
 Positioning devices such as prone standers or standing
frames.
 Night splints
 Electrical stimulation of muscles for younger children
 Family education
 Do not exercise at maximal level, may injure muscle
tissue (overwork injury).
 Supervise use of adaptive equipment as needed.
ERB-DUCHENNE
 C5-C6

 upper arm paralysis

 may involve rhomboids, levatorscapulae, serratusanterior,

deltoid, supraspinatus, infraspinatus, biceps brachii,
brachioradialis, brachialis, supinator and long extensors of
wrist fingers, and thumb
 “waiter’s tip deformity”

 decreased shoulder girdle function with I: I

hurneroscapularmovement.
 Test reflexes: Moro, biceps, radial reflexes are not present,
grasp is intact.
KLUMPKE
 C8-Tl,lower arm

 paralysis, involves intrinsic muscles of hand, flexors

and extensors of wrist and fingers
 Decreased wrist and hand function

 Claw hand deformity

ERB-KLUMPKE
 Whole arm paralysis
INTERVENTIONS
 Partial immobilization of limb across upper abdomen
for 1-2 weeks to avoid further injury.
 Gentle ROM after initial immobilization to avoid
contractures.
 Elicit muscle activity with age appropriate functional
movements of upper extremity.
 May use gentle constraint of unaffected arm to
facilitate use of affected UE.
 Prognosis depends on severity of nerve injury,
Positioning Lower extremity orthoses
 Standers  AFO

 Side-lyers  KAFO

 Adaptive seating  HKAFO

 Abductor pad  RGO

Equipment for therapeutic  Pavlik harness

exercise Mobility aids
 Balls  Wheelchairs
 Wedges  walkers
 Swings