Pediatric gross motor milestones/ conditions/ reflexes

Gross Motor Development

• Primitive reflexes dominate movement before cortical control

• General before localized responses

• Flexor tone before extensor tone

• Once antigravity/ upright: Extensor tome progress before flexor tone

• Cephalic to caudal development

• Proximal to distal development

• Gross motor before fine motor control

PEDS Milestones- Month 1-2

• Physiologic flexion

• Eat, sleep, cry and shit

PEDS Milestones- Month 3

• Prone on elbows

• Can lift head in prone

• Belly crawl (3-9 months) AKA Army crawl

PEDS Milestones- Month 3-4

• Supine to side lying

  • half transitions

PEDS Milestones- Month 5-6

• Prone to supine →babies hate prone

• Pull to sit without head lag

• Sitting with UE support

• Feet to mouth

• Propped (supported sitting) or ring sitting with high guard (arms up)

PEDS Milestones- Month 6-7

• Supine to prone

• Quadruped → creeping

• Transfers objects between hands (when in sitting)

• Trunk rotation in sitting

PEDS Milestones- Month 9-10

• Quadped creeping

• Cruises to sideways → using furniture to walk

• Plantigrade, pulls to stand

• Upright unsupported sitting (9 months)

• Improving grasping skills, pincer, three jaw chuck (10 months)

PEDS Milestones- Month 10-15

• Begins to walk unassisted

• Transitions in and out of squatting (10 months)

• Control grasp AND release

  • Fine pincer grasp (15 months)

• Stacks two cubes

Plagiocephaly

• Results from prolonged asymmetrical pressure on the premature skull

• Creates a parallelogram shape when viewed from the vertex

• ipsilateral occipitoparietal flattening and contralateral occipital bossing

• Ipsilateral frontal bossing and anterior displacement of the ear

• Assess c/s ROM and strength, educate parents on positioning, exercises, helmet, and tummy time

• with R-sided plagiocephaly → L-sided torticollis

Classification of Cerebral palsy (CP)

• Classification of CP is according to mvmt disorders

  • Spastic: velocity dependent resistance of muscle to stretch (most common)

    • synergy patterns, contractures, crouched gait, toe walking

• Ataxia: disorder if coordination, force and timing, associated with cerebellar involvement

  • low tone, tremor, poor balance, wide BOS, nystagmus

• Dyskinetic: disorder or involuntary mvmts that are slow and writhing (athetosis), associated with BG involvement

  • Poor stability, hand tremor, fluctuating tone, hypo becomes hyper

Gross motor function classification system (GMFCS)

• Level 1: patient will walk without restrictions but will have limitations in more advanced gross motor skills

• Level 2: Patient will walk without AD with limitations in walking outdoors and in the community

• Level 3: Patient will walk with AD with limitations in walking outdoors and in the community

  • AD > W/C

• Level 4” patient self mobility will be severely limited; children are transported or use power mobility outdoors and in the community

  • W/C > AD

• Level 5: Patient self-mobility will be severely limited, even with the use of assistive technology, and requires caregiver

Key Tx implications for CP

• Posterior walkers promote upright posture

• Address high/ low toe

• Standers/ standing frames should be used by age 2 to promote therapeutic benefits of standing

• Consider AFOs for plantar flexor contractures

• Tendon lengthening procedures : WBAT ad gentle PROM progressing slowly, avoid aggressive end range motion and strengthening

Pediatric Evaluation of Disability

• Children 6 months- 7.5 years

• Three domains: self care, mobility, social function

• Also rates level of caregiver assistance or activity modifications/ equipment needed

• Normal score 50 ± 10 points compared to age matched peers

Functional independence measure for children (WeeFIM)

• children 6 months- 7 years

• adaptations of FIM scores, rating level of assistance from 1 (total assistance) to 7 (complete independence)

• Three domains: self care, mobility, cognition

• Mean score varies from 18-120 dependent upon age

Duchenne’s Muscular Dystrophy (DMD)

• x-linked recessive, inherited by boys

• Dystrophin gene missing- destruction of muscle cells

• Causes pseudohypertrophy (collagen and adipose tissue) → especially in calves

Examination

• Strength, ROM, functional tests, skeletal alignment, cardiopulmonary function, assess need for adaptive equipment

PT interventions

• Maintain mobility and preserve strength

• Maintain joint ROM with active/ passive

• DO NOT OVER FATIGUE

Downs syndrome

• Results from presence of full or partial extra copy of the 21st chromosome; trisomy 21

• Increased risk with increased age of mother

• Forceful neck flexion and rotation activities should be limited due to laxity of odontoid ligament and potential for subluxation of atlanto-axial joint

• Encourage motor function and avoid hyper extension of the elbows and knees during WB activities

S/s od downs syndrome

• Hypotonia, ligamentous laxity

• Delayed motor milestones (running and jumping most delayed)

• Deficits in memory and expressive language

• Impairments in postural control and coordination

• decreased quadriceps and hip abductor strength

• Inefficient movement strategies due to hypotonia

Autism Spectrum disorder

• Social/ communication skill limitations, especially non-verbal skills

• Repetitive behaviors (Routines, highly focused interest, spinning of hands)

• Sensory processing issues

• Difficulty developing relationships

• Can be either hypo-reactive (sensory seeking) or Hyper-reactive (sensory avoiding) to sensory input

Intervention for autism spectrum disorder

• Controlled, multi-sensory input

• Give specific information

• Behavioral interventions

• Encouraging motor development

• coordination

• visual supports (lines on the floors for gait)

• Using first, then (or sequencing)

• Consistency

Scheuermann Disease

• Examination

  • Schmorl’s Nodes and angled/ wedged thoracic spine

  • Pain without thoracic extension and rotation

  • Aggravation with long periods of standing/ sitting or physical activity

  • Increased thoracic kyphosis & lumbar lordotic curve

• PT Interventions

  • The schroth method, stretch pecs, strengthen thoracic extensors and scapular stabilizers

Erbs palsy

• C5-C6

• MOI: stretching head downward

• Loss of mvmts: Loss of abduction and lateral rotation of the shoulder

• Deformity: waiter’s tip deformity

Klumpke’s palsy

• C8-T1

• MOI: stretching of arm overhead

• Loss of mvmt: Paralysis of the intrinsics of the hand

• Deformity: claw hand

Flexor withdrawal

• Onset: 28 weeks of gestation

• Integrated: 1-2 months

• Stimulus: noxious stim to sole of foot

• Respons: Toes extend, foot dorsiflexes, LE flexes uncontrollably

Crossed Extension

• Onset: 28 weeks of gestation

• Integrated: 1-2 months

• Stimulus: Noxious stim to ball of foot of fixed (held in place) in extension

• Response: Opposite LE flexes, them adducts and extends

Traction

• Onset: 28 weeks of gestation

• Integrated: 2-5 months

• Stimulus: grasp forearm and pull up from supine into sitting position (head lags behind)

• Response: grasp and total flexion of the UE

Asymmetrical Tonic Neck reflex (ATNR)

• Onset: birth

• Integrated: 4-6 months

• Stimulus: Rotation of the head to one side

• Response: Flexion of skull limbs (back of head), extension of the jaw limbs (face)

  • Bow and arrow posture (flexion of one side, extension of the opposite side → face turn)

Palmar grasp

• Onset: birth

• Integrated: 4-6 months

• Stimulus: maintained pressure to palm of hand

• Response: maintained flexion of fingers

Moro

• Onset: 28 weeks gestation

• Integrated: 5-6 months

• Stimulus: drop patient backward from sitting position

• Response: extension, abduction of UE’s, hand opening, and crying followed by flexion, adduction of arms across chest

Symmetrical Tonic Labyrinthine (TLR/ STLR) Reflex

• Onset: birth

• Integrated: 6 months

• Stimulus: prone or supine (preferred to try both)

• Response:

  • Prone: Increased flexor tone of all limbs

  • Supine: increased extensor tone of all limbs

Positive Support Reflex

• Onset: birth

• Integrated: 6 months

• Stimulus: contact to the ball of the foot in upright standing position

• Response: rigid extension (co-contraction) of the LE'‘s

Plantar Grasp

• Onset: 28 weeks of gestation

• Integrated: 9 months

• Stimulus: maintained pressure to ball of foot under toes

• Response: Maintained flexion of toes

Symmetrical Tonic Neck (STNR)

• Onset: 4-6 months

• Integrated: persists

• Stimulus: flexion or extension of the head

• Response:

  • Head extension: Extension of UEs, flexion of LEs

  • Head of flexion: Flexion of UEs, extension of LEs

Startle

• Onset: birth

• Integrated: persists

• Stimulus: sudden loud or harsh noise

• Response: sudden extension or abduction of UE, crying (adults usually scream)

Galant Reflex

• Integrated: by 12 months

• Stimulus: in prone, stroke along the vertebral border

• Response: trunk curves around/ toward the stimulus (lateral trunk flexion)

Summary of Persistent Reflexes

• Persistent ATNR affects- feeding, supine to prone rolling

• Persistent STNR affects- crawling, quadruped

• Persistent Plantar grasp affect- standing & walking

• Persistent TLR affects- reciprocal creeping or functional movement in supine or prone