POOR NECK CONTROL

IN CEREBRAL PASLY .
PEADIATRICS UNIT
PRESENTATION
By

NNAMDI CHIKWEM PRINCE.

Table of Contents

Introduction.
Relevant Anatomy.
Prevalence.
Predisposing factors.
Causes.
Types
Symptoms
Complications.
Assessments
Management.
INTRODUCTION

Cerebral Palsy is a group of permanent, but not

unchanging, disorders of movement and/or posture
and of motor function, which are due to a non-
progressive interference, lesion, or abnormality of
the developing/immature brain.(SCPE. Dev Med
Child Neurol 42 (2000) 816-824).
Any non-progressive central nervous system (CNS)
injury occurring during the first 2 (some say 5) years
of life is considered to be CP.
Paediatric reduced head control is when a child does
not have full control over the movement and support
of their head. The child may not be able to hold its
head upright and may find it difficult to turn its head.
This can affect a child’s development as it can limit
what the child can do such as looking at and
registering objects.
Infants generally have a large head compared to the
rest of their habitus, and the cervical group of
paraspinal muscles is relatively weak at birth. Hence
the reason for the notable head lag (poor neck
control), especially during the first few weeks of life.
During this stage, caregivers routinely support the
infant's head until neck control is achieved.This
innate maturational process of the neck and trunk
muscles is expected to evolve rapidly during the
infancy stage.
When an infant is pulled by the hand from a lying to sitting
position, the expected response is to activate the head
righting reflex and maintain the head position in line with
his/her shoulders. Conversely, infant head lag is observed
when the head seems to flop around or lags posteriorly
behind the trunk during the pull-to-sit maneuver.
Once neck control is attained, infants participate actively in
a normal pick-up routine by stiffening their neck muscles
while tensing up their trunk to decrease the lag between
the chin and chest.
Persistent poor neck control (head lag)beyond age 4
months has been associated with poor
neurodevelopmental outcomes. There is a higher
incidence of head lag amongst preterm neonates and
infants with cerebral palsy, and it is a likely predictor
of developmental outcome.
CLINICAL ANATOMY.
 THE NECK MUSCLES.
These muscles are mainly responsible for the
movement of the head in all directions. They consist
of 3 main groups of muscles: anterior, lateral and
posterior groups, based on their position in the neck.
The position of a muscle or group of muscles in the
neck generally relates to the function of the muscles.
For example, the muscles in the posterior neck are
responsible for extension of the neck.
1.Anterior muscles of the neck includes Platysma,
sternocleidomastoid,Digastric, mylohyoid,
geniohyoid, stylohyoid ,Sternohyoid, sternothyroid,
thyrohyoid, omohyoid, Rectus capitis, longus capitis,
longus colli.
2.Lateral (vertebral) muscles of the neck includes
Anterior scalene, middle scalene, posterior scalene
muscles
3. Posterior muscles of the neck includes Trapezius,
splenius capitis, splenius cervicis, Cervical
transversospinales muscles, rectus capitis posterior
major, rectus capitis posterior minor, obliquus capitis
superior, obliquus capitis inferior.
The muscle are majorly innervated by anterior rami
of spinal nerves C1-C3, and vascularized by the
ascending pharyngeal artery.
PREVALENCE

Poor neck control(head lag) is more prevalent in

preterm infants up to term-equivalent age; contrarily,
most full-term infants can maintain their head
position during the pull-to-sit test.An article
published by the American Journal of Occupational
Therapy investigated changes in head lag across
postmenstrual age (PMA) in infants born before 30
weeks gestation.
It revealed that 90% of infants exhibited head lag at
30 weeks PMA, about 60.5% at 34 weeks PMA, and
57.8% at term-equivalent age. More head lag was
also witnessed in infants who had perinatal
complications.
One prospective study at Hadassah Medical Centre in
Jerusalem, Israel, found that only 4% of full-term
newborn infants had head lag on routine clinical
examination.
However, 20% of these infants with head lag had
other risk factors, including vacuum delivery,
probable sepsis, and congenital malformations. In
the remaining 80% (i.e., the group without risk
factors), 62.5% had mild head lag, and 37.5% had
moderate to severe head lag.
PREDISPOSING FACTORS/
CAUSES.

Reduced head control in children can be caused by:

Reduced tone (hypotonia)
Reduced motor control
Neck muscle weakness
Cerebral palsy
Acquired brain injury
Developmental delays.
RISK FACTORS

1.Low gestational age,

2.Polyhydramnios,
3.Breech presentation,
4. Parental age,
5. Drug or teratogen exposure,
6. Consanguinity,
7. Maternal diseases (epilepsy/diabetes)
8. Congenital infections (TORCHES)
9. Post-natal insults (sepsis and prolonged NICU stay).
TYPES

Head lag can be divided into three categories based on

severity.The degree of head lag is measured by how far
the head falls posteriorly behind the shoulders during the
pull-to-sit test(Linder N,etal 1998).
1.Mild head lag is when the infant tries to maintain
his/her head when pulled forward to a sitting position.
2.Moderate head lag occurred when no effort was made
to keep the head in an upright position while being pulled
forward, but he/she could maintain the head position
while sitting.
3. Severe head lag is when an infant cannot raise his
head during the pull-to-sit maneuver and failed to
hold his/her head upright while sitting.
Mild head lag is a common finding in newborns and
usually resolves by itself; however, the presence of
severe persistent head lag beyond 3 to 4 months of
age typically points to disorders related to hypotonia
and muscle weakness in infance
SYMPTOMS.

Reduced head control in children can have the

following symptoms:
Child is unable to look in certain directions
Child is unable to support own head
Child props up head on surrounding objects
Child finds it difficult to move head
Child struggles to follow objects
Child looks to one side more often.
COMPLICATIONS

Infants with head lag can have trouble breastfeeding

due to poor latching. Other problems are specific to
the associated secondary cause, e.g., respiratory
distress in infantile myasthenia gravis.
ASSESSMENT

Specific attention must be given to pregnancy, birth

history, post-natal period, developmental milestones,
and family history. A complete physical examination
is necessary to assess for potential syndromes and
other associated causes of infantile hypotonia.
Dysmorphic features increase the chances of CNS
dysfunction as an explanation for hypotonia.
When assessing tone, it helps to keep the child
relaxed, not crying, and alert. Truncal and nuchal
tone examination is done using vertical and
horizontal suspension tests. On horizontal
suspension, the infant should maintain a straight
back with the head upright and limbs flexed. On
vertical suspension, a vigorous infant should keep the
head upright while sitting.
Management

Systematic reviews have demonstrated that early

intervention, through specific motor training routines
and global developmental programs where parents
are taught how to promote infant development,
maybe the most reliable approach to promoting
infant motor function and neck control in babies
living with cerebral palsy.Occupational therapists and
physical therapists play an essential role in
addressing sensorimotor skills to improve infants'
participation.
PHYSIOTHERAPY MANAGEMENT

1.Postural and play advice

Some motor training routines include home exercises
like tummy time.
2.Sensory integration techniques
3.Neck muscle strengthening and stretching exercises
4.Practice of head movements e.g. getting child to lift
or turn head to look at pictures or toys.
SUMMARY

Assessment of head lag should be a routine part of

well child care in the first six months of life. It is
essential to properly educate the parents about the
timeline of motor developmental milestones. This
information helps prevent unnecessary anxiety and
intervention by the parents while also keeping them
abreast of what to expect and when to see a
physician for further evaluation of a pathological
head lag.
Head lag beyond four months typically requires
investigation, and early intervention through home
physical therapy, with the parents, actively involved,
has been shown to improve outcomes.
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Thank you.