NPTE Peds

ATNR (Asymmetrical tonic neck reflex)

Stim: rotate head to one side

Response: flexion of skull arm and extension of jaw arm (fencing position)

Onset: birth

Integration: 4-6 months

Prolonged/persists= scoliosis or subluxation of hip potentially

Crossed extension reflex

Stim: noxious stim to the ball of LE fixed in extension

Response: opp LE flexes, ADD and extends

-Pt with hemiplegia, lifting uninvolved leg off ground in gait results in in creased extensor tone of involved leg

Onset: 28 weeks gestation

Integration: 1-2 months

Equilibrium Reactions

Stim: displace COG by tilting or moving support surface

Response: curvature of trunk toward upward side and extension/ABD of extremities; protective extension on downward side

Onset: 6 mo and sequentially development

-prone 6 mo

-supine 7-8 mo

-sitting 7-8 mo

-kneeling 9-12 mo

-standing 12-21 mo

Integration: persists

Grasp Reflex

Stim: pressure to palm or plantar/ball of foot

Response: curling of toes or grasping with fingers

Onset:

-Palmar: Birth

-Plantar: 28 weeks gestation

Integration:

-Palmar: 4-6 mo

-Plantar 9 mo

Landau's Reflex

Stim: lift child under thorax in prone

Response: head/back and legs extend

-if head is pushed into flexion all extensor tone disappears

Onset: 3 mo

Integration: 2 years

(absent in those with strong flexor spasticity)

Moro reflex (startle reflex)

Stim: sudden head change in relation to the trunk (drop backward from sitting to supine)

Response: extension and ABD of UE with open hands and crying

-followed by flexion, ADD and arms crossed

Onset: 28 weeks gestation

Integrated: 5-6 mo

Optical and labyrinthine righting reflexes

Stim: alter body position by tipping body in all directions (labyrinthine- vision is occluded)

Response: head orients to vertical position and mouth horizontal

Onset: 2 mo

Integrated: persists

Positive Supporting Reaction

Stim: contact to ball of the foot in upright standing posture

Response: rigid extension of LE with ankle PF and inversions, toes clawing and hip IR

Onset: birth

Integration: 6 mo

Variations:

-CP= adductor spasticity

-hemiplegia pt, may produce hip ABD

-ambulation will be disrupted by inability to DF to foot or properly move leg joints

Protective Extension Reaction

Stim: displace COG outside BOS

Response: arms or legs extend and ABD to support and protect body

-Parachute reflex for downward protection occurs first, then forward, lateral and backwards is last

Onset:

Arms: 4-6 mo

Legs: 6-9 mo

Integrated: persists

Rooting Reflex

Stim: touch to side of face with LT

Response: infant turns head and opens mouth to suck

Onset: present in premature infants

Integrates: 3 mo

STNR (symmetrical tonic neck reflex)

Stim: flexion or extension of head

Response:

-Head Flexion: UE flexion and LE extension

-Head Extension: UE extension and LE flexion

Onset: 4-6 mo

Integration: 8-12 mo

Tonic Labyrinthine Reflex

Stim: prone or supine position

Response:

-Prone: increased flexor tone

-Supine: increased extensor tone

Onset: Birth

Integrated: 6 mo

May be impossible to be sidelying due to extensor tone limits flexion of shoulder and hip on one side needed for rolling

Traction Reflex (pull to sit)

Stim: grasp forearms and pull from supine to sitting

Response:

-grasp and total flexion of upper extremity and head will lag behind

Onset: 28 weeks gestation

Integrated: 2-5 mo

Developmental Behaviors: 1 months

-lifts head

-follows moving object

-Stepping reflex

-Positive support reflex

-Decreased flexion (from physiological flexion at birth)

-hands fisted with indwelling thumb

-Reciprocal and symmetrical kicking and neonatal reaching

Developmental Behaviors: 2 months

-45 deg head lift

-head lags on pull to sit

-smiles

-begins prone on elbows with elbows behind shoulders

-head bob in supported sitting

Developmental Behaviors: 3 months

-head lift to 90 deg

-prop self on elbow in prone with weight in forearms

-takes weight with toes curled in supported standing

Developmental Behaviors: 4 months

-no head lag with pull to sit

-Sits with support

-Laughs

-Rolls prone to side, supine to side

-Optical and labyrinthine reflex present

-ulnar palmar grasp

Developmental Behaviors: 5 months

-roll to from prone to supine

-Head control in supported sitting

-weight shift onto one forearm in prone

Developmental Behaviors: 6 months

-Independent sitting

-rolls supine to prone

-pulls to stand

-prone on hands

Developmental Behaviors: 7 months

-Quadruped position

-pivots on belly

-prone extension

-Prone Pivot

-trunk rotation in sitting

Developmental Behaviors: 8-9 months

-belly crawls

-quadruped creep

-side-sitting

-pulls to stand through kneeling

-Cruising

-stand alone

-pincer grasp

-object transfer between hands

-quadruped to sitting

Developmental Behaviors: 10-15 months

-stands and begins walking

-self-feeding

-searches for hidden objects

-Reaches in supination

Developmental Behaviors: 18-20 months

-walk up and down stairs with assistance

-ascends with step to pattern

-sit on small chairs

-Running begins

-Jumps off bottom step

-Plays make-believe

Developmental Behaviors: 2 years

-Runs well

-Up with reciprocal gait

-active/restless

-tantrums

Developmental Behaviors: 3 years

-up AND down stairs with reciprocal gait

-rides trike

-catch ball

-jumps with 2 feet

-sharing

-SL briefly

Developmental Behaviors: 3.5 years

-Hops on one foot

-Kicks ball

Developmental Behaviors: 4 years

-hops on one foot several times

-climbs

-throws overhand

-stands on tiptoes

-relates to friends

Developmental Behaviors: 5 years

-Skips

-kicks ball well

-dresses and undresses self

Erb's Palsy (upper)

What: C5-C6 nerve root stretched during birthing process

Clinical presentation

-decreased shoulder girdle function with 1:1 humeroscapular movement

-weakness in scapular stabilizers, GH ABD and ER and elbow flexion and supination

-Posture = arm is ADD and IR (waiter's tip)

Klumpke's paralysis (lower)

What: C8-T1 nerve roots stretched during birthing process

Clinical presentation:

-Decreased wrist and hand function

-Weakness in wrist flexors, finger flexors, hand/thumb and finger intrinsic muscles

-Posture - claw hand and mainly affects hand function (Ulnar nerve root distribution and Ulnar nerve does a lot of hand fxn)

GMFCS

What: Gross Motor Function Classification System used for standardized comparing of children with CP

Level 1: Walks without limitation

Level 2: Walks with limitation but no AD

Level 3: Walks using hand-held mobility device

Level 4: Self-mobility with limitations, may use powered mobility

Level 5: Transported in manual w/c

Down Syndrome Atlantoaxial Instability

increased distance between C1 and C2 joints. medical clearance for sports. cervical spine xray including lateral view. restricted from contact sports. DS w/o instability - low impact sports until 3-5 years of age

-no forward rolls and no trampolines

Kiddos with Down Syndrome ambulate by roughly what month of age?

30 month

Spina Bifida: Thoracic level

-May use THKAFO or HKAFO for standing

-Parapodium

-W/c long term use

Spina Bifida: L1-L2

-May use KAFO or RGO with walker or crutches for short household distances

-w/c Long term

Spina Bifida: L3 (-L4)

-Mya use KAFO with walker or crutches for short household distances or in community

-w/c long term

Spina Bifida: L4

-Use AFO and crutches in community

-Community ambulator but w/c for long distances

Spina Bifida: L5

-May or may not AFO or FO in community, crutches for long distances

-Community ambulator but w/c for sports

Spina Bifida: Sacral

-May or may not use FO in community or SMOs

-Community ambulator

DMD (Duchenne's Muscular Dystrophy)

What: genetic, progressive disease that affects males and causes destruction of muscle cells (X-linked carried by mothers)

Hallmark sign: WEAKNESS

-these kiddos start to not be able to do ADLs and normal things (parents see regression of skills/difficulty doing skills already mastered)

Clinical presentation

-(+) Gower's sign

-increased lordosis

-Lack heel strike

-waddling gait

-hanging on Y ligament

Tx:

-maintain flexibility (selective stretching)

-allow compenstations

-identify when need to transition to w/c but keep them walking as long as possible

-Avoid eccentric and max resistive exercises (increase muscular breakdown)

Classifications of CP

Diplegia: two limbs

1 UE and 1 LE on same side: Hemiplegia

All 4 limbs: quadriplegia

Movement Disorders of CP: Athetosis

-Fluctuating muscle tone, involuntary slow writhing movements

-Lesion of the basal ganglia

Talipes Equinovarus

Clubbed foot

Down Syndrome

What: Trisomy 21

Clinical presentation:

-hypotonia

-decreased force generation of muscles

-delayed gross motor development

-congenital heart defects

-hypermobility of limbs

Condensed Major Milestones in months 0-5

2-3 months: prone on elbows and head lift in prone

3-4 months: supine to sidelying

4-5 months: Prone to supine roll, pull to sit w/p head lag, sitting w/ UE support, feet to mouth

Integration of flexor withdrawal, crossed extension, rooting and traction reflex

Condensed Major Milestones in months 6-7 months

6-7 months: Supine to prone, quadruped transitions in and out to sitting, INDEP sitting, trunk rotate in sitting

8-9 months: Quadruped creep (hands and knees and belly off the ground), cruising, can stand indep briefly, improving gasping, pass toys between hands

10-15 moths: walking, transitions in an out of squatting, floor to stand, pincer grasp, stacks 2 cubes

Integration of reflexes:

6 mon: Palmar, ATNR, Moro, TLR, Positive support (PAM TP)

9 mon: Plantar

12: BS - Babinski and STNR

Neonatal reflex integration short way to remember:

1-2 months: infants only flex and extend (flex withdrawal and crossed extension

3 months: lips look like a 3 therefore rooting integrates at 3 months

2-5 months: cervical traction requires 25# of pull for joint distraction, traction reflex integrates between 2-5 months

6 months: PAM had a 6 month stash of TP during covid

Palmart grasp, ATNR, Moro, TLR and Positive Support

9 months: Toes look like 9s so Plantar grasp integrates at 9 months

12 months- seeing babies grow up so fast is BS - Babinski and STNR

APGAR scale

What: standard measure for infant assessment at 1 min and 5 min post birth (sometimes 10 min)

Scoring:

-low= not good

-high= better

-7/10 is normal baby

Appearance:

-0= Blue

-1= blue extremities by normal core

-2= no blue

Pulse:

-0= Absent

-1= <100 bpm

-2= 100-140 bpm

Grimace (reflex irritability):

-0= No response

-1= Grimace

-2= Cry and/or withdrawal

Activity (muscle tone):

-0= Flaccid

-1= Some flexion

-2= Active motion of extremities

Respiration:

-0= Absent

-1= Weak cry and hypoventilation

-2= Strong loud cry

Corrected Age or Adjusted age

1st: Subtract weeks born at from 40 weeks = how early infant was born

2nd: subtract number weeks early from chronological age= adjusted age for milestones and expectations

Only adjust till age 2

Plagiocephaly will be _______ (opposite/same) of the side of torticollis.

Plagiocephaly will be opposite of the side of torticollis.

Ex

R torticollis = L plagiocephaly

Sheuermann's Disease

Scheuermann's

What: Anterior angled/wedge shaped vertebrae causing severe thoracic kyphosis

Who: Teenage boys

Clinical Presentation:

-Schmorl Nodes

-Pain with thoracic extension and rotation

-aggravation with long periods of standing and sitting or PA

Treatment:

-Schroth method

-Stretch pecs, strengthen thoracic extensors and scap stabilizers

Sch, Sch, Sch